AMSP Junior Scholar Outline 4

AMSP Junior Scholar Outline

Christina M. Delos Reyes, MD

April 13, 2003

Substance Use Disorders: DoesTreatment Work?SLIDE1

I. Introduction

A.The lecture reviews:

1.Biases about substance use disorders.

2.Effectiveness of treatment.

3.The importance of recognizing patients with these disorders.

B.The following topics will be covered:SLIDE2

1.Clinician hopelessness about treating SUDs.

2.Definitions and models of SUDs.

3.The medical model perspective.

4.Treatment approaches.

5.Evaluating outcome and efficacy.

6.Increasing clinician optimism.

II. Clinician hopelessnessabout treating SUDs.SLIDE3

Reflects attitudes ofsociety. [1]

Clinicians influenced bymoral model of dependence as willful action.

Implies persons withdependence should be rejected and punished, not treated.

Personal experiences‹³analcoholic is someone who drinks more than I do.² [2]

Differential exposure tosevere and late stages of disease.

Recognition of ³obvious²alcoholic with cirrhosis‹yet cirrhosis only seen in 15% of alcoholics. [3]

Ignore highlyfunctioning average alcoholic with employment and family.

Missed diagnosis byassuming all alcoholics are ³derelict². [4]

Little knowledge orexposure to friends, colleagues, and patients in stable recovery.

Negative feelings goboth ways. [2]

Patient distrust ofclinicians based on previous negative experiences.

Clinicians react withanger or fear to patient¹s defensiveness.

Negative reactionsreinforce each other, and become ³self-fulfilling.²

Clinician training aboutSUDs is inadequateSLIDE4

Attending and residentattitudes learned and internalized [4]

Pejorative language like³winos², ³junkies², or ³crackheads².

Negative attitudes abouttreatment³don¹t waste your time because treatment doesn¹t work.²

Training seriously outof proportion to the prevalence of SUDs.

a. Estimated 25% prevalence of SUDsin medical and surgical inpatients. [3]

1% ofrequired curriculum hours on SUDs in medical school during the 1980s. [5]

Medical school trainingstill inadequate

1993‹ 20% of US medicalschools had no SUDs elective. [6]

1998‹survey of preclinical medical students. [7]

i.20% ³no training in substance use disorders².

ii.56% ³small amount of training in substance use disorders².

Residency traininginappropriate in scope and amount.

1989 study of 169psychiatry residencies. [8]

a minority providedclinical training in SUDs.

ii.nearly 50% had no exposure to Twelve-Step programs.

b. 2000 study ofcurricula in ER, psychiatry, primary care, and ob-gyn residency programs. [9]

i.44% had no required SUD curriculum.

ii.56% required only 4 to 15 hours of training, with median of 7 hours.

c. Subspecialty ofaddiction psychiatry in its infancy‹only since 1993.

Unfortunate results ofinadequate training.

1994 study of familyphysicians, internists, and psychiatrists.[10]

i.often do not recognize SUDs.

ii.therefore, do not counsel or refer patients for treatment.

2001 study of primarycare doctors. [11]

i.33% do not ask new patients about illicit drug use.

ii. 15% do not offer any intervention to patients whoabuse drugs.

III. Definitions of SUDs.

A.The DSM-IV definitions are:[12]SLIDE5

1.Dependence

a.3 of 7 criteria in the same 12 months

b.2 criteria are physiological

i. tolerance

ii. withdrawal

c.5 criteria describe loss of control over use

i. using more than intended

ii. unable to cut down

iii. increasing time spentusing

iv. giving up other lifeactivities

v. use despite consequences

2. AbuseSLIDE6

a.1 of 4 criteria in the same 12 months

i. recurrent role failures

ii. recurrent hazardous use

iii. recurrent legalproblems

iv. recurrent interpersonalproblems

b.Only diagnose if never met criteria for dependence.

B. Models describing SUDs. [1]SLIDE7

1.The ³moral model²: a bad person seeking goodness.

a.Dependent persons are irresponsible.

b.They choose to be immoral and weak.

c.Change occurs via remorse or increased will power.

2.The ³spiritual model²: an empty person seeking serenity.

a.Dependent persons are empty.

b.They have character defects of pride and resentment.

c.Change occurs via surrender to a Higher Power.

3.The ³psychological model²: a deficient person seeking better control.

a. Dependent persons have ego deficits.

b. They have no internal or external impulse controls.

c. Change occurs via improved insight.

