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Substance Use Disorders Among Schizophrenics: Psychotherapeutic Interventions Evaristo O. Akerele, M.D. Assistant Professor of Clinical Psychiatry College of Physicians and Surgeons, Columbia University
Slide 1: The overall goal of this talk is to assist primary care physicians and other health care professionals in the recognition and treatment of “at risk drinking”. “At risk drinking” and alcohol dependence are common and major public health problems. 19% of men and 8% of women have a lifetime diagnosis of alcohol dependence. Since heavy drinking and alcohol dependence are associated with many medical and psychiatric problems, individuals with “at risk drinking” and alcohol dependence are commonly seen in physicians’ offices. The purpose of this talk is to discuss a screening procedure for alcohol dependence and “at risk drinking” and brief interventions that can be done in a primary care office.
References
Bush, K., Kivlahan, D.R., McDonell, M.B., Fihn, S.D. and Bradley, K.A. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Archives of Internal Medicine 158: , 1998.
Camargo, C.A.J., Stampfer, M.J., Glynn, R.J., et al. Moderate alcohol consumption and risk for angina pectoris or myocardial infarction in U.S. male physicians. Annals of Internal Medicine 126: , 1997.
Fleming, M.F., Barry, K.L., Manwell, L.B., Johnson, K. and London, R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices. JAMA 277: , 1997.
Fleming, M.F., Manwell, L.B., Barry, K.L. and Johnson, K. At-risk drinking in an HMO primary care sample: prevalence and health policy implications. American Journal of Public Health 88:90-93, 1998.
Fuchs, C.S., Stampfer, M.J., Colditz, G.A., et al. Alcohol consumption and mortality among women [published erratum appears in N Engl J Med 1997 Feb 13;336(7):523]. New England Journal of Medicine 332: , 1995.
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Introduction
Prevalence
Consequences
Etiology
Psychotherapeutic interventions
Limitations
Conclusions
Slide 8: Brief interventions are often used by primary care physicians and can be effective in non alcohol dependent subjects. Most interventions are 4 sessions or fewer and are even effective if they are just a few minutes.
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Sources of Data
Epidemiological Catchment Area
National Comorbidity Survey
Emergency Room Data
National Household Survey
Slide 9: The goal of brief intervention is for patients to moderate their drinking to below an “at risk drinking” level. Abstinence is not the goal.
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4. Lifetime Risks: General Population
Schizophrenia 1%
Nicotine dependence 28% men & women
Alcohol dependence 12% men, 5% women
Marijuana dependence 5%
Cocaine dependence 2%
Slide 10: The steps involved in brief interventions are FACT-
Feedback
Advice
Commitment
Tracking
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5. Lifetime Risks: Schizophrenic Population
Nicotine dependence 70%
Alcohol dependence 37%
Marijuana dependence 23%
Cocaine dependence 13%
Slide 11: Feedback: Physicians need to provide feedback to patients regarding their drinking habits. This feedback should include any physical and laboratory findings that are consequences of drinking.
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Emergency Room ( )
Marijuana 0 to 27%
Cocaine 0 to 73%
Opiates have not changed, 11%
Slide 12: Advice: Explicit advice to reduce drinking needs to be given. Also, education about levels of drinking that are moderate should be discussed. The drinking goal needs to negotiated by the physician and patient. This goal should be written – in the form of a prescription to be followed.
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Consequences
General population
Special issues in schizophrenics
Slide 13: Commitment: Brief intervention to emphasize the patient’s responsibility and opportunity to choose to change. Telling the patient, “No one can make you change. What you do about your drinking is up to you.” is important in placing the commitment to change in the hands of the patient.
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8. Consequences of Alcohol in General Population
Intoxication: Poor judgment, anger, violence, impaired coordination
Medical complications: Cardiomyopathy, anemia, cirrhosis
Hallucinations
Delirium tremens
Slide 13: Commitment: Brief intervention to emphasize the patient’s responsibility and opportunity to choose to change. Telling the patient, “No one can make you change. What you do about your drinking is up to you.” is important in placing the commitment to change in the hands of the patient.
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9. Consequences of Alcohol in Schizophrenics: Special Issues
Small amounts have greater effect
Alcohol can increase cognitive deficits and enhance depression
Slide 13: Commitment: Brief intervention to emphasize the patient’s responsibility and opportunity to choose to change. Telling the patient, “No one can make you change. What you do about your drinking is up to you.” is important in placing the commitment to change in the hands of the patient.
