Transcript Slide - Alcohol and Drug Abuse Institute

Screening and Brief Intervention for Alcohol Misuse in Primary Care:
What Comes After the Screening Validation Studies and RCT’s
CJ 556; 10/17/07
Dan Kivlahan, Ph.D.
[email protected]
VA Puget Sound & University of Washington
VA Motto:
Lincoln’s 2nd Inaugural
March 4, 1865
“With malice toward none, with charity for all,
with firmness in the right
as God gives us to see the right,
let us strive on to finish the work we are in,
to bind up the nation’s wounds,
to care for him [sic] who shall have borne the battle
and for his [sic] widow, and his [sic] orphan,
to do all which may achieve and cherish
a just and lasting peace among ourselves and with
all nations.”
Veterans Health Administration
- US largest integrated healthcare system
- >5M veterans served in FY07
- 157 medical centers
- 721 community-based outpatient clinics
- 21 regions
Infrastructure Advantages of VA
National systems for administrative data
Integrated electronic health record
VA Office of Quality and Performance
- Incentivized performance monitoring
- Evidence-based treatment guidelines
VA Health Services Research
- QUERI
Quality Enhancement Research
Initiative
QUERI Steps
Select patient populations
Identify E-B Guidelines/Recommendations
Assess Performance Gaps
Design/Implement Improvement Programs
Evaluate impact on clinical outcomes
Evaluate impact on health-related quality of life
Unique patients with SUD seen in
VA 2002-2006
Figure 1. Unique SUD Pateints in FY02 Through FY06
400,000
342,387
354,507
326,800
350,000
299,138
289,908
300,000
250,000
200,000
150,000
127,590
121,798
121,042
121,926
119,158
100,000
50,000
0
FY2002
FY2003
FY2004
Specialized
FY2005
Non Specialized
FY2006
Stages of Change in Substance Abuse &
Dependence: Intervention Strategies
UW/ABRC
Maintenance
Stage
Precontemplation
Stage
Contemplation
Stage
Preparation
Stage
Action
Stage
Relapse
Stage
Motivational
Enhancement
Strategies
Assessment
& Treatment
Matching
Relapse
Prevention
& Relapse
Management
Perceived Need for Treatment of
SUD: NSDUH 2006
Where Past Year Substance Use
Treatment Was Received: 2006
Goals of SUD QUERI
Improve detection and mgmt of alcohol misuse in
primary care
Improve retention of patients in continuing specialty
care for SUD
Implement effective smoking cessation treatment
Improve detection and mgmt of patients with SUDs
and SUD-related co-occurring disorders seen in
primary care and other medical settings
•
•
infectious disease (i.e., HIV, Hepatitis C)
psychiatric co-morbidity
The Spectrum of Alcohol Use
Alcohol Use
Disorders
Alcoholism
Dependence
Harmful, abuse
Problem
Risky
Lower risk
Abstinence
Unhealthy
alcohol use
What is Alcohol
Dependence?
3 or more of these criteria in
a 12-month period:
1. Tolerance
2. Withdrawal
3. More or longer consumption than intended
4. Cannot cut down or control alcohol use
5. A great deal of time getting, using, recovering
6. Activities given up or reduced
7. Use despite knowledge of health problem
APA, 1994.
Indicates impaired control
Preoccupation
Characteristics of 5 empirically-derived
AD subtypes in the U.S. population
(Moss et al. in press, Drug & Alc Dep)
What is Alcohol Misuse?

Drinking above NIAAA recommended limits
OR

Diagnosis of abuse or dependence

Together referred to as “alcohol misuse”
NIAAA recommended limits
(US standard drink ~ 14 g alcohol)

Men
> 14 drinks/week or
> 4 drinks/occasion

Women
> 7 drinks/week or
> 3 drinks/occasion
How to Detect Alcohol Misuse?


Biomarkers
Self-report
New Biomarkers of Excess Alcohol?






