treatment: options and effectiveness national partnership on alcohol misuse and crime meeting on...

Treatment: Options and Effectiveness

National Partnership On Alcohol Misuse and Crime Meeting on Treatment, Washington, DC

Richard N Rosenthal, MDRichard N Rosenthal, MDProfessor of Clinical PsychiatryProfessor of Clinical PsychiatryColumbia University College of Physicians & SurgeonsColumbia University College of Physicians & SurgeonsChairman, Dept of PsychiatryChairman, Dept of PsychiatrySt. Luke’s-Roosevelt Hospital Center, NYSt. Luke’s-Roosevelt Hospital Center, NY

June 2, 2009June 2, 2009

Disclosure

RESEARCH GRANT SUPPORT:RESEARCH GRANT SUPPORT:2006 - 2008 Forest Laboratories, Inc. 2006 - 2008 Forest Laboratories, Inc. Principal Principal

InvestigatorInvestigator2007 - 2008 2007 - 2008 Titan Pharmaceuticals, Inc. Titan Pharmaceuticals, Inc. Principal Investigator Principal Investigator 2007 - 2012 2007 - 2012 National Institute on Drug AbuseNational Institute on Drug Abuse Co-InvestigatorCo-Investigator2008 - 2010 2008 - 2010 The National Institute of Diabetes, The National Institute of Diabetes, Co-InvestigatorCo-Investigator

Digestive and Kidney DiseaseDigestive and Kidney Disease

AFFILIATIONS:AFFILIATIONS:2008 - Sequest Technologies, Lisle, IL. 2008 - Sequest Technologies, Lisle, IL. Advisory BoardAdvisory Board

Overview

Who needs Treatment?Who needs Treatment?

What is the Treatment Process?What is the Treatment Process?How does it begin?How does it begin?

Who is involved?Who is involved?

Importance of Screening and AssessmentImportance of Screening and Assessment

Consideration of Prior ConvictionsConsideration of Prior Convictions

Pre-treatmentPre-treatment

Brief Interventions/Motivational InterviewingBrief Interventions/Motivational Interviewing

Overview

Treatment Options and EffectivenessTreatment Options and EffectivenessCounseling Models and Outcome DifferencesCounseling Models and Outcome Differences

Motivational Enhancement TherapyMotivational Enhancement TherapyCognitive Behavioral TherapyCognitive Behavioral Therapy

Patient Placement Criteria: settings and levels of Patient Placement Criteria: settings and levels of carecare

Role of Detoxification Role of Detoxification Role of residential rehabilitation/halfway houseRole of residential rehabilitation/halfway house

Voluntary vs. Mandatory TreatmentVoluntary vs. Mandatory TreatmentTreatment Vs. EducationTreatment Vs. Education

Role of 12-Step and Support GroupRole of 12-Step and Support Group

Who Needs Treatment?

Heavy/at Risk drinkersHeavy/at Risk drinkersMedical Impact even without a “diagnosis”Medical Impact even without a “diagnosis”

Diagnosis of Alcohol Abuse - where Diagnosis of Alcohol Abuse - where symptoms increase likelihood of further symptoms increase likelihood of further sanctions due to impaired judgment/controlsanctions due to impaired judgment/control

DUI, assault, loss of external social supports, DUI, assault, loss of external social supports, missed appointmentsmissed appointments

Diagnosis of Alcohol DependenceDiagnosis of Alcohol DependenceImpairment, disabilityImpairment, disability

The Scope of Alcohol Problems in the Criminal Justice System

21.6 percent of victims of violent crimes thought or knew the offender 21.6 percent of victims of violent crimes thought or knew the offender had consumed alcohol; another 1.5 percent of the victims thought had consumed alcohol; another 1.5 percent of the victims thought the offender had used either alcohol or another drug (Bureau of the offender had used either alcohol or another drug (Bureau of Justice Statistics 2003).Justice Statistics 2003).40 percent of offenders on probation, in State prisons, or in local jails 40 percent of offenders on probation, in State prisons, or in local jails reported using alcohol at the time of their offense (Bureau of reported using alcohol at the time of their offense (Bureau of Statistics 1998).Statistics 1998).18 percent of Federal prison inmates and about 25 percent of State 18 percent of Federal prison inmates and about 25 percent of State prison inmates reported having experienced problems consistent prison inmates reported having experienced problems consistent with a history of alcohol abuse and dependence (Knight et al. 2002).with a history of alcohol abuse and dependence (Knight et al. 2002).29 percent of Federal and 40 percent of State prisoners reported a 29 percent of Federal and 40 percent of State prisoners reported a previous domestic violence dispute involving alcohol (Knight et al. previous domestic violence dispute involving alcohol (Knight et al. 2002).2002).There were 1.4 million DWI arrests in 2001, making DWI the number There were 1.4 million DWI arrests in 2001, making DWI the number one crime, besides drug possession, for which Americans are one crime, besides drug possession, for which Americans are arrested (NHTSA 2003).arrested (NHTSA 2003).About two-thirds of convicted DWI offenders are alcohol dependent About two-thirds of convicted DWI offenders are alcohol dependent (Lapham et al. 2001).(Lapham et al. 2001).

http://pubs.niaaa.nih.gov/publications/arh28-2/85-93.htm

The Scope of Alcohol Problems in the Criminal Justice System

In a study of first-time DWI offenders interviewed In a study of first-time DWI offenders interviewed 5 years after first being referred to screening 5 years after first being referred to screening following their DWI offense (Lapham et al. 2001):following their DWI offense (Lapham et al. 2001):

85% of female and 91% of male DWI offenders had 85% of female and 91% of male DWI offenders had met the criteria for alcohol abuse or dependence at met the criteria for alcohol abuse or dependence at some time in their lives.some time in their lives.32% of female and 38% of male offenders had met 32% of female and 38% of male offenders had met criteria for abuse of or dependence on another drug at criteria for abuse of or dependence on another drug at some time in their lives.some time in their lives.50% of women with an alcohol use disorder and 33% 50% of women with an alcohol use disorder and 33% of men with an AUD also had at least one psychiatric of men with an AUD also had at least one psychiatric disorder (not drug-related), most commonly disorder (not drug-related), most commonly depression and post-traumatic stress disorder.depression and post-traumatic stress disorder.

http://pubs.niaaa.nih.gov/publications/arh28-2/85-93.htm

Why Are Alcohol Use Disorders (AUD) Underdiagnosed ≈ 50% time?

Clinicians:Clinicians:Typically lack proper training in screening and Typically lack proper training in screening and recognition recognition Miss diagnosis if presentation is not obvious, e.g. Miss diagnosis if presentation is not obvious, e.g. “skid row bum” “Alcohol on Breath,” etc. “skid row bum” “Alcohol on Breath,” etc. Are practical professionals, spend time on Are practical professionals, spend time on “fixable problems”“fixable problems”Frequently believe alcohol dependence isn’t Frequently believe alcohol dependence isn’t treatable, leading to professional denialtreatable, leading to professional denial

Why Are Alcohol Use Disorders Underdiagnosed ≈ 50% time?

