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:
1Treatment: Options and Effectiveness National Partnership On Alcohol Misuse and Crime Meeting on Treatment, Washington, DCRichard N Rosenthal, MDProfessor of Clinical PsychiatryColumbia University College of Physicians & SurgeonsChairman, Dept of PsychiatrySt. Luke’s-Roosevelt Hospital Center, NYJune 2, 2009
2Disclosure 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 DiseaseAFFILIATIONS:2008 - Sequest Technologies, Lisle, IL. Advisory Board
3Overview Who needs Treatment? What is the Treatment Process? How does it begin?Who is involved?Importance of Screening and AssessmentConsideration of Prior ConvictionsPre-treatmentBrief Interventions/Motivational Interviewing
4Overview Treatment Options and Effectiveness Counseling Models and Outcome DifferencesMotivational Enhancement TherapyCognitive Behavioral TherapyPatient Placement Criteria: settings and levels of careRole of DetoxificationRole of residential rehabilitation/halfway houseVoluntary vs. Mandatory TreatmentTreatment Vs. EducationRole of 12-Step and Support Group
5Who 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/controlDUI, assault, loss of external social supports, missed appointmentsDiagnosis of Alcohol DependenceImpairment, disability
6The 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).
7The 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.
8Why Are Alcohol Use Disorders (AUD) Underdiagnosed ≈ 50% time? Clinicians:Typically lack proper training in screening and recognitionMiss 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
9Why Are Alcohol Use Disorders Underdiagnosed ≈ 50% time? Patients with AUD typically:minimize or deny strongly problem usedeny physical and psychological problems could be related to drinkingrationalize work and interpersonal problems as cause of use, not resultPresent 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 evaluationAdapted from Waldinger RJ: Substance-Related Disorders and Eating Disorders, in Psychiatry for Medical Students. 3rd Ed. American Psychiatric Press, Inc. Washington DC, 1997.
10Screening 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 disordersIn 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
11Screening 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
12When 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 jailMorral, A.R et al. Drug and Alcohol Dependence 66(Suppl.):S124–S125, 2002.
13Screening and Assessment in Correctional Settings Substance Use history: patterns of use, treatment, acute symptoms, need for detoxCriminal historyPersonality traits related to criminalityMental health issues, including suicide potential, acute symptoms, treatment history, psychiatric medicationsAbuse and trauma history, as victim/perpHigh-risk behaviorsMotivation for treatmentEducation and literacyPhysical disabilitiesRelationships with significant others, family, dependentsPhysical health, acute conditions, infectious diseases including STD’s, HIV/AIDS, TB, and hepatitis
14Screening for AUD Screening: determines the likelihood of alcohol use disorderestablishes the need for an in-depth assessment.Begin at the earliest point of clinical contact with the offender and continue throughout treatment, if providedSeveral 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 riskMAST 21-item self report, scores > 6 probable alcohol dependenceAUDIT 10 item self report, score > 8 in men, probable AUD> 4 in woman, probable AUD
15Screening for AUD CAGE – 4 Items < 1 minute to administer ≥ 2 “yes” answers = high risk for AUDHigh sensitivity for AUD (60-95%)No questions about frequency of useNo quantity of consumption questionsNo frequency of heavy drinking questionsBecause consequence-focused, won’t flag early problem drinkers
16Screening for AUD MAST – 25 Items ≥ 7 Probable Alcohol Dependence 5-6 Borderline Alcoholism≤ 4 No problem drinkingHigh Sensitivity for AUD (86-98%)Questions elicit lifetime history rather than current drinking behavior (Magruder-Habib et al., 1991)
17Screening for AUD AUDIT – 10 Items, assesses over past year WHO Collaborative effortMulticultural (Babor & Grant, 1989)Designed to screen earlier-level problems in primary-care settingsSensitivity – 92%, Specificity – 93%Three Domains: amount & frequency; alcohol dependence; alcohol-induced problemsCutoff score of 8 of 40 = probable AUD
