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Treatment: Options and Effectiveness National Partnership On Alcohol Misuse and Crime Meeting on Treatment, Washington, DC Richard N Rosenthal, MD Professor.

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Presentation on theme: "Treatment: Options and Effectiveness National Partnership On Alcohol Misuse and Crime Meeting on Treatment, Washington, DC Richard N Rosenthal, MD Professor."— Presentation transcript:

1 Treatment: Options and Effectiveness National 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. Luke’s-Roosevelt Hospital Center, NY June 2, 2009

2 Disclosure RESEARCH GRANT SUPPORT: Forest Laboratories, Inc. Principal Investigator Titan Pharmaceuticals, Inc. Principal Investigator National Institute on Drug Abuse Co-Investigator The National Institute of Diabetes, Co-Investigator Digestive and Kidney Disease AFFILIATIONS: 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).

7 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.

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 isn’t 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. 3 rd 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 N=1,078 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 76:135–141, 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 76:135–141, 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.):S124–S125, 2002.

13 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 STD’s, HIV/AIDS, TB, and hepatitis

14 Screening for AUD Screening: determines the likelihood of alcohol use disorder determines the likelihood of alcohol use disorder establishes the need for an in-depth assessment. 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 > 6 probable alcohol dependence AUDIT 10 item self report, score > 8 in men, probable AUD > 4 in woman, probable AUD > 4 in woman, probable AUD

15 Screening for AUD CAGE – 4 Items < 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, won’t 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

18 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) 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 Clinician’s 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 Total US Population Population Over 12 Years (~237 M) (~237 M) Current Alcohol Users: 50.3% (~121 M people) NESARC Any AUD 17.6 M (8.46 %) Binge Binge Drinkers: 22.8 % Drinkers: 22.8 % (55 M) (55 M) HeavyDrinkers: 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: >14 drinks/week or >4 drinks/occasion Women: >7 drinks/week or >3 drinks/ occasion Hazardous alcohol consumption = 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):2207–2212. 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 Compulsive behavior despite negative consequences, i.e., loss of control Salience – primacy in a person’s life Salience – primacy in a person’s life Cognitive – dominates mental life Cognitive – dominates mental life Behavioral – dominates activity Behavioral – dominates activity Functional Impairment Functional Impairment

24 DSM -IV Substance Dependence Three (or more) of the following over 12 Months: ToleranceWithdrawal 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

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. 2003;98(9): 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. 2005;29(6):

29

30 Impact of Hazardous Drinking 1,419 HMO primary care clinic patients, 13.9 K comparison group; AUDIT screen 1,419 HMO primary care clinic patients, 13.9 K comparison group; AUDIT screen Hazardous drinking prevalence of 7.5% Hazardous drinking prevalence of 7.5% Alcohol abuse prevalence was only 0.38% 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. 2005;29(6):

31

32 Systematic Review Findings: Alcohol and Hypertension 11 randomized controlled trials Dose related effects < 2 drinks/day or 10/week – usually decreases > 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 33-56% lower incidence of diabetes 34-55% lower incidence of diabetes-related coronary heart disease 34-55% lower incidence of diabetes-related coronary heart disease Heavy alcohol (>3 drinks/day): up to 43% increased risk of diabetes Howard, A.A. et al. Ann Int. Med. 2004;140:

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 N=723 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 *p< * % excessive use ETOH 7 d 3.1* # binges 30 d 11.5* # drinks 7 d 12-month Intervention Baseline Intervention 12-month Control Baseline Control Fewer hospitalization days in Exp group, χ 2 (P < 0.01) Fleming MF, et al. JAMA 1997;277:

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 Naltrexone’s 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 Precontemplation Precontemplation Contemplation Contemplation Preparation Preparation Action Action Maintenance Maintenance Stages of Change Model Prochaska, J.O.; DiClemente, C.C. & Norcross, J.C. Am Psychol 47(9): , 1992 Prochaska, J.O.; DiClemente, C.C. & Norcross, J.C. Am Psychol 47(9): , 1992.

43 Precontemplation- Overestimates costs of change and underestimates benefits. No intention to take action due to: Precontemplation- Overestimates costs of change and underestimates benefits. No intention to take action due to: lack of information lack of information not understanding consequences of not changing not understanding consequences of not changing demoralization after repeated failures demoralization after repeated failures No inherent motivation (e.g. crawling to walking) – progress due to events, differential processing No inherent motivation (e.g. crawling to walking) – progress due to events, differential processing Developmental, e.g., hitting 39 th birthday, taking stock Environmental: Beloved dog dies of lung cancer Heavy-smoking wife quits smoking Heavy-smoking husband buys new dog! Stages of Change Model Prochaska, J.O. in: Ries R. et al. Eds, Principles of Addiction Medicine, 4 th Ed. Lippincott, Williams & Wilkins, 2009, pp Lippincott, Williams & Wilkins, 2009, pp

44 Contemplation– More aware of the benefits of change, acutely aware of the costs 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 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 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 Maintenance– Working to prevent relapse Stages of Change Model Prochaska, J.O. in: Ries R. et al. Eds, Principles of Addiction Medicine, 4 th Ed. Lippincott, Williams & Wilkins, 2009, p Lippincott, Williams & Wilkins, 2009, p

45 Clinical Impact: Change ModelPrecontemplation Contemplation Preparation Action Maintenance slip relapse + drop out relapse

46 Principles of Motivational Interviewing MI differs from traditional counseling in that it is client- centered: 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 teaching new coping skills reshaping cognitions reshaping cognitions exploring the past 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 doesn’t 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.

