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Treatment: Options and Effectiveness
National Partnership On Alcohol
Misuse and Crime Meeting on
Treatment, Washington, DC
Richard N Rosenthal, MD
Professor of Clinical Psychiatry
Columbia University College of Physicians & Surgeons
Chairman, Dept of Psychiatry
St. Luke’s-Roosevelt Hospital Center, NY
June 2, 2009
Disclosure
RESEARCH GRANT SUPPORT:
2006 - 2008 Forest Laboratories, Inc.
Principal Investigator
2007 - 2008 Titan Pharmaceuticals, Inc.
Principal Investigator
2007 - 2012 National Institute on Drug Abuse Co-Investigator
2008 - 2010 The National Institute of Diabetes, Co-Investigator
Digestive and Kidney Disease
AFFILIATIONS:
2008 Sequest Technologies, Lisle, IL.
Advisory Board
Overview
Who needs Treatment?
What is the Treatment Process?
How does it begin?
Who is involved?
Importance of Screening and Assessment
Consideration of Prior Convictions
Pre-treatment
Brief Interventions/Motivational Interviewing
Overview
Treatment Options and Effectiveness
Counseling Models and Outcome Differences
Motivational Enhancement Therapy
Cognitive Behavioral Therapy
Patient Placement Criteria: settings and levels of
care
Role of Detoxification
Role of residential rehabilitation/halfway house
Voluntary vs. Mandatory Treatment
Treatment Vs. Education
Role of 12-Step and Support Group
Who Needs Treatment?
Heavy/at Risk drinkers
Medical Impact even without a “diagnosis”
Diagnosis of Alcohol Abuse - where
symptoms increase likelihood of further
sanctions due to impaired judgment/control
DUI, assault, loss of external social supports,
missed appointments
Diagnosis of Alcohol Dependence
Impairment, disability
The Scope of Alcohol Problems
in the Criminal Justice System
21.6 percent of victims of violent crimes thought or knew the offender
had consumed alcohol; another 1.5 percent of the victims thought
the offender had used either alcohol or another drug (Bureau of
Justice Statistics 2003).
40 percent of offenders on probation, in State prisons, or in local jails
reported using alcohol at the time of their offense (Bureau of
Statistics 1998).
18 percent of Federal prison inmates and about 25 percent of State
prison inmates reported having experienced problems consistent
with a history of alcohol abuse and dependence (Knight et al. 2002).
29 percent of Federal and 40 percent of State prisoners reported a
previous domestic violence dispute involving alcohol (Knight et al.
2002).
There were 1.4 million DWI arrests in 2001, making DWI the number
one crime, besides drug possession, for which Americans are
arrested (NHTSA 2003).
About two-thirds of convicted DWI offenders are alcohol dependent
(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
5 years after first being referred to screening
following their DWI offense (Lapham et al. 2001):
85% of female and 91% of male DWI offenders had
met the criteria for alcohol abuse or dependence at
some time in their lives.
32% of female and 38% of male offenders had met
criteria for abuse of or dependence on another drug at
some time in their lives.
50% of women with an alcohol use disorder and 33%
of men with an AUD also had at least one psychiatric
disorder (not drug-related), most commonly
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:
Typically lack proper training in screening and
recognition
Miss diagnosis if presentation is not obvious, e.g.
“skid row bum” “Alcohol on Breath,” etc.
Are practical professionals, spend time on
“fixable problems”
Frequently believe alcohol dependence isn’t
treatable, leading to professional denial
Why Are Alcohol Use Disorders
Underdiagnosed ≈ 50% time?
Patients with AUD typically:
minimize or deny strongly problem use
deny physical and psychological problems could
be related to drinking
rationalize work and interpersonal problems as
cause of use, not result
Present with emotional complaints (anxiety, mood
disturbance) without linking them to alcohol use.
Significant others/family/friends in best position to
report problems with alcohol but not present at
screening or evaluation
Adapted from Waldinger RJ: Substance-Related Disorders and Eating Disorders, in Psychiatry for
Medical Students. 3rd Ed. American Psychiatric Press, Inc. Washington DC, 1997.
