Improving treatment adoption and reach for unhealthy alcohol use in Veterans

By Implementation Research Institute (IRI)

Image for Improving treatment adoption and reach for unhealthy alcohol use in Veterans

Translational Science Benefits

Icon for Clinical & medical benefits

Clinical

Icon for Community & public health benefits

Community

Icon for Economic benefits

Economic

Icon for Policy & legislative benefits

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.

Icon for Community & public health benefits

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.

Icon for Community & public health benefits

Community

Health care accessibility

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

Icon for Community & public health benefits

Community

Health care delivery

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

Icon for Community & public health benefits

Community

Health care quality

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

Icon for Community & public health benefits

Community

Life expectancy & quality of life

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

Icon for Economic benefits

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.

  1. Griswold MG, Fullman N, Hawley C, et al. Alcohol use and burden for 195 countries and territories, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. The Lancet. 2018;392(10152):1015-1035.
  2. Bradley KA, Maynard C, Kivlahan DR, McDonell MB, Fihn SD, Ambulatory Care Quality Improvement Project Investigators. The relationship between alcohol screening questionnaires and mortality among male veteran outpatients. J Stud Alcohol. 2001;62(6):826-833.
  3. Vinson DC, Manning BK, Galliher JM, Dickinson LM, Pace WD, Turner BJ. Alcohol and Sleep Problems in Primary Care Patients: A Report from the AAFP National Research Network. Ann Fam Med. 2010;8(6):484-492.
  4. Jonas DE, Garbutt JC, Amick HR, et al. Behavioral Counseling After Screening for Alcohol Misuse in Primary Care: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2012;157(9):645-654.
  5. Kaner EFS, Dickinson HO, Beyer F, et al. The effectiveness of brief alcohol interventions in primary care settings: A systematic review: Brief intervention effectiveness. Drug Alcohol Rev. 2009;28(3):301-323.
  6. OʼConnor EA, Perdue LA, Senger CA, et al. Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2018;320(18):1910-1928.
  7. Anton RF, OʼMalley SS, Ciraulo DA, et al. Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence: The COMBINE Study: A Randomized Controlled Trial. JAMA. 2006;295(17):2003-2017.
  8. U.S. Department of Veterans Affairs and U.S. Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders (Version 4.0). 2021.
  9. National Institute for Health Care Excellence. Alcohol-use disorders: Prevention. 2010.
  10. Bradley KA, Kivlahan DR. Bringing patient-centered care to patients with Alcohol Use Disorders. JAMA. 2014;311(18):1861.
  11. Bradley KA, Williams EC, Achtmeyer CE, Volpp B, Collins BJ, Kivlahan DR. Implementation of evidence-based alcohol screening in the Veterans Health Administration. Am J Manag Care. 2006;12(10):597-606.
  12. Moyer A, Finney JW. Meeting the challenges for research and practice for brief alcohol intervention. Addiction. 2010;105(6):963-964.
  13. Williams EC, Lapham G, Achtmeyer CE, Volpp B, Kivlahan DR, Bradley KA. Use of an Electronic Clinical Reminder for Brief Alcohol Counseling is Associated with Resolution of Unhealthy Alcohol Use at Follow-Up Screening. J Gen Intern Med. 2010;25(S1):11-17.
  14. National Institute on Alcohol Abuse and Alcoholism. Leveraging Electronic Health Records for Alcohol Services Research (R21/R33 Clinical Trial Optional) (FOA No. PAR-18-203). 2017.
  15. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Notice of Intent to Publish Funding Opportunity Announcement to Promote Screening and Management of Unhealthy Alcohol Use in Primary Care (R18) (Notice No. NOT-HS-18-011). 2018.
  16. Williams EC, Lapham GT, Shortreed SM, et al. Among patients with unhealthy alcohol use, those with HIV are less likely than those without to receive evidence-based alcohol-related care: A national VA study. Drug Alcohol Depend. 2017;174:113-120.
  17. Frost MC, Glass JE, Bradley KA, Williams EC. Documented brief intervention associated with reduced linkage to specialty addictions treatment in a national sample of VA patients with unhealthy alcohol use with and without alcohol use disorders. Addiction. 2020 Apr;115(4):668-78.
  18. Drexler K, Burden J. VHA National Addictions Teleconference. February 2019.
  19. Williams EC, Achtmeyer CE, Young JP, et al. Barriers to and Facilitators of Alcohol Use Disorder Pharmacotherapy in Primary Care: A Qualitative Study in Five VA Clinics. J Gen Intern Med. 2018;33(3):258-267.
  20. Borges G, Bagge CL, Cherpitel CJ, Conner KR, Orozco R, Rossow I. A meta-analysis of acute use of alcohol and the risk of suicide attempt. Psychol Med. 2017;47(5):949-957.
  21. Darvishi N, Farhadi M, Haghtalab T, Poorolajal J. Alcohol-Related Risk of Suicidal Ideation, Suicide Attempt, and Completed Suicide: A Meta-Analysis. Voracek M, ed. PLOS ONE. 2015;10(5):e0126870.
  22. Jia-Richards M, Williams EC, Rosland AM, Boudreaux-Kelly MY, Luther JF, Mikolic J, Chinman MJ, Daniels K, Bachrach RL. Unhealthy alcohol use and brief intervention rates among high and low complexity veterans seeking primary care services in the Veterans Health Administration. Journal of Substance Use and Addiction Treatment. 2023 Sep 1;152:209117.
  23. Williams EC, Lapham GT, Rubinsky AD, Chavez LJ, Berger D, Bradley KA. Influence of a targeted performance measure for brief intervention on gender differences in receipt of brief intervention among patients with unhealthy alcohol use in the Veterans Health Administration. Journal of Substance Abuse Treatment. 2017 Oct 1;81:11-6.
  24. Bachrach, R.L., Frost, M.C., Fletcher, O.V., Chen, J.A., Chinman, M., Ellis, R., & Williams, E.C. (in press). Receipt of medications for Alcohol Use Disorder in the Veterans Health Administration: Comparison of rates at the intersections of racialized and ethnic identity with both sex and transgender status. J Addict Med.
  25. Chen JA, Glass JE, Bensley KM, Goldberg SB, Lehavot K, Williams EC. Racial/ethnic and gender differences in receipt of brief intervention among patients with unhealthy alcohol use in the US Veterans Health Administration. Journal of Substance Abuse Treatment. 2020 Dec 1;119:108078.
  26. Luke DA, Sarli CC, Suiter AM, et al. The Translational Science Benefits Model: A New Framework for Assessing the Health and Societal Benefits of Clinical and Translational Sciences. Clin Transl Sci. 2018;11(1):77-84.