Make Referrals: Connect Patients to Alcohol Treatment That Meets Their Needs

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    Takeaways

    • For some patients, alcohol treatment referral may not be a single event but instead part of an ongoing process of engagement.
    • You can help patients surmount barriers to following through on a treatment referral by countering the effects of stigma, conveying that treatment can be effective, and offering a range of choices for care.
    • Today’s treatment options may be more acceptable to many patients, including FDA-approved medications for alcohol use disorder that can be offered in primary care, along with flexible, lower-intensity outpatient and telehealth options for specialty care.
    • The NIAAA Alcohol Treatment Navigator can help healthcare professionals and patients to find specialty programs and individual providers that offer evidence-based care tailored to each individual’s needs.

    Only about 7% of adults who had alcohol use disorder (AUD) in the past year accessed any kind of treatment; thus, a sizeable number of people who could benefit are not receiving treatment.1

    Once you determine that a patient has AUD, the next step for patient care depends in part on the level of AUD severity. (See Core article on screening and assessment.) Some patients may be able to receive treatment in primary care via brief interventions and FDA-approved AUD medications, whereas those with more severe AUD or with mental health comorbidities will likely need a referral to specialty behavioral and pharmacologic care.2 (See Core articles on brief intervention, treatment, and mental health issues.)

    Connecting patients to specialty treatment for AUD involves typical referral challenges such as identifying the patients in need, finding local specialists with availability, and exchanging information with the specialists.3,4 Further, referral for AUD is compounded by barriers related to perceptions about AUD treatment and the logistics of finding quality specialty care that the patient can afford.5,6 Here, we describe some of these barriers and possible ways to reduce them.

    What perceptions may set up barriers to AUD referral?

    Both clinicians and patients may live in a context of intense social stigma around AUD. (See Core article on stigma.) Thus, each may have erroneous beliefs about specialist referral,6,7 including:

    • Mistaken beliefs that treatment for AUD is ineffective, that motivated patients should be able to stop on their own, or that prior relapse predicts future nonresponse to treatment.
    • Misguided assumptions that patients must “hit rock bottom” before they will accept treatment or that referral is appropriate only for patients who desire complete abstinence from alcohol.
    • Judging incorrectly that a patient’s problem isn’t serious enough to warrant specialty referral, or holding stereotypes that treatment is only for a certain, other kind of person. These barriers may be particularly prominent when alcohol problems are identified by screening rather than raised by the patient.

    These misperceptions can be magnified by a common, dated, and narrow view of alcohol treatment options, including:

    • Misunderstandings that treatment is limited to options such as inpatient rehab and 12-step programs, which benefit many patients but will not be a good fit for all.
    • Lack of knowledge about newer AUD medications (acamprosate and naltrexone) that patients may find more appealing than the older medication (disulfiram), which makes people sick when they drink alcohol.8

    To learn about the current broad range of evidence-backed treatment options, available at different levels of intensity, see the Core article on treatment and the NIAAA Alcohol Treatment Navigator

    What logistical barriers complicate referral for AUD?

    Historically, addiction treatment in the U.S. has been separated from the rest of healthcare, addressed in physically and organizationally distinct institutions, often without medical providers.9 Although policy changes have encouraged integration,10 persistent silos may create barriers to making referrals for AUD. These barriers are compounded by privacy protections specific to addiction treatment that can hamper information exchange across institutions.9,11 In addition, financial hurdles have been reduced but not eliminated,12 despite legal changes requiring insurance payment parity for alcohol and other substance use disorders.10

    Moreover, it’s not always easy to find evidence-based care for AUD. In much of the U.S., specialty treatment for addiction is limited in availability and variable in quality.12–15 Licensing requirements for addiction treatment vary by state. Education and training of providers may be limited and standards may be inadequate to ensure uptake of evidence-based practices.14 The next section describes an online tool NIAAA designed to facilitate the search for high quality, evidence-based alcohol treatment.

    How can you best locate quality, evidence-based care for patients with AUD?