18Simple 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, orAUDIT score of ≥ 8 for men or ≥ 4 for womenIf endorsed, then a clinical evaluation
19Clinician’s Initial Evaluation Document current and past use of alcohol and each other substance separately – pattern?, who with?Log prior quit attempts & treatmentsMedications: how used? how long ?Psychosocial treatment?Assess current motivation to quit (pros & cons; quit date)Assess triggers, withdrawal, and dependenceAssess social support
20SAMHSA HOUSEHOLD SURVEY, 2004 Total USPopulationOver 12 Years(~237 M)CurrentAlcohol Users:50.3% (~121 M people)BingeDrinkers: 22.8 %(55 M)NESARCAny AUD17.6 M (8.46 %)HeavyDrinkers:6.9% (~16.7M)(NSDUH, 2005)
21Hazardous Drinking A “standard drink” contains about 14 g alcohol At-Risk or Heavy Drinking is defined as:Men: >14 drinks/week or >4 drinks/occasionWomen: >7 drinks/week or >3 drinks/ occasionHazardous alcohol consumption = g alcoholGood predictor of alcohol-related problemsNegative Impact on chronic medical illnessSignificant increased morbidity and mortalityMcGinnis JM, Foege WH. JAMA. 1993; 270(18):2207– NIAAA (2004) Helping Patients With Alcohol Problems. DHHS, Wash., DC.
22DSM -IV Substance Abuse Substance use leading to clinically significant impairment manifested by one (or more):Failure to fulfill major role obligationsHazardous situationsLegal problemsContinued substance use despite having persistent or recurrent social or interpersonal problemsNever met the criteria for substance dependence
23Addiction: Classical and Contemporary Constructs Classical (Peele 1985):CravingIncreased tolerancePhysiologic withdrawalContemporary: Behavioral DysregulationCompulsive behavior despite negative consequences, i.e., loss of controlSalience – primacy in a person’s lifeCognitive – dominates mental lifeBehavioral – dominates activityFunctional Impairment
24DSM -IV Substance Dependence Three (or more) of the following over 12 Months:ToleranceWithdrawalLarger amounts or over longer period than intendedPersistent desire or unsuccessful efforts to cut downMuch time spent in acquiring, using, or recovering from effectsAbandonment/reduction of important social, work, or recreational activitiesContinued use despite knowledge of having an alcohol-induced or exacerbated physical or mental problemLoss of ControlSalienceFunctional Impairment
25Targeting Heavy Drinking Proxy for ImpairmentImpact of Heavy DrinkingDifferences in NESARC diagnoses rates and rates of binge and heavy drinking
262000 National Household Surveys on Drug Abuse (NHSDA) Highest rates binge, heavy drinking young adults aged 21 to 25Peak 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
27Impact of Heavy Drinking About 25% have alcohol dependenceIncreased risk:gastrointestinal bleeding, sleep disorders, major depression, hemorrhagic stroke,cirrhosis of the liver, and several cancersRehm J Addiction. 2003;98(9):NIAAA (2004) Helping Patients With Alcohol Problems. DHHS, Wash., DC.
28Hazardous 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):
30Impact of Hazardous Drinking 1,419 HMO primary care clinic patients, 13.9 K comparison group; AUDIT screenHazardous drinking prevalence of 7.5%Alcohol abuse prevalence was only 0.38%↑prevalences of 8 medical conditions:Pneumonia, COPDCostly conditions such as injury and hypertensionDepression, anxiety disorders, and major psychosesMertens, JR et al., Alc Clin Exp Res. 2005;29(6):
32Systematic Review Findings: Alcohol and Hypertension 11 randomized controlled trialsDose related effects< 2 drinks/day or 10/week – usually decreases> 3 drinks/day or 14/week – significant increaseMagnitude of effect about the same as salt intakeEffect of alcohol greatest in subjects with pre-existing hypertensionMcFadden et al. Am J Hypertension. In press. Slide courtesy A.T. McLellan, PhD
33Systematic Review Findings: Alcohol and Diabetes 32 studiesU-shaped associationModerate alcohol (1-3 drinks/ day)33-56% lower incidence of diabetes34-55% lower incidence of diabetes-related coronary heart diseaseHeavy alcohol (>3 drinks/day): up to 43% increased risk of diabetesHoward, A.A. et al. Ann Int. Med. 2004;140:
35Screening 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 sessionsAre not conducted in a specialized alcoholism treatment facility, andAre performed by health care providers and others who are not specialized in addiction treatment.
