Abstract
Background
Three medications are FDA-approved and recommended for treating alcohol use disorders (AUD) but they are not offered to most patients with AUD. Primary care (PC) may be an optimal setting in which to offer and prescribe AUD medications, but multiple barriers are likely.
Objective
This qualitative study used social marketing theory, a behavior change approach that employs business marketing techniques including “segmenting the market,” to describe (1) barriers and facilitators to prescribing AUD medications in PC, and (2) beliefs of PC providers after they were segmented into groups more and less willing to prescribe AUD medications.
Design
Qualitative, interview-based study.
Participants
Twenty-four providers from five VA PC clinics.
Approach
Providers completed in-person semi-structured interviews, which were recorded, transcribed, and analyzed using social marketing theory and thematic analysis. Providers were divided into two groups based on consensus review.
Key Results
Barriers included lack of knowledge and experience, beliefs that medications cannot replace specialty addiction treatment, and alcohol-related stigma. Facilitators included training, support for prescribing, and behavioral staff to support follow-up. Providers more willing to prescribe viewed prescribing for AUD as part of their role as a PC provider, framed medications as a potentially effective “tool” or “foot in the door” for treating AUD, and believed that providing AUD medications in PC might catalyze change while reducing stigma and addressing other barriers to specialty treatment. Those less willing believed that medications could not effectively treat AUD, and that treating AUD was the role of specialty addiction treatment providers, not PC providers, and would require time and expertise they do not have.
Conclusions
We identified barriers to and facilitators of prescribing AUD medications in PC, which, if addressed and/or capitalized on, may increase provision of AUD medications. Providers more willing to prescribe may be the optimal target of a customized implementation intervention to promote changes in prescribing.
Similar content being viewed by others
INTRODUCTION
Alcohol use disorders (AUDs) are common, chronic, and undertreated.1 , 2 This is particularly true for U.S. veterans, for whom the estimated lifetime prevalence of AUD is 32%,3 relative to an estimated lifetime prevalence of 29% in the U.S. general population.4 Although specialty addiction treatment improves outcomes for patients with AUD,5 , 6 most never receive it,7 and many do not want to attend specialty addiction programs.7 Experts have called for expansion of evidence-based treatment options offered to patients with AUD and increased management of AUD in non-specialty settings, especially primary care (PC).8,9, – 10
Three medications for AUD are approved by the U.S. Food and Drug Administration (FDA).11 , 12 They include disulfiram, which causes an adverse reaction if patients drink alcohol; naltrexone, an opiate antagonist that is available for both oral administration and via monthly injections; and acamprosate, a glutamate modulator that reduces symptoms associated with abstinence from alcohol.13 Other medications, such as topiramate, have strong meta-analytic support for treating AUD.14 A meta-analysis of the evidence for the effectiveness of AUD medications found the strongest evidence for acamprosate and oral naltrexone, with no clear difference in effectiveness between them.14
Medications for treating AUD can be prescribed and managed in PC.14 While the majority of the evidence for AUD medications originates from specialty treatment settings, and a “gold standard” for AUD medication management in PC has not been established, some studies have evaluated interventions that could be adapted to PC settings.14 For instance, the nine-arm COMBINE trial11 , 15 demonstrated that AUD medications with ongoing “medical management” could be as effective as a state-of-the-art behavioral intervention.11 Further, the emergence of new models of PC–mental health integration and/or patient-centered medical homes may enable PC providers to prescribe and integrate these medications into existing care systems.16 , 17 However, there are likely multiple barriers to PC providers’ prescribing these medications. Previous research in addiction treatment settings has identified barriers related to knowledge, skills, and beliefs.18 However, barriers to the use of AUD medications in PC have not been described previously, and are likely to include additional barriers unique to the PC setting, as care for AUD has historically been separated from PC.14
Conceptual models of implementation suggest a strong role for peer leaders in the diffusion of innovations.19 , 20 Similarly, social marketing theory21 , 22—focused on identifying and changing underlying emotions that influence behavior—employs business marketing techniques, such as “segmenting the market,” to identify groups that may lead change. To optimize implementation of AUD medications in PC, it may be important to identify barriers specific to “segments” of PC providers based on willingness to prescribe. Addressing barriers among those most willing to prescribe may result in a segment of peer leaders who can lead implementation across groups.
Therefore, using social marketing theory, we conducted this qualitative study of PC providers in the Veteran’s Health Administration (VA) to describe barriers to and facilitators of the use of AUD medications, and secondarily to describe barriers and facilitators specific to subgroups based on willingness to prescribe.
