Brief Interventions & Brief Treatment Reid K. Hester, Ph.D. Director, Research Division Behavior Therapy Associates, LLC Senior Science Advisor Checkup and Choices LLC reid@checkupandchoices.com
Overview Prevalence of Excessive & Problem Drinking Evidence-based brief interventions Motivational interventions: Should I change? Action stage interventions: How do I change? Expected outcomes Reductions in heavy drinking and drug misuse Reductions in healthcare costs Return on investment
Consumption, alcohol related problems & interventions None Mild Consumption Moderate Substantial Severe Severe None Mild Moderate Alcohol Problems Substantial IOM, 1990 free download at http://tinyurl.com/q3xhouz
Swedish Data in thousands 500 400 300 200 100 0 450 Levels of Problem Drinking 300 250 Hazardous Harmful Low/Mod Severity Levels of Problem Drinking 50 High Severity Population 9 million Andreasson, et al., 2011
Prevalence of Problem Drinking Good news: It s not increasing as it is in U.S. Not so good news: It s stable. Heavy drinkers who are not significantly dependent don t go to abstinence-only focused alcohol treatment programs. While most eventually will change w/o help, they average 10 years of alcohol related problems before changing.
What to do? A broader perspective on alcohol problems and solutions. How you think about it drives what you do about it. Screen for drinking in primary care. Implement evidence-based brief interventions that can address the needs of people across the spectrum.
Strategies to Address Need Routine and better screening annually during Primary Care Physician visits. Interventions provided by Primary Care Physicians or Nurse Practitioners using feedback from screenings. Warm handoff to wellness counselors embedded in primary care. Psychologists & counselors trained in MI and BMIs, also able to provide brief tx. Clinicians may refer patients to outside treatment providers when needed.
Strategies to Address Need Wellness counselor coordination with Doctors for medications for patients and referrals to Brief tx programs (e.g., Riddargatan1) Community mutual-help resources. Online mutual-help resources. More intensive tx protocols as needed for more dependent patients. Detox, outpatient, residential tx. programs
Strategies to Address Need Patients could also be referred to these mutualhelp groups: Moderation.org Moderation Management SMARTRecovery.org A CBT, abstinence focused mutual help group http://www.smartrecoverysverige.org http://www.smartrecovery.org/meetings_db/view/ show_countrysw.php
Strategies to Address Need Additional online resources: Drinkerscheckup.com ModerateDrinking.com OvercomingAddictions.net
What works? As with medicine, the basis for making treatment decisions should come from scientific research. Randomized clinical trials provide the most credible evidence of effectiveness. Even within RCTs, one must consider the details
What works? Brief interventions Motivational enhancement Bibliotherapy Medications Moderation training http://behaviortherapy.com/researchdiv/whatworks.aspx
Brief Interventions Most heavy drinkers and drug users come to treatment ambivalent about changing. Brief interventions are designed to help clients discover their own internal motivation for change and resolve ambivalence about changing. They help answer the question Should I change my drinking?
Brief Intervention Elements Feedback (from assessment) is personalized and presented in a non-judgmental manner Responsibility for changing rests with the client Advice is given but carefully Menu of options is offered when a decision to change is made Empathy: The healthcare provider/counselor/web app takes an empathic approach throughout the process. Self-efficacy is supported.
Brief Motivational Interventions The Drinker s Check-up is an example of a BMI with strong empirical support. Face-to-face: 1-3 sessions of assessment, feedback, and motivational enhancement (motivational interviewing). Web app: 1 ~45 min. session (www.drinkerscheckup.com)
Then what? Stepped care model: Provide what is needed but only that much. For many, a brief intervention is sufficient. Others though may need help and support in the process of making the changes, the action stage of change.
How do I change interventions Moderation protocols Behavioral self-control training (that have cognitive & behavioral components) Face-to-face (individual or group) Bibliotherapy Web apps (e.g., www.moderatedrinking.com) Combinations of these protocols depending on client preference.
Bibliotherapy: Moderation Controlling your drinking, Tools to make moderation work for you (2 nd ed., Miller & Munoz, 2013) Responsible drinking: A Moderation Management approach for problem drinkers (Rotgers & Kern, 2002). Problem drinkers: Guided self-change treatment (Sobell & Sobell, 1993) & iselfchange iphone app
Bibliotherapy: Effectiveness Controlling your drinking, Tools to make moderation work for you (2 nd ed., Miller & Munoz, 2013) 1 st ed. extensively studied in randomized clinical trials. Reductions in drinking & problems in ~50% range out to 12 mo. Overall, bibliotherapy = face-to-face individual = group. Adding elements did not improve outcomes
iselfchange RCT w/2 mo follow-up Iphone app (not available for Android) vs. Email pdfs of exercises Non-significant differences between groups Significant reductions in drinking (15 drinks/wk pre vs. 10 post) & alcohol-related problems in both groups
Self-help web app Effectiveness www.moderatedrinking.com (MD) and Moderation Management (MM). RCT found better 12 mo outcomes on some measures in combined tx compared to MM alone No dose-response relationship to outcomes.
How do I change interventions Abstinence-focused interventions Community Reinforcement Approach (CRA) CRAFT (for family members) Other CBT protocols Face-to-face (individual or group) Web apps (e.g., www.overcomingaddictions.net) Combinations of these protocols depending on client preference. Abstinence-focused protocols can be delivered within a stepped care, brief tx. model
CheckupandChoices.com A free-standing web app that screens & then intervenes using empirically supported protocols. Fits within a model of Stepped Care, providing as much care as needed but not more.
CC Advantages Few primary care practices have wellness counselors & many counselors lack expertise in empirically supported tx. across range of severity of drinking. App consistently & cost-effectively delivers empirically supported protocols.
Flowchart Screen: Age, Alcohol, Drugs, Readiness to Change Brief motivational interventions No Drug use only Yes Yes Drinker s Check-up (25+) College Drinker s Check-up (<25) Action-oriented interventions Moderate Drinking: moderatedrinking.com Overcoming Addictions: Overcomingaddictions.net
Expected Outcomes Reduced heavy drinking & alcohol-related problems (including health problems). Reduced healthcare costs that persist beyond the year the intervention provided.
References Andreasson, S (2011) Fleming, M.F., Mundt, M.F., French M.T., Manwell, L.B., Stauffacher, E.A., & Barry, K.L. (2000). Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings. Medical Care, 38(1), 7-18.
References National Institute on Alcohol Abuse and Alcoholism (2013). Drinking statistics. Retrieved September 11, 2013 from http://www.niaaa.nih.gov/alcoholhealth/overview-alcohol-consumption/drinkingstatistics. Open Society Institute (2009). Unforeseen benefits: Addiction treatment reduces healthcare costs. Downloaded 8/28/13 from www.opensocietyfoundations.org/reports/unforeseenbenefits-addiction-treatment-reduces-health-carecosts
References Wickizer, T.M., Krupski, A., Stark, K., Mancuso, D., & Campbell, K. (2006). The Effect of Substance Abuse Treatment on Medicaid Expenditures among General Assistance Welfare Clients in Washington State. Milibank Quarterly, 84(3), 555-576.