1. Surrey Health Partners 1 Structured preparation in the treatment of Alcohol Dependence; is there enough evidence to support a change of the treatment paradigm? Results of a prospective cohort evaluation. Christos Kouimtsidis, Ekta Sharma; Avril Smith; Kelly-Jo Charge Consultant Psychiatrist in Addictions, Surrey & Borders Partnership NHS Foundation Trust Lead Mental Health Clinical Academic Group, SHP Hon. Senior Research Associate UCL

2. Surrey Health Partners 2 Why is this important?

3. Surrey Health Partners 3 background Current treatment guidelines: Planned detox and emphasis on structured aftercare. CBT interventions and family interventions good evidence for relapse prevention Challenge 1: <60% completing detoxification engage in structured aftercare.

4. Surrey Health Partners 4 Challenge 2

5. Surrey Health Partners 5 Multiple detoxifications (medically assisted or not): Are related to withdrawal‐induced impairment in mental functioning. Changes may confer inability in conflict resolution and increased sensitivity to stress (both relapse risk factors). Can exacerbate craving, impacting on subsequent attempts at achieving abstinence such that repeated attempts may be less likely to result in positive outcomes.

6. Surrey Health Partners 6 references Duka T, Townshend JM, Collier K, Stephens DN. Kindling of Withdrawal: A Study of Craving and Anxiety After Multiple Detoxifications in Alcoholic Inpatients. Alcoholism: Clinical and Experimental Research. 2002;26(6):785-95. Duka T, Townshend JM, Collier K, Stephens DN. Impairment in Cognitive Functions After Multiple Detoxifications in Alcoholic Inpatients. Alcoholism: Clinical and Experimental Research. 2003;27(10):1563-72. Duka, Theodora, Gentry, John, Malcolm, Robert, Ripley, Tamzin L, Borlikova, Gilyana, Stephens, Dai N, Veatch, Lynn M, Becker, Howard C and Crews, Fulton T (2004) Consequences of multiple withdrawal from alcohol. Alcoholism: Clinical and Experimental Research, 28 (2). pp. 233-246. ISSN 0145-6008Consequences of multiple withdrawal from alcohol. Stephens, David N and Duka, Theodora (2008) Cognitive and emotional consequences of binge drinking: role of amygdala and prefrontal cortex. Philosophical Transactions B: Biological Sciences, 363 (1507). pp. 3169-3179. ISSN 1471-2970Cognitive and emotional consequences of binge drinking: role of amygdala and prefrontal cortex. Loeber S, Duka T, Welzel H, Nakovics H, Heinz A, Flor H, et al. Impairment of Cognitive Abilities and Decision Making after Chronic Use of Alcohol: The Impact of Multiple Detoxifications. Alcohol and Alcoholism. 2009;44(4):372-81. Loeber S, Duka T, Welzel Márquez H, Nakovics H, Heinz A, Mann K, et al. Effects of Repeated Withdrawal from Alcohol on Recovery of Cognitive Impairment under Abstinence and Rate of Relapse. Alcohol and Alcoholism. 2010;45(6):541-7. Duka, Theodora, Trick, Leanne, Nikolaou, Kyriaki, Gray, Marcus A, Kempton, Matthew J, Williams, Hugh, Williams, Steven C R, Critchley, Hugo D and Stephens, David N (2011) Unique brain areas associated with abstinence control are damaged in multiply detoxified alcoholics. Biological Psychiatry, 70 (6). pp. 545-552. ISSN 1873-2402Unique brain areas associated with abstinence control are damaged in multiply detoxified alcoholics.

7. Surrey Health Partners 7 What should we change in medically assisted withdrawal? Duration? Method? Are the observed symptoms the tip of the iceberg? Frequency of attempts? Medication used?

8. Surrey Health Partners 8 Or should we change our overall approach? How is this similar to the change of practice regarding antibiotics?

9. Surrey Health Partners 9 Structured preparation

10. Surrey Health Partners 10 Intervention APG groups bring forward and initiate prior detoxification a modified version of the Relapse Prevention Groups, a post detoxification intervention supported by evidence. APG groups are based on principles of Learning theory and PRIME theory APG groups use Cognitive Behaviour Therapy (CBT) techniques

11. Surrey Health Partners 11 Intervention aims Stabilise the amount and pattern of drinking Devise and implement lifestyle changes that support regaining of control over drinking Increase coping skills and self-efficacy, which are considered necessary for the maintenance of abstinent lifestyle.

12. Surrey Health Partners 12 Hertfordshire experience 2005-2012

13. Surrey Health Partners 13

14. Surrey Health Partners 14 Surrey cohort July-December 2013

15. Surrey Health Partners 15 25/60=42% abstinent & 49% PDA 9 outstanding:19/60=32% abstinent & 48% PDA

16. Surrey Health Partners 16 17 (94%) abstinent at 1 month post detox 18 (51%) guided self- detox during stage 1 11 (61%) abstinent at 3 months post detox 10 (55.5%) abstinent at 6 months post detox Guided self detoxification

17. Surrey Health Partners 17 Kouimtsidis C, Kolli S. 2014. Preparation for alcohol detoxification group programme. Service users’ evaluation of individual sessions. Journal of Substance Use, Vol. 19, No. 1-2, 184-187. Kouimtsidis C. Drabble K & Ford L. 2012. Implementation and evaluation of a three stages community treatment programme for alcohol dependence. A short report. Drugs: Education, Prevention and Policy, 19 (1), 81-83. Kouimtsidis C. 2013. Community alcohol detoxification; the challenge of changing service provision. Short report. Journal of Substance Use, 18(2), 166-169. Kouimtsidis C. & Ford L. 2011. A staged programme approach for alcohol dependence: Cognitive Behaviour Therapy groups for detoxification preparation and aftercare; preliminary findings. Short report. Drugs: Education, Prevention and Policy, 18 (3),237-239. Croxford A, Notley C, Maskrey V, Holland R, Kouimtsidis C. 2014. An exploratory qualitative study seeking participant views evaluating group Cognitive Behavioural Therapy preparation for alcohol detoxification. Journal of Substance Use (in print).

18. Surrey Health Partners 18 SPADe A randomised controlled trial of Structured Preparation for Detoxification in moderate and severe Alcohol dependence, within specialist treatment services. SPADe Collaborators: SABP, C&I, Surrey U, Sussex U, Imperial UL. 42 months Funding proposal to NIHR/HTA; January 2015

19. Surrey Health Partners 19 SPADe Multi-centre, single blind, pragmatic, two-arm parallel RCT, comparing intervention as an adjunct to treatment as usual vs TAU. Specialist community alcohol services, publicly funded (Surrey, Hounslow, Camden & Islington). Adults with moderate to severe alcohol dependence (SADQ> 16); seeking abstinence; wishing to participate in group intervention.

20. Surrey Health Partners 20 SPADe objectives Does participation in SPADe groups Improve long term abstinence compared to a control group receiving treatment as usual (no group preparation prior detoxification) ? Reduce the hypothesised adverse cognitive effect of the medically assisted withdrawal on the brain? Reduce the experience of cravings, which have an adverse impact on subsequent attempts at achieving abstinence? Does the addition of SPADe groups in the existing treatment pathways reduce the overall treatment cost by improving treatment outcomes?

21. Surrey Health Partners 21 SPADe We are looking for 2 more recruiting partners. If you would like to join us please get in touch

22. Surrey Health Partners 22 Thank you drckouimtsidis@hotmail.com christos.kouimtsidis@sabp.nhs.uk drckouimtsidis@hotmail.com