Thomas R. Kosten MD JH Waggoner Chair and Professor of

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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

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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.

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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

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Stopping drinking is easy,Ive done it hundreds
of times

• Mark Twain

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Alcohol Screening on AUDIT-C Q3 FY06 by VISN
(. Target)
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Rates of Provider Advice (B.I.)

• Patient Survey (n14,000 screen)
• In the past year did a VA provider advise you
  to decrease drinking or not drink?
• National Mean28 (VISN range 20-36)
• Thus Brief Interventions (BI) done Uncommonly

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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

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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

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Behavioral interventions during withdrawal
treatment Motivational Interventions

• Brief Motivational Interventions Course
• INTRAnet 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.

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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

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Naltrexone and Relapse Rate by Mu Opiate Receptor
Genotype
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Perhaps it would help if I go over it one more
time.