Screening in the Criminal Justice
System
In 2002, Criminal justice/DWI referrals accounted for 40%
of alcoholism treatment admissions to alone, and 34% of
admissions to alcohol and other drugs treatment
programs (SAMHSA 2004).
Court-ordered screening misses many people with AUD
and other disorders
In N=1,078 convicted offenders, later voluntary screening
reported proportionally more alcohol abuse or alcohol
dependence compared to the court-ordered initial
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
criminal justice system include:
No screening instruments are available that have
proven validity to assess both AOD use and the range
of mental health problems found in criminal justice
populations.
Lack of screening instruments validated specifically for
criminal justice offenders.
Most current screening instruments rely on self report.
Court-ordered screening is by definition coercive.
Screening and treatment programs have limited
financial resources; costs may be passed on to people
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 occur soon after the offender enters the system.
Offenders screened at various stages of the judicial
process, including at arrest or arraignment, at pretrial
investigation, during interactions with court staff, or as a
post-sentence action.
Screening and interventions with offenders who have
AUD will probably be more effective if initiated soon after
the offense, (laws are most likely to deter illegal behavior
(e.g., DWI) if perceived to result in swift, certain, and
severe sanctions (e.g., Morral et al. 2002).
National Commission on Correctional Health Care:
Comprehensive health assessment (including substance abuse
history) 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
symptoms, need for detox
Criminal history
Personality traits related to criminality
Mental health issues, including suicide potential, acute
symptoms, treatment history, psychiatric medications
Abuse and trauma history, as victim/perp
High-risk behaviors
Motivation for treatment
Education and literacy
Physical disabilities
Relationships with significant others, family, dependents
Physical health, acute conditions, infectious diseases
including STD’s, HIV/AIDS, TB, and hepatitis
Screening for AUD
Screening:
determines the likelihood of alcohol use disorder
establishes the need for an in-depth assessment.
Begin at the earliest point of clinical contact with the
offender and continue throughout treatment, if provided
Several screening tools can help determine the likelihood
of the presence of problem alcohol use.
CAGE 4-item self report , scores 0-4, 2+ answers flag high risk
MAST 21-item self report, scores > 6 probable alcohol
dependence
AUDIT 10 item self report, score > 8 in men, probable AUD
> 4 in woman, probable AUD
Screening for AUD
CAGE – 4 Items
< 1 minute to administer
≥ 2 “yes” answers = high risk for AUD
High sensitivity for AUD (60-95%)
No questions about frequency of use
No quantity of consumption questions
No frequency of heavy drinking questions
Because consequence-focused, won’t flag early
problem drinkers
Screening for AUD
MAST – 25 Items
≥ 7 Probable Alcohol Dependence
5-6 Borderline Alcoholism
≤ 4 No problem drinking
High Sensitivity for AUD (86-98%)
Questions elicit lifetime history rather than
current drinking behavior (Magruder-Habib et
al., 1991)
Screening for AUD
AUDIT – 10 Items, assesses over past year
WHO Collaborative effort
Multicultural (Babor & Grant, 1989)
Designed to screen earlier-level problems in primarycare settings
Sensitivity – 92%, Specificity – 93%
Three Domains: amount & frequency; alcohol
dependence; alcohol-induced problems
Cutoff score of 8 of 40 = probable AUD
Simple Screening for AUD
Ask the screening question about heavy drinking
days: How many times in the past year have you
had 5 or more drinks in a day? (for men)
4 or more drinks in a day? (for women)
One standard drink is equivalent to 12 ounces of
beer, 5 ounces of wine, or 1.5 ounces of 80-proof
spirits —
1 or more heavy drinking days, or
AUDIT score of ≥ 8 for men or ≥ 4 for women
If endorsed, then a clinical evaluation
Clinician’s Initial Evaluation
Document current and past use of alcohol and
each other substance separately – pattern?, who
with?
Log prior quit attempts & treatments
Medications: how used? how long ?
Psychosocial treatment?
