I n t e g r i t y - S e r v i c e - E x c e l l e n c e Headquarters U.S. Air Force 1 MTF Toolkit for CoRC Implementation: Bucket 3/Tertiary Care Insert your name here

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 2 We need more emphasis, outside of ADAPT, on substance use because….

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 3 U.S. Statistics 63% U.S population are current drinkers (CDC, 2002) 5% U.S. adults heavy drinkers 20% adults, 5+ drinks 1x/past year 3 of 10 adults in the U.S. engage in risky drinking (NIAAA) 40% traffic fatalities due to alcohol (50% for age 18-24) “1700 college students die each year from alcohol related injuries” (Wake Forest Univ, O’Brien 2005) 400,000 students between had unprotected sex 100,000 were too intoxicated to know if they consented to having sex (Hingson, et al., 2002)

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 4 Alcohol Misuse in the Air Force: A Clear and Present Danger Alcohol misuse is involved in: 33% of suicides 57% sexual assaults 28.5% domestic violence cases 44% PMV accidents

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 5 Heavy Alcohol Use* Past 30 Days, Ages 18–55 *standardized 2001 NHSDA Note: yr estimate significantly different from civilian estimate at 95% confidence

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 6 Alcohol-Related Effects Total DoD * Statistically significant increase from 1998 * * Source: 2002 HRB Survey

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 7 The best model for change…

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 8 CoRC’s Success Requires Collaboration: Research Says…. Comprehensive community approach ideal: Leadership Driven, Environmental Change, Information, Early Identification and Intervention, Policy/Deterrence, & Alternative Activities Key: Identify those at of risk Population based screening/assessment Good evidence for brief interventions Tailored feedback (in-person and mailed), Brief Interventions, Primary Care, Web-based programs, etc… Based on SAMHSA and NIAAA recommendations for prevention and early intervention in youth & young adults

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 9 The role of LSSC and FAP…

I n t e g r i t y - S e r v i c e - E x c e l l e n c e  Many alcohol problems aren’t seen in ADAPT  We need to screen and treat in all clinics 82% of AF heavy drinkers Receive NO Intervention Source: DoD WorldWide Survey, 2002 Why Bother?

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 11 Co-morbidity Co-morbid D/O Alcohol Abuse Alcohol Dependence Mood D/Os Maj Depression Bipolar D/O Anxiety D/O GAD Panic D/O PTSD From: National Co morbidity Survey (Keesler et al. 1996) All data is 1-year rate: the percent of people who met the criteria for the disorder during the year prior to the survey

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 12 Treatment Research Says…. Alcohol Treatment (all)—1 year outcomes Miller et al, in 4 clients remain continuously abstinent 1 in 10 use alcohol in moderation without problems Mortality about 1.5% Remaining clients abstained an avg. of 3 out of 4 days Remaining clients reduced overall consumption by 87% Reduced from avg. of 77/wk to 10/wk

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 13 Treatment Research Says…. Alcohol Review “ Mesa Grande” Miller and Wilbourne, controlled studies-weighted on methodological strength Strongest Efficacy: Brief Interventions Social Skills Training Community Reinforcement Behavioral Contracting Behavioral Marital Therapy Opiate antagonists (naltrexone, nalmefone) and acamprosate Least Efficacy: Education, Confrontation, Shock or Insight Driven Methods, Mandatory AA, etc..

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 14 Treatment Research Says…. Brief interventions for alcohol problems (15 min- 4 sessions) (Moyers et al, 2002 meta-analysis) Non-treatment seeking populations: Brief interventions better than control conditions Treatment seeking populations: Brief interventions as good as more extended treatment No difference in response by gender

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 15 Targeted/Tertiary Prevention Screening, Assessment & Brief Intervention For behavioral health outside of ADAPT Family Advocacy and Life Skills Support Centers Recommend screening at each new intake Identify and treat “sub-clinical” alcohol misuse Identify substance use disorders (Abuse and Dependence) Refer these cases to ADAPT for assistance with treatment When not an abuse or dependence diagnosis, it is generally appropriate to incorporate hazardous drinking into the existing treatment plan at FAP or LSSC Surgeon General’s Toolkit: Bucket 3

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 16 Step 1: Include screening as part of intake process They drink and Had problems with alcohol in the past Had at least 1 binge episode within the past year 4 or more drinks in a sitting for women 5 or more drinks in a sitting for men Surgeon General’s Toolkit: Bucket 3

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 17 Step 2: Assess further Recommend standardized screening (e.g. AUDIT) DSM-IV-TR checklist also included in tool kit If positive for Abuse or Dependence Diagnosis Refer to ADAPT If not positive for Abuse or Dependence Diagnosis Consider and act on any fitness fro duty issues, if any Consider incorporating reduction of hazardous drinking into existing treatment plan Surgeon General’s Toolkit: Bucket 3

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 18 Recommended Screening Tool: Alcohol Use Disorders Test (AUDIT) The AUDIT is a 10-item questionnaire assessing the patient’s drinking habits and risk for developing alcohol related problems in the future Aggregate score has predictive value as a screener for alcohol problems Cut Off Scores > 8 men/7women = High risk > 15 = Warrant additional assessment, counseling

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 19 Step 3: Assess Readiness for Change “Are you interested in reducing your drinking level?” Use Readiness to Change Questionnaire in Toolkit Step 4: If ready, develop a treatment and follow-up plan tailored to the patient’s needs Consider using Motivational interviewing approach Brief Intervention Resources in Toolkit Recommended: NIAAA’s Helping Patients Who Drink to MUCH: A Clinician’s Guide, 2005 Edition Consider ordering SAMHSA’s free TIPS (website on info sheet) : TIP 34: Enhancing Motivation for Change in Substance Abuse Treatment TIP 35: Brief Interventions and Brief Therapies for Substance Abuse Surgeon General’s Toolkit: Bucket 3

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 20 For more specialized training and guidance, please consult with your local ADAPT staff Surgeon General’s Toolkit: Bucket 3

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 21 See Surgeon General’s Toolkit for Details about Bucket 3