METHODS
Participants and Setting
This study took place at five distinct, freestanding PC clinics associated with a single large VA healthcare system in the northwestern United States. Three clinics were located within two large urban centers, which serve approximately 21,000 patients each (both ~88% male). Two clinics were VA-managed community-based outpatient clinics (CBOCs), which are more rural and serve approximately 4000 (~90% male) and 6500 patients (~92% male), respectively. PC providers with prescribing privileges were eligible.
Recruitment
We first identified a key point of contact at each clinic in order to introduce the study and determine the best way to opportunistically recruit and conduct interviews with participants, while minimizing disruption to clinic operations and patient care. Clinical contacts and participants were not blinded to the purpose of the study. Depending on clinic preference, recruitment strategies involved emailing invitations to all providers in the clinic to request and arrange a time for interviews, or coordinating with clinic leadership to be on site to recruit participants opportunistically. The latter was the most frequent method of recruitment. Potential participants were given a verbal overview of the study, provided with an information sheet, and asked to provide verbal consent. The study, including a waiver of written informed consent, was approved by the VA Puget Sound Institutional Review Board.
Data Collection
In-person semi-structured interviews were conducted between August 2014 and July 2015 by an interviewer trained in qualitative methodology (CEA or JPY). One interviewer (CEA) is also a PC provider. The interview guide (Appendix 1) was developed based on domains of behavior change articulated in a social marketing framework,22 previous barriers identified in addiction treatment settings,18 and hypothesized barriers in PC settings.14 The guide assessed knowledge about/experience with AUD medications, barriers to prescribing, perception of skills and resources needed to prescribe, optimism regarding the usefulness of AUD medications, possible facilitators, and willingness to prescribe. The interview included three sections of open-ended questions, with suggested follow-up questions. The first two sections addressed the participants’ general experience with/approach to patients with AUD and AUD medications, and are the focus of the present study. The third addressed issues related to pharmacogenetics, and findings have been reported previously.23 Interviews lasted approximately 20 min and were digitally recorded, transcribed, and reviewed for accuracy. Interviews were conducted until saturation of themes occurred (e.g., investigator consensus that no new information was identified).
Data Analysis
Data were analyzed iteratively using thematic analysis24,25, – 26 to identify both expected (a priori) and emergent themes. Midway through data collection, interim analysis was conducted to review early emergent themes, triangulate data with existing theory and research, modify procedures in response, and check for saturation.27,28, – 29 Preliminary analyses were conducted using the Rapid Assessment Process,27 in which data from each interview transcript were reduced to a templated summary corresponding to interview questions and distributed to the full multidisciplinary team for review. This process confirmed a priori themes, identified emergent themes, and served as the initial codebook for full data analysis. Consistent with social marketing theory, this process also allowed “market segmentation,” which included categorizing participants into one of two groups (more willing and less willing) based on consensus among investigators after independent data review.
After interviews were complete, all data were analyzed using ATLAS.ti.30 Two master’s level investigators trained in public health (JY and JR) and social work (JY) independently coded all data using the codebook established during interim analysis; both added new codes if evidence accumulated in support of new themes.24,25, – 26 Discrepancies in coding were resolved via consensus among investigators. Coded content was reviewed iteratively by the multidisciplinary investigator team, and coded data were grouped into distinct themes for all participants and across subgroups based on willingness to prescribe. All investigators reviewed coded data to finalize themes, check conclusions against the data, and identify prototypical content within each theme for presentation.31 , 32
RESULTS
Twenty-four PC providers were recruited. This included all providers practicing at both CBOCs (n = 11), and all we attempted to recruit at two of the three urban clinics associated with large medical centers (n = 13). Recruitment at the third urban clinic was challenging due to changes in leadership during the study, and ultimately only one provider from this clinic participated. Recruited providers included 19 medical doctors (MDs), one doctor of osteopathy (DO), and four nurse practitioners (NPs); 53% were female. Participating providers had been practicing in PC for a mean of 15 years (SD 11.9) and spent an average of 25.7 hours (SD 9.0) with patients per week.
Barriers to and Facilitators of Prescribing AUD Medications
Three barriers and three facilitators to prescribing AUD medications were identified in the sample of all participants and are described below.
