e-Solutions April 2015
Alcohol use disorders are chronic conditions with promising treatment response rates. Yet, many people who have an alcohol use disorder do not get treatment for this chronic condition.
The first problem is that the majority of people don’t get any treatment at all. The second problem is that when they do get treatment, they don’t always get evidence-based treatment – they may just go through detox.
Alcohol use and health
Alcohol use affects all aspects of health. One of the most common diseases in the world is hypertension, or high blood pressure, and alcohol is often a cause. Alcohol can cause liver damage, sleep disorders and can complicate diabetes treatment. The most common co-occurring condition with alcohol use disorders is depression. ,,  This is important for providers to remember because in the presence of alcohol, antidepressants don’t work well and the risk of suicide increases.
Effective treatment means treating these conditions together. In a study on treating co-occurring alcohol use and depression at the University of Pennsylvania, people who received treatment for both disorders simultaneously had the best health outcomes. The study also found that doctors were comfortable treating one condition or another, but not both. And few doctors, even psychiatrists, had training on how to treat alcohol use.
Early intervention and primary care
One characteristic of alcohol use disorders is denial. People may not want to admit how much alcohol they use. When primary care clinicians regularly screen for and are trained in how to ask about alcohol use, they contribute to successful outcomes.
Early detection of alcohol use is important: the earlier you start an intervention, the more successful it will be. A 2014 study in the Journal of the American Medical Association found that screening and integrating behavioral health care into primary care led to effective treatment for moderate to severe alcohol use disorders.
Beyond improving health, treating alcohol use also reduces cost. Procedures such as liver transplants are expensive, and 30 percent of liver failures are caused by alcohol abuse. Many cost benefit studies show that addressing alcohol use in both primary care and specialty behavioral health settings can save the health care system money and lower an individual’s overall health care costs.,,,,
Address all underlying causes and cravings
We’ve learned a lot from brain imaging. People with an alcohol use disorder train their brain to drink heavily. If you play the piano or a sport, your brain is trained to complete that activity. It is the same for alcohol use. When a person with an alcohol use disorder sees a cue, their brain triggers cravings. And cravings often precede relapse.
A new study in the American Journal of Psychiatry shows a clear brain pattern for alcohol cravings and how cues lead to intense cravings. Providers must offer behavioral treatments to counter these cues. If someone is in detox, it is best not to have them participate in various activities that merely make them feel at ease. Instead, providers should focus on how to reduce and counter their cravings.
Alcohol use disorders stem from a combination of culture, environment and genes. On the cultural influences, for example, American college students often think excessive drinking is normal. If their use doesn’t escalate into bigger problems, they will often decrease their use later. But if they have genes that put them at risk, then it is likely they will experience an alcohol use disorder.
The Food and Drug Administration (FDA) has approved multiple medications for alcohol use disorders; yet, only about 10 percent of people in treatment receive those medications. Often, this is attributable to a lack of training administrating these medications. We take medication to lower cholesterol, and it lowers risk for the condition. Why wouldn’t we do the same for treating alcohol use disorders?
Putting science to practice
Providers must prepare to address both the culture and biology driving this disease. We can keep doing clinical trials and other studies, but until providers adopt these approaches into their practice, the findings just sit there. Integrated care providers have the opportunity to show that people with alcohol use disorders can have better treatment outcomes and recovery rates than other chronic conditions.
Let’s ensure that science goes to practice, and let’s work together to provide the best evidence-based care available.
See this month’s Quick Tips for more advice on how to address alcohol use in integrated care settings.
Of the 17.3 million adults with an alcohol disorder in the US, only 7.7 percent received treatment in the past year. That’s a small percentage of the 82 percent of American adults who had contact with a health care professional last year.
Integrated primary and behavioral health care centers such as Stanley Street Treatment and Resources (SSTAR), a SAMHSA primary and behavioral health care integration (PBHCI) grantee, are working to close that treatment gap.
SSTAR’s history, starting as the Center for Alcohol Problems as a detox and alcohol treatment program in 1977, means that addressing alcohol use has long been a priority for the center in serving communities in Southeastern Massachusetts and Rhode Island. Now, SSTAR is a federally qualified health center (FQHC) and a mental health clinic and provides inpatient and outpatient care spanning the health care spectrum. Although their services have expanded to all areas of health care, 19 percent of those they serve have an alcohol use disorder.
Starting with screening
SSTAR’s primary care providers ask about alcohol use and drinking habits during primary care visits with the CAGE AID screening tool. In addition to universal screening, SSTAR’s physicians are trained to look for signs and symptoms related to heavy alcohol use. When a potential concern arises, the physician can connect to a care manager on staff to work with the individual and to create a treatment plan.
All primary care physicians at SSTAR are required to be trained in how to administer medication assisted treatment for people with alcohol use disorders. SSTAR hosts monthly trainings for all staff on topics around treating substance use disorders, in particular alcohol use. Training topics include how to respond to specific situations, such as what to do if someone screens positive for risky alcohol use. Staff also have access to an online learning library to keep current with trends in treatment.
