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Table 2 Study designs and intervention effects on AUD medication receipt

From: Strategies to increase implementation of pharmacotherapy for alcohol use disorders: a structured review of care delivery and implementation interventions

Study
(Author, abbreviated name, and reference)
Sample size
(Patients/sites)
% Receiving AUD medications Measure of AUD medication receipt Intervention and intervention effect
SAITZ, AHEAD CCM [32] 563/1 BASELINE:
Intervention 4%
Control 8%
Receipt of addiction medication (buprenorphine, methadone, naltrexone, Acamprosate, disulfiram) Program Name and Brief Description: The Addiction Health Evaluation and Disease (AHEAD) Management Chronic Care Management (CCM) model “included longitudinal care coordinated with a primary care clinician; motivational enhancement therapy; relapse prevention counseling; and on-site medical, addiction, and psychiatric treatment, social work assistance, and referrals (including mutual help). The control group received a primary care appointment and a list of treatment resources including a telephone number to arrange counseling.” AHEAD CCM was delivered by a multidisciplinary team (nurse care manager, social worker, internists, psychiatrist with addiction expertise)
Setting: Hospital-based primary care practice (patients recruited from residential detoxification unit and referrals from urban teaching hospital) in Boston, MA
Goal: Harm reduction
Key Components: Use of registry to track and proactively reach out to patients, longitudinal care coordinated with primary care clinician and facilitated by shared electronic health record (EHR), motivational enhancement therapy, relapse prevention counseling, on-site medical, addiction and psychiatric treatment, social work assistance, and referrals (including to mutual help)
Effect on Medication Receipt: OR = 1.88 (95% CI 1.28–2.75) p = 0.001
Effect on Alcohol Use Outcomes: Not significant
FOLLOW-UP:
Intervention 21%
Control 15%
OSLIN Alcohol Care Management [31] 163/3 BASELINE:
Not reported
Receipt of naltrexone Program Name and Brief Description: Alcohol Care Management “focused on the use of pharmacotherapy and psychosocial support. Alcohol Care Management was delivered in-person or by telephone within the primary care clinic. The control group received standard treatment in a specialty outpatient addiction treatment program” Delivered by a behavioral health provider in-person or over-the-phone with primary care provider recommendation and support. Behavioral health providers were trained in motivational interviewing
Setting: Veteran Affairs (VA) primary care in New York and Philadelphia
Goal: Abstinence
Key Components: Weekly 30 min visits, individualized patient education, pharmacotherapy and psychosocial support, repeated assessment of alcohol use, encouraged treatment adherence, monitoring of problems and management of potential side effects, use of shared EHR for communication with primary care provider
Effect on Medication Receipt: Naltrexone prescribed in 65.9% of the Alcohol Care Management group relative to 11.5% in control; Chi2 50.10, p < 0.001
Effect on Alcohol Use Outcomes: The Alcohol Care Management group was more likely to refrain from heavy drinking than the control (OR = 2.16, 96% CI 1.27–3.66) but no effect on any alcohol use (OR = 1.40, 95% CI 0.75–2.59)
FOLLOW-UP:
Intervention 65.9%
Control 11.5%
WATKINS SUMMIT [35,36,37,38] 377/2 BASELINE:
Not reported
Receipt of any “medication assisted treatment” with either long-acting injectable naltrexone or buprenorphine/naloxone. Program Name and Brief Description: Collaborative care “was a system-level intervention, designed to increase the delivery of either a 6-session brief psychotherapy treatment and/or medication-assisted treatment with either sublingual buprenorphine/naloxone for opioid use disorders (OUDs) or long-acting injectable naltrexone for alcohol use disorders (AUDs). The control group was told that the clinic provided opioid and/or alcohol use disorder treatment and given a number for appointment scheduling and list of community referrals.” Delivered by care coordinators and therapists with a social work degree
Setting: Primary care at Federally Qualified Health Center in L.A., CA
Goal: Increase screening and brief intervention for unhealthy alcohol use
Key components: Intended 6 sessions of brief psychotherapy and/or med-assisted treatment (buprenorphine/naloxone for OUD and naltrexone for AUDs), repeated assessments of substance use, use of registry to track and proactively reach out to patients, motivation and encouragement of engagement in therapy
Effect on Medication Receipt: OR comparing intervention to control at 6-months follow-up for patients with AUD and/or OUD = 1.23 (95% CI 0.60–2.40) p = 0.53. Published commentary from SUMMIT investigators [37] suggests similar non-significant findings among patients with AUD only
Effect on Alcohol Use Outcomes: Among patients with AUD only (54% of the sample) the SUMMIT intervention was significantly associated with abstinence from any alcohol use and all opioids at follow-up and was borderline significant for no heavy drinking in the past 30 days.
