Screening and Brief Intervention for Alcohol Misuse in Primary Care:

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 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.”

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

127,590121,042 121,798

119,158

121,926

354,507342,387

326,800

299,138

289,908

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

FY2002 FY2003 FY2004 FY2005 FY2006

Specialized Non Specialized

UW/ABRC

Precontemplation Stage

Contemplation Stage

Preparation Stage

Action Stage

Maintenance Stage

Relapse Stage

Motivational Enhancement

Strategies Assessment & Treatment

Matching

Relapse Prevention & Relapse

Management

Stages of Change in Substance Abuse & Dependence: Intervention

Strategies

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 UseThe Spectrum of Alcohol Use

heav

y severe

cons

umpt

ion

none

none

consequences

Risky

Lower risk

Alcohol Use Disorders

Alcohol Use Disorders

Abstinence

Harmful, abuse

Problem

AlcoholismDependence

Unhealthy alcohol use

Unhealthy alcohol use

Indicates impaired controlPreoccupation

What is Alcohol Dependence?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.

Characteristics of 5 empirically-derived AD subtypes in the U.S. population

(Moss et al. in press, Drug & Alc Dep)

What is Alcohol Misuse?What is Alcohol Misuse?

Drinking above NIAAA recommended Drinking above NIAAA recommended limitslimits

OR OR Diagnosis of abuse or dependenceDiagnosis of abuse or dependence

Together referred to as “alcohol Together referred to as “alcohol misuse”misuse”

NIAAA recommended limits NIAAA recommended limits (US standard drink ~ 14 g alcohol)(US standard drink ~ 14 g alcohol)

Men Men > 14 drinks/week or > 14 drinks/week or

> 4 drinks/occasion> 4 drinks/occasion

Women Women > 7 drinks/week or> 7 drinks/week or

> > 3 drinks/occasion3 drinks/occasion

How to Detect Alcohol How to Detect Alcohol Misuse?Misuse?

BiomarkersBiomarkers Self-reportSelf-report

New Biomarkers of Excess New Biomarkers of Excess AlcoholAlcohol??

Carbohydrate-Deficient Transferrin (CDT)Carbohydrate-Deficient Transferrin (CDT) Ethylglucuronide (EtG)Ethylglucuronide (EtG) Transdermal devicesTransdermal devices Composite index from blood serum panelComposite index from blood serum panel Hemoglobin Associated AcetaldehydeHemoglobin Associated Acetaldehyde Fatty Acid Ethyl Esters (in hair)Fatty Acid Ethyl Esters (in hair)

Limitations of biological Limitations of biological assaysassays

Cost and logisticsCost and logistics InvasivenessInvasiveness Lack of sensitivity - timingLack of sensitivity - timing

Self-Report Alcohol Misuse Self-Report Alcohol Misuse ScreensScreens

CAGE (4 items)CAGE (4 items) MAST (10-25 items) MAST (10-25 items)

Michigan Alcoholism Screening TestMichigan Alcoholism Screening Test AUDIT (10 items) AUDIT (10 items)

Alcohol Use Disorders Identification TestAlcohol Use Disorders Identification Test

The CAGE QuestionsThe 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 ScreeningAlcohol Misuse Screening

Drinking within Recommended Levels

Hazardous Drinking

Problem Drinking

Alcohol Dependence

AUDIT-C At-risk Drinking

CAGEQuestionnaire

AUDIT-CAUDIT-C PointsPoints

NeverNever 00One or less/month One or less/month 112-4 times/month2-4 times/month 222-3 times/week 2-3 times/week 33> 4 times/week> 4 times/week 440 drinks0 drinks 001-2 drinks1-2 drinks 003-4 drinks3-4 drinks 115-6 drinks5-6 drinks 227-9 drinks7-9 drinks 3310 drinks10 drinks 44Never Never 00< monthly< monthly 11>Monthly>Monthly 22WeeklyWeekly 33Daily Daily 44

1. 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 women0

Do Patients Accurately Report Drinking?