4.The ³behavioral² model: a person with a habit that requires change.

a.Dependent persons learn how to behave.

b.They respond to positive and negative reinforcers of use.

c.Change occurs when the ³bad outweighs the good.²

IV. The medical modelperspective: a sick person seeking health and wellness.

A.SUDs are diseases. [13]SLIDE8

1.Biological basis.

2.Identifiable signs and symptoms.

3.Predictable course and outcome.

4.Identification and treatment necessary for change.

B.Biological basis of SUDs.SLIDE9

Genetic influences. [3]

Four-fold increased riskfor children of alcoholics, even when adopted out.

Identical twins havehigher concordance rates than fraternal twins or same-sex siblings.

Biochemical correlates.

Role ofdopamine‹neurotransmitter [14]

i.dopamine mediates pleasure and reward

ii.alcohol and drugs of abuse causedopamine release in ventral tegmental area and nucleus accumbens

Role of CRF(corticotropin releasing factor)‹stress neuropeptide

i.increased brain levels in acute withdrawal [15]

ii.may correlate to intensity of cocaine cravings

Concept of allostasis. [15]

i.re-setting of the brain¹s reward system at a lower level

ii.need for dependent person to use ³just to feel normal²

C.Identifiable signs and symptoms.

See definitions ofDSM-IV Substance Dependence and Abuse.

See also ICD-10definitions.

D.Alcohol dependence has a predictable course. [3] SLIDE10

Ages are predictable.

Most onset by age 31.

Present for treatment 10years later.

Has a fluctuatingcourse.

50% ofdependent persons abstinent in any given month

4+ months abstinent in any 1-2 year period

Longer abstinence common.

10% to 30% spontaneousremission‹without any treatment. [16]

Decreases life span by10 to 15 years. [3]SLIDE11

5.Leading causes of death:

Cardiovascular/stroke.

Cancers.

Accidents.

Suicide.

V. Treatment approaches.

Once recognized andreferred for treatment most do well.

Estimated 65% of typical alcoholics (with family,jobs) maintain abstinence for 1 year after treatment. [17]

Estimated 50% drop in illicit drug use aftertreatment. [18]

Cognitive/behavioralelements of treatment similar to treatment approaches for other chronicdisorders (e.g. diabetes, hypertension). [19]

Treatment has four basicgoals: [17]SLIDE12

Enhance functioning.

Optimize motivationtoward abstinence.

Help restructure lifewithout substances.

Relapse prevention.

Most dependent personsdon¹t need active detox. [17]SLIDE13

Clinically-relevantabstinence syndrome only seen with depressants, stimulants, or opioids.

Stimulant withdrawalonly treated with education and reassurance.

Detox for depressantsand opioids is straightforward.

Detox is not rehab.

Forms of rehab [17]

Short-term inpatient(2-4 weeks).

Outpatient drug-free (4to 6 weeks).

Long-term residential.

Outpatient methadone.

Aftercare (6 to 12 months).

Treatment componentsinclude: [17]SLIDE14

Educational lectures.

Counseling‹group,individual, and family.

AA and other self-helpgroups.

Vocationalrehabilitation.

Pharmacotherapy.

VI. Evaluating treatment outcome and efficacy.SLIDE15

Outcomes‹how people arefunctioning at follow-up after treatment.

Length of continuousabstinence.SLIDE16

Amount of drug oralcohol use.

Level of criminalactivity.

Psychosocial measures,e.g. employment and relationships.

Physical and mentalhealth.

Efficacy‹comparing outcomesin a treatment group vs. control group to see if treatment is responsible forthe outcomes.

Persons evaluated onmultiple measures before and after treatment.

Patient factorsassociated with better outcomes: [20]SLIDE17

Decreased severity of substance dependence

Absence of psychiatric symptoms.

c. Social supports.

d. Increased motivation.

e. Decreased criminal involvement.

f. Treatment completion.

Program factorsassociated with better outcomes: [20]SLIDE18

a.Increased range, frequency, intensity of services.

Flexible, individualizedtreatment.

Increased length of timein treatment‹

i.Intense treatment 2-4 weeks, then several months aftercare.

ii.Cumulative impact of multiple treatment episodes.

Predictors ofnon-compliance and relapse similar across all chronic illnesses (hypertension,diabetes, drug and alcohol dependence): [19]

Poverty.

Lack of family support.

Psychiatric comorbidity.

National multi-site drugtreatment research outcome studies:SLIDE19

TOPS‹Treatment OutcomesProspective Study. [21]

NIDA-funded, Hubbard etal. 1989.

10,000 persons with druguse disorders in 37 treatment programs in 10 US cities between 1979 and 1981

60% reduced weeklyheroin use 1 year post-treatment; SLIDE20

70% reduction 2years post-treatment.

35% reduced weeklycocaine use 1 year post-treatment; 56% reduction at 2 years post-treatment.

Proportion of clientsworking increased from 31% to 45% after treatment.SLIDE21

27% reduction inpredatory crime 1 year post-treatment; 45% reduction at 2 years post-treatment.

NTIES‹National TreatmentImprovement Evaluation Study. [22]

Congressionally mandatedevaluation of federally-funded treatment programs, Gerstein et al. 1997.

About 6,600 persons in78 programs enrolled in 1993-1994.

Drug use in the 12months prior to treatment vs. 12 months after treatment:SLIDE22

i.crack cocaine: 50% vs. 25%

ii.cocaine: 40% vs. 18%

iii.heroin: 24% vs. 13%

Percent decreases incriminal behavior after treatment:SLIDE23

i.78% decrease for selling drugs.

ii.82%decrease for shoplifting.

iii.78% decrease for assault.

iv.51% decrease in arrests for drug possession.

v.64% decrease in arrests on any charge.

Percent decreases inphysical and mental health problems 12 months before vs. 12 months aftertreatment:SLIDE24

i.54% fewer persons with alcohol/other drug related medical visits.

ii.40% fewer suicide attempts related to alcohol or drug use.

iii.48% fewer suicide attempts unrelated to alcohol or drug use.

iv.57% fewer persons with inpatient mental health visits.

vi.96% fewer clients with panic symptoms related to alcohol/drug use.

DATOS‹Drug AbuseTreatment Outcome Study. [23]

NIDA-funded, Hubbard etal. 1997.

10,000 persons in 96treatment programs in 11 US cities with intake between 1991 and 1993.

12 months after the endof treatment:SLIDE25

i.outpatient methadone programs‹69% reduction in weekly heroin users and 48%reduction in weekly cocaine users.

ii.long-term residential programs‹67% reduction in weekly cocaine users and 53% reductionin heavy drinking.

iii. outpatient drug-free programs‹57% reduction inweekly cocaine users and 52% reduction in heavy drinkers.

d. Percent of persons in jail the yearprior to treatment decreased from about 70% to about 30% in the year after treatment.SLIDE26

Project MATCH‹Matching Alcoholism Treatment to ClientHeterogeneity. [24,25]

NIAAA-funded, randomizedcomparison of 3 treatment approaches, Project Match Research Group 1997, 1998).SLIDE27

Treatment approacheswere CBT (cognitive behavioral therapy), TSF (Twelve Step Facilitation), andMET (motivational enhancement therapy).

About 1600alcohol-dependent persons at 10 sites.

Up to 50% of patientswere abstinent or had significantly reduced drinking both 1 and 3 years aftertreatment.SLIDE28

All three treatmentgroups were effective in reducing drinking.

CATOR‹Chemical Abuse Treatment Outcome Registry.SLIDE 29

Study of privateprograms, Hoffman and Harrison 1991. [26]

3300 persons across 13US states.

40% totally abstinentfor 1 year after treatment

33% totally abstinentfor 2 years after treatment

VII. Increasing clinicianoptimism.

Redefining treatmentsuccess.SLIDE30

Treatment outcomes forSUDs are comparable to chronic, relapsing diseases with a behavioral component,like diabetes, hypertension, and asthma. [19]SLIDE31

a.Medication compliance

i. Less than 60% of adults with Type 1 diabetes

ii.Less than 40% of patients with hypertension or asthma adhere fully tomedication regimens

b.Less than 30% of patients with asthma, hypertension, or diabetes adhere todiet/behavioral changes.

c.Relapse or exacerbation of illness

i. 30% to 50% of adults with type 1 diabetes per year

ii. 50% to 70% of adults with hypertension or asthmaper year

iii. SUDs often treated as acute illnessesneeding only 1 or 2 treatment episodes over the lifetime of the illness

Reasonable expectationsabout what treatment can do.[19]SLIDE 32

Higher expectations forSUD treatment

i.100% compliance with treatment (total and continuous abstinence) consideredeffective.

ii.highblood glucose or high blood pressure readings viewed differently

Relapse to previouscondition after stopping treatment

i.Considered evidence of treatment failure in SUDs

ii.Considered evidence of treatment effectiveness for diabetes, hypertension, andasthma.

Improved training aboutSUDs should:

Increase clinicianconfidence.SLIDE33

Increase theidentification and treatment rates of persons with SUDs.

Optimism begetsoptimism.

Concept ofself-fulfilling prophecy.

Belief in helpfulness oftreatment increases patient hopefulness about recovery.

