Treatment: Options and Effectiveness National Partnership On Alcohol Misuse and Crime Meeting on Treatment, Washington, DC

1
Treatment Options and EffectivenessNational
Partnership On Alcohol Misuse and Crime Meeting
on Treatment, Washington, DC

• Richard N Rosenthal, MD
• Professor of Clinical Psychiatry
• Columbia University College of Physicians
  Surgeons
• Chairman, Dept of Psychiatry
• St. Lukes-Roosevelt Hospital Center, NY
• June 2, 2009

2
Disclosure

• RESEARCH  GRANT  SUPPORT
• 2006 - 2008  Forest Laboratories, Inc.
  Principal Investigator
• 2007 - 2008  Titan Pharmaceuticals, Inc.
  Principal Investigator
• 2007 - 2012  National Institute on Drug Abuse
  Co-Investigator
• 2008 - 2010  The National Institute of Diabetes,
  Co-Investigator Digestive and Kidney
  Disease
• AFFILIATIONS
• 2008 -           Sequest Technologies, Lisle, IL.
  Advisory Board

3
Overview

• Who needs Treatment?
• What is the Treatment Process?
• How does it begin?
• Who is involved?
• Importance of Screening and Assessment
• Consideration of Prior Convictions
• Pre-treatment
• Brief Interventions/Motivational Interviewing

4
Overview

• Treatment Options and Effectiveness
• Counseling Models and Outcome Differences
• Motivational Enhancement Therapy
• Cognitive Behavioral Therapy
• Patient Placement Criteria settings and levels
  of care
• Role of Detoxification
• Role of residential rehabilitation/halfway house
• Voluntary vs. Mandatory Treatment
• Treatment Vs. Education
• Role of 12-Step and Support Group

5
Who Needs Treatment?

• Heavy/at Risk drinkers
• Medical Impact even without a diagnosis
• Diagnosis of Alcohol Abuse - where symptoms
  increase likelihood of further sanctions due to
  impaired judgment/control
• DUI, assault, loss of external social supports,
  missed appointments
• Diagnosis of Alcohol Dependence
• Impairment, disability

6
The Scope of Alcohol Problems in the Criminal
Justice System

• 21.6 percent of victims of violent crimes thought
  or knew the offender had consumed alcohol
  another 1.5 percent of the victims thought the
  offender had used either alcohol or another drug
  (Bureau of Justice Statistics 2003).
• 40 percent of offenders on probation, in State
  prisons, or in local jails reported using alcohol
  at the time of their offense (Bureau of
  Statistics 1998).
• 18 percent of Federal prison inmates and about 25
  percent of State prison inmates reported having
  experienced problems consistent with a history of
  alcohol abuse and dependence (Knight et al.
  2002).
• 29 percent of Federal and 40 percent of State
  prisoners reported a previous domestic violence
  dispute involving alcohol (Knight et al. 2002).
• There were 1.4 million DWI arrests in 2001,
  making DWI the number one crime, besides drug
  possession, for which Americans are arrested
  (NHTSA 2003).
• About two-thirds of convicted DWI offenders are
  alcohol dependent (Lapham et al. 2001).

http//pubs.niaaa.nih.gov/publications/arh28-2/85-
93.htm
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The Scope of Alcohol Problems in the Criminal
Justice System

• In a study of first-time DWI offenders
  interviewed 5 years after first being referred to
  screening following their DWI offense (Lapham et
  al. 2001)
• 85 of female and 91 of male DWI offenders had
  met the criteria for alcohol abuse or dependence
  at some time in their lives.
• 32 of female and 38 of male offenders had met
  criteria for abuse of or dependence on another
  drug at some time in their lives.
• 50 of women with an alcohol use disorder and 33
  of men with an AUD also had at least one
  psychiatric disorder (not drug-related), most
  commonly depression and post-traumatic stress
  disorder.

http//pubs.niaaa.nih.gov/publications/arh28-2/85-
93.htm
8
Why Are Alcohol Use Disorders (AUD)
Underdiagnosed 50 time?