-
Barrier 1: Limited knowledge of and experience with prescribing AUD medications
Participants reported limited knowledge of and experience with prescribing AUD medications. Some had heard of some of the medications and/or recognized the name of one or more, and some had treated patients who had received prescriptions from another provider. Participants were more familiar with some medications than others: Antabuse® (disulfiram) was the medication most commonly recognized/mentioned by providers, acamprosate the least. However, few had received any training or education on AUD medications, most reported lacking the practical knowledge needed to prescribe or manage them, and few reported having ever prescribed them. One provider (PCP1) said, “I don’t have the education or experience … I definitely wouldn’t do that [prescribe].” Participants attributed discomfort and/or reluctance to prescribe to their limited knowledge and lack of prescribing experience. One (PCP2) said, “I don’t think I’d feel comfortable enough even if the patient was started on it, to renew it …. if I’ve never prescribed it, it’s not in my scope of practice, then I don’t know what to tell them to look out for.”
-
Barrier 2. Concern that medications should not be offered without counseling and beliefs that specialty addiction treatment is the only option for treatment
Providers expressed concern that prescribing AUD medications without providing concurrent behavioral therapy represented substandard AUD treatment. For instance, one participant (PCP3) said, “I think if I’m prescribing naltrexone … that it’s a far inferior option than having somebody engaged with ATC [the addiction treatment center].” Another (PCP4) said, “Do I think you can start somebody on naltrexone and pat them on the back and then send them on their way? No, I don’t. … if this is where it stops [at AUD medications], we’re not going to be successful.”
Providers believed in specialty addiction treatment as the only option for treatment, and based on this perspective, some expressed reluctance to prescribe medications. One (PCP6) said, “I’m not convinced that they’re [medications] all that helpful, to be honest. …they’re more of an adjunct, they’re not the treatment … the main treatment is the program, right?” Some felt that the inclusion of a 12-step model of treatment was an essential component of successful AUD care. One (PCP7) said, “Maybe a medication alone could do it for some people, but it’s part of broader behavioral … reinforcement … all the 12 steps.”.
-
Barrier 3. Expressions of alcohol-related stigma
Multiple expressions of alcohol-related stigma, or prejudicial societal beliefs and attitudes that discredit individuals based on their alcohol use,33 were identified. Consistent with definitions of stigma in the literature,34,35, – 36 these included: perceptions of character flaws (e.g., untrustworthiness), social distancing (e.g., someone else should treat this condition), perceptions of control of and culpability for AUD (e.g., beliefs that patients are choosing their condition and can quit if they are willing to do the work), and labeling language (e.g., “those people” and “alcoholics”). Prototypical examples are presented in Table 1.
Facilitators
Facilitator 1: Training and Education
Participants articulated that they would feel more comfortable prescribing AUD medications with training and education. Content suggestions included training on medication characteristics (options, side effects, safety profiles, contraindications), effectiveness, prescribing (how to start and stop medications, dosing and adjustment, duration, lab monitoring, choosing the right medication for the right patient), and education about specialty care services and treatment. One participant (PCP8) summarized the need for information: “Give me the tools, give me the rules, give me the pros and cons. Let’s make sure everybody’s educated … then why wouldn’t you do it?”
Regarding the method of training delivery, participants suggested education via flyers, handouts, and PowerPoint presentations; facilitated training such as in-services or mini-residencies; and integration of AUD medication and prescribing information into existing electronic clinical decision support applications. They also identified potential leaders who should deliver training, including addiction and mental health providers or pharmacists.
Facilitator 2: Support for Prescribing
Many participants suggested having ongoing external support for prescribing AUD medications (e.g., from mental health or addiction specialists, pharmacists). One provider (PCP2) said, “I feel it does have to be spoon fed to us. I’m totally willing to do it, but it would need to be someone telling me what to prescribe.” Possibilities for this type of support ranged from self-initiated consults with specialists outside PC (e.g., teleconferences or non-visit consults, just to “run it by” someone), to requesting ongoing consultation with mental health providers or pharmacists (e.g., “I’d have to have my hand held a little bit … probably working with pharmacy” PCP18), to integrating staff with addictions expertise within PC (e.g., a “larger sort of addiction team [to provide] close and regular follow up, support, compliance” PCP5).
Facilitator 3: Provision of Behavioral Follow-Up Completed by Mental Health or Specialty Care Staff
Providers also suggested having mental health or specialty addiction providers onsite and available to provide behavioral follow-up for patients. One (PCP6) said, “I think you’d want somebody at the clinic itself here … managing the substance dependence.” Some expressed that having these resources would be essential to their comfort/ability to prescribe. One provider (PCP10) said, “I don’t want them to just be getting medications from me and then not having the backup of a therapist.” And another (PCP2) described wanting “someone doing the talk therapy … and then me just checking in just like I check in on their heart disease.”