Assess current motivation to quit (pros & cons;
quit date)
Assess triggers, withdrawal, and dependence
Assess social support
Total US
Population
Over 12 Years
(~237 M)
SAMHSA HOUSEHOLD
SURVEY, 2004
Current
Alcohol Users:
50.3% (~121 M people)
NESARC
Any AUD
17.6 M (8.46 %)
(NSDUH, 2005)
Binge
Drinkers: 22.8 %
(55 M)
Heavy
Drinkers:
6.9% (~16.7M)
Hazardous Drinking
A “standard drink” contains about 14 g
alcohol
At-Risk or Heavy Drinking is defined as:
Men: >14 drinks/week or >4 drinks/occasion
Women: >7 drinks/week or >3 drinks/ occasion
Hazardous alcohol consumption = 60-90 g
alcohol
Good predictor of alcohol-related problems
Negative Impact on chronic medical illness
Significant increased morbidity and mortality
McGinnis JM, Foege WH. JAMA. 1993; 270(18):2207–2212. NIAAA (2004) Helping
Patients With Alcohol Problems. DHHS, Wash., DC.
DSM -IV Substance Abuse
Substance use leading to clinically
significant impairment manifested by one
(or more):
Failure to fulfill major role obligations
Hazardous situations
Legal problems
Continued substance use despite having persistent
or recurrent social or interpersonal problems
Never met the criteria for substance
dependence
Addiction: Classical and
Contemporary Constructs
Classical (Peele 1985):
Craving
Increased tolerance
Physiologic withdrawal
Contemporary: Behavioral Dysregulation
Compulsive behavior despite negative
consequences, i.e., loss of control
Salience – primacy in a person’s life
Cognitive – dominates mental life
Behavioral – dominates activity
Functional Impairment
DSM -IV Substance Dependence
Three (or more) of the following over 12 Months:
Tolerance
Withdrawal
Larger amounts or over longer period than intended
Persistent desire or unsuccessful efforts to cut down
Much time spent in acquiring, using, or recovering from
effects
Abandonment/reduction of important social, work, or
recreational activities
Continued use despite knowledge of having an alcoholinduced or exacerbated physical or mental problem
Targeting Heavy Drinking
Proxy for Impairment
Impact of Heavy Drinking
Differences in NESARC diagnoses rates
and rates of binge and heavy drinking
2000 National Household Surveys on
Drug Abuse (NHSDA)
Highest rates binge, heavy drinking young
adults aged 21 to 25
Peak rate 65 % at age 21 (45 % binge
drinking, 17 % heavy drinking)
Binge and heavy alcohol use rates decrease
faster with age than rates of past month
alcohol use
http://www.samhsa.gov/oas/2k2/alcNS/alcNS.htm
Impact of Heavy Drinking
About 25% have alcohol dependence
Increased risk:
gastrointestinal bleeding,
sleep disorders,
major depression,
hemorrhagic stroke,
cirrhosis of the liver, and
several cancers
Rehm J Addiction. 2003;98(9):1209-1228.
NIAAA (2004) Helping Patients With Alcohol Problems. DHHS, Wash., DC.
Hazardous Drinking
Defined as AUDIT scores: 8+
Sample Patient:
(Babor et al., 2001)
drank 2 – 3 times a week (3 points)
drank  2 drinks/day typically (1 point)
had  6 drinks on one occasion at least monthly (2 points)
“had a relative or friend, a doctor or other health worker” say
that they have “been concerned about your drinking or
suggested you cut down” in past year (4 points)
Total score = 10.
Mertens, 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
comparison group; AUDIT screen
Hazardous drinking prevalence of 7.5%
Alcohol abuse prevalence was only 0.38%
↑prevalences of 8 medical conditions:
Pneumonia, COPD
Costly conditions such as injury and hypertension
Depression, anxiety disorders, and major psychoses
Mertens, JR et al., Alc Clin Exp Res. 2005;29(6):989-998
Systematic Review Findings: Alcohol
and Hypertension
11 randomized controlled trials
Dose related effects
< 2 drinks/day or 10/week – usually decreases
> 3 drinks/day or 14/week – significant increase
Magnitude of effect about the same as salt
intake
Effect of alcohol greatest in subjects with
pre-existing hypertension
McFadden et al. Am J Hypertension. In press. Slide courtesy A.T. McLellan, PhD
Systematic Review Findings:
Alcohol and Diabetes
32 studies
U-shaped association
Moderate alcohol (1-3 drinks/ day)
33-56% lower incidence of diabetes
34-55% lower incidence of diabetes-related
coronary heart disease
Heavy alcohol (>3 drinks/day): up to 43%
increased 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
are recommended for patients who misuse
alcohol and are at risk for dependence, but who
are not alcohol dependent.