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10. Consequences of Cocaine in the General Population
Myocardial infarction
Arrhythmias
Cerebrovascular accident
“Crack lung”: chestpains, dyspnea, hyperthermia, chest X ray normal
Paranoia
Mood swings
Reduced DA uptake
Slide 14: Tracking: Follow up of the intervention is important and may involve telephone calls, repeat office visits and laboratory tests. Follow up allows the physician to assess progress (or lack of progress), identify problems that may impede successful change, and offer ongoing support.
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11. Consequences of Cocaine in Schizophrenics: Special Issues
Financial and housing difficulties
Frequent rehospitalizations
Less satisfying family relationships
Increased odds of violent behavior
Increased risk of HIV infections
Poor treatment compliance
Slide 14: Tracking: Follow up of the intervention is important and may involve telephone calls, repeat office visits and laboratory tests. Follow up allows the physician to assess progress (or lack of progress), identify problems that may impede successful change, and offer ongoing support.
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12. Combined Cocaine and Alcohol (Cocaethylene) Use
Direct toxic effect on myocardium
Additive effect on locus coerleus, increased risk of panic
Increases duration of blood pressure elevation
Cocaine use and liking increases
Slide 14: Tracking: Follow up of the intervention is important and may involve telephone calls, repeat office visits and laboratory tests. Follow up allows the physician to assess progress (or lack of progress), identify problems that may impede successful change, and offer ongoing support.
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Etiology
Genetic
Self medication
Minimization of side effects
Availability
Impulsivity and reinforcing effects
Slide 15: A randomized controlled study performed in 22 primary care physician offices was completed in which patients were screened for “at risk drinking”. 8% to 20% of patients were identified as drinking at “risky” levels”. The intervention arm of the study, certain offices were instructed on brief interventions. In the control are of the study, usual care was given.
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14. Psychotherapeutic Interventions: Modalities
Motivational enhancement therapy (MET)
Program for assertive community treatment (PACT)
Contingency management
12 step groups
Relapse prevention
Slide 16: Brief interventions reduce drinking levels .
Results of Brief Physician Advice for Problem Drinkers
Initial Follow Up
Weekly Alcohol Use:
Intervention drinks 11.5 drinks
Control drinks 15.5 drinks
Binge Drinking
Intervention 5.7 per month 3.1 per month
Control 5.3 per month 4.2 per month
Excessive Drinking
Intervention 47.5% 17.8%
Control 48.1% 32.5%
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15. Psychotherapeutic Interventions: Phases
Engagement
Persuasion
Active treatment
Relapse prevention
Slide 16: Brief interventions reduce drinking levels .
Results of Brief Physician Advice for Problem Drinkers
Initial Follow Up
Weekly Alcohol Use:
Intervention drinks 11.5 drinks
Control drinks 15.5 drinks
Binge Drinking
Intervention 5.7 per month 3.1 per month
Control 5.3 per month 4.2 per month
Excessive Drinking
Intervention 47.5% 17.8%
Control 48.1% 32.5%
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16. Motivational Enhancement Therapy
Definition
Modality:counseling, nonconfrontational, patient-centered
Principles
Controlled studies: project match
Utility: engagement & active phases
Limitation: need for motivation
Slide 16: Brief interventions reduce drinking levels .
Results of Brief Physician Advice for Problem Drinkers
Initial Follow Up
Weekly Alcohol Use:
Intervention drinks 11.5 drinks
Control drinks 15.5 drinks
Binge Drinking
Intervention 5.7 per month 3.1 per month
Control 5.3 per month 4.2 per month
Excessive Drinking
Intervention 47.5% 17.8%
Control 48.1% 32.5%
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17. Motivational Enhancement Therapy: Principles
Expression of empathy
Development of discrepancy
Avoidance of argumentation
Rolling with the resistance
Supporting self efficacy
Slide 16: Brief interventions reduce drinking levels .
