V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K
majority of VA’s SUD treatment programs are in clinics or other outpatient facilities. The power of even the most effective treatments to help veterans recover from SUD will remain limited as long as only about 10 percent of veterans with SUD are receiving them. This shortfall has made VA SUD treatment one of 10 high-priority issues addressed by VA’s Health Services Research and Development (HSR&D) Service, through its CREATE initiative: Collaborative Research to Enhance and Advance Transformation and Excellence. The SUD CREATE is a cluster of studies aimed at increasing the value of, and veteran access to, VA SUD treatment. One of the SUD CREATE investigators is Christine Timko, Ph.D., a senior research career scientist at the Palo Alto VA studying the problem of how to deliver SUD treatment to veterans who’ve been discharged from inpatient detoxification programs. For a variety of reasons – some of them patient centered, such as motivational or environmental; some system related, such as the number of available treatment slots – most veterans don’t engage in SUD treatment after detox. Timko recently completed a study designed to extend the reach of SUD counseling professionals and coaches through enhanced telephone monitoring. “The coach and the patient talk for maybe 15 to 30 minutes, every other week for three months,” Timko said. “The coach is encouraging the patient to think about getting treatment and supporting patients in getting that kind of help. It’s a very low-intensity, lowdemand kind of help.” The results of the study, Timko said, were surprising: “The main outcome was the group that got the telephone calls was less likely to go back into detox again. But they were not more likely to actually get substance abuse treatment.” She speculated that the
phone calls in themselves may have functioned as a kind of informal counseling intervention, keeping patients’ attention on their substance use. “When the telephone calls stopped, the improved outcomes for the telephone patients also stopped.” Two areas of further research have opened up as a result of Timko’s study: She’s leading a team in examining whether telephone monitoring might be beneficial to veterans with SUD who aren’t in detox, but who have both medical/surgical conditions and untreated problems related to alcohol use. Another team has a project designed to guide research priorities for the management of severe alcohol withdrawal syndrome. Timko is leading the translation of this research for communities to improve population outcomes, including reduced morbidity and mortality among alcohol detoxification patients. The SUD CREATE is led by Keith Humphreys, Ph.D., M.A., a senior research career scientist at the Palo Alto VA and the Esther Ting Memorial Professor at the Stanford University School of Medicine. He’s also conducting his own study of the effectiveness of a web-based intervention to reduce alcohol use among veterans with Hepatitis C and other liver diseases. So far his team has designed the intervention, tailoring it to more narrowly focus on a group of about 140 veterans with liver disease who use alcohol, and delivered it in a randomized clinical trial at sites in San Francisco and Palo Alto. “All the data is collected,” Humphreys said. “We’re analyzing it now to see whether or not the intervention lowered their drinking, and also whether it affected any other areas of their health. And then last, what the implications might be for their health care utilization. You know, if it works, maybe they’ll be less likely to end up in the hospital later. That’s the hope.”
A successful web-based intervention, said Humphreys, would constitute a lowcost alternative to treatment for patients with a critical need. “It’s a computer program,” he said. “We can make a million copies by pressing a button. It doesn’t cost anything, and it’s all free and public access.” If it proves even moderately effective, Humphreys said, the VA could email an invitation to participate out to thousands of veterans with current or prior alcohol use disorder and liver disease. “If ... only half the people look at it, and only 25 percent of those complete the whole thing and they cut their drinking a bit, that’s a great investment of VA resources,” he said. Two of the SUD CREATE projects are bigger-picture evaluations of how VA’s SUD treatment system is working overall. Austin Frakt, Ph.D., a health economist at the Boston VA, is studying how funding models and staffing levels influence patient outcomes. At the Ci2i in Palo Alto, Alex Harris, Ph.D., is working to validate more than 40 new measures of addiction treatment quality. Most of these measures are developed by VA mental health experts such as Humphreys – “But sometimes,” Humphreys said, “expert judgment is wrong.” Harris is using data, gathered from interventions with veteran patients, to see if VA programs are, in fact, improving outcomes. “The interesting thing,” said Humphreys, “is that we assume a lot of quality measures we track and encourage clinicians to follow help patients, but sometimes they don’t. So this is really important work.” Like the CREATE’s more patient-focused investigations, these studies of how VA administers and delivers SUD treatment are aimed at the same objectives: lowering the overall cost of care, improving its quality and value, and maximizing the number of veterans who can be helped by it.
Medications such as methadone, buprenorphine, and naltrexone target the same receptors as opioids and have proven effective in reducing opioid use and the related symptoms.
www.defensemedianetwork.com
79
