Christina M. Delos Reyes, MD
April 13, 2003
Substance Use Disorders: Does
Treatment Work? SLIDE
1
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: SLIDE
2
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 hopelessness
about treating SUDs. SLIDE
3
A.
Reflects attitudes of
society. [1]
1.
Clinicians influenced by
moral model of dependence as willful action.
2.
Implies persons with
dependence should be rejected and punished, not treated.
B.
Personal experiences‹³an
alcoholic is someone who drinks more than I do.² [2]
C.
Differential exposure to
severe and late stages of disease.
1.
Recognition of ³obvious²
alcoholic with cirrhosis‹yet cirrhosis only seen in 15% of alcoholics. [3]
2.
Ignore highly
functioning average alcoholic with employment and family.
3.
Missed diagnosis by
assuming all alcoholics are ³derelict². [4]
4.
Little knowledge or
exposure to friends, colleagues, and patients in stable recovery.
D.
Negative feelings go
both ways. [2]
1.
Patient distrust of
clinicians based on previous negative experiences.
2.
Clinicians react with
anger or fear to patient¹s defensiveness.
3.
Negative reactions
reinforce each other, and become ³self-fulfilling.²
E.
Clinician training about
SUDs is inadequate SLIDE
4
1.
Attending and resident
attitudes learned and internalized [4]
a.
Pejorative language like
³winos², ³junkies², or ³crackheads².
b.
Negative attitudes about
treatment³don¹t waste your time because treatment doesn¹t work.²
2.
Training seriously out
of proportion to the prevalence of SUDs.
a. Estimated 25% prevalence of SUDs
in medical and surgical inpatients. [3]
b. 1% of
required curriculum hours on SUDs in medical school during the 1980s. [5]
3.
Medical school training
still inadequate
a.
1993‹ 20% of US medical
schools had no SUDs elective. [6]
b. 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.
4.
Residency training
inappropriate in scope and amount.
a.
1989 study of 169
psychiatry residencies. [8]
i.
a minority provided
clinical training in SUDs.
ii.
nearly 50% had no exposure to Twelve-Step programs.
b. 2000 study of
curricula 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 of
addiction psychiatry in its infancy‹only since 1993.
5.
Unfortunate results of
inadequate training.
a.
1994 study of family
physicians, internists, and psychiatrists.[10]
i.
often do not recognize SUDs.
ii.
therefore, do not counsel or refer patients for treatment.
b.
2001 study of primary
care doctors. [11]
i.
33% do not ask new patients about illicit drug use.
ii. 15% do not offer any intervention to patients who
abuse drugs.
III. Definitions of SUDs.
A.
The DSM-IV definitions are:[12] SLIDE
5
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 spent
using
iv. giving up other life
activities
v. use despite consequences
2. Abuse SLIDE
6
a.
1 of 4 criteria in the same 12 months
i. recurrent role failures
ii. recurrent hazardous use
iii. recurrent legal
problems
iv. recurrent interpersonal
problems
b.
Only diagnose if never met criteria for dependence.
B. Models describing SUDs. [1] SLIDE
7
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 model
perspective: a sick person seeking health and wellness.
A.
SUDs are diseases. [13] SLIDE
8
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. SLIDE
9
1.
Genetic influences. [3]
a.
Four-fold increased risk
for children of alcoholics, even when adopted out.
b.
Identical twins have
higher concordance rates than fraternal twins or same-sex siblings.
2.
Biochemical correlates.
a.
Role of
dopamine‹neurotransmitter [14]
i.
dopamine mediates pleasure and reward
ii.
alcohol and drugs of abuse cause
dopamine release in ventral tegmental area and nucleus accumbens
b.
Role of CRF
(corticotropin releasing factor)‹stress neuropeptide
i.
increased brain levels in acute withdrawal [15]
ii.
may correlate to intensity of cocaine cravings
c. 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.
1.
See definitions of
DSM-IV Substance Dependence and Abuse.
2.
See also ICD-10
definitions.
D.
