From screening into treatment:From screening into treatment: Implementation solutions for Implementation solutions for

Alcoholism therapyAlcoholism therapy

Thomas R. Kosten MDThomas R. Kosten MD

JH Waggoner Chair and Professor of Psychiatry & NeuroscienceJH Waggoner Chair and Professor of Psychiatry & Neuroscience

Baylor College of MedicineBaylor College of Medicine

Research CoordinatorResearch Coordinator

VA Substance Use Disorders QUERIVA Substance Use Disorders QUERI

Purpose of this ProgramPurpose of this Program

To compare barriers and benefits in PCC for To compare barriers and benefits in PCC for treating problem drinking using Brief treating problem drinking using Brief Interventions (BI) and for treating alcoholism Interventions (BI) and for treating alcoholism using naltrexone (NTX). using naltrexone (NTX).

To compare VISNs and facilities in providing BI To compare VISNs and facilities in providing BI and NTX using 3 care models: TIDES, and NTX using 3 care models: TIDES, Behavioral Health Laboratory (BHL), and the Behavioral Health Laboratory (BHL), and the PCC providers themselves. PCC providers themselves.

Outline of PresentationsOutline of Presentations

Kosten: introduce BI and NTX for alcohol use disorders (AUD). Kosten: introduce BI and NTX for alcohol use disorders (AUD).

Harris (PERC): very limited use of NTX for AUD in VA. Harris (PERC): very limited use of NTX for AUD in VA.

Bradley: EPRP chart reviews of AUD treatment in PCC. Bradley: EPRP chart reviews of AUD treatment in PCC.

Oslin: BHL outcomes in providing BI and NTX for AUD in PCC. Oslin: BHL outcomes in providing BI and NTX for AUD in PCC.

Kirchner: implementing TIDES for AUD treatment in PCCKirchner: implementing TIDES for AUD treatment in PCC

Daily: 2 year implementation of TIDES for treating AUD in PCC Daily: 2 year implementation of TIDES for treating AUD in PCC across VISN 16 across VISN 16

Stopping drinking is easy,Stopping drinking is easy,I’ve done it hundreds of timesI’ve done it hundreds of times

Mark TwainMark Twain

Alcohol Screening on AUDIT-C: Alcohol Screening on AUDIT-C: Q3 FY06 by VISNQ3 FY06 by VISN ( (…. …. Target)Target)

Rates of Provider Advice (B.I.)Rates of Provider Advice (B.I.)

Patient Survey (n=14,000 screen+) Patient Survey (n=14,000 screen+)

““In the past year did a VA provider advise you to In the past year did a VA provider advise you to decrease drinking or not drink?”decrease drinking or not drink?”

National Mean=28% (VISN range = 20-36%)National Mean=28% (VISN range = 20-36%)

Thus: Brief Interventions (BI) done Thus: Brief Interventions (BI) done UncommonlyUncommonly

Alcohol Withdrawal SyndromeAlcohol Withdrawal Syndrome

Signs: tremor, blood pressure and pulse Signs: tremor, blood pressure and pulse elevated, adrenergic arousalelevated, adrenergic arousal

Symptoms: agitation, anxiety, hallucinationsSymptoms: agitation, anxiety, hallucinations

Peak at 3 days, Last 7-10 days Peak at 3 days, Last 7-10 days

Seizures: Delirium Tremens: fatal complicationSeizures: Delirium Tremens: fatal complication

Are medications needed for detox treatment?Are medications needed for detox treatment?

Obtain breath alcohol level – withdrawal occurs as Obtain breath alcohol level – withdrawal occurs as level falls and usually not above 100-150 mg%level falls and usually not above 100-150 mg%

Assess level of withdrawal symptoms (CIWA)Assess level of withdrawal symptoms (CIWA)

Level of care needed: inpatient, medical setting, Level of care needed: inpatient, medical setting, duration, medical complications, support?duration, medical complications, support?

Types of medicationsTypes of medications

Setting & support needed for medical safety & Setting & support needed for medical safety & adherenceadherence

Behavioral interventions during Behavioral interventions during withdrawal treatment: Motivational Interventionswithdrawal treatment: Motivational Interventions

Brief Motivational Interventions CourseBrief Motivational Interventions Course – INTRAnet: INTRAnet: www.bmiforsuv.orgwww.bmiforsuv.org

Over 750 VA staff in Primary Care completed course Over 750 VA staff in Primary Care completed course

Four course modules: Four course modules: – Background, MI Basics, Assessment, FeedbackBackground, MI Basics, Assessment, Feedback

Four separate shorter modules available by Dec 15th.Four separate shorter modules available by Dec 15th.

Can medications reduce alcohol relapse? YES!Can medications reduce alcohol relapse? YES!

Naltrexone – opiate antagonist taken orally or by Naltrexone – opiate antagonist taken orally or by once monthly injection (Vivatrol)once monthly injection (Vivatrol)

Over 25 studies showing clinical and cost efficacy Over 25 studies showing clinical and cost efficacy over placebo in preventing relapseover placebo in preventing relapse

Pharmacogenetic selection of best candidates Pharmacogenetic selection of best candidates (family HX good surrogate)(family HX good surrogate)

Other medications – acamprosate, disulfiram, Other medications – acamprosate, disulfiram, topiramate, carbamazepine, also combinationstopiramate, carbamazepine, also combinations

Most effective, if abstinent at medication startMost effective, if abstinent at medication start

Days

8470564228140

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.1

0.0

Naltrexone /Asp40 Allele (A/G, G/G)

Naltrexone Asn40 Allele (A/A)

Placebo /Asp40 Allele (A/G, G/G)

Placebo /Asn40 Allele (A/Al)

Days

8470564228140

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.1

0.0

Naltrexone /Asp40 Allele (A/G, G/G)

Naltrexone Asn40 Allele (A/A)

Placebo /Asp40 Allele (A/G, G/G)

Placebo /Asn40 Allele (A/Al)

Days

8470564228140

1.0.9

.8

.7

.6

.5

.4

.3

.2

.1

0.0

Naltrexone- mutantOpiate receptor

Placebo Asp40 Allele (A/G, G/G)

P laceboAsn40 Allele (A/Al)

No

n-r

elap

sed

Naltrexone and Relapse Rate by Mu Opiate Naltrexone and Relapse Rate by Mu Opiate Receptor GenotypeReceptor Genotype

“Perhaps it would help if I go over it one more time.”