WEB-BASED INTERVENTIONS: A STEPPED CARE APPROACH FOR PROBLEM DRINKERS

Reid K. Hester, Ph.D. Director, Research Division Behavior Therapy Associates, LLC www.behaviortherapy.com reidhester@behaviortherapy.comTel. 505.345.6100

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Reid K Hester, Ph.D.

DCU Owns copyright

CDCU Owns copyright, patent pend.

ModerateDrinking app

Owns copyright

Overcoming Addictions app

Owns copyright

Checkup & Choices app

Owns copyright, patent pending

Thanks NIAAA for funding Research staff (RAs, T. Haney, H.

Delaney, Bo & Bill Miller, consultants) Study participants

Overview Problem drinkers: The big picture Stages of Change & matched

interventions Stepped care: only as much as needed BMIs Action-oriented protocols Management issues

Consumption & alcohol related problems

NoneMild

Moderate

Substantial

Severe

Alcohol Problems

None Mild

Moderate

SubstantialSevere

Consumption

IOM, 1990

Spectrum of interventions

NoneMild

Moderate

Thresholdfor action

Brief intervention, moderation training

Abstinence focused treatment

Substantial

Severe

Alcohol Problems

Stages of Change

Contemplation (Should I change

my drinking?) [DCU/CDCU]

Preparation (Goals, What Would it look like? [DCU/CDCU]

Action (How do I change my drink-

ing?) [MD.com/OA]

Maintenance

Relapse

Precontemplation

Permanent exit

Using a stepped care model for screening & intervention Using the minimal amount of

intervention needed to resolve problems (Sobell & Sobell, 2000). Screening (1 question) BMIs Action-oriented protocols

Moderation programs Abstinence programs

Detecting & screening Screen as integral part of lifestyle

assessment Consider drinking from health

standpoint, not disease standpoint

Will (non-dependent) heavy drinkers be interested?

When Patient Screens Positive

Assess extent of drinking & for heavy drinkers answer question, “Should I change my drinking?”

BMIs The Drinker’s Check-up (25+ y/o) The College Drinker’s Check-up (<25 y/o)

The Drinker’s Check-ups (DCU & CDCU)

Web version www.drinkerscheckup.com

Randomized clinical trial: moderate drinking outcomes far more common than abstinence (10%) (Hester et al., 2005).

Average Peak BAC per Drinking Day

0

50

100

150

200

Immediate 193.9 102.8 108.4 66.7Delayed 150.8 115 75

Baseline 4 weeks 8 weeks 12 mo

Preparation State: Goals of Change

Cut back or abstain Natural recovery literature (Sobell et al.)

Most people w/alcohol problems reduce their drinking w/o any professional or self-help Tend to be the less dependent drinkers

Relationship of hx. alcohol problems & success in reducing alcohol problems w/moderation (Miller et al., 1992)

Non-Dependent Problem Drinkers

Prevalence is increasing (NIAAA, 2004) Tend to not seek abstinence-oriented

treatment. Constitute the majority of those who

recover w/o formal treatment (i.e. natural recovery) At same time they have long histories of

alcohol-related problems.

Are moderation protocols effective?

Outcome summary from Hester & Miller (2003) www.behaviortherapy.com/whatworks.htm More controlled clinical trials of BSCT than

any other treatment until recently Variety of ways to provide the tx. (face-to-

face, bibliotherapy, web app.)

Moderate Drinking 2-3 Std drinks for men, 1-2 for women 3-4 days/wk Peak BACs <.055 Maximum limits 3/7 day/week women,

4/14 day/week men (<65 y/o)

Resources Moderation Management (

www.moderation.org) Moderation training protocols (e.g.,

www.moderatedrinking.com)

Moderate Drinking & Moderation Management: Results of a randomized clinical trial

80 heavy drinkers randomly assigned to: a) MD + MM or b) MM alone

Follow-ups at 3, 6, & 12 mo. 73% had outcome data at all 3 f-

up points

Baseline DataGroup

MD +MM MM onlyAge 48.7 52.1Education in Years 15.7 15.1MAST score 14.1 13.2Drinks (SECs)/Week 33.0 35.4Percent Days Abstinent (PDA)

16.3 16.2

Mean Drinks per Drinking Day

5.5 6.1

Group

MD +MM MM only

Mean Peak BAC per Drinking Day 111mg% 119mg%

Hours BAC > 80 mg% (in prior week, descending curve)

21.9 26.1

DrInC Recent Total score 24.3 21.3

AUDIT score 17.7 18.3

Baseline Data

Median Peak BAC/Drinking Day

40

50

60

70

80

90

100

Baseline 3 Mo F-up 6 Mo F-up 12 Mo F-up

MD + MM MM only

Percent Days Abstinent

0

10

20

30

40

50

Baseline 3 Mo F-up 6 Mo F-up 12 Mo F-up

MD + MM MM only

DrInC Recent Total Scores

0

10

20

30

Baseline 3 Mo F-up 6 Mo F-up 12 Mo F-up

MD + MM MM only

Parameters for Moderation AUDIT score over 8 MAST score under 20 Medical hx to screen for

contraindications Clients with less severe alcohol-related

problems Clients who refuse abstinence without

first trying moderation

Ethical and practical issues

Moderation achievable by many, but not all

Predictors of success not perfect Lack of success by 6-8 weeks not good

sign for chances of long term success in moderation

What to do with the clearly dependent client? Share info about likelihood of success with

moderating drinking (Miller, et al., 1992)

