Program Activities

Management of alcohol use disorders (AUDs) among TB patients in Tomsk, Russia

S. Shin1,2, D. Taran3, S. Yanov4, R. Mazitov3, A. Golubkov1, T. Mathew5, S. Mishustin6 1Partners In Health, Boston, MA, USA; 2Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA; 3Partners In Health, Moscow Oblast, Russian Federation; 4Tomsk Oblast Clinical

TB Hospital, Tomsk Oblast, Russian Federation; 5Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS, USA; 6Tomsk Oblast TB Services, Tomsk Oblast, Russian Federation

Introduction• 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.

Literature Cited1. Khomenko AG, Rudoi NM, Utkin VV, Mikheeva LP. Alkogolizm i tuberkulez legkikh. Vestnik Akademii Meditsinskikh Nauk SSSR. 1989(2):50-8. 2. 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. 3. 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. 4. 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: non-

adherence, default and the acquisition of multidrug resistance. Bulletin of the World Health Organization 2007; Sep;85(9):703-11. 5. Fleming PM. Drug and alcohol user treatment/intervention services in Russia--a Western perspective. Substance Use & Misuse 1996; 31(1): 103-14. 6. 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. 7. Saitz R. Unhealthy Alcohol Use. N Engl J Med 2005;352:596-607.

Conclusions and Recommendations

Acknowledgments: Charmaine S. Lastimoso, Hana Akselrod

Starting in October of 2005, we imple-mented a brief instrument, the Alcohol Use Disorders Identification Test (AUDIT)6, for universal screening of AUDs.

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 pharmaco-

therapy as well as self-help guides, social support, and referral to AA groups). • Close monitoring of all activities was enhanced.

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).

CHALLENGES

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 patient-

oriented approaches. • Alcoholic Anonymous groups are hard to establish within the official inpatient TB services (for BC ”-” patients).

TOTBS/PIH

Стандартная Порция Алкоголя (СПА) Standard Drinks Card

4% 1000 мл= 3 СПА

4% 500 мл= 1,5 СПА

4% 330 мл= 1 СПА

Beer / ПИВО Wine / ВИНО

12% 750 мл= 7,3 СПА

40% 700 мл= 22 СПА

14% 750 мл= 8,3 СПА

Vodka / ВОДКАSamogon

Cognac / КОНЬЯКWhiskey ,Gin / ВИСКИ, ДЖИН

TINCTURE, EAU-DE-COLOGNE /Настойки , Одеколоны

40% 500 мл= 16 СПА

40% 100 мл= 3,2 СПА

40% 30 мл= 1 СПА

5% 330 мл= 1,3 СПА

62% 100 мл= 5 СПА

Surrogate Spirits, Technical Spirits/ Технические Жидкости

90% 700 мл= 50 СПА

90% 500 мл= 35,6 СПА

90% 200 мл (стакан)= 14 СПА

Liqueur, Port/Sherry Wine/Ликёры, Наливки, Портвейн

20% (25%) 100 мл= 1,6 (2) СПА

Figure 2. Standard Drinks Card

Figure 1. Tomsk Oblast in Western Siberia

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

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).

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

80,0%

90,0%

2004 2005 2006

Screened by AUDIT, outpatient

Screened by AUDIT, inpatient

Successfully referred to specialists, among those with AUDs, outpatient

Successfully referred to specialists, among those with AUDs, inpatient

Results

Map accessed at http://www.geog.uu.nl/fg/casus/Welcome.html on October 24, 2007.