April 25, 2018

Patient-centered care for alcohol use disorders: What’s next?


Sharing CHOICE trial results, KPWHRI takes next steps to advance research on alcohol-related care at Kaiser Permanente Washington and beyond.

by Katharine Bradley, MD, MPH, senior researcher at Kaiser Permanente Washington Health Research Institute and internal medicine physician at Washington Permanente Medical Group

From sporting events to holidays to happy hours, drinking alcohol is a valued part of life for many people. Through mass advertising, we also see countless positive images of alcohol — for example healthy young adults relaxing on the beach with beer in hand.

But what those ads don’t tell us is that about a third of U.S. adults will have an alcohol use disorder (AUD) at some time in their lives — meaning they are drinking more than they want to and/or their drinking is causing them repeated problems. One in 8 adults have a current AUD.

AUDs result from repeated heavy drinking, but inherited risk plays a role. Together our genes and how we drink can combine to cause brain changes, making it harder to control drinking. Over time this leads to problems with work, relationships, and health.

Newer medications like naltrexone can help people stop drinking or cut down — but most people are never offered them. In fact, fewer than 1 in 5 people with AUDs receive any form of treatment.

As an AUD researcher, my goal is to find ways to help people address alcohol-related problems in their doctors’ office — ideally before those problems become severe.

Because research has shown that no one treatment works best for all people, experts recommend offering ongoing patient-centered primary care — focused on motiving change and offering both medications and referral to other treatments. But is that enough?

The CHOICE study: Engaging patients in alcohol-related care

To help answer this question, we are conducting a series of studies, including the CHOICE trial: “Choosing Healthier Drinking Options in Primary Care.” The CHOICE trial tested individualized care management for patients who drink heavily and received their primary care through Veterans Affairs (VA) Puget Sound Healthcare System. Our research team, which included colleagues from the University of Washington and the VA, recently published primary findings from CHOICE in JAMA Internal Medicine.

Our goal was to see if patients who received up to 12 months of alcohol care management from a trained nurse would drink less and have fewer alcohol-related problems than patients who received usual care. What we found is that many patients in both groups drank less and had fewer alcohol-related problems — but there was no difference between groups in our primary outcomes. Even though patients in the care management group were more engaged in treatment and more likely to try AUD medications, they weren’t drinking less or experiencing fewer alcohol-related problems than patients in the usual care group after 12 months.

This surprised us. We had expected that engaging patients in alcohol-related care would make them more likely to drink less and have fewer alcohol-related problems. And while it’s easy to think of these results as discouraging, the upside is that we learned some important lessons.

What we learned from the CHOICE study

All patients in the study answered many questions about their drinking, and that alone might have been enough to spark changes.

Also, it’s important to note that CHOICE nurses who offered care management did not recommend one approach over another. They did not even recommend that patients stop drinking.

Although we know that stopping drinking is the best way for people to avoid alcohol-related problems in the future, many people resolve AUDs while continuing to drink at low levels. So we expected that letting patients choose their own drinking goal might lead more of them to change than patients in the usual care group.

But, in fact, patients who did not receive alcohol care management were more likely to stop drinking — one of many secondary outcomes.

A similar study conducted elsewhere also let patients choose their own drinking goal and showed no benefit. In contrast, 3 other alcohol care management studies that recommended that people with AUDs stop drinking helped people drink less and/or decrease alcohol-related problems.

What this means for our ongoing work

We’re taking these considerations to heart as we continue our work to help patients with AUDs in primary care at Kaiser Permanente Washington.

As part of the organization’s Behavioral Health Integration (BHI) initiative, we are conducting an ongoing trial to improve alcohol-related care in all our primary care clinics. With BHI, all adult patients are asked about their alcohol use once a year and assessed for alcohol-related problems if they report drinking above a certain level. In light of CHOICE results, we are now urging primary care clinicians and social workers to support patients in choosing the approach to treatment that’s best for them — while making it clear that stopping drinking is our medical recommendation.

One key challenge is that many patients and providers are hesitant to talk about problems caused by drinking. These conversations can be uncomfortable because of stigma that surrounds drinking problems. So we are pilot testing an alcohol use decision aid we developed to help make those conversations more comfortable, informed, and productive.

What’s next?

As we continue looking for ways to make alcohol-related care as helpful as possible for our patients at Kaiser Permanente Washington, my research colleagues and I are pursuing funding for some key next steps. One example: testing how to get the alcohol use decision aid to patients who will benefit most from it. We also want to test whether it can help them drink less and have fewer related problems.

As always, we’ll share what we learn with other health systems and providers, so that patients everywhere can benefit.

In the meantime, I’m encouraged by the positive stories I hear from primary care doctors, nurses, medical assistants, front desk staff, practice coaches, and social workers across Kaiser Permanente Washington: It’s clear that offering people support to change their drinking is already making a difference for individual patients — and for the many clinicians and staff who care for them.

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