Carbohydrate-Deficient Transferrin (CDT)
Ethylglucuronide (EtG)
Transdermal devices
Composite index from blood serum panel
Hemoglobin Associated Acetaldehyde
Fatty Acid Ethyl Esters (in hair)
Limitations of biological assays



Cost and logistics
Invasiveness
Lack of sensitivity - timing
Self-Report Alcohol Misuse Screens


CAGE (4 items)
MAST (10-25 items)


Michigan Alcoholism Screening Test
AUDIT (10 items)

Alcohol Use Disorders Identification Test
The CAGE Questions
• Have you ever felt you should
Cut down on your drinking?
• Have people Annoyed you by
criticizing your drinking?
• Have you ever felt bad or Guilty
about your drinking?
• Have you ever taken a drink first thing
in the morning (Eye-opener) to steady
your nerves or get rid of a hangover?
Mayfield et al 1974
Alcohol Misuse Screening
Alcohol
CAGE
Questionnaire
Dependence
Problem
Drinking
Hazardous Drinking
Drinking within
Recommended Levels
AUDIT-C
 At-risk
Drinking
AUDIT-C
Never
One or less/month
1. How often did you have a drink
containing alcohol in the past
2-4 times/month
year?
2-3 times/week
> 4 times/week
0 drinks
2. On days in the past year when
1-2 drinks
you drank alcohol how many
3-4 drinks
drinks did you typically drink?
5-6 drinks
7-9 drinks
10 drinks
3. How often do you have 6 or more Never
drinks on an occasion in the past < monthly
year?
>Monthly
Weekly
Daily
Points
0
1
2
3
4
0
0
1
2
3
4
0
1
2
3
4
AUDIT-C Score: 0-12; > 4 positive for men; > 3 women
Do Patients Accurately Report Drinking?
Screening for Hazardous Drinking or
Alcohol Abuse or Dependence
ROC Curve
1.00
.75
CAGE Score (0.73)
Source of the Curve
AUDIT-C (0.88)
.50
Ref erence Line
AUDIT Q#3 (0.84)
.25
CAGESCOR
AUDSCR3
0.00
Six or more
0.00
.25
1 - Specificity
.50
.75
1.00
AUDIT-C Score Reflects Risk
+ Likelihood Ratio Risky Drinking OR Active Alcohol
Abuse or Dependence (95% CI)
Men ___
Women_____
AUDIT-C > 4
AUDIT-C > 5
AUDIT-C > 6
AUDIT-C > 7
AUDIT-C > 8
3.1 (2.3 - 4.1)
>2
7.0 (4.1-11.6)
>3
9.5 (4.7-19.0)
>4
21.5 (6.9 - 67.1)
26.5 (6.5 -107.3)
5.9 (4.3 - 7.9)
13.9 (8.0 - 24.4)
23.2 (9.4 - 57.6)
Bush et al Arch Intern Med 1998
Bradley et al Arch Intern Med 2003
AUDIT-C Summary
Score reflects severity and readiness to
change

Score may not accurately measure alcohol
exposure (marker vs. measure)

Can be used to risk-stratify for:


Brief alcohol counseling

Specialty care referral
Why Screen for Alcohol Misuse?



Risk for adverse health outcomes (multiple
studies; meta-analyses)
Indication for brief alcohol counseling (BAC)
that reduces alcohol consumption
2006 National Commission on Prevention
Priorities identified BAC among top 10
prevention activities
Risk for adverse health outcomes
Chronic heavy alcohol use
Liver disease 2 drinks/day (m)
Hypertension 3 drinks/day (m/w)
Stroke 4 drinks/day (m/w)
Mortality 4 drinks/day (m)
Episodic heavy drinking
Injury
5 drinks/occasion (m)
STDs
4 drinks/occasion (w)
Why Screen for Alcohol Misuse?