These interventions typically:
Involve four or fewer sessions
Are not conducted in a specialized alcoholism
treatment facility, and
Are performed by health care providers and others
who are not specialized in addiction treatment.
Impact of Brief Physician Advice
for Heavy Drinkers
TrEAT study (Trial for Early Alcohol Treatment)
RCT N=723 subjects, 12 and 48-month followup, 64 MDs in 17 primary care offices
Two 10-15’ physician-delivered, counseling
visits
Review drinking norms, patient-specific effects,
Worksheet on drinking cues, diary cards
Drinking agreement as a prescription
Fleming 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 calls
Measures:
Alcohol use,
ER visits and
Hospital days
Fleming MF, et al. Alcohol Clin Exp Res. 2002(Jan);26(1):36-43
Impact of Brief Physician Advice
for Problem Drinkers
Baseline 12-month
Control
Control
Baseline
Intervention
12-month
Intervention
# drinks 7 d
18.9
15.5
19.1
11.5*
# binges 30 d
5.3
4.2
5.7
3.1*
48.1
32.5
47.5
17.8*
% excessive
use ETOH 7 d
*p<0.001
Fewer hospitalization days in Exp group, χ2(P < 0.01)
Fleming MF, et al. JAMA 1997;277:1039-1045
Impact of Brief Physician Advice
for Problem Drinkers
Significant reductions
7-day alcohol use
Number of binge episodes
Frequency of excessive drinking
Effects by 6 months, sustained at 48 months
Fewer hospital days and ER visits
For every $10K invested in early intervention,
$43K future health cost reduction (without
including MVA and crime costs)
Fleming MF, et al. Alcohol Clin Exp Res. 2002(Jan);26(1):36-43
Targeting Heavy Drinking
Psychosocial interventions that reduce alcohol
intake have important clinical effects
Why not use medications that might accomplish
the same?
Proxy diagnosis “hazardous or heavy drinkers” versus
categorical one
Drinkers without diagnoses might not want to be
abstinent
Large potential social utility
Naltrexone’s main effect is reduction in heavy drinking
MotivationaI Interviewing
Definition: Motivational Interviewing is
a client-centered, directive method
for enhancing intrinsic motivation to change
by exploring and resolving ambivalence,
typically in a particular direction of change.
Miller R, Rollnick S. Motivational Interviewing: Preparing People for Change, New York: Guilford, 2002
Stages of Change Model
Precontemplation
Contemplation
Preparation
Action
Maintenance
Prochaska, J.O.; DiClemente, C.C. & Norcross, J.C. Am Psychol 47(9):1102-1114, 1992.
Stages of Change Model
Precontemplation- Overestimates costs of change
and underestimates benefits. No intention to take
action due to:
lack of information
not understanding consequences of not changing
demoralization after repeated failures
No inherent motivation (e.g. crawling to walking) –
progress due to events, differential processing
Developmental, e.g., hitting 39th birthday, taking stock
Environmental: Beloved dog dies of lung cancer
Heavy-smoking wife quits smoking
Heavy-smoking husband buys new dog!
Prochaska, J.O. in: Ries R. et al. Eds, Principles of Addiction Medicine, 4th Ed.
Lippincott, Williams & Wilkins, 2009, pp 745-755.
Stages of Change Model
Contemplation– More aware of the benefits of
change, acutely aware of the costs
Can present as profound ambivalence
Client can entertain the reality of a problem
Preparation– Decisional balance has tipped in favor
of change, which is being planned for in next 30 days
Plan of action: go to AA, talk to physician, buy a self-help
book, etc.