FOLLOW-UP:
Intervention 13.4%
Control 12.6%
BRADLEY CHOICE [33, 34] 304/3 BASELINE:
Intervention 1% versus Control 2%
Receipt of naltrexone, Acamprosate or disulfiram Program Name and Brief Description: Choosing Healthier Options in Primary Care (CHOICE) was a care management intervention in which “nurse care managers offered outreach and engagement, repeated brief counseling using motivational interviewing and shared decision making about treatment options, and nurse practitioner–prescribed AUD medications (if desired), supported by an interdisciplinary team (CHOICE intervention). The control group received usual primary care.”
Setting: VA Primary care in Washington State
Goal: Harm reduction
Key components: Proactive outreach and engagement, repeated brief counseling using MI and shared decision-making about treatment options (AUD medication, biomarker assessment if abnormal baseline, behavioral goal-setting and skills development for reducing drinking, encouragement of mutual help and/or specialty addictions treatment, self-monitoring)
Effect on Medication Receipt: OR = 6.3 (95% CI 3.4–11.8) p < 0.0001
Effect on Alcohol Use Outcomes: Not significant
FOLLOW-UP:
Intervention 32% versus Control 8%
ROBINSON, Group Management [44] 1600/1 BASELINE:
Increasing 0.08%/month in pre-implementation period
Receipt of naltrexone or Acamprosate, or extended-release naltrexone Program Name and Brief Description: Group Management of pharmacotherapy initially implemented to provide continued access during a staffing shortage, sought to provide psychosocial education on medication management for alcohol dependence. Delivered by an addiction psychiatrist in collaboration with either an Addiction Therapist or a Certified Nurse Specialist
Setting: VA San Diego Health Care System
Goal: Increase adoption of pharmacotherapy for AUD
Key components: Group participants capped at 8, review of naltrexone and Acamprosate, discussion of side effects or benefits, discussion of barriers to sobriety in group format. Sessions lasted 1 h
Effect on Medication Receipt: The rate of increase in the percent of patients treated pharmacologically for alcohol dependence increased 0.08% per month in the pre-implementation period to 0.21% per month after group visits were implemented
Effect on Alcohol Use Outcomes: Not measured
FOLLOW-UP:
Increasing 0.21%/month in post-implementation period
HARRIS, VA Academic Detailing Program [40] NA/37 BASELINE:
Intervention 4.56%
Control 6.01%
Monthly rates of receipt of naltrexone (oral or injectable), Acamprosate, disulfiram, or topiramate Program Name and Brief Description: VA Academic Detailing Program in which “The academic detailers strove to educate, motivate, and enable key health care providers to identify and address the spectrum of hazardous alcohol use, especially to facilitate more active consideration of pharmacological treatment options for AUD.” Academic detailers were clinical pharmacy specialists
Setting: VA medical centers and outpatient clinics in California, Nevada and the Pacific Islands
Goal: Increase adoption of pharmacotherapy for AUD
Key components: Local champions and leadership buy-in, dashboard for identifying patient candidates for AUD medication, repeated in-person visits to educate and build rapport with priority providers, problem-solve barriers and address knowledge gaps/misunderstanding about AUD meds, additional educational resources (e.g., patient education tools and pocket cards), integrated audit and feedback tools into EHR for identifying AUD patients, commitment from providers to increase prescribing patterns for AUD medication, monitoring and follow-up
Effect on Medication Receipt: Slope of intervention sites increased more steeply than slope at control sites (p < 0.001). From immediately pre-intervention to the end of the observation period (Month 16–Month 36), the percent of patients with AUD who received medication increased 3.36% in absolute terms and 67.77% in relative terms
Effect on Alcohol Use Outcomes: Not measured
FOLLOW-UP:
Intervention 8.32%
Control 6.90%
HAGEDORN, ADaPT–PC [39, 42] NA/3 BASELINE:
Intervention 3.8%
at end of pre-implementation period
