Presentation on theme: "Computer Delivered Interventions: A stepped care approach for problem drinkers Reid K. Hester, Ph.D. Director, Research Division Behavior Therapy Associates,"— Presentation transcript:
Computer Delivered Interventions: A stepped care approach for problem drinkers Reid K. Hester, Ph.D. Director, Research Division Behavior Therapy Associates, LLP Tel
Thanks & Conflict of Interest NIAAA for funding Research staff (RAs, T. Haney, H. Delaney, Bo & Bill Miller, consultants) Conflict of interest: I own copyright and patent pending on these programs.
Overview Problem drinkers: The big picture Stages of Change & matched interventions Stepped care: only as much as needed BMIs Action-oriented protocols Management issues
Consumption & alcohol related problems None Mild Moderate Substantial Severe Alcohol Problems None Mild Moderate Substantial Severe Consumption IOM, 1990
Spectrum of intervention responses None Mild Moderate Threshold for action Brief intervention, moderation training Specialized treatment Substantial Severe Alcohol Problems
Stages of Change Precontemplation Permanent exit
Using a stepped care model for screening & intervention Using the minimal amount of intervention needed to resolve problems (Sobell & Sobell, 2000). Screening (1 question) BMIs Action-oriented protocols Moderation programs Abstinence programs
Detecting & screening for alcohol-related problems Screen as integral part of lifestyle assessment Ask routinely as you would about smoking, exercise, sleep, etc. Consider drinking from health standpoint, not disease standpoint
When Pt. Screens positive: Next step Assess extent of drinking & for heavy drinkers answer question, “Should I change my drinking?” BMIs The Drinker’s Check-up (25+ y/o) The College Drinker’s Check-up (<25 y/o)
The Drinker’s Check-up (DCU) Windows version for healthcare providers Web version Randomized clinical trial: moderate drinking outcomes far more common than abstinence (10%) (Hester et al., 2005).
The College Drinker’s Check-up (CDCU) Windows & web versions RCT: outcomes similar to the DCU for older adults (Hester et al., under review).
DCU Outcomes: Log Average Drinks/Day (Form 90)
Average Peak BAC per Drinking Day (DCU)
Effect Sizes d Baseline vs 4 wks Baseline vs 8 wks Baseline vs 12 mo Log Av Drinks Immediate Delayed Log Drinks/Drink Day Immediate Delayed
Effect Sizes d Baseline vs 4 wks Baseline vs 8 wks Baseline vs 12 mo Log Av peak BAC Immediate Delayed Mean of all Form 90 q/f variables Immediate Delayed Overall Mean
Preparation State: Goals of Change Cut back or abstain Natural recovery literature (Sobell et al.) Most people w/alcohol problems reduce their drinking w/o any professional or self-help Tend to be the less dependent drinkers Relationship of hx. alcohol problems & success in reducing alcohol problems w/moderation (Miller et al., 1992)
Non-Dependent Problem Drinkers Prevalence is increasing (NIAAA, 2004) Tend to not seek abstinence-oriented treatment. Constitute the majority of those who recover w/o formal treatment (i.e. natural recovery) At same time they have long histories of alcohol-related problems.
Moderate Drinking 2-3 Std drinks for men, 1-2 for women 3-4 days/wk Peak BACs <.055 Maximum limits 3/7 day/week women, 4/14 day/week men (<65 y/o)
Resources Moderation Management (www.moderation.org)www.moderation.org Only mutual-help group reaching out to non-dependent problem drinkers Supportive of both moderate drinking & abstaining Online & face-to-face meetings, listserv, forum Moderation training protocols
Are moderation protocols effective? Reviews of the literature Outcome summary from Hester & Miller (2003) More controlled clinical trials of BSCT than any other treatment until recently (e.g. MI, BMIs) Tested in wide variety of clinical pop. Variety of ways to provide the tx. (face- to-face, bibliotherapy, web app.)
Moderate Drinking & Moderation Management: Results of a randomized clinical trial
In God We Trust. Everyone else has to show their data 80 heavy drinkers randomly assigned to either a) MD + MM or b) MM alone Follow-ups at 3, 6, & 12 mo. 73% had outcome data at all 3 f-up points
Hypotheses 1. Both groups will reduce their drinking and alcohol-related problems at follow- ups. 2. The experimental group (MD + MM) will have reduce their drinking and alcohol-related problems to a greater extent than the control group.