    Thousands of programs and providers in the U.S. offer evidence-based alcohol treatment, and NIAAA created the Alcohol Treatment Navigator to help people find them. Unlike many other resources you and your patients may find online, the Navigator has no commercial sponsors. The Navigator notes that the most expensive treatment is not always the best; offers expert advice on how to recognize quality, evidence-backed care; and provides links to search for local specialists. It emphasizes the diversity of treatment options, which includes not only traditional, higher-intensity inpatient or residential programs, but also individual therapists and specialty physicians who can offer lower intensity (and potentially more affordable) outpatient and telehealth care. The Navigator’s portal for healthcare professionals shows how to expand your referral lists and share the Navigator with patients.

    What can you and your practice do to facilitate specialist referrals for AUD?

    To address problematic patterns of alcohol use, many healthcare professionals and systems provide screening, brief intervention, and referral to treatment (SBIRT).16 (See Core articles on screening and brief intervention.) National survey data suggests that among people with AUD in the past year, those who received alcohol SBIRT in a past-year medical visit were more likely to attend specialty treatment than those whose medical visits did not include SBIRT.17

    The strategies described below may facilitate referrals. First, you can identify patients who might benefit from referral by using structured tools such as a brief alcohol screener and an AUD symptom checklist. (See Core article on screening and assessment.) Then, in discussing referral, it may be helpful to:

    • Proactively acknowledge and reduce stigma. Help patients understand that AUD is a common, treatable health condition that can happen to anyone. Normalize AUD treatment as similar to specialty care for other chronic medical conditions.18 (See Core article on stigma.)
    • Inform your patients that AUD treatment is effective and that a range of medications and behavioral health treatments can help them cut down or quit drinking or achieve abstinence.19
    • Consider patient preferences and note potentially appealing treatment options, such as flexible outpatient or telehealth care that helps preserve patient privacy and routines, AUD medications, and, for some, stepped treatment goals that may start with significantly reducing the amount and frequency of alcohol consumed. (See Core articles on brief intervention and treatment and the Navigator.)
    • Consider patients’ ability to pay for treatment when making referrals. Become familiar with options for patients with limited financial means (see Resources).
    • Note that the most expensive treatment is not always the best, as mentioned previously, whereas getting individualized, evidence-based care matters most. (See Core article on treatment.)

    At the health system level, steps to support referral may aim for integration of addiction treatment, including basic coordination of services, co-location of services, or even fully integrated teams. As a first step in coordination, affiliation or service agreements can standardize referrals and facilitate information exchange across institutions in ways consistent with privacy regulations.20 Regarding co-location of services, recent studies with hospital patients have demonstrated improved referral completion when SBIRT was performed on-site by specialists who were on staff or from a local substance use treatment center.21,22 Some U.S. grant-funded SBIRT programs have moved towards fully integrated teams using specialized staff to perform SBIRT.23

    How do you refer patients to mutual support groups?

    Although mutual support groups are not professionally-led treatments, you can offer referral for patients who are interested in this approach by providing lists of groups that meet online or in-person (see resources below). You can enhance the referral process by describing different groups and recommending ones in which other patients have done well.24 When following up, you might ask about attendance, impressions, and whether the patient has found a sponsor.

    Although Alcoholics Anonymous (AA) is the largest mutual support group, it’s important to be familiar with alternatives. Some groups such as Secular AA or SMART Recovery are structured without spiritual or 12-step components, some are for women only, and some focus on harm reduction rather than abstinence. Even within organizations, individual groups vary widely, so encourage patients to try multiple options as needed to find a good fit.

    Research has demonstrated that patients may get more out of mutual support groups when they receive twelve-step facilitation, a structured clinical support approach.25,26 Even without special training in this support model, you can help patients make the most of their participation in mutual support groups by explaining concepts, locating meetings, and promoting attendance and engagement.

    When considering referrals to specialists or mutual support groups, keep in mind that no single treatment approach will be appealing or effective for all your patients with AUD. Some may benefit from a blend of approaches. See the Core article on treatment for an overview of all the evidence-based options, which can be combined and tailored to each patient’s needs.