Risk for adverse health outcomes (multiple
studies; meta-analyses)
Indication for brief alcohol counseling (BAC)
that reduces drinking risk
2006 National Commission on Prevention
Priorities identified BAC among top 10
prevention activities
Authors' conclusions
•
28 controlled trials from various countries
– general practice (23 trials) or an emergency setting (5 trials).
•
At trial entry, participants drank an average of 320 grams/week
– over 30 standard European drinks
•
•
•
•
•
N> 7000 randomized to receive a brief intervention (BI) or a control
intervention, including assessment only.
At one year's follow up (17 trials), people who had received the BI
drank less alcohol (mean difference of 41 grams).
For men, the benefit of brief intervention was a reduction of 57
grams/week (range 25 to 89 grams).
The benefit was not clear for women.
Longer duration of counseling probably has little additional effect.
Why Screen for Alcohol Misuse?



Risk for adverse health outcomes (multiple
studies; meta-analyses)
Indication for brief alcohol counseling (BAC)
that reduces drinking risk
2006 National Commission on Prevention
Priorities identified BAC among top 10
prevention activities
Priorities among Clinical Prevention
Services (Maciosek et al, Am J Prev Med 2006)
Service
 Aspirin chemoprophylaxis
 Childhood immunization series
 Tobacco screening and
Brief Int.
 Colorectal concern screening
 Hypertension screening
 Influenza immunization
 Pneumocacal immunization
 Alcohol misuse Screening
& Brief Intervention (SBI)
 Vision screening
 Cervical cancer screening
 Cholesterol screening
 Breast cancer screening
CPB (Quintile)
5
5
5
CE (Quintile)
5
5
5
4
5
4
3
4
4
3
4
5
4
3
4
5
4
5
3
2
2
CPB: Clinically Preventable Burden. CE: Cost Effectiveness.
Benefits of Brief Alcohol Counseling
 2007 Cochrane review and 9 other metaanalyses have demonstrated efficacy

especially in men
 One of the top 10 US prevention priorities
 US: NNT 7-9 to move one patient from risky
to non-risky drinking
 After 4 years, for every $1.00 spent on brief
alcohol counseling, $4.30 saved on inpatient
and emergency care
Kaner, Cochrane, 2007; Fleming, JAMA, 1997; Fleming, ACER, 2002;
M. Maciosek Am J Prev Health 2006
Helping Patients Who Drink
Too Much: 5 A’s
• ASK about alcohol use
• ASSESS severity and readiness to
change
• ADVISE cutting down or abstinence,
and assist in goal setting
• ASSIST with further treatment when
necessary
• ARRANGE follow-up to monitor
progress
Five General Principles
UW/ABRC
 Express Empathy
 Develop Discrepancy
 Avoid Argumentation
 Roll with Resistance
 Support Self-Efficacy
PRINCIPLES OF MOTIVATIONAL
INTERVIEWING
•
•
•
•
•
•
Respect client autonomy, culture and choices.
Acknowledge client as the active decision maker.
Negotiate an agenda for change.
Offer information in a neutral, non-personal manner.
Ask open-ended questions.
Practice reflective listening to encourage patients to
talk about their drinking and the barriers to change.
• Accept resistance as a normal response.
• Avoid confrontation, labeling, stereotyping and forcing
patients to accept a label or diagnosis.
Demystifying Motivational
Interviewing for SUD
• “So this weekend I went into a store to buy
some paint…The fellow at the
counter…saw ‘CASAA’ on my shirt and
asked what it is. I told him it’s an addiction
treatment research center…he said, ‘I help
people with that problem sometimes.’
• “Really? What do you do?”
Bill Miller e-mail to MI Network of Trainers 3/29/05
Demystifying Motivational
Interviewing for SUD
• “I just talk to them… I just do volunteer
counseling. I help them see that they have a
choice. We lay out the two sides – what
happens if they continue on as they are, and
what else they could do. And then I ask
them which way they want to go. I don’t tell
them what to do. It has to come from them.
That’s what I do, and it just seems to help.”
• He had a 6th grade education
Bill Miller e-mail to MI Network of Trainers 3/29/05
Promoting Action on Research Implementation
in Health Services (PARIHS)
2 “Simple” Principles of Facilitation
Feedback on local performance
•
•
•
carefully defined
accurately measured
ongoing
Accessible supervision or “coaching” from
someone with more expertise about
improvement
Miller, Sorensen, Selzer, Brigham. JSAT, 2006;21:25-39
How to Measure Performance for
Brief Alcohol Counseling ?




