2. Center for Integrated Behavioral Health Policy Department of Health Policy, The George Washington University Medical Center Eric Goplerud, Ph.D. Conference of Western Attorneys General Sun Valley, Idaho August 4, 2009 The Importance of Alcohol Abstinence Deterrence and Behavior Change

3. Transforming practice. Expanding access. Improving health. Center for Integrated Behavioral Health Policy Department of Health Policy, The George Washington University Medical Center

4. How important is abstinence?

6. Top 10 Leading Causes of Death in the United States for 2001, by Age Group

7. 13,000 in US die annually due to alcohol impaired driving. More than 500,000 injuries and $16 billion in property damage. Alcohol involved in: 33% of suicides 57% sexual assaults 28.5% domestic violence cases 44% PMV accidents

8. What are we trying to accomplish? Deterrence? Behavior change? Punishment? Prevention?

9. State Power Restrict movement Restrict pleasurable activities Require payment of fines and fees

10. Thinking About Deterrence Threat of punishment deters bad behavior ‣ Rationality ‣ Cause and effect ‣ Perception of fairness ‣ Risk of detection

11. Thinking About Addiction Compulsion Ignore negative consequences Denial

12. Impact of heavy, long term alcohol use on the brain

13. Cognitive Impairment and Abstinence

14. A Problematic Pattern Focus on deterrence Limited assessment Same intervention for everyone Limited treatment Ineffective treatments

16. What we don’t do that’s effective! SBI, CBT, Medications

17. What do we really do? What doesn’t work! AA, Counseling, Educational Lectures

18. Cognitive Behavioral Model Social learning Rewards and costs Stages of change

19. Preventing Relapse Coping Self-efficacy Reduced risk Trigger Lapse Relapse

20. Deterrence & Addiction A pathway to prison -- or worse.

21. Two Models Deterrence ‣ Detention ‣ Fines Cognitive Behavioral ‣ Coaching ‣ Therapy

22. (Gentillelo, 2008)

28. Spectrum of Offenders IrrationalRational Susceptible to deterrence Resistant to deterrence

30. Population affected by deterrence Population resistant to deterrence Reason for Plateau

31. 5%HarmfulUse 21% (26.25 million) At Risk Exceed daily limits. 70% (87.5 million) No Problem Never exceed daily limits. 3% (3.75 million) Dependence Daily or near-daily heavy drinking. Related problems. Withdrawal. 1% (1.25 million) Chronic Dependence Almost daily heavy drinking. Related problems. Withdrawal. Chronic or relapsing. 5% (6.25 million) Harmful Use Exceed daily limits. Related problems. Willenbring, 2007 Spectrum of Alcohol Problems

32. The Need for Abstinence Not always necessary Short-term vs. Long-term Support for behavior change Effective part of relapse prevention

33. Effective Response to Alcohol-related Crime

34. Deterrence & Prevention Social marketing Regulation Enforcement

35. Screening & Assessment Golden opportunity to identify problems Screen Assess Determine appropriate intervention

36. Recovery Support Individual and group therapy Medical monitoring and medication Technology as part of relapse prevention ‣ Interlock ‣ Testing ‣ Remote alcohol monitoring

38. https://webmeeting.nih.gov/intro

39. Eric Goplerud Director 2021 K St. NW, Suite 800 Washington, DC goplerud@gwu.edu integratedbehavioralhealth.org Center for Integrated Behavioral Health Policy Department of Health Policy, The George Washington University Medical Center