• Clinicians
• Typically lack proper training in screening and
  recognition
• Miss diagnosis if presentation is not obvious,
  e.g. skid row bum Alcohol on Breath, etc.
• Are practical professionals, spend time on
  fixable problems
• Frequently believe alcohol dependence isnt
  treatable, leading to professional denial

9
Why Are Alcohol Use Disorders Underdiagnosed
50 time?

• Patients with AUD typically
• minimize or deny strongly problem use
• deny physical and psychological problems could be
  related to drinking
• rationalize work and interpersonal problems as
  cause of use, not result
• Present with emotional complaints (anxiety, mood
  disturbance) without linking them to alcohol use.
• Significant others/family/friends in best
  position to report problems with alcohol but not
  present at screening or evaluation

Adapted from Waldinger RJ Substance-Related
Disorders and Eating Disorders, in Psychiatry for
Medical Students. 3rd Ed. American Psychiatric
Press, Inc. Washington DC, 1997.
10
Screening in the Criminal Justice System

• In 2002, Criminal justice/DWI referrals accounted
  for 40 of alcoholism treatment admissions to
  alone, and 34 of admissions to alcohol and other
  drugs treatment programs (SAMHSA 2004).
• Court-ordered screening misses many people with
  AUD and other disorders
• In N1,078 convicted offenders, later voluntary
  screening reported proportionally more alcohol
  abuse or alcohol dependence compared to the
  court-ordered initial screening for alcohol
  problems (Lapham et al. 2004).

Lapham, S.C et al., Drug and Alcohol Dependence
76135141, 2004
11
Screening in the Criminal Justice System

• Limitations of screening procedures in the
  criminal justice system include
• No screening instruments are available that have
  proven validity to assess both AOD use and the
  range of mental health problems found in criminal
  justice populations.
• Lack of screening instruments validated
  specifically for criminal justice offenders.
• Most current screening instruments rely on self
  report.
• Court-ordered screening is by definition
  coercive.
• Screening and treatment programs have limited
  financial resources costs may be passed on to
  people being screened or treated who may be
  unable to pay.

Lapham, S.C et al., Drug and Alcohol Dependence
76135141, 2004
12
When to Implement Screening

• A planned, purposeful and usually brief process
  that should occur soon after the offender enters
  the system.
• Offenders screened at various stages of the
  judicial process, including at arrest or
  arraignment, at pretrial investigation, during
  interactions with court staff, or as a
  post-sentence action.
• Screening and interventions with offenders who
  have AUD will probably be more effective if
  initiated soon after the offense, (laws are most
  likely to deter illegal behavior (e.g., DWI) if
  perceived to result in swift, certain, and severe
  sanctions (e.g., Morral et al. 2002).
• National Commission on Correctional Health Care
• Comprehensive health assessment (including
  substance abuse history) within 7 days of arrival
  in prison, 14 days of arrival in jail

Morral, A.R et al. Drug and Alcohol Dependence
66(Suppl.)S124S125, 2002.
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Screening and Assessment in Correctional Settings

• Substance Use history patterns of use,
  treatment, acute symptoms, need for detox
• Criminal history
• Personality traits related to criminality
• Mental health issues, including suicide
  potential, acute symptoms, treatment history,
  psychiatric medications
• Abuse and trauma history, as victim/perp
• High-risk behaviors
• Motivation for treatment
• Education and literacy
• Physical disabilities
• Relationships with significant others, family,
  dependents
• Physical health, acute conditions, infectious
  diseases including STDs, HIV/AIDS, TB, and
  hepatitis

14
Screening for AUD

• Screening
• determines the likelihood of alcohol use
  disorder
• establishes the need for an in-depth assessment.
• Begin at the earliest point of clinical contact
  with the offender and continue throughout
  treatment, if provided
• Several screening tools can help determine the
  likelihood of the presence of problem alcohol
  use.
• CAGE 4-item self report , scores 0-4, 2 answers
  flag high risk
• MAST 21-item self report, scores gt 6 probable
  alcohol dependence
• AUDIT 10 item self report, score gt 8 in men,
  probable AUD
• 
  gt 4 in woman, probable AUD

15
Screening for AUD

• CAGE 4 Items
• lt 1 minute to administer
• 2 yes answers high risk for AUD
• High sensitivity for AUD (60-95)
• No questions about frequency of use
• No quantity of consumption questions
• No frequency of heavy drinking questions
• Because consequence-focused, wont flag early
  problem drinkers

