Gaps in clinical prevention and treatment for alcohol use disorders: costs, consequences, and strategies.

Heavy drinking causes significant morbidity, premature mortality, and other social and economic burdens on society, prompting numerous prevention and treatment efforts to avoid or ameliorate the prevalence of heavy drinking and its consequences. However, the impact on public health of current selective (i.e., clinical) prevention and treatment strategies is unclear. Screening and brief counseling for at-risk drinkers in ambulatory primary care has the strongest evidence for efficacy, and some evidence indicates this approach is cost-effective and reduces excess morbidity and dysfunction. Widespread implementation of screening and brief counseling of nondependent heavy drinkers outside of the medical context has the potential to have a large public health impact. For people with functional dependence, no appropriate treatment and prevention approaches currently exist, although such strategies might be able to prevent or reduce the morbidity and other harmful consequences associated with the condition before its eventual natural resolution. For people with alcohol use disorders, particularly severe and recurrent dependence, treatment studies have shown improvement in the short term. However, there is no compelling evidence that treatment of alcohol use disorders has resulted in reductions in overall disease burden. More research is needed on ways to address functional alcohol dependence as well as severe and recurrent alcohol dependence.

Significant reductions in drinking following brief alcohol treatment provided in a hepatitis C clinic.

BACKGROUND: Although the hepatitis C virus (HCV) alone increases the risk of cirrhosis, alcohol use is thought to act synergistically with HCV to significantly hasten the development of fibrosis. OBJECTIVE: The authors assessed the impact of brief medical counseling or integrated-care approaches to lessen or eliminate alcohol use in these vulnerable patients. METHOD: This retrospective study describes the effect of brief alcohol treatment delivered in a hepatitis clinic on drinking outcomes and antiviral treatment eligibility: 47 heavy-drinking chronic hepatitis C patients received a brief intervention performed by medical clinicians, with follow-up by a psychiatric nurse-specialist. RESULTS: At the last follow-up, 62% of patients reported >50% drinking reduction; these included 36% who achieved abstinence. Only 6% of patients were excluded from antiviral therapy. DISCUSSION: Brief treatment addressing heavy drinking delivered by hepatitis clinicians with psychiatric-specialist follow-up was associated with abstinence or a significant reduction in alcohol consumption in over 50% of patients.

The past and future of research on treatment of alcohol dependence.

Research on the treatment of alcoholism has gained significant ground over the past 40 years. Studies such as the National Institute on Alcohol Abuse and Alcoholism's Project MATCH, which examined the prospect of tailoring treatments for particular people to better suit their needs, and Project COMBINE, which examined in-depth, cognitive-behavioral therapy and medical management, helped pave the way for a new way of approaching alcoholism treatment. New findings garnered through the National Epidemiologic Survey on Alcohol and Related Conditions further defined the problem. At the heart of this research has been the development of procedures to characterize, measure, and monitor the fidelity to a particular conceptual psychotherapeutic approach so that clear comparisons can be made between conceptually and technically distinct approaches. Advances in scientific methodology and statistics have provided tools to analyze complex datasets. The resulting findings mark an improvement over the first models of treatment developed decades ago, which tended to focus on anecdotal findings and assumptions. This hard-earned progress has enabled scientists today to move ahead and address the next set of challenges. Future research, coupled with a restructured treatment system capable of making new scientific findings rapidly available to the community, hold the key to significantly improving treatment outcomes and reducing suffering from alcohol-related disorders.

Helping patients who drink too much: an evidence-based guide for primary care clinicians.

Excessive alcohol consumption is a leading cause of preventable morbidity and mortality, but few heavy drinkers receive treatment. Primary care physicians are in a position to address heavy drinking and alcohol use disorders with patients, and can do so quickly and effectively. The National Institute on Alcohol Abuse and Alcoholism has published a guide for physicians that offers an evidence-based approach to screening, assessing, and treating alcohol use disorders in general health care settings. Screening can be performed by asking patients how many heavy drinking days they have per week. Assessing patients' willingness to change their drinking behaviors can guide treatment. Treatment recommendations should be presented in a clear, nonjudgmental way. Patients who are not alcohol-dependent may opt to reduce drinking to lower risk levels. Patients with alcohol dependence should receive pharmacotherapy and brief behavioral support, as well as disease management for chronic relapsing dependence. All patients with alcohol dependence should be encouraged to participate in community support groups

Expanding the role of health services research as a tool to reduce the public health burden of alcohol use disorders.