Alcohol dependence has a predictable course. [3] SLIDE
10
1.
Ages are predictable.
a.
Most onset by age 31.
b.
Present for treatment 10
years later.
2.
Has a fluctuating
course.
a. 50% of
dependent persons abstinent in any given month
b. 4+ months abstinent in any 1-2 year period
c. Longer abstinence common.
3.
10% to 30% spontaneous
remission‹without any treatment. [16]
4.
Decreases life span by
10 to 15 years. [3] SLIDE
11
5.
Leading causes of death:
a.
Cardiovascular/stroke.
b.
Cancers.
c.
Accidents.
d. Suicide.
V. Treatment approaches.
A.
Once recognized and
referred for treatment most do well.
1. Estimated 65% of typical alcoholics (with family,
jobs) maintain abstinence for 1 year after treatment. [17]
2. Estimated 50% drop in illicit drug use after
treatment. [18]
B.
Cognitive/behavioral
elements of treatment similar to treatment approaches for other chronic
disorders (e.g. diabetes, hypertension). [19]
C.
Treatment has four basic
goals: [17] SLIDE
12
1.
Enhance functioning.
2.
Optimize motivation
toward abstinence.
3.
Help restructure life
without substances.
4.
Relapse prevention.
D.
Most dependent persons
don¹t need active detox. [17] SLIDE
13
1.
Clinically-relevant
abstinence syndrome only seen with depressants, stimulants, or opioids.
2.
Stimulant withdrawal
only treated with education and reassurance.
3.
Detox for depressants
and opioids is straightforward.
4.
Detox is not rehab.
1.
Short-term inpatient
(2-4 weeks).
2.
Outpatient drug-free (4
to 6 weeks).
3.
Long-term residential.
4.
Outpatient methadone.
5. Aftercare (6 to 12 months).
F.
Treatment components
include: [17] SLIDE
14
1.
Educational lectures.
2.
Counseling‹group,
individual, and family.
3.
AA and other self-help
groups.
4.
Vocational
rehabilitation.
5.
Pharmacotherapy.
VI. Evaluating treatment outcome and efficacy. SLIDE
15
A.
Outcomes‹how people are
functioning at follow-up after treatment.
1.
Length of continuous
abstinence. SLIDE
16
2.
Amount of drug or
alcohol use.
3.
Level of criminal
activity.
4.
Psychosocial measures,
e.g. employment and relationships.
5.
Physical and mental
health.
B.
Efficacy‹comparing outcomes
in a treatment group vs. control group to see if treatment is responsible for
the outcomes.
1.
Persons evaluated on
multiple measures before and after treatment.
2.
Patient factors
associated with better outcomes: [20] SLIDE
17
a. Decreased severity of substance dependence
b. Absence of psychiatric symptoms.
c. Social supports.
d. Increased motivation.
e. Decreased criminal involvement.
f. Treatment completion.
3.
Program factors
associated with better outcomes: [20] SLIDE
18
a.
Increased range, frequency, intensity of services.
b.
Flexible, individualized
treatment.
c.
Increased length of time
in treatment‹
i.
Intense treatment 2-4 weeks, then several months aftercare.
ii.
Cumulative impact of multiple treatment episodes.
4.
Predictors of
non-compliance and relapse similar across all chronic illnesses (hypertension,
diabetes, drug and alcohol dependence): [19]
a.
Poverty.
b.
Lack of family support.
c.
Psychiatric comorbidity.
C.
National multi-site drug
treatment research outcome studies: SLIDE
19
1.
TOPS‹Treatment Outcomes
Prospective Study. [21]
a.
NIDA-funded, Hubbard et
al. 1989.
b.
10,000 persons with drug
use disorders in 37 treatment programs in 10 US cities between 1979 and 1981
c.
60% reduced weekly
heroin use 1 year post-treatment; SLIDE
20
70% reduction 2
years post-treatment.
d.
35% reduced weekly
cocaine use 1 year post-treatment; 56% reduction at 2 years post-treatment.
e.