16
Screening for AUD

• MAST 25 Items
• 7 Probable Alcohol Dependence
• 5-6 Borderline Alcoholism
• 4 No problem drinking
• High Sensitivity for AUD (86-98)
• Questions elicit lifetime history rather than
  current drinking behavior (Magruder-Habib et al.,
  1991)

17
Screening for AUD

• AUDIT 10 Items, assesses over past year
• WHO Collaborative effort
• Multicultural (Babor Grant, 1989)
• Designed to screen earlier-level problems in
  primary-care settings
• Sensitivity 92, Specificity 93
• Three Domains amount frequency alcohol
  dependence alcohol-induced problems
• Cutoff score of 8 of 40 probable AUD

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Simple Screening for AUD

• Ask the screening question about heavy drinking
  days How many times in the past year have you
  had 5 or more drinks in a day? (for men)
• 4 or more drinks in a day? (for women)
  
• One standard drink is equivalent to 12 ounces of
  beer, 5 ounces of wine, or 1.5 ounces of 80-proof
  spirits
• 1 or more heavy drinking days, or
• AUDIT score of 8 for men or 4 for women
• If endorsed, then a clinical evaluation

19
Clinicians Initial Evaluation

• Document current and past use of alcohol and each
  other substance separately pattern?, who with?
• Log prior quit attempts treatments
• Medications how used? how long ?
• Psychosocial treatment?
• Assess current motivation to quit (pros cons
  quit date)
• Assess triggers, withdrawal, and dependence
• Assess social support

20
SAMHSA HOUSEHOLD SURVEY, 2004
Total US Population Over 12 Years
(237 M)
Current Alcohol Users 50.3 (121 M people)
Binge Drinkers 22.8
(55 M)
Heavy Drinkers 6.9 (16.7M)
(NSDUH, 2005)
21
Hazardous Drinking

• A standard drink contains about 14 g alcohol
• At-Risk or Heavy Drinking is defined as
• Men gt14 drinks/week or gt4 drinks/occasion
• Women gt7 drinks/week or gt3 drinks/ occasion
• Hazardous alcohol consumption 60-90 g alcohol
• Good predictor of alcohol-related problems
• Negative Impact on chronic medical illness
• Significant increased morbidity and mortality

McGinnis JM, Foege WH. JAMA. 1993
270(18)22072212. NIAAA (2004) Helping Patients
With Alcohol Problems. DHHS, Wash., DC.
22
DSM -IV Substance Abuse

• Substance use leading to clinically significant
  impairment manifested by one (or more)
• Failure to fulfill major role obligations
• Hazardous situations
• Legal problems
• Continued substance use despite having persistent
  or recurrent social or interpersonal problems
• Never met the criteria for substance dependence

23
Addiction Classical and Contemporary Constructs

• Classical (Peele 1985)
• Craving
• Increased tolerance
• Physiologic withdrawal
• Contemporary Behavioral Dysregulation
• Compulsive behavior despite negative
  consequences, i.e., loss of control
• Salience primacy in a persons life
• Cognitive dominates mental life
• Behavioral dominates activity
• Functional Impairment

24
DSM -IV Substance Dependence

• Three (or more) of the following over 12 Months
• Tolerance
• Withdrawal
• Larger amounts or over longer period than
  intended
• Persistent desire or unsuccessful efforts to cut
  down
• Much time spent in acquiring, using, or
  recovering from effects
• Abandonment/reduction of important social, work,
  or recreational activities
• Continued use despite knowledge of having an
  alcohol-induced or exacerbated physical or mental
  problem

25
Targeting Heavy Drinking

• Proxy for Impairment
• Impact of Heavy Drinking
• Differences in NESARC diagnoses rates and rates
  of binge and heavy drinking

26
2000 National Household Surveys on Drug Abuse
(NHSDA)

• Highest rates binge, heavy drinking young adults
  aged 21 to 25
• Peak rate 65 at age 21 (45 binge drinking, 17
  heavy drinking)
• Binge and heavy alcohol use rates decrease faster
  with age than rates of past month alcohol use

http//www.samhsa.gov/oas/2k2/alcNS/alcNS.htm
27
Impact of Heavy Drinking

• About 25 have alcohol dependence
• Increased risk
• gastrointestinal bleeding, 
• sleep disorders, 
• major depression, 
• hemorrhagic stroke,
• cirrhosis of the liver, and 
• several cancers

