Routes to Intervention on Drinking. Gerard M. Schippers

Transcription

1 Alcohol Symposium Opening RESCueH and PAUSE University of Southern Denmark, Odense, 3 June 2013 Routes to Intervention on Drinking Gerard M. Schippers THE AMSTERDAM INSTITUTE FOR The Amsterdam Institute for ADDICTION Addiction Research RESEARCH Academic Medical Centre University of Amsterdam Three Questions 1. Which are the interventions on drinking? 2. Which interventions are effective for which persons? 1

2 Identifying Alcoholics in an End-State almost continuously under the influence of alcohol restricted life perspective due to bad somatic condition strong and persistent wish to continue drinking not suicidal treatment history with failures refusing all treatment directed at limiting drinking accepting other forms of help of sound mind and judgment when sober 2

3 Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons With Severe Alcohol Problems Mary E. Larimer, PhDDaniel K. Malone, MPHMichelle D. Garner, MSW, PhDDavid C. Atkins, PhDBonnie Burlingham, MPHHeather S. Lonczak, PhDKenneth Tanzer, BAJoshua Ginzler, PhDSeema L. Clifasefi, PhDWilliam G. Hobson, MAG. Alan Marlatt, PhD JAMA. 2009;301(13): In this population of chronically homeless individuals with high service use and costs, a Housing First program was associated with a relative decrease in costs after 6 months. These benefits increased to the extent that participants were retained in housing longer. Is Alcohol Dependency a Chronic Disease? Yes, for a substantial number of people that are or have been in treatment for alcohol dependence 3

4 Is Alcohol Dependency a Chronic Disease? McLellan, AT et al JAMA, 2000 DM=diabetes mellitus; HTN = hypertension Disease Management Model of Alcohol Problems SEVERITY OF ALCOHOL PROBLEMS Prevalence of Alcohol Problems None or mild Moderate Substantial Severe Primary Prevention (Health promoting actions) Brief intervention Specialized Treatment Care Source:Institute of Medicine (1990), Broadening the Base of Treatment for Alcohol Problems. Washington DC: National Academy Press. 4

5 Alcohol problems in Denmark (2005) Heavy drinking: 20% and Harmful alcohol use: 14% ca persons at risk Alcohol Dependent: 3% ca persons Hansen AB, Hvidtfeldt UA, Grønbæk M, Becker U, Nielsen AS, Tolstrup JS (2011). The number of persons with alcohol problems in the Danish population. Scand J Public Health. Mar;39(2): Estimation in regular treatment: ca 10% of the dependent and < 2% of the population at risk Therefor: alcohol problems do present a treatment gap 5

6 This is considered a problematic situation: failure of the treatment system But is this fully justified? Recovery Alcohol Disorders in General Population Large Dutch (n=7076) representative survey (with comparable prevalence figures as in Denmark) Dutch survey had follow-ups at 1 and 3 years. Alcohol abuse has a favourable course: 81% after 1 year and 85% after 3 year NO abuse anymore Alcohol dependency somewhat less favourable course: 67% after 1 year 69% after 3 jaar NO dependency anymore Only 4-12% of the abusers and only 0-14% of those recovered after 1 year relapsed (at 3 year) CONCLUSION: in general population large spontaneous recovery De Bruijn, Van den Brink, De Graaf, & Volleberg (2005). The three year course of alcohol use disorders in the general population. Addiction. 6

7 For those at risk Many can recover on their own, and many can profit from a little help SEVERITY OF ALCOHOL PROBLEMS None or mild Moderate Substantial Severe Screening and brief interventions (SBI) SCREENING for alcohol problems As part of routine examination By general practicioner, emergency care, and medical specialists Using simple screening tools (CAGE, AUDIT etc) Or reacting to possible signals and brief interventions 7

8 SBI: 1-4 sessions, applying FRAMES Feedback about risks of substance use Responsibility placed on client to change Advice to cut down / abstain etc. Menu of options and choices Empathic approach Self-efficacy: using a non-confrontational counselling style which encourages & reinforces client s strengths Motivational Interviewing Style Brief Interventions: the Evidence Effective in opportunistic samples with hazardous/harmful drinking (Moyer et al, 2002) Significant effect at follow-up for up to 2 years (Berglund et al, 2003) Longer-term effects less evident: booster sessions required (Fleming et al, 2002) Reduce alcohol-related problems and mortality (Cuypers et al, 2004) Involving patients crucial (RESCueH-project) 8

9 But Is face-to-face contact always necessary? May be not, when using the internet: ehealth Internet Self-help and Treatment (Jellinek) 9

10 2011 Meta-analysis Alcohol J Med Internet Res 2011;13(2):e42) Effects comparison Internet Self-help (IS) Internet Therapy (IT) 10

11 Drinks per week (TLFB) 10/2/2013 Alcohol reduction (TLFB) IT WL IS baseline 3 months 6 months Time Internet Therapy is Cost-effective IT more expensive than IS More effects, more costs If willingness to pay >= 14,000 per QALY, then IT has larger probability of cost-effectiveness than IS 11