Patients with AUD typically:Patients with AUD typically:minimize or deny strongly problem useminimize or deny strongly problem usedeny physical and psychological problems could deny physical and psychological problems could be related to drinkingbe related to drinkingrationalize work and interpersonal problems as rationalize work and interpersonal problems as cause of use, not resultcause of use, not resultPresent with emotional complaints (anxiety, mood Present with emotional complaints (anxiety, mood disturbance) without linking them to alcohol use.disturbance) without linking them to alcohol use.

Significant others/family/friends in best position to Significant others/family/friends in best position to report problems with alcohol but not present at report problems with alcohol but not present at screening or evaluationscreening or evaluation

Adapted from Waldinger RJ: Substance-Related Disorders and Eating Disorders, in Adapted from Waldinger RJ: Substance-Related Disorders and Eating Disorders, in Psychiatry for Psychiatry for Medical StudentsMedical Students. 3. 3rdrd Ed. American Psychiatric Press, Inc. Washington DC, 1997. Ed. American Psychiatric Press, Inc. Washington DC, 1997.

Screening in the Criminal Justice System

In 2002, Criminal justice/DWI referrals accounted for 40% In 2002, Criminal justice/DWI referrals accounted for 40% of alcoholism treatment admissions to alone, and 34% of of alcoholism treatment admissions to alone, and 34% of admissions to alcohol and other drugs treatment admissions to alcohol and other drugs treatment programs (SAMHSA 2004).programs (SAMHSA 2004).

Court-ordered screening misses many people with AUD Court-ordered screening misses many people with AUD and other disordersand other disorders

In N=1,078 convicted offenders, later voluntary screening In N=1,078 convicted offenders, later voluntary screening reported proportionally more alcohol abuse or alcohol reported proportionally more alcohol abuse or alcohol dependence compared to the court-ordered initial dependence compared to the court-ordered initial screening for alcohol problems (Lapham et al. 2004).screening for alcohol problems (Lapham et al. 2004).

Lapham, S.C et al., Drug and Alcohol Dependence 76:135–141, 2004

Screening in the Criminal Justice System

Limitations of screening procedures in the Limitations of screening procedures in the criminal justice system include:criminal justice system include:

No screening instruments are available that have No screening instruments are available that have proven validity to assess both AOD use and the range proven validity to assess both AOD use and the range of mental health problems found in criminal justice of mental health problems found in criminal justice populations.populations.Lack of screening instruments validated specifically for Lack of screening instruments validated specifically for criminal justice offenders.criminal justice offenders.Most current screening instruments rely on self report.Most current screening instruments rely on self report.Court-ordered screening is by definition coercive.Court-ordered screening is by definition coercive.Screening and treatment programs have limited Screening and treatment programs have limited financial resources; costs may be passed on to people financial resources; costs may be passed on to people being screened or treated who may be unable to pay.being screened or treated who may be unable to pay.

Lapham, S.C et al., Drug and Alcohol Dependence 76:135–141, 2004

When to Implement Screening

A planned, purposeful and usually brief process that should A planned, purposeful and usually brief process that should occur soon after the offender enters the system.occur soon after the offender enters the system.

Offenders screened at various stages of the judicial process, Offenders screened at various stages of the judicial process, including at arrest or arraignment, at pretrial investigation, including at arrest or arraignment, at pretrial investigation, during interactions with court staff, or as a post-sentence during interactions with court staff, or as a post-sentence action. action.

Screening and interventions with offenders who have AUD will Screening and interventions with offenders who have AUD will probably be more effective if initiated soon after the offense, probably be more effective if initiated soon after the offense, (laws are most likely to deter illegal behavior (e.g., DWI) if (laws are most likely to deter illegal behavior (e.g., DWI) if perceived to result in swift, certain, and severe sanctions (e.g., perceived to result in swift, certain, and severe sanctions (e.g., Morral et al. 2002). Morral et al. 2002).

National Commission on Correctional Health Care:National Commission on Correctional Health Care:Comprehensive health assessment (including substance abuse Comprehensive health assessment (including substance abuse history) within 7 days of arrival in prison, 14 days of arrival in jailhistory) within 7 days of arrival in prison, 14 days of arrival in jail

Morral, A.R et al. Drug and Alcohol Dependence 66(Suppl.):S124–S125, 2002.

Screening and Assessment in Correctional Settings

Substance Use history: patterns of use, treatment, acute Substance Use history: patterns of use, treatment, acute symptoms, need for detoxsymptoms, need for detoxCriminal historyCriminal historyPersonality traits related to criminalityPersonality traits related to criminalityMental health issues, including suicide potential, acute Mental health issues, including suicide potential, acute symptoms, treatment history, psychiatric medicationssymptoms, treatment history, psychiatric medicationsAbuse and trauma history, as victim/perpAbuse and trauma history, as victim/perpHigh-risk behaviorsHigh-risk behaviorsMotivation for treatmentMotivation for treatmentEducation and literacyEducation and literacyPhysical disabilitiesPhysical disabilitiesRelationships with significant others, family, dependentsRelationships with significant others, family, dependentsPhysical health, acute conditions, infectious diseases Physical health, acute conditions, infectious diseases including STD’s, HIV/AIDS, TB, and hepatitisincluding STD’s, HIV/AIDS, TB, and hepatitis

Screening for AUD

Screening:Screening: determines the likelihood of alcohol use disorder determines the likelihood of alcohol use disorder establishes the need for an in-depth assessment.establishes the need for an in-depth assessment.

Begin at the earliest point of clinical contact with the Begin at the earliest point of clinical contact with the offender and continue throughout treatment, if providedoffender and continue throughout treatment, if provided

Several screening tools can help determine the likelihood Several screening tools can help determine the likelihood of the presence of problem alcohol use.of the presence of problem alcohol use.

