Addictions –what

actually works

Don Wilson

Overview of Alcohol Use

Increase in use of alcohol over last 20 years

31% increase in per capita consumption in UK

13-23.5% life-time prevalence of substance

dependence (Kessler 1994).

Conservatively 6% currently actively dependent

Men > Women

Pattern of use changing to binge type drinking

Overview 2

¼ of male and ½ of female alcohol dependent

individuals have depressive symptoms –

increases morbidity.

19% have co-morbid anxiety related disorders.

90% are smokers

Add this to the chronic relapsing medical illness

which is alcohol dependence and you realise

why we have to manage this aggressively.

Treatment – some optimism

7 studies have shown, in treatment seeking pts, in one year follow-up, 87% reduction in quantity and abstinence on 80% of days

From natural history >50% who survive ultimately get sober

Brief interventions (a simple intervention) shows decrease in morbidity and mortality

Skid row detoxs - 10% one year sobriety

Recovering professionals in Ohio - 80-85% three year sobriety rates

Amount of drinking that

put people at risk

Per Week Per Occasion

Men >14 drinks > 5 drinks

Women > 7 drinks > 3 drinks

Elderly > 7 drinks > 1 drink

Strategies for improving success

Increase training of health care staff

Multi-disciplinary approach

Implement early effective assessment and screening tools

Use strategies shown to work

Monitor - monitor - monitor

Specialised consultative back-up

Use community resources

A good assessment includes-

Establishing a rapport and then assessing:

Is this a Substance Use Disorder? Quantity and Frequency/AUDIT/CAGE

The severity of the SUD. Look for dependence or addiction factors

What level of care is needed – education, OPD, in-pt, medical unit

What are your or your patients goals? Short term and long term

What services will be needed – individual, partner, family

Screening – all patients should be

screened for alcohol problems

Quantity and frequency questions How many drinking occasions/week? How many drinks per occasion? How often do you have 5 or more drinks?

Patterns and Consequences questions CAGE - cut down, annoyed by comments Guilt, Eye-opener

A score of >2 = abuse/dependence

AUDIT – >8 = harmful/hazardous

drinking 1. How often do you have a drink

containing alcohol?

2. How many standard drinks containing alcohol do you have on a standard day when drinking?

3. How often do you have six or more drinks on one occasion?

4. During the past year, how often have you found that you were not able to stop drinking once you had started?

5. During the past year, how often have you failed to do what was normally expected of you because of drinking?

6. During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?

7. During the past year, how often have you had a feeling of guilt or remorse after drinking?

8. During the past year, have you been unable to remember what happened the night before because you had been drinking?

9. Have you or someone else been injured as a result of your drinking?

10. Has a relative or friend, doctor or other health care worker been concerned about your drinking and suggested you cut down?

What works in dependence?

Despite years of managing alcoholism there is

still uncertainty as to evidence base for

treatment and its cost effectiveness – however

that is changing.

The big question is – what actually works?

If government handed you unlimited budget and

asked to put a cost-effective and efficacious

programme together, what interventions would

you include?

Miller’s Mesa Grande Project

Review of treatment outcome research

Accumulated data and methods of review

over 30 years and developed a

Cumulative Evidence Score

Looked at treatment efficacy (% of studies

with +ve findings for each modality)

Looked at methodology and how to weigh

it (methodological quality score MQS).

Severity of alcoholism of treatment groups

Bill Miller’s Summary – ‘what really

works’

1. Brief interventions

2. Motivational Enhancement/Intervention

3. Pharmacology (Acamprosate, Naltrexone)

4. Community Reinforcement (includes AA)

5. Self change manuals

Top ten

6. Behaviour self control training

7. Social Skills/Anxiety management

8. Behaviour contracting

9. Marital Therapy

10. Aversive Therapy (Disulfiram)

Package of treatment

A good treatment programme should by

common sense include as many of the top ten

interventions that work within its package.

Most look at changing behaviour and habit but

there is a move to looking at pharmacology as

well.

Duration of in-pt therapy? Traditionally 28 days –

now less with more out-pt input.

1. Brief Intervention

What is it? A few minutes sharing of the substance use diagnosis with the patient

Does it work? It lowers morbidity and mortality in both 6 month and 5 year follow-up.

Simple structured advice that aims to reduce consumption to less risky levels

Brief Intervention continued

Should be non-judgmental

Delivered by generalists across medical setting

Provide tools to change

Provides help on how to deal with underlying problems

How do you do it?

Brief Interventions - SOAPE

Support and empathy

Optimism

Absolution

Plan

Explanatory model

Elements of Brief Intervention

Forecast Difficult News

Be clear, compassionate and concise.

I want to tell you that based on what you

have told me, you have and alcohol

problem.

I want to help you (support) and you will

get better sooner than later (optimism)

Elements of Brief Intervention

cont.

