Alcohol-Related Nurse Care Management in Primary Care

Abstract

IMPORTANCE Experts recommend that alcohol use disorders (AUDs) be managed in primary care, but effective approaches are unclear.OBJECTIVE To test whether 12 months of alcohol care management, compared with usual care, improved drinking outcomes among patients with or at high risk for AUDs. DESIGN, SETTING, AND PARTICIPANTSThis randomized clinical trial was conducted at 3 Veterans Affairs (VA) primary care clinics. Between October 11, 2011, and September 30, 2014, the study enrolled 304 outpatients who reported heavy drinking (Ն4 drinks per day for women and Ն5 drinks per day for men).INTERVENTIONS Nurse care managers offered outreach and engagement, repeated brief counseling using motivational interviewing and shared decision making about treatment options, and nurse practitioner-prescribed AUD medications (if desired), supported by an interdisciplinary team (CHOICE intervention). The comparison was usual primary care. MAIN OUTCOMES AND MEASURESPrimary outcomes, assessed by blinded telephone interviewers at 12 months, were percentage of heavy drinking days in the prior 28 days measured by timeline follow-back interviews and a binary good drinking outcome, defined as abstinence or drinking below recommended limits in the prior 28 days (according to timeline follow-back interviews) and no alcohol-related symptoms in the past 3 months as measured by the Short Inventory of Problems. RESULTSOf 304 participants, 275 (90%) were male, 206 (68%) were white, and the mean (SD) age was 51.4 (13.8) years. At baseline, both the CHOICE intervention (n = 150) and usual care (n = 154) groups reported heavy drinking on 61% of days (95% CI, 56%-66%). During the 12-month intervention, 137 of 150 patients in the intervention group (91%) had at least 1 nurse visit, and 77 of 150 (51%) had at least 6 nurse visits. A greater proportion of patients in the intervention group than in the usual care group received alcohol-related care: 42% (95% CI, 35%-49%; 63 of 150 patients) vs 26% (95% CI, 19%-35%; 40 of 154 patients). Alcohol-related care included more AUD medication use: 32% (95% CI, 26%-39%; 48 of 150 patients in the intervention group) vs 8% (95% CI, 5%-13%; 13 of 154 patients in the usual care group). No significant differences in primary outcomes were observed at 12 months between patients in both groups. The percentages of heavy drinking days were 39% (95% CI, 32%-47%) and 35% (95% CI, 28%-42%), and the percentages of patients with a good drinking outcome were 15% (95% CI, 9%-22%; 18 of 124 patients) and 20% (95 % CI, 14%-28%; 27 of 134 patients), in the intervention and usual care groups, respectively (P = .32-.44). Findings at 3 months were similar. CONCLUSIONS AND RELEVANCEThe CHOICE intervention did not decrease heavy drinking or related problems despite increased engagement in alcohol-related care.TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01400581

Conceptualizing patient-centered care for substance use disorder treatment: findings from a systematic scoping review

“…Coded categories were not mutually exclusive such that a reference might have defined the principle of patient-centered care at more than one category. Bracketed numbers represent the number of unique references coded at each category b References coded at this category [20, 40, 42, 43, 45, 47, 50, 52, 64, 69, 72–89] c References coded at this category [25, 40, 43, 46, 47, 50, 52–57, 63, 67, 71, 75–77, 84, 87, 90–93] d References coded at this category [20, 45, 52–54, 64, 67, 72, 74, 86, 88]…”

“…c References coded at this category [25, 40, 43, 46, 47, 50, 52–57, 63, 67, 71, 75–77, 84, 87, 90–93]…”

Strategies to increase implementation of pharmacotherapy for alcohol use disorders: a structured review of care delivery and implementation interventions

“…The effects of the interventions on receipt of AUD pharmacotherapy were also variable across studies (Table 2). In three of the four randomized evaluations of care delivery models [31–33], the interventions were associated with varying magnitude of increased receipt of AUD medications. At follow-up, treatment group rates of medication receipt ranged from 13 [36] to almost 70% [31].…”

“…The control group was told that the clinic provided opioid and/or alcohol use disorder treatment and given a number for appointment scheduling and list of community referrals.” Delivered by care coordinators and therapists with a social work degree Setting : Primary care at Federally Qualified Health Center in L.A., CA Goal : Increase screening and brief intervention for unhealthy alcohol use Key components : Intended 6 sessions of brief psychotherapy and/or med-assisted treatment (buprenorphine/naloxone for OUD and naltrexone for AUDs), repeated assessments of substance use, use of registry to track and proactively reach out to patients, motivation and encouragement of engagement in therapy Effect on Medication Receipt : OR comparing intervention to control at 6-months follow-up for patients with AUD and/or OUD = 1.23 (95% CI 0.60–2.40) p = 0.53. Published commentary from SUMMIT investigators [37] suggests similar non-significant findings among patients with AUD only Effect on Alcohol Use Outcomes : Among patients with AUD only (54% of the sample) the SUMMIT intervention was significantly associated with abstinence from any alcohol use and all opioids at follow-up and was borderline significant for no heavy drinking in the past 30 days. FOLLOW-UP :Intervention 13.4%Control 12.6%BRADLEY CHOICE [33, 34]304/3 BASELINE :Intervention 1% versus Control 2%Receipt of naltrexone, Acamprosate or disulfiram Program Name and Brief Description : Choosing Healthier Options in Primary Care (CHOICE) was a care management intervention in which “nurse care managers offered outreach and engagement, repeated brief counseling using motivational interviewing and shared decision making about treatment options, and nurse practitioner–prescribed AUD medications (if desired), supported by an interdisciplinary team (CHOICE intervention). The control group received usual primary care.” Setting : VA Primary care in Washington State Goal : Harm reduction Key components : Proactive outreach and engagement, repeated brief counseling using MI and shared decision-making about treatment options (AUD medication, biomarker assessment if abnormal baseline, behavioral goal-setting and skills development for reducing drinking, encouragement of mutual help and/or specialty addictions treatment, self-monitoring) Effect on Medication Receipt : OR = 6.3 (95% CI 3.4–11.8) p < 0.0001 Effect on Alcohol Use Outcomes : Not significant FOLLOW-UP :Intervention 32% versus Control 8%ROBINSON, Group Management [44]1600/1 BASELINE :Increasing 0.08%/month in pre-implementation periodReceipt of naltrexone or Acamprosate, or extended-release naltrexone Program Name and Brief Description : Group Management of pharmacotherapy initially implemented to provide continued access during a staffing shortage, sought to provide psychosocial education on medication management for alcohol dependence.…”

Implementing alcohol use disorder pharmacotherapy in primary care settings: a qualitative analysis of provider-identified barriers and impact on implementation outcomes

“…Clearly, different care delivery models are needed to offer and increase accessibility of treatment for individuals with AUD. Although the need is great and interest in integration of AUD treatment into primary care settings is high, few models for implementation of AUD treatment into primary care have been tested [13][14][15][16][17]. Several of these models have incorporated pharmacotherapy for AUD which is recognized as an important treatment option but continues to be rarely used in clinical care.…”