36Impact 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 officesTwo 10-15’ physician-delivered, counseling visitsReview drinking norms, patient-specific effects,Worksheet on drinking cues, diary cardsDrinking agreement as a prescriptionFleming MF, et al. Alcohol Clin Exp Res. 2002(Jan);26(1):36-43
37Impact of Brief Physician Advice for Problem Drinkers 2 nurse follow-up callsMeasures:Alcohol use,ER visits andHospital daysFleming MF, et al. Alcohol Clin Exp Res. 2002(Jan);26(1):36-43
38Impact of Brief Physician Advice for Problem Drinkers Baseline Control12-month ControlBaseline Intervention12-month Intervention# drinks 7 d18.915.519.111.5*# binges 30 d188.8.131.52.1*% excessive use ETOH 7 d48.132.547.517.8**p<0.001Fewer hospitalization days in Exp group, χ2(P < 0.01)Fleming MF, et al. JAMA 1997;277:
39Impact of Brief Physician Advice for Problem Drinkers Significant reductions7-day alcohol useNumber of binge episodesFrequency of excessive drinkingEffects by 6 months, sustained at 48 monthsFewer hospital days and ER visitsFor 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
40Targeting Heavy Drinking Psychosocial interventions that reduce alcohol intake have important clinical effectsWhy not use medications that might accomplish the same?Proxy diagnosis “hazardous or heavy drinkers” versus categorical oneDrinkers without diagnoses might not want to be abstinentLarge potential social utilityNaltrexone’s main effect is reduction in heavy drinking
41MotivationaI Interviewing Definition: Motivational Interviewing isa client-centered, directive methodfor enhancing intrinsic motivation to changeby 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
42Stages of Change Model Precontemplation Contemplation Preparation ActionMaintenanceProchaska, J.O.; DiClemente, C.C. & Norcross, J.C. Am Psychol 47(9): , 1992.
43Stages of Change ModelPrecontemplation- Overestimates costs of change and underestimates benefits. No intention to take action due to:lack of informationnot understanding consequences of not changingdemoralization after repeated failuresNo inherent motivation (e.g. crawling to walking) – progress due to events, differential processingDevelopmental, e.g., hitting 39th birthday, taking stockEnvironmental: Beloved dog dies of lung cancerHeavy-smoking wife quits smokingHeavy-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
44Stages of Change ModelContemplation– More aware of the benefits of change, acutely aware of the costsCan present as profound ambivalenceClient can entertain the reality of a problemPreparation– Decisional balance has tipped in favor of change, which is being planned for in next 30 daysPlan of action: go to AA, talk to physician, buy a self-help book, etc.Action– Client makes specific, overt changes in lifestyleOnly modifications of behavior that results in reduction of disease risk is deemed effective actionMaintenance– Working to prevent relapseProchaska, J.O. in: Ries R. et al. Eds, Principles of Addiction Medicine, 4th Ed.Lippincott, Williams & Wilkins, 2009, p
45Clinical Impact: Change Model PrecontemplationMaintenancesliprelapse +drop outrelapseContemplationActionPreparation
46Principles of Motivational Interviewing MI differs from traditional counseling in that it is client-centered:Collaborates rather than confrontsEvocates rather than educatesRespects autonomy rather than imposing authorityNot focused on:teaching new coping skillsreshaping cognitionsexploring the pastA way of being with rather than to do something toElicits 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
47Clinical Assessment/Intervention Integrate Motivational Interviewing into the clinical assessment interview for treatment seeking clients:understand the motives clients have for addressing their substance use problemsgather the clinical and administrative information needed to plan their carebuild and strengthen their readiness for changeMartino, 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.