Baseline Data Group MD +MMMM only Age Education in Years MAST score Drinks (SECs)/Week Percent Days Abstinent (PDA) Mean Drinks per Drinking Day
Group MD +MMMM only Mean Peak BAC per Drinking Day 111mg%119mg% Hours BAC > 80 mg% (in prior week, descending curve) DrInC Recent Total score AUDIT score
Median Peak BAC/Drinking Day
Hypothesis 2: PDA by Group
Hypothesis 2: DrInC Recent Total Scores
Heavier vs. Less Heavy Drinkers A consistent research finding: those with greater symptoms of dependence benefit less from moderation protocols. Participants whose drinking, on average, did not meet NIAAA's definition of binge drinking, had somewhat better outcomes in the experimental group which had access to more resources and more opportunities to learn moderate drinking skills.
Moderation in drinking AUDIT score over 8 MAST score under 20 Give medical history to screen for contraindications Clients with less severe alcohol-related problems Clients who refuse abstinence without first trying moderation
Ethical and practical issues Moderation achievable by many, but not all Predictors of success not perfect Lack of success by 6-8 weeks not good sign for chances of long term success in moderation
Explore client's concerns/thoughts about drinking Listening to clients tells you their Stage of Change Negotiate goals of change and option of moderation Chances of success (Table from Proj. MATCH MET manual, pg. 33)
What to do with the clearly dependent client Share info about likelihood of success with moderating drinking (Miller, Leckman, Delaney, & Tinkcom 1992) Discourage abstinent alcoholics from trying moderation Urge "vacation" from drinking Agree to BSCT trial w/contract to abstain if unsuccessful
Moderation issues Most significantly dependent clients won't opt for moderation, especially once it is explained to them Clients will always choose their own goal Sanchez-Craig's BSCT study w/abstinence & moderation gps Behavioral contracting w/dependent clients unwilling to consider abstinence w/o trial of moderation training first
Abstinence Oriented protocol Overcoming Addictions, A SMART Recovery web application Under development, RCT 9/1/11 A 4-step, CB-T & MET protocol Build, maintain motivation Dealing w/urges, cravings Managing thoughts, feelings, actions Lifestyle balance for relapse prevention
SMART Recovery face-to-face meetings Daily online meetings Forum for support Manuals, etc. on their web site
Clinical Management For many problem drinkers, BMI is sufficient Some will benefit from moderation protocols, some will need abstinence- oriented protocols Brief follow-ups key to knowing how much has been enough
Implementation Clinical IT issues
References Hester, R.K., Delaney, H.D., & Campbell, W. (Under review). The College Drinker’s Check-up: Outcomes of two randomized clinical trials of a computer-based brief motivational intervention. Hester, R.K., Delaney, H.D., & Campbell, W., (In press). Moderatedrinking.com and Moderation Management: 12-month outcomes of a randomized clinical trial. Journal of Consulting and Clinical Psychology. Abstract at Hester, R.K., Delaney, H.D., Campbell, W., & Handmaker, N.(2009). A web application for moderation training: Initial results of a randomized clinical trial. Journal of Substance Abuse Treatment, 37(3),
Hester, R.K., Squires, D.D., & Delaney, H.D. (2005). The Computer-based Drinker’s Check-up: 12 month outcomes of a controlled clinical trial with problem drinkers. Journal of Substance Abuse Treatment, 28(2), Hester, R.K., & Miller, W.R. (Eds.) (2003). Handbook of alcoholism treatment approaches: Effective alternatives, (3rd edition). Boston, MA: Allyn & Bacon. Hester, R.K. (2003). Self-control training. In R.K. Hester & W.R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives, (3rd edition). Boston, MA: Allyn & Bacon.
Miller, W. R., Leckman, A. L., Delaney, H. D., & Tinkcom, M. (1992). Long-term follow-up of behavioral self-control training. Journal of Studies on Alcohol, 53, National Institute on Alcohol Abuse and Alcoholism. (2004a). Alcohol abuse increases, dependence declines across decade. Sobell, M. B., & Sobell, L. C. (2000). Stepped care as a heuristic approach to the treatment of alcohol problems. Journal of Consulting and Clinical Psychology, 68, 573–579.