Innovation summary

Globally, alcohol dependence (AD) accounts for 71% alcohol attributable mortality burden and 60% of social costs attributable to alcohol.1 In India, 17-26% of people who drink alcohol have AD, translating to an average prevalence of 4% in the community and approximately 14 million people.2 The detoxification centres set up by the Indian government are not adequate to meet the requirements of this patient group and hence a large proportion of people with AD do not have access to help for their alcohol related problems.3

Community Orientated Non Specialist Treatment for Alcohol Dependence (CONTAD) aims to reduce this treatment gap by systematically developing a community detoxification package and a psychosocial intervention to address relapse prevention that will be delivered by lay health workers (LHW). The research project innovation will consist of two related packages of care for people with AD, delivered by LHWs: the first to enable them to detoxify from alcohol; the second, a psychosocial relapse prevention intervention, will enable sobriety.

Impact summary

At this stage only indicators of coverage are available:

  • 2695 men screened for alcohol dependence in Primary Health Centres in the public sector
  • 564 men screened for alcohol dependence in private GP clinics
  • 31 men with alcohol dependence in the de-addiction centre in a district hospital screened for eligibility to receive relapse prevention treatment

"CONTAD aims to increase the access treatment for severe alcohol problems by taking it out of hospitals and delivering it in the community with the help of non-specialist health workers supervised by experienced specialists"

 

-Dr Abhijit Nadkarni, PI of CONTAD

This innovation is funded by Grand Challenges Canada.

Innovation details

CONTAD aims to systematically develop an approach to deliver two packages of care for AD which address the acute care needs related to alcohol detoxification and the longer term goal of relapse prevention. Both these packages will be delivered by LHWs at home or in primary healthcare centres (PHC) and will seek to increase remission rates and reduce relapse rates in men with AD.  More specifically, the project aims to:

  • Develop a community detoxification package and psychosocial intervention for relapse prevention
  • Develop a training, supervision and competence assessment system for the LHWs
  • Recruit and train PHC doctors to provide shared collaborative care (diagnosis and prescription of medicines, monitor patient’s clinical condition in the Detoxification Package) with LHWs in providing community detoxification and relapse prevention
  • Demonstrate that the packages are acceptable to AD patients and their families
  • Provide preliminary evidence that the packages increase remission and reduce relapse

Key drivers

The anticipated drivers for the program are as follows:

Strong Collaborative Links

Sangath - the organization involved in implementing this project - has strong collaborative links with the Directorate of Health Services responsible for both the de-addiction centre and PHCs in which the program will be based

Combined Team Experience

The investigators and Sangath have extensive experience of conducting structured formative work in developing complex interventions.

Challenges

Potential challenges to the program include:

PHC Doctors Resistant to Collaborate

Resistance from PHC doctors to collaborate in the delivery of the Detoxification Package due to safety or other concerns 

LHWs Reluctant or Unable to Monitor Patients

LHWs may be reluctant or unable to monitor patients’ physical symptoms and/or medications

Engaging and Retaining Patients

Difficulty in engaging and retaining patients in treatment

Continuation

On successful development of this complex intervention the plan is to apply for funding to test its cost effectiveness in a definitive RCT.

Evaluation methods

This intervention will be evaluated through a treatment cohort. The intervention will be evaluated using mixed methods. The following components will be measured:

Qualitative data

  • LHWs to determine acceptability and feasibility of the interventions
  • PHC and deaddiction centre doctors to determine acceptability and feasibility of supervision of home detoxification done by LHWs
  • Treatment completers/ family members to determine acceptability of the interventions
  • Treatment drop outs to determine reasons for noncompletion (nonacceptability)

Quantitative data

  • Process indicators: No. of: screen positives, patients accepting treatment, refusals and reasons for refusal, patients completing treatment, and dropouts
  • Ratings of structured role plays and audio-tapes of treatment sessions to determine competence and quality of sessions delivered
  • Comparison of number and types of adverse events, between cohorts recruited from PHC (receiving community based detoxification) with those receiving facility based detoxification in the deaddiction centre
  • Effectiveness of the treatment packages by measuring abstinence from alcohol (no alcohol for the past two weeks at follow up) and changes in Short Inventory of Problems scores

Impact details

At this stage only indicators of coverage are available as we have not yet completed outcome data collection.

We screened the following: 2695 men for alcohol dependence in Primary Health Centres in the public sector, and 564 men for alcohol dependence in private GP clinics to assess for eligibility to receive home detoxification and relapse prevention treatment. We screened 31 men with alcohol dependence in the de-addiction centre in a district hospital for eligibility to receive relapse prevention treatment.

References

  1. Rehm J et al (2012) Alcohol Related Morbidity and Mortality [Internet]. National Institute on Alcohol Abuse and Alcoholism.
  2. Murthy P et al (2010) Substance use and addiction research in India. Indian Journal of Psychiatry. 52(7): 189-99.
  3. Benegal V (2005) India: alcohol and public health. Addiction.100(8):1051-6.
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Comments

Great proposal. Love to have details in case the investigator can share the same. The biggest challenge will be hand holding (appropriate training) the LHW as well as Primary health care doctors and keeping their morale high . In our experience , one of the reason is that the primary health care providers poor participation is that they are scared about severe withdrawals, complications, co-morbidities etc. Hence an assurance/mechanism that if they find difficulty in acute management, they can call or contact a team of addiction experts will increase their self-efficacy. And probably this experience of their needs to be recognized formally. We are trying to do the same by connecting a multidisciplinary team from NIMHANS with community practitioners as well as young trainees through weekly online LIVE interactive clinical case management (multi-point videoconferencing) and linking with a certificate module/CME credit points from NIMHANS. Hope is that the patients in the community gets the "best practice" care , visit our website vlc.nimhans.ac.in . We are yet to formalize a study plan, hence interested to know about the outcome parameters used in the CONTAD. Good luck
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