Educating families and the community
SSTAR has three family support groups a week, one which is Al-Anon. SSTAR also provides a weekly Addiction 101 educational class on the weekends to help individuals, families and friends that may be affected by alcohol use understand how the body becomes addicted and what to look for as an addiction progresses. Often, individuals will attend the class with their parents or family members.
Keeping up with innovation
To equip all providers with the latest innovation and research available to treat alcohol use and substance use disorders, SSTAR partners with Mclean Hospital of Harvard University and four other community treatment programs across New England as part of their participation with the National Institute of Drug Abuse’s Clinical Trial Network. Through this network, SSTAR is involved in clinical trials that allow them to stay on the pulse of which cutting-edge treatments achieve the best outcomes for different populations.
Connecting need with treatment
When a person’s enrolls in SSTAR’s care, they complete an assessment (the Basis 24) to measure the severity of their disorder and assess their needs. In their detox unit, if someone has an alcohol use disorder, a nurse completes both a physical assessment in terms of signs and symptoms or withdrawal in addition to completing a psychological assessment. To support providing the appropriate treatment by population, SSTAR has two separate detox units, one that is a general detox facility and the other specifically for people with co-occurring mental illness. Since beginning this approach, SSTAR has seen more individuals with severe concerns get well.
In what ways does your center make addressing alcohol use a priority? Tell us your story at Integration@theNationalCouncil.org.
What can you do to address alcohol use across your entire organization? Here are some additional tips from Charles O’Brien on how to address alcohol use in integrated primary and behavioral health care settings.
- Always ask about a person’s drinking habits. Just as providers should always ask about depression and assess for suicide, clinicians must be comfortable talking about alcohol use. There are standard questions everyone can ask. Start with universal screening.
- Train staff in evidence-based practices. Review evidence-based practices on SAMHSA’s National Registry of Evidence Based Programs and Practices. Ensure staff train in these practices to stay up-to-date with the array of treatment options available. Make sure staff are aware of the connection between certain conditions and alcohol use.
- Be flexible and take advantage of all possible treatment options available. Strategies such as group therapy, family therapy and 12-step groups can be helpful, but providers should incorporate biological approaches (i.e., medications) as well. Providers should not be opposed to new approaches.
- Work with individuals with the long-term in mind. Teach people behaviors to adopt long-term to counter the cues that prompt cravings. Talk to individuals and family members about long-term treatment plans. Not where people should expect to be one month later, but year after year. Teach them skills to help them prevent relapse.
- Remember abstinence isn’t the only approach. Abstinence is the safest approach for someone with an alcohol use disorder, but reducing heavy drinking can also improve health. The FDA clarified that they will consider approving drugs for reduction of heavy drinking; not just those for abstinence. Even after detox, some people will have a strong tendency to keep going back. If someone chooses to continue to drink, we should not consider that a full-on relapse.
Looking for more resources on alcohol use? CIHS’ substance use web page includes additional resources on treating alcohol use disorders and other substance use disorders.
Expanding the Use of Medications to Treat Individuals with Substance Use Disorders outlines the lessons learned from a year-long collaborative with safety-net providers to explore the barriers and opportunities for communities to implement use of medications for addictions treatment. A companion Medication Assisted Treatment Implementation Checklist outlines the key questions to consider before engaging in efforts to increase access to medication assisted treatment for addictions.
SAMHSA’s Medication for the Treatment of Alcohol Use Disorder: A Brief Guide provides clinical guidance on the use of medication-assisted treatment for alcohol use disorders, screening and assessment options, treatment planning and patient monitoring.
HHS announced $1 million in new grant funds for the Community Interoperability Health Information Exchange (HIE) Program to support and enable the flow of health information at the community level. The deadline to submit intent to apply notices is May 15, and applications are due on June 15.
SAMHSA is accepting applications for Statewide Peer Networks for Recovery and Resiliency to create or enhance statewide networks that improve access to services, treatment and recovery supports. Applications are due July 23.
The Joint Commission announced a Integrated Care Certification program for Joint Commission-accredited hospitals, critical access hospitals and ambulatory health care providers. The voluntary certification focuses on promoting and supporting clinically integrated patient care among hospitals and ambulatory health care providers.
A new report from SAMHSA indicates nearly 1 in 10 full-time workers have had a substance use disorder in the past year. The report, first of its kind since 2007, compares rates of illicit drug use and heavy alcohol use across different industries.
In observance of Children’s Mental Health Awareness Day, SAMHSA and HRSA present Consultation for Kids: Models of Psychiatric Consultation in Pediatric Primary Care. Join this webinar on May 4 at 2pm Eastern to learn about the pediatric psychiatric consultation model, hear from a safety-net pediatrician on how a busy clinician can effectively tap into psychiatric consultation to provide high quality mental health care, and learn which components of psychiatric consultation models can be implemented or better utilized in your region, state or community.