Can collaborative care help patients with alcohol use disorders?

Beer commercials show laughter in romantically lit bars, dinner parties keep wine flowing, happy hours abound. We’re surrounded by messages about enjoying alcohol. But some people drink too much, likely harming their health.

Many face internal barriers to getting help for problem drinking, believing they can manage it alone or that professional help means “just quit.” A new study asks, what if help for unhealthy drinking could begin as part of routine primary care?

The National Institute on Alcohol Abuse and Addiction (NIAAA) recently awarded Group Health Research Institute (GHRI) $3.2 million over five years to study whether people with alcohol use disorders can reduce their unhealthy drinking through a collaborative-care intervention. Called Considering Healthier Drinking Options In Collaborative Care (CHOICE), the study is enrolling patients receiving care at Veterans Affairs (VA) Puget Sound. GHRI Senior Investigator Kathy Bradley, MD, MPH, an alcohol-misuse expert who joined the Institute from the VA last year, is the study’s principal investigator.

She expects the CHOICE study will benefit from GHRI’s acclaimed success with the collaborative care model, where care is coordinated, patient-centered, and everyone on the patient’s team—doctors, nurses, lab techs, pharmacists, counselors, and specialists behind the scenes—share pertinent information. “The intervention team will focus on managing the patient population, identifying who needs help, and reaching out,” says Dr. Bradley. “It’s proactive, as opposed to assuming the problem will just get taken care of.”

She’s eager to see if a patient-directed collaborative care intervention can strengthen primary care’s ability to address risky drinking. “This study builds on the Institute’s incredible experience doing collaborative care trials,” says Dr. Bradley, “but what’s critical is taking on this condition that’s been so neglected by the medical community.”

Participants are recruited through doctors’ letters and posters offering help for those who want healthier drinking options. Because the VA has a 95 percent rate of alcohol-misuse screening, patients are eligible for an invitation letter based on their AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) score. Using phone screening and in-person interviews, the study team will further quantify patients’ alcohol use and suitability for the study. Men must report drinking five or more drinks per day at least twice a week; women must report four or more to be eligible.

Those randomly chosen for the intervention will talk as often as weekly with a nurse care-manager during the year-long intervention. These specially trained nurses will help patients discover individual motivations for change, explore any ambivalence, and provide active listening—highlighting patients’ values and helping them gain confidence. All participants will get periodic lab tests, checking for liver damage or impaired red blood cell production—feedback that may motivate patients randomized to the intervention to talk to their nurse care-managers and consider making changes.

The aim is to meet the patients wherever they are, says Dr. Bradley. “They don’t have to stop drinking. We’re saying, ‘We’re interested in talking to you about your drinking and your health and seeing if you’re interested in what we might offer to help you cut down.’” Three FDA-approved medications that help patients with alcohol dependence will be offered to eligible patients who are interested. While many patients know about the medication disulfiram (Antabuse), which makes users sick if they drink, they are often unaware there are two other medications that reduce drinking by other mechanisms.

Clinical psychologist and GHRI Senior Research Associate Evette Ludman, PhD, is Dr. Bradley’s GHRI co-investigator, bringing extensive expertise in collaborative care interventions, behavior-change interventions, and chronic illness self-management support. “These patients will have an entire team behind them, and a trusted relationship with one care manager,” says Dr. Ludman. She co-authored GHRI’s lauded TEAMcare study, where nurses worked closely with patients and health teams to manage care for combined depression and chronic illness.

Primary care could be the ideal setting for patients to get help recognizing risky drinking and understanding problems like organ damage, depression, medication interference, increased cancer risk, and public health concerns like domestic violence, accidents, lost workplace productivity, and trauma. Dr. Bradley says many people have barriers to seeking traditional alcohol-misuse treatment—including beliefs that it’s time-consuming, could cause them to lose their job, or that their drinking isn’t a real problem. She says there is often the assumption, “‘Stop drinking first, then we’ll treat you.’” The CHOICE trial is testing whether reaching out and engaging patients who are not yet ready to stop drinking improves drinking and health outcomes.

“It’s exciting to take the collaborative care principles we developed and apply them to alcohol abuse,” Dr. Ludman says. “We see incredible results using collaborative care with depression, but we really don’t know how the approach is going to work here.”

By Gretchen Konrady