Transcript Harm Reduction - University of Washington

Harm Reduction
UW/ABRC
G. Alan Marlatt, Ph.D.
University of Washington
Addictive Behaviors Research Center
[email protected]
http://depts.washington.edu/abrc/
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Harm Reduction: History
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 U.K. Model
 Medicalization Approach
 Netherlands
 Normalization Approach
 Junkie bond
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Dutch Model
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 Realistic and pragmatic
 Social/health approach
 Openness, “Normalization” leads
to access, control
 Distinction between “soft” and
“hard” drugs
 Low threshold treatment policies
Dutch vs. American Drug Policies
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 Low vs. High threshold access to
prevention and treatment
programs
 Public health vs. Criminal justice
approach
 Tolerance vs. Zero-tolerance
 Normalization vs.
Denormalization policies
Harm Reduction: Central Assumptions
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 Public health alternatives to
moral/criminal and disease
models of drug use and addiction
 Recognizes abstinence as an ideal
outcome, but accepts other
alternatives
 Often partners with the group to
obtain input on programs
Harm Reduction: Overview
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 Harmful consequences of drug
use can be placed on a continuum
 Goal: to move along this
continuum by taking steps to
reduce harm
Harm Reduction
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“Habit is habit and not to be flung
out of the window by any man, but
coaxed downstairs a step at a time.”
Mark Twain,
Pudd’nhead Wilson’s Calendar,
Chapter 6
Harm Reduction: Methods
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 Safer route of drug administration
 Alternative, safer substances
 Reduce frequency of drug use
 Reduce intensity of drug use
 Reduce harmful consequences of
drug use
Harm Reduction: Behavior Change
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 Individual
 Environment
 Policy
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How was I supposed to know that the
apple was a controlled substance?
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Young Heavy Drinkers
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Heaviest drinking period in life
Problems common, yet more isolated
Development in adulthood?
Problems associated with peer
influence, impulsivity, conduct history
 Do not see drinking as a problem
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Spectrum of Intervention Response
Thresholds for Action
No
Problems
Mild
Problems
Moderate
Problems
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Severe
Problems
Treatment
Brief Intervention
Primary Prevention
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Social Norms and
the Prevention UW/ABRC
of
Alcohol Misuse in
Collegiate Contexts
H. WESLEY PERKINS, PH.D.
Department of Anthropology
and Sociology, Hobart and
William Smith Colleges,
Geneva, New York 14456
(315) 781-3437
[email protected]
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Alcohol Skills Training Program
Components of Skills Training Program for Secondary Prevention
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Training in self-monitoring of blood alcohol levels
and drinking moderation techniques
Training to anticipate and prepare for situations
involving increased risk of heavy drinking (e.g. social
pressure, or negative emotional states)
Training to recognize and modify alcohol outcome
expectancies (i.e. placebo vs. drug effects)
Training to alternate stress coping skills (e.g.
relaxation & aerobic exercise)
Training in relapse prevention to enhance
maintenance of drinking behavior change
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Peak Blood Alcohol Concentration
by Group
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0.14
0.12
BAC
0.1
0.08
0.06
0.04
0.02
0
Pre
Post
4-month
8-month
12-month
Assessment Interval
Skills Training Program
Alcohol Information
Assessment Control
Project
Brief Alcohol Screening and Intervention for College Students
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Principal Investigator
Co-Principal Investigator
Co-Principal Investigator
Project Coordinators
Research Coordinator
Research Study Assistant
Graduate Research Assistant
Funding By:
The National Institute of
Alcohol Abuse and
Alcoholism
Grant # 5R37-AA05591
G. Alan Marlatt, Ph.D
John S. Baer, Ph.D.
Daniel R. Kivlahan, Ph.D.
Lori Quigley, Ph.D.
Mary E. Larimer, Ph.D.
Sally Weatherford, Ph.D.
Dan Irvine, BS
Ken Weingardt, MS
Lisa Roberts, MA
Lizza Miller, BA
Jason Kilmer, MS
Linda Dimeff, MS
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Stages of Change Intervention Strategies
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Assessment
& Treatment
Matching
Precontemplation a Contemplation a Preparation a Action a Maintenance a Relapse
Motivational
Enhancement
Strategies
Relapse
Prevention &
Relapse
Management
Prevalence of Alcohol-Related Consequences
Among Fraternity and Sorority Members
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50.0%
47.8%
41.7%
40.0%
39.2%
38.9%
36.8%
36.6%
36.3%
33.7%
29.8%
24.2%
21.9%
16.2%
16.1%
8.1%
7.9%
7.5%
Neglected your responsibilities
Missed a day (or part of a day) of school or work
Not able to do your homework or study for a test
Got into fights, acted bad, or did mean things
Felt you needed more alcohol . . . to get same effect
Caused shame or embarrassment to someone
Had a fight, an argument or bad feelings with a friend
Drove shortly after having more than two drinks
Had blackouts
Noticed a change in your personality
Passed out
Missed out on things . . . spent too much . . . on alcohol
Drove shortly after drinking more than four drinks
Went to work or school high or drunk
Felt that you had a problem with alcohol
Felt physically or psychologically dependent
Felt you were going crazy
Had withdrawal symptoms
BASICS Design