Rehm J Addiction. 200398(9)1209-1228. NIAAA
(2004) Helping Patients With Alcohol Problems.
DHHS, Wash., DC.
28
Hazardous Drinking

• Defined as AUDIT scores 8 (Babor et al., 2001)
• Sample Patient
• drank 2 3 times a week (3 points)
• drank ? 2 drinks/day typically (1 point)
• had ? 6 drinks on one occasion at least monthly
  (2 points)
• had a relative or friend, a doctor or other
  health worker say that they have been concerned
  about your drinking or suggested you cut down in
  past year (4 points)
• Total score 10.

Mertens, JR et al., Alc Clin Exp Res.
200529(6)989-998
29
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Impact of Hazardous Drinking

• 1,419 HMO primary care clinic patients, 13.9 K
  comparison group AUDIT screen
• Hazardous drinking prevalence of 7.5
• Alcohol abuse prevalence was only 0.38
• ?prevalences of 8 medical conditions
• Pneumonia, COPD
• Costly conditions such as injury and hypertension
• Depression, anxiety disorders, and major
  psychoses

Mertens, JR et al., Alc Clin Exp Res.
200529(6)989-998
31
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32
Systematic Review Findings Alcohol and
Hypertension

• 11 randomized controlled trials
• Dose related effects
• lt 2 drinks/day or 10/week usually decreases
• gt 3 drinks/day or 14/week significant increase
• Magnitude of effect about the same as salt intake
• Effect of alcohol greatest in subjects with
  pre-existing hypertension

McFadden et al. Am J Hypertension. In press.
Slide courtesy A.T. McLellan, PhD
33
Systematic Review Findings Alcohol and Diabetes

• 32 studies
• U-shaped association
• Moderate alcohol (1-3 drinks/ day)
• 33-56 lower incidence of diabetes
• 34-55 lower incidence of diabetes-related
  coronary heart disease
• Heavy alcohol (gt3 drinks/day) up to 43
  increased risk of diabetes

Howard, A.A. et al. Ann Int. Med. 2004140211-219
34
Interventions for Heavy Drinkers
35
Screening as a Brief Intervention

• In various medical settings, brief interventions
  are recommended for patients who misuse alcohol
  and are at risk for dependence, but who are not
  alcohol dependent.
• These interventions typically
• Involve four or fewer sessions
• Are not conducted in a specialized alcoholism
  treatment facility, and
• Are performed by health care providers and others
  who are not specialized in addiction treatment.

36
Impact of Brief Physician Advice for Heavy
Drinkers

• TrEAT study (Trial for Early Alcohol Treatment)
• RCT N723 subjects, 12 and 48-month follow-up, 64
  MDs in 17 primary care offices
• Two 10-15 physician-delivered, counseling visits
• Review drinking norms, patient-specific effects,
• Worksheet on drinking cues, diary cards
• Drinking agreement as a prescription

Fleming MF, et al. Alcohol Clin Exp Res.
2002(Jan)26(1)36-43
37
Impact of Brief Physician Advice for Problem
Drinkers

• 2 nurse follow-up calls
• Measures
• Alcohol use,
• ER visits and
• Hospital days

Fleming MF, et al. Alcohol Clin Exp Res.
2002(Jan)26(1)36-43
38
Impact of Brief Physician Advice for Problem
Drinkers
12-month Intervention
Baseline Intervention
12-month Control
Baseline Control
11.5
19.1
15.5
18.9
drinks 7 d
3.1
5.7
4.2
5.3
binges 30 d
17.8
47.5
32.5
48.1
excessive use ETOH 7 d
plt0.001
Fewer hospitalization days in Exp group, ?2(P lt
0.01)
Fleming MF, et al. JAMA 19972771039-1045
39
Impact of Brief Physician Advice for Problem
Drinkers

• Significant reductions
• 7-day alcohol use
• Number of binge episodes
• Frequency of excessive drinking
• Effects by 6 months, sustained at 48 months
• Fewer hospital days and ER visits
• For every 10K invested in early intervention,
  43K future health cost reduction (without
  including MVA and crime costs)

