Transcript Interventions for patients with alcohol problems

Interventions for patients with
alcohol problems
Ann Morrison MD
Outline of this Talk
Quick review of theoretical models for
alcohol use disorders and their treatment
Major developments in treatment of
alcohol use disorders
What can be applied on the inpatient
medical ward
The Scope of the Problem
2004: 17.6 mill (8.5%) Americans met
criteria for Alcohol Disorders
2003: of 22.2 mill who need treatment for
substance abuse, only 1.9 mill received it
2000: Societal Costs Substance abuse
$184.6 bill
Deaths/year attributable to alcohol 150
thou (7.5%)
Project MAINSTREAM
Drug Dependence, a Chronic Medical Illness
Implications for Treatment, Insurance, and Outcomes
Evaluation
A. Thomas McLellan, PhD; David C. Lewis, MD; Charles P.
O'Brien, MD, PhD; Herbert D. Kleber, MD
JAMA. 2000;284:1689-1695.
The effects of drug dependence on social systems has helped shape the generally
held view that drug dependence is primarily a social problem, not a health problem.
In turn, medical approaches to prevention and treatment are lacking. We examined
evidence that drug (including alcohol) dependence is a chronic medical illness. A
literature review compared the diagnoses, heritability, etiology (genetic and
environmental factors), pathophysiology, and response to treatments (adherence
and relapse) of drug dependence vs type 2 diabetes mellitus, hypertension, and
asthma. Genetic heritability, personal choice, and environmental factors are
comparably involved in the etiology and course of all of these disorders. Drug
dependence produces significant and lasting changes in brain chemistry and
function. Effective medications are available for treating nicotine, alcohol, and
opiate dependence but not stimulant or marijuana dependence. Medication
adherence and relapse rates are similar across these illnesses. Drug dependence
generally has been treated as if it were an acute illness. Review results suggest
that long-term care strategies of medication management and continued monitoring
produce lasting benefits. Drug dependence should be insured, treated, and
evaluated like other chronic illnesses.
How is alcohol like a chronic
disease?
Biological basis (Neurobiology of
addiction)
Heredity
Successful treatment depends on behavior
change and compliance with therapy
Progression (disease becomes more
difficult to treat as it becomes more
severe)
McLellan et al. Drug dependence, a chronic medical illness
JAMA 2000
Continuum of Alcohol Use
The severity of unhealthy alcohol use in hospitalized medical
patients. The spectrum is narrow.
Saitz R, Freedner N, Palfai TP, Horton NJ, Samet JH.
J Gen Intern Med. 2006 Apr;21(4):381-5.
BACKGROUND: Professional organizations recommend screening and brief
intervention for unhealthy alcohol use; however, brief intervention has established
efficacy only for people without alcohol dependence. Whether many medical
inpatients with unhealthy alcohol use have nondependent use, and thus might benefit
from brief intervention, is unknown. OBJECTIVE: To determine the prevalence and
spectrum of unhealthy alcohol use in medical inpatients. DESIGN: Interviews of
medical inpatients (March 2001 to June 2003). SUBJECTS: Adult medical inpatients
(5,813) in an urban teaching hospital. MEASUREMENTS: Proportion drinking risky
amounts in the past month (defined by national standards); proportion drinking risky
amounts with a current alcohol diagnosis (determined by diagnostic interview).
RESULTS: Seventeen percent (986) were drinking risky amounts; 97% exceeded
per occasion limits. Most scored > or =8 on the Alcohol Use Disorders Identification
Test, strongly correlating with alcohol diagnoses. Most of a subsample of subjects
who drank risky amounts and received further evaluation had dependence
(77%). CONCLUSIONS: Drinking risky amounts was common in medical inpatients.
Most drinkers of risky amounts had dependence, not the broad spectrum of unhealthy
alcohol use anticipated. Screening on a medicine service largely identifies patients
with dependence--a group for whom the efficacy of brief intervention (a
recommended practice) is not well established.
PMID: 16686818 [PubMed - indexed for MEDLINE]
Stages of Change
What can we do?
Mesa Grande: A systematic review
of alcohol treatment studies
361 studies
72,052 subjects
46 treatments studied
Studies are rated with methodological
quality scores
Treatments are ranked by accumulation of
+ support
Miller & Wilbourne. Mesa Grande: a methodological analysis of clinical trials of treatment
of alcohol use disorders. Addiction 2002
Mesa Grande
requirements for review
Evaluate at least one treatment for alcohol
use disorders
Comparison with an alternative condition
Used a procedure designed to create
alternative groups
Reported at least one outcome of drinking
are alcohol-related complications
Treatments with the + evidence
Brief Interventions
Motivational Enhancement Therapy
Gaba agonists
Opiate antagonists
Social skills training
Treatments with evidence of lack
effect
Educational lectures, films and groups
General alcohol counseling
Psychotherapy
Confrontational Therapy
Relaxation Therapy
Brief Interventions
in Mesa Grande
31 studies
68 % are +
Mean MQS is 12.68 (out of 17)
48% of studies are excellent (MQS >14)
Evidence is as strong in clinical settings as
in research settings
Brief Interventions
What are they?
One 15-30 minute session
Up to 3 brief follow up contacts (face-toface or telephone)
May include educational materials
Focus on hazardous or harmful drinkers
Purpose is to elicit behavior change
Goal is harm reduction
Brief Interventions: content
Feedback of personal risk
Responsibility of the patient
Advice to change
Menu of ways to reduce drinking
Empathetic counseling style
Support self efficacy
Results of RTCs for Brief
Interventions
Lower self-reported consumption
Lower GGT levels
Better work attendance
Decreased ER visits
Decreased hospitalizations
BMJ. 2004 Feb 7;328(7435):318. Epub 2004 Jan 16.
Effectiveness of opportunistic brief interventions for problem
drinking in a general hospital setting: systematic review.
Emmen MJ, Schippers GM, Bleijenberg G, Wollersheim H.
Amsterdam Institute for Addiction Research, PO Box 3907 1001 AS
Amsterdam, Netherlands. [email protected]
OBJECTIVE: To determine the effectiveness of opportunistic brief
interventions for problem drinking in a general hospital setting.
DESIGN: Systematic review. DATA SOURCES: Medline, PsychInfo,
Cochrane Library, reference lists from identified studies and review
articles, and contact with experts. MAIN OUTCOME MEASURE:
Change in alcohol consumption. RESULTS: Eight studies were
retrieved. Most had methodological weaknesses. Only one study,
with a relatively intensive intervention and a short follow up period,
showed a significantly large reduction in alcohol consumption in the
intervention group. CONCLUSIONS: Evidence for the
effectiveness of opportunistic brief interventions in a general
hospital setting for problem drinkers is still inconclusive.
Medications for Alcohol
Dependence
Works best as an adjunct to treatment
Most work in the setting of abstinence
Continue for 3 months- 1 year
Specific Meds
– Naltrexone
– Acamprosate
– Disulfram
– Topiramate
Naltrexone
Mechanism: Blocks opiate receptors in the
“reward center”
Available either as an oral medication or
Efficacy
– Cuts risk of relapse to heavy drinking in
3months by 36% (27%vs 43%)
– Less effective in maintaining abstinence (25%
in heavy drinking days)
– More effective in men and lead-in abstinence
Naltrexone
4 studies
83% positive
Average MQS 11.3
None are excellent quality
Acamprosate
Mechanism: acts on GABA and glutamate
systems. Thought to reduce Sx of
protracted abstinence
Efficacy: increases rate of abstinence at 6
months 36% vs 23% in European studies.
(Not confirmed in US trials)
More effective in more severe dependence
and with prolonged abstinence
Topirmate
Mechanism: ? Increases GABA
transmission? Reduces glutamate
transmission?
Efficacy: Increased % of patients with 28
consecutive days of abstinence or
controlled drinking (14 week studies)
May be used in non-abstinence
Not FDA approved for this indication
Disulfram
Mechanism: interferes with degradation of
alcohol resulting in accumulation of
acetaldehyde
Utility in monitored settings or with highly
motivated patients
Study Profile
Anton, R. F. et al. JAMA 2006;295:2003-2017.
Copyright restrictions may apply.
COMBINE: Subjects
N=1383
Seeking treatment
4-21 days of abstinence
Exclusion criteria:
– Other substance use disorders
– Psychiatric dx requiring meds
– Unstable medical condition
COMBINE: Intervention
16 weeks
9 treatment groups- combination of
pharmacotherapy and behavioral
counseling
Pharmacotherapy: 2x2 combination of
naltrexone and acamprosate
Behavioral intervention: Medical
management vs CBI
COMBINE:Outcomes
“Good Clinical Outcome”= moderate
alcohol use, with no more than 2 days of
binging during the last 8 weeks of the
study.
Days to first heavy drinking day
% days abstinent
Adverse Events During Treatment by Medication Group
Anton, R. F. et al. JAMA 2006;295:2003-2017.
Copyright restrictions may apply.
COMBINE:results
Good Clinical Outcome at 16 weeks
– MM (58%)
– MM/CBI (71%), NNT=6
– MM/natrexone/CBI (74%), NNT=7
– MM/naltrexone (74%), NNT=7
Between group differences persisted to 1 yr of
follow up but were no longer significant
Odds Ratios for Good Composite Clinical Outcome at End of Treatment Compared With Placebo
Naltrexone/No Combined Behavioral Intervention (CBI)
Anton, R. F. et al. JAMA 2006;295:2003-2017.
Copyright restrictions may apply.
Overall effects
% days abstinent increased overall from
25.1 to 73.1
Drinks per drinking day decreased 44%
from 12.6 to 7.1
Alcohol consumption decreased from 66 to
13 drinks per week
Overall reductions in alcohol exceeded
differences between arms
Drinking Outcomes Through End of Treatment
Anton, R. F. et al. JAMA 2006;295:2003-2017.
Copyright restrictions may apply.
Description of Medical Interventions During 1-Year Posttreatment in Participants
Anton, R. F. et al. JAMA 2006;295:2003-2017.
Copyright restrictions may apply.
Conclusions
There is a growing literature on treatment
for alcohol problems
Brief Intervention have the strongest
evidence base, but as yet, are unproven in
the inpatient setting
Pharmacotherapy is a promising avenue
of treatment