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Interventions for patients with alcohol problems Ann Morrison MD.

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Presentation on theme: "Interventions for patients with alcohol problems Ann Morrison MD."— Presentation transcript:


2 Interventions for patients with alcohol problems Ann Morrison MD

3 Outline of this Talk Quick review of theoretical models for alcohol use disorders and their treatment Major developments in treatment of alcohol use disorders What can be applied on the inpatient medical ward

4 The Scope of the Problem 2004: 17.6 mill (8.5%) Americans met criteria for Alcohol Disorders 2003: of 22.2 mill who need treatment for substance abuse, only 1.9 mill received it 2000: Societal Costs Substance abuse $184.6 bill Deaths/year attributable to alcohol 150 thou (7.5%) Project MAINSTREAM

5 Drug Dependence, a Chronic Medical Illness Implications for Treatment, Insurance, and Outcomes Evaluation A. Thomas McLellan, PhD; David C. Lewis, MD; Charles P. O'Brien, MD, PhD; Herbert D. Kleber, MD JAMA. 2000;284:1689-1695. The effects of drug dependence on social systems has helped shape the generally held view that drug dependence is primarily a social problem, not a health problem. In turn, medical approaches to prevention and treatment are lacking. We examined evidence that drug (including alcohol) dependence is a chronic medical illness. A literature review compared the diagnoses, heritability, etiology (genetic and environmental factors), pathophysiology, and response to treatments (adherence and relapse) of drug dependence vs type 2 diabetes mellitus, hypertension, and asthma. Genetic heritability, personal choice, and environmental factors are comparably involved in the etiology and course of all of these disorders. Drug dependence produces significant and lasting changes in brain chemistry and function. Effective medications are available for treating nicotine, alcohol, and opiate dependence but not stimulant or marijuana dependence. Medication adherence and relapse rates are similar across these illnesses. Drug dependence generally has been treated as if it were an acute illness. Review results suggest that long-term care strategies of medication management and continued monitoring produce lasting benefits. Drug dependence should be insured, treated, and evaluated like other chronic illnesses.

6 How is alcohol like a chronic disease? Biological basis (Neurobiology of addiction) Heredity Successful treatment depends on behavior change and compliance with therapy Progression (disease becomes more difficult to treat as it becomes more severe) McLellan et al. Drug dependence, a chronic medical illness JAMA 2000

7 Continuum of Alcohol Use

8 The severity of unhealthy alcohol use in hospitalized medical patients. The spectrum is narrow. Saitz R, Freedner N, Palfai TP, Horton NJ, Samet JH. J Gen Intern Med. 2006 Apr;21(4):381-5. Saitz RFreedner NPalfai TPHorton NJSamet JH Saitz RFreedner NPalfai TPHorton NJSamet JH BACKGROUND: Professional organizations recommend screening and brief intervention for unhealthy alcohol use; however, brief intervention has established efficacy only for people without alcohol dependence. Whether many medical inpatients with unhealthy alcohol use have nondependent use, and thus might benefit from brief intervention, is unknown. OBJECTIVE: To determine the prevalence and spectrum of unhealthy alcohol use in medical inpatients. DESIGN: Interviews of medical inpatients (March 2001 to June 2003). SUBJECTS: Adult medical inpatients (5,813) in an urban teaching hospital. MEASUREMENTS: Proportion drinking risky amounts in the past month (defined by national standards); proportion drinking risky amounts with a current alcohol diagnosis (determined by diagnostic interview). RESULTS: Seventeen percent (986) were drinking risky amounts; 97% exceeded per occasion limits. Most scored > or =8 on the Alcohol Use Disorders Identification Test, strongly correlating with alcohol diagnoses. Most of a subsample of subjects who drank risky amounts and received further evaluation had dependence (77%). CONCLUSIONS: Drinking risky amounts was common in medical inpatients. Most drinkers of risky amounts had dependence, not the broad spectrum of unhealthy alcohol use anticipated. Screening on a medicine service largely identifies patients with dependence--a group for whom the efficacy of brief intervention (a recommended practice) is not well established. PMID: 16686818 [PubMed - indexed for MEDLINE]

9 Stages of Change

10 What can we do?

11 Mesa Grande: A systematic review of alcohol treatment studies 361 studies 72,052 subjects 46 treatments studied Studies are rated with methodological quality scores Treatments are ranked by accumulation of + support Miller & Wilbourne. Mesa Grande: a methodological analysis of clinical trials of treatment of alcohol use disorders. Addiction 2002

12 Mesa Grande requirements for review Evaluate at least one treatment for alcohol use disorders Comparison with an alternative condition Used a procedure designed to create alternative groups Reported at least one outcome of drinking are alcohol-related complications

13 Treatments with the + evidence Brief Interventions Motivational Enhancement Therapy Gaba agonists Opiate antagonists Social skills training

14 Treatments with evidence of lack effect Educational lectures, films and groups General alcohol counseling Psychotherapy Confrontational Therapy Relaxation Therapy

15 Brief Interventions in Mesa Grande 31 studies 68 % are + Mean MQS is 12.68 (out of 17) 48% of studies are excellent (MQS >14) Evidence is as strong in clinical settings as in research settings