Action– Client makes specific, overt changes in
lifestyle
Only modifications of behavior that results in reduction of
disease risk is deemed effective action
Maintenance– Working to prevent relapse
Prochaska, J.O. in: Ries R. et al. Eds, Principles of Addiction Medicine, 4th Ed.
Lippincott, Williams & Wilkins, 2009, p 745-755.
Clinical Impact: Change Model
Maintenance
Precontemplation
slip
relapse +
drop out
relapse
Contemplation
Action
Preparation
Principles of Motivational
Interviewing
MI differs from traditional counseling in that it is clientcentered:
Collaborates rather than confronts
Evocates rather than educates
Respects autonomy rather than imposing authority
Not focused on:
teaching new coping skills
reshaping cognitions
exploring the past
A way of being with rather than to do something to
Elicits intrinsic motivation rather than using extrinsic ones
(coercion such as legal sanction, punishment, social pressure, or
reward such as financial gain).
Negative contingency frequently doesn’t work (as you well know).
Miller R, Rollnick S. Motivational Interviewing: Preparing People for Change, New York: Guilford, 2002
Clinical Assessment/Intervention
Integrate Motivational Interviewing into the
clinical assessment interview for treatment
seeking clients:
understand the motives clients have for
addressing their substance use problems
gather the clinical and administrative
information needed to plan their care
build and strengthen their readiness for
change
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
motivating people with comorbid psychiatric
disorders contemplating behavior change (Blume
& Marlatt, Addict Behav, 2000)

Pilot data: one-session preadmission 45-60’
motivational interview more effective than
standard preadmission interview - partial hospital
program. (Martino et al., Am J Addict, 2000)
High-Grade Evidence of MI Efficacy
http://www.motivationalinterview.org/library/index.html
Dunn C, Deroo L, Rivara FP. The use of brief interventions
adapted from motivational interviewing across behavioral
domains: a systematic review. Addiction 2001;96:1725–42.
Burke BL, Arkowitz H, Menchola M. The efficacy of motivational
interviewing: a meta-analysis of controlled clinical trials. J Consult
Clin Psychol 2003;71:843–61.
Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational
interviewing: a systematic review and metaanalysis. Br J Gen
Pract 2005;55:305–12.
Motivational Enhancement
Therapy
View of the patient as self-directed and
responsible for and capable of changing his or
her behavior.
The clinician assists the patient in mobilizing his
or her own inner resources.
MET allows the patient to determine treatment
goals and encourages movement from one
motivational stage to the next.
Motivational Enhancement Therapy
(FRAMES)
Feedback of personal impairment
Personal Responsibility for change
Clear Advice to change
A Menu of alternatives
Therapist Empathy
Facilitate Self-efficacy or optimism
MI in a Broader Context
Addictive disorders
Pathological gambling
Heavy drinking college students
Engagement and Adherence to treatment
Pharmacotherapy
Dietary parameters (e.g. DM)
Chronic disease management
Mental disorders
Medical disorders: Diabetes, HIV
Health promotion
ACOG committee opinion
HIV and other STD risk reduction
Weight loss
Reducing alcohol use in pregnancy
ACOG Committee Opinion No. 423. Obstet Gynecol. 2009 Jan;113(1):243-6.
Relapse Pathways
3 major biological mechanisms associated
with relapse following extinction of drugseeking behavior:
Exposure to the drug1 (reward/extinction)
Exposure to conditioned cues (ie, people, places, and
things)2 (craving/dysphoria)
Exposure to nonspecific stress3 (stress)
1Monti
et al. Addiction. 2000;95:S229.
2McBride et al. Alcohol Clin Exp Res. 2002;26:280.
3Koob. Addiction. 2000;95:S73.
