PHP 1540: Alcohol Use & Misuse

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Presentation transcript:

PHP 1540: Alcohol Use & Misuse Introduction to Treatment

Mismatch between Need & Treatment in the USA (see Hasin et al. 2007): 8.5% of the US population (~25 million) currently have an AUD Minority of people who need treatment get it at any given time 12% of those with AUDs in last 12M 4% from 12-step 5% from health professionals 24% of those with lifetime AUDs ever receive any type of treatment Hasin et al (2007): current/12M AUDs = 8.5%; lifetime AUDS = 30% Current dx 12% received tx; lifetime dx 24% ever received it Among people with 12M AUDs: largest subsets sought help from 12-step programs (4%) and physicians or other health professionals (5%) US pop 301Million in July 2007

Why do problem drinkers not go to treatment ? Stigma about being labeled “alcoholic” Desire to handle problems on one’s own Concerns about privacy Beliefs that problems are not serious enough to warrant intensive treatment Lack of access ($, work, childcare, programs) Acceptability of abstinence goal We have to ask ourselves, why is treatment not attractive or appealing to problem drinkers? Well, research has shown that there are several common reasons: Stigma; don’t want to engage in a program that insists on accepting the label of alcoholic Preference to handle things on their own; many Americans have an independent streak Believing that their problems aren’t serious enough to fit the stereotype of alcoholic, and/or don’t justify the investment in intensive treatment (which might require taking time from work, etc.) Because there are few alternatives IN THE US to programs that require abstinence, many problem drinkers say that they just don’t want to be told that abstinence is the only solution. Encourage help-seeking & Offer many ways of getting help

Recovery Spectrum Lower thresholds Varied intensity Include self-help, mutual help groups, screening and brief interventions, outpatient programs, detox, inpatient rehab Facilitate entry in and out of treatment Self-help = web-based self-guided interventions; bibliotherapy; GSC program; Behavioral Self-Control Training; consultation with MDs, clergy or friends

Structurally, treatments vary on several dimensions: Specific components Outcome goals Level of intensity-severity of problem Inpatient vs outpatient length

What treatments don’t work: (Miller & Wilbourne, 2002) Treatment methods with no support from outcome studies Educational lectures/films General alcoholism counseling Confrontational therapies Psychotherapy Hypnosis Miller & Wilbourne (2002) Mesa Grande meta-analysis 361 controlled studies that evaluated a treatment for AUDs compared to a control Randomized to conditions Measured drinking outcomes

What treatments work? (Miller & Wilbourne, 2002) Treatment methods with strong support from many well-designed outcome studies Brief interventions Motivational enhancement Medications: Acamprosate, Naltrexone Community Reinforcement approach Social skills training Behavioral marital therapy Cognitive-behavioral therapies

Treatment goals: Zero-tolerance, i.e. abstinence only Moderate drinking Reduction of quantity consumed so that one avoids alcohol-related problems Harm reduction Harm reduction refers to policies, programs and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop Harm reduction : http://www.ihra.net/files/2010/05/31/IHRA_HRStatement.pdf

Is controlled drinking a viable treatment goal??? Sanchez-Craig et al. (1984) : abstinence vs controlled drinking goals Outcomes were similar Some assigned abstinence developed controlled drinking Some assigned controlled drinking became abstinent People like choice: if abstinence is not acceptable, then a trial of controlled drinking may engage a person in change Sanchez-Craig et al. (1984) randomly assigned early-stage problem drinkers to cognitive-behavioral therapy with either abstinence or controlled drinking goals

Who are good candidates for: Controlled drinking Younger Fewer dependence symptoms Fewer alcohol-related problems Female Older age of onset FHN Abstinence Older More dependence symptoms More lifetime alcohol problems Comorbid mental disorders FHP

The triangle again represents the population of the US, with the spectrum of alcohol problems experienced by the population shown on the upper side. Appropriate responses to the problems are shown on the lower side. In general specialized and intensive treatment is indicated for people with severe problems (these include those with alcohol dependence, and perhaps those with comorbid mental health disorders); briefer interventions are indicated for persons with mild or moderate problems; and primary prevention is indicated for persons who have not had any alcohol-related problems, but are at risk for developing them.

Stepped Care Model (Sobell & Sobell, 2000) INTENSITY – SHOULD BE MATCHED TO SEVERITY OF PROBLEM OR LACK OF RESPONSE TO PREVIOUS INTERVENTIONS. Exploring low intensity interventions that can produce change with minimal investment from the drinker and society is consistent with a model of STEPPED CARE, proposed by Mark Sobell for the alcohol treatment field. Stepped care as a heuristic approach to the treatment of alcohol problems. Sobell, Mark B.; Sobell, Linda C. Journal of Consulting and Clinical Psychology, Vol 68(4), Aug 2000, 573-579. doi: 10.1037/0022-006X.68.4.573 In this approach the preference is to start with the least intensive, least restrictive intervention -- in this case “treatment A” may involve something as low-level as mailed pamphlets or feedback. Experience suggests that this low level intervention may have positive outcomes for quite a few problem drinkers, who will not need anything more. However, for the proportion of PDs who didn’t respond to the first level of treatment, a second level is offered. This mght look like an individualized brief intervention. Again, this will be sufficient for a number of PDs, who will have positive outcomes for a relatively small investment of their time and our resources. Higher levels of treament intensity would be reserved for those who have not successfully changed. This model has considerable appeal; the challenge is to develop and implement low intensity options so we have tx A, and B to offer.

SBIRT Model Screening Brief Intervention Referral to Treatment http://www.integration.samhsa.gov/clinical-practice/sbirt

AUDIT questionnaire 0 – 7 low risk > 8 hazardous drinking whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf whqlibdoc.who.int/hq/2001/who_msd_msb_01.6b.pdf 0 – 7 low risk > 8 hazardous drinking >15 harmful drinking > 20 likely dependence The AUDIT-C is a 3 question screen that can help identify patients with alcohol misuse. The AUDIT-C is scored on a scale of 0-12 points (scores of 0 reflect no alcohol use in the past year). In men, a score of 4 points or more is considered positive for alcohol misuse; in women, a score of 3 points or more is considered positive

KEY TO SBIRT IS USE OF ASSESSMENT RESULTS TO INFORM DECISION MAKING! Babor article distinguishes BI vs BT BI = assessment, brief advice, self-help materials BT = [next slide]

brief treatment Outside of alcohol or drug agency settings Goal: reduce harmful use Typically one or two 15-30 min. sessions Suited for low-moderate risk drinkers Usually combination of motivational enhancement and skills training approaches Low threshold Does not require self-labeling Can be minimally invasive

ASK = SCREEN ASSESS = FOR AUDS ADVISE & ASSIST = IF NO AUD, OFFER BI (ADVISE ON SAFE GUIDELINES, SET GOAL, MAKE PLAN) IF AUD, OFFER BI + REFERRAL TO ADDICTION SPECIALIST + CONSIDER MHG USES NIAAA DEFINITION OF MODERATE DRINKING AS GUIDE http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf

key elements of effective brief treatments Feedback about risk Responsibility lies with patient Advice to change Menu of ways to reduce drinking Empathetic counseling style Self-efficacy/optimism of patient BT = CBT + MI