Themes Identified within Provider “Segments” Based on Willingness to Prescribe
Social marketing advocates identification of population “segments” that differ in key attitudes or behaviors, and tailors interventions to those segments.37 We identified two segments—providers more and less willing to prescribe—that differed in their beliefs regarding the role of PC in AUD treatment, the effectiveness and role of medications in treating AUD, and the potential for prescribing AUD medications in PC. A summary of beliefs reflected in each group is provided below; prototypical examples within each group are presented in Appendix 2.
Those who were less willing to prescribe expressed beliefs that: medications cannot effectively treat AUD; treating AUD is not the role of PC; specialty addiction treatment providers are and should remain the experts; and substantial changes would be necessary for them to prescribe AUD medications. Additionally, these providers indicated that there was no time to treat AUD in PC. Specifically, they noted that: management of AUD is time-intensive and requires a great deal of follow-up; effective medication prescription would require providers to also address psychosocial issues with their patients, which is not practical; and PC is already handling too many agendas for the short time they have with their patients.
Those who were more willing to prescribe expressed beliefs that medications are a “tool that can be useful” or a “first step” in treating AUD. This was accompanied by the perspective that treating AUD involves a continuum of approaches and that medications can be one part of that approach, and may even help open the patient to behavioral or psychosocial treatment. These providers believed that PC represents an optimal setting in which to prescribe medications, because it reduces barriers to specialty addiction treatment, such as stigma or geographical or other logistical barriers, and may enable capitalizing on prime moments for behavior change given that PC is a “first line” of treatment. These providers also believed that prescribing AUD medications was within the scope of PC and would be similar to prescribing for other conditions, such as smoking or depression. Finally, they believed that the role of the PC provider was to choose anything that might help the patient (e.g., even if a combination of medication and therapy might be best, they would be willing to try medication alone if that is what the patient wanted) and that to not prescribe medication might deny patients the opportunity for change.
Discussion
This qualitative study identified barriers to and facilitators of prescribing AUD medications in PC, and applied social marketing theory to identify two groups of providers who were distinguished based on their willingness to prescribe and beliefs regarding AUD pharmacotherapy in PC. The findings suggest that lack of knowledge and experience, beliefs regarding the superiority of behavioral treatments for AUD provided in specialty settings, and alcohol-related stigma may constitute barriers to the provision of AUD medications in PC, whereas training, support, and integrated care models may facilitate provision.
While previous studies have described barriers experienced by specialty addiction care providers18 , 38,39,40, – 41 and providers in HIV PC clinics,42, this is the first to our knowledgeto have assessed barriers in general PC. The barriers that were identified overlap with those previously reported in other settings—specifically, lack of knowledge/training, optimism, and confidence in the use of medications, and a belief that medication treatment is not consistent with traditional treatment philosophy.18 , 38,39,40,41, – 42 PC providers reflected similar feelings and perceptions; they lacked knowledge, confidence, and optimism regarding both prescribing and managing AUD medications, and articulated beliefs that patients were best served by expert providers in specialty addiction treatment. In addition to barriers that may be common across settings, findings from the present study suggest hurdles that are unique to PC. Specifically, providers believed that medication prescribing in PC would only have a chance of being effective if additional staff were available to provide behavioral support.
While specialty addiction treatment is effective for patients who engage, most patients with AUD (~85%)7 do not engage.43,44, – 45 Therefore, offering only specialty addiction treatment may contradict contemporary standards of evidence-based46 and patient-centered care.46 , 47 Provision of AUD treatment in PC is one way to increase patient-centered care for AUD.10 With the emergence of studies suggesting that effective AUD treatment could be provided in PC, there is potential to expand on treatment options. Specifically, in the COMBINE trial, patients were offered “medical management,” which was designed to be feasible in PC and included up to nine manual-guided counseling visits over 16 weeks following medication prescription.11 Though the first visit was longer—45 min—follow-up visits were approximately 20 min each, and the content of the counseling was focused on advice to reduce drinking, adverse effects, the importance of adherence, and encouragement for 12-step attendance if patients were interested.11 , 14 , 15 In conjunction with AUD medications, this model was as effective as specialty addiction treatment.11 , 15 In another study of PC patients with AUD, an alcohol care management intervention focused on treatment with naltrexone and delivered by behavioral health providers (nurses and psychologists) with support from a nurse practitioner resulted in high rates of patient engagement with medications and fewer heavy drinking days relative to usual care (referral to specialty treatment).48 Findings from these studies in recruited populations of patients with AUD suggest the possibility that—if given the time, support, and/or training to do so— PC providers and/or teams can provide the needed adjunct to medications, similar to prescribing medications for depression. Such approaches would be compatible with patient-centered medical homes,49,50, – 51 integrated primary and mental health care,52 and collaborative care models for other behavioral health conditions.53
Expressions of alcohol-related stigma were common in this study. Because stigma is deeply embedded in social and cultural norms,34 and AUD is one of the most highly stigmatized mental health disorders,54 these findings are unsurprising. Stigma influences how medical care is provided.35 , 36 , 55 For instance, in a study of 728 mental health providers randomly assigned to one of two vignettes that differed only in the terminology used to refer to a patient, providers randomly assigned to the term “substance abuser” were more likely than those assigned the term “substance use disorder” to agree with the notion that the patient was personally culpable for his condition and to suggest punitive measures be taken (as opposed to treatment).36 Stigma is also a barrier to treatment receipt for patients with AUD due to perceptions of control and culpability. Among persons with AUD who had considered seeking treatment in a national sample, 44% felt they should be strong enough to handle their disorder alone, 18% were too embarrassed to discuss it, and 10% “hated answering personal questions.”7 Because stigmatized attitudes toward patients with AUD influence the provision or quality of AUD care and/or patient response or openness to care, interventions focused on changing social norms and/or beliefs56 among patients and providers may be needed.