It’s not your fault that you have this disease but it

is your responsibility to manage it (absolution)

I’m recommending we do (planning based on

readiness to change) – a menu of options

This can be hard to hear. I wonder if you have

anything to say? This is a chemical disease and

not poor moral fibre (explanation)

2. Motivational

Enhancement/Intervention

Readiness for change model similar to Brief Intervention

Full assessment in supportive relationship.

Precontemplative (I don’t have a problem)

Contemplative (maybe yes, maybe no)

Action phase (what should I do about it)

Maintenance (support and AA)

Relapse (rejoin the cycle)

Motivational Interviewing

Spirit of Motivational Interviewing

Miller and Rollnick (2002)

Collaboration – approach as partner, explore

+ support, non-authorative (confrontation)

Evocation – draw out motivation, look at goals

(enlightenment by expert)

Autonomy – responsible for change, respect

autonomy, can accept/reject counsel (told

what to do)

Basic Methods

Open questions

Affirmation

Reflective listening

Summary

Eliciting change talk

Goals with Precontemplative

patient (30% of pts) Patient says - I don’t have a problem

Do a brief intervention

Maintain the relationship

Assess the stage of readiness over time by doing intermittent brief interventions

Observe disadvantage of status quo

Encourage returns by checking BP, liver function, family function etc

Goals with Contemplative patient

(40% of patients)

‘I may have a problem, I may not’

Do brief intervention

Maintain the relationship

Validate ambivalence

Highlight dissonance

Optimism about change

Facilitate evolution towards action

Goals with an Action Stage

Patient (30% of patients)

What do I do?

Do a brief intervention

Assess withdrawal or suicide risk.

Admit those at risk

Identify useful past strategies and start with these

Offer additional treatment options

Action–Maintenance Stage

Add these to package

Self help meetings - AA/NA

Encourage sober organisations (religion)

Individual counselling referral

Out or in-patient treatment programme

Detoxification

Pharmacotherapy

Family Counselling

Office monitoring

Relapse (+ Relapse Prevention)

Fail to keep appointments, refuse testing

Feelings of disappointment and shame present with anger, sarcasm and suicidal ideation. Understand this response.

A lot of relapse prevention models – Terry Gorski gives reasonable outline

Identify early and reach out and encourage positive outcome

Don’t ignore or forget about them

Psychoactive Drugs (including

alcohol) - Affect the brain:

• Cross the blood brain barrier

• Evoke positive subjective effects

(including euphoria)

• Act at molecular targets in brain

• Release dopamine in reward

pathway

• Hijack the reward pathway

Ventral tegmental area (VTA-

reward): When stimulated, sends a

signal (release of

Dopamine) to the Nucleus

Accumbens, and signals

this pleasure to the

prefrontal cortex

The role of the Amygdala

Assists with

associations

(companions, smells,

sounds, tastes) which

also stimulate dopamine

release

Reward circuit

The mesolimbic pathway (the VTA & NA) can be stimulated or modulated by the following:

The brains own:

morphine – endorphins

cannibinoids - anandamide

cocaine/amphetamines – dopamine

nicotine- acetylcholine

and also by serotonin, glutamate, glycine, GABA

3. Pharmacological Strategies

Naltrexone - Anti-craving – blocks opiate

receptors and reduces dopamine rush

Acamprosate – acts on glutamate –

reduces craving and urge to drink

Disulfiram - aversive

Naltrexone 1

Alcohol has a complex relationship that

affects the production, secretion and

binding of opioids to their receptors

Naltrexone (Revia)- mu opioid receptor

antagonist – blocks dopamine release and

alters positive re-inforcing effects of

alcohol

Naltrexone 2

Works best in familial or biologically loaded pts

Produces a negative mood – fatigue, tension,

tired, confusion and nausea and vomiting – not

nice to take! Issues with compliance.

Reduces relapse for 6/12

Reduces impulse drinking

Need >90% compliance for success

Acamprosate

Antagonist of N-methyl-D-aspartate (NMDA) glutamate receptors and restores balance between excitatory and inhibitory neurotransmitters dysregulated by chronic alcohol consumption.

Reduces negative affect and craving post-abstinence

Small but positive effect in European but not in USA studies

Future studies to delineate which subtypes of alcohol dependent individuals will benefit.

Other - 1

Disulfiram – aversive therapy – action on aldehyde dehydrogenase. (Also reduces noredranaline synthesis – potential treatment for cocaine dependence)

Serotonin 1 Partial agonist – Buspirone in pts with anxiety co-morbidity

Serotonin 3 Receptor antagonist – 5HT3 mediates alcohol’s re-inforcing effects - ondansetron. Maybe useful in early onset alcohol dependence

Other 2

Dopamine receptor antagonists – atypical antipsychotics. Aripiprazole and Quetiapine are currently being tested.

GABA Receptor agonists – Baclofen – early findings are supportive of reducing alcohol intake.

