Journal of General Internal Medicine

, Volume 29, Issue 1, pp 162–168 | Cite as

A Randomized Clinical Trial of Alcohol Care Management Delivered in Department of Veterans Affairs Primary Care Clinics Versus Specialty Addiction Treatment

  • David W. OslinEmail author
  • Kevin G. Lynch
  • Stephen A. Maisto
  • Larry J. Lantinga
  • James R. McKay
  • Kyle Possemato
  • Erin Ingram
  • Michael Wierzbicki
Original Research



Alcohol use disorder is one of the leading causes of disability worldwide. Despite the availability of efficacious treatments, few individuals with an alcohol use disorder are actively engaged in treatment. Available evidence suggests that primary care may play a crucial role in the identification of patients with an alcohol use disorder, delivery of interventions, and the success of treatment.


The principal aims of this study were to test the effectiveness of a primary care-based Alcohol Care Management (ACM) program for alcohol use disorder and treatment engagement in veterans.


The design of the study was a 26-week single-blind randomized clinical trial. The study was conducted in the primary care practices at three VA medical centers. Participants were randomly assigned to treatment in ACM or standard treatment in a specialty outpatient addiction treatment program.


One hundred and sixty-three alcohol-dependent veterans were randomized.


ACM focused on the use of pharmacotherapy and psychosocial support. ACM was delivered in-person or by telephone within the primary care clinic.


Engagement in treatment and heavy alcohol consumption.


The ACM condition had a significantly higher proportion of participants engaged in treatment over the 26 weeks [OR = 5.36, 95 % CI = (2.99, 9.59)]. The percentage of heavy drinking days were significantly lower in the ACM condition [OR = 2.16, 95 % CI = (1.27, 3.66)], while overall abstinence did not differ between groups.


Results demonstrate that treatment for an alcohol use disorder can be delivered effectively within primary care, leading to greater rates of engagement in treatment and greater reductions in heavy drinking.


addiction primary care treatment randomized clinical trial 




We thank the primary care providers who fully participated in the study and their dedication to improving outcomes for addictive disorders.


Supported, for the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript, by the following sources:

• Health Services Research and Development Program of the Department of Veteran Affairs (IIR)

• The VISN 4 Mental Illness Research, Education, and Clinical Center at the Philadelphia VA Medical Center

• The VISN 2 Center for Integrated Healthcare

• Career Development Award [K05 AA16928 (Dr. Maisto)]

• NIDA (K24 DA029062) and NIAAA (P01-AA016821) (Dr. McKay)

Prior Presentations

There have been no prior presentations of the outcome data.

Conflicts of Interest

Potential conflicts of interest include funding from the Caron Foundation (McKay); Hazelden Foundation (Oslin and McKay); Treatment Research Institute (McKay), University of Wisconsin (McKay), Wright State University (McKay), Research Foundation for Mental Hygiene (McKay), National Quality Forum (McKay), Altarum (McKay), the State of Pennsylvania (Oslin, Lynch) and the Human Service Center (McKay). The remaining authors declare that they do not have a conflict of interest.