    What can you do when a patient declines referral or doesn’t follow through?

    Despite your efforts, many patients may not accept or follow through on a referral, at least initially. In these cases, extended or repeated brief interventions can focus on the patient’s readiness for and confidence in making a change. (See Core article on brief interventions.) These interventions may occur in primary care settings or after specialty or emergency room visits related to alcohol use. They may involve the initial treating clinician or specially trained staff and may be done in person or by phone.7,23 

    If you see patients for ongoing care for other conditions, you can use the rapport developed through those visits to break down stigma and encourage acceptance of alcohol treatment. Conversely, if the original interaction was expected to be a single visit, arranging telehealth or in-person follow-up regarding alcohol can convey genuine concern.

    For patients who choose not to pursue specialty treatment, care management, including medications, can be offered in primary care, as noted previously. Self-management with web-based resources27,28 or joining a mutual support group are additional non-specialist alternatives (see Resources). Note that the natural history of AUD is varied. Although some people recover without formal treatment,29–31 research shows that treatment improves rates of abstinence and nonheavy drinking among people with moderate to severe AUD.32 (See Core article on recovery.)

    In closing, referral may be a process rather than a one-time event. Simple persistence and optimism may be required. If a conversation with a patient does not lead to a referral, nonetheless it may plant a seed, increasing the potential for treatment seeking down the line. It may help to advise patients that regardless of whether they accept treatment, they should not wait for a crisis or to “hit rock bottom” to reduce their alcohol consumption. Making a change sooner rather than later is likely to be more successful and can mitigate harm to individuals and their families.

    Resources

    Referral Resources

    Mutual Support Groups

    More resources for a variety of healthcare professionals can be found in the Additional Links for Patient Care.

