BACKGROUND/RATIONALE:
Untreated or under-treated alcoholism continues to be a major public health concern that leads to significant personal morbidity and significant societal burden in lost days of employment, increased utilization of medical services and increased mortality. Despite advances in the treatment of alcoholism, there remains a gap between the efficacy of treatments demonstrated in randomized clinical trials and outcomes in primary care clinics. Specifically, primary care patients are often not diagnosed or referred for treatment. Primary care physicians in the VA are required to include screening as part of routine clinical practice as a method of identifying patients in need of treatment. However, screening and identification, while necessary, are not sufficient to increase access to treatment.

OBJECTIVE(S):
The aim of this study is to test for improvements in treatment outcomes for primary care patients with at-risk drinking when cared for using telephone disease management (TDM) compared to those treated with usual care. Based on our pilot data, TDM for at-risk drinking may be a viable method for reducing alcohol consumption in this population.

METHODS:
200 patients with at-risk drinking will be recruited from 4 primary care clinics at the Philadelphia VAMC and 3 Community Based Outpatient Clinics. Subjects will also be recruited from the primary care clinics (including the CBOCs) at the Coatesville VAMC. Patients will be referred for study evaluation by their primary care clinician (PCP) based on existing clinic screening and clinical exams. After referral by the primary care physician, the baseline assessment, either in the primary care clinic or by telephone, will be conducted within 48 hours of the referral. Those patients found to be eligible and who agree to participate will have follow-up telephone assessments at 3, 6, and 12 months.

The baseline assessment will establish eligibility for participation in the study but will also allow patient triage. For all patients referred, including those not eligible or who refuse participation, a written summary of the baseline assessment, similar to a lab report, will be sent to the PCP to assist in the delivery of care. Eligible patients will be randomly assigned to TDM or the lower intensity intervention. For those patients assigned to the lower intensity intervention, the physician will administer further evaluations and treatment as he/she sees fit. For those assigned to TDM, a behavioral health specialist will maintain regularly scheduled telephone contact to develop a treatment plan, to monitor treatment effectiveness and adverse effects, assess and encourage treatment adherence, and offer support and education. The health specialist will communicate assessment information with the PCP in order to coordinate treatment decisions.

FINDINGS/RESULTS:
The implementation of the Behavioral Health Laboratory has been a success at the PVAMC with over 9000 assessments conducted in the last 5 years for depression, at-risk drinking, PTSD and other mental health issues. The BHL procedures were recently published in the Journal of General Internal Medicine. The BHL was also selected as one of the Best MH/SA Clinical Practices. To date, 147 patients have been randomized with more than 80% recieving at least one session of TDM in that arm.

Although the final analyses are still being reviewed, the early results suggests substantial reductions in drinking and binge drinking in both groups (usual care and intervention). Satisfaction was greater in the intervention arm.

Oslin DW, Ross J, Sayers S, Murphy J, Kane V, Katz IR. Screening, assessment, and management of depression in VA primary care clinics: The Behavioral Health Laboratory. Journal of General Internal Medicine 21: 46 - 50, 2006.

IMPACT:
Results favoring TDM may provide a low-cost, highly efficient mechanism for integrating behavioral health care with primary care for these patients. This project thus meets several of the priority areas for HSR&D funding including improving access to care, the implementation of practice guidelines, use of telemedicine, and patient-centered care.

While telephone care was found to be highly successful the primary outcome appears not to differ between groups. More analyses are under way looking at secondary measures. A manuscript is being prepared for submission.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. McKay JR, Van Horn DH, Oslin DW, Lynch KG, Ivey M, Ward K, Drapkin ML, Becher JR, Coviello DM. A randomized trial of extended telephone-based continuing care for alcohol dependence: within-treatment substance use outcomes. Journal of consulting and clinical psychology. 2010 Dec 1; 78(6):912-23. [view]
2. Oslin DW, Sayers S, Ross J, Kane V, Ten Have T, Conigliaro J, Cornelius J. Disease management for depression and at-risk drinking via telephone in an older population of veterans. Psychosomatic medicine. 2003 Nov 1; 65(6):931-7. [view]
3. McKay JR, Van Horn D, Oslin DW, Ivey M, Drapkin ML, Coviello DM, Yu Q, Lynch KG. Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses. Addiction (Abingdon, England). 2011 Oct 1; 106(10):1760-9. [view]
4. Oslin DW, Ross J, Sayers S, Murphy J, Kane V, Katz IR. Screening, assessment, and management of depression in VA primary care clinics. The Behavioral Health Laboratory. Journal of general internal medicine. 2006 Jan 1; 21(1):46-50. [view]
5. Datto CJ, Thompson R, Horowitz D, Disbot M, Oslin DW. The pilot study of a telephone disease management program for depression. General hospital psychiatry. 2003 May 1; 25(3):169-77. [view]

Conference Presentations

1. Oslin DW. Accessing and delivering substance use/abuse treatment in different settings: the VA perspective. Paper presented at: National Institute on Drug Abuse Annual Conference; 2008 Dec 1; Washington, DC. [view]
2. Oslin DW, Ross J, Sayers S, Murphy J, Katz I. Screening, assessment, and management of depression and alcohol misuse in primary care: effects of the Behavioral Health Laboratory. Paper presented at: VA HSR&D National Meeting; 2005 Feb 17; Baltimore, MD. [view]
3. Zanjani J, Miller B, Turiano NA, Ross JT, Eakin AC, Gerlach LB, Beswick CE, Oslin DW. Telephone based referral-care management treatment outcomes. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA. [view]
4. Oslin DW, Walker P, Sayers S, Conigliaro J, Cornelius J, Belinson S, Katz IJ. Telephone disease management for alcoholism and depression extending service in primary care. Presented at: Research Society on Alcoholism Annual Scientific Meeting; 2002 Nov 10; San Francisco, CA. [view]

DRA: Substance Use Disorders, Health Systems
DRE: none
Keywords: Alcohol, Primary care, Telemedicine
MeSH Terms: none