48Motivational 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)
49High-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.
50Motivational 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.
51Motivational Enhancement Therapy (FRAMES) Feedback of personal impairmentPersonal Responsibility for changeClear Advice to changeA Menu of alternativesTherapist EmpathyFacilitate Self-efficacy or optimism
52MI in a Broader Context Addictive disorders Pathological gamblingHeavy drinking college studentsEngagement and Adherence to treatmentPharmacotherapyDietary parameters (e.g. DM)Chronic disease managementMental disordersMedical disorders: Diabetes, HIVHealth promotionACOG committee opinionHIV and other STD risk reductionWeight lossReducing alcohol use in pregnancyACOG Committee Opinion No Obstet Gynecol Jan;113(1):243-6.
53Relapse Pathways3 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. 2000;95:S229.2McBride et al. Alcohol Clin Exp Res. 2002;26:280.3Koob. Addiction. 2000;95:S73.
54Benefits of Psychotherapies Help patients to cope with 2 of 3 major factors in relapse:Reducing exposure to cues associated with use of substancesLearning healthy pleasures – changing rewardsAdopting refusal skillsAvoiding people, places and things associated with substance useReducing stressDecreasing negative emotional statesIncreasing resilience to stressors through support, remoralization, self-efficacy
55Treatment Works Reduction in Percentage of Drinking Days Baseline 12-month follow-up80604020Cognitive Behavioral TherapyMotivational Enhancement Therapy12-StepFacilitationProject Match Research Group. J Studies Alcohol 58:7-29, 1997
56Cognitive 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
57CBT 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 useDevelop 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
58CBT 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 affectsRounsaville & Carroll, Ch 38., In: Lowinson, Ruiz, Millman, Langrod (Eds.) Substance Abuse A Comprehensive Textbook, 2nd Ed. 1992
59CBT 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 processesRationalizations to engage in criminal or addictive behaviorsSelf–monitoring skills to identify maladaptive thoughts and replace or restructure themPeters RH et al. Substance Abuse: A Comprehensive Textbook, Ch 46, pg , 2005
60Relapse Prevention: Specific Techniques Assessing internal and external cues for craving and usageDefining relapses ("slips")Discussing "seemingly irrelevant decisions"Itemizing the characteristics of relapseExploring dreams involving drugsDeveloping coping and relaxation skillsEmploying drug-refusal exercisesManaging a slipUnderstanding the Abstinence Violation Effect
61Cognitive 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 AUDMiller WR, Wilbourne PL. Addiction 2002; 97:265–277
62Behavioral 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 effortsRefrain from arguments or discussions about the patient’s drinking behavior (O’Farrell and Bayog, 1986).
63Behavioral 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 andrelationship satisfaction (Powers et al., 2008)Effects of BCT tend to fade over time as domestic partners tend to regress back towards dysfunctional relatingBooster relapse prevention sessions provided to couples after the main treatment had ended supported the maintenance of treatment gains (O’Farrell et al., 1993).