Fleming MF, et al. Alcohol Clin Exp Res.
2002(Jan)26(1)36-43
40
Targeting Heavy Drinking

• Psychosocial interventions that reduce alcohol
  intake have important clinical effects
• Why not use medications that might accomplish the
  same?
• Proxy diagnosis hazardous or heavy drinkers
  versus categorical one
• Drinkers without diagnoses might not want to be
  abstinent
• Large potential social utility
• Naltrexones main effect is reduction in heavy
  drinking

41
MotivationaI Interviewing

• Definition Motivational Interviewing is
• a client-centered, directive method
• for enhancing intrinsic motivation to change
• by exploring and resolving ambivalence,
• typically in a particular direction of change.

Miller R, Rollnick S. Motivational Interviewing
Preparing People for Change, New York Guilford,
2002
42
Stages of Change Model

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance

Prochaska, J.O. DiClemente, C.C. Norcross,
J.C. Am Psychol 47(9)1102-1114, 1992.
43
Stages of Change Model

• Precontemplation- Overestimates costs of change
  and underestimates benefits. No intention to take
  action due to
• lack of information
• not understanding consequences of not changing
• demoralization after repeated failures
• No inherent motivation (e.g. crawling to
  walking) progress due to events, differential
  processing
• Developmental, e.g., hitting 39th birthday,
  taking stock
• Environmental Beloved dog dies of lung cancer
• Heavy-smoking wife quits smoking
• Heavy-smoking husband buys new dog!

Prochaska, J.O. in Ries R. et al. Eds,
Principles of Addiction Medicine, 4th Ed.
Lippincott, Williams Wilkins, 2009, pp 745-755.
44
Stages of Change Model

• Contemplation More aware of the benefits of
  change, acutely aware of the costs
• Can present as profound ambivalence
• Client can entertain the reality of a problem
• Preparation Decisional balance has tipped in
  favor of change, which is being planned for in
  next 30 days
• Plan of action go to AA, talk to physician, buy
  a self-help book, etc.
• Action Client makes specific, overt changes in
  lifestyle
• Only modifications of behavior that results in
  reduction of disease risk is deemed effective
  action
• Maintenance Working to prevent relapse

Prochaska, J.O. in Ries R. et al. Eds,
Principles of Addiction Medicine, 4th Ed.
Lippincott, Williams Wilkins, 2009, p 745-755.
45
Clinical Impact Change Model
Precontemplation
Maintenance
slip
relapse drop out
relapse
Contemplation
Action
Preparation
46
Principles of Motivational Interviewing

• MI differs from traditional counseling in that
  it is client-centered
• Collaborates rather than confronts
• Evocates rather than educates
• Respects autonomy rather than imposing authority
• Not focused on
• teaching new coping skills
• reshaping cognitions
• exploring the past
• A way of being with rather than to do something
  to
• Elicits intrinsic motivation rather than using
  extrinsic ones (coercion such as legal sanction,
  punishment, social pressure, or reward such as
  financial gain).
• Negative contingency frequently doesnt work (as
  you well know).

Miller R, Rollnick S. Motivational Interviewing
Preparing People for Change, New York Guilford,
2002
47
Clinical Assessment/Intervention

• Integrate Motivational Interviewing into the
  clinical assessment interview for treatment
  seeking clients
• understand the motives clients have for
  addressing their substance use problems
• gather the clinical and administrative
  information needed to plan their care
• build and strengthen their readiness for change

Martino, S. et al. (2006) Motivational
Interviewing Assessment Supervisory Tools for
Enhancing Proficiency. Salem, OR Northwest
Frontier Addiction Technology Transfer Center,
Oregon Health and Science University. http//www.m
otivationalinterview.org/library/MIA-STEP.pdf
48
Motivational Interviewing

• Identifying substance-related losses important
  for motivating people with comorbid psychiatric
  disorders contemplating behavior change (Blume
  Marlatt, Addict Behav, 2000)
• Pilot data one-session preadmission 45-60
  motivational interview more effective than
  standard preadmission interview - partial
  hospital program. (Martino et al., Am J Addict,
  2000)

49
High-Grade Evidence of MI Efficacy

• http//www.motivationalinterview.org/library/index
  .html
• Dunn C, Deroo L, Rivara FP. The use of brief
  interventions adapted from motivational
  interviewing across behavioral domains a
  systematic review. Addiction 200196172542.
• Burke BL, Arkowitz H, Menchola M. The efficacy of
  motivational interviewing a meta-analysis of
  controlled clinical trials. J Consult Clin
  Psychol 20037184361.
• Rubak S, Sandbaek A, Lauritzen T, Christensen B.
  Motivational interviewing a systematic review
  and metaanalysis. Br J Gen Pract 20055530512.