Cholinergic Receptor antagonist – Varenicline – used in smokers – early studies demonstrate attenuated craving and improved mood.

4. Community Reinforcement

Approach

People use alcohol because it is re-inforcing

Vital to change person’s social environment so that sobriety is more re-inforcing. Use family, friends and social workers to reinforce sobriety and withdraw these reinforcers if person drinks or drugs.

Involves the use of resources such as support groups, AA and NA (12 Step Facilitation Model).

Get to know where these resources are in your community

5. Self-Change Manual

Self help manuals – mostly orientated to moderation as a goal of therapy (part of Harm Reduction strategy).

Most models in SA move to abstinence as a goal.

Harm reduction is an area of debate particularly in managing the young alcoholic

Probably shouldn’t be considered if co-morbid psychiatric condition or severe dependence

Self-Change Manuals

Manual: Responsible Drinking: A Moderation

Management approach for problem drinkers.

For those wanting abstinence:

Sex, Drugs, Gambling and Chocolate

www.downyourdrink.org.uk. Helps reduce

drinking.

www.drinkaware.org.uk. Effects of alcohol

6. Behaviour Self Control Training

A behavioural programme that’s usually

used to teach clients how to manage their

drinking, with a goal of either moderation

or abstinence.

Often used with less severely dependent

drinkers.

7. Social Skill and Anxiety

Management

What we do with most patients

Retraining in behaviour and communication

needed for social interaction and job seeking

Reducing anxiety and phobic behaviour

Building assertiveness and self-confidence and

coping skills for sober living

Often tied in with CBT

CBT: Active Ingredients Although thirteenth on the list most therapists

use elements of CBT in therapy

Functional Analysis of behavior

Individualized training - coping with cravings, managing thoughts, problem solving, planning for emergencies, refusal skills

Examination of cognitive processes

Identification of high-risk situations

Encouragement of extra-session practice

In-session practice

GPs network

Build up a network of resources in your area

GP does assessment, Brief Intervention,

Motivational counselling and Medication

Psychologist – for CBT and Family Work

Social Worker for Community Reinforcement

Psychiatrist for co-morbidity and medication

OT for social skills and anxiety management

THANKS & ENJOY THE DAY

Positive Prognostic Factors

Lack of physiologic dependence

Intact family/job

Presence of prior treatment (1-3 previous

treatment experiences)

Absence of other psychiatric disorder

Presence of long term monitoring

arrangements (MA or Employee

programme)

Negative Prognostic Factors

Being intoxicated at interviews

Loss of job, family or home

Multiple unsuccessful treatment attempts

Severe physiologic dependence (DTs, fits)

Absence of long term monitoring

Useful Literature

Bill Miller’s MesaGrande Project (381 controlled

studies) – ongoing reviews of addiction literature

Hester and Miller’s Handbook of alcoholism

treatment approaches. Effective Treatment. 3rd

Ed. 2003

Jason Luty’s – What works in alcohol use

disorders. Advances in Psych Treat. 2006

Parker’s Clinical review in March 2008 BMJ

AUDIT – >8 = harmful/hazardous

drinking 1. How often do you have a drink containing alcohol?

(0) Never

(1) Monthly or less

(2) 4 times a month

(3) 2–3 times a week

(4) 4 or more times a week

2. How many standard drinks containing alcohol do you have on a standard day when drinking?

(0) 1 or 2

(1) 3 or 4

(2) 5 or 6

(3) 7 to 9

(4) 10 or more

3. How often do you have six or more drinks on one occasion?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

4. During the past year, how often have you found that you were not able to stop drinking once you had started?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

5. During the past year, how often have you failed to do what was normally expected of you because of drinking?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

6. During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

AUDIT - continued

7. During the past year, how often have you had a feeling of guilt or remorse after drinking?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

8. During the past year, have you been unable to remember what happened the night before because you had been drinking?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

9. Have you or someone else been injured as a result of your drinking?

(0) No

(2) Yes, but not in past year

(4) Yes, during the past year

10. Has a relative or friend, doctor or other health care worker been concerned about your drinking and suggested you cut down?

(0) No

(2) Yes, but not in past year

(4) Yes, during the past year

Bill Miller’s Summary – ‘what really

works’

1. Brief interventions

2. Motivational Enhancement/Intervention

3. Pharmacology (Acamprosate, Naltrexone)

4. Community Reinforcement (includes AA)

5. Self change manuals

6. Behaviour self control training

7. Social Skills/Anxiety management

Bill Miller’s Summary – the rest

Behaviour contracting

Marital therapy – behavioural

Aversion therapy – nausea

Case management

CBT

Aversion therapy – covert sensitization

Aversion therapy – apnoeic

Family Therapy

Acupuncture

Bill Miller’s Summary – more of the

rest

Client centred counselling

Aversion therapy – electrical

Exercise

Stress management

Aversion therapy –disulfiram

Antidepressants SSRIs

Problem solving

Lithium