16 Brief Interventions What are they? One 15-30 minute session Up to 3 brief follow up contacts (face-to- face or telephone) May include educational materials Focus on hazardous or harmful drinkers Purpose is to elicit behavior change Goal is harm reduction

17 Brief Interventions: content Feedback of personal risk Responsibility of the patient Advice to change Menu of ways to reduce drinking Empathetic counseling style Support self efficacy

18 Results of RTCs for Brief Interventions Lower self-reported consumption Lower GGT levels Better work attendance Decreased ER visits Decreased hospitalizations

19 BMJ. 2004 Feb 7;328(7435):318. Epub 2004 Jan 16. Effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting: systematic review. Emmen MJ, Schippers GM, Bleijenberg G, Wollersheim H. Emmen MJSchippers GMBleijenberg GWollersheim H Emmen MJSchippers GMBleijenberg GWollersheim H Amsterdam Institute for Addiction Research, PO Box 3907 1001 AS Amsterdam, Netherlands. OBJECTIVE: To determine the effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting. DESIGN: Systematic review. DATA SOURCES: Medline, PsychInfo, Cochrane Library, reference lists from identified studies and review articles, and contact with experts. MAIN OUTCOME MEASURE: Change in alcohol consumption. RESULTS: Eight studies were retrieved. Most had methodological weaknesses. Only one study, with a relatively intensive intervention and a short follow up period, showed a significantly large reduction in alcohol consumption in the intervention group. CONCLUSIONS: Evidence for the effectiveness of opportunistic brief interventions in a general hospital setting for problem drinkers is still inconclusive.

20 Medications for Alcohol Dependence Works best as an adjunct to treatment Most work in the setting of abstinence Continue for 3 months- 1 year Specific Meds –Naltrexone –Acamprosate –Disulfram –Topiramate

21 Naltrexone Mechanism: Blocks opiate receptors in the reward center Available either as an oral medication or Efficacy –Cuts risk of relapse to heavy drinking in 3months by 36% (27%vs 43%) –Less effective in maintaining abstinence (25% in heavy drinking days) –More effective in men and lead-in abstinence

22 Naltrexone 4 studies 83% positive Average MQS 11.3 None are excellent quality

23 Acamprosate Mechanism: acts on GABA and glutamate systems. Thought to reduce Sx of protracted abstinence Efficacy: increases rate of abstinence at 6 months 36% vs 23% in European studies. (Not confirmed in US trials) More effective in more severe dependence and with prolonged abstinence

24 Topirmate Mechanism: ? Increases GABA transmission? Reduces glutamate transmission? Efficacy: Increased % of patients with 28 consecutive days of abstinence or controlled drinking (14 week studies) May be used in non-abstinence Not FDA approved for this indication

25 Disulfram Mechanism: interferes with degradation of alcohol resulting in accumulation of acetaldehyde Utility in monitored settings or with highly motivated patients

26 Copyright restrictions may apply. Anton, R. F. et al. JAMA 2006;295:2003-2017. Study Profile

27 COMBINE: Subjects N=1383 Seeking treatment 4-21 days of abstinence Exclusion criteria: –Other substance use disorders –Psychiatric dx requiring meds –Unstable medical condition

28 COMBINE: Intervention 16 weeks 9 treatment groups- combination of pharmacotherapy and behavioral counseling Pharmacotherapy: 2x2 combination of naltrexone and acamprosate Behavioral intervention: Medical management vs CBI

29 COMBINE:Outcomes Good Clinical Outcome= moderate alcohol use, with no more than 2 days of binging during the last 8 weeks of the study. Days to first heavy drinking day % days abstinent

30 Copyright restrictions may apply. Anton, R. F. et al. JAMA 2006;295:2003-2017. Adverse Events During Treatment by Medication Group

31 COMBINE:results Good Clinical Outcome at 16 weeks –MM (58%) –MM/CBI (71%), NNT=6 –MM/natrexone/CBI (74%), NNT=7 –MM/naltrexone (74%), NNT=7 Between group differences persisted to 1 yr of follow up but were no longer significant

32 Copyright restrictions may apply. Anton, R. F. et al. JAMA 2006;295:2003-2017. Odds Ratios for Good Composite Clinical Outcome at End of Treatment Compared With Placebo Naltrexone/No Combined Behavioral Intervention (CBI)

33 Overall effects % days abstinent increased overall from 25.1 to 73.1 Drinks per drinking day decreased 44% from 12.6 to 7.1 Alcohol consumption decreased from 66 to 13 drinks per week Overall reductions in alcohol exceeded differences between arms

34 Copyright restrictions may apply. Anton, R. F. et al. JAMA 2006;295:2003-2017. Drinking Outcomes Through End of Treatment

35 Copyright restrictions may apply. Anton, R. F. et al. JAMA 2006;295:2003-2017. Description of Medical Interventions During 1-Year Posttreatment in Participants

36 Conclusions There is a growing literature on treatment for alcohol problems Brief Intervention have the strongest evidence base, but as yet, are unproven in the inpatient setting Pharmacotherapy is a promising avenue of treatment

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