Improving Treatment Adoption and Reach for Unhealthy Alcohol Use in Veterans

By Implementation Research Institute (IRI)

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Translational Science Benefits

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Clinical

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Community

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Economic

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Policy

Summary

Alcohol use is a significant risk factor for disability and death for U.S. adults. Unhealthy alcohol use, defined as a spectrum of alcohol use ranging from drinking above recommended daily/weekly limits to meeting criteria for alcohol use disorder, is common among US Veterans. Approximately one out of every six Veterans seen in primary care report unhealthy alcohol use.1,2,3 U.S. Department of Veterans Affairs (VA) clinical guidelines for managing unhealthy alcohol use state that all Veterans should receive alcohol-related screening in primary care, and providers should deliver evidence-based alcohol care for Veterans who score in the range of unhealthy use. This includes delivery of brief counseling interventions (BI) to convey recommendations such as cutting back or abstaining from drinking.4-10 For those at risk of meeting criteria for an alcohol use disorder (AUD), additional interventions should be offered (e.g., medications, referrals to specialty substance use treatment clinics).4-10

The VA was the first large health care system in the U.S. to implement yearly alcohol screening and BI in primary care,11-13 yet substantial gaps remain.14,15 For example, approximately 25% of Veterans with unhealthy alcohol use still do not receive a BI after a positive alcohol screen.16 In addition, treatments for those with more severe unhealthy alcohol use (i.e., AUD) are still underutilized as rates for referrals to specialty substance use treatment and prescribing of medications to treat AUD are low.8, 17-19 To improve treatment rates for unhealthy alcohol use, we implemented a strategy called facilitation. Facilitation is an evidence-backed method that involves various strategies to help increase access to care, including figuring out what makes it hard or easy to get care, finding key supporters, getting leaders involved, and offering education and training for better care. We implemented facilitation at one VA primary care clinic to pilot test whether facilitation had the potential to improve the adoption and reach of alcohol-related care.

Significance

This research directly addresses one of the largest public health crises of our time, as alcohol is one of the leading causes of preventable death in the U.S., and deaths involving alcohol use are increasing.19 In addition, unhealthy alcohol use is associated with increased risk of suicide attempt and completed suicides.19-21 Thus, this work may improve the lives of Veterans and others who use alcohol.

Disparities in alcohol-related care exist for certain patient populations, including for Veterans identifying with certain sociodemographic characteristics (e.g., minoritized patients, women patients) and clinical conditions.22-25 Although the current study was not focused on reducing disparities in alcohol-related care, it is hoped that as reach and adoption of care increases, equity will improve. In addition, findings from the current project will be used to inform a larger implementation-related study aiming to reduce racial and gender disparities in care for AUD across all VA medical centers.

Benefits

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Reduce unhealthy alcohol use among patients receiving alcohol-related care. potential.

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Community

Disease prevention & reduction

Increase access to alcohol-related care, including brief interventions, psychotherapy for alcohol use disorder, and pharmacotherapy for alcohol use disorder. potential.

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Community

Health care accessibility

Increase treatment reach of alcohol-related care by using facilitation strategies in a VA primary care clinic. potential.

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Community

Health care delivery

Increase quality of brief alcohol-related interventions delivered in primary care. potential.

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Community

Health care quality

Improve mortality rates and functioning for patients engaged in alcohol-related care. potential.

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Community

Life expectancy & quality of life

Improving and increasing access to alcohol-related care has the potential to reduce alcohol-related healthcare costs. potential.

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Economic

Societal & financial cost of illness

This research has community and economic implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.26 

Community

The current implementation intervention being piloted in one VA primary care clinic has the potential to increase adoption of alcohol-related care, increase reach of alcohol-related care among Veterans with unhealthy alcohol use, and reduce unhealthy alcohol use over time.

Economic

The current implementation intervention directly addresses one of the largest public health crises of our time.19 By improving and increasing access to alcohol-related care there is the potential to reduce alcohol-related healthcare and societal costs.

Lessons Learned

Discussions with providers yielded unique perspectives on delivering alcohol-related care within a primary care clinic supported development of a tailored facilitation intervention for the clinic that capitalized on facilitators and minimized barriers. Talking with Veteran patients also informed the facilitation intervention; these discussions highlighted Veterans’ needs which we communicated to the clinic, including their appreciation for providers who build compassionate relationships with them and offer non-judgmental evidence-based advice and treatment options regarding alcohol use, ideally from a shared decision-making approach. Discussions with Veterans also suggested that patients are open to talking about their alcohol use with other practitioners in primary care (e.g., clinical pharmacists, behavioral health providers), which could help increase access to alcohol-related care. Findings from the pilot implementation trial are still pending, but given this was a single site pilot test, a future large-scale implementation trial is necessary to understand whether facilitation can increase reach and adoption of alcohol-related care.

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