CAGE 4-item self report , scores 0-4, 2+ answers flag high riskCAGE 4-item self report , scores 0-4, 2+ answers flag high riskMAST 21-item self report, scores > 6 probable alcohol MAST 21-item self report, scores > 6 probable alcohol dependencedependenceAUDIT 10 item self report, score > 8 in men, probable AUDAUDIT 10 item self report, score > 8 in men, probable AUD

> 4 in woman, probable AUD> 4 in woman, probable AUD

Screening for AUD

CAGE – 4 Items CAGE – 4 Items < 1 minute to administer< 1 minute to administer≥ ≥ 2 “yes” answers = high risk for AUD2 “yes” answers = high risk for AUDHigh sensitivity for AUD (60-95%)High sensitivity for AUD (60-95%)No questions about frequency of useNo questions about frequency of useNo quantity of consumption questionsNo quantity of consumption questionsNo frequency of heavy drinking questionsNo frequency of heavy drinking questionsBecause consequence-focused, won’t flag early Because consequence-focused, won’t flag early problem drinkersproblem drinkers

Screening for AUD

MAST – 25 ItemsMAST – 25 Items≥ ≥ 7 Probable Alcohol Dependence7 Probable Alcohol Dependence5-6 Borderline Alcoholism5-6 Borderline Alcoholism≤ ≤ 4 No problem drinking4 No problem drinkingHigh Sensitivity for AUD (86-98%)High Sensitivity for AUD (86-98%)Questions elicit lifetime history rather than Questions elicit lifetime history rather than current drinking behavior (Magruder-Habib et current drinking behavior (Magruder-Habib et al., 1991)al., 1991)

Screening for AUD

AUDIT – 10 Items, assesses over past yearAUDIT – 10 Items, assesses over past yearWHO Collaborative effortWHO Collaborative effortMulticultural (Babor & Grant, 1989)Multicultural (Babor & Grant, 1989)Designed to screen earlier-level problems in primary-Designed to screen earlier-level problems in primary-care settingscare settingsSensitivity – 92%, Specificity – 93%Sensitivity – 92%, Specificity – 93%Three Domains: amount & frequency; alcohol Three Domains: amount & frequency; alcohol dependence; alcohol-induced problemsdependence; alcohol-induced problemsCutoff score of 8 of 40 = probable AUDCutoff score of 8 of 40 = probable AUD

Simple Screening for AUD

Ask the screening question about heavy drinking Ask the screening question about heavy drinking days: How many times in the past year have you days: How many times in the past year have you had had 5 or more5 or more drinks in a day? ( drinks in a day? (for menfor men) )

4 or more4 or more drinks in a day? ( drinks in a day? (for womenfor women) ) One standard drink is equivalent to 12 ounces of One standard drink is equivalent to 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits —spirits —

1 or more heavy drinking days, or1 or more heavy drinking days, orAUDIT score of ≥ 8 for men or ≥ 4 for women AUDIT score of ≥ 8 for men or ≥ 4 for women

If endorsed, then a clinical evaluationIf endorsed, then a clinical evaluation

Clinician’s Initial Evaluation

Document current and past use of alcohol and each Document current and past use of alcohol and each other substance separately – pattern?, who with?other substance separately – pattern?, who with?

Log prior quit attempts & treatmentsLog prior quit attempts & treatments

Medications: how used? how long ?Medications: how used? how long ?

Psychosocial treatment?Psychosocial treatment?

Assess current motivation to quit (pros & cons; quit Assess current motivation to quit (pros & cons; quit date)date)

Assess triggers, withdrawal, and dependenceAssess triggers, withdrawal, and dependence

Assess social supportAssess social support

SAMHSA HOUSEHOLD SURVEY, 2004

Total US Total US Population Population Over 12 YearsOver 12 Years (~237 M)(~237 M) Current Current

Alcohol Users:Alcohol Users:50.3% (~121 M people)50.3% (~121 M people)

NESARCNESARCAny AUD Any AUD 17.6 M (8.46 %)17.6 M (8.46 %)

Binge Binge Drinkers: 22.8 % Drinkers: 22.8 % (55 M)(55 M)

HeavyHeavyDrinkers:Drinkers:

6.9% (~16.7M)6.9% (~16.7M)

(NSDUH, 2005)(NSDUH, 2005)

Hazardous Drinking

A “standard drink” contains about 14 g A “standard drink” contains about 14 g alcoholalcoholAt-Risk or Heavy Drinking is defined as:At-Risk or Heavy Drinking is defined as:

MenMen: >14 drinks/week or >4 drinks/occasion : >14 drinks/week or >4 drinks/occasion Women:Women: >7 drinks/week or >3 drinks/ occasion >7 drinks/week or >3 drinks/ occasion

Hazardous alcohol consumption = 60-90 g Hazardous alcohol consumption = 60-90 g alcoholalcohol

Good predictor of alcohol-related problemsGood predictor of alcohol-related problemsNegative Impact on chronic medical illnessNegative Impact on chronic medical illnessSignificant increased morbidity and mortalitySignificant increased morbidity and mortality

McGinnis JM, Foege WH. JAMA. 1993; 270(18):2207–2212. NIAAA (2004) Helping McGinnis JM, Foege WH. JAMA. 1993; 270(18):2207–2212. NIAAA (2004) Helping Patients With Alcohol Problems. DHHS, Wash., DC. Patients With Alcohol Problems. DHHS, Wash., DC.

DSM -IV Substance Abuse

Substance use leading to clinically significant Substance use leading to clinically significant impairment manifested by one (or more):impairment manifested by one (or more):

Failure to fulfill major role obligationsFailure to fulfill major role obligations

Hazardous situationsHazardous situations

Legal problemsLegal problems

Continued substance use despite having persistent or Continued substance use despite having persistent or recurrent social or interpersonal problemsrecurrent social or interpersonal problems

Never met the criteria for substance Never met the criteria for substance dependencedependence

Addiction: Classical and Contemporary Constructs

Classical (Peele 1985):Classical (Peele 1985):CravingCravingIncreased toleranceIncreased tolerancePhysiologic withdrawalPhysiologic withdrawal

Contemporary: Behavioral Contemporary: Behavioral DysregulationDysregulation

Compulsive behavior despite negative Compulsive behavior despite negative consequences, i.e., loss of controlconsequences, i.e., loss of control Salience – primacy in a person’s lifeSalience – primacy in a person’s life

Cognitive – dominates mental lifeCognitive – dominates mental life Behavioral – dominates activityBehavioral – dominates activity

Functional ImpairmentFunctional Impairment

DSM -IV Substance Dependence

Three (or more) of the following over 12 Months:Three (or more) of the following over 12 Months:ToleranceTolerance

WithdrawalWithdrawal

Larger amounts or over longer period than intendedLarger amounts or over longer period than intended

Persistent desire or unsuccessful efforts to cut downPersistent desire or unsuccessful efforts to cut down

Much time spent in acquiring, using, or recovering from effectsMuch time spent in acquiring, using, or recovering from effects

Abandonment/reduction of important social, work, or recreational activitiesAbandonment/reduction of important social, work, or recreational activities

Continued use despite knowledge of having an alcohol-induced or exacerbated Continued use despite knowledge of having an alcohol-induced or exacerbated physical or mental problemphysical or mental problem

Targeting Heavy Drinking

Proxy for ImpairmentProxy for Impairment

Impact of Heavy DrinkingImpact of Heavy Drinking

Differences in NESARC diagnoses rates Differences in NESARC diagnoses rates and rates of binge and heavy drinkingand rates of binge and heavy drinking

