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

Abstract

BackgroundEffective medications for treating alcohol use disorders (AUD) are available but underutilized. Multiple barriers to their provision have been identified, and optimal strategies for addressing and overcoming barriers to use of medications for AUD treatment remain elusive. We conducted a structured review of published care delivery and implementation studies evaluating interventions that aimed to increase medication treatment for patients with AUD to identify interventions and component strategies that were most effective.MethodsWe reviewed literature through May 2018 and used networking to identify intervention studies with AUD medication receipt reported as a primary or secondary outcome. Studies were identified as care delivery studies, characterized by patient-level recruitment and willingness to be randomized to candidate treatment options, and implementation studies, characterized by inclusion of all patients treated at sites involved in the study. Each identified study was independently coded by two investigators for strategies used, guided by a published taxonomy of implementation strategies. All authors reviewed coding discrepancies and revised codes based on consensus. After reaching internal consensus, we solicited feedback from lead investigators on studies to code additional strategies. We reviewed implementation strategies used across studies to assess their relationship with medication receipt, as well as alcohol use outcomes, as available.ResultsNine studies were identified: four RCTs of care delivery interventions, four quasi-experimental evaluations of large-scale implementation interventions, and one quasi-experimental evaluation of a targeted single-site implementation intervention. Implementation strategies used were variable across studies; no strategy was universally used. Effects of the interventions on receipt of AUD pharmacotherapy and alcohol use outcomes also varied. Three of four care delivery interventions resulted in increased receipt of AUD medications, but only one of these three improved alcohol use outcomes. One large-scale and one single-site implementation intervention were associated with increased AUD medication receipt, and these studies did not assess alcohol use outcomes. Patterns of implementation strategies did not clearly distinguish studies that successfully increased use of pharmacotherapy versus those that did not.ConclusionsOur review did not reveal strategies most effective for implementing AUD medications. Interventions designed to overcome identified barriers may have missed the mark, or differences in the intensity or targets of strategies may matter more than differences in strategies. Further research is needed to understand effective implementation methods and to better understand patient-level perspective, preferences and barriers to receipt of medications.

Impact of Alcohol Use Disorder Treatment on Clinical Outcomes Among Patients With Cirrhosis

“…For example, the VA successfully implemented a multifaceted academic detailing program to increase AUD pharmacotherapy in general populations . Although this program increased AUD pharmacotherapy from 5% to 8% in intervention sites, more work is needed to develop implementation strategies to address this evidence‐to‐practice gap . Moreover, given the unique medical complexities of patients with cirrhosis, it is likely that unique approaches to AUD care may be required, such as colocation of care for AUD and cirrhosis…”

Chronic Chemogenetic Stimulation of the Nucleus Accumbens Produces Lasting Reductions in Binge Drinking and Ameliorates Alcohol-Related Morphological and Transcriptional Changes

“…Currently, three FDA-approved medications are available for AUD treatment: disulfiram, acamprosate and naltrexone [48]. However, these medications are often underutilized, only improve symptoms in a small fraction of treated individuals, and any improvements do not last beyond treatment [49]. Further, although DBS of the NAc appears to be a potentially promising therapeutic approach, it is quite invasive and does not produce lasting reductions in drinking or craving.…”

Multiple Psychiatric Morbidity and Continued Use of Naltrexone for Alcohol Use Disorder

“…25,26 This has led to implementation facilitation initiatives focusing on educating patients and providers about medications for the treatment of AUD. 25,[27][28][29] Several methodological limitations require comment. First, this is an observational study based on administrative data and thus we did not test causal hypotheses of factors that facilitate or encourage use of naltrexone.…”