The public and private cost of "heavy alcohol use" is estimated to be more than 187 billion in lost productivity, health care and criminal justice expenditures, and other costs. This does not include the emotional and psychological costs to family, friends, and the community. Investments by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) have led to a number of important advances in pharmacological and behavioral treatments for alcohol disorders. Yet, there continues to be a significant gap between research findings and progress in community-based care. Additionally, limited capacity, a lack of acknowledged standards, and a separation between the specialty substance use treatment sector and general medical practice contribute to this gap. As part of its ongoing efforts to encourage translation from clinical research to practice, NIAAA undertook a review of its alcohol related health services research program for the purpose of creating a vision for the next 10 yr that is sensitive to the changing needs of both the clinical and research communities. Central to the development of a new research agenda is a reconceptualization of alcohol use and misuse along a continuum that takes into account quantity and frequency of use as well as the consequences from "heavy use" and misuse of alcohol. This public health approach recommends a number of high priority areas to expand and improve the system of care for "heavy alcohol users" who may be at-risk or who may have developed an alcohol use disorder. These recommendations include research on dissemination and implementation of evidence-based practices, and improving access and utilization to care for individuals who are "heavy users." The paper concludes by outlining some of the steps taken by NIAAA to further the continuing development of alcohol health services research.

The impact of depressive symptoms on alcohol and cigarette consumption following treatment for alcohol and nicotine dependence.

BACKGROUND: Although depression is common among alcohol and tobacco dependent patients, its impact on treatment outcomes is not well established. The purpose of this study was to examine the impact of depressive symptoms on abstinence from tobacco and alcohol after treatment for alcohol dependence and nicotine dependence. METHODS: The Timing of Alcohol and Smoking Cessation Study (TASC) randomized adults receiving intensive alcohol dependence treatment, who were also smokers, to concurrent or delayed smoking cessation treatment. The sample consisted of 462 adults who completed depression and substance use (alcohol and smoking) assessments at treatment entry and 6, 12, and 18 months posttreatment. Longitudinal regression models were used to examine the relationships between depression and subsequent abstinence from alcohol and tobacco after baseline characteristics, including alcohol and smoking histories, were considered. RESULTS: Depressive symptoms were prospectively related to nonabstinence from alcohol. Depressive symptoms at the previous assessment increased the odds of drinking at the subsequent time point by a factor of 1.67 (95% CI 1.14, 2.43), p < 0.01. Depressive symptoms were not significantly related to subsequent abstinence from cigarettes. CONCLUSIONS: Depression is an important negative predictor of the ability to maintain abstinence from alcohol within the context of intensive alcoholism and smoking treatment. It may be important to include depression-specific interventions for alcohol and tobacco dependent individuals to facilitate successful drinking treatment outcomes.

Outcomes of a Hepatitis C screening program at a large urban VA medical center.

GOALS: To determine the outcomes of implementing clinical care guidelines for Hepatitis C screening, evaluation, and treatment in a large urban Veterans Affairs Medical Center. BACKGROUND: Little information exists regarding the actual outcomes of institutional screening programs for Hepatitis C. STUDY: Retrospective review of all patients tested for Hepatitis C at the Minneapolis Veterans Affairs Medical Center from January 1, 2000 to December 31, 2001. Logistic regression was used to determine factors related to successful referral and treatment. RESULTS: During this period 36,422 unique patients were screened for Hepatitis C virus (HCV) risk factors, resulting in 12,485 HCV enzyme-linked immunoassay antibody tests. HCV antibodies were positive in 681 (5.4%) patients and 520 (4.2%) were HCV-RNA-positive. Of HCV-RNA-positive patients, 430 (83%) were referred, 382 (73%) attended the Hepatitis clinic, and 232 (44.6%) received liver biopsies. Patients referred had significantly fewer comorbidities, known marital status, and greater prior clinic attendance than those not referred. Overall, 124 patients with established fibrosis received antiviral therapy (32% of patients attending clinic or 24% of viremic cohort). White race, fewer major medical problems, and age less than 60 years predicted antiviral treatment. Sustained virologic response occurred in 46 (37%) of treated patients (9% of the viremic cohort). Patients with a sustained virologic response include 17 patients with stage 3 to 4 fibrosis. CONCLUSIONS: This screening and referral program resulted in 73% of HCV-RNA-positive patients attending a specialty Hepatitis C clinic and 24% of those most likely to benefit received antiviral therapy. Measures to increase referral, engagement in care, and antiviral treatment are needed.

