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PHP 1540: Alcohol Use & Misuse Introduction to Treatment Mismatch between Need & Treatment in the USA (see Hasin et al. 2007): 8.5% of the US population (~25 million) currently have an AUD Minority of people who need treatment get it at any given time 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 ? Stigma about being labeled “alcoholic” Desire to handle problems on one’s own Concerns about privacy Beliefs that problems are not serious enough to warrant intensive treatment Lack of access ($, work, childcare, programs) Acceptability of abstinence goal Recovery Spectrum 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: Specific components Outcome goals Level of intensity-severity of problem Inpatient vs outpatient length What treatments don’t work: (Miller & Wilbourne, 2002) Treatment methods with no support from outcome studies Educational lectures/films General alcoholism counseling Confrontational therapies Psychotherapy Hypnosis What treatments work? (Miller & Wilbourne, 2002) Treatment methods with strong support from many well-designed outcome studies Brief interventions Motivational enhancement Medications: Acamprosate, Naltrexone Community Reinforcement approach Social skills training Behavioral marital therapy Cognitive-behavioral therapies Treatment goals: Zero-tolerance, i.e. abstinence only Moderate drinking Reduction of quantity consumed so that one avoids alcohol-related problems Harm reduction 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??? 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 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 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 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 Feedback about risk Responsibility lies with patient Advice to change Menu of ways to reduce drinking Empathetic counseling style Self-efficacy/optimism of patient