Screening and Brief Intervention for Alcohol Misuse in Primary Care:

1. 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. daniel.kivlahan@va.gov VA Puget Sound & University of Washington

3. 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 battleand for his [sic] widow, and his [sic] orphan,to do all which may achieve and cherisha just and lasting peace among ourselves and with all nations.”

4. Veterans Health Administration • - US largest integrated healthcare system • - >5M veterans served in FY07 • - 157 medical centers • - 721 community-based outpatient clinics • - 21 regions

5. 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

6. Quality Enhancement Research Initiative

7. 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

8. Unique patients with SUD seen in VA 2002-2006

9. Stages of Change in Substance Abuse & Dependence: Intervention Strategies

10. Perceived Need for Treatment of SUD: NSDUH 2006

11. Where Past Year Substance Use Treatment Was Received: 2006

12. 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

13. The Spectrum of Alcohol Use heavy Alcohol Use Disorders Unhealthy alcohol use severe Alcoholism Dependence Harmful, abuse Problem consumption consequences Risky Lower risk Abstinence none none

14. 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 Indicates impaired control Preoccupation APA, 1994.

15. Characteristics of 5 empirically-derived AD subtypes in the U.S. population(Moss et al. in press, Drug & Alc Dep)

16. What is Alcohol Misuse? • Drinking above NIAAA recommended limits OR • Diagnosis of abuse or dependence • Together referred to as “alcohol misuse”

17. 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

18. How to Detect Alcohol Misuse? • Biomarkers • Self-report

19. 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)

20. Limitations of biological assays • Cost and logistics • Invasiveness • Lack of sensitivity - timing

21. Self-Report Alcohol Misuse Screens • CAGE (4 items) • MAST (10-25 items) • Michigan Alcoholism Screening Test • AUDIT (10 items) • Alcohol Use Disorders Identification Test

22. 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 Guiltyabout 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

23. AlcoholDependence CAGE Questionnaire Problem Drinking HazardousDrinking Drinking within Recommended Levels Alcohol Misuse Screening AUDIT-C  At-risk Drinking

24. Points Never 0 One or less/month 1 2-4 times/month 2 2-3 times/week 3 > 4 times/week 4 0 drinks 0 1-2 drinks 0 3-4 drinks 1 5-6 drinks 2 7-9 drinks 3 10 drinks 4 Never 0 < monthly 1 >Monthly 2 Weekly 3 Daily 4 AUDIT-C • How often did you have a drink containing alcohol in the past year? • 2. On days in the past year when you drank alcohol how many drinks did you typically drink? • 3. How often do you have 6 or more drinks on an occasion in the past year? • AUDIT-C Score: 0-12; > 4 positive for men; > 3 women • 0

25. Do Patients Accurately Report Drinking?

28. Screening for Hazardous Drinking orAlcohol Abuse or Dependence CAGE Score (0.73) AUDIT-C (0.88) AUDIT Q#3 (0.84)

29. AUDIT-C Score Reflects Risk + Likelihood Ratio Risky Drinking OR Active Alcohol Abuse or Dependence (95% CI) Men ___ Women_____ AUDIT-C > 4 3.1 (2.3 - 4.1) > 2 5.9 (4.3 - 7.9) AUDIT-C > 5 7.0 (4.1-11.6) > 3 13.9 (8.0 - 24.4) AUDIT-C > 6 9.5 (4.7-19.0) > 4 23.2 (9.4 - 57.6) AUDIT-C > 7 21.5 (6.9 - 67.1) AUDIT-C > 8 26.5 (6.5 -107.3) Bush et al Arch Intern Med 1998 Bradley et al Arch Intern Med 2003

30. 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 AUDIT-C Summary

31. 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

32. 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)

33. 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

35. 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.

37. 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

38. 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) CE (Quintile) 5 5 5 5 5 5 4 4 5 3 4 4 3 5 4 4 3 5 4 3 5 2 4 2 Priorities among Clinical Prevention Services (Maciosek et al, Am J Prev Med 2006) CPB: Clinically Preventable Burden. CE: Cost Effectiveness.

39. 2007 Cochrane review and 9 other meta-analyses 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 Benefits of Brief Alcohol Counseling Kaner, Cochrane, 2007; Fleming, JAMA, 1997; Fleming, ACER, 2002; M. Maciosek Am J Prev Health 2006

44. 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

45. Five General Principles Express Empathy Develop Discrepancy Avoid Argumentation Roll with Resistance Support Self-Efficacy Motivational Interviewing

46. 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.

47. 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

48. 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

50. Promoting Action on Research Implementation in Health Services (PARIHS)