Control 3.7%
Monthly rates of filled prescription for AUD medication (oral/injectable naltrexone, Acamprosate, disulfiram, topiramate) within 30 days after PC visit Program Name and Brief Description: Alcohol Use Disorder Pharmacotherapy and Treatment in Primary Care settings (ADaPT–PC) “targets stakeholder groups with tailored strategies based on implementation theory and prior research identifying barriers to implementation of AUD pharmacotherapy. Local SUD providers and primary care mental health integration (PCMHI) providers are trained to serve as local implementation/clinical champions and receive external facilitation. Primary care providers receive access to consultation from local and national clinical champions, educational materials, and a dashboard of patients with AUD on their caseloads for case identification. Veterans with AUD diagnoses receive educational information in the mail just prior to a scheduled PC visit.” Delivered by site champions and external facilitators
Setting: VA primary care
Goal: Increase adoption of pharmacotherapy for AUD
Key components: Training local champions, website with educational materials for primary care providers, a case-finding dashboard, technical assistance from local and national experts
Effect on Medication Receipt: Rate of change (slope) increased significantly in the implementation period (p = 0.0023). Immediate post-implementation change not significant (p = 0.3401). Change over 12-month post-implementation relative to pre-implementation change significant (0.0033). No difference between intervention and control sites in immediate post-implementation change (p-0.8508). No difference between intervention and control sites in post-implementation slope (p = 0.4793)
Effect on Alcohol Use Outcomes: Not measured
FOLLOW-UP:
Intervention 5.2%
at end of implementation period
Control 5.8%
FORD
Medication Research Partnership [43]
3887/9 BASELINE:
Intervention 9.0%
Control 11.4%
Receipt of AUD medication during an episode of care Program Name and Brief Description: Medication Research Partnership, “a collaboration between a national commercial health plan and nine addiction treatment centers, implemented organizational and system changes to promote use of federally approved medications for treatment of alcohol and opioid use disorders.” Delivered by commercial health plan, “nationally recognized experts in the substance abuse field,” and “change leaders.”
Setting: Specialty addiction treatment centers located on Northeastern seaboard of the U.S.
Goal: Promote use of federally approved medications for AUD/OUD
Key components: “Change leaders” and “change teams,” external coaches, rapid change cycles to test strategies to promote medication use, provider training and technical assistance
Effect on Medication Receipt: Difference in differences at Year 3:
Unadjusted: 5.8%; Adjusted: 5.2% (95% CI − 4.1 to 14.5) p = 0.27
Effect on Alcohol Use Outcomes: Not measured
3-YEAR FOLLOW-UP:
Intervention 26.5%
Control 23.1%
ORNSTEIN PPRNet-TRIP [41] 15053/19 EARLY INTERVENTION CLINICS:
Phase 1: 2.6%
Phase 2: 5.5%
Prescription for disulfiram, naltrexone (oral or injectable), Acamprosate, or topiramate Program Name and Brief Description: Practice Partner Research Network-Translating Research Into Practice (PPRNet-TRIP) involved “practice site visits for academic detailing and participatory planning and network meetings for ‘best practice’ dissemination”
Setting: Primary care practices from 15 U.S. States
Goal: Increased prescription for disulfiram, naltrexone (oral or injectable), Acamprosate, or topiramate for those with an AUD
Key components: EHR template, performance reports, provider education, and development of an implementation plan
Effect on Medication Receipt: Due to small proportions of subjects receiving medications, pre-post (phase 1 versus phase 2) comparison of medication receipt was only estimable in the early intervention clinics. The adjusted OR for phase 1 versus phase 2 in the early intervention clinics was 2.24 (95% CI 1.03 -4.88) p < 0.05
Effect on Alcohol Use Outcomes: Not measured
DELAYED INTERVENTION CLINICS:
Phase 1: 0%
Phase 2: 2.4%