  1. 1.
    Murray C, Lopez A. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. In: Murray C, Lopez A, eds. The global burden of disease and injury series, Vol. 1. Boston: Harvard University Press; 1996.Google Scholar
  2. 2.
    Cohen E, et al. Alcohol treatment utilization: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend. 2007;86(2–3):214–21.PubMedCrossRefGoogle Scholar
  3. 3.
    Substance Abuse and Mental Health Services Administration, O.o.A.S., Treatment Episode Data Set (TEDS): 2005. Discharges from substance abuse treatment services. Rockville, MD: U.S. Department of Health and Human Services; 2008.Google Scholar
  4. 4.
    U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med. 2004;140:554–6.Google Scholar
  5. 5.
    Poikolainen K. Effectiveness of brief interventions to reduce alcohol intake in primary health care populations: a meta-analysis. Prev Med. 1999;28:503–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Moyer A, et al. Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction. 2002;97:279–92.PubMedCrossRefGoogle Scholar
  7. 7.
    Babor TF, et al. 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.PubMedCrossRefGoogle Scholar
  8. 8.
    Maust DT, et al. Missed opportunities: fewer service referrals after positive alcohol misuse screens in VA primary care. Psychiatr Serv. 2011;62(3):310–2.PubMedCrossRefGoogle Scholar
  9. 9.
    Harris AH, et al. Pharmacotherapy of alcohol use disorders by the Veterans Health Administration: patterns of receipt and persistence. Psychiatr Serv. 2012;63(7):679–85.PubMedCrossRefGoogle Scholar
  10. 10.
    Kivlahan DR. Outcomes from AUDIT screen throughout the VA system., D. Oslin, Editor 2013.Google Scholar
  11. 11.
    Willenbring ML, Olson DH. A randomized trial of integrated outpatient treatment for medically ill alcoholic men. Arch Intern Med. 1999;159(16):1946–52.PubMedCrossRefGoogle Scholar
  12. 12.
    O’Connor PG, et al. A preliminary investigation of the management of alcohol dependence with naltrexone by primary care providers. Am J Med. 1997;103(6):477–82.PubMedCrossRefGoogle Scholar
  13. 13.
    Lee JD, et al. Extended-release naltrexone for treatment of alcohol dependence in primary care. J Subst Abus Treat. 2010;39(1):14–21.CrossRefGoogle Scholar
  14. 14.
    Kiefer F, et al. Pharmacological relapse prevention of alcoholism: clinical predictors of outcome. Eur Addict Res. 2005;11(2):83–91.PubMedCrossRefGoogle Scholar
  15. 15.
    Garbutt J, et al. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. J Am Med Inform Assoc. 2005;293:1617–25.CrossRefGoogle Scholar
  16. 16.
    Maisel NC, et al. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction. 2013;108(2):275–93.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Srisurapanont M, Jarusuraisin N. Naltrexone for the treatment of alcoholism: a meta-analysis of randomized controlled trials. Int J Neuropsychopharmacol. 2005;8:1–14.Google Scholar
  18. 18.
    Bouza C, et al. Efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence: a systematic review. Addiction. 2004;99(7):811–28.PubMedCrossRefGoogle Scholar
  19. 19.
    Oslin D, ed. Foundations for Integrated Care. Department of Veterans Affairs; 2013.Google Scholar
  20. 20.
    Bradley KA, et al. The AUDIT alcohol consumption questions: reliability, validity, and responsiveness to change in older male primary care patients. Alcohol Clin Exp Res. 1842;22(8):1842–9.Google Scholar
  21. 21.
    Tew J, Klaus J, Oslin DW. The Behavioral Health Laboratory: building a stronger foundation for the patient-centered medical home. Fam Syst Health. 2010;28(2):130–45.PubMedCrossRefGoogle Scholar
  22. 22.
    Pettinati H, et al. Medical management treatment manual: a clinical research guide for medically trained clinicians providing pharmacotherapy as part of the treatment for alcohol dependence 2004. Bethesda, MD: NIAAA, DHHS Publication # 04-5289.Google Scholar
  23. 23.
    Sobell L, et al. Reliability of a timeline method: assessing normal drinkers’ reports of recent drinking and a comparative evaluation across several populations. Br J Addict. 1988;83:393–402.PubMedCrossRefGoogle Scholar
  24. 24.
    Sobell LC, Sobell MB. Timeline follow-back: a technique for assessing self-reported alcohol consumption. In: Litten R, Allen J, eds. Measuring alcohol consumption. Totowa, NJ: Humana Press Inc; 1992:41–65.CrossRefGoogle Scholar
  25. 25.
    Anton R. New methodologies for pharmacological treatment trials for alcohol dependence. Alcohol Clin Exp Res. 1996;20:3A–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Volpicelli JR, et al. Naltrexone in the treatment of alcohol dependence.[see comment]. Arch Gen Psychiatry. 1992;49(11):876–80.PubMedCrossRefGoogle Scholar
  27. 27.
    Kranzler HR, et al. Efficacy of naltrexone and acamprosate for alcoholism treatment: a meta-analysis. Alcohol Clin Exp Res. 2001;25(9):1335–41.PubMedCrossRefGoogle Scholar
  28. 28.
    Miller W, Tonigan J, Longabaugh R. The Drinker Inventory of Consequences (DrInC): an instrument for assessing adverse consequences of alcohol abuse. Vol. Vol. 4. Washington, D.C: U.S. Government Printing Office; 1995.CrossRefGoogle Scholar
  29. 29.
    Biener L, Abrams DB. The Contemplation Ladder: validation of a measure of readiness to consider smoking cessation. Health Psychol. 1991;10(5):360–5.PubMedCrossRefGoogle Scholar
  30. 30.
    Ware J, Kosinski M, Keller S. A 12-item Short-form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;32:220–33.CrossRefGoogle Scholar
  31. 31.
    Diggle P, et al. Analysis of longitudinal data. 2nd ed. Oxford Statistical Science Series #252002, New York: Oxford University Press Inc.Google Scholar
  32. 32.
    Molenberghs G, Verbeke G. Models for discrete longitudinal data. Statistics2005: Springer.Google Scholar
  33. 33.
    Verbeke G, MG. Linear mixed models for longitudinal data. Statistics2000: Springer.Google Scholar

Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • David W. Oslin
    • 1
    • 2
    Email author
  • Kevin G. Lynch
    • 2
  • Stephen A. Maisto
    • 3
    • 4
  • Larry J. Lantinga
    • 3
    • 4
  • James R. McKay
    • 1
    • 2
  • Kyle Possemato
    • 3
    • 4
  • Erin Ingram
    • 1
  • Michael Wierzbicki
    • 5
  1. 1.Mental Illness Research, Education and Clinical Center at the Philadelphia VA Medical CenterUniversity of PennsylvaniaPhiladelphiaUSA
  2. 2.Department of PsychiatryUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaUSA
  3. 3.Department of PsychologySyracuse UniversitySyracuseUSA
  4. 4.Center for Integrated HealthcareDepartment of Veterans Affairs, VISN2SyracuseUSA
  5. 5.Department of Biostatistics and Epidemiology, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA

Personalised recommendations