2000 National Household Surveys on Drug Abuse (NHSDA)

Highest rates binge, heavy drinking young Highest rates binge, heavy drinking young adults aged 21 to 25adults aged 21 to 25

Peak rate 65 % at age 21 (45 % binge Peak rate 65 % at age 21 (45 % binge drinking, 17 % heavy drinking) drinking, 17 % heavy drinking)

Binge and heavy alcohol use rates decrease Binge and heavy alcohol use rates decrease faster with age than rates of past month faster with age than rates of past month alcohol usealcohol use

http://www.samhsa.gov/oas/2k2/alcNS/alcNS.htmhttp://www.samhsa.gov/oas/2k2/alcNS/alcNS.htm

Impact of Heavy Drinking

About 25% have alcohol dependenceAbout 25% have alcohol dependence

Increased risk:Increased risk:gastrointestinal bleeding, gastrointestinal bleeding,

sleep disorders, sleep disorders,

major depression, major depression,

hemorrhagic stroke, hemorrhagic stroke,

cirrhosis of the liver, and cirrhosis of the liver, and

several cancersseveral cancers

Rehm J Addiction. 2003;98(9):1209-1228.Rehm J Addiction. 2003;98(9):1209-1228.NIAAA (2004) Helping Patients With Alcohol Problems. DHHS, Wash., DC.NIAAA (2004) Helping Patients With Alcohol Problems. DHHS, Wash., DC.

Hazardous Drinking

Defined as AUDIT scores: 8+ Defined as AUDIT scores: 8+ (Babor et al., 2001)(Babor et al., 2001)

Sample Patient:Sample Patient:drank 2 – 3 times a week (3 points)drank 2 – 3 times a week (3 points)drank drank 2 drinks/day typically (1 point) 2 drinks/day typically (1 point)had had 6 drinks on one occasion at least monthly (2 points) 6 drinks on one occasion at least monthly (2 points) ““had a relative or friend, a doctor or other health worker” say had a relative or friend, a doctor or other health worker” say that they have “been concerned about your drinking or that they have “been concerned about your drinking or suggested you cut down” in past year (4 points)suggested you cut down” in past year (4 points)

Total score = 10.Total score = 10.

Mertens, JR et al., Alc Clin Exp Res. 2005;29(6):989-998Mertens, JR et al., Alc Clin Exp Res. 2005;29(6):989-998

Impact of Hazardous Drinking

1,419 HMO primary care clinic patients, 13.9 K 1,419 HMO primary care clinic patients, 13.9 K comparison group; AUDIT screencomparison group; AUDIT screen

Hazardous drinking prevalence of 7.5%Hazardous drinking prevalence of 7.5%

Alcohol abuse prevalence was only 0.38% Alcohol abuse prevalence was only 0.38%

↑↑prevalences of 8 medical conditions:prevalences of 8 medical conditions:Pneumonia, COPD Pneumonia, COPD

Costly conditions such as injury and hypertensionCostly conditions such as injury and hypertension

Depression, anxiety disorders, and major psychoses Depression, anxiety disorders, and major psychoses

Mertens, JR et al., Alc Clin Exp Res. 2005;29(6):989-998Mertens, JR et al., Alc Clin Exp Res. 2005;29(6):989-998

Systematic Review Findings: Alcohol and Hypertension

11 randomized controlled trials11 randomized controlled trials

Dose related effectsDose related effects< 2 drinks/day or 10/week< 2 drinks/day or 10/week – usually decreases – usually decreases> 3 drinks/day or 14/week> 3 drinks/day or 14/week – – significant increasesignificant increase

Magnitude of effect about the same as salt Magnitude of effect about the same as salt intakeintake

Effect of alcohol greatest in subjects with Effect of alcohol greatest in subjects with pre-existing hypertensionpre-existing hypertension

McFadden et al. Am J Hypertension. In press. Slide courtesy A.T. McLellan, PhD

Systematic Review Findings: Alcohol and Diabetes

32 studies32 studies

U-shaped association U-shaped association

Moderate alcohol (1-3 drinks/ day) Moderate alcohol (1-3 drinks/ day)

33-56% lower incidence of diabetes33-56% lower incidence of diabetes

34-55% lower incidence of diabetes-related coronary 34-55% lower incidence of diabetes-related coronary heart diseaseheart disease

Heavy alcohol (>3 drinks/day): up to 43% Heavy alcohol (>3 drinks/day): up to 43% increased risk of diabetesincreased risk of diabetes

Howard, A.A. et al. Ann Int. Med. 2004;140:211-219

Interventions for Heavy Drinkers

Screening as a Brief Intervention

In various medical settings, brief interventions In various medical settings, brief interventions are recommended for patients who misuse are recommended for patients who misuse alcohol and are at risk for dependence, but who alcohol and are at risk for dependence, but who are not alcohol dependent.are not alcohol dependent.

These interventions typically:These interventions typically:Involve four or fewer sessionsInvolve four or fewer sessions

Are not conducted in a specialized alcoholism Are not conducted in a specialized alcoholism treatment facility, andtreatment facility, and

Are performed by health care providers and others Are performed by health care providers and others who are not specialized in addiction treatment.who are not specialized in addiction treatment.

Impact of Brief Physician Advice for Heavy Drinkers

TrEAT study (Trial for Early Alcohol Treatment)TrEAT study (Trial for Early Alcohol Treatment)

RCT N=723 subjects, 12 and 48-month follow-up, 64 RCT N=723 subjects, 12 and 48-month follow-up, 64 MDs in 17 primary care offices MDs in 17 primary care offices

Two 10-15’ physician-delivered, counseling visitsTwo 10-15’ physician-delivered, counseling visitsReview drinking norms, patient-specific effects,Review drinking norms, patient-specific effects,Worksheet on drinking cues, diary cardsWorksheet on drinking cues, diary cardsDrinking agreement as a prescriptionDrinking agreement as a prescription

Fleming MF, et al. Alcohol Clin Exp Res. 2002(Jan);26(1):36-43Fleming MF, et al. Alcohol Clin Exp Res. 2002(Jan);26(1):36-43

Impact of Brief Physician Advice for Problem Drinkers

2 nurse follow-up calls2 nurse follow-up calls

Measures: Measures: Alcohol use, Alcohol use, ER visits and ER visits and Hospital daysHospital days



*p<0.001

17.8*47.532.548.1% excessive use ETOH 7 d

3.1*5.74.25.3# binges 30 d

11.5*19.115.518.9# drinks 7 d

12-month 12-month InterventionIntervention

BaselineBaseline InterventionIntervention

12-month 12-month ControlControl

Baseline Baseline ControlControl

Fewer hospitalization days in Exp group, χFewer hospitalization days in Exp group, χ22(P < 0.01)(P < 0.01)

Fleming MF, et al. JAMA 1997;277:1039-1045Fleming MF, et al. JAMA 1997;277:1039-1045


Significant reductionsSignificant reductions7-day alcohol use7-day alcohol useNumber of binge episodesNumber of binge episodesFrequency of excessive drinkingFrequency of excessive drinking

Effects by 6 months, sustained at 48 monthsEffects by 6 months, sustained at 48 months

Fewer hospital days and ER visitsFewer hospital days and ER visits

For every $10K invested in early intervention, $43K future health cost For every $10K invested in early intervention, $43K future health cost reduction (without including MVA and crime costs)reduction (without including MVA and crime costs)


Targeting Heavy Drinking

Psychosocial interventions that reduce alcohol Psychosocial interventions that reduce alcohol intake have important clinical effectsintake have important clinical effects

Why not use medications that might accomplish Why not use medications that might accomplish the same?the same?