Despite identification of several barriers, findings from this study offer multiple reasons for optimism regarding provision of AUD pharmacotherapy in PC. First, participating providers described models of care for facilitating the provision of AUD pharmacotherapy in PC that were consistent with efficacious models.11 , 48 Moreover, providers offered several actionable suggestions, including training on the use of AUD medications in PC and support for prescribing from pharmacists or specialty addiction treatment providers. They also suggested specific modes of delivery for training and support, such as webinars and electronic consults with pharmacists. Moreover, this study identified a subgroup of providers who indicated greater willingness to prescribe and who shared beliefs that may facilitate provision of AUD pharmacotherapy. According to social marketing theory, if encouraged via interventions, this group of providers may serve as leaders of changes in beliefs and attitudes across providers.21 , 22 , 37 , 57,58,59,60,61, – 62
This study has several noteworthy limitations. While interviews were conducted with providers from five different PC clinics to the point of saturation, findings within segments may require further exploration. Additionally, findings may not represent the experiences of PC providers elsewhere. Previous research has suggested variability in the provision of AUD pharmacotherapy across VA facilities.63 It is possible that levels of comfort among providers at the study clinics differed from those at other sites. In addition, because participants were not blinded to the study purpose, responses may have been influenced by social desirability bias. Further, providers were asked only about prescription of medications. They may have responded differently if asked whether they would be willing to prescribe AUD medications if systems for assistance with care management and/or linkage with other services were in place.
Despite these limitations, this is the first study to have identified barriers and facilitators to the provision of AUD pharmacotherapy in PC. Because most patients with AUD do not receive evidence-based treatment for their AUD,7 and because PC may be the optimal care setting in which to treat AUD,8,9, – 10 identifying opportunities to address barriers and capitalize on facilitators serves as an important foundation for efforts to increase access to quality care for AUD.64 This study identifies several such opportunities. Training and augmenting PC with team members who can help willing PC providers manage AUD, and interventions aimed at modifying beliefs held by PC providers may be the optimal targets for moving treatment of AUD into PC.
References
Room R, Babor T, Rehm J. Alcohol and public health. Lancet 2005;365(9458):519-530.
Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291(10):1238-1245.
Lan C-W, Fiellin DA, Barry DT, et al. The epidemiology of substance use disorders in US Veterans: A systematic review and analysis of assessment methods. Am J Addict 2016;25:7-24.
Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA psychiatry 2015;72(8):757-766.
Weisner C, Matzger H, Kaskutas LA. How important is treatment? One-year outcomes of treated and untreated alcohol-dependent individuals. Addiction 2003;98(7):901-911.
Dawson DA, Grant BF, Stinson FS, Chou PS. Estimating the effect of help-seeking on achieving recovery from alcohol dependence. Addiction 2006;101(6):824-834.
Cohen E, Feinn R, Arias A, Kranzler HR. Alcohol treatment utilization: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend 2007;86(2–3):214-221.
McLellan AT. Reducing heavy drinking: a public health strategy and a treatment goal? J Subst Abus Treat 2007;33(1):81-83.
Willenbring ML. Medications to treat alcohol dependence: adding to the continuum of care. JAMA 2007;298(14):1691-1692.
Bradley KA, Kivlahan DR. Bringing patient-centered care to patients with alcohol use disorders. JAMA 2014;311(18):1861-1862.
Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA 2006;295(17):2003-2017.
National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide (Updated 2005 Edition). Washington, D.C.: National Institutes of Health, U.S. Department of Health and Human Services; 2007.
Lingford-Hughes AR, Welch S, Peters L, Nutt DJ. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. J Psychopharmacol 2012;26(7):899-952.
Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA 2014;311(18):1889-1900.
Pettinati HM, Weiss RD, Dundon W, et al. A structured approach to medical management: a psychosocial intervention to support pharmacotherapy in the treatment of alcohol dependence. J Stud Alcohol Suppl 2005(15):170-178; discussion 168-179.
Nelson KM, Helfrich C, Sun H, et al. Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. JAMA Intern Med 2014;174(8):1350-1358.
Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care 2009;15(9):e71-87.
Oliva EM, Maisel NC, Gordon AJ, Harris AHS. Barriers to Use of Pharmacotherapy for Addiction Disorders and How to Overcome Them. Curr Psychiatry Rep 2011;13(5):374-381.
Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 2004;82(4):581-629.
Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009;4:50.
Siegel M, Lotenberg LD. Marketing public health: strategies to promote social change. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2007.
Robinson L. Social marketing - a 7 step approach. 2010. https://www.comminit.com/content/social-marketing-7-step-approach. Accessed 10 Aug 2017.
Williams EC, Young JP, Achtmeyer CE, Hendershot CS. Primary Care Providers' Interest in Using a Genetic Test to Guide Alcohol Use Disorder Treatment. J Subst Abus Treat 2016;70:14-20.
Braun V, Clarke V. Thematic analysis. In: Lyons PRA, ed. Qualitative research in clinical and health psychology. Bassingstoke: Palgrave MacMillan; 2014.
Brauns V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77-101.
Miles MB, Huberman M. Qualitative data analysis : an expanded sourcebook. 2nd ed ed. Thousand Oaks: Sage Publications; 1994.
Beebe J. Rapid assessment process: an introduction. Altmira Press; 2001.
Hamilton A. Rapid turn-around: tips for speeding up qualitative projects. 5th Annual Planning for Qualitative Research: Design, Analysis and Software Intergration; 2014; University of North Carolina - Chapel Hill, NC
McMullen CK, Ash JS, Sittig DF, et al. Rapid assessment of clinical information systems in the healthcare setting: an efficient method for time-pressed evaluation. Methods Inf Med 2011;50(4):299-307.
Atlas.ti [computer program]. Version 7.5.12. Berlin, Germany: GmbH; 2016.
Morse JM, Barrett M, Mayan M, Olson K, Spiers J. Verification strategies for establishing reliability and validity in qualitative research. Int J Qual Methods 2002;1(2):13-22.
Creswell JW. Qualitative inquiry and research design: Choosing among five traditions. Thousand Oaks, CA: Sage; 1997.
Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol 1997;27:363-385.
Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link BG. "A disease like any other"? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. Am J Psychiatry 2010;167(11):1321-1330.
Kelly JF, Wakeman SE, Saitz R. Stop talking 'dirty': clinicians, language, and quality of care for the leading cause of preventable death in the United States. Am J Med 2015;128(1):8-9.
Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy 2010;21(3):202-207.
Lee NR, Kotler P. Social marketing: influencing behaviors for good. 4th ed. Thousand Oaks, CA: SAGE Publications, Inc.; 2011.
Harris AH, Ellerbe L, Reeder RN, et al. Pharmacotherapy for alcohol dependence: perceived treatment barriers and action strategies among Veterans Health Administration service providers. Psychol Serv 2013;10(4):410-419.
Mark TL, Kranzler HR, Poole VH, Hagen CA, McLeod C, Crosse S. Barriers to the use of medications to treat alcoholism. Am J Addict 2003;12(4):281-294.
Mark TL, Kranzler HR, Song X. Understanding US addiction physicians' low rate of naltrexone prescription. Drug Alcohol Depend. 2003;71(3):219-228.
Mark TL, Kranzler HR, Song X, Bransberger P, Poole VH, Crosse S. Physicians' opinions about medications to treat alcoholism. Addiction 2003;98:617-626.
Chander G, Monroe AK, Crane HM, et al. HIV primary care providers-Screening, knowledge, attitudes and behaviors related to alcohol interventions. Drug Alcohol Depend 2016.
National Center on Addiction and Substance Abuse. Addiction medicine: closing the gap between science and practice. 2012. Available from http://www.casacolumbia.org/upload/2012/20120626addictionmed.pdf. Accessed 10 Aug 2017.
