Leveraging virtual care strategies to improve access and treatment for individuals with alcohol use disorders

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Project Summary/Abstract Despite the efficacy of psychotherapies, ~90% of people with alcohol use disorder (AUD) do not receive treatment for this chronic condition and there are notable disparities in care. Access to and involvement in efficacious AUD care is even lower for women, Black/African American individuals, and people from other under-represented groups. Novel virtual care approaches (telephone, video, portal therapies) conceptually rooted in efficacious therapies [e.g., motivational interviewing (MI), cognitive behavioral therapy (CBT)] and theory can potentially improve treatment accessibility and appeal and reduce stigma. Virtual approaches have had limited use in AUD care, recently increasing in COVID-19 to provide ongoing care (telephone/video therapy) for current patients in specialty clinics, while treatment initiation remains low. There is an untapped potential for virtual approaches to engage individuals across health systems, who otherwise do not receive treatment, but could benefit. Virtual strategies, including telephone and video sessions and patient portals, are promising for reaching and engaging substance-using populations, including under-represented individuals, within health systems. Using a portal messaging system and phone calls to virtually engage patients in AUD treatment outside of clinics and in their preferred locations is an innovative treatment model that can potentially be implemented in health systems, but must be tested to inform broader dissemination. We will use a sequential, multiple assignment randomized trial (SMART) to identify critical adaptive intervention (AI) strategies for a virtually-delivered AUD engagement and care model. Adults with AUD (50% women, 25% Black/African American, 5% Latinx) will be randomized to a 1st stage strategy for drinking reduction and AUD care engagement integrating referral for AUD care: 1) a single telephone MI session (T- engage), or 2) 4-weeks of a MI-focused portal messaging (P-engage). At 4 weeks, non-responders will be randomized to a 2nd stage strategy: 1) step up to a video 8-session MI-CBT for AUD (phone delivery as needed), or 2) continued 1st stage (i.e., 4 weeks of P-engage with greater depth, a second T-engage session building on the first). Outcomes will be assessed at 4-, 8-, and 12-months. Aim 1 will compare 1st-stage strategies (T-engage vs. P-engage) on alcohol outcomes and AUD treatment utilization. In Aim 2, among 1st- stage non-responders, we will identify the most efficacious 2nd-stage strategy. Aim 3 includes an implementation planning phase, with cost measures, and key stakeholder interviews and qualitative analysis of barriers and facilitators to implementation and adoption of a virtual care model. Secondary aims include: examining the moderating effects of race/ethnicity and sex on outcomes given our enriched sample and examining the best sequence of AIs. Our proposed project will have high public health impact by evaluating a novel virtual care model focused on increasing both treatment engagement and delivery that can be integrated in health systems to increase AUD treatment appeal and accessibility and help address treatment disparities.