Proxy diagnosis “hazardous or heavy drinkers” versus Proxy diagnosis “hazardous or heavy drinkers” versus categorical onecategorical oneDrinkers without diagnoses might not want to be Drinkers without diagnoses might not want to be abstinentabstinentLarge potential social utilityLarge potential social utilityNaltrexone’s main effect is reduction in heavy drinkingNaltrexone’s main effect is reduction in heavy drinking

MotivationaI Interviewing

Definition: Motivational Interviewing is Definition: Motivational Interviewing is a client-centered, directive method a client-centered, directive method

for enhancing intrinsic motivation to change for enhancing intrinsic motivation to change

by exploring and resolving ambivalence, by exploring and resolving ambivalence,

typically in a particular direction of change.typically in a particular direction of change.

Miller R, Rollnick S. Motivational Interviewing: Preparing People for Change, New York: Guilford, 2002

PrecontemplationPrecontemplation

ContemplationContemplation

PreparationPreparation

ActionAction

MaintenanceMaintenance

Stages of Change Model

Prochaska, J.O.; DiClemente, C.C. & Norcross, J.C. Am Psychol 47(9):1102-1114, 1992Prochaska, J.O.; DiClemente, C.C. & Norcross, J.C. Am Psychol 47(9):1102-1114, 1992.

Precontemplation- Overestimates costs of change Precontemplation- Overestimates costs of change and underestimates benefits. No intention to take and underestimates benefits. No intention to take action due to: action due to:

lack of informationlack of information not understanding consequences of not changingnot understanding consequences of not changing demoralization after repeated failuresdemoralization after repeated failures

No inherent motivation (e.g. crawling to walking) – No inherent motivation (e.g. crawling to walking) – progress due to events, differential processingprogress due to events, differential processing

Developmental, e.g., hitting 39Developmental, e.g., hitting 39thth birthday, taking stock birthday, taking stockEnvironmental: Beloved dog dies of lung cancerEnvironmental: Beloved dog dies of lung cancer

Heavy-smoking wife quits smokingHeavy-smoking wife quits smokingHeavy-smoking husband buys new dog!Heavy-smoking husband buys new dog!


Prochaska, J.O. in: Ries R. et al. Eds, Principles of Addiction Medicine, 4Prochaska, J.O. in: Ries R. et al. Eds, Principles of Addiction Medicine, 4 thth Ed. Ed. Lippincott, Williams & Wilkins, 2009, pp 745-755Lippincott, Williams & Wilkins, 2009, pp 745-755.

Contemplation– More aware of the benefits of Contemplation– More aware of the benefits of change, acutely aware of the costschange, acutely aware of the costs

Can present as profound ambivalenceCan present as profound ambivalenceClient can entertain the reality of a problemClient can entertain the reality of a problem

Preparation– Decisional balance has tipped in favor Preparation– Decisional balance has tipped in favor of change, which is being planned for in next 30 daysof change, which is being planned for in next 30 days

Plan of action: go to AA, talk to physician, buy a self-help Plan of action: go to AA, talk to physician, buy a self-help book, etc.book, etc.

Action– Client makes specific, overt changes in Action– Client makes specific, overt changes in lifestylelifestyle

Only modifications of behavior that results in reduction of Only modifications of behavior that results in reduction of disease risk is deemed effective actiondisease risk is deemed effective action

Maintenance– Working to prevent relapseMaintenance– Working to prevent relapse


Prochaska, J.O. in: Ries R. et al. Eds, Principles of Addiction Medicine, 4Prochaska, J.O. in: Ries R. et al. Eds, Principles of Addiction Medicine, 4 thth Ed. Ed. Lippincott, Williams & Wilkins, 2009, p 745-755Lippincott, Williams & Wilkins, 2009, p 745-755.

Clinical Impact: Change Model

PrecontemplationPrecontemplation

ContemplationContemplation

PreparationPreparation

ActionAction

MaintenanceMaintenance

slipsliprelapse +relapse +drop outdrop out

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Principles of Motivational Interviewing

MI differs from traditional counseling in that it is client-MI differs from traditional counseling in that it is client-centered:centered:

Collaborates rather than confrontsCollaborates rather than confrontsEvocates rather than educatesEvocates rather than educatesRespects autonomy rather than imposing authorityRespects autonomy rather than imposing authorityNot focused on:Not focused on:

teaching new coping skillsteaching new coping skills reshaping cognitionsreshaping cognitions exploring the pastexploring the past

A way of being with rather than to do something toA way of being with rather than to do something toElicits intrinsic motivation rather than using extrinsic ones Elicits intrinsic motivation rather than using extrinsic ones (coercion such as legal sanction, punishment, social pressure, or (coercion such as legal sanction, punishment, social pressure, or reward such as financial gain). reward such as financial gain). Negative contingency frequently doesn’t work (as you well know). Negative contingency frequently doesn’t work (as you well know).

