Barriers to use of pharmacotherapy for alcohol dependence in VA primary care

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Background: Alcohol dependence is a common, chronic condition affecting 4.2% of VA patients. While specialty addictions treatment programs are effective for treating alcohol dependence, a majority (~66%) of VA patients with alcohol dependence never receive it. Three medications are approved by the Food and Drug Administration (FDA) for alcohol dependence and are considered standard care for alcohol dependence in VA, but ~95% of VA patients with alcohol dependence do not receive them. As such, increasing access to these medications is a major goal of multiple VA stakeholders. While the co-located and team-based care in VA's Primary Care Mental Health Integration Initiative and VA's Patient Aligned Care Teams could enable primary care providers to prescribe and integrate these medications into existing systems of care, there are likely substantial barriers to such integration due to the historic separation of addictions care from mainstream medicine, and alcohol-related stigma. Although previous research in the VA has focused on describing barriers and facilitators to use of medications to treat alcohol dependence among specialty addictions care providers, no previous study has described barriers and facilitators to use of medications to treat alcohol dependence in primary care. An initial step in implementation is to understand primary care providers' perceptions of the feasibility of and barriers to managing alcohol dependence with medications. Objective: The specific aims of the proposed research are to: 1) Describe barriers to and facilitators of primary care providers' use of medications to treat alcohol dependence in VA primary care using qualitative, semi- structured interviews at 9 local primary care clinics, and 2) Develop a survey to assess determinants of use of medications to treat alcohol dependence among a generalizable sample of VA primary care providers. Research Plan: This study will conduct qualitative semi-structured interviews with VA primary care providers at 9 primary care clinics associated with a single local VA medical facility to describe barriers to and facilitators of use of medications to treat alcohol dependence in VA primary care and to develop a subsequent survey. All primary care providers with prescribing privileges who practice at least one half day per week in one of the 9 clinics will be eligible. The recruitment strategy will employ methods previously successfully used by the study team. Providers will be recruited by first establishing communication with a key point-of-contact at each clinic to introduce the study and establish the best method for conducting interviews at the clinic in a way that minimizes the disruption of clinic flow and patient care. Depending on the clinic, interviews will be arranged via email with individual primary care providers or through on-site recruitment. Each potential participant will be asked for referrals to one or more other providers (snowball sampling). An effort will be made to interview providers across job classifications (i.e., staff physicians, resident physicians, and nurse practitioners) and those with potential differing barriers to behavior change regarding treatment of alcohol dependence. Semi- structured interviews will be developed based on a social marketing conceptual framework, which is focused on identifying and removing obstacles to behavior change. All interviews will be digitally recorded and transcribed. Data will be analyzed in an iterative fashion using template analysis (also called thematic coding). The initial template of codes will be based on Robinson's model, but the template will be revised in an iterative fashion. After the template of codes is finalized, two coders will code all interview transcripts. Discrepancies between coders will be reviewed by the study team and resolved with consensus. Content will then be sorted by domain for reporting; key observations in each domain and sub-domain will be abstracted for presentation and used to develop a survey, which will be fielded in a subsequent study.