Enhancing access to alcohol use disorder pharmacotherapy and treatment in primary care settings: ADaPT-PC

Abstract

BackgroundOnly 7.8 % of individuals meeting diagnostic criteria for alcohol use disorder (AUD) receive treatment in a given year. Most individuals with AUDs are identified in primary care (PC) settings and referred to substance use disorders (SUD) clinics; however, only a minority of those referred attend treatment services. Safe and effective pharmacological treatments for AUD exist, but they are rarely prescribed by PC providers. The objective of this study is to refine, implement, and evaluate an intervention to integrate pharmacological AUD treatment options into PC settings. This paper provides a detailed description of the intervention design and the evaluation components.Methods/designThree large Veterans Health Administration (VHA) facilities are participating in the intervention. The intervention targets stakeholder groups with tailored strategies based on implementation theory and prior research identifying barriers to implementation of AUD pharmacotherapy. Local SUD providers and primary care mental health integration (PCMHI) providers are trained to serve as local implementation/clinical champions and receive external facilitation. PC providers receive access to consultation from local and national clinical champions, educational materials, and a dashboard of patients with AUD on their caseloads for case identification. Veterans with AUD diagnoses receive educational information in the mail just prior to a scheduled PC visit. Effectiveness of the intervention will be evaluated through an interrupted time series with matched controls to monitor change in facility level AUD pharmacotherapy prescribing rates. Following Stetler’s four-phase formative evaluation (FE) strategy, FE methods include (1) developmental FE (pre-implementation interviews with champions, PC providers, and Veterans), (2) implementation-focused FE (tracking attendance at facilitation meetings, academic detailing efforts by local champions, and patient dashboard utilization), (3) progress-focused FE (tracking rates of AUD pharmacotherapy prescribing and rates of referral to PCMHI and SUD specialty care), and (4) interpretive FE (post-implementation interviews with champions and PC providers). Analysis of FE data will be guided by the Consolidated Framework for Implementation Research (CFIR).DiscussionIf demonstrated to be successful, this implementation strategy will provide a replicable, feasible, and relative low-cost method for integrating AUD treatment services into PC settings, thereby increasing access to AUD treatment.

Influence of comorbid drug use disorder on receipt of evidence-based treatment for alcohol use disorder among VA patients with alcohol use disorder and Hepatitis C and/or HIV

“…Pharmacological options include three FDA-approved medications (acamprosate, disulfiram, and oral or injectable naltrexone) (Jonas et al, 2014; NIAAA, 2007), and a fourth, topiramate, was found to have strong evidence for treatment of AUD in a meta-analysis (Jonas et al, 2014). Despite strong evidence for these treatments, they are underused among patients with AUD (Cohen et al, 2007; Harris et al, 2012; Rubinsky et al, 2015), and multiple barriers to treatment receipt and implementation have been documented (Alanis-Hirsch et al, 2016; Finlay et al, 2017; Hagedorn et al, 2016; Harris et al, 2013; Knudsen and Roman, 2014; Ober et al, 2017; Oliva et al, 2011; Williams et al, 2017a). People with infectious diseases (HCV and HIV) may be even less likely to receive evidence-based treatment for AUD compared to people without these conditions (Owens et al, 2018; Williams et al, 2017d).…”

Alcohol use dependence in fragile X syndrome

“…Then it is critical to treat this problem. Although an alcohol treatment program can be effective (31) and there is an urge to find improved medications to treat alcohol dependence (32) this may not be available in a rural, poor setting such as seen in Ricaurte. Acamprosate, an FDA-approved drug for the maintenance of abstinence from alcohol use in adults is also a targeted treatment for FXS (33).…”

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

“…Four were randomized clinical trials of care delivery interventions designed to improve alcohol-related outcomes [31–38]. Four were quasi-experimental evaluations of large-scale implementation interventions designed to increase medication receipt [39–43], and one was a quasi-experimental evaluation of targeted implementation intervention in a single-site [44]. Two additional studies were identified but not included.…”