Transcript My problem isn`t that serious

Treating the patient who wants to cut
down, not abstain
Roger D. Weiss, MD
Chief, Division of Alcohol and Drug Abuse
McLean Hospital, Belmont, MA
Professor of Psychiatry
Harvard Medical School
Cutting down vs. quitting
• Many patients don’t want to stop drinking
• Realizing that SUD treatment programs
are abstinence-oriented, this may keep
them from seeking any treatment, or even
telling anyone that they have a problem
• Most U.S. clinicians advocate abstinence
(though variable in many other countries)
• How to successfully engage patients who
don’t initially want to quit?
2
How to work with such patients?
• Insist on abstinence?
• Tell them to come back when they are
ready?
• Work with them to help achieve
reduction?
3
“Warm turkey” (Miller&Page,
1991)
• “Client reluctance or refusal to accept a
total abstinence goal is a common
problem
• Head on argumentation and confrontation
may be ineffective, only serving to amplify
resistance
• Inflexible insistence on immediate and
abrupt abstention may undermine the
achievement of long-term abstinence”
4
“Warm turkey” strategies
• Sobriety sampling
• Tapering down
• A trial of moderation
5
Sobriety Sampling
• Also referred to as a ‘trial of abstinence’
• Viewed as an experiment, not like
abstaining for Lent
• How long should the trial be?
• Talk about it like an adventure
• ‘When it’s over, we should discuss whether
you want to sign on for more time’
• Sobriety generally sells itself
6
Tapering down
• Common strategy for tobacco smoking
cessation
• Critical for physical dependence
• Otherwise, not generally useful
7
A trial of moderation
• When to do it (if ever)
• How to do it
• Are there some patients with whom you
should not try this?
8
Controlled drinking vs.
moderate drinking
9
Recent shift in FDA regulations re
alcohol medications
.
• An alcohol medication can be approved
as efficacious if it eliminates heavy
drinking days (>4 standard drinks in a day
for a man, >3 drinks in a day for a
woman), not just if it produces total
abstinence
10
One standard drink
• 12 ounces of regular beer (5% alcohol)
• 5 ounces of wine (12% alcohol)
• 1.5 ounces of distilled spirits (40% alcohol)
As-needed nalmefene
• 667 pts instructed to take nalmefene (mu
opioid antagonist) 18 mg or placebo if they
felt at risk to drink, 1-2 hours ahead of
time; 2 study cohorts in Europe
• Heavy drinking days at end of 6-month tx:
14 vs. 9 in one study cohort, 12 vs. 10 in
another
• 9 vs. 11 abstinent days per month
• Statistically significant differences
• How clinically significant?
Van den Brink et al., 2013
Nalmefene
• Now approved by the European Medicines
Agency (their equivalent of the FDA) ‘to
help reduce alcohol consumption in adults
with alcohol dependence who consume
more than 60 grams of alcohol per day (for
men) or more than 40 grams per day (for
women)
• One standard drink = approximately 14
grams of alcohol)
Commonly stated reasons to
not want to quit
• I’ve never really tried that hard to cut back.
• My problem isn’t that serious.
• I know I should quit, I just don’t want to.
14
I’ve never really tried that hard to
cut back
In primary care or mental health care,
people may not have tried cutting back
In specialty SUD care, they all have
15
My problem isn’t that serious
• Alcohol problems occur along a
continuum of severity: it is possible to be
“slightly alcoholic”
• DSM-5 codifies this: 2-3 symptoms (of 11)
are considered a mild substance use
disorder; 4-5 is moderate, 6 or more is
severe
16
My problem isn’t that serious
• Don’t say ‘yet’
• Alcohol problems do not always progress.
Progression is the exception, not the rule.
• Even if they will progress, they won’t
believe you when you say that they will
• Using the analogy of being 20 pounds
overweight
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My problem isn’t that serious
• Focus on recovery, not progression. What
does the patient think life will be like when
one year sober?
• Better? Worse?
.
18
Helping the patient understand
loss of control
• Understanding the pattern of drinking may
help explain why people can’t control their
drinking.
19
Effect
Alcohol dose by effect
Number of drinks
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I know I should quit, I just don’t want
to.
Never wait until you want to stop drinking.
Knowing that you need to do it is enough.
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How do people who do control
their substance use do it?
.
• Rules that they never break
• For alcohol, no more than 2 standard
drinks in a day, EVER
• Timing: no more than one drink per hour
• Stopwatch technique
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Helpful responses
• Stopping drinking is much easier than
controlling drinking, in the long run, and
much more satisfying
• Preoccupation as a core symptom of an
SUD
• Potato chip analogy
23
Alcohol vs. drugs
.
• MJ users rarely want to quit
• Opioid dependence: buprenorphine vs.
methadone experience
• What about people who use more than
one substance?
24
.
What happens to people who cut
back?
• Initial success, gradual slippage common
• Sometimes followed by bargaining for new
rules
• May lead to Plan B (abstinence, usually
quite solid) or stopping treatment
• Even those who stop treatment are
usually drinking less than at the start
• Unusual variants
25
Reality is more persuasive
than persuasiveness
True both for sobriety sampling (usually
positive) and attempts at controlled drinking
(usually negative)
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Conclusion
• Working with those who want to cut back
can be a challenge
• Patience and gentle persuasion are
required
• Let reality do the work
• Results are often very rewarding
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