1. PHP 1540: Alcohol Use & Misuse
Introduction to Treatment

2. 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

4. 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

5. 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

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

7. 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

8. 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

9. 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 :

10. 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

11. 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

12. 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.

13. 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, doi: / X
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.

14. SBIRT Model Screening Brief Intervention Referral to Treatment

15. 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

17. 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]

18. brief treatment Outside of alcohol or drug agency settings
Goal: reduce harmful use
Typically one or two 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

19. 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

20. 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