50
Motivational Enhancement Therapy

• View of the patient as self-directed and
  responsible for and capable of changing his or
  her behavior.
• The clinician assists the patient in mobilizing
  his or her own inner resources.
• MET allows the patient to determine treatment
  goals and encourages movement from one
  motivational stage to the next.

51
Motivational Enhancement Therapy (FRAMES)

• Feedback of personal impairment
• Personal Responsibility for change
• Clear Advice to change
• A Menu of alternatives
• Therapist Empathy
• Facilitate Self-efficacy or optimism

52
MI in a Broader Context

• Addictive disorders
• Pathological gambling
• Heavy drinking college students
• Engagement and Adherence to treatment
• Pharmacotherapy
• Dietary parameters (e.g. DM)
• Chronic disease management
• Mental disorders
• Medical disorders Diabetes, HIV
• Health promotion
• ACOG committee opinion
• HIV and other STD risk reduction
• Weight loss
• Reducing alcohol use in pregnancy

ACOG Committee Opinion No. 423. Obstet Gynecol.
2009 Jan113(1)243-6.
53
Relapse Pathways

• 3 major biological mechanisms associated with
  relapse following extinction of drug-seeking
  behavior
• Exposure to the drug1 (reward/extinction)
• Exposure to conditioned cues (ie, people, places,
  and things)2 (craving/dysphoria)
• Exposure to nonspecific stress3 (stress)

1Monti et al. Addiction. 200095S229. 2McBride
et al. Alcohol Clin Exp Res. 200226280. 3Koob.
Addiction. 200095S73.
54
Benefits of Psychotherapies

• Help patients to cope with 2 of 3 major factors
  in relapse
• Reducing exposure to cues associated with use of
  substances
• Learning healthy pleasures changing rewards
• Adopting refusal skills
• Avoiding people, places and things associated
  with substance use
• Reducing stress
• Decreasing negative emotional states
• Increasing resilience to stressors through
  support, remoralization, self-efficacy

55
Treatment Works
Reduction in Percentage of Drinking Days
Baseline
12-month follow-up
80
60
40
20
0
Cognitive Behavioral Therapy
Motivational Enhancement Therapy
12-Step Facilitation
Project Match Research Group. J Studies Alcohol
587-29, 1997
56
Cognitive Behavioral Therapy

• CBT help patients recognize, avoid, and cope.
• RECOGNIZE situations in which they are most
  likely to use,
• AVOID these situations when appropriate,
• and COPE more effectively with a range of
  problems and problematic behaviors associated
  with substance abuse

57
CBT Addresses Critical Tasks

• Foster the motivation for abstinence.
• Decisional analysis which clarifies loss or gain
  with continued use.
• Teach coping skills.
• Recognize the high-risk situations in which they
  are most likely to use
• Develop other, more effective means of coping
  with them.

Rounsaville Carroll, Ch 38., In Lowinson,
Ruiz, Millman, Langrod (Eds.) Substance Abuse A
Comprehensive Textbook, 2nd Ed. 1992
58
CBT Critical Tasks (contd)

• Change reinforcement contingencies. Drug use
  excludes other experiences and rewards.
• Identify and reduce drug-associated habits by
  substituting positive activities rewards.
  (Healthy pleasures)
• Foster management of painful affects.
• Techniques to recognize and cope with urges to
  use
• Model for learning to tolerate other strong
  affects
• Rounsaville Carroll, Ch 38., In Lowinson,
  Ruiz, Millman, Langrod (Eds.) Substance Abuse A
  Comprehensive Textbook, 2nd Ed. 1992

