Download 20-Intro to treatment

PHP 1540: Alcohol Use & Misuse
Introduction to Treatment
Mismatch between Need & Treatment in
the USA (see Hasin et al. 2007):
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8.5% of the US population (~25 million)
currently have an AUD
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Minority of people who need treatment get it
at any given time
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12% of those with AUDs in last 12M
4% from 12-step
5% from health professionals
24% of those with lifetime AUDs ever receive
any type of treatment
Why do problem drinkers not go to
treatment ?
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Stigma about being labeled “alcoholic”
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Desire to handle problems on one’s own
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Concerns about privacy
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Beliefs that problems are not serious enough to
warrant intensive treatment
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Lack of access ($, work, childcare, programs)
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Acceptability of abstinence goal
Recovery Spectrum
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Lower thresholds
Varied intensity
Include self-help, mutual help groups,
screening and brief interventions,
outpatient programs, detox, inpatient
rehab
Facilitate entry in and out of treatment
Structurally, treatments vary on
several dimensions:
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Specific components
Outcome goals
Level of intensity-severity of problem
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Inpatient vs outpatient
length
What treatments don’t work:
(Miller & Wilbourne, 2002)
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Treatment methods with no support from outcome
studies
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Educational lectures/films
General alcoholism counseling
Confrontational therapies
Psychotherapy
Hypnosis
What treatments work?
(Miller & Wilbourne, 2002)
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Treatment methods with strong support from many
well-designed outcome studies
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Brief interventions
Motivational enhancement
Medications: Acamprosate, Naltrexone
Community Reinforcement approach
Social skills training
Behavioral marital therapy
Cognitive-behavioral therapies
Treatment goals:
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Zero-tolerance, i.e. abstinence only
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Moderate drinking
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Reduction of quantity consumed so that one avoids
alcohol-related problems
Harm reduction
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Harm reduction refers to policies, programs and
practices that aim to reduce the harms associated with
the use of psychoactive drugs in people unable or
unwilling to stop
Is controlled drinking a viable
treatment goal???
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Sanchez-Craig et al. (1984) : abstinence vs controlled
drinking goals
 Outcomes were similar
 Some assigned abstinence developed controlled
drinking
 Some assigned controlled drinking became abstinent
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People like choice: if abstinence is not acceptable, then
a trial of controlled drinking may engage a person in
change
Who are good candidates for:
Controlled drinking
 Younger
 Fewer dependence
symptoms
 Fewer alcoholrelated problems
 Female
 Older age of onset
 FHN
Abstinence
 Older
 More dependence
symptoms
 More lifetime alcohol
problems
 Comorbid mental
disorders
 FHP
Stepped Care Model
(Sobell & Sobell, 2000)
SBIRT Model
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Screening
Brief Intervention
Referral to Treatment
http://www.integration.samhsa.gov/clinical-practice/sbirt
AUDIT
questionnaire
whqlibdoc.who.int/hq/2001/W
HO_MSD_MSB_01.6a.pdf
whqlibdoc.who.int/hq/2001/wh
o_msd_msb_01.6b.pdf
0 – 7 low risk
> 8 hazardous drinking
>15 harmful drinking
> 20 likely dependence
brief treatment
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Outside of alcohol or drug agency settings
Goal: reduce harmful use
Typically one or two 15-30 min. sessions
Suited for low-moderate risk drinkers
Usually combination of motivational
enhancement and skills training approaches
http://pubs.niaaa.nih.gov/publications/
Practitioner/CliniciansGuide2005/guide
.pdf
key elements of
effective brief treatments
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Feedback about risk
Responsibility lies with patient
Advice to change
Menu of ways to reduce drinking
Empathetic counseling style
Self-efficacy/optimism of patient