Treatment is aworthwhile venture.SLIDE34

SUDs are common, easilyidentified diseases.

Treatment is effective.

Treatment outcomes comparable to other chronicillnesses.

Early recognition and referral is key to positiveoutcomes.

REFERENCES:

1. Institute of Medicine. Treating Drug Problems. Washington, DC: National Academy Press, 1990.

1. Chappel, JN. Attitudes toward the treatment of substance abusers. In Lowinson JH et al. (Eds.) Substance Abuse: A Comprehensive Textbook, 2nd ed. Baltimore: Williams and Wilkins, 1992.

1. Schuckit MA. Drug and Alcohol Abuse: A Clinical Guide to Diagnosis and Treatment, 5th ed. New York: Kluwer Academic/Plenum Publishers, 2000.

1. Chappel, JN. Physician attitudes and the treatment of alcohol and drug dependent patients. Journal of Psychedelic Drugs. 1978; 10:27-34.

1. Delos Reyes, CM. Overcoming pessimism about treatment of addiction. JAMA. 2002; 287:1857.

1. Association of American Medical Colleges. Curriculum Directory 1993-1994. Washington, DC: AAMC, 1993.

1. Hoffman NG, Chang AJ, Lewis DC. Medical student attitudes toward drug addiction policy. J Addict Dis. 2000; 19:1-12.

1. Galanter M, Kaufman E, Taintor Z, et al. The current status of psychiatric education in alcoholism and drug abuse. Am J Psychiatry. 1989; 146: 35-39.

1. Isaacson JH, Fleming M, Kraus M, et al. A national survey of training in substance use disorders in residency programs. J Stud Alcohol. 2000; 61:912-15.

1. Fleming M. Competencies for substance abuse training. Training About Alcohol and Substance Abuse for All Primary Care Physicians. New York: Josiah Macy, Jr. Foundation, 1994.

1. Friedman PD, McCullough D, Saitz R. Screening and intervention for illicit drug abuse: a national survey of primary care physicians and psychiatrists. Arch Int Med. 2001; 161:

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994.

1. Lewis DC. A disease model of addiction. In Miller NS (Ed.) Principles of Addiction Medicine. Chevy Chase, MD: American Society of Addiction Medicine, 1994.

1. Dupont RL. The Selfish Brain: Learning from Addiction. Washington, DC: American Psychiatric Press, Inc., 1997.

1. Koob GF, LeMoal M. Drug addiction, dysregulation of reward, and allostasis. Neuropsychopharmacology. 2001; 24: 97-129.

1. Sobell LC, Sobell MB, Toneatto T, and Leo GI. What triggers the resolution of alcohol problems without treatment? Alcohol Clin Exp Res. 1993; 17: 217-224.

1. Schuckit MA. Educating yourself about alcohol and drugs: a people¹s primer, Revised ed. Reading, MA: Perseus Books, 1998.

1. Principles of Drug Addiction Treatment: A Research-Based Guide. NIH publication 00-4180. Bethesda, MD: National Institute on Drug Abuse, October 1999; reprinted July 2000.

1. McLellan AT, Lewis DC, O¹Brien CP and Kleber HD. Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance, and Outcomes Evaluation. JAMA 2000;284: 1689-1695.

1. Horgan C, Skwara KC, Strickler G. Substance Abuse: The Nation¹s Number One Health Problem, 2nd ed. Princeton, NJ: Robert Wood Johnson Foundation, Feb 2001.

1. Hubbard RL, Marsden ME, Rachal JV, et al. Drug Abuse Treatment‹A National Study of Effectiveness. Chapel Hill, NC: University of North Carolina Press, 1989.

1. Gerstein DR, Datta AR, Ingels JS, et al. The National Treatment Evaluation Study: Final Report. Rockville, MD: SAMHSA, Center for Substance Abuse Treatment, 1997.

1. Hubbard RL, Craddock SG, Flynn PM, et al. Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors. 1997; 11: 261-278.

1. Project MATCH Research Group. Matching alcoholism treatment to client heterogeneity: Project MATCH posttreatment drinking outcomes. J Stud Alcohol. 1997; 58:7-29.

1. Project MATCH Research Group. Matching alcoholism treatment to client heterogeneity: treatment main effects and matching effects on drinking during treatment. J Stud Alcohol. 1998: 59.

1. Hoffman N, Harrison P. The Chemical Abuse Treatment Outcome Registry (CATOR): Treatment outcome from private programs. In Spicer J (Ed.) Does your program measure up? An addiction professional¹s guide to evaluating treatment effectiveness. Center City, MN: Hazelden, 1991.