Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Integrated outpatient treatment increased abstinence in men with alcohol-related illness who were ongoing drinkers

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ACP J Club. 2000 Mar-Apr;132:67. doi:10.7326/ACPJC-2000-132-2-067


Source Citation

Willenbring ML, Olson DH. A randomized trial of integrated outpatient treatment for medically ill alcoholic men. Arch Intern Med. 1999;159:1946-52. [PubMed ID: 10493326]


Abstract

Question

In men with alcohol-related illness who were ongoing drinkers, does integrated outpatient treatment (IOT) increase abstinence, remission of alcohol dependence, quality of life, and survival?

Design

Randomized (allocation concealed*), unblinded,* controlled trial with 2-year follow-up.

Setting

Veterans Affairs Medical Center, Minneapolis, Minnesota, USA.

Patients

105 men (mean age 55 y) who had severe alcohol-related medical illness and had been drinking heavily in the previous 6 months. Exclusion criteria were inability or unwillingness to attend monthly visits, non-alcohol–-related illness with poor prognosis, severe dementia, major psychiatric disorder other than depression, current substance abuse other than alcohol, or civil commitment to treatment or pending commitment. Follow-up was 96%.

Intervention

Men were allocated to IOT (n = 48) or standard care (n = 53). IOT consisted of an inpatient evaluation by a multidisciplinary team; a treatment plan, including specific goals negotiated with the patient; monthly primary care visits to measure biological indicators of heavy drinking and offer encouragement and problem-solving help; and efforts to involve family members.

Main outcome measures

Drinking in previous 30 days, alcohol dependence symptoms in previous year, Addiction Severity Index (ASI) scores, medical service use, quality of life (Treatment of Mild Hypertension Study Health and Well-being Scale scores), and death at 2 years.

Main results

Men in the IOT group were more likely to report abstinence (P = 0.02) (Table) and have outpatient visits (mean 42 vs 17 visits, P < 0.01) than were men in the control group. ASI psychiatric ratings were higher in the IOT group than in the control group at baseline and follow-up. The groups did not differ for mean alcohol-dependence symptoms, quality of life, ASI scores, use of hospital services, or survival at follow-up (Table) except where differences existed at baseline.

Conclusion

In men with alcohol-related medical conditions who were ongoing drinkers, integrated outpatient treatment was associated with greater self-reported abstinence and use of outpatient services than was standard care.

*See Glossary.

Source of funding: Department of Veterans Affairs Research Service.

For correspondence: Dr. M.L. Willenbring, Psychiatry Service (116A), Veterans Affairs Medical Center, 1 Veterans Drive, Minneapolis, MN 55417-2300, USA. FAX 612-970-5891. E-mail vhaminwillem@med.va.gov.


Table. Integrated outpatient treatment (IOT) vs standard care for alcohol-related illness and ongoing drinking†

Outcomes at 2 y IOT Standard care RBI (95% CI) NNT (CI)
Survival 81% 70% 16% (−7 to 48) Not significant
Abstinence in previous 30 d 74% 49% 51% (5 to 128) 4 (3 to 35)

†Abbreviations defined in Glossary; RBI, NNT, and CI calculated from data in article.


Commentary

This provocative study by Willenbring and Olson is the first randomized controlled trial of a longitudinal, primary care intervention in alcohol-dependent patients who have serious alcohol-related medical conditions. A larger trial, with blinded assessment of outcomes in interviews, is needed to unequivocally show the benefit of this approach. However, this study is important for several reasons. First, the intervention was acceptable to patients. Patients who were unlikely to accept referral for specialized alcohol treatment were willing to see primary care providers monthly. Second, the program did not require patients to accept a goal of abstinence but nevertheless resulted in increased self-reported abstinence. Third, the intervention focused partly on tracking biologic markers of disease, which is done routinely in the management of other chronic conditions and is likely to make the intervention acceptable to primary care providers.

Future studies will need to evaluate specific components of the multifaceted intervention. Potential active ingredients include negotiation of treatment goals with patients (1), standardized progress notes that may act as prompts to address the patient’s drinking at each visit, repeated review of objective biologic indicators of harmful drinking (2), and use of protocols and consultants to support primary care providers (3).

Until future study results are available, providers who work with actively drinking patients who have alcohol-related medical conditions should consider scheduling frequent visits specifically to address patients’ drinking, to identify and provide repeated feedback to patients about any improvement or deterioration in objective measures of alcohol-related harm, and to offer referrals as needed to support achievement of abstinence.

Katharine A. Bradley, MD
Veterans Affairs Puget Sound Health Care System, American Lake
Seattle, Washington, USA


References

1. Williams GC, Quill TE, Deci EL, Ryan RM. “The facts concerning the recent carnival of smoking in Connecticut” and elsewhere. Ann Intern Med. 1991;115:59-63. [PubMed ID: 2048862]

2. Kristenson H, Ohlin H, Hultén-Nosslin MB, Trell E, Hood B. Identification and intervention of heavy drinking in middle-aged men: results and follow-up of 24-60 months of long-term study with randomized controls. Alcohol Clin Exp Res. 1983;7:203-9. [PubMed ID: 6135365]

3. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995;273:1026-31. [PubMed ID: 7897786]

1. Lieber CS, Weiss DG, Groszmann R, Paronetto F, Schenker S, for the For the Veterans Affairs Cooperative Study 391 Group I. Veterans Affairs Cooperative Study of polyenylphosphatidylcholine in alcoholic liver disease: effects on drinking behavior by nurse/physician teams. Alcohol Clin Exp Res. 2003;27:1757-64. [PubMed ID: 14634491]