McLellan AT. Public accountability in addiction treatment. Lancet 2009;374(9697):1220-1221.
McLellan AT. Treatment given high priority in new White House drug control policy. Interview by Bridget Kuehn JAMA 2010;303(9):821-822.
Selby JV, Beal AC, Frank L. The Patient-Centered Outcomes Research Institute (PCORI) national priorities for research and initial research agenda. JAMA 2012;307(15):1583-1584.
Barry MJ, Edgman-Levitan S. Shared decision making--pinnacle of patient-centered care. N Engl J Med 2012;366(9):780-781.
Oslin DW, Lynch KG, Maisto SA, et al. A randomized clinical trial of alcohol care management delivered in Department of Veterans Affairs primary care clinics versus specialty addiction treatment. J Gen Intern Med 2014;29:162–168.
Carrier E, Gourevitch MN, Shah NR. Medical homes: challenges in translating theory into practice. Med Care 2009;47(7):714-722.
Larson EB, Reid R. The patient-centered medical home movement: why now? JAMA 2010;303(16):1644-1645.
AHRQ updates on primary care research: the AHRQ Patient-Centered Medical Home Resource Center. Ann Fam Med. 2014;12(6):586.
Felker BL, Chaney E, Rubenstein LV, et al. Developing effective collaboration between primary care and mental health providers. Prim Care Companion J Clin Psychiatry 2006;8(1):12-16.
Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract 1998;1(1):2-4.
Schomerus G, Lucht M, Holzinger A, Matschinger H, Carta MG, Angermeyer MC. The stigma of alcohol dependence compared with other mental disorders: a review of population studies. Alcohol Alcohol 2011;46(2):105-112.
Chang J, Dubbin L, Shim J. Negotiating substance use stigma: the role of cultural health capital in provider-patient interactions. Sociol Health Illn 2016;38(1):90-108.
Corrigan P, Gelb B. Three programs that use mass approaches to challenge the stigma of mental illness. Psychiatr Serv 2006;57(3):393-398.
Daniel KL, Bernhardt JM, Eroglu D. Social marketing and health communication: from people to places. Am J Public Health 2009;99(12):2120-2122.
Evans WD. How social marketing works in health care. BMJ 2006;332(7551):1207-1210.
Evans WD, McCormack L. Applying social marketing in health care: communicating evidence to change consumer behavior. Med Decis Mak 2008;28(5):781-792.
Gordon R, McDermott L, Stead M, Angus K. The effectiveness of social marketing interventions for health improvement: what's the evidence? Public Health 2006;120(12):1133-1139.
Janssen MM, Mathijssen JJ, van Bon Martens MJ, van Oers HA, Garretsen HF. Effectiveness of alcohol prevention interventions based on the principles of social marketing: a systematic review. Subst Abuse Treat Prev Policy 2013;8(1):18.
Morris ZS, Clarkson PJ. Does social marketing provide a framework for changing healthcare practice? Health Policy 2009;91(2):135-141.
Harris AH, Oliva E, Bowe T, Humphreys KN, Kivlahan DR, Trafton JA. Pharmacotherapy of alcohol use disorders by the Veterans Health Administration: patterns of receipt and persistence. Psychiatr Serv 2012;63(7):679-685.
National Institute on Alcohol Abuse and Alcoholism. Increasing the use of medications for the treatment of alcohol use disorders (R01). 2016; Available at: https://grants.nih.gov/grants/guide/pa-files/PAR-17-079.html. Accessed 10 Aug 2017.
Acknowledgements
The authors gratefully acknowledge the participants of this study for generously allowing us to solicit and report on their perspectives. This study was funded by VA Health Services Research & Development and VA Quality Enhancement Research Initiative (RRP 12-528; Williams PI). Dr. Williams is supported by a Career Development Award from VA Health Services Research & Development (CDA 12-276); Dr. Bradley is supported by a mid-career mentoring award from the National Institute on Alcohol Abuse and Alcoholism (K24-AA022128). Results from this study were presented at the annual meeting of the Research Society on Alcoholism (June 2015), the annual meeting of the International Network on Evidence Based Brief Interventions for Alcohol and Drugs (September 2015), and the 8th Annual Conference on the Science of Dissemination and Implementation (December 2015).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Disclaimer
Views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, the United States government, the University of Washington, or Kaiser Permanente Washington Health Research Institute.
Appendices
Appendix 1: Interview Guide
Introduction to participant: The VA wants to improve care for patients with alcohol use disorders and is looking at some different ways of doing this. We will be asking you questions in three main areas: first, about your general experience with patients with alcohol use disorders in your practice; second, about medications to treat alcohol use disorders; and third, about use of genetic testing.