Benefits of Psychotherapies
Help patients to cope with 2 of 3 major factors in
relapse:
Reducing exposure to cues associated with use of
substances
Learning healthy pleasures – changing rewards
Adopting refusal skills
Avoiding people, places and things associated with substance
use
Reducing stress
Decreasing negative emotional states
Increasing resilience to stressors through support,
remoralization, self-efficacy
Treatment Works
Reduction in Percentage of Drinking Days
Baseline
12-month follow-up
80
60
40
20
0
Cognitive
Motivational
Behavioral Therapy Enhancement Therapy
12-Step
Facilitation
Project Match Research Group. J Studies Alcohol 58:7-29, 1997
Cognitive Behavioral Therapy




CBT: help patients recognize, avoid,
and cope.
RECOGNIZE situations in which they
are most likely to use,
AVOID these situations when
appropriate,
and COPE more effectively with a range
of problems and problematic behaviors
associated with substance abuse
CBT Addresses Critical Tasks
Foster the motivation for abstinence.
Decisional analysis which clarifies loss or
gain with continued use.
Teach coping skills.
Recognize the high-risk situations in which
they are most likely to use
Develop other, more effective means of
coping with them.
Rounsaville & Carroll, Ch 38., In: Lowinson, Ruiz, Millman, Langrod
(Eds.) Substance Abuse A Comprehensive Textbook, 2nd Ed. 1992
CBT Critical Tasks (cont’d)
Change reinforcement contingencies. Drug
use excludes other experiences and rewards.
Identify and reduce drug-associated habits by
substituting positive activities + rewards.
(Healthy pleasures)
Foster management of painful affects.
Techniques to recognize and cope with urges
to use;
Model for learning to tolerate other strong
affects
Rounsaville & Carroll, Ch 38., In: Lowinson, Ruiz, Millman, Langrod (Eds.)
Substance Abuse A Comprehensive Textbook, 2nd Ed. 1992
CBT Critical Tasks (cont’d)
Improve interpersonal functioning and
enhance social supports.
Interpersonal skills training and strategies to help
patients expand their social support networks and
build enduring, drug-free relationships.
Cognitive skills interventions to aid
recognition of behavioral problems rooted in
distorted thought processes
Rationalizations to engage in criminal or addictive
behaviors
Self–monitoring skills to identify maladaptive
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
and usage
Defining relapses ("slips")
Discussing "seemingly irrelevant decisions"
Itemizing the characteristics of relapse
Exploring dreams involving drugs
Developing coping and relaxation skills
Employing drug-refusal exercises
Managing a slip
Understanding 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
that:
The partner observes and records on a calendar the
patient taking the daily medication (disulfiram) dose,
The patient and partner then thank each other for
their efforts
Refrain from arguments or discussions about the
patient’s drinking behavior (O’Farrell and Bayog,
1986).
Behavioral Couples Therapy
Meta-analysis of BCT studies demonstrate its superiority
over individual interventions for alcohol and drug abuse
at treatment follow-up on:
frequency of use,
consequences of use and
relationship satisfaction (Powers et al., 2008)
Effects of BCT tend to fade over time as domestic
partners tend to regress back towards dysfunctional
relating
Booster relapse prevention sessions provided to couples
after the main treatment had ended supported the
maintenance of treatment gains (O’Farrell et al., 1993).
Recovery
The Big Book
Subtitle: The Story of How Many Thousands of Men
and Women Have Recovered From Alcoholism
Foreward to 1st Ed.: To show other alcoholics
precisely how we have recovered is the main
purpose of this book.
Personal Stories: How Forty-Two Alcoholics
Recovered From Their Malady
Alcoholics Anonymous World Services, Inc.; 4 edition (February 10, 2002)
Common Factors:
Recovery Mutual Aid
Recovery societies strategies:
Public confession
Public commitment to abstinence
Sober fellowship through experience-sharing meetings
Discovery of resources within/beyond self
Reconstruction of personal values, identity,
relationships
Service to others as self-healing mechanism
Unclear if it’s reform, redemption, recovery,
reconstruction, maturation or transformation
Time element matches chronic illness model:
always recovering (never “recovered”)
White W. Substance Use & Misuse 43:1987-2000, 2008
Alcoholics Anonymous
May be only treatment available in some
correctional settings
Is synergistic with clinical approaches, best
when offender is initially in a controlled
environment, since it is an abstinence
model
Time Abstinent Makes a Difference
Days
Days
The hazard functions for the log-logistic distribution for alcohol (left) and nicotine (right) studies.
