From screening into treatment: Implementation solutions for Alcoholism therapy

1. From screening into treatment: Implementation solutions for Alcoholism therapy Thomas R. Kosten MD JH Waggoner Chair and Professor of Psychiatry & Neuroscience Baylor College of Medicine Research Coordinator VA Substance Use Disorders QUERI

2. Purpose of this Program • To compare barriers and benefits in PCC for treating problem drinking using Brief Interventions (BI) and for treating alcoholism using naltrexone (NTX). • To compare VISNs and facilities in providing BI and NTX using 3 care models: TIDES, Behavioral Health Laboratory (BHL), and the PCC providers themselves.

3. Outline of Presentations • Kosten: introduce BI and NTX for alcohol use disorders (AUD). • Harris (PERC): very limited use of NTX for AUD in VA. • Bradley: EPRP chart reviews of AUD treatment in PCC. • Oslin: BHL outcomes in providing BI and NTX for AUD in PCC. • Kirchner: implementing TIDES for AUD treatment in PCC • Daily: 2 year implementation of TIDES for treating AUD in PCC across VISN 16

4. Stopping drinking is easy,I’ve done it hundreds of times Mark Twain

5. Alcohol Screening on AUDIT-C: Q3 FY06 by VISN (…. Target)

6. Patient Survey (n=14,000 screen+) “In the past year did a VA provider advise you to decrease drinking or not drink?” National Mean=28% (VISN range = 20-36%) Thus: Brief Interventions (BI) done Uncommonly Rates of Provider Advice (B.I.)

7. Alcohol Withdrawal Syndrome • Signs: tremor, blood pressure and pulse elevated, adrenergic arousal • Symptoms: agitation, anxiety, hallucinations • Peak at 3 days, Last 7-10 days • Seizures: Delirium Tremens: fatal complication

8. Are medications needed for detox treatment? • Obtain breath alcohol level – withdrawal occurs as level falls and usually not above 100-150 mg% • Assess level of withdrawal symptoms (CIWA) • Level of care needed: inpatient, medical setting, duration, medical complications, support? • Types of medications • Setting & support needed for medical safety & adherence

9. Behavioral interventions during withdrawal treatment: Motivational Interventions • Brief Motivational Interventions Course • INTRAnet: www.bmiforsuv.org • Over 750 VA staff in Primary Care completed course • Four course modules: • Background, MI Basics, Assessment, Feedback • Four separate shorter modules available by Dec 15th.

10. Can medications reduce alcohol relapse? YES! • Naltrexone – opiate antagonist taken orally or by once monthly injection (Vivatrol) • Over 25 studies showing clinical and cost efficacy over placebo in preventing relapse • Pharmacogenetic selection of best candidates (family HX good surrogate) • Other medications – acamprosate, disulfiram, topiramate, carbamazepine, also combinations • Most effective, if abstinent at medication start

11. Naltrexone and Relapse Rate by Mu Opiate Receptor Genotype 1.0 1.0 1.0 .9 .9 .9 Naltrexone / Naltrexone / Naltrexone- mutant Opiate receptor .8 .8 .8 Asp40 Allele (A/G, G/G) Asp40 Allele (A/G, G/G) .7 .7 .7 Naltrexone Naltrexone .6 .6 .6 Asn40 Allele (A/A) Asn40 Allele (A/A) Non-relapsed Placebo / Placebo / Placebo .5 .5 .5 Asp40 Allele (A/G, G/G) Asp40 Allele (A/G, G/G) Asp40 Allele (A/G, G/G) .4 .4 .4 Placebo / Placebo / P lacebo Asn40 Allele (A/Al) Asn40 Allele (A/Al) Asn40 Allele (A/Al) .3 .3 .3 .2 .2 .2 .1 .1 .1 0.0 0.0 0.0 0 0 0 14 14 14 28 28 28 42 42 42 56 56 56 70 70 70 84 84 84 Days Days Days

12. “Perhaps it would help if I go over it one more time.”