Section 1: General approach
-
1)
How do you work with patients with alcohol use disorders, or who are drinking too much, in your practice? What is your approach?
-
a)
How do you know that a patient is drinking too much?
-
b)
After you identify they are drinking too much, then what do you do?
-
i)
If needed: What do you tell them?
-
ii)
If needed: How do patients respond?
-
iii)
If needed: What do you do next?
-
i)
-
c)
How do you decide what to do?
-
d)
What resources do you offer?
-
a)
-
2)
How do you decide someone should be referred to specialty care/addiction treatment center (ATC)?
-
a)
If needed: How do you know when someone is ready for referral?
-
b)
If someone is drinking too much but does not want to go to specialty care/ATC, but is still on your panel, what do you do then? What is your role?
-
c)
Who do you consult with or get advice from about patients who are drinking too much?
-
a)
-
3)
How well does the VA support your care of patients with alcohol use disorders?
-
a)
What is working or is supportive?
-
b)
What is not working or is not supportive?
-
a)
-
4)
How do you define ‘success’ in working with patients who are drinking too much?
Section 2: AUD medications: The VA is in the early stages of exploring whether there is a role for primary care in prescribing medications for alcohol use disorders. You probably know this, but there are three FDA-approved medications: Antabuse, naltrexone and acamprosate. Antabuse is a deterrent (patients get sick when they drink), but naltrexone and acamprosate are different and reduce alcohol cravings for some patients.
-
1)
Have you seen any of your patients on these medications: Antabuse, Naltrexone or Acamprosate?
-
a)
What are your thoughts about these medications based on what you have seen?
-
b)
Do you think they could be/are helpful for patients? If so, which patients?
-
a)
-
2)
Do you see any role for primary care in prescribing any of these medications?
-
a)
If yes: What is that role for primary care?
-
b)
If no: Whose role should it be?
-
c)
What would that [the role described by participant] look like? How would that work?
-
d)
What are the pros of primary care prescribing medications for alcohol use disorders?
-
e)
What are the cons or downsides of primary care prescribing medications for alcohol use disorders?
-
a)
-
3)
Have you ever prescribed these medications or seen them prescribed?
-
a)
If yes: Tell me about a time when you prescribed or when they were prescribed.
-
a)
-
4)
Have you ever had a patient ask for any of these medications?
-
a)
If yes: Tell me about that time.
-
a)
-
5)
How would you feel about prescribing these medications?
-
a)
What would you need to feel ready to prescribe?
-
b)
Are there any circumstances where you might suggest a patient start on one of these medications?
-
a)
-
6)
Now we are going to ask you a few scenarios:
-
a)
Would you renew a prescription made by another provider (e.g., the patient is already on the medication but needs a refill)?
-
b)
Would you start a prescription with follow up by mental health or care management?
-
c)
If a mental health addiction specialist thought a patient on your panel would benefit from one of these medications and made a recommendation, would you prescribe the recommended medication to the patient?
-
a)
-
7)
Do you have other thoughts or concerns about prescribing these medications that we should include?
Section 3: Genetics:There is some evidence that suggests that patients with certain genetic profiles may respond better to certain alcohol medications like naltrexone. In the future, a genetic test may be available that would allow us to determine which patients are more likely to respond to naltrexone.
-
1)
If such a genetic test was available to you, would you be interested in using it?
-
a)
Why or why not?
-
a)
-
2)
Would having such a test available to you influence your decisions to prescribe these medications?
-
a)
If yes, how would it influence your decisions to prescribe?
-
b)
If no, how would it not influence your decisions to prescribe?
-
a)
-
3)
If a test came back suggesting that a patient would be more likely to respond to a medication, would that influence your prescribing decision?
-
a)
If yes, how would it influence your prescribing decision?
-
b)
If no, how would it not influence your prescribing decision?
-
a)
-
4)
How do you think the use of a genetic test would influence patients’ interest in medications for alcohol dependence?
-
5)
Would the results of such a test influence a patient’s willingness to try a medication for alcohol dependence?
Appendix 2
Rights and permissions
About this article
Cite this article
Williams, E.C., Achtmeyer, C.E., Young, J.P. et al. Barriers to and Facilitators of Alcohol Use Disorder Pharmacotherapy in Primary Care: A Qualitative Study in Five VA Clinics. J GEN INTERN MED 33, 258–267 (2018). https://doi.org/10.1007/s11606-017-4202-z
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-017-4202-z