1. Copyright Alcohol Medical Scholars Program1 Substance Use Disorders: Does Treatment Work? Christina M. Delos Reyes, MD Department of Psychiatry CWRU School of Medicine

2. Copyright Alcohol Medical Scholars Program2 Topics to be covered Clinician hopelessness Medical model of SUDs Treatment effectiveness Increasing clinician optimism

3. Copyright Alcohol Medical Scholars Program3 Clinician Hopelessness Society’s attitudes Personal experiences Exposure to severe, late stage disease Negative reactions are reinforcing and self-fulfilling Inadequate training of clinicians

4. Copyright Alcohol Medical Scholars Program4 Inadequate SUD Training Attitudes learned and internalized Medical school –75% “little or no training in SUDs” Residency programs –44% with no required curriculum Clinicians in practice –33% fail to screen for SUDs

5. Copyright Alcohol Medical Scholars Program5 Substance Dependence 3 of 7 criteria in 12-month period - Tolerance - Withdrawal - More than intended - Cut down - Time spent using - Limit activities - Use despite consequences

6. Copyright Alcohol Medical Scholars Program6 Substance Abuse Never met criteria for dependence 1 of 4 criteria in 12-month period - Role failures - Hazardous use - Legal problems - Interpersonal problems

7. Copyright Alcohol Medical Scholars Program7 Explanatory Models Moral  wrong Spiritual  empty Psychological  impulse control Behavioral  habit Medical  disease

8. Copyright Alcohol Medical Scholars Program8 Medical Model Sick person seeking wellness SUDs as chronic diseases –Biological basis –Identifiable signs and symptoms –Predictable course and outcome Treatment improves outcomes

9. Copyright Alcohol Medical Scholars Program9 Biological Basis of SUDs Genetic influences –4x  risk in children of alcoholics – Concordance in identical twins Biochemical correlates –Dopamine and the reward system –CRF and craving

10. Copyright Alcohol Medical Scholars Program10 Predictable Course of Alcohol Dependence Onset by age 31 Present for Rx by age 41 Fluctuating course 10-30% spontaneous remission

11. Copyright Alcohol Medical Scholars Program11 Predictable Course of Alcohol Dependence Life span decreased by 10-15 yrs Leading causes of death 1. Cardiovascular 2. Stroke 3. Cancers 4. Accidents 5. Suicide

12. Copyright Alcohol Medical Scholars Program12 What is treatment? Comprehensive approach to a chronic disease Four basic goals –Enhance function –Optimize motivation toward abstinence –Restructure life without substances –Relapse prevention

13. Copyright Alcohol Medical Scholars Program13 Treatment Structure Detox is not always needed Several forms of rehab –Short-term inpatient –Outpatient drug-free –Long-term residential –Outpatient maintenance –Aftercare

14. Copyright Alcohol Medical Scholars Program14 Treatment Components Educational lectures Counseling –Group –Individual –Family AA and other 12-Step groups Vocational rehabilitation Pharmacotherapy

15. Copyright Alcohol Medical Scholars Program15 Does Treatment Work? Outcomes –Functioning at followup after treatment Efficacy –Comparing outcomes in treatment group vs. control group

16. Copyright Alcohol Medical Scholars Program16 Treatment Outcomes Continuous abstinence Amount of use Criminal activity Employment Relationships Health

17. Copyright Alcohol Medical Scholars Program17 Patient Factors Predicting Better Outcomes  Severity of substance dependence  Motivation No psychiatric disorders Social supports  Criminal involvement Treatment completion

18. Copyright Alcohol Medical Scholars Program18 Program Factors Predicting Better Outcomes  Range, frequency, intensity of services Flexible, individualized treatment  Length of time in treatment

19. Copyright Alcohol Medical Scholars Program19 National Multi-site Outcome Research Study NameDate published TOPS1989 CATOR1991 NTIES1997 DATOS1997 Project MATCH1997

20. Copyright Alcohol Medical Scholars Program20 Treatment Outcome Prospective Study % Reduction in weekly cocaine use –1-year post-treatment 35% –2-years post-treatment56% % Reduction in weekly heroin use –1-year post-treatment 60% –2-years post-treatment70%

21. Copyright Alcohol Medical Scholars Program21 Treatment Outcome Prospective Study Increase in % of clients working –Before treatment31% –After treatment45% % Reduction in predatory crime –1 year post-treatment27% –2 years post-treatment45%

22. Copyright Alcohol Medical Scholars Program22 Chemical Abuse Treatment Outcome Registry Total abstinence at followup –1 year40% –2 years33%

23. Copyright Alcohol Medical Scholars Program23 National Treatment Improvement Evaluation Study DRUG USE YEAR BEFORE RX YEAR AFTER RX Crack Cocaine 50%25% Powder Cocaine40%18% Heroin24%13%

24. Copyright Alcohol Medical Scholars Program24 National Treatment Improvement Evaluation Study % Decrease in criminal behavior 51%drug possession 64%arrests 78%assault 78%selling drugs 82%shoplifting

25. Copyright Alcohol Medical Scholars Program25 National Treatment Improvement Evaluation Study % Reduction in health problems AOD-related medical visits54% Suicide attempts +AOD40% Suicide attempts –AOD48% Inpatient MH visits 57% Panic symptoms+AOD96%

26. Copyright Alcohol Medical Scholars Program26 Drug Abuse Treatment Outcome Study % Reduction at 1 year followup Heavy drinking 52% Weekly cocaine use ~ 60% Weekly heroin use 69%

27. Copyright Alcohol Medical Scholars Program27 Drug Abuse Treatment Outcome Study % Spending time in jail Year prior to treatment70% Year after treatment30%

28. Copyright Alcohol Medical Scholars Program28 Matching Alcoholism Treatment to Client Heterogeneity Can certain patients be matched to different treatments? CBT: Cognitive Behavioral Therapy TSF: Twelve Step Facilitation MET: Motivational Enhancement Therapy

29. Copyright Alcohol Medical Scholars Program29 Matching Alcoholism Treatment to Client Heterogeneity ~50% abstinent or significantly reduced drinking at 1-year and 3-year followup All 3 approaches were effective

30. Copyright Alcohol Medical Scholars Program30 Comparison to Other Chronic Diseases Med compliance Required hospital stay annually Follow diet & behavior change DM I<60 %~40 %<30 % HTN<40 %~60 %<30 % Asthma<40 %~60 %<30 %

31. Copyright Alcohol Medical Scholars Program31 Redefining Success Appropriate comparisons –Treat SUDs as chronic diseases –Comparable to other chronic diseases Reasonable expectations –Complete abstinence is not the only successful outcome

32. Copyright Alcohol Medical Scholars Program32 Reasonable Expectations Higher expectations for SUD treatment “Relapse” = Failure in SUDs “Relapse” = Effectiveness in other chronic diseases

33. Copyright Alcohol Medical Scholars Program33 Increasing Clinician Optimism Improved training –Increase recognition and treatment of SUDs –Enhance clinician confidence –Share hope of recovery with patient

34. Copyright Alcohol Medical Scholars Program34 Treatment is Worthwhile! SUDs common and easily identified Effective treatment exists Similar outcomes to other chronic diseases Transform hopelessness into optimism