A broader view of change in drinking behavior.

Most research concerning change in drinking behavior has taken place within the context of specialized treatment for a help-seeking population. However, treatment approaches with different purported mechanisms of action yield very similar results, suggesting that common elements, rather than specific mechanisms, may be responsible for the bulk of the individual change process. Mechanisms of change have not been explicitly examined. Other factors such as social pressure may be more important mediators of change, which may occur prior to treatment entry. Also, most change occurs outside the context of specific treatment. A broader perspective focusing on mechanisms of change will need to account for change occurring both with and without professional treatment. Future research must be interdisciplinary in nature, seeking to relate social, behavioral, and neurophysiologic correlates of behavior change.

Symptom-driven lorazepam protocol for treatment of severe alcohol withdrawal delirium in the intensive care unit.

STUDY OBJECTIVE: To compare outcomes of treating alcohol withdrawal delirium (AWD) with a symptom-driven benzodiazepine protocol versus nonprotocol benzodiazepine infusions in the intensive care unit (ICU). DESIGN: Retrospective observational study of a quality improvement project. SETTING: Medical intensive care unit at a Veterans Affairs medical center. PATIENTS: Thirty-six patients who had 40 ICU admissions for AWD between January 1, 1994, and May 31, 2003. Sixteen episodes (15 patients [historical controls]) occurred before implementation of the symptom-driven protocol in 1998, and 24 episodes (21 patients) occurred after implementation. MEASUREMENTS AND MAIN RESULTS: Outcomes evaluated were time to reach symptom control, total dose of benzodiazepine, amount of time receiving continuous benzodiazepine infusion, length of ICU and hospital stay, polypharmacy (use of multiple benzodiazepines), and complications of treatment. The historical control group was treated according to physician preference, which consisted of continuous-infusion midazolam without a protocol. The symptom-driven protocol used lorazepam administered initially as intermittent intravenous doses, progressing to a continuous intravenous infusion according to a locally developed symptom scale. The mean +/- SD values for the outcomes in the historical control group versus the protocol group were as follows: time to control symptoms 19.4 +/- 9.7 versus 7.7 +/- 4.9 hours (p=0.002), cumulative benzodiazepine dose in lorazepam equivalents 1677 +/- 937 versus 1044 +/- 534 mg (p=0.014), time receiving benzodiazepine continuous infusion 122.1 +/- 64.4 versus 52.0 +/- 35.1 hours (p=0.001), length of stay in the ICU 7.7 +/- 6.3 versus 5.6 +/- 1.7 days (p=0.21), and length of hospital stay 15.3 +/- 8.9 versus 11.2 +/- 3.4 days (p=0.43). CONCLUSIONS: Use of a symptom-driven protocol was associated with significantly decreased time to symptom control, amount of sedative required, and time spent receiving benzodiazepine infusion compared with historical controls. The use of the protocol is effective but requires close monitoring to ensure protocol compliance and to avoid potential propylene glycol toxicity.

Integrated psychiatric/medical care in a chronic hepatitis C clinic: effect on antiviral treatment evaluation and outcomes.

OBJECTIVES: Psychiatric and substance use disorders are common in hepatitis C patients and represent barriers to antiviral treatment. We evaluated the effect of integrating psychiatric and medical care on evaluation for and initiation of antiviral treatment in a cohort of 184 patients with chronic hepatitis C. METHODS: Integrated care consisted of screening for psychiatric problems with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), Beck Depression Inventory (BDI), Urine Drug Screen (UDS), and Primary Care Posttraumatic Stress Disorder (PC-PTSD) screens, referral based on specified cutoff scores to an established mental health (MH) provider, to a colocated psychiatric clinical nurse specialist (PCNS), or both. Data were collected retrospectively by chart review. RESULTS: Most patients (149/184, 81.0%) had at least one positive screen, 25.5% had a positive UDS. Among patients with positive screens, 38.3% had established MH providers, 47.0% had no MH provider and were referred to the PCNS, and 15.0% refused any psychiatric referral. Patients receiving integrated care with a colocated PCNS were significantly more likely to complete evaluation for and start antiviral treatment than other patients with positive screens, and at a rate similar to that of patients with negative screens. Patients with positive screens followed by any MH provider had significantly greater adherence to antiviral therapy than patients without positive screens. CONCLUSION: An integrated MH and medical approach was associated with rates of antiviral therapy recommendation and initiation similar to patients without risks for psychiatric or substance use problems. MH care was associated with improved adherence to antiviral therapy. Integrated care offers promise as an approach for addressing psychiatric comorbidity in this traditionally difficult to treat population.