Proportion of clients
working increased from 31% to 45% after treatment. SLIDE
21
f.
27% reduction in
predatory crime 1 year post-treatment; 45% reduction at 2 years post-treatment.
2.
NTIES‹National Treatment
Improvement Evaluation Study. [22]
a.
Congressionally mandated
evaluation of federally-funded treatment programs, Gerstein et al. 1997.
b.
About 6,600 persons in
78 programs enrolled in 1993-1994.
c.
Drug use in the 12
months prior to treatment vs. 12 months after treatment: SLIDE
22
i.
crack cocaine: 50% vs. 25%
ii.
cocaine: 40% vs. 18%
iii.
heroin: 24% vs. 13%
d.
Percent decreases in
criminal behavior after treatment: SLIDE
23
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.
e.
Percent decreases in
physical and mental health problems 12 months before vs. 12 months after
treatment: SLIDE
24
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.
3.
DATOS‹Drug Abuse
Treatment Outcome Study. [23]
a.
NIDA-funded, Hubbard et
al. 1997.
b.
10,000 persons in 96
treatment programs in 11 US cities with intake between 1991 and 1993.
c.
12 months after the end
of treatment: SLIDE
25
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% reduction
in heavy drinking.
iii. outpatient drug-free programs‹57% reduction in weekly cocaine users and 52% reduction in heavy drinkers.
d. Percent of persons in jail the year
prior to treatment decreased from about 70% to about 30% in the year after treatment. SLIDE
26
4. Project MATCH‹Matching Alcoholism Treatment to Client
Heterogeneity. [24,25]
a.
NIAAA-funded, randomized
comparison of 3 treatment approaches, Project Match Research Group 1997, 1998). SLIDE
27
b.
Treatment approaches
were CBT (cognitive behavioral therapy), TSF (Twelve Step Facilitation), and
MET (motivational enhancement therapy).
c.
About 1600
alcohol-dependent persons at 10 sites.
d.
Up to 50% of patients
were abstinent or had significantly reduced drinking both 1 and 3 years after
treatment. SLIDE
28
e.
All three treatment
groups were effective in reducing drinking.
5. CATOR‹Chemical Abuse Treatment Outcome Registry. SLIDE 29
a.
Study of private
programs, Hoffman and Harrison 1991. [26]
b.
3300 persons across 13
US states.
c.
40% totally abstinent
for 1 year after treatment
d.
33% totally abstinent
for 2 years after treatment
VII. Increasing clinician
optimism.
A.
Redefining treatment
success. SLIDE
30
1.
Treatment outcomes for
SUDs are comparable to chronic, relapsing diseases with a behavioral component,
like diabetes, hypertension, and asthma. [19] SLIDE
31
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 to
medication regimens
b.
Less than 30% of patients with asthma, hypertension, or diabetes adhere to
diet/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 asthma
per year
iii. SUDs often treated as acute illnesses
needing only 1 or 2 treatment episodes over the lifetime of the illness
2.
Reasonable expectations
about what treatment can do.[19] SLIDE 32
a.
Higher expectations for
SUD treatment
i.
100% compliance with treatment (total and continuous abstinence) considered
effective.
ii.high
blood glucose or high blood pressure readings viewed differently
b.
Relapse to previous
condition after stopping treatment
i.
Considered evidence of treatment failure in SUDs
ii.
Considered evidence of treatment effectiveness for diabetes, hypertension, and
asthma.
B.
Improved training about
SUDs should:
1.
Increase clinician
confidence. SLIDE
33
2.
Increase the
identification and treatment rates of persons with SUDs.
C.
Optimism begets
optimism.
1.
Concept of
self-fulfilling prophecy.
2.
Belief in helpfulness of
treatment increases patient hopefulness about recovery.
D.
Treatment is a
worthwhile venture. SLIDE
34
1.
SUDs are common, easily
identified diseases.
2.
Treatment is effective.
3. Treatment outcomes comparable to other chronic
illnesses.
4. Early recognition and referral is key to positive
outcomes.
REFERENCES: