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Alcohol Interventions : Successful and
Innovative Intervention Strategies
John B Saunders MD, FRACP
Professor of Alcohol and Drug Studies, University of Queensland,
Director, Alcohol and Drug Service, Royal Brisbane
and Women’s Hospital, Queensland Health,
Co-Director, WHO Collaborating Centre on Substance Misuse and
Mental Health; Member, Australian National Council on Drugs
The Spectrum of Use and Misuse
Dependence
Hazardous/Harmful
Use/Substance
Abuse
Non-Hazardous
Use
Non-use
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The Development of Substance Use Disorders
Repeated use of:
• alcohol
• certain medications
• drugs
Development of a
repetitive behaviour
Hazardous / Harmful
Use/ Substance
Abuse
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Mechanisms of Substance Dependence
Repeated use of:
• alcohol
• certain medications
• drugs
Re-setting of
dopamine reward
centres
Substance
dependence
syndrome
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Alcohol’s Effects on Opioid
Neurotransmission
Dopaminergic neurone
GABA
Neurone
Opioid (eg β endorphin)
neurone
Ventral
tegmental
area
Nucleus
accumbens
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The Dependence Syndrome
A psychobiological syndrome - a powerful internal
driving force.
Features of the dependence syndrome:
• impaired control over substance use
• a strong desire to take the particular substance
• preoccupation with substance use (given greater
priority than other activities)
• increased tolerance
• withdrawal symptoms on cessation of substance
use, or relief of withdrawal symptoms by further
use
• continuation of use despite harmful effects
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Dependence and the Reinstatement Phenomenon
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ALCOHOL
A FEW DAYS
5 - 10 YEARS
INTAKE
AND
SEVERITY
OF
DEPENDENCE
TIME
Implications
If a person is physically dependent on alcohol to the extent that they
repeatedly (>twice per week) suffer withdrawal symptoms, he/she is
best advised to abstain rather than attempt moderated or controlled
drinking.
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Responses to Substance Misuse
Tertiary intervention
Brief
intervention
(Secondary
prevention)
Primary
prevention
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Rapid Assessment
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Audit
Select from the answers below and place the number that corresponds with your answer in the box
1. How often do you have a drink containing alcohol?
Score
4 4 or more
times a week
o
4 10 or more
o
4 Daily or almost daily
o
4. How often during the last year have you found that you were not able to stop drinking once you had started?
0 Never
1 Less than monthly
2 Monthly
3 Weekly
4 Daily or almost daily
o
5. How often during the last year have you failed to do what was normally expected from you because of drinking?
0 Never
1 Less than monthly
2 Monthly
3 Weekly
4 Daily or almost daily
o
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy
drinking session?
0 Never
1 Less than monthly
2 Monthly
3 Weekly
4 Daily or almost daily
o
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
0 Never
1 Less than monthly
2 Monthly
3 Weekly
o
0 Never
1 or less
2 2 to 4
3 2 to 3
times a month
times a week
2. How many standard drinks do you have on a typical day when you are drinking?
0 1 or 2
1 2 to 4
2 5 or 6
3 7, 8 or 9
3. How often do you have six or more drinks in one occasion?
0 Never
1 Less than monthly
2 Monthly
3 Weekly
4 Daily or almost daily
8. How often during the lst year have you been unable to remember what happened the night before because you had been
drinking?
o
0 Never
1 Less than monthly
2 Monthly
3 Weekly
4 Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
o
0 No
2 Yes, but not in the
4 Yes, during the last
last year
year
10. Has a relative, a friend, a doctor or another health worker been concerned about your drinking or suggested you cut down?
o
0 No
2 Yes, but not in the
4 Yes, during the last
last year
year
RECORD TOTAL OF SPECIFIC ITEMS HERE
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o
Interpretation of the
AUDIT Score
0
Abstainer
1-7
Non-hazardous
“safe” drinking
8-12
Hazardous or
harmful alcohol use
13+
High risk of alcohol
dependence
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Decision Tree
Offer AUDIT questionnaire
Review AUDIT score
Non-hazardous
range
•
Feedback,
or no further
action
Hazardous or
harmful range
•
•
Feedback
Brief intervention
Alcohol dependent
range
•
•
•
•
Feedback
Referral to specialist
Need for detoxification?
Pharmacotherapy
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Brief Alcohol Intervention
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What is Brief Alcohol
Intervention?
• A brief and flexible form of therapy, comprising
advice to reduce hazardous alcohol consumption
and brief strategies to achieve this
• Ranges from 4 - 5 minutes to 2 - 3 sessions of up
to 30 - 60 minutes
• Appropriate for people with hazardous alcohol use
and a range of common mental health disorders
• Can complement other treatments for people who
have an alcohol dependence syndrome
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Aims of Brief Alcohol
Intervention
• Advice is usually to reduce drinking, rather than
abstinence
• Aims to prevent exacerbation of drinking and
alcohol-related harm and progression to
dependence
• Can complement the treatment of alcohol
dependence but is not appropriate as the sole
treatment
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WHO Brief Intervention Study findings from Australian Centre I
Aim:
To determine the effectiveness of three types of
brief intervention to assist persons with hazardous
or harmful alcohol consumption reduce their intake
and risk of harm
Design:
Controlled clinical trial with random assignment to:
(1) No treatment control
(2) Simple advice (5 minutes and leaflet)
(3) Advice and brief counselling (20 minutes +
manual)
(4) Advice and extended counselling (40 minutes
over 2 - 3 sessions)
Saunders et al (1998)
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WHO Brief Intervention Study - findings
from Australian Centre II
Subjects:
Males and females aged 17 - 70 years, fulfilling
mean intake or binge drinking criteria
Settings:
General practice, general outpatient clinics,
health screening programs
Follow Up:
at 9 months, 2 years and 10 years
Measures:
Average weekly alcohol intake, frequency of
drinking to intoxication, occurrence of hazardous
drinking, alcohol-related problems score,
laboratory test results
Evaluation: By repeated measures analysis of variance and
regression modelling
Saunders et al (1998)
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WHO - RPAH Early Intervention Trial
Results at nine months
Average weekly alcohol intake (grams)
Condition
Intake at
Recruitment
Intake at
Follow up
% reduction
Control
402
402
0
Simple advice
424
307
27.5
Advice and
counselling
480
341
29.0
Extended
counselling
460
285
38.0
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Aggregate Effect Sizes for Brief Intervention versus
Control in Non-Treatment-Seeking Populations
1. Composite Outcome
Follow-up
period
No. of
Studies
Effect Size
Heterogeneity (Q)
< 3 months
4
0.30*
4.5
3 – 6 months
11
0.14*
10.6
6 – 12 months
23
0.24*
30.6
> 12 months
5
0.13#
7.4
* P < 0.01
# P = 0.05
Moyer et al (2002)
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Conclusions for Meta-analyses
• Brief interventions lead to a reduction in
hazardous alcohol use, alcohol-related
problems and biochemical abnormalities
for at least 12 months
• No differential response according to
gender or age
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Four-year Outcome after Brief
Intervention
Medical use (48-months postbaseline)
Emergency department visits
Days of hospitalization
Motor vehicle events (48-months postbaseline)
Motor vehicle crash with fatality
Motor vehicle crash with non-fatal injuries
Motor vehicle crash with property damage only
Operating while intoxicated