Screening for Hazardous Drinking or Alcohol Abuse or Dependence

CAGE Score (0.73)

AUDIT-C (0.88)

AUDIT Q#3 (0.84)

AUDIT-C Score Reflects RiskAUDIT-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 1998Bradley et al Arch Intern Med 2003

AUDIT-C SummaryAUDIT-C Summary

Score reflects severity and readiness Score reflects severity and readiness to changeto change

Score may not accurately measure Score may not accurately measure alcohol alcohol exposureexposure (marker vs. (marker vs. measure)measure)

Can be used to risk-stratify for:Can be used to risk-stratify for: Brief alcohol counselingBrief alcohol counseling

Specialty care referralSpecialty care referral

Why Screen for Alcohol Why Screen for Alcohol Misuse?Misuse?

Risk for adverse health outcomes Risk for adverse health outcomes (multiple studies; meta-analyses)(multiple studies; meta-analyses)

Indication for brief alcohol counseling Indication for brief alcohol counseling (BAC) that reduces alcohol (BAC) that reduces alcohol consumptionconsumption

2006 National Commission on 2006 National Commission on Prevention Priorities identified BAC Prevention Priorities identified BAC among top 10 prevention activitiesamong top 10 prevention activities

Risk for adverse health Risk for adverse health outcomesoutcomes

Chronic heavy alcohol useChronic heavy alcohol use

Liver diseaseLiver disease 2 drinks/day (m)2 drinks/day (m)

Hypertension Hypertension 3 drinks/day (m/w)3 drinks/day (m/w)

Stroke Stroke 4 drinks/day (m/w)4 drinks/day (m/w)

MortalityMortality 4 drinks/day (m)4 drinks/day (m)

Episodic heavy drinkingEpisodic heavy drinking

InjuryInjury 5 drinks/occasion (m)5 drinks/occasion (m)

STDsSTDs4 drinks/occasion (w)4 drinks/occasion (w)

Why Screen for Alcohol Why Screen for Alcohol Misuse?Misuse?

Risk for adverse health outcomes Risk for adverse health outcomes (multiple studies; meta-analyses)(multiple studies; meta-analyses)

Indication for brief alcohol counseling Indication for brief alcohol counseling (BAC) that reduces drinking risk(BAC) that reduces drinking risk

2006 National Commission on 2006 National Commission on Prevention Priorities identified BAC Prevention Priorities identified BAC among top 10 prevention activitiesamong 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 Why Screen for Alcohol Misuse?Misuse?

Risk for adverse health outcomes Risk for adverse health outcomes (multiple studies; meta-analyses)(multiple studies; meta-analyses)

Indication for brief alcohol counseling Indication for brief alcohol counseling (BAC) that reduces drinking risk(BAC) that reduces drinking risk

2006 National Commission on 2006 National Commission on Prevention Priorities identified BAC Prevention Priorities identified BAC among top 10 prevention activities among top 10 prevention activities

Priorities among Clinical Priorities among Clinical Prevention Services Prevention Services (Maciosek et al, (Maciosek et al,

Am J Prev Med 2006)Am J Prev Med 2006)ServiceService Aspirin chemoprophylaxisAspirin chemoprophylaxis Childhood immunization seriesChildhood immunization series Tobacco screening and Brief Tobacco screening and Brief

Int.Int. Colorectal concern screeningColorectal concern screening Hypertension screeningHypertension screening Influenza immunizationInfluenza immunization Pneumocacal immunizationPneumocacal immunization Alcohol misuse Screening & Alcohol misuse Screening &

Brief Intervention (SBI)Brief Intervention (SBI) Vision screeningVision screening Cervical cancer screeningCervical cancer screening Cholesterol screeningCholesterol screening Breast cancer screeningBreast cancer screening

CPB (Quintile)CPB (Quintile) CE (Quintile)CE (Quintile) 55 5 5 55 5 5 55 5 5

44 4 4 55 3 3 44 4 4 33 5 5 44 4 4

33 5 5 44 3 3 55 2 2 44 2 2

CPB: Clinically Preventable Burden. CE: Cost Effectiveness.