64RecoveryThe Big BookSubtitle: The Story of How Many Thousands of Men and Women Have Recovered From AlcoholismForeward to 1st 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 MaladyAlcoholics Anonymous World Services, Inc.; 4 edition (February 10, 2002)
65Common Factors: Recovery Mutual Aid Recovery societies strategies:Public confessionPublic commitment to abstinenceSober fellowship through experience-sharing meetingsDiscovery of resources within/beyond selfReconstruction of personal values, identity, relationshipsService to others as self-healing mechanismUnclear if it’s reform, redemption, recovery, reconstruction, maturation or transformationTime element matches chronic illness model: always recovering (never “recovered”)White W. Substance Use & Misuse 43: , 2008
66Alcoholics AnonymousMay be only treatment available in some correctional settingsIs synergistic with clinical approaches, best when offender is initially in a controlled environment, since it is an abstinence model
67Time Abstinent Makes a Difference DaysDaysThe hazard functions for the log-logistic distribution for alcohol (left) and nicotine (right) studies.Kirschenbaum et al., Journal of Substance Abuse Treatment 36:8–17, 2009
68Twelve Step Facilitation Developed by Nowinski, Baker & Carroll (1992) for NIAAA’s Project MATCH as an approach which was:Manual guided, delivered on an Individual basisSharply contrasts with CBT and Motivational InterviewingAscribes 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 sobrietyApproximated frequently used counseling methods that invoked 12 Step recoverySought to facilitate meaningful involvement in self help groups
69Twelve 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 AnonymousTreatment goal is abstinenceEmphasis on first 3 Steps and fostering involvement in AACore topics include the assessment plus acceptance, surrender, and getting active; also elective sessionsNot equivalent to AA, NA referralNot equivalent to ‘treatment as usual’Has been adapted to a group format
70Twelve Step Facilitation TSF does appear to facilitate self-help attendance/involvementTSF’s effectiveness appears to apply to a range of addiction problems, including methadone maintenanceIS NOT equivalent to ‘treatment as usual’Seasoned clinicians can learn and use TSFTSF has shown to substantially increase the likelihood that patients will become engaged with these AA resources.
71Why Use Medications?Addiction is a chronic disease requiring long-term treatment, not different from hypertension or diabetesThese illnesses also have psychosocial interventions that improve outcomesMedication for addiction works best in the context of psychosocial treatmentEffect sizes for no one treatment is large
72Why Use Medications?There are no “slam dunk” medications anymore than there are “slam dunk” psychosocial interventionsGetting the ball through the hoop is a team effort!Therefore, combinations of medical and psychosocial treatment optimizes outcomes
73Facility Services Offered – NSSATS 2003 TotalPrivate non-profitPrivate for-profitLocal/State gov’tFederal gov’t*Number of Programs13,6238,2583,4031454339Percentage of Programs100%61%25%11%2%Medications(% of Type)2,73920%1,33816%76823%37622%22968%Antabuse2,26817%1,08413% 60218%34324%21363%Naltrexone1,65612%83510%45518516950%*Serves veterans, military personnel, inmates, or Native Americans.
74Adherence Treatments don’t make you better if you don’t take them. Be aware of factors that reduce adherence, such asdenial of illness or its chronicity,complex dosing schedules,side effects,poor social support, anddepression or amotivation (DiMatteo, 2004; DiMatteo et al, 2000; Perkins, 2002)
75Addiction Treatment Works Reductions in Healthcare Services UtilizationHospitalizations 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)
76Underlying Concepts of ASAM PPC Biopsychosocial Perspective of AddictionBiopsychosocial in etiology, expression, Tx.Comprehensive assessment and treatmentExplains clinical diversity with commonalitiesPromotes integration of knowledge
77Determine Level of Care ASAM PPC-2R DimensionsAcute Intoxication and/or Withdrawal PotentialBiomedical Conditions and ComplicationsEmotional, Behavioral, or Cognitive Conditions and ComplicationsReadiness to ChangeRelapse, Continued Use, or Continued Problem PotentialRecovery/Living Environment
78Treatment Levels of Service I Outpatient TreatmentII Intensive Outpatient and Partial HospitalizationIII Residential/Inpatient TreatmentIV Medically-Managed Intensive Inpatient Treatment
79Mandated TreatmentCoerced 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 2005Sullivan M et al., The American Journal on Addictions, 17: 36–47, 2008
80Mandated TreatmentIntensive 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.