Other moving violations
Legal events (48-months postbaseline)
Assault/Battery/Child abuse
Resist/Obstruct officer/Disorderly conduct
Controlled substance/Liquor violation
Criminal damage/Property damage
Theft/Robbery
Other arrests
* p < 0.10
** p < 0.05
Treatment
Control
(n = 392)
302*
420**
(n = 382)
376*
664**
0
20
67
25
169
2
31
72
25
177
8
8
2**
2
3
6
Fleming et al (2002)
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11
6
11**
1
3
9
Drink-less: getting started
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The Drink-less Program -how it works
 Screening
– Receptionist gives
AUDIT
questionnaire to
patient
– Patient brings
questionnaire to
consultation
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NSW Alcohol Interlock Program
• Voluntary means of reducing a lengthy
disqualification
• Combines brief alcohol intervention and fitting
an interlock device to the motor vehicle
• Operates on a ‘user pays’ basis
• Interlock Driver Licence holders are subject to a
BAC < 0.02
• Failure to comply with requirements of Program
results in loss of licence
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The Treatment of
Alcohol Dependence
Alcohol Withdrawal
SYNDROME
Simple
Complicated
by fits
Delirium Tremens
TIME OF ONSET
6 - 48 hours
4 - 48 hours
48 hours - 7 days
DURATION
24 hours - 5 days
Usually single
3 - 10 days
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Alcohol 2 Protocol - Regular Diazepam
6 am
12 md
6 pm
12 mn
Day 1
10 mg
10 mg
10 mg
10 mg
Day 2
10 mg
10 mg
10 mg
10 mg
Day 3
5 mg
5 mg
5 mg
10 mg
Day 4
5 mg
5 mg
5 mg
10 mg
Day 5
Nil
5 mg
Nil
5 mg
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Pharmacotherapies for Alcohol
Dependence
•
•
•
•
•
•
Acamprosate (Campral)
Naltrexone (Revia)
Disulfiram (Antabuse)
Topiramate
Ondansetron
Buspirone (for alcohol dependence and
comorbid social anxiety)
• SSRIs (for underlying or residual depression)
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Acamprosate
• A derivative of the amino-acid, taurine. Chemically
calcium bis acetyl homotaurine
• Complex pharmacological actions
• Interacts with the GABAA receptor, facilitating GABAergic
inhibitory neurotransmission
• Inhibits glutamate excitatory neurotransmission by
interacting with NMDA glutamate receptor
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Alcohol’s Actions on Glutamate
Neurotransmission
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Controlled trials of Acamprosate
in Alcohol Dependence. II
Authors
Country No.
Duration
Outcome
Abstinence
Paille et al. (1995 )
France
538
1 year
A:
C:
Sass et al. (1997)
Germany
272
1 year
330
6 months
A:
C:
A:
C:
A:
C:
A:
C:
Tempesta et al. (1998) Italy
Besson et al. (1998)
Switzerland 110
Ritson,Chick et al.
(1999)
U.K.
581
1 year
6 months
% abstinent days Biochemistry
61%
47%
43%
21%
58%
45%
25%
5%
12%
11%
62%
45%
66%
54%
40%
21%
Biological markers
showed greater
improvement in
acamprosate group
No difference
No difference
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Naltrexone
• A specific antagonist of opioids
• Introduced in Australia in 1999 for the
treatment of alcohol dependence
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Alcohol’s Effects on Opioid
Neurotransmission
Dopaminergic neurone
GABA
Neurone
Opioid (eg ß endorphin)
neurone
Ventral
tegmental
area
Nucleus
accumbens
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Controlled Trials of Naltrexone
in Alcohol Dependence. I
Authors
Country No.