Benefits of Brief Alcohol Benefits of Brief Alcohol CounselingCounseling

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

Kaner, Cochrane, 2007; Fleming, JAMA, 1997; Fleming, ACER, 2002; M. Maciosek Am J Prev Health 2006

Helping Patients Who Drink Too Much: 5 A’sHelping 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

UW/ABRC

Five General Principles

Express Empathy

Develop Discrepancy

Avoid Argumentation

Roll with Resistance

Support Self-Efficacy

PRINCIPLES OF MOTIVATIONAL PRINCIPLES OF MOTIVATIONAL INTERVIEWINGINTERVIEWING

• Respect client autonomy, culture and choices.Respect client autonomy, culture and choices.• Acknowledge client as the active decision maker. Acknowledge client as the active decision maker. • Negotiate an agenda for change.Negotiate an agenda for change.• Offer information in a neutral, non-personal manner.Offer information in a neutral, non-personal manner.• Ask open-ended questions.Ask open-ended questions.• Practice reflective listening to encourage patients to Practice reflective listening to encourage patients to

talk about their drinking and the barriers to change. talk about their drinking and the barriers to change. • Accept resistance as a normal response.Accept resistance as a normal response.• Avoid confrontation, labeling, stereotyping and forcing Avoid confrontation, labeling, stereotyping and forcing

patients to accept a label or diagnosis.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 How to Measure Performance for Brief Alcohol Counseling ?for Brief Alcohol Counseling ?

No established performance measures No established performance measures No health care system has implemented No health care system has implemented

brief alcohol counseling effectivelybrief alcohol counseling effectively VA is leader in routine alcohol screening VA is leader in routine alcohol screening WHO study to implement brief alcohol WHO study to implement brief alcohol

counseling found rates so low, 10% counseling found rates so low, 10% considered “excellent” 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 Developing a Brief Alcohol Counseling Performance Counseling Performance

MeasureMeasure Evidence is strongest in non-dependent Evidence is strongest in non-dependent

alcohol misuse, but recommended for all alcohol misuse, but recommended for all alcohol misuse – need to risk-stratifyalcohol misuse – need to risk-stratify

Key components of BAC: Key components of BAC: Advice: abstain or decrease drinking below limitsAdvice: abstain or decrease drinking below limits Feedback linking drinking to healthFeedback linking drinking to health

Completed specialty referral also acceptable Completed specialty referral also acceptable follow-up of screening resultsfollow-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)

Optionaldocument

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 dependenceConsider referral

Alcohol Counseling Clinical Reminder

0%

10%

20%

30%

40%

50%

60%

70%

80%

June Aug Oct Dec Feb April J une Aug Oct Dec Feb April

AUDIT-C 5-7AUDIT-C 8-12

2004 2005 2006

SummarySummary Implemented screening for alcohol misuseImplemented screening for alcohol misuse Need appropriate follow-upNeed appropriate follow-up

Brief alcohol counseling or completed referralBrief alcohol counseling or completed referral Higher than other health care systems, but Higher than other health care systems, but

much room for improvementmuch room for improvement Developed new performance measureDeveloped new performance measure

Clinical reminder improves Clinical reminder improves documenteddocumented BACBAC

Increased Increased documenteddocumented counseling: 55-70% counseling: 55-70% Especially increased rates in mild/moderate Especially increased rates in mild/moderate

abuse who might benefit mostabuse who might benefit most What about reduced risk?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 TeamKathy Bradley, MDCarol Achtmeyer, ARNPAnna DeBenedetti, BAGwen Greiner, MPHEric Hawkins, PhDEmily 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/clinicians_guide.htm

Motivational Interviewing8 training videotapes:

http://www.motivationalinterview.org/training/videos.html NIDA trainings including MI:

http://mia.nattc.org/aboutUs/blendingInitiative/products2.htm#mi

ReferencesBiomarkers pf Alcohol MisuseBean, 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-CBabor 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 OutcomesAu DH, et al. Alcohol Screening Scores and Risk of Hospitalizations for GI Conditions in Men. Alcoholism, clinical and experimental research 2007;31:443-451Bradley KA, et al. The relationship between alcohol screening questionnaires and mortality among male veteran outpatients. J Stud Alcohol 2001;62:826-833Bradley, 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/BACKaner 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.htmWhitlock 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 RCTFleming 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 MeasurementGreenhalgh, 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;7:149–58Miller 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 self-report

as data sources for ambulatory care? Med Care. 2006 Feb;44(2):132-40.

Contact information

Daniel Kivlahan, PhDDirector, CESATEClinical Coordinator, SUD QUERI

VA Puget Sound Health Care System

Phone: 206-768-5483E-Mail: [email protected]

Appendix

The Clients Perspective