Miller R, Rollnick S. Motivational Interviewing: Preparing People for Change, New York: Guilford, 2002 Miller R, Rollnick S. Motivational Interviewing: Preparing People for Change, New York: Guilford, 2002

Clinical Assessment/Intervention

Integrate Motivational Interviewing into the Integrate Motivational Interviewing into the clinical assessment interview for treatment clinical assessment interview for treatment seeking clients: seeking clients:

understand the motives clients have for understand the motives clients have for addressing their substance use problems addressing their substance use problems

gather the clinical and administrative gather the clinical and administrative information needed to plan their care information needed to plan their care

build and strengthen their readiness for build and strengthen their readiness for changechange

Martino, S. et al. (2006) Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency. Salem, OR: Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University.http://www.motivationalinterview.org/library/MIA-STEP.pdf

Motivational Interviewing

Identifying substance-related losses important for Identifying substance-related losses important for motivating people with comorbid psychiatric motivating people with comorbid psychiatric disorders contemplating behavior change (Blume disorders contemplating behavior change (Blume & Marlatt, Addict Behav, 2000)& Marlatt, Addict Behav, 2000)

Pilot data: one-session preadmission 45-60’ Pilot data: one-session preadmission 45-60’ motivational interview more effective than motivational interview more effective than standard preadmission interview - partial hospital standard preadmission interview - partial hospital program. (Martino et al., Am J Addict, 2000)program. (Martino et al., Am J Addict, 2000)

High-Grade Evidence of MI Efficacy

http://www.motivationalinterview.org/library/index.htmlhttp://www.motivationalinterview.org/library/index.html

Dunn C, Deroo L, Rivara FP. The use of brief interventions Dunn C, Deroo L, Rivara FP. The use of brief interventions adapted from motivational interviewing across behavioral adapted from motivational interviewing across behavioral domains: a systematic review. Addiction 2001;96:1725–42.domains: a systematic review. Addiction 2001;96:1725–42.

Burke BL, Arkowitz H, Menchola M. The efficacy of motivational Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. J interviewing: a meta-analysis of controlled clinical trials. J Consult Clin Psychol 2003;71:843–61.Consult Clin Psychol 2003;71:843–61.

Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and metaanalysis. Br J Gen interviewing: a systematic review and metaanalysis. Br J Gen Pract 2005;55:305–12.Pract 2005;55:305–12.

Motivational Enhancement Therapy

View of the patient as self-directed and View of the patient as self-directed and responsible for and capable of changing his or responsible for and capable of changing his or her behavior.her behavior.

The clinician assists the patient in mobilizing his The clinician assists the patient in mobilizing his or her own inner resources.or her own inner resources.

MET allows the patient to determine treatment MET allows the patient to determine treatment goals and encourages movement from one goals and encourages movement from one motivational stage to the next.motivational stage to the next.

Motivational Enhancement Therapy (FRAMES)

FFeedbackeedback of personal impairment of personal impairment

Personal Personal RResponsibilityesponsibility for change for change

Clear Clear AAdvicedvice to change to change

AA MMenuenu of alternatives of alternatives

Therapist Therapist EEmpathympathy

Facilitate Facilitate SSelf-efficacyelf-efficacy or optimism or optimism

MI in a Broader Context

Addictive disordersAddictive disordersPathological gamblingPathological gamblingHeavy drinking college studentsHeavy drinking college students

Engagement and Adherence to treatment Engagement and Adherence to treatment PharmacotherapyPharmacotherapyDietary parameters (e.g. DM) Dietary parameters (e.g. DM)

Chronic disease managementChronic disease managementMental disordersMental disordersMedical disorders: Diabetes, HIV Medical disorders: Diabetes, HIV

Health promotionHealth promotionACOG committee opinionACOG committee opinionHIV and other STD risk reductionHIV and other STD risk reductionWeight lossWeight lossReducing alcohol use in pregnancyReducing alcohol use in pregnancy

ACOG Committee Opinion No. 423. Obstet Gynecol. 2009 Jan;113(1):243-6.ACOG Committee Opinion No. 423. Obstet Gynecol. 2009 Jan;113(1):243-6.

Relapse Pathways

3 major biological mechanisms associated 3 major biological mechanisms associated with relapse following extinction of drug-with relapse following extinction of drug-seeking behavior: seeking behavior:

Exposure to the drugExposure to the drug11 (reward/extinction)(reward/extinction)

Exposure to conditioned cues (ie, people, places, and Exposure to conditioned cues (ie, people, places, and things)things)22 (craving/dysphoria)(craving/dysphoria)

Exposure to nonspecific stressExposure to nonspecific stress3 3 (stress)(stress)

11Monti et al. Monti et al. Addiction.Addiction. 2000;95:S229. 2000;95:S229. 22McBride et al. McBride et al. Alcohol Clin Exp Res.Alcohol Clin Exp Res. 2002;26:280. 2002;26:280. 33Koob. Koob. Addiction.Addiction. 2000;95:S73. 2000;95:S73.

Benefits of Psychotherapies

Help patients to cope with 2 of 3 major factors in Help patients to cope with 2 of 3 major factors in relapse:relapse:

Reducing exposure to cues associated with use of Reducing exposure to cues associated with use of substances substances

Learning healthy pleasures – changing rewardsLearning healthy pleasures – changing rewardsAdopting refusal skillsAdopting refusal skillsAvoiding people, places and things associated with Avoiding people, places and things associated with substance usesubstance use

Reducing stressReducing stressDecreasing negative emotional statesDecreasing negative emotional statesIncreasing resilience to stressors through support, Increasing resilience to stressors through support, remoralization, self-efficacyremoralization, self-efficacy

Treatment Works

Baseline 12-month follow-up

0

20

40

60

80

Cognitive Cognitive Behavioral TherapyBehavioral Therapy

Motivational Motivational Enhancement TherapyEnhancement Therapy

12-Step12-StepFacilitationFacilitation

Reduction in Percentage of Drinking DaysReduction in Percentage of Drinking Days

Project Match Research Group. J Studies Alcohol 58:7-29, 1997

Cognitive Behavioral Therapy

CBT: help patients recognize, avoid, and CBT: help patients recognize, avoid, and cope. cope.

RECOGNIZE situations in which they are RECOGNIZE situations in which they are most likely to use,most likely to use,

AVOID these situations when AVOID these situations when appropriate, appropriate,

and COPE more effectively with a range and COPE more effectively with a range of problems and problematic behaviors of problems and problematic behaviors associated with substance abuseassociated with substance abuse

CBT Addresses Critical Tasks

Foster the motivation for abstinence. Foster the motivation for abstinence.

Decisional analysis which clarifies loss or Decisional analysis which clarifies loss or gain with continued use.gain with continued use.

Teach coping skills. Teach coping skills.

Recognize the high-risk situations in which Recognize the high-risk situations in which they are most likely to use they are most likely to use

Develop other, more effective means of Develop other, more effective means of coping with them. coping with them.

Rounsaville & Carroll, Ch 38., In: Lowinson, Ruiz, Millman, Langrod Rounsaville & Carroll, Ch 38., In: Lowinson, Ruiz, Millman, Langrod (Eds.) Substance Abuse A Comprehensive Textbook, 2nd Ed. 1992(Eds.) Substance Abuse A Comprehensive Textbook, 2nd Ed. 1992

CBT Critical Tasks (cont’d)

Change reinforcement contingencies. Drug use Change reinforcement contingencies. Drug use excludes other experiences and rewards.excludes other experiences and rewards.