59
CBT Critical Tasks (contd)

• Improve interpersonal functioning and enhance
  social supports.
• Interpersonal skills training and strategies to
  help patients expand their social support
  networks and build enduring, drug-free
  relationships.
• Cognitive skills interventions to aid recognition
  of behavioral problems rooted in distorted
  thought processes
• Rationalizations to engage in criminal or
  addictive behaviors
• Selfmonitoring skills to identify maladaptive
  thoughts and replace or restructure them

Peters RH et al. Substance Abuse A Comprehensive
Textbook, Ch 46, pg 707-722, 2005
60
Relapse Prevention Specific Techniques

• Assessing internal and external cues for craving
  and usage
• Defining relapses ("slips")
• Discussing "seemingly irrelevant decisions"
• Itemizing the characteristics of relapse
• Exploring dreams involving drugs
• Developing coping and relaxation skills
• Employing drug-refusal exercises
• Managing a slip
• Understanding the Abstinence Violation Effect

61
Cognitive Behavioral Therapy

• The Evidence
• Meta-analyses and extensive reviews of the
  literature have established that cognitive
  behavior approaches have strong empirical support
  for use in treatment of AUD

Miller WR, Wilbourne PL. Addiction 2002
97265277
62
Behavioral Couples Therapy

• Couple enters into a contract stipulating that
• The partner observes and records on a calendar
  the patient taking the daily medication
  (disulfiram) dose,
• The patient and partner then thank each other
  for their efforts
• Refrain from arguments or discussions about the
  patients drinking behavior (OFarrell and
  Bayog, 1986).

63
Behavioral Couples Therapy

• Meta-analysis of BCT studies demonstrate its
  superiority over individual interventions for
  alcohol and drug abuse at treatment follow-up on
  
• frequency of use,
• consequences of use and
• relationship satisfaction (Powers et al., 2008)
• Effects of BCT tend to fade over time as domestic
  partners tend to regress back towards
  dysfunctional relating
• Booster relapse prevention sessions provided to
  couples after the main treatment had ended
  supported the maintenance of treatment gains
  (OFarrell et al., 1993).

64
Recovery

• The Big Book
• Subtitle The Story of How Many Thousands of Men
  and Women Have Recovered From Alcoholism
• Foreward to 1st Ed. To show other alcoholics
  precisely how we have recovered is the main
  purpose of this book.
• Personal Stories How Forty-Two
  AlcoholicsRecovered From Their Malady

Alcoholics Anonymous World Services, Inc. 4
edition (February 10, 2002)
65
Common Factors Recovery Mutual Aid

• Recovery societies strategies
• Public confession
• Public commitment to abstinence
• Sober fellowship through experience-sharing
  meetings
• Discovery of resources within/beyond self
• Reconstruction of personal values, identity,
  relationships
• Service to others as self-healing mechanism
• Unclear if its reform, redemption, recovery,
  reconstruction, maturation or transformation
• Time element matches chronic illness model
  always recovering (never recovered)

White W. Substance Use Misuse 431987-2000, 2008
66
Alcoholics Anonymous

• May be only treatment available in some
  correctional settings
• Is synergistic with clinical approaches, best
  when offender is initially in a controlled
  environment, since it is an abstinence model

67
Time Abstinent Makes a Difference
Days
Days
The hazard functions for the log-logistic
distribution for alcohol (left) and nicotine
(right) studies.
Kirschenbaum et al., Journal of Substance Abuse
Treatment 36817, 2009
68
Twelve Step Facilitation

• Developed by Nowinski, Baker Carroll (1992) for
  NIAAAs Project MATCH as an approach which was
• Manual guided, delivered on an Individual basis
• Sharply contrasts with CBT and Motivational
  Interviewing
• Ascribes to the AA/NA philosophy that relies
  heavily on a combination of spirituality and
  pragmatism, and advocates peer support as the
  primary means for achieving sustained sobriety
• Approximated frequently used counseling methods
  that invoked 12 Step recovery
• Sought to facilitate meaningful involvement in
  self help groups

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Twelve Step Facilitation

• Intended to be implemented on an individual basis
  in 12 to 15 sessions and is based in behavioral,
  spiritual, and cognitive principles that form the
  core of 12-step fellowships such as Alcoholics
  Anonymous (AA)
• Based on principles of Alcoholics Anonymous
• Treatment goal is abstinence
• Emphasis on first 3 Steps and fostering
  involvement in AA
• Core topics include the assessment plus
  acceptance, surrender, and getting active also
  elective sessions
• Not equivalent to AA, NA referral
• Not equivalent to treatment as usual
• Has been adapted to a group format

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Twelve Step Facilitation

• TSF does appear to facilitate self-help
  attendance/involvement
• TSFs effectiveness appears to apply to a range
  of addiction problems, including methadone
  maintenance
• IS NOT equivalent to treatment as usual
• Seasoned clinicians can learn and use TSF
• TSF has shown to substantially increase the
  likelihood that patients will become engaged with
  these AA resources.