No established performance measures
No health care system has implemented
brief alcohol counseling effectively
VA is leader in routine alcohol screening
WHO study to implement brief alcohol
counseling found rates so low, 10%
considered “excellent”
Data Sources for BAC Performance Measure:
Limits and Feasibility
Self-reported Alcohol-related Advice
If Screen+ for Alcohol Misuse
Developing a Brief Alcohol
Counseling Performance Measure


Evidence is strongest in non-dependent
alcohol misuse, but recommended for all
alcohol misuse – need to risk-stratify
Key components of BAC:



Advice: abstain or decrease drinking below limits
Feedback linking drinking to health
Completed specialty referral also acceptable
follow-up of screening results
A Measure of Brief Alcohol Counseling
Based on Medical Record Review
Scores of 5-7 (moderate risk)


Most patients NOT alcohol dependent
However, history of alcohol treatment increases risk
Empathetic,
Patient-centered Tone…
“I’m concerned that
your drinking might be
harming your health”
Empathetic Tone
“I’m concerned that
your drinking might be
harming your health”
Advice to Abstain
“It would be best for your
health if you did not
drink alcohol at all” OR…
Empathetic Tone
“I am concerned that
your drinking might be
harming your health”
Advice to abstain
Feedback linking
drinking and health
“I’m concerned that your
drinking might be raising
your blood pressure
and worsening your
depression…”
Empathetic Tone
“Your alcohol screening
results indicate you‘re
drinking at a level that
could harm your health.”
Advice to cut down
“I recommend
you cut down to
no more than …”
(see recommended
gender-specific
limits at upper left)
Optional
document
patient response
Optional
• Assess in more detail
• Referral
AUDIT-C Scores 8-12 (severe risk)
 Higher risk of dependence
 Increased risk of GI hospitalizations*
mortality** and other co-morbidity
* D. Au et a. Alc Clin Exper Res 2007
**K. Bradley et al. J Stud Alc 2001
Many patients with
AUDIT-C 8-12
have dependence
Consider referral
Alcohol Counseling Clinical Reminder
80%
70%
60%
50%
AUDIT-C 5-7
AUDIT-C 8-12
40%
30%
20%
10%
0%
June
Aug
2004
Oct
Dec
Feb
April June
2005
Aug
Oct
Dec
Feb
April
2006
Summary