    References

    1. Alcohol Facts and Statistics | National Institute on Alcohol Abuse and Alcoholism (NIAAA) [Internet]. [cited 2021 Sep 2]. Available from: https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcoho…
    2. Saitz R. Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking. Drug Alcohol Rev. 2010 Nov;29(6):631–640. PMCID: PMC2966031
    3. Mehrotra A, Forrest CB, Lin CY. Dropping the baton: specialty referrals in the United States. Milbank Q. 2011 Mar;89(1):39–68. PMCID: PMC3160594
    4. Greenwood-Lee J, Jewett L, Woodhouse L, Marshall DA. A categorisation of problems and solutions to improve patient referrals from primary to specialty care. BMC Health Serv Res. 2018 Dec 20;18(1):986. PMCID: PMC6302393
    5. Saitz R. “SBIRT” is the answer? Probably not. Addiction. 2015 Sep;110(9):1416–1417. PMID: 26223169
    6. Glass JE, Andréasson S, Bradley KA, Finn SW, Williams EC, Bakshi A-S, Gual A, Heather N, Sainz MT, Benegal V, Saitz R. Rethinking alcohol interventions in health care: a thematic meeting of the International Network on Brief Interventions for Alcohol & Other Drugs (INEBRIA). Addict Sci Clin Pract. 2017 10;12(1):14. PMCID: PMC5425968
    7. Cucciare MA, Coleman EA, Timko C. A conceptual model to facilitate transitions from primary care to specialty substance use disorder care: a review of the literature. Prim Health Care Res Dev. 2015 Sep;16(5):492–505. PMID: 24818752
    8. Wallhed Finn S, Bakshi A-S, Andréasson S. Alcohol consumption, dependence, and treatment barriers: perceptions among nontreatment seekers with alcohol dependence. Subst Use Misuse. 2014 May;49(6):762–769. PMID: 24601784
    9. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health [Internet]. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health [Internet]. Washington, D.C.: HSS; 2016 [cited 2020 May 23]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK424848/
    10. Buck JA. The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act. Health Aff (Millwood). 2011 Aug;30(8):1402–1410. PMID: 21821557
    11. 42 CFR Part 2.
    12. Geissler KH, Evans EA. Changes in Medicaid Acceptance by Substance Abuse Treatment Facilities After Implementation of Federal Parity. Med Care. 2020;58(2):101–107. PMID: 31688556
    13. Carroll KM. Dissemination of evidence-based practices: how far we’ve come, and how much further we’ve got to go. Addiction. 2012 Jun;107(6):1031–1033. PMID: 22324509
    14. Addiction Medicine: Closing the Gap Between Science and Practice. National Center on Addiction and Substance Abuse at Columbia University; 2012.
    15. McLellan AT, Meyers K. Contemporary addiction treatment: a review of systems problems for adults and adolescents. Biol Psychiatry. 2004 Nov 15;56(10):764–770. PMID: 15556121
    16. Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, Brief Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of substance abuse. Subst Abus. 2007;28(3):7–30. PMID: 18077300
    17. Bandara SN, Samples H, Crum RM, Saloner B. Is screening and intervention associated with treatment receipt among individuals with alcohol use disorder? Evidence from a national survey. J Subst Abuse Treat. 2018;92:85–90. PMCID: PMC6423981
    18. McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug Dependence, a Chronic Medical IllnessImplications for Treatment, Insurance, and Outcomes Evaluation. JAMA. 2000 Oct 4;284(13):1689–1695.
    19. Witkiewitz K, Litten RZ, Leggio L. Advances in the science and treatment of alcohol use disorder. Sci Adv. 2019 Sep;5(9):eaax4043. PMCID: PMC6760932
    20. Massachusetts Department of Public Health. SBIRT: A Step by Step Guide. [Internet]. SA3522; 2012. Available from: https://massclearinghouse.ehs.state.ma.us/PROG-BSAS-SBIRT/SA3522.html
    21. Bruguera P, Barrio P, Oliveras C, Braddick F, Gavotti C, Bruguera C, López-Pelayo H, Miquel L, Segura L, Colom J, Ortega L, Vieta E, Gual A. Effectiveness of a Specialized Brief Intervention for At-risk Drinkers in an Emergency Department: Short-term Results of a Randomized Controlled Trial. Acad Emerg Med. 2018;25(5):517–525. PMID: 29418049
    22. Schwarz A-S, Nielsen B, Søgaard J, Søgaard Nielsen A. Making a bridge between general hospital and specialised community-based treatment for alcohol use disorder-A pragmatic randomised controlled trial. Drug Alcohol Depend. 2019 01;196:51–56. PMID: 30665152
    23. Vendetti J, Gmyrek A, Damon D, Singh M, McRee B, Del Boca F. Screening, brief intervention and referral to treatment (SBIRT): implementation barriers, facilitators and model migration. Addiction. 2017;112 Suppl 2:23–33. PMID: 28074571
    24. Timko C, Debenedetti A, Billow R. Intensive referral to 12-Step self-help groups and 6-month substance use disorder outcomes. Addiction. 2006 May;101(5):678–688. PMID: 16669901
    25. Kelly JF, Humphreys K, Ferri M. Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database of Systematic Reviews [Internet]. John Wiley & Sons, Ltd; 2020 [cited 2020 May 28];(3). Available from: https://www-cochranelibrary-com.offcampus.lib.washington.edu/cdsr/doi/1…
    26. McCrady BS. Recent Research into Twelve-Step Programs. In: Fiellin DA, Miller SC, Saitz R, Rosenthal RN, editors. The ASAM principles of addiction medicine. Sixth edition. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2019.
    27. Kiluk BD, Devore KA, Buck MB, Nich C, Frankforter TL, LaPaglia DM, Yates BT, Gordon MA, Carroll KM. Randomized Trial of Computerized Cognitive Behavioral Therapy for Alcohol Use Disorders: Efficacy as a Virtual Stand-Alone and Treatment Add-On Compared with Standard Outpatient Treatment. Alcohol Clin Exp Res. 2016;40(9):1991–2000. PMCID: PMC5008977
    28. Hester RK, Squires DD, Delaney HD. The Drinker’s Check-up: 12-month outcomes of a controlled clinical trial of a stand-alone software program for problem drinkers. J Subst Abuse Treat. 2005 Mar;28(2):159–169. PMID: 15780546
    29. Dawson DA, Grant BF, Stinson FS, Chou PS, Huang B, Ruan WJ. Recovery from DSM-IV alcohol dependence: United States, 2001-2002. Addiction. 2005 Mar;100(3):281–292. PMID: 15733237
    30. Fan AZ, Chou SP, Zhang H, Jung J, Grant BF. Prevalence and Correlates of Past-Year Recovery From DSM-5 Alcohol Use Disorder: Results From National Epidemiologic Survey on Alcohol and Related Conditions-III. Alcohol Clin Exp Res. 2019 Nov;43(11):2406–2420. PMID: 31580502
    31. Tucker JA, Chandler SD, Witkiewitz K. Epidemiology of Recovery From Alcohol Use Disorder. Alcohol Res. 2020;40(3):02. PMCID: PMC7643818
    32. 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.
    Earn CME/CE Credit