Results of Brief Physician Advice for Problem Drinkers
Initial Follow Up
Weekly Alcohol Use:
Intervention drinks 11.5 drinks
Control drinks 15.5 drinks
Binge Drinking
Intervention 5.7 per month 3.1 per month
Control 5.3 per month 4.2 per month
Excessive Drinking
Intervention 47.5% 17.8%
Control 48.1% 32.5%
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18. Program for Assertive Community Treatment
Definition
Modality: 24hrs/7days
Principles: emphasize strength, provide support
Controlled studies: fewer symptoms, shorter hospital stay
Utility: engagement phase
Limitation: expensive
Slide 16: Brief interventions reduce drinking levels .
Results of Brief Physician Advice for Problem Drinkers
Initial Follow Up
Weekly Alcohol Use:
Intervention drinks 11.5 drinks
Control drinks 15.5 drinks
Binge Drinking
Intervention 5.7 per month 3.1 per month
Control 5.3 per month 4.2 per month
Excessive Drinking
Intervention 47.5% 17.8%
Control 48.1% 32.5%
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19. Contingency Management
Definition
Modality: alternative reinforcers
Principles: operant conditioning
Controlled studies: 4 positive
Utility: active phase
Limitation: short term efficacy
Slide 16: Brief interventions reduce drinking levels .
Results of Brief Physician Advice for Problem Drinkers
Initial Follow Up
Weekly Alcohol Use:
Intervention drinks 11.5 drinks
Control drinks 15.5 drinks
Binge Drinking
Intervention 5.7 per month 3.1 per month
Control 5.3 per month 4.2 per month
Excessive Drinking
Intervention 47.5% 17.8%
Control 48.1% 32.5%
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12-Step Groups
Definition
Modality: self motivation & peer support
Principles: abstinence based
Controlled studies: data not conclusive
Utility: persuasion & maintenance phases
Limitations: emotionally charged & confrontational
Slide 16: Brief interventions reduce drinking levels .
Results of Brief Physician Advice for Problem Drinkers
Initial Follow Up
Weekly Alcohol Use:
Intervention drinks 11.5 drinks
Control drinks 15.5 drinks
Binge Drinking
Intervention 5.7 per month 3.1 per month
Control 5.3 per month 4.2 per month
Excessive Drinking
Intervention 47.5% 17.8%
Control 48.1% 32.5%
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Relapse Prevention
Definition
Modality: CBT
Principles: learn and correct triggers
Controlled studies: support efficacy
Utility: maintenance phase
Limitation: requires good cognition
Slide 16: Brief interventions reduce drinking levels .
Results of Brief Physician Advice for Problem Drinkers
Initial Follow Up
Weekly Alcohol Use:
Intervention drinks 11.5 drinks
Control drinks 15.5 drinks
Binge Drinking
Intervention 5.7 per month 3.1 per month
Control 5.3 per month 4.2 per month
Excessive Drinking
Intervention 47.5% 17.8%
Control 48.1% 32.5%
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22. Limitations of Current Psychotherapeutic Interventions
Inadequate controlled trials
Difficulty applying these modalities to schizophrenic substance use
Focus on systems of care
Slide 16: Brief interventions reduce drinking levels .
Results of Brief Physician Advice for Problem Drinkers
Initial Follow Up
Weekly Alcohol Use:
Intervention drinks 11.5 drinks
Control drinks 15.5 drinks
Binge Drinking
Intervention 5.7 per month 3.1 per month
Control 5.3 per month 4.2 per month
Excessive Drinking
Intervention 47.5% 17.8%
Control 48.1% 32.5%
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Conclusions
Substance use by schizophrenics is a major public health issue
Well-tailored interventions are lacking
Outcome maybe significantly affected by psychosocial factors
Slide 16: Brief interventions reduce drinking levels .
Results of Brief Physician Advice for Problem Drinkers
Initial Follow Up
Weekly Alcohol Use:
Intervention drinks 11.5 drinks
Control drinks 15.5 drinks
Binge Drinking
Intervention 5.7 per month 3.1 per month
Control 5.3 per month 4.2 per month
Excessive Drinking
Intervention 47.5% 17.8%
Control 48.1% 32.5%
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Audience
Medical students
Psychiatric residents
Others: social workers, psychiatric nurses, etc.
Slide 5: “At risk drinking is a level of “At risk drinking” is a level of alcohol consumption that is directly harmful or is correlated with a greater risk for the development of health problems. “At risk drinking” is defined for men and women as follows:
Men
Greater than 14 drinks per week
5 or more drinks per occasion
Women
Greater than 7 drinks per week
4 or more drinks per occasion
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