Slide 2 Interventions for patients with alcohol problems Ann
Morrison MD Slide 3 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 Slide 4 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 Slide 5 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. Slide
6 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 Slide 7
Continuum of Alcohol Use Slide 8 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. Saitz RFreedner NPalfai TPHorton NJSamet JH
Saitz RFreedner NPalfai TPHorton NJSamet JH 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] Slide 9 Stages of
Change Slide 10 What can we do? Slide 11 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 Slide
12 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 Slide 13 Treatments with the + evidence Brief
Interventions Motivational Enhancement Therapy Gaba agonists Opiate
antagonists Social skills training Slide 14 Treatments with
evidence of lack effect Educational lectures, films and groups
General alcohol counseling Psychotherapy Confrontational Therapy
Relaxation Therapy Slide 15 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 Slide 16 Brief Interventions What are they?
One 15-30 minute session Up to 3 brief follow up contacts (face-to-
face or telephone) May include educational materials Focus on
hazardous or harmful drinkers Purpose is to elicit behavior change
Goal is harm reduction Slide 17 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 Slide 18 Results of RTCs for Brief
Interventions Lower self-reported consumption Lower GGT levels
Better work attendance Decreased ER visits Decreased
hospitalizations Slide 19 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. Emmen
MJSchippers GMBleijenberg GWollersheim H Emmen MJSchippers
GMBleijenberg GWollersheim 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. Slide 20 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 Slide 21
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 Slide 22 Naltrexone 4
studies 83% positive Average MQS 11.3 None are excellent quality
Slide 23 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 Slide 24 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 Slide 25
Disulfram Mechanism: interferes with degradation of alcohol
resulting in accumulation of acetaldehyde Utility in monitored
settings or with highly motivated patients Slide 26 Copyright
restrictions may apply. Anton, R. F. et al. JAMA
2006;295:2003-2017. Study Profile Slide 27 COMBINE: Subjects N=1383
Seeking treatment 4-21 days of abstinence Exclusion criteria: Other
substance use disorders Psychiatric dx requiring meds Unstable
medical condition Slide 28 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
Slide 29 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 Slide
30 Copyright restrictions may apply. Anton, R. F. et al. JAMA
2006;295:2003-2017. Adverse Events During Treatment by Medication
Group Slide 31 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 Slide 32 Copyright
restrictions may apply. Anton, R. F. et al. JAMA
2006;295:2003-2017. Odds Ratios for Good Composite Clinical Outcome
at End of Treatment Compared With Placebo Naltrexone/No Combined
Behavioral Intervention (CBI) Slide 33 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 Slide 34 Copyright restrictions
may apply. Anton, R. F. et al. JAMA 2006;295:2003-2017. Drinking
Outcomes Through End of Treatment Slide 35 Copyright restrictions
may apply. Anton, R. F. et al. JAMA 2006;295:2003-2017. Description
of Medical Interventions During 1-Year Posttreatment in
Participants Slide 36 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
