Barriers to and facilitators of pharmacotherapy for alcohol use disorder in VA residential treatment programs

Abstract

Among US military veterans, alcohol use disorder (AUD) is prevalent and in severe cases patients need intensive AUD treatment beyond outpatient care. The Department of Veterans Affairs (VA) delivers intensive, highly structured addiction and psychosocial treatment through residential programs. Despite the evidence supporting pharmacotherapy among the effective treatments for AUD, receipt of these medications (e.g., naltrexone, acamprosate) among patients in residential treatment programs varies widely. In order to better understand this variation, the current study examined barriers and facilitators to use of pharmacotherapy for AUD among patients in VA residential treatment programs. Semi-structured qualitative interviews with residential program management and staff were conducted and the Consolidated Framework for Implementation Research was used to guide coding and analysis of interview transcripts. Barriers to use of pharmacotherapy for AUD included cultural norms or philosophy against prescribing, lack of access to willing prescribers, lack of interest from leadership, and perceived lack of patient interest or need. Facilitators included cultural norms of openness or active promotion of pharmacotherapy; education for patients, program staff and prescribers; having prescribers on staff, and care coordination within residential treatment and with other clinic settings in and outside VA. Developing and testing improvement strategies to increase care coordination and consistent support from leadership may also yield increases in the use of pharmacotherapy for AUD among residential patients.

Influence of comorbid drug use disorder on receipt of evidence-based treatment for alcohol use disorder among VA patients with alcohol use disorder and Hepatitis C and/or HIV

“…Pharmacological options include three FDA-approved medications (acamprosate, disulfiram, and oral or injectable naltrexone) (Jonas et al, 2014; NIAAA, 2007), and a fourth, topiramate, was found to have strong evidence for treatment of AUD in a meta-analysis (Jonas et al, 2014). Despite strong evidence for these treatments, they are underused among patients with AUD (Cohen et al, 2007; Harris et al, 2012; Rubinsky et al, 2015), and multiple barriers to treatment receipt and implementation have been documented (Alanis-Hirsch et al, 2016; Finlay et al, 2017; Hagedorn et al, 2016; Harris et al, 2013; Knudsen and Roman, 2014; Ober et al, 2017; Oliva et al, 2011; Williams et al, 2017a). People with infectious diseases (HCV and HIV) may be even less likely to receive evidence-based treatment for AUD compared to people without these conditions (Owens et al, 2018; Williams et al, 2017d).…”

Barriers and Facilitators to Implementation of Pharmacotherapy for Opioid Use Disorders in VHA Residential Treatment Programs

“…The current study was part of a larger mixed-methods study to develop performance metrics specific to residential substance use disorder treatment programs based on electronic health record data (Ellerbe, et al, 2017; Finlay et al, 2017; Rubinsky et al, 2017). The study protocol was approved by the Stanford University Institutional Review Board (IRB) and the VA Palo Alto Research & Development committee.…”

Use of pharmacotherapy for alcohol use disorder in Manitoba, Canada: A whole-population cohort study

“…Despite the substantial individual, societal, and global public health burden of AUD, it appears to be largely untreated [1,15]. Even though effective pharmacotherapies for AUD have been available for decades and are supported by numerous systematic reviews and meta-analyses establishing both their efficacy and safety [16][17][18][19], drugs such as naltrexone and acamprosate have been found to be severely underutilized among AUD patients in select populations [20][21][22]. For example, in studies of US military veterans with AUD, fewer than 5% received any kind of pharmacotherapy [21,22].…”