Sunday, 24 April 2011

TUBERCULOSIS: Treating Russian tuberculosis patients suffering from alcoholism

Posted on 04/20/11

Alcoholic TB patients disproportionately live in rural areas.

In the district of Tomsk, Russia, between one-half and one-third of people living with tuberculosis (TB) suffer from alcoholism, with a majority of these people binge drinking alcohol upwards of three or more times a week. For people suffering from a potentially fatal and highly contagious disease, addiction manifests in irregular medication use--which can lead to drug-resistant strains of TB--and an increased risk of HIV co-infection. All of these factors have left this Siberian region of just over a million people with the unfortunate distinction of having some of the world’s highest TB and alcohol consumption rates.
In response, PIH-Russia, Brigham and Women’s Hospital’s Division of Global Health Equity, McLean Hospital, and the Tomsk TB-Alcohol Working Group implemented an initiative aimed at curbing those numbers. The six-year clinical trial—called IMPACT—will conclude in June 2011.
Treating tuberculosis and preventing its spread in this isolated region historically posed seemingly insurmountable challenges for health care workers in Tomsk. In 1998, the government of this remote Russian province partnered with PIH to bolster the efforts of the local health system. With proven results treating TB in Peru, PIH was well equipped to meet a similar challenge in central Russia.
While TB rates in the region have continued to decline in the past decade, shockingly widespread alcoholism rates threaten to reverse those trends.
Even without the factor of TB, alcoholism is a major concern. According to “Alcohol and cause-specific mortality in Russia,” an article published in the medical journal Lancet in 2009, 52 percent of deaths in people aged 15-54 are associated with alcohol abuse. In fact, twelve of the top 20 causes of death in Russia are alcohol related, killing more than 300,000 people in the country annually.
“Heavy drinking has a long tradition in Russia. This has led many commentators to argue that it is so deep-rooted as to be impossible to tackle,” writes Dr. Namvar Zohoori, lead author of Monitoring Health Conditions in the Russian Federation. “Roughly 70 percent of men and 45 percent of women drink alcohol,” he states in the report.
Roughly 20 percent of men binge drink more than 100 grams (3.5 oz, or roughly seven mixed drinks) of alcohol per day.
The problem is so pervasive that between 1991 and 2001 life expectancy among men fell from 63.5 years to 58.9 years. To put that in perspective, men in the US live to 75 on average. Estimates associate Alcohol with approximately one-third of all deaths in the country.
Prior to this intervention, surprisingly little to nothing was being done in the public sector to address this crisis.

Startling numbers from Russia:
Over half deaths of people aged 15-54 are related to alcohol abuse
20 percent of men binge drink more than 100 grams (3.5 oz, or roughly seven mixed drinks) of alcohol per day
“The longstanding failure to integrate treatment for alcoholism into the primary care of TB patients suffering from both diseases represents a missed opportunity with serious clinical and public health implications,” says PIH’s Dr. Sonya Shin.
In 2007, PIH’s Russia-based project, Партнеры во имя здоровья, began integrating alcohol treatment into 200 patients’ tuberculosis regimens. Since TB treatment requires between six and 24 months of daily doses of medication (depending on the severity of the case), the time and effort required to provide treatment is enough to also simultaneously address alcohol addiction.
Because patients with aggressively contagious strains of TB are often quarantined for the first few months of treatment, PIH-Russia and Tomsk’s TB-focused clinicians created treatment communities within the hospital setting.
“To our knowledge, this is the first study to examine the feasibility of delivering alcohol treatment as part of routine TB care and to assess this treatment model’s impact on both TB and alcohol outcomes,” says Dr. Shin. “If proven feasible and effective, this treatment model could be adapted for alcohol dependant TB patients.”
In order to determine how best to confront TB infections induced or worsened by alcohol, clinicians tested to see if patients addicted to alcohol were more likely to complete an anti-TB drug regimen if they were also taking an opioid that reduces a patient’s craving for alcohol called naltrexone.

Patients were given one of four randomized treatments:
Oral naltrexone + Brief therapy during treatment + TB medication regime
Brief counseling intervention + TB medication regime
Naltrexone + Brief therapy and brief counseling during treatment + TB medication regime

TB medication regime
Under the watchful eye of nurses or clinicians responsible for supervising the administration of TB drugs, patients received naltrexone for six months in conjunction with directly observed therapy for tuberculosis.
Although naltrexone is approved for the treatment of alcoholism in Russia, access to this medication is scarce and primarily used for heroin addiction.

Staff take samples from TB patients regularly.
“At the time of signing the consent form, none of the 200 patients knew which group they will be assigned,” says Viktoriya Livchits, PIH-Russia’s research coordinator. “A number of the patients had some experience being treated for alcoholism.”
“In the end, all of the patients liked talking to their doctors and would recommend counseling interventions to other patients.”
While researchers will continue working with the data for months before publishing, it is safe to say that the program was a success—both for the patients who received care and for the cadre of health care workers trained to simultaneously address TB and alcoholism.
That is not to say the program did not run into a few glitches. Local physicians were initially worried about an increased work burden, while patients were hesitant to participate.
In Russia, patients pay out-of-pocket for drug and alcohol addiction services and they are required to register with the government’s Narcology Services department upon entering rehab. Registration can result in difficulty seeking employment, employment loss, and restrictions in owning or driving a car.
Men and women enrolled in this clinical trial were not registered with the government’s narcology department.
“Suffering from alcoholism and chronic medical illness further contributes to a cycle of poverty, displacement and socioeconomic disempowerment that often makes recovery unattainable, even for the most motivated patients,” says Dr. Shin.
“The decrease in overall alcohol consumption will improve TB outcomes and decrease HIV risk behavior,” continues Dr. Shin. “Ideally the patient is able to break his or her dependency on alcohol as well.”
In the end, nearly all 200 participants saw the program through from beginning to end.
“The study was challenging,” says Dr. Shin. “Nonetheless, our experiences implementing this care taught us the necessity of working within cultural contexts, delivering services as an integral component of treatment for other chronic medical conditions, employing community health workers, and accompanying our patients through each step of alcohol treatment.”

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