Discourage abstinent alcoholics from trying moderation

Urge "vacation" from drinking Agree to moderation trial w/contract to

abstain if unsuccessful

Moderation issues Most significantly dependent clients won't

opt for moderation, especially once it is explained to them

Clients will always choose their own goal (see Sanchez-Craig's BSCT study w/abstinence & moderation gps)

Abstinence Oriented protocol Overcoming Addictions, A SMART

Recovery web application (www.overcomingaddictions.net)

A 4-step, CB-T & MET protocol Build, maintain motivation Dealing w/urges, cravings Managing thoughts, feelings, actions Lifestyle balance for relapse prevention

SMART Recovery www.smartrecovery.org

1,000+ face-to-face meetings 30 Online meetings/week Forum for support Manuals, etc. on their web site

Variable Overall Group    SR SR + OA OA

    (n = 86) (n = 83) (n = 19)

Female n (%) 114 (60.6%)

52 (61%) 50 (60%) 12 (63%)

Age M (SD) 44.3 (10.9) 43.4 (10.6) 44.6 (11.1) 48.3 (8.4)

Ethnicity n (%)        

White 170 (90.4%) 76 (88.4%) 77 (92.8%) 17 (89.5%)

Hispanic 5 (2.7%) 3 (3.5%) 1 (1.2%) 1 (5.3%)

Other 7 (6.9%) 7 (8.1%) 5 (6.0%) 1 (5.3%)

         

Education M (SD)

16.1 (2.4) 15.93 (2.5) 16.0 (2.3) 17.3 (2.1)

AUDIT M (SD)a 24.7 (8.1) 24.8 (8.1) 23.95 (8.2) 27.4 (7.2)

BSI M (SD)b 17.4 (12.9) 19.35 (12.5) 15.95 (13.6) 14.8 (11.0)

InDUC M (SD)c 41.4 (17.9) 42.2 (19.0) 40.6 (17.5) 40.8 (15.6)

Baseline characteristics

Percent Days Abstinent

Baseline 3 months 6 months35

45

55

65

75

85

OA onlyOA + SRSR only

Drinks per Drinking Day

Baseline 3 months 6 months0123456789

10

OA onlyOA + SRSR only

Alcohol Problems

Baseline 3 months 6 months0

10

20

30

40

OA onlyOA + SRSR only

www.CheckupandChoices.com

Our newest web app integrates: DCU, CDCU, MD, & OA

Designed for use with patients in primary care

Screens for heavy drinking, drug use Provides BMI Segues to MD & OA

Clinical Management For many problem drinkers, BMI is

sufficient Some will benefit from moderation

protocols, some will need abstinence-oriented protocols

Brief follow-ups key to knowing how much has been enough

References Hester, R.K., Delaney, H.D., & Campbell, W. (2012). The College

Drinker’s Check-up: Outcomes of two randomized clinical trials of a computer-based brief motivational intervention. Psychology of Addictive Behaviors,

Hester, R.K., Delaney, H.D., & Campbell, W., (2011). Moderatedrinking.com and Moderation Management: 12-month outcomes of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 79, 215-224. Abstract at http://psycnet.apa.org/psycinfo/2011-03047-001

Hester, R.K., Delaney, H.D., Campbell, W., & Handmaker, N.(2009). A web application for moderation training: Initial results of a randomized clinical trial. Journal of Substance Abuse Treatment, 37(3), 266-276.

Hester, R.K., Lenberg, K.L., Campbell, W., & Delaney, H.D.D. (2013). Overcoming Addictions, a web-based application, and SMART Recovery, an online and in-person mutual help group for problem drinkers Part 1: Three-Month Outcomes of a Randomized Controlled Trial. Journal of Medical Internet Research, 15(7):e134.

Hester, R.K., Squires, D.D., & Delaney, H.D. (2005). The Computer-based Drinker’s Check-up: 12 month outcomes of a controlled clinical trial with problem drinkers. Journal of Substance Abuse Treatment, 28(2), 159-169.

Miller, W. R., Leckman, A. L., Delaney, H. D., & Tinkcom, M. (1992). Long-term follow-up of behavioral self-control training. Journal of Studies on Alcohol, 53, 249-261.

National Institute on Alcohol Abuse and Alcoholism. (2004a). Alcohol abuse increases, dependence declines across decade. www.niaaa.nih.gov/press/2004/NESARCNews.htm

Sobell, M. B., & Sobell, L. C. (2000). Stepped care as a heuristic approach to the treatment of alcohol problems. Journal of Consulting and Clinical Psychology, 68, 573–579.