Implemented screening for alcohol misuse
Need appropriate follow-up




Clinical reminder improves documented BAC



Brief alcohol counseling or completed referral
Higher than other health care systems, but much
room for improvement
Developed new performance measure
Increased documented counseling: 55-70%
Especially increased rates in mild/moderate
abuse who might benefit most
What about reduced risk?
If you cannot measure it, you cannot improve it.
“If you can measure that of which you speak
and express it in numbers,
you know something about your subject;
but if you cannot measure it,
your knowledge is of a very meager and
unsatisfactory kind.” (1883)
William Thomson (Lord Kelvin) (1824-1907).
Research Team
Kathy Bradley, MD
Carol Achtmeyer, ARNP
Anna DeBenedetti, BA
Gwen Greiner, MPH
Eric Hawkins, PhD
Emily Williams, MPH
Funding from
• CESATE
• VA HSR&D
• NIAAA R21AA14672
BAC & MI Web Resources
Brief alcohol counseling
4 minute Boston University demo video (Case 3 at:
http://www.bu.edu/act/mdalcoholtraining/cases.html
NIAAA Clinicians Guide – updated 2007
http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clin
icians_guide.htm
Motivational Interviewing
8 training videotapes:
http://www.motivationalinterview.org/training/videos.html
NIDA trainings including MI:
http://mia.nattc.org/aboutUs/blendingInitiative/products2.htm#
mi
References
Biomarkers pf Alcohol Misuse
Bean, P. Update on new biomarkers for detecting excessive alcohol use. AlcoholMD.com. November 2002. Available at:
http://www.alcoholmd.com/pro/courses/biomarkers_of_alcohol_abuse.asp
Wolff, K, Farrell, M, Marsden, J: A review of biological indicators of illicit drug use: Practical considerations and clinical usefulness. Addiction, 94:1279-98, 1999
Screening Validity of AUDIT and AUDIT-C
Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro M. AUDIT - The Alcohol Use Disorders Identification Test: Guidelines for use in primary health care. World Health
Organization, 2001 http://www.who.int/substance_abuse/PDFfiles/auditbro.pdf
Bradley, K.A., Bush, K., Epler, A., Dobie, D., Davis, T., Sporleder, J., Maynard, C., Burman, M. & Kivlahan, D. (2003). Two brief alcohol screening tests from the Alcohol Use
Disorders Identification Test (AUDIT): Validation in a female VA patient population, Arch Int Med, 163, 821-829
Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA: The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Arch
Intern Med 158:1789-1795, 1998
Association of AUDIT-C and Health Outcomes
Au DH, et al. Alcohol Screening Scores and Risk of Hospitalizations for GI Conditions in Men. Alcoholism, clinical and experimental research 2007;31:443-451
Bradley KA, et al. The relationship between alcohol screening questionnaires and mortality among male veteran outpatients. J Stud Alcohol 2001;62:826-833
Bradley, KA, et al. (2004). "Using alcohol screening results and treatment history to assess the severity of at-risk drinking in VA primary care patients." Alcohol Clin Exp Res
28(3): 448-455.
Reviews on BI/BAC
Kaner E, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev 2007:CD004148 (Nice Cochrane review of brief alcohol
counseling.)
Maciosek MV, et al. Priorities among effective clinical preventive services results of a systematic review and analysis. Am J Prev Med 2006;31:52-61 (Established brief alcohol
counseling one of top 10 US prevention priorities)
NIAAA Clinicians Guide – updated 2007 (Includes DSM criteria for alcohol use disorders and review of medications for alcohol dependence.)
http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm
Whitlock EP, et al. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: A summary of the evidence for the U.S. Preventive Services
Task Force. Ann Intern Med 2004;140:557-568 (Nice USPSTF review of evidence for brief alcohol counseling)
Important RCT
Fleming MF. Letters: Brief physician advice for problem alcohol drinkers. JAMA 1997;278:1059-1060. Economic analyses: Brief physician advice for problem drinkers: long-term
efficacy and benefit-cost analysis. Alcoholism, clinical and experimental research 2002;26:36-43
Implementation and Performance Measurement
Greenhalgh, T., et al., (2004). Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 82(4):581-629
Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care 1998;7:149–58
Miller WR, Sorensen JL, Selzer JA, Brigham GS. Disseminating evidence-based practices in substance abuse treatment: a review with suggestions. J. Subst
Abuse Treat. 2006 31, 25-39.
Pincus, H., et al. (2007). Can psychiatry cross the quality chasm? Improving the quality of health care for mental and substance use conditions. Am J
Psychiatry,164(5):712-9.
VA Quality Enhancement Research Initiative (QUERI) http://www.hsrd.research.va.gov/queri
Tisnado DM, Adams JL, Liu H, Damberg CL, Chen WP, Hu FA, Carlisle DM, Mangione CM, Kahn KL.What is the concordance between the medical record and patient selfreport as data sources for ambulatory care? Med Care. 2006 Feb;44(2):132-40.
Contact information
Daniel Kivlahan, PhD
Director, CESATE
Clinical Coordinator, SUD QUERI
VA Puget Sound Health Care System
Phone: 206-768-5483
E-Mail: [email protected]
Appendix
The Clients Perspective