Identify and reduce drug-associated habits by Identify and reduce drug-associated habits by substituting positive activities + rewards. (Healthy substituting positive activities + rewards. (Healthy pleasures)pleasures)

Foster management of painful affects. Foster management of painful affects. Techniques to recognize and cope with urges to Techniques to recognize and cope with urges to use; use; Model for learning to tolerate other strong affectsModel for learning to tolerate other strong affects

Rounsaville & Carroll, Ch 38., In: Lowinson, Ruiz, Millman, Langrod (Eds.) Rounsaville & Carroll, Ch 38., In: Lowinson, Ruiz, Millman, Langrod (Eds.) Substance Abuse A Comprehensive Textbook, 2nd Ed. 1992Substance Abuse A Comprehensive Textbook, 2nd Ed. 1992

CBT Critical Tasks (cont’d)

Improve interpersonal functioning and Improve interpersonal functioning and enhance social supports.enhance social supports.

Interpersonal skills training and strategies to help Interpersonal skills training and strategies to help patients expand their social support networks and patients expand their social support networks and build enduring, drug-free relationships.build enduring, drug-free relationships.

Cognitive skills interventions toCognitive skills interventions to aid aid recognition of behavioral problems rooted in recognition of behavioral problems rooted in distorted thought processesdistorted thought processes

Rationalizations to engage in criminal or addictive Rationalizations to engage in criminal or addictive behaviorsbehaviorsSelf–monitoring skills to identify maladaptive Self–monitoring skills to identify maladaptive thoughts and replace or restructure them thoughts and replace or restructure them

Peters RH et al. Substance Abuse: A Comprehensive Textbook, Ch 46, pg 707-722, 2005

Relapse Prevention: Specific Techniques

Assessing internal and external cues for craving Assessing internal and external cues for craving and usageand usageDefining relapses ("slips")Defining relapses ("slips")Discussing "seemingly irrelevant decisions" Discussing "seemingly irrelevant decisions" Itemizing the characteristics of relapseItemizing the characteristics of relapseExploring dreams involving drugsExploring dreams involving drugsDeveloping coping and relaxation skillsDeveloping coping and relaxation skillsEmploying drug-refusal exercisesEmploying drug-refusal exercisesManaging a slipManaging a slipUnderstanding the Abstinence Violation EffectUnderstanding the Abstinence Violation Effect

Cognitive Behavioral Therapy

The Evidence:Meta-analyses and extensive reviews of the literature have established that cognitive behavior approaches have strong empirical support for use in treatment of AUD

Miller WR, Wilbourne PL. Addiction 2002; 97:265–277

Behavioral Couples Therapy

Couple enters into a contract stipulating Couple enters into a contract stipulating that:that:

The partner observes and records on a calendar the The partner observes and records on a calendar the patient taking the daily medication (disulfiram) dose, patient taking the daily medication (disulfiram) dose,

The patient and partner then thank each other for The patient and partner then thank each other for their effortstheir efforts

Refrain from arguments or discussions about the Refrain from arguments or discussions about the patient’s drinking behavior (O’Farrell and Bayog, patient’s drinking behavior (O’Farrell and Bayog, 1986).1986).

Behavioral Couples Therapy

Meta-analysis of BCT studies demonstrate its superiority Meta-analysis of BCT studies demonstrate its superiority over individual interventions for alcohol and drug abuse over individual interventions for alcohol and drug abuse at treatment follow-up on: at treatment follow-up on:

frequency of use, frequency of use, consequences of use and consequences of use and relationship satisfaction (Powers et al., 2008)relationship satisfaction (Powers et al., 2008)

Effects of BCT tend to fade over time as domestic Effects of BCT tend to fade over time as domestic partners tend to regress back towards dysfunctional partners tend to regress back towards dysfunctional relating relating Booster relapse prevention sessions provided to couples Booster relapse prevention sessions provided to couples after the main treatment had ended supported the after the main treatment had ended supported the maintenance of treatment gains (O’Farrell et al., 1993).maintenance of treatment gains (O’Farrell et al., 1993).

RecoveryRecovery

The Big BookThe Big BookSubtitle: The Story of How Many Thousands of Men Subtitle: The Story of How Many Thousands of Men and Women Have Recovered From Alcoholismand Women Have Recovered From AlcoholismForeward to 1Foreward to 1stst Ed.: To show other alcoholics Ed.: To show other alcoholics precisely how we have recovered is the main precisely how we have recovered is the main purpose of this book.purpose of this book. Personal Stories: How Forty-Two AlcoholicsPersonal Stories: How Forty-Two AlcoholicsRecovered From Their Malady Recovered From Their Malady

Alcoholics Anonymous World Services, Inc.; 4 edition (February 10, 2002)

Common Factors: Recovery Mutual Aid

Recovery societies strategies:Recovery societies strategies:Public confessionPublic confessionPublic commitment to abstinencePublic commitment to abstinenceSober fellowship through experience-sharing meetingsSober fellowship through experience-sharing meetingsDiscovery of resources within/beyond self Discovery of resources within/beyond self Reconstruction of personal values, identity, Reconstruction of personal values, identity, relationshipsrelationshipsService to others as self-healing mechanismService to others as self-healing mechanism

Unclear if it’s reform, redemption, recovery, Unclear if it’s reform, redemption, recovery, reconstruction, maturation or transformationreconstruction, maturation or transformationTime element matches chronic illness model: Time element matches chronic illness model: always recovering (never “recovered”)always recovering (never “recovered”)

White W. Substance Use & Misuse 43:1987-2000, 2008

Alcoholics Anonymous

May be only treatment available in some May be only treatment available in some correctional settingscorrectional settings

Is synergistic with clinical approaches, best Is synergistic with clinical approaches, best when offender is initially in a controlled when offender is initially in a controlled environment, since it is an abstinence environment, since it is an abstinence modelmodel

Time Abstinent Makes a Difference

Kirschenbaum et al., Journal of Substance Abuse Treatment 36:8–17, 2009

The hazard functions for the log-logistic distribution for alcohol (left) and nicotine (right) studies.The hazard functions for the log-logistic distribution for alcohol (left) and nicotine (right) studies.

Days Days

Twelve Step Facilitation

Developed by Nowinski, Baker & Carroll (1992) for NIAAA’s Project MATCH as an approach which was:Manual guided, delivered on an Individual basisSharply contrasts with CBT and Motivational InterviewingAscribes to the AA/NA philosophy that relies heavily on a combination of spirituality and pragmatism, and advocates peer support as the primary means for achieving sustained sobriety Approximated frequently used counseling methods that invoked 12 Step recoverySought to facilitate meaningful involvement in self help groups


Intended to be implemented on an individual basis in 12 to 15 sessions and is based in behavioral, spiritual, and cognitive principles that form the core of 12-step fellowships such as Alcoholics Anonymous (AA)

Based on principles of Alcoholics AnonymousTreatment goal is abstinenceEmphasis on first 3 Steps and fostering involvement in AACore topics include the assessment plus acceptance, surrender, and getting active; also elective sessionsNot equivalent to AA, NA referralNot equivalent to ‘treatment as usual’

Has been adapted to a group format


TSF does appear to facilitate self-help attendance/involvementTSF’s effectiveness appears to apply to a range of addiction problems, including methadone maintenanceIS NOT equivalent to ‘treatment as usual’Seasoned clinicians can learn and use TSFTSF has shown to substantially increase the likelihood that patients will become engaged with these AA resources.

