Transcript Treating AOD users is worthwhile!

Treatment
Options
& Efficacy
Treatment Options and Efficacy
Treating AOD Users is Worthwhile!
“The general public and many clinicians are
of the opinion that treatment
for drug and alcohol use is ineffective.
In contrast, there is a growing consensus
among the research community that
treatment does work”
At the very least, treatment can lead to some
reduction in the use of psychoactive drugs and
related problems in the majority of patients.
Nathan & Gorman (1998) in
Proudfoot & Teesson (2000 p. v.)
Treatment Options and Efficacy
Evidence Supporting Treatments (1)
Approach
Making Contact &
Engaging Users
All Illicit Drugs
Residential
Rehabilitation
** Rates of drop-out from treatment tend to
be high. For people who complete treatment,
outcomes are good.
Self-help Groups
* May be effective in reducing relapse.
Participation, not just attendance, is critical.
** Peer education & community outreach
programs (e.g. needle & syringe programs)
promote entry to treatment & encourage a
degree of behaviour change.
**** Strong Evidence; *** Moderate Evidence; ** Some Evidence; * Degree of evidence
of efficacy.
Treatment Options and Efficacy
Evidence Supporting Treatments (2)
Approach
Cannabis Psychostimulants
Opioids
*
*
** or ***
***
***
?
Pharmacotherapy
?
****
** (Naltrexone)
Substitution
Therapy
?
?
*** or ****
Withdrawal
Management
CBT
(Methadone/
Buprenorphine/
LAAM)
**** Strong Evidence; *** Moderate Evidence; ** Some Evidence; * Little Evidence.
Treatment Options and Efficacy
Treating Less Severe Cases
• People who are not drug-dependent respond
well to Brief Interventions
– the majority of patients are non-dependent
yet account for much of the harm resulting
from intoxication and regular use
• Brief Interventions can range from a few minutes
to a few hours and are ideal for primary care
• Brief Intervention can reduce alcohol
consumption by 30–40%.
Treatment Options and Efficacy
Brief Intervention Components (1)
• Assess at least current use and related
problems (provide feedback)
• A (mini) motivational interview
• Impart information, gentle advice & goal
setting (particularly with regard to harm
minimisation strategies)
• Discuss relapse prevention and management
strategies (may include problem-solving
strategies).
Treatment Options and Efficacy
Brief Intervention Components (2)
• Provide the patient with self-help manual (which has
all the core features of brief intervention)
• Monitor progress
• Intensive treatment is recommended for those with:
– severe dependence
– acute physical and/or severe psychological issues
– cognitive impairment / poor literacy
– few social supports.
Treatment Options and Efficacy
Cognitive-Behavioural Therapy (1)
CBT involves:
• changing AOD-related beliefs and expectations,
positive self-talk, enhancing motivation
• mastering urges to use via exposure to AOD
triggers (cue exposure)
• self-monitoring and self-reinforcement
• improving social / coping skills
• a relapse prevention / management focus uses
all of the above strategies.
Treatment Options and Efficacy
Cognitive-Behavioural Therapy (2)
‘The outcomes associated with
naltrexone, methadone and other
pharmacotherapies are improved
when Cognitive-Behavioural Therapy
is used as an adjunctive therapy…’
Treatment Options and Efficacy
CRA: The Community
Reinforcement Approach (1)
• Some of the most successful outcomes
ever achieved with alcohol, cocaine and
heroin users can be attributed to CRA
• CRA seeks to remove any rewards that
maintain high-risk AOD use and to strengthen
rewards for a non-drug focused lifestyle.
Treatment Options and Efficacy
CRA: The Community
Reinforcement Approach (2)
Includes:
•
training family members to stop rewarding high-risk AOD
use, and to reward alternative behaviours
•
improving the communication skills of AOD users and their
family members
•
encouraging rewarding activities that are not AOD-centred
•
assisting with job-seeking help or other satisfying social
roles
•
providing accommodation (if necessary)
•
providing incentives for participation in the program (e.g.,
swap vouchers for goods compatible with a healthy lifestyle).
Treatment Options and Efficacy
CRA: The Community
Reinforcement Approach (3)
• CRA is intensive and expensive, but it
indicates some of the elements required
for highly successful outcomes!
• Shared care arrangements can
approximate CRA if services are very
well-coordinated.
Treatment Options and Efficacy
Pharmacotherapies (1)
‘…while prescribing itself brings
some benefits, the effectiveness of
treatment is improved when
combined with treatment addressing
psychological and social issues that
accompany dependence.’
Treatment Options and Efficacy
Pharmacotherapies (2)
• Are the mainstay of treatment and harm
minimisation for those dependent on heroin
• Play an increasingly important role in the
treatment of alcohol dependence but only as
an adjunct to psychosocial treatments
• Limited evidence to date regarding the role of
pharmacotherapies for other drug dependence
(with the exception of tobacco).
