Transcript Substance Use Disorders: Does Treatment Work?

Substance Use Disorders:
Does Treatment Work?
Christina M. Delos Reyes, MD
Department of Psychiatry
CWRU School of Medicine
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Topics to be covered
• Clinician hopelessness
• Medical model of SUDs
• Treatment effectiveness
• Increasing clinician optimism
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Clinician Hopelessness
• Society’s attitudes
• Personal experiences
• Exposure to severe, late stage
disease
• Negative reactions are reinforcing
and self-fulfilling
• Inadequate training of clinicians
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Inadequate SUD Training
• Attitudes learned and internalized
• Medical school
– 75% “little or no training in SUDs”
• Residency programs
– 44% with no required curriculum
• Clinicians in practice
– 33% fail to screen for SUDs
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Substance Dependence
• 3 of 7 criteria in 12-month period
- Tolerance
- Withdrawal
- More than intended
- Cut down
- Time spent using
- Limit activities
- Use despite consequences
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Substance Abuse
• Never met criteria for dependence
• 1 of 4 criteria in 12-month period
- Role failures
- Hazardous use
- Legal problems
- Interpersonal problems
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Explanatory Models
• Moral  wrong
• Spiritual  empty
• Psychological  impulse control
• Behavioral  habit
• Medical  disease
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Medical Model
• Sick person seeking wellness
• SUDs as chronic diseases
– Biological basis
– Identifiable signs and symptoms
– Predictable course and outcome
• Treatment improves outcomes
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Biological Basis of SUDs
• Genetic influences
– 4x  risk in children of alcoholics
–  Concordance in identical twins
• Biochemical correlates
– Dopamine and the reward system
– CRF and craving
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Predictable Course
of Alcohol Dependence
• Onset by age 31
• Present for Rx by age 41
• Fluctuating course
• 10-30% spontaneous remission
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Predictable Course
of Alcohol Dependence
• Life span decreased by 10-15 yrs
• Leading causes of death
1.
2.
3.
4.
5.
Cardiovascular
Stroke
Cancers
Accidents
Suicide
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What is treatment?
• Comprehensive approach to a
chronic disease
• Four basic goals
– Enhance function
– Optimize motivation toward
abstinence
– Restructure life without substances
– Relapse prevention
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Treatment Structure
• Detox is not always needed
• Several forms of rehab
– Short-term inpatient
– Outpatient drug-free
– Long-term residential
– Outpatient maintenance
– Aftercare
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Treatment Components
• Educational lectures
• Counseling
– Group
– Individual
– Family
• AA and other 12-Step groups
• Vocational rehabilitation
• Pharmacotherapy
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Does Treatment Work?
• Outcomes
–Functioning at followup after
treatment
• Efficacy
–Comparing outcomes in
treatment group vs. control
group
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Treatment Outcomes
• Continuous abstinence
• Amount of use
• Criminal activity
• Employment
• Relationships
• Health
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Patient Factors Predicting
Better Outcomes
•  Severity of substance
dependence
•  Motivation
• No psychiatric disorders
• Social supports
•  Criminal involvement
• Treatment completion
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Program Factors Predicting
Better Outcomes
•  Range, frequency, intensity
of services
• Flexible, individualized
treatment
•  Length of time in treatment
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National Multi-site
Outcome Research
Study Name
Date published
• TOPS
1989
• CATOR
1991
• NTIES
1997
• DATOS
1997
• Project MATCH
1997
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Treatment Outcome
Prospective Study
• % Reduction in weekly cocaine use
–1-year post-treatment
35%
–2-years post-treatment
56%
• % Reduction in weekly heroin use
–1-year post-treatment
60%
–2-years post-treatment
70%
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Treatment Outcome
Prospective Study
• Increase in % of clients working
–Before treatment
31%
–After treatment
45%
• % Reduction in predatory crime
–1 year post-treatment
27%
–2 years post-treatment45%
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Chemical Abuse Treatment
Outcome Registry
• Total abstinence at followup
–1 year
40%
–2 years
33%
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National Treatment
Improvement Evaluation
Study
DRUG
USE
Crack
Cocaine
YEAR
YEAR
BEFORE RX AFTER RX
50%
25%
Powder
Cocaine
40%
18%
Heroin
24%
13%
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National Treatment
Improvement Evaluation
Study
% Decrease in criminal behavior
51%
64%
78%
78%
82%





drug possession
arrests
assault
selling drugs
shoplifting
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National Treatment
Improvement Evaluation
Study
% Reduction in health problems
AOD-related medical visits
Suicide attempts +AOD
Suicide attempts –AOD
Inpatient MH visits
Panic symptoms+AOD
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54%
40%
48%
57%
96%
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Drug Abuse Treatment
Outcome Study
% Reduction at 1 year followup
Heavy drinking
Weekly cocaine use
Weekly heroin use
52%
~ 60%
69%
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Drug Abuse Treatment
Outcome Study
% Spending time in jail
Year prior to treatment
Year after treatment
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70%
30%
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Matching Alcoholism
Treatment to Client
Heterogeneity
Can certain patients be matched
to different treatments?
• CBT: Cognitive Behavioral Therapy
• TSF: Twelve Step Facilitation
• MET: Motivational Enhancement
Therapy
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Matching Alcoholism
Treatment to Client
Heterogeneity
• ~50% abstinent or
significantly reduced drinking
at 1-year and 3-year followup
• All 3 approaches were effective
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Comparison to Other
Chronic Diseases
Med
Required Follow diet
compliance hospital & behavior
stay
change
annually
DM I
<60 %
~40 %
<30 %
HTN
<40 %
~60 %
<30 %
Asthma <40 %
~60 %
<30 %
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Redefining Success
Appropriate comparisons
–Treat SUDs as chronic diseases
–Comparable to other chronic
diseases
• Reasonable expectations
–Complete abstinence is not the
only successful outcome
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Reasonable Expectations
• Higher expectations for SUD
treatment
• “Relapse” = Failure in SUDs
• “Relapse” = Effectiveness in
other chronic diseases
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Increasing
Clinician Optimism
• Improved training
–Increase recognition and
treatment of SUDs
–Enhance clinician confidence
–Share hope of recovery with
patient
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Treatment is Worthwhile!
• SUDs common and easily
identified
• Effective treatment exists
• Similar outcomes to other
chronic diseases
• Transform hopelessness into
optimism
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