Addiction Telemedicine Consultation in Primary Care: Increasing Access to Pharmacotherapy and Specialty Treatment for Alcohol Problems

摘要 酒精使用障碍（AUD）是一个主要的公共卫生问题，并对 临床医生、患者和卫生系统。 AUD 与严重的医疗状况有关，可能会使情况复杂化 医疗治疗并增加可避免的卫生服务利用率和成本。然而大多数患者会 受益于基于证据的 AUD 治疗，包括药物治疗，不接受这些服务。 尽管纳曲酮、阿坎酸和双硫仑等药物对中度至重度患者有效 酒精问题、初级保健提供者 (PCP) 往往不愿意开处方，并且 AUD 药物仍然存在 未得到充分利用。需要创新的护理模式，为 PCP 提供解决初级 AUD 问题所需的工具 护理机构，但很少有研究探讨改善 AUD 药物输送和专业的干预措施 护理启动。为了解决证据基础上的这一巨大差距，这项务实的整群随机试验 在一个种族和社会经济多元化的大型医疗保健系统中，成人初级保健诊所（n = 20）将 检查创新的多方面干预措施的有效性：成瘾远程医疗顾问 服务，或“ATC”。 ATC 提供了一种灵活、高效、集中的方法来引入成瘾医学 专业知识直接进入初级保健。 PCP 可以通过三种途径访问 ATC：实时视频或电话 初级保健就诊、异步电子邮件和电话咨询期间的连接。 ATC，临床 药剂师可以评估患者，与 PCP 和患者讨论适当的 AUD 药物，如果 在适当的情况下，指导 PCP 开具处方，或自行开具处方。的 经过动机性访谈培训的 ATC 也可能鼓励患者开始专业成瘾治疗 并促进与本地程序的连接。 ATC 干预措施还将提供初步的持续医疗服务 向所有 PCP 提供有关 AUD 和 AUD 药物处方的教育培训以及持续的技术援助 ATC 臂。我们将 ATC 臂与常规护理进行比较，后者包括常规酒精筛查、简要说明 初级保健中的干预和转诊治疗 (SBIRT)。我们进行了试点可行性研究 ATC 模型和拟议的试验建立在我们的试点结果、现有文献的基础上，并结合了 利益相关者对其设计的反馈。我们将使用在过程中捕获的电子健康记录数据 定期临床护理，检查治疗组对实施结果的影响（AUD 药物 处方率和成瘾治疗转诊率）和患者结果（澳元药物填充率、 开始成瘾治疗、饮酒（每周饮酒天数、每周饮酒次数、“重度”饮酒天数） （过去 90 天内 4/5/天），以及两年多的卫生服务利用率和成本。如果干预是 有效，这项研究有能力刺激使用安全、有效的 AUD 药物治疗作为标准 在初级保健机构中的实践并深刻影响我们如何治疗和研究全方位的酒精使用 问题。

ABSTRACT Alcohol use disorders (AUDs) are a major public health problem and pose significant challenges to clinicians, patients, and health systems. AUDs are associated with serious medical conditions, can complicate medical treatment and increase avoidable health service utilization and costs. Yet most patients who would benefit from evidence-based AUD treatment, including pharmacotherapy, do not receive these services. Although medications such as naltrexone, acamprosate and disulfiram can be effective for moderate to severe alcohol problems, primary care providers (PCPs) are often reluctant to prescribe, and AUD medications remain underused. Innovative care models are needed to give PCPs the tools they need to address AUDs in primary care settings, but few studies have examined interventions to improve AUD medication delivery and specialty care initiation. To address this substantial gap in the evidence base, this pragmatic, cluster-randomized trial in adult primary care clinics (n=20) in a large, ethnically and socioeconomically diverse healthcare system, will examine the effectiveness of an innovative, multi-faceted intervention: the Addiction Telemedicine Consultant service, or “ATC.” The ATC provides a flexible, efficient, centralized approach to bringing Addiction Medicine expertise directly into primary care. PCPs can access the ATC via three routes: real-time video or telephone connection during primary care visits, asynchronous email, and telephone consultation. The ATC, a clinical pharmacist, may assess the patient, discuss appropriate AUD medications with the PCP and patient, and if appropriate, guide the PCP through prescribing logistics, or initiate the prescription themselves. The motivational interviewing-trained ATC may also encourage the patient to initiate specialty addiction treatment and facilitate connection to a local program. The ATC intervention will also offer initial continuing medical education training on AUDs and AUD medication prescribing, and ongoing technical assistance, to all PCPs in the ATC arm. We will compare the ATC arm to Usual Care, which includes routine alcohol screening, brief intervention and referral to treatment (SBIRT) in primary care. We conducted a pilot feasibility study of the ATC model, and the proposed trial builds on our pilot findings, the extant literature, and incorporates stakeholder feedback in its design. We will use electronic health record data captured during the course of regular clinical care to examine treatment arm effects on implementation outcomes (AUD medication prescription rates and addiction treatment referral rates) and patient outcomes (AUD medication fill rates, addiction treatment initiation, alcohol use (drinking days/week, # drinks/week, # of “heavy” drinking days (4+/5+/day) in past 90 days), and health services utilization and costs, over two years. If the intervention is effective, this study has the capacity to spur the use of safe, effective pharmacotherapy for AUDs as a standard practice in primary care settings and profoundly affect how we treat and study the full spectrum of alcohol use problems.