AMSP Junior Scholar Outline

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.


E.    Forms of rehab [17]                                                                                 

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.





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