Freshman Year of University
Spring
Quarter
Autumn
Quarter
Select and
assess
high-risk
sample
(random
assignment)
Treatment
No
Treatment
Winter
Quarter
Spring
Quarter
Autumn
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Quarter
Feedback
And
Advise
Stepped
Care
Options
Stepped
Care
Options
Assessment
Assessment
Assessment
Assessment
Assessment
Assessment
Assessment
Assessment
Assessment
Screen all
incoming
Freshman
Select and
assess
control
sample
Participant Recruitment
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4000 Screening Questionnaires mailed
2179 Returned Questionnaires (54%)
2041 Usable Questionnaires interested in participation (51%)
508 High-risk identified (25%)
366 High-risk agreed to participate
- 11 clinical cases
- 7 late responders
- 348 randomized for intervention
174 – High-risk control
174 – High-risk intervention
151 Randomized control group selected
- 115 agreed to participate
(overlap of 26 with high-risk group)
Constructs and Measures
Drinking Measures
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Construct
Measure
Time Frame___
Alcohol
Quantity (6pt)
All points
Consumption
Frequency (7pt)
Peak (6pt)
Alcohol Negative
Consequences
Collateral Report
Daily Drinking Questionnaire
Baseline & FU
Rutgers Alcohol Problem Index (RAPI)
All points
Alcohol Dependence Scale
Baseline& FU
DSM IIIr Dependency Scale (SCID)
Baseline & FU
Quantity, Frequency, & Problems
Baseline & FU
Cues for Overdrinking
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 The people you are with
 The place where you are drinking
 The Time and Day
 Hunger and Thirst
 Special Situational Factors
 Emotional Factors
Five General Principles
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 Express Empathy
 Develop Discrepancy
 Avoid Argumentation
 Roll with Resistance
 Support Self-Efficacy
Therapist tasks during PRECONTEMPLATION
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 Raise doubt about current behavior
 Increase the client’s awareness of the
risks of current behavior
 Increase the client’s awareness of the
problems caused by current behavior
Therapist tasks during CONTEMPLATION
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 Tip the balance
 Evoke reasons to change
 Highlight the risk of not changing
 Strengthen the client’s self-efficacy for
changing the current behavior
Negotiating a Plan for Change
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 Settings Goals
 Considering Options
 Arriving at a Plan
 Encouraging Action
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Blood Alcohol Concentration*
as a Function of Drinks Consumed
and Time Taken to Consume
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Number of Drinks
Number of Hours
1
2
3
4
5
6
7
8
9
10
11
12
0
0.020
0.040
0.060
0.080
0.100
0.120
0.140
0.160
0.180
0.200
0.220
0.240
1
0.004
0.024
0.044
0.064
0.084
0.104
0.124
0.144
0.164
0.184
0.204
0.224
2
0.000
0.008
0.028
0.048
0.068
0.088
0.108
0.128
0.148
0.168
0.188
0.208
3
0.000
0.000
0.012
0.032
0.052
0.072
0.092
0.112
0.132
0.152
0.172
0.192
4
0.000
0.000
0.000
0.016
0.036
0.056
0.076
0.096
0.116
0.136
0.156
0.176
5
0.000
0.000
0.000
0.000
0.020
0.040
0.060
0.080
0.100
0.120
0.140
0.160
6
0.000
0.000
0.000
0.000
0.004
0.024
0.044
0.064
0.084
0.104
0.124
0.144
7
0.000
0.000
0.000
0.000
0.000
0.008
0.028
0.048
0.068
0.088
0.108
0.128
8
0.000
0.000
0.000
0.000
0.000
0.000
0.012
0.032
0.052
0.072
0.092
0.112
9
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.016
0.036
0.056
0.076
0.096
10
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.020
0.040
0.060
0.080
* for a MALE, 185 lbs.
Strategies to Reduce
Alcohol Consumption
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 Keep Track
 Slow Down
 Space Your Drinks
 Select Different Types of Drinks
 Drink for Quality instead of Quantity
 Enjoy Mild Effects
Graphic Feedback
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Frequency of Alcohol Consumption
from High School to College
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Frequency Scale
3
2.5
2
1.5
1
0.5
0
Spring High School
Random Sample
Autumn College
High Risk Sample
Four Year Outcome Results
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Drinking Problems
Drinking Problem Z-Score
1.4
1.2
1
0.8
0.6
0.4
0.2
0
-0.2
-0.4
Baseline
Year 1
Year 2
Random Comparison
High-Risk Control
Year 3
Year 4
High-Risk Treatment
Four Year Outcome Results
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Drinking Rates
Drinking Pattern Z-Score
1
0.8
0.6
0.4
0.2
0
-0.2
Baseline
Year 1
Year 2
Random Comparison
High-Risk Control
Year 3
Year 4
High-Risk Treatment
for Young Heavy Drinkers
 Low Threshold
- Avoids Labels
- Avoids Rules
 Public Health Model
-Treats young people as adults
-Tolerates “illegal” activity
 Flexible
-Tailored to personal history
-Tailored to risk status
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The Three Dangerous Drives in
Adolescent Motivation
Drinking
Dating
Driving
Are YOU are Harm Reduction therapist?
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1. Are you a licensed or certified health care provider, or
work under the supervision of one?
2. Do you provide health services to individuals who suffer
from drug-related harm?
3. Are your health services guided by the principles of
compassion, engagement, collaboration, selfdetermination, and pragmatism?
4. Are your health services ethical, culturally competent,
evidence-based, and guided by an assessment of your
clients’ specific needs, goals, strengths, and resources?
5. Are you willing to deliver low-threshold health service that
reduce drug-related harm to clients who are unable or
unwilling to stop using, and to their loved ones?
Are YOU are Harm Reduction therapist?
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If you answered Yes to all five questions, then
you ARE a harm Reduction Therapist, and we
would like to invite you to join your colleagues
as a member of the Association for Harm
Reduction Therapy (AHRT)!
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Thank You.