12 SEVERITY OF ALCOHOL PROBLEMS None or mild Moderate Substantial Severe Treatment How does SUD treatment look like? It is not just keeping someone from using alcohol or drugs 12

13 Treatment of alcohol problems is Providing insight [psycho-education] Helping considering consequences [sociotherapy, familytherapy, self help] Learning to make choices [motivational interviewing, individual and group counseling] Treating craving [medication] Teaching skills [behavioral, cognitive and emotional training; relapse prevention] Treating co-morbid psychopathology (pharmacotherapy and/or psychotherapy) Support in practical and social circumstances (social services) What does research tell us on the effectiveness of treatment on addictive behavior (consumption of drugs)? 13

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15 Alcohol: Top 10 Effective Interventions Brief intervention Motivational enhancement GABA agonist Opiate antagonist Social skills training Community reinforcement approach (CRA) Behavior contracting Behavioral marital therapy Case management Self-monitoring General Consensus Lots of evidence available Best evidence for behavioural oriented treatment Best in combination with medication Relative modest effects (but comparable with other chronic illnesses) No outcome differences between residential and outpatient treatments Matching might be crucial (RESCueH) 15

16 UK, 2011 NL, 2009 Australia, 2003 Finland, 2010 Scotland, 2003 Some National Clinical Guidelines Treatment: self-control training and influencing the environment motivating Influencing readiness to change self control training: changing drinking behavior relapse prevention social and affective skills training influencing environment Social: family, job, community Physical: medication, constraints 16

17 Motivation enhancement f.e by Motivational Interviewing Responsibility for change is left with the individual The individual is free to take our advice or not The strategies are more supportive than argumentative Goal is to increase the intrinsic motivation The client presents the arguments for change Self control training Monitoring use (how much, what, when, how and in what circumstances am I using) Setting limits (how much, what, when, how and in what circumstances do I allow myself to use) Consequential rewards punishments (what do I do or not do / don t keep my promisses) Choice of alternative behavior (what do I do instead of) Planning for emergencie (what if I fail) 17

18 Relapse prevention Assessing risk situations Training alternative behaviors Training alternative emotions Emotional skills training (craving) Cue exposure (RESCueH-project) Training alternative cognitions training in self confidence harm reduction after relapse training phantasies Medications for Alcohol Dependence Disulfiram (Antabuse ) Naltrexone (Revia ) Acamprosate (Campral ) Nalmefene ** NEW 18

19 Integration of Psychosocial and Pharmaceutical Treatment Necessary Pharmacotherapy for alcohol dependence should always be accompanied by psychosocial and/or behavioral treatments Disease Management Model of Alcohol Problems SEVERITY OF ALCOHOL PROBLEMS Prevalence of Alcohol Problems None or mild Moderate Substantial Severe Primary Prevention (Health promoting actions) Brief intervention Specialized Treatment Care Source:Institute of Medicine (1990), Broadening the Base of Treatment for Alcohol Problems. Washington DC: National Academy Press. 19

20 Disease Management Model Recquires adequate measurement of patient characteristics Measurement of Addictions for Triage and Evaluation New, general, up-to-date assessment instrument for patiënt characteristics in substance abuse treatment European alternative Designed for treatment allocation (triage) in a disease management model 20

21 Disease Management Model Staging and profiling chronic ill patients, to match to proper level and kinds of care Model developed inspired by the staging and profiling of cancer treatment Van den Brink & Schippers (2012) Stageing and profiling in substance abuse treatment. TNM System Analogy ONCOLOGY T = Tumor size N = Nodes M = Metastasis G = Grade R = Resection c = clinical inform p = pathologist inform y = adjuvant therapy ADDICTION Stage of the disorder Psychiatric/somatic comorbidity Social dysfunctioning Addictive Substance Reaction on former treatment Clinical (fenotypical) information Endofenotypical/genetic information Combination treatment Van den Brink & Schippers (2012) Staging and profiling in substance abuse treatment. 21

22 Testing Allocation Algorithm Concluding Remarks Ample evidence available for effective alcohol treatment Implementation of evidence-based treatments in routine practice insufficient Due to the course of the disorder adequate matching procedures necessary RESCueH projects will contribute to new and applicable knowledge 22

23 Success! Also available: MATE-Outcomes, for treatment outcome measurements MATE-Crimi targeted for criminal and addictive behaviours MATE-Youth, targeted for year Developed and tested in the Netherlands and Germany Dutch, English, German, and Italian versions available 23

24 Drinker s Check-Up Dutch version (1994) Drinker s Check-Up is a proven effective two-session brief motivational intervention, developed by W. R. Miller (1988). Providing assessment and personalized non-judgmental feedback and motivating advice (Screening and) Brief Interventions Agenda Advice Assess Introduce the topic Inform and advice Assess use and problems One session Assist Arrange Inform about support in behavior change Guide and refer 2-4 sessions Treatment > 4 sessions 24