Treatment Options and Efficacy
Pharmacotherapies: Alcohol
Greater evidence of efficacy for:
• Naltrexone (a competitive opioid antagonist)
and
• Acamprosate (a GABA-receptor agonist)
Less commonly used:
• Disulfiram (results in a toxic build-up of
acetaldehyde if alcohol consumed)
• Antidepressant and anxiolytic drugs.
Treatment Options and Efficacy
Pharmacotherapies: Opioids (1)
Methadone (long-acting synthetic opioid)
Indications:
• withdrawal management
• maintenance
– stabilises patients
– increases retention in treatment
– improves psychosocial functioning (multiple indicators)
– reduces death rate
– individualised dose is critical to good outcomes
– higher doses important for longer term effectiveness
and retention in treatment.
Treatment Options and Efficacy
Pharmacotherapies: Opioids (2)
• Naltrexone
– opiate antagonist
• Buprenorphine
– opioid analgesic, partial agonist and
antagonist
• Levo-alpha-acetylmethadol (LAAM)
– synthetic opioid.
Treatment Options and Efficacy
What Has Limited Evidence (1)
• Aversion therapy
• Relaxation therapy
• Hypnosis
• Acupuncture
• Generic non-specific counselling
• Psychodynamic therapies
• Confrontational techniques.
Treatment Options and Efficacy
What Has Limited Evidence (2)
• In-patient over outpatient treatment
– unless patients have severely dependent or
major physical, psychological and social needs
• Therapeutic Communities
– without integration back into the community
• 12-Step self-help groups
– at the expense of recommended treatments
– may be useful as an adjunct to ‘evidencebased’ treatments for some patients.
Treatment Options and Efficacy
What is the Role of
Generic Counselling?
• There is no evidence that non-directive, traditional
counselling results in a change in AOD use
– i.e., it is not recommended as a stand-alone
treatment
• However, the micro-skills of good counselling should
be utilised in assessment and treatment:
– e.g., active listening, open-ended questions,
reflection of feeling, paraphrasing, summarising.
Treatment Options and Efficacy
Residential Programs
• Residential and ‘therapeutic communities’ are
indicated for patients
– with few social supports
– with long-standing severe dependence
– who are enmeshed in AOD-using lifestyle
• Occasionally advocated for some patients despite high
attrition rates and high relapse rates on re-entry to
society
• Can have highly variable orientations / philosophies
(some are CBT-oriented, others are 12-step based).
Treatment Options and Efficacy
12-step Self-help Groups
•
•
•
•
Not well researched
Restricted to a goal of abstinence
Spiritual emphasis can be off-putting
Attendance less than weekly does not improve
outcomes
• High attrition rates
• Some evidence that those who self-select into
regular participation do well, particularly if offered
as an adjunct to other treatments
• Positives
– widespread availability
– low cost.
Treatment Options and Efficacy
It’s The Patient’s Choice!
• GPs can discuss treatment options with
patients and make recommendations, but
ultimately it is the patient’s choice
regarding selection of treatments and AOD
goals (i.e., abstinence or controlled use)
• Offer a ‘menu’ of treatment options
• There is no clear evidence of better
outcomes from ‘matching’ certain patients
(based on their personal characteristics)
to specific treatments.
Treatment Options and Efficacy
Goal: To Give Up or Cut Down?
• Reduced or controlled use is possible when the
patient:
– is not highly dependent
– is younger, with a more malleable lifestyle
– has plenty of social supports
– has full cognitive abilities and no physical or
psychological contraindications to AOD use
• The converse of the above indicates abstention as a
preferred goal
• A period of abstinence may be recommended prior to
attempting controlled use.
Treatment Options and Efficacy
Patients with Special Needs (1)
Women
• very high rates of physical / sexual abuse in
women presenting for help with AOD issues
– contraindicates group therapy with male
patients
– female clinicians often preferred
• female-oriented treatments with provision for
childcare may be preferable for women
The Cognitively Impaired
• need highly structured treatments.
Treatment Options and Efficacy
Patients with Special Needs (2)
Young polydrug users
• alienated from their families need intensive
support regimes and an emphasis on harm
minimisation strategies
Indigenous patients
• the culturally and linguistically diverse may
be best helped by those from within their
communities
The socially isolated
• require intensive, supportive treatments.
Treatment Options and Efficacy
Patients with Special Needs (3)
Concurrent AOD and psychiatric problems
• people with comorbid psychiatric and drug use
conditions have special treatment requirements
• GPs are critically important in the screening and
detection of comorbid disorders
• the patients often are ‘bounced’ between mental
health and AOD services
• shared care is essential to provide effective treatment
• the GP can play an important role in the shared care
treatment of patients with comorbid disorders.
Treatment Options and Efficacy