Randomized trial of an intervention to facilitate recycling for relapsed smokers.

BACKGROUND: Tobacco dependence is a chronic condition requiring repeat treatment and long-term follow-up. However, current evidence regarding best approaches to providing these services is fairly limited. This study assessed the effectiveness of an intervention for increasing repeat tobacco-dependence treatment in a population of relapsed smokers. DESIGN: The study was a multicenter randomized controlled trial. SETTING/PARTICIPANTS: Patients aged 19 and older receiving a prescription for nicotine replacement therapy or bupropion for smoking cessation in 2002 at one of five participating Veterans Affairs (VA) facilities were eligible. INTERVENTION: A total of 1900 eligible veterans were randomized to (1) patient phone call to assess smoking status, quit challenges, and treatment preferences, and computerized progress note to providers communicating this information (intervention); or (2) usual care (control). MAIN OUTCOME MEASURES: Outcomes, assessed in 2003, included the proportion of patients receiving repeat pharmacologic or behavioral smoking-cessation treatment in the 6-month follow-up period (assessed from VA pharmacy and outpatient data), 7-day point prevalence abstinence, and satisfaction (assessed by patient survey). RESULTS: Thirty-four percent of intervention participants versus 22% of controls received treatment for tobacco dependence in the follow-up period (p = 0.0001). Thirty-two percent of intervention participants versus 21% of controls received pharmacologic treatment (p = 0.0001), and 12% of intervention subjects versus 8% of controls received behavioral treatment (p = 0.005). Abstinence rates at follow-up were 25% for intervention subjects and 22% for controls (p = 0.15). Intervention subjects were more likely than controls to report being satisfied with the general smoking-cessation help (87% vs 82%, p = 0.01), as well as the pharmacologic help that they received from the VA (89 vs 84%, p = 0.01). CONCLUSIONS: The intervention significantly increased repeat treatment rates and satisfaction with services but did not have a significant effect on abstinence rates.

Organizational change in management of hepatitis C: evaluation of a CME program.

INTRODUCTION: Effective treatment regimens exist for the hepatitis C virus (HCV); however, clinicians are often resistant to evaluation or treatment of patients with alcohol or substance abuse problems. We describe a continuing medical education (CME) program for clinicians in a nationwide health care system, with emphasis on current treatment practices, multispecialty collaboration, and organizational change. METHODS: Quantitative measures were used to assess changes in knowledge and treatment confidence, and site-specific organizational changes were qualitatively evaluated. The CME program included a preassessment of current HCV knowledge and care; a 2-day preceptorship; and follow-up with coaching calls at 1, 3, and 6 months. Program attendees included 54 medical and mental health providers from 28 Veterans Affairs Medical Centers. RESULTS: Knowledge following the CME program increased significantly. In 93% of the sites, there were organizational changes such as HCV support group-initiated group education, in-service training, improvement in patient notification or scheduling processes, hiring of new clinical staff, development of a business plans, and discussions about changes with administration. Of all sites, 15 (54%) changed existing antiviral treatment protocols, 18 (64%) established collaborative relationships, and almost half (13/28) established regular use of depression and alcohol use screening tools. Major barriers to change included lack of administrative support or resources (or both) and difficulty collaborating with mental health colleagues. DISCUSSION: This multifaceted CME program with follow-up coaching calls significantly increased individual knowledge and confidence scores and resulted in improved clinic processes and structures. Organizational change was facilitated by the development of an action plan. The major change agent was a nurse; the primary deterrent was an administrator.

Course of recovery from alcoholism.

