Psychosociale interventies bij verslaving Gerard M. Schippers

10/2/2013
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
RESEARCH
Addiction
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
10/2/2013
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
10/2/2013
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):1349-1357
“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
10/2/2013
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
Care
Brief
intervention
Specialized
Treatment
Primary Prevention
(Health promoting actions)
Source:Institute of Medicine (1990), Broadening the Base of Treatment for
Alcohol Problems. Washington DC: National Academy Press.
4
10/2/2013
Alcohol problems in Denmark (2005)
Heavy drinking: 20% and Harmful alcohol use: 14%

ca 1.480.000 persons ‘at risk’

Alcohol Dependent: 3%
ca 150.000 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):128-36.
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
10/2/2013
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
10/2/2013
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
10/2/2013
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
10/2/2013
But
Is face-to-face contact always necessary?
May be not, when using the internet:
eHealth
Internet Self-help and Treatment (Jellinek)
9
10/2/2013
2011 Meta-analysis Alcohol
J Med Internet Res 2011;13(2):e42)
Effects comparison
Internet Self-help (IS)
Internet Therapy (IT)
10
10/2/2013
Alcohol reduction (TLFB)
Drinks per week (TLFB)
55
45
IT
WL
IS
35
25
15
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
10/2/2013
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
10/2/2013
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
10/2/2013
14
10/2/2013
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
10/2/2013
UK, 2011
NL, 2009
Finland, 2010
Australia, 2003
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
10/2/2013
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
10/2/2013
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
10/2/2013
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
Prevalence of Alcohol
Problems
None or mild
ALCOHOL PROBLEMS
Moderate
Substantial Severe
Care
Brief
intervention
Specialized
Treatment
Primary Prevention
(Health promoting actions)
Source:Institute of Medicine (1990), Broadening the Base of Treatment for
Alcohol Problems. Washington DC: National Academy Press.
19
10/2/2013
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
10/2/2013
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
•
•
•
ADDICTION
Stage of the disorder
Psychiatric/somatic comorbidity
Social dysfunctioning
•
•
G = Grade
R = Resection
•
•
Addictive Substance
Reaction on former treatment
•
•
•
c = clinical inform
p = pathologist inform
y = adjuvant therapy
•
•
•
Clinical (fenotypical) information
Endofenotypical/genetic information
Combination treatment
Van den Brink & Schippers (2012) Staging and profiling in substance
abuse treatment.
21
10/2/2013
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
10/2/2013
Success!
Also available:
MATE-Outcomes, for treatment outcome
measurements
MATE-Crimi targeted for criminal and
addictive behaviours
MATE-Youth, targeted for 12-23 year
Developed and tested in the Netherlands
and Germany
Dutch, English, German, and Italian versions
available
23
10/2/2013
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
• Assist
• Inform about support in
behavior change
• Arrange
Treatment
One
session
• Assess use and problems
2-4
sessions
• Guide and refer
> 4 sessions
24