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Why Use Medications?

• Addiction is a chronic disease requiring
  long-term treatment, not different from
  hypertension or diabetes
• These illnesses also have psychosocial
  interventions that improve outcomes
• Medication for addiction works best in the
  context of psychosocial treatment
• Effect sizes for no one treatment is large

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Why Use Medications?

• There are no slam dunk medications anymore than
  there are slam dunk psychosocial interventions
• Getting the ball through the hoop is a team
  effort!
• Therefore, combinations of medical and
  psychosocial treatment optimizes outcomes

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Facility Services Offered NSSATS 2003
Total Privatenon-profit Privatefor-profit Local/ Stategovt Federalgovt
Number of Programs 13,623 8,258 3,403 1454 339
Percentage of Programs 100 61 25 11 2
Medications ( of Type) 2,739 20 1,338 16 768 23 376 22 229 68
Antabuse ( of Type) 2,268 17 1,084 13   602 18 343 24 213 63
Naltrexone ( of Type) 1,656 12 835 10 455 13 185 13 169 50
Serves veterans, military personnel, inmates, or
Native Americans.
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Adherence

• Treatments dont make you better if you dont
  take them.
• Be aware of factors that reduce adherence, such
  as
• denial of illness or its chronicity,
• complex dosing schedules,
• side effects,
• poor social support, and
• depression or amotivation (DiMatteo, 2004
  DiMatteo et al, 2000 Perkins, 2002)

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Addiction Treatment Works
Reductions in Healthcare Services Utilization

• Hospitalizations for Physical health 36 Drug
  overdose 58 Mental health 44
• Number of Hospital days 25 ER
  visits 38 Doctor visits 14 Mental health 3

Gerstein, Harwood, Fountain et al. CALDATA, 1994
(http//www.adp.state.ca.us)
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Underlying Concepts of ASAM PPC

• Biopsychosocial Perspective of Addiction
• Biopsychosocial in etiology, expression, Tx.
• Comprehensive assessment and treatment
• Explains clinical diversity with commonalities
• Promotes integration of knowledge

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Determine Level of Care
ASAM PPC-2R Dimensions

1. Acute Intoxication and/or Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions
   and Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem
   Potential
6. Recovery/Living Environment

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Treatment Levels of Service

• I Outpatient Treatment
• II Intensive Outpatient and Partial
  Hospitalization
• III Residential/Inpatient Treatment
• IV Medically-Managed Intensive Inpatient Treatment

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Mandated Treatment

• Coerced or involuntary treatment comprises an
  integral, often positive component of treatment
  for addictive disorders, but raises numerous
  ethical, clinical, legal, political, cultural,
  and philosophical issues.
• Health care professionals should appreciate the
  indications, methods, advantages, and associated
  liabilities.
• Addiction Committee of the Group for the
  Advancement of Psychiatry they searched the
  literature using Pubmed from 1985 to 2005

Sullivan M et al., The American Journal on
Addictions, 17 3647, 2008
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Mandated Treatment

• Intensive outpatient treatment has shown In
  therapy-resistant chronic alcoholics that
  monitored ingestion of disulfiram, as well as
  regular urine analysis for alcohol, yielded an
  abstinence rate of 60 at 626 months.
• In comparing methods of referral, groups with
  coerced referral to outpatient addiction
  treatment were more likely to complete treatment
  than those in the non-coercive referral groups.
• Coercive techniques can be effective and may be
  warranted in some circumstances e.g. monitoring.

Ehrenreich H, et al. Eur Arch Psychiatry Clin
Neurosci. 19972475154. Loneck B, et al. Am J
Drug Alcohol Abuse. 199622233246.