Transcript Document

Management of alcohol use disorders (AUDs) among TB patients
in Tomsk, Russia
S. Shin1,2, D. Taran3, S. Yanov4, R. Mazitov3, A. Golubkov1, T. Mathew5, S. Mishustin6
In Health, Boston, MA, USA; 2Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA; 3Partners In Health, Moscow Oblast, Russian Federation; 4Tomsk Oblast Clinical TB
Hospital, Tomsk Oblast, Russian Federation; 5Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS, USA; 6Tomsk Oblast TB Services, Tomsk Oblast, Russian Federation
1Partners
Introduction
Figure 1. Tomsk Oblast in Western Siberia
• Up to 62% of TB patients in Russia may have concomitant
alcohol use disorders (AUDs).1-2
• AUDs are associated with poor TB treatment outcomes.3-4
• In the Former Soviet Union, AUDs pose a substantial barrier to
TB care because of high rates and limited resources to diagnose
and treat addictions.5
• We started a project to integrate alcohol diagnosis and care into
TB services in Tomsk.
Project Goal:
To increase the effectiveness of the treatment of TB patients in Tomsk by
lowering negative consequences due to alcohol use.
Map accessed at http://www.geog.uu.nl/fg/casus/Welcome.html on October 24, 2007.
Program Activities
The Standard Drinks Card was developed as a
useful “pocket reference” for TB physicians, who
reported that visual cues made it easier for
patients to estimate the type and volume of alcohol
typically consumed. The card also functions to
facilitate calculation by physicians of the equivalent
standard portion of alcohol (Figure 2).
Starting in October of 2005, we implemented a brief instrument, the Alcohol
Use Disorders Identification Test
(AUDIT)6, for universal screening of
AUDs.
Figure Алкоголя
2. Standard
Drinks
CardDrinks Card
Стандартная Порция
(СПА)
Standard
In early 2006, a TB/Alcohol Subprogram
was established within a grant from
the Global Fund to Fight AIDS
Tuberculosis, and Malaria.
Cognac / КОНЬЯК
Whiskey ,Gin / ВИСКИ, ДЖИН
Beer / ПИВО
Wine / ВИНО
12% 750 мл
= 7,3 СПА
4% 1000 мл
= 3 СПА
• Several psychologists and addictions
4% 500 мл
= 1,5 СПА
Vodka / ВОДКА
Samogon
4% 330 мл
= 1 СПА
5% 330 мл
= 1,3 СПА
Liqueur, Port/Sherry Wine
/Ликёры, Наливки, Портвейн
40% 500 мл
= 16 СПА
14% 750 мл
= 8,3 СПА
40% 100 мл
= 3,2 СПА
TINCTURE, EAU-DE-COLOGNE
/Настойки , Одеколоны
Surrogate Spirits, Technical Spirits
/ Технические Жидкости
specialists were hired.
• Referral procedures were established.
• New evidence-based treatment options were introduced (i.e. psycho- and pharmacotherapy as well as self-help guides, social support, and referral to AA groups).
40% 700 мл
= 22 СПА
40% 30 мл
= 1 СПА
90% 700 мл
= 50 СПА
20% (25%) 100 мл
= 1,6 (2) СПА
• Close monitoring of all activities was enhanced.
62% 100 мл
= 5 СПА
90% 500 мл
= 35,6 СПА
90% 200 мл (стакан)
= 14 СПА
TOTBS/PIH
Figure 3. Trends in AUDIT screening and successful referral of individuals with AUDs
to addictions specialists and/or psychologist alcohol use disorders, by treatment site
Results
From October, 2005 through May 31, 2007:
• 1077 of 2063 patients (52.5%) completed the AUDIT
questionnaire at initiation of TB treatment.
• 51.5% of patients tested had an AUDIT score > 8 (at risk), and
of these 23.1% had not been diagnosed with an alcohol
problem.
• Of the 612 patients with AUDIT > 8 and/or diagnosis of AUD,
38.1% were successfully referred to an addictions specialist.
90,0%
80,0%
70,0%
60,0%
50,0%
40,0%
30,0%
20,0%
10,0%
0,0%
• Referral rate increased with AUDIT score (p<0.0001). AUDIT
administration went from 61.9% to 53.1% over time (p=0.08)
while the rate of specialist referral remained stable (p=0.45).
C
H
A
L
L
E
N
G
E
S
2004
2005
2006
Screened by AUDIT, outpatient
Screened by AUDIT, inpatient
Successfully referred to specialists, among those with AUDs, outpatient
Successfully referred to specialists, among those with AUDs, inpatient
1. Recruitment of addictions specialists due to both fear of contracting TB and reduced financial compensation
compared to private practice.
• No official positions (stravka) available within TB Services for these specialists (psychologists, psychotherapists, or
social workers), leading to frequent staff turnover.
2. TB patients subsequently reluctant to receive treatment due to:
• The pre-contemplative state of patients and the stigma associated with narcologist care.
• The misconception that acknowledging active alcohol use during TB treatment will negatively impact care received.
3. Limited communication between AUD specialists, physicians, and patients.
• Strong supervision is needed to support referral to specialists and to set up interdisciplinary teams with patientoriented approaches.
• Alcoholic Anonymous groups are hard to establish within the official inpatient TB services (for BC ”-” patients).
Conclusions and Recommendations
We successfully implemented a program to manage AUDs in Siberian TB facilities.
• The AUDIT test could be implemented as part of standard Russian TB practice. Scores could be reported by primary care
providers, ideally through a prikaz (mandated programmatic policy).
• Official positions must be created for psychologists, social workers, and psychotherapists in Russian TB Services and
adequate compensation must be provided.
• Training is necessary for psychologists and addiction specialists to provide evidence-based, standardized interventions to
patients.
• Patient-directed group therapy and rehabilitation should be incorporated as recommended by other international programs
addressing similar patient populations7.
Literature Cited
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Acknowledgments: Charmaine S. Lastimoso, Hana Akselrod