Dec. 31, 2009 The integration of alcohol screening, treatment and referral into primary care and other medical settings is not routinely done. Nor are there any studies evaluating the effectiveness of integrating care for alcohol use disorders (AUDs) into routine treatment for tuberculosis (TB), despite the high co-occurrence and mortality associated with these two diseases. Accordingly, researchers have designed a trial study to determine the effectiveness of integrating pharmacotherapy and behavioral treatments for AUDs into routine care for TB.
The study will be published in the February 2010 issue of Alcoholism: Clinical & Experimental Research.
"In many primary-care settings, screening for drinking problems is not necessarily a routine part of visits," said Shelly F. Greenfield, director of clinical and health services research and education in the Alcohol and Drug Abuse Treatment Program at McLean Hospital and corresponding author for the study. "In many specialized medical settings, screening for alcohol problems is even less frequent," she added. "For example, in clinics that treat TB, it would not be common practice to screen for alcohol problems, yet alcohol problems often co-occur among patients with TB."
Greenfield said she and her colleagues chose to conduct their study in Tomsk, Russia because of its high rates of both alcohol problems and tuberculosis. "In Tomsk, we found that alcohol disorders in this population are common, with 50 percent of all TB patients meeting criteria for alcohol abuse or dependence sometime during their lifetime."
"This study is particularly important for Russia where multi-drug resistant TB is common," observed George Woody, a professor in the department of psychiatry at the University of Pennsylvania and Treatment Research Institute, "and where medical specialties are divided into silos that require patients to visit multiple providers for problems that are closely linked and could be better managed by integrated approaches like the one the authors are testing."
"Alcohol disorders not only place individuals at increased risk for acquiring a number of diseases, but once people acquire a disease like TB, alcohol places them at higher risk for poor outcome and death," added Greenfield. "This is because alcohol can suppress the immune system, alcohol hepatitis can complicate TB treatment since many TB medications are potentially toxic for the liver, and people with drinking problems are also less likely to be able to adhere to their TB treatment."
As part of the Integrated Management of Physician-delivered Alcohol Care for Tuberculosis (IMPACT) trial, Greenfield and her colleagues divided 200 patients -- confirmed to have alcohol abuse or dependence, newly diagnosed with TB, and initiating treatment in the Tomsk Oblast Tuberculosis Service -- into one of four groups: 1) oral naltrexone + brief behavioral compliance enhancement therapy (BBCET) + treatment as usual (TAU); 2) brief counseling intervention (BCI) + TAU; 3) naltrexone + BBCET + BCI + TAU; and 4) TAU alone. The trial is ongoing.
"To our knowledge, this is the first study to examine the feasibility of delivering alcohol treatment as part of routine TB care," said Greenfield, "and to assess this treatment model's impact on both TB and alcohol outcomes. If proven feasible and effective, this treatment model could be adapted for patients with AUDs and co-occurring medical conditions in other settings, specifically, anywhere co-occurring AUDs adversely affect TB outcomes, including the United States."
"The idea of integrated treatments is not new, but only just beginning to be studied and implemented in Russia and other countries, including the U.S.," said Woody. "These findings show the universality, practicality, and potential importance of developing integrated treatments for alcoholism, HIV, and other serious health problems. They could be life-saving not only for the affected individuals, but also for the community that is at risk for the spread of TB via cases that are inadequately treated due to poor adherence to prescribed medication. Finally, these findings could easily be applied, would likely be cost-effective, and could contribute to current efforts to reduce overall medical treatment costs."
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