Results Summary
What was the research about?
Medicines designed to treat alcohol use disorder may help patients stop drinking. But few patients use these medicines.
In this study, the research team designed a set of graphic novels to help counselors and patients who are deciding whether to use medicine for alcohol use disorder. Graphic novels are made in the style of comic books. The novels talked about what to expect in alcohol use disorder treatment. Each novel showed conversations between patients and counselors about recovery and making decisions about treatment and medicine. Counselors led four structured sessions with patients on the graphic novel topics over four to six weeks.
The research team compared patients who used the graphic novels and patients who received usual care. The team wanted to learn if the novels were useful in making decisions about treatment. They also got feedback on the graphic novels from counselors and patients who used them.
What were the results?
The study wasn’t large enough to say for sure if using the graphic novels to help make decisions about alcohol use disorder treatment worked better than usual care. Patients who used the graphic novels and patients who received usual care didn’t differ in
- How often counselors asked them about using medicine for alcohol use disorder
- How satisfied they were with their treatment sessions
- How often they used drugs or alcohol
More patients who received usual care said they followed up on getting medicine for treatment than patients who used the graphic novels.
In group discussions, counselors and patients who used the graphic novels had neutral or positive views on the materials and said they were useful for starting conversations about treatment.
Who was in the study?
The study included 37 patients with alcohol use disorder. Of these, 70 percent were African American, 14 percent were white, and 16 percent were other races. The average age was 43, and 65 percent were men. All patients received treatment at a medical center in Philadelphia.
What did the research team do?
The research team assigned counselors by chance to use the graphic novels or provide usual care. In the graphic novel group, the team trained counselors on how to use the novels.
In the usual care group, counselors received training on the same topics but didn’t use the novels. They also led four sessions over four to six weeks. These counselors had more flexibility to decide which topics to focus on and when.
Patients completed surveys before the study began and again 6 and 12 weeks later. The research team led group discussions with counselors and patients to get feedback on using the graphic novels. The counselor groups took place at week six. The patient groups took place at week 12.
Addiction counselors, patients, and patient advocates helped design the graphic novels and provided input throughout the study.
What were the limits of the study?
The study took place at one medical center. Results may differ in other places.
Future research could test the graphic novels with a larger group of patients to know how well the novels work.
How can people use the results?
Patients with alcohol use disorder and their counselors could consider the results when discussing treatment choices. But more research is needed to say how well the graphic novels help patients make decisions about medicine.
Professional Abstract
Objective
To assess the feasibility and acceptability of using a shared decision making training curriculum and graphic novels to reduce substance use and increase medication-assisted treatment (MAT) uptake in patients with alcohol use disorder
Study Design
| Design Element | Description |
|---|---|
| Design | Feasibility study |
| Population | 37 patients with alcohol use disorder |
| Interventions/ Comparators |
|
| Outcomes | Shared decision making conversation rate, session satisfaction and acceptability, substance use, MAT initiation |
| 12-week follow-up for study outcomes |
This exploratory study examined the use of a Health Education Toolkit to train counselors of patients with alcohol use disorder to conduct shared decision making conversations to reduce substance use and increase MAT uptake. The Toolkit included a set of four graphic novels, which used stories about patients at a drug and alcohol treatment facility to describe what to expect during treatment; model shared decision making conversations about medication; and offer educational resources about recovery, treatment, and medication choices.
The research team randomly assigned counselors to lead sessions using the Toolkit or to provide usual care. In the Toolkit group, counselors received a brief training on using the Toolkit and then led a structured, four-session series on the graphic novel topics with patients over four to six weeks. In the usual care group, counselors received training on topic areas comparable to the Toolkit and led a four-session series with patients over four to six weeks, with flexibility to decide which topics to emphasize and when to present them.
The study included 37 patients with alcohol use disorder who received treatment at a medical center in Philadelphia. Of these, 70% were African American, 14% were white, and 16% were other races. The average age was 43, and 65% were male.
Patients completed measures of shared decision making, session satisfaction and acceptability, substance use, and MAT initiation before the study and 6 and 12 weeks later. The research team conducted focus groups with counselors after the six-week follow-up and with patients after the 12-week follow-up about their experiences using the Toolkit.
Addiction treatment professionals, patients with substance use disorder, and patient advocates helped design the graphic novels and provided input throughout the study.
Results
The study did not have a large enough sample to detect differences between the groups; therefore, results are preliminary and inconclusive. Patients who attended sessions in which counselors used the Toolkit and patients who received usual care did not differ significantly in measures of shared decision making, session satisfaction and acceptability, or substance use. In the usual care group, 33% of patients reported following up on a MAT evaluation or referral compared with 6% in the Toolkit group.
In the focus groups, counselors and patients who used the Toolkit generally had neutral or positive views on the quality of the graphic novels. In addition, counselors and patients gave positive feedback on the usefulness of the graphic novels in creating a dialogue between counselors and patients.
Limitations
The study took place in one medical center. Findings may differ in other settings or locations.
Conclusions and Relevance
The study could not draw conclusions about the usefulness of the Health Education Toolkit in reducing substance use or increasing MAT uptake among patients with alcohol use disorder. Focus group findings indicate that counselors and patients found the Toolkit to be useful.
Future Research Needs
Future research could test the Health Education Toolkit with samples large enough to detect statistically significant differences.
Final Research Report
View this project's final research report.
More About This Research
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers noted that the report should describe the study as a randomized control trial that was not able to test hypotheses, rather than as a feasibility study. They asked that the authors clearly describe the initial hypotheses and planned comparisons. The reviewers also asked that the researchers describe lessons learned and to discuss whether the planned outcome measures might be useful in future research. The researchers revised their report to give a more in-depth explanation of the processes used, to review the utility of the measures used, and to explore what went wrong with recruiting sites and patients, rather than the results of the outcome measures.
- The reviewers asked that the conclusions be consistent with the data presented, and not conclude that the health education toolkit the investigators developed is acceptable and feasible when the results do not support that conclusion. The researchers softened the language they used and clarified that this study failed to draw conclusions about the acceptability or feasibility of the intervention.
- The researchers asked for greater explanation for why a graphic novel was chosen as the format for the intervention curriculum. They asked why other formats or strategies for improved patient engagement were not considered. The researchers acknowledged that they had not done background research to verify that the graphic novel toolkit format matched the literacy level of the intended patients. The researchers explained that the choice to develop a graphic novel curriculum was made with the project’s patient and counselor team. They said the team spent a great deal of time working on the graphic novel content, time that could have perhaps been more profitably spent thinking about other ways to achieve patient engagement. The researchers expanded the limitations section.
- The reviewers noted that the patient and counselor team included the perspectives of patients, providers, and payers. However, it did not include experts in health communication, education, creative writing, or multimedia, so the team’s focus on developing health education material seemed like a mismatch between skills and aims. The researchers agreed that they could have greatly streamlined and strengthened the development process. They added this point as a limitation of the study.
Conflict of Interest Disclosures
View the COI disclosure form.
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers noted that the report should describe the study as a randomized control trial that was not able to test hypotheses, rather than as a feasibility study. They asked that the authors clearly describe the initial hypotheses and planned comparisons. The reviewers also asked that the researchers describe lessons learned and to discuss whether the planned outcome measures might be useful in future research. The researchers revised their report to give a more in-depth explanation of the processes used, to review the utility of the measures used, and to explore what went wrong with recruiting sites and patients, rather than the results of the outcome measures.
- The reviewers asked that the conclusions be consistent with the data presented, and not conclude that the health education toolkit the investigators developed is acceptable and feasible when the results do not support that conclusion. The researchers softened the language they used and clarified that this study failed to draw conclusions about the acceptability or feasibility of the intervention.
- The researchers asked for greater explanation for why a graphic novel was chosen as the format for the intervention curriculum. They asked why other formats or strategies for improved patient engagement were not considered. The researchers acknowledged that they had not done background research to verify that the graphic novel toolkit format matched the literacy level of the intended patients. The researchers explained that the choice to develop a graphic novel curriculum was made with the project’s patient and counselor team. They said the team spent a great deal of time working on the graphic novel content, time that could have perhaps been more profitably spent thinking about other ways to achieve patient engagement. The researchers expanded the limitations section.
- The reviewers noted that the patient and counselor team included the perspectives of patients, providers, and payers. However, it did not include experts in health communication, education, creative writing, or multimedia, so the team’s focus on developing health education material seemed like a mismatch between skills and aims. The researchers agreed that they could have greatly streamlined and strengthened the development process. They added this point as a limitation of the study.
Project Information
Key Dates
Study Registration Information
^The original organization for this project was Treatment Research Institute, Inc.