1. From screening into treatment: Implementation solutions for Alcoholism therapy Thomas R. Kosten MD JH Waggoner Chair and Professor of Psychiatry & Neuroscience Baylor College of Medicine Research Coordinator VA Substance Use Disorders QUERI

2. Purpose of this Program  To compare barriers and benefits in PCC for treating problem drinking using Brief Interventions (BI) and for treating alcoholism using naltrexone (NTX).  To compare VISNs and facilities in providing BI and NTX using 3 care models: TIDES, Behavioral Health Laboratory (BHL), and the PCC providers themselves.

3. Outline of Presentations  Kosten: introduce BI and NTX for alcohol use disorders (AUD).  Harris (PERC): very limited use of NTX for AUD in VA.  Bradley: EPRP chart reviews of AUD treatment in PCC.  Oslin: BHL outcomes in providing BI and NTX for AUD in PCC.  Kirchner: implementing TIDES for AUD treatment in PCC  Daily: 2 year implementation of TIDES for treating AUD in PCC across VISN 16

4. Stopping drinking is easy, I’ve done it hundreds of times Mark Twain

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

6. Rates of Provider Advice (B.I.) Rates of Provider Advice (B.I.)  Patient Survey (n=14,000 screen+) “In the past year did a VA provider advise you to decrease drinking or not drink?”  National Mean=28% (VISN range = 20-36%)  Thus: Brief Interventions (BI) done Uncommonly

7. Alcohol Withdrawal Syndrome  Signs: tremor, blood pressure and pulse elevated, adrenergic arousal  Symptoms: agitation, anxiety, hallucinations  Peak at 3 days, Last 7-10 days  Seizures: Delirium Tremens: fatal complication

8. Are medications needed for detox treatment?  Obtain breath alcohol level – withdrawal occurs as level falls and usually not above 100-150 mg%  Assess level of withdrawal symptoms (CIWA)  Level of care needed: inpatient, medical setting, duration, medical complications, support?  Types of medications  Setting & support needed for medical safety & adherence

9. Behavioral interventions during withdrawal treatment: Motivational Interventions  Brief Motivational Interventions Course – INTRAnet: www.bmiforsuv.org www.bmiforsuv.org  Over 750 VA staff in Primary Care completed course  Four course modules: – Background, MI Basics, Assessment, Feedback  Four separate shorter modules available by Dec 15th.

10. Can medications reduce alcohol relapse? YES!  Naltrexone – opiate antagonist taken orally or by once monthly injection (Vivatrol)  Over 25 studies showing clinical and cost efficacy over placebo in preventing relapse  Pharmacogenetic selection of best candidates (family HX good surrogate)  Other medications – acamprosate, disulfiram, topiramate, carbamazepine, also combinations  Most effective, if abstinent at medication start

11. Naltrexone and Relapse Rate by Mu Opiate Receptor Genotype

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