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:
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).

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. 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 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
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

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)
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
Population
Over 12 Years
(~237 M)
Current
Alcohol Users:
50.3% (~121 M people)
Binge
Drinkers: 22.8 %
(55 M)
NESARC
Any AUD
17.6 M (8.46 %)
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: >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– 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 person’s 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
Loss of Control
Salience
Functional Impairment

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):

30. 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. 2005;29(6):

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
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
Baseline Control
12-month Control
Baseline Intervention
12-month Intervention
# drinks 7 d
18.9
15.5
19.1
11.5*
# binges 30 d
5.3
4.2
5.7
3.1*
% excessive use ETOH 7 d
48.1
32.5
47.5
17.8*
*p<0.001
Fewer hospitalization days in Exp group, χ2(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. Stages of Change Model Precontemplation Contemplation Preparation
Action
Maintenance
Prochaska, J.O.; DiClemente, C.C. & Norcross, J.C. Am Psychol 47(9): , 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

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

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 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
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
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)
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 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 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.

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
Cognitive Behavioral Therapy
Motivational Enhancement Therapy
12-Step
Facilitation
Project Match Research Group. J Studies Alcohol 58:7-29, 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 (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 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).

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 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 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
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 36:8–17, 2009

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
13,623
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
2,268
17%
1,084
13%
  602
18%
343
24%
213
63%
Naltrexone
1,656
12%
835
10%
455
185
169
50%
*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
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 (

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
ASAM PPC-2R Dimensions
Acute Intoxication and/or Withdrawal Potential
Biomedical Conditions and Complications
Emotional, Behavioral, or Cognitive Conditions and Complications
Readiness to Change
Relapse, Continued Use, or Continued Problem Potential
Recovery/Living Environment

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.