    We invite healthcare professionals including primary care physicians, physician assistants, nurses, pharmacists, and psychologists to complete a post-test after reviewing this article to earn FREE continuing education (CME/CE) credit. This CME/CE credit opportunity is jointly provided by the Postgraduate Institute for Medicine and NIAAA.

    CME/CE Activity — Make Referrals: Connect Patients to Alcohol Treatment That Meets Their Needs

    Released on 5/6/2022
    Expires on 5/10/2023

    Complete CME/CE Post-Test

    Please note that you will need to log into or create an account on CME University in order to complete this post-test.

    Learning Objectives

    After completing this activity, the participant should be better able to:

    • Identify barriers to making effective referrals to treatment for AUD.
    • Discuss various treatment options to which patients with AUD may be referred.
    • Develop practice processes that will address the steps of screening to referral.

    Contributors

    Contributors to this article for the NIAAA Core Resource on Alcohol include the writer for the full article, content contributors to subsections, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff.

    External Writers

    Douglas Berger MD, MLitt
    Staff Physician, VA Puget Sound,
    Associate Professor of Medicine,
    University of Washington, Seattle, WA

    NIAAA Content Contributors

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    External Reviewers

    Douglas Berger MD, MLitt
    Staff Physician, VA Puget Sound,
    Associate Professor of Medicine,
    University of Washington, Seattle, WA

    Kenneth R. Conner, PsyD, MPH
    Professor, Emergency Medicine
    and Psychiatry,
    University of Rochester Medical Center,
    Rochester, NY

    Anne C. Fernandez, PhD
    Assistant Professor, Department of
    Psychiatry, University of Michigan,
    Ann Arbor, MI 

    Joseph Edwin Glass, PhD, MSW
    Associate Investigator Kaiser Permanente,
    Washington Health Research Institute,
    Seattle, WA

    NIAAA Reviewers

    George F. Koob, PhD
    Director, NIAAA

    Patricia Powell, PhD
    Deputy Director, NIAAA

    Falk W. Lohoff, MD
    Lasker Clinical Research Scholar;
    Chief, Section on Clinical Genomics and Experimental Therapeutics, NIAAA

    Lorenzo Leggio, MD, PhD
    NIDA/NIAAA Senior Clinical Investigator and Section Chief;
    NIDA Branch Chief;
    NIDA Deputy Scientific Director;
    Senior Medical Advisor to the NIAAA Director

    Aaron White, PhD
    Senior Scientific Advisor to
    the NIAAA Director, NIAAA

    Editorial Team

    NIAAA

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    Contractor Support

    Elyssa Warner, PhD
    Co-Lead Technical Editor,
    Ripple Effect

    Daria Turner, MPH
    Reference and Resource Analyst,
    Ripple Effect

    To learn more about CME/CE credit offered as well as disclosures, visit our CME/CE General Information page. You may also click here to learn more about contributors.

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