This article represents the proceedings of a symposium at the 2005 Research Society on Alcoholism meeting in Santa Barbara, California, organized and chaired by Kamilla L. Venner. This symposium integrated current empirical research on the course of recovery from alcoholism from multiple perspectives, an aim that is consistent with NIAAA's new focus on the process of recovery. The presentations and presenters were as follows: (1) The Role of Community Services and Informal Support on 7-Year Drinking Outcomes in Treated and Untreated Drinkers, by Helen Matzger; (2) The Sequence of Recovery Events in a Native American Sample, by Kamilla L. Venner; (3) Transformational Change in Recovery, by Alyssa A. Forcehimes; (4) Social Settings and Substance Use: Contextual Factors in Recovery, by Rudolf H. Moos; and (5) A Broader View of Change in Drinking Behavior, by discussant Mark L. Willenbring. A theme connecting the presentations was that treatment is but one discrete aspect to recovery and that sustained recovery is often influenced by an individual interaction with others within a social context. Collectively, presentations underscored the need to think more broadly about factors contributing to the remission of alcohol dependence.

Promoting repeat tobacco dependence treatment: are relapsed smokers interested?

BACKGROUND: Promotion of repeat tobacco dependence treatment among relapsed smokers interested in "recycling" (repeat quit attempt) may be a promising approach to increase quit rates. OBJECTIVE: To report relapsed smokers' interest in recycling and their treatment preferences. STUDY DESIGN: Descriptive analysis of a population of relapsed smokers who were randomized to receive a recycling intervention strategy to increase tobacco dependence treatment rates, as part of a randomized controlled trial at 5 Veterans Affairs medical centers. METHODS: Individuals prescribed a tobacco dependence medication in 2002 were eligible and were identified from the Department of Veterans Affairs Pharmacy Benefits Management database. Intervention group participants (n = 951) were contacted for a standardized telephone interview approximately 6 months after the prescription fill date to assess smoking status, interest in recycling, and treatment preferences. Bivariate analyses and generalized linear mixed-model regressions were used to describe outcomes. RESULTS: The response rate to the intervention telephone call was 62% (586/951), at which 61% (357/586) of respondents had relapsed. Almost two thirds of relapsed smokers were interested in recycling within 30 days. Of these, 91% wanted behavioral or pharmacologic smoking cessation treatment, and 64% wanted behavioral and pharmacologic treatment. In multivariate analyses, independent predictors of interest in recycling within 30 days included black race, lower smoking level, and greater number of smoking-related medical conditions. CONCLUSION: Most smokers who attempt to quit but relapse want to quit again right away, and most are interested in receiving behavioral and pharmacologic treatment.

Advances in the pharmacotherapy of alcoholism: challenging misconceptions.

This article highlights the proceedings of a symposium presented at the 28th Annual Scientific Meeting of the Research Society on Alcoholism in Santa Barbara, CA, June 27, 2005. The organizer and chair was Henry R. Kranzler. The presentations included: (1) Introduction, by Henry R. Kranzler; (2) Neurobiology of Alcohol Dependence: Implications for Medical Treatment, by George Koob; (3) Advances in Alcoholism Pharmacotherapy, by Henry R. Kranzler; (4) Patient Acceptance of Alcoholism Pharmacotherapy, by David R. Gastfriend; (5) System Challenges in the Adoption of Pharmacotherapy, by Robert M. Swift; and (6) Pharmacotherapy for Alcohol Dependence: Strengths, Challenges, and Future Directions, by Mark L. Willenbring.

Addressing substance abuse in health care settings.

This article summarizes the proceedings of a roundtable discussion at the 2005 annual meeting of the Research Society on Alcoholism in Santa Barbara, California. The chair was William R. Miller. The presentations were as follows: (1) Screening and Brief Intervention for Alcohol Problems, by Allen Zweben; (2) Three Intervention Models and Their Impact on Medical Records, by Denise Ernst; (3) Pharmacotherapies for Managing Alcohol Dependence in Health Care Settings, by Roger D. Weiss; (4) The Trauma Center as an Opportunity, by Carol R. Schermer; (5) Motivational Interviewing by Telephone and Telemedicine, by Catherine Baca; (6) Health Care as a Context for Treating Drug Abuse and Dependence, by Wilson M. Compton; and (7) Interventions for Heavy Drinking in Health Care settings: Barriers and Strategies, by Mark L. Willenbring.