Duration
Outcome
Abstinence
O’Malley et al. (1992 ) USA
104
3 months
Volpicelli et al. (1992) USA
70
3 months
Chick et al. (1999)
UK
175
3 months
Anton et al. (1999)
USA
131
3 months
Morris et al. (2001)
Australia
111
3 months
N:
C:
N:
C:
N:
C:
N:
C:
51%
23%
77%
46%
18%
19%
62%
40%
N:
C:
51%
25%
Relapse free
Biochemistry
69%
40%
79%
59%
% with heavy
drinking days less
in those on naltrexone
Improvement in those
on naltrexone
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Combined Pharmacotherapies for
Alcohol Dependence. I :
Naltrexone and Acamprosate
Kiefer et al (2003) Study
• Randomised, controlled trial of 160 alcohol dependent patients
• Assigned, following detoxification, to one of four treatments
– placebo drug
– naltrexone
– acamprosate
– naltrexone + acamprosate
• In addition, participants were encouraged to attend group therapy in
a clinic setting
• Follow up at weekly intervals for three months
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Combined Pharmacotherapies for
Alcohol Dependence. I :
Naltrexone and Acamprosate
Results of Kiefer et al (2003) Study
As judged by time to first drink and time to relapse,
• Naltrexone was superior to placebo
• Acamprosate was superior to placebo
• Combination of naltrexone and acamprosate was
superior to acamprosate alone
• There was a trend for of naltrexone and acamprosate
combined to be superior to naltrexone alone
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Alcohol-sensitising Drugs
• Aldehyde dehydrogenase inhibitors
Examples - disulfiram (“Antabuse”) 250 - 500mg daily
• Result in an unpleasant flush reaction when alcohol is taken
• Indications:
- alcohol dependence
- accepts goal of abstinence
- need for external aid to abstinence
- high risk situations for drinking imminent
• Controlled trials indicate the abstinence rate is higher in the first
3-6 months when patients take these drugs
• Best results are when given under supervision with contingency
management strategies
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Topiramate in the Treatment of Alcohol
Dependence
• Inhibits glutamate hypersensitivity and
facilitates GABAergic function
• 150 patients assigned to either topiramate or
placebo
• Greater reduction in quantity and intensity of
alcohol consumption compared with placebo
• Reduction in GGT in topiramate-treated group
compared with placebo
Johnson et al., 2003
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Ondansetron
• Early indications that ondansetron may be a
useful treatment for early-onset alcohol
dependence (likely to be those with a positive
family history)
• No support for its use in later onset alcohol
dependence
• More evidence needed from controlled trials
• Not approved for the treatment of alcohol
dependence in Australia
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Buspirone
• A 5HTIA partial agonist
• An anti-anxiety drug
• Shown in some small-scale trials to increase cumulative
days of abstinence in people with alcohol dependence
and comorbid social anxiety compared with placebo
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SSRIs
• Trialled (with high hopes) in the 1980s
• Reduce alcohol consumption by 20% in low
dependence drinkers, but effect wears off after
1-2 months
• Do not increase abstinence rates in alcohol
dependent people
• No change in overall alcohol intake in alcohol
dependent people
• Reserved for patients with persistent depression
after detoxification
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Treatments for Alcohol Misuse
Best practice
Bad practice
Available
Brief interventions
Just say no!
CBT
MET
12 -step approaches
Acamprosate
Naltrexone
(limited)
(limited)
12-step approaches
(limited, if at all)
(limited)
Analytic psychotherapy
Confrontation therapy
Supportive counselling
Analytic psychotherapy
Confrontation therapy
Supportive counselling
Aversion therapy
Hypnosis
Benzodiazepines
(post-detox)
Anti-depressants
Benzodiazepines
for detox and beyond
Anti-depressants
Residential treatment
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Cost-effectiveness of Treatment
for Hazardous Alcohol Use
and Alcohol Dependence
• Cost-effectiveness of brief alcohol
interventions:
$3 to $7 return for each $1 invested
• Cost-effectiveness of treatment for alcohol
dependence:
$4 to $5 return for each $1 invested
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Treatments for Alcohol Misuse:
Looking to the Future
• Correspondence-based, CD-ROM and Internet
therapies
• Combined CBT/motivational therapy and
pharmacotherapy
• Combined pharmacotherapies
 Acamprosate and naltrexone
 Acamprosate and disulfiram
 Naltrexone and ondansetron
• Depot preparations
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