Management of alcohol use disorders (AUDs) among TB patients in Tomsk, Russia S. Shin 1, 2, D. Taran 3, S. Yanov 4, R. Mazitov 3, A. Golubkov 1, T. Mathew 5, S. Mishustin 6 1 Partners In Health, Boston, MA, USA; 2 Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA; 3 Partners In Health, Moscow Oblast, Russian Federation; 4 Tomsk Oblast Clinical TB Hospital, Tomsk Oblast, Russian Federation; 5 Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS, USA; 6 Tomsk Oblast TB Services, Tomsk Oblast, Russian Federation Introduction Figure 1. Tomsk Oblast in Western Siberia • Up to 62% of TB patients in Russia may have concomitant alcohol use disorders (AUDs). 1 -2 • AUDs are associated with poor TB treatment outcomes. 3 -4 • In the Former Soviet Union, AUDs pose a substantial barrier to TB care because of high rates and limited resources to diagnose and treat addictions. 5 • We started a project to integrate alcohol diagnosis and care into TB services in Tomsk. Project Goal: To increase the effectiveness of the treatment of TB patients in Tomsk by lowering negative consequences due to alcohol use. Map accessed at http: //www. geog. uu. nl/fg/casus/Welcome. html on October 24, 2007. Program Activities The Standard Drinks Card was developed as a useful “pocket reference” for TB physicians, who reported that visual cues made it easier for patients to estimate the type and volume of alcohol typically consumed. The card also functions to facilitate calculation by physicians of the equivalent standard portion of alcohol (Figure 2). Starting in October of 2005, we implemented a brief instrument, the Alcohol Use Disorders Identification Test (AUDIT)6, for universal screening of AUDs. Figure 2. Standard Drinks Card In early 2006, a TB/Alcohol Subprogram was established within a grant from the Global Fund to Fight AIDS Tuberculosis, and Malaria. • Several psychologists and addictions specialists were hired. • Referral procedures were established. • New evidence-based treatment options were introduced (i. e. psycho- and pharmacotherapy as well as self-help guides, social support, and referral to AA groups). • Close monitoring of all activities was enhanced. Figure 3. Trends in AUDIT screening and successful referral of individuals with AUDs to addictions specialists and/or psychologist alcohol use disorders, by treatment site Results From October, 2005 through May 31, 2007: • 1077 of 2063 patients (52. 5%) completed the AUDIT questionnaire at initiation of TB treatment. • 51. 5% of patients tested had an AUDIT score > 8 (at risk), and of these 23. 1% had not been diagnosed with an alcohol problem. • Of the 612 patients with AUDIT > 8 and/or diagnosis of AUD, 38. 1% were successfully referred to an addictions specialist. • Referral rate increased with AUDIT score (p<0. 0001). AUDIT administration went from 61. 9% to 53. 1% over time (p=0. 08) while the rate of specialist referral remained stable (p=0. 45). C H A L L E N G E S 1. Recruitment of addictions specialists due to both fear of contracting TB and reduced financial compensation compared to private practice. • No official positions (stravka) available within TB Services for these specialists (psychologists, psychotherapists, or social workers), leading to frequent staff turnover. 2. TB patients subsequently reluctant to receive treatment due to: • The pre-contemplative state of patients and the stigma associated with narcologist care. • The misconception that acknowledging active alcohol use during TB treatment will negatively impact care received. 3. Limited communication between AUD specialists, physicians, and patients. • Strong supervision is needed to support referral to specialists and to set up interdisciplinary teams with patientoriented approaches. • Alcoholic Anonymous groups are hard to establish within the official inpatient TB services (for BC ”-” patients). Conclusions and Recommendations We successfully implemented a program to manage AUDs in Siberian TB facilities. • The AUDIT test could be implemented as part of standard Russian TB practice. Scores could be reported by primary care providers, ideally through a prikaz (mandated programmatic policy). • Official positions must be created for psychologists, social workers, and psychotherapists in Russian TB Services and adequate compensation must be provided. • Training is necessary for psychologists and addiction specialists to provide evidence-based, standardized interventions to patients. • Patient-directed group therapy and rehabilitation should be incorporated as recommended by other international programs addressing similar patient populations 7. Literature Cited 1. 2. 3. 4. 5. 6. 7. Khomenko AG, Rudoi NM, Utkin VV, Mikheeva LP. Alkogolizm i tuberkulez legkikh. Vestnik Akademii Meditsinskikh Nauk SSSR. 1989(2): 50 -8. Fleming MF, Krupitsky E, Tsoy M, Zvartau E, Brazhenko N, Jakubowiak W, et al. Alcohol and drug use disorders, HIV status and drug resistance in a sample of Russian TB patients. Int J Tuberc Lung Dis. 2006 May; 10(5): 565 -70. Shin SS, Pasechnikov AD, Gelmanova IY, Peremitin GG, Strelis AK, Mishustin S, et al. Treatment outcomes in an integrated civilian and prison MDR-TB treatment program in Russia. Int J Tuberc Lung Dis. 2006 Apr; 10(4): 402 -8. Gelmanova IY, Keshavjee S, Golubchikova VT, Berezina VI, Strelis AK, Yanova GV, Atwoodd S & Murray M. Barriers to successful tuberculosis treatment in Tomsk, the Russian Federation: nonadherence, default and the acquisition of multidrug resistance. Bulletin of the World Health Organization 2007; Sep; 85(9): 703 -11. Fleming PM. Drug and alcohol user treatment/intervention services in Russia--a Western perspective. Substance Use & Misuse 1996; 31(1): 103 -14. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The Alcohol Use Disorders Identification Test (AUDIT): Guidelines for Use in Primary Care. 2 ed: World Health Organization, Department of Mental Health and Substance Abuse; 2001. Saitz R. Unhealthy Alcohol Use. N Engl J Med 2005; 352: 596 -607. Acknowledgments: Charmaine S. Lastimoso, Hana Akselrod
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