Kirschenbaum et al., Journal of Substance Abuse Treatment 36:8–17, 2009
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 basis
Sharply contrasts with CBT and Motivational Interviewing
Ascribes 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 recovery
Sought to facilitate meaningful involvement in self help
groups
Twelve Step Facilitation
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 Anonymous
Treatment goal is abstinence
Emphasis on first 3 Steps and fostering involvement in
AA
Core topics include the assessment plus acceptance,
surrender, and getting active; also elective sessions
Not equivalent to AA, NA referral
Not equivalent to ‘treatment as usual’
Has been adapted to a group format
Twelve Step Facilitation
TSF does appear to facilitate self-help
attendance/involvement
TSF’s effectiveness appears to apply to a range
of addiction problems, including methadone
maintenance
IS NOT equivalent to ‘treatment as usual’
Seasoned clinicians can learn and use TSF
TSF 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
long-term treatment, not different from
hypertension or diabetes
These illnesses also have psychosocial
interventions that improve outcomes
Medication for addiction works best in the
context of psychosocial treatment
Effect sizes for no one treatment is large
Why Use Medications?
There are no “slam dunk” medications anymore
than there are “slam dunk” psychosocial
interventions
Getting the ball through the hoop is a team effort!
Therefore, combinations of medical and
psychosocial treatment optimizes outcomes
Facility Services Offered – NSSATS
2003
Total
Private
nonprofit
Private
for-profit
Local/
State
gov’t
Federal
gov’t*
Number of
Programs
13,623
8,258
3,403
1454
339
Percentage of
Programs
100%
61%
25%
11%
2%
Medications
(% of Type)
2,739
20%
1,338
16%
768
23%
376
22%
229
68%
Antabuse
(% of Type)
2,268
17%
1,084
13%
602
18%
343
24%
213
63%
Naltrexone
(% of Type)
1,656
12%
835
10%
455
13%
185
13%
169
50%
*Serves veterans, military personnel, inmates, or Native Americans.
Adherence
Treatments don’t make you better if you don’t
take them.
Be aware of factors that reduce adherence, such
as
denial of illness or its chronicity,
complex dosing schedules,
side effects,
poor social support, and
depression or amotivation (DiMatteo, 2004; DiMatteo
et al, 2000; Perkins, 2002)
Addiction Treatment Works
Reductions in Healthcare Services Utilization
Hospitalizations for:
Physical health 36%
Drug overdose 58%
Mental health 44%
Number of:
Hospital days
ER visits
Doctor visits
Mental health
25%
38%
14%
3%
Gerstein, Harwood, Fountain et al. CALDATA, 1994 (http://www.adp.state.ca.us)
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
ASAM PPC-2R Dimensions
1. Acute Intoxication and/or Withdrawal
Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive
Conditions and Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued
Problem Potential
6. Recovery/Living Environment
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
integral, often positive component of treatment
for addictive disorders, but raises numerous
ethical, clinical, legal, political, cultural, and
philosophical issues.
Health care professionals should appreciate the
indications, methods, advantages, and
associated liabilities.
Addiction Committee of the Group for the
Advancement of Psychiatry they searched the
literature using Pubmed from 1985 to 2005
Sullivan M et al., The American Journal on Addictions, 17: 36–47, 2008
Mandated Treatment
Intensive outpatient treatment has shown In
therapy-resistant chronic alcoholics that
monitored ingestion of disulfiram, as well as
regular urine analysis for alcohol, yielded an
abstinence rate of 60% at 6–26 months.
In comparing methods of referral, groups with
coerced referral to outpatient addiction treatment
were more likely to complete treatment than
those in the non-coercive referral groups.
Coercive techniques can be effective and may
be warranted in some circumstances: e.g.
monitoring.
Ehrenreich H, et al. Eur Arch Psychiatry Clin Neurosci. 1997;247:51–54.
Loneck B, et al. Am J Drug Alcohol Abuse. 1996;22:233–246.