48 Motivational Interviewing l Identifying substance-related losses important for motivating people with comorbid psychiatric disorders contemplating behavior change (Blume & Marlatt, Addict Behav, 2000) l 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 Dunn C, Deroo L, Rivara FP. The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review. Addiction 2001;96:1725–42. Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. J Consult Clin Psychol 2003;71:843–61. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and metaanalysis. Br J Gen Pract 2005;55:305–12.

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) F eedback of personal impairment Personal R esponsibility for change Clear A dvice to change A M enu of alternatives Therapist E mpathy Facilitate S elf-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 Obstet Gynecol Jan;113(1):243-6.

53 Relapse Pathways 3 major biological mechanisms associated with relapse following extinction of drug- seeking behavior: Exposure to the drug 1 (reward/extinction) Exposure to conditioned cues (ie, people, places, and things) 2 (craving/dysphoria) Exposure to nonspecific stress 3 (stress) 1 Monti et al. Addiction. 2000;95:S McBride et al. Alcohol Clin Exp Res. 2002;26: Koob. Addiction. 2000;95:S73.

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 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 Baseline12-month follow-up Cognitive Behavioral Therapy Motivational Enhancement Therapy 12-StepFacilitation Reduction in Percentage of Drinking Days Project Match Research Group. J Studies Alcohol 58:7-29, 1997

56 Cognitive Behavioral Therapy l CBT: help patients recognize, avoid, and cope. l RECOGNIZE situations in which they are most likely to use, l AVOID these situations when appropriate, l 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. 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 (cont’d) 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 (cont’d) 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 Self–monitoring skills to identify maladaptive thoughts and replace or restructure them Peters RH et al. Substance Abuse: A Comprehensive Textbook, Ch 46, pg , 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; 97:265–277

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 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 The patient and partner then thank each other for their efforts Refrain from arguments or discussions about the patient’s drinking behavior (O’Farrell and Bayog, 1986). Refrain from arguments or discussions about the patient’s drinking behavior (O’Farrell 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 (O’Farrell 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 1 st Ed.: To show other alcoholics precisely how we have recovered is the main purpose of this book. Personal Stories: How Forty-Two Alcoholics Recovered 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 it’s reform, redemption, recovery, reconstruction, maturation or transformation Time element matches chronic illness model: always recovering (never “recovered”) White W. Substance Use & Misuse 43: , 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 Kirschenbaum et al., Journal of Substance Abuse Treatment 36:8–17, 2009 The hazard functions for the log-logistic distribution for alcohol (left) and nicotine (right) studies. Days

68 Twelve Step Facilitation Developed by Nowinski, Baker & Carroll (1992) for NIAAA’s 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

69 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

70 Twelve Step Facilitation TSF does appear to facilitate self-help attendance/involvement TSF’s 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.

71 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

72 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

73 Facility Services Offered – NSSATS 2003 Total Private non- profit Private for-profit Local/ State gov’t Federal gov’t* Number of Programs 13,6238,2583, Percentage of Programs 100%61%25%11%2% Medications (% of Type) 2,73920%1,338 16% 16% % 23%376 22% 22%22968% Antabuse (% of Type) 2,26817%1,08413% % 18%343 24% 24%21363% Naltrexone (% of Type) 1,65612% % 10% % 13% % *Serves veterans, military personnel, inmates, or Native Americans.

74 Adherence Treatments don’t make you better if you don’t 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)

75 Addiction Treatment Works Hospitalizations for:Physical health36% Drug overdose58% Mental health44% Number of:Hospital days25% ER visits38% Doctor visits14% Mental health3% Gerstein, Harwood, Fountain et al. CALDATA, 1994 (http://www.adp.state.ca.us) Reductions in Healthcare Services Utilization

76 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

77 Determine Level of Care 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 ASAM PPC-2R Dimensions

78 Treatment Levels of Service I Outpatient Treatment II Intensive Outpatient and Partial Hospitalization III Residential/Inpatient Treatment IV Medically-Managed Intensive Inpatient Treatment

79 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: 36–47, 2008

80 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 6–26 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. 1997;247:51–54. Loneck B, et al. Am J Drug Alcohol Abuse. 1996;22:233–246.


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