Why Use Medications?

Addiction is a chronic disease requiring Addiction is a chronic disease requiring long-term treatment, not different from long-term treatment, not different from hypertension or diabeteshypertension or diabetes

These illnesses also have psychosocial These illnesses also have psychosocial interventions that improve outcomesinterventions that improve outcomes

Medication for addiction works best in the Medication for addiction works best in the context of psychosocial treatmentcontext of psychosocial treatment

Effect sizes for no one treatment is largeEffect sizes for no one treatment is large

Why Use Medications?

There are no “slam dunk” medications anymore There are no “slam dunk” medications anymore than there are “slam dunk” psychosocial than there are “slam dunk” psychosocial interventionsinterventions

Getting the ball through the hoop is a team effort!Getting the ball through the hoop is a team effort!

Therefore, combinations of medical and Therefore, combinations of medical and psychosocial treatment optimizes outcomespsychosocial treatment optimizes outcomes

Facility Services Offered – NSSATS 2003

Total Total PrivatePrivatenon-non-

profit profit

PrivatePrivatefor-profit for-profit

Local/Local/

StateStategov’t gov’t

FederalFederalgov’t* gov’t*

Number of Number of ProgramsPrograms

13,623 13,623 8,258 8,258 3,403 3,403 1454 1454 339 339

Percentage of Percentage of ProgramsPrograms

100%100% 61%61% 25%25% 11%11% 2%2%

MedicationsMedications

(% of Type)(% of Type)

2,739 2,739

20%20%

1,3381,338

16%16%

768768

23%23%

376376

22%22%

229229

68% 68%

Antabuse Antabuse


2,268 2,268

17%17%

1,0841,084

13%13%

602602

18%18%

343 343

24%24%

213 213

63%63%

NaltrexoneNaltrexone


1,6561,656

12%12%

835835

10% 10%

455455

13%13%

185185

13%13%

169169

50%50%

*Serves veterans, military personnel, inmates, or Native Americans.

Adherence

Treatments don’t make you better if you don’t Treatments don’t make you better if you don’t take them.take them.

Be aware of factors that reduce adherence, such Be aware of factors that reduce adherence, such as as

denial of illness or its chronicity, denial of illness or its chronicity, complex dosing schedules, complex dosing schedules, side effects, side effects, poor social support, and poor social support, and depression or amotivation (DiMatteo, 2004; DiMatteo depression or amotivation (DiMatteo, 2004; DiMatteo et al, 2000; Perkins, 2002) et al, 2000; Perkins, 2002)

Addiction Treatment Works

Hospitalizations for:Hospitalizations for: Physical healthPhysical health 36%36%Drug overdoseDrug overdose 58%58%Mental healthMental health 44%44%

Number of:Number of: Hospital daysHospital days 25%25%ER visitsER visits 38%38%Doctor visitsDoctor visits 14%14%Mental healthMental health 3%3%

Gerstein, Harwood, Fountain et al. CALDATA, 1994 (http://www.adp.state.ca.us)

Reductions in Healthcare Services UtilizationReductions in Healthcare Services Utilization

Underlying Concepts of ASAM PPC

Biopsychosocial Perspective of Addiction

Biopsychosocial in etiology, expression, Tx.

Comprehensive assessment and treatment

Explains clinical diversity with commonalities

Promotes integration of knowledge

Determine Level of Care

1.1. Acute Intoxication and/or Withdrawal Acute Intoxication and/or Withdrawal PotentialPotential

2.2. Biomedical Conditions and ComplicationsBiomedical Conditions and Complications

3.3. Emotional, Behavioral, or Cognitive Emotional, Behavioral, or Cognitive Conditions and ComplicationsConditions and Complications

4.4. Readiness to ChangeReadiness to Change

5.5. Relapse, Continued Use, or Continued Relapse, Continued Use, or Continued Problem PotentialProblem Potential

6.6. Recovery/Living EnvironmentRecovery/Living Environment

ASAM PPC-2R Dimensions

Treatment Levels of Service

I Outpatient Treatment

II Intensive Outpatient and Partial Hospitalization

III Residential/Inpatient Treatment

IV Medically-Managed Intensive Inpatient Treatment

Mandated Treatment

Coerced or involuntary treatment comprises an Coerced or involuntary treatment comprises an integral, often positive component of treatment integral, often positive component of treatment for addictive disorders, but raises numerous for addictive disorders, but raises numerous ethical, clinical, legal, political, cultural, and ethical, clinical, legal, political, cultural, and philosophical issues. philosophical issues. Health care professionals should appreciate the Health care professionals should appreciate the indications, methods, advantages, and indications, methods, advantages, and associated liabilities. associated liabilities. Addiction Committee of the Group for the Addiction Committee of the Group for the Advancement of Psychiatry they searched the Advancement of Psychiatry they searched the literature using Pubmed from 1985 to 2005 literature using Pubmed from 1985 to 2005

Sullivan M et al., The American Journal on Addictions, 17: 36–47, 2008Sullivan M et al., The American Journal on Addictions, 17: 36–47, 2008

Mandated Treatment

Intensive outpatient treatment has shown In Intensive outpatient treatment has shown In therapy-resistant chronic alcoholics that therapy-resistant chronic alcoholics that monitored ingestion of disulfiram, as well as monitored ingestion of disulfiram, as well as regular urine analysis for alcohol, yielded an regular urine analysis for alcohol, yielded an abstinence rate of 60% at 6–26 months.abstinence rate of 60% at 6–26 months.In comparing methods of referral, groups with In comparing methods of referral, groups with coerced referral to outpatient addiction treatment coerced referral to outpatient addiction treatment were more likely to complete treatment than were more likely to complete treatment than those in the non-coercive referral groups.those in the non-coercive referral groups.Coercive techniques can be effective and may Coercive techniques can be effective and may be warranted in some circumstances: e.g. be warranted in some circumstances: e.g. monitoring. monitoring.

Ehrenreich H, et al. Ehrenreich H, et al. Eur Arch Psychiatry Clin Neurosci. Eur Arch Psychiatry Clin Neurosci. 1997;247:51–54.1997;247:51–54.Loneck B, et al. Loneck B, et al. Am J Drug Alcohol Abuse. Am J Drug Alcohol Abuse. 1996;22:233–246.1996;22:233–246.

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