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

Abstract

Background and aims Alcohol screening, brief intervention (BI) and referral to treatment is often considered stepped care, such that BI with referral links patients to treatment. A meta‐analysis of randomized trials found no evidence that BI increases treatment for alcohol use disorder (AUD). This study aimed to determine whether BI is associated with receipt of treatment for AUD among patients receiving BI as part of routine care. Design Regression analysis. Setting US Veterans Health Administration (VA), in which BI is supported by performance measurement and electronic clinical reminders. Participants VA outpatients with positive Alcohol Use Disorders Identification Test Consumption screens (≥ 5) (n = 830,825) documented nationally from 1 October 2009 to 30 May 2013. Measurements Regression models estimated the prevalence of receiving VA specialty addictions treatment within 0–365 days for patients with documented BI (advice to reduce/abstain within 0–14 days) compared to those without. Models clustered on patient and adjusted for demographics and mental health and substance use conditions were fit among all patients and stratified across documented past‐year AUD diagnosis. Multiple secondary analyses assessed robustness of findings, including assessing repeated BI as a predictor. Findings Among 830,825 VA outpatients with unhealthy alcohol use (1,172,606 positive screens), documented BI was associated with lower likelihood of receiving VA specialty addictions treatment [adjusted incidence rate ratio (aIRR) = 0.84, 95% confidence interval (CI) = 0.83–0.84]. Associations were similar for those with and without AUD (aIRR = 0.83, 95% CI = 0.82–0.84 and aIRR = 0.86, 95% CI = 0.83–0.88, respectively) and in most secondary analyses. However, among patients without AUD, documentation of more than one BI was associated with greater likelihood of treatment relative to no BI (aIRR = 1.75, 95% CI = 1.68–1.83). Conclusions In a national sample of US Veterans Health Administration patients with unhealthy alcohol use, documented brief intervention for alcohol use was associated with lower likelihood of receiving specialty addictions treatment regardless of alcohol use disorder diagnosis.

Treating alcohol use disorders in primary care – a qualitative evaluation of a new innovation: the 15-method

“…One way to reduce stigma and increase treatment seeking is to offer alcohol interventions in primary care. This is also in line with current discussions in the field of alcohol treatment [ 2 , 3 ]. Most research on alcohol interventions in primary care have up until now focused on secondary prevention – screening and brief interventions (SBI), which have been found efficacious for individuals with hazardous and harmful alcohol use [ 4 ].…”

“…One important factor for this reluctance among GPs is a perceived lack of expertise in managing AUD [ 23 ]. Given that screening will identify not only hazardous consumers, but also those who have developed alcohol dependence, practitioners may hesitate to raise the initial question of alcohol use in the absence of routines to handle dependence and the known difficulties of referring patients to specialist treatment [ 3 , 40 ]. The results from this study and the RCT are therefore important - GPs with a brief training in a stepped care manual can achieve similar treatment outcomes as addiction specialists for the large group of socially well-adjusted individuals with alcohol dependence.…”

Integrated stepped alcohol treatment for patients with HIV and at-risk alcohol use: a randomized trial

“…Whether this model and treatment receipt translates into changes in alcohol use and HIV-related outcomes for PWH with at-risk alcohol use, however, is not yet clear. In addition, our findings should be interpreted in the context of recent VA-based analyses demonstrating that brief intervention is associated with decreased likelihood of receipt of specialty addiction services [45]; however, it is an empirical question how these findings generalize to PWH seen in HIV clinics, where mental health services are often embedded. In addition, the recognized harmful effects of concurrent alcohol and tobacco use [46,47] and our findings that current smoking was negatively associated with alcohol reductions over time together reinforce the need for evaluation of targeted interventions to address these commonly co-occurring, mutually-reinforcing behaviors [48].…”

Using practice facilitation to improve alcohol-related care in primary care: a mixed-methods pilot study protocol

“…However, higher BI rates are needed, and the treatment landscape is more complicated for those with AUD. While the VA has a clinical guideline recommending further assessment coupled with provision of pharmacotherapy and/or referral to specialty addiction treatment [ 8 , 20 , 21 ] using shared decision making [ 22 ] for patients with AUDIT-C scores ≥ 8 (those at greatest risk of AUD [ 23 , 24 ]) and/or those with documented AUD, most patients with AUD do not receive this care: ~ 12% receive pharmacotherapy, only ~ 26% receive specialty addictions treatment, and receipt of BI has been shown to be associated with decreased likelihood of receiving specialty care (relative to patients with AUD not receiving BI) [ 25 , 26 ].…”