Treatment Options & Efficacy
Treating AOD Users is Worthwhile! “The general public and many clinicians are of the opinion that treatment for drug and alcohol use is ineffective. In contrast, there is a growing consensus among the research community that treatment does work” At the very least, treatment can lead to some reduction in the use of psychoactive drugs and related problems in the majority of patients. Nathan & Gorman (1998) in Proudfoot & Teesson (2000 p. v.)
Evidence Supporting Treatments (1) **** Strong Evidence; *** Moderate Evidence; ** Some Evidence; * Degree of evidence of efficacy.
Evidence Supporting Treatments (2) **** Strong Evidence; *** Moderate Evidence; ** Some Evidence; * Little Evidence.
Treating Less Severe Cases • People who are not drug-dependent respond well to Brief Interventions • the majority of patients are non-dependent yet account for much of the harm resulting from intoxication and regular use • Brief Interventions can range from a few minutes to a few hours and are ideal for primary care • Brief Intervention can reduce alcohol consumption by 30–40%.
Brief Intervention Components (1) • Assess at least current use and related problems (provide feedback) • A (mini) motivational interview • Impart information, gentle advice & goal setting (particularly with regard to harm minimisation strategies) • Discuss relapse prevention and management strategies (may include problem-solving strategies).
Brief Intervention Components (2) • Provide the patient with self-help manual (which has all the core features of brief intervention) • Monitor progress • Intensive treatment is recommended for those with: • severe dependence • acute physical and/or severe psychological issues • cognitive impairment / poor literacy • few social supports.
Cognitive-Behavioural Therapy (1) CBT involves: • changing AOD-related beliefs and expectations, positive self-talk, enhancing motivation • mastering urges to use via exposure to AODtriggers (cue exposure) • self-monitoring and self-reinforcement • improving social / coping skills • a relapse prevention / management focus uses all of the above strategies.
Cognitive-Behavioural Therapy (2) ‘The outcomes associated with naltrexone, methadone and other pharmacotherapies are improved when Cognitive-Behavioural Therapy is used as an adjunctive therapy…’
CRA: The Community Reinforcement Approach (1) • Some of the most successful outcomes ever achieved with alcohol, cocaine and heroin users can be attributed to CRA • CRA seeks to remove any rewards that maintain high-risk AOD use and to strengthen rewards for a non-drug focused lifestyle.
CRA: The Community Reinforcement Approach (2) Includes: • training family members to stop rewarding high-risk AOD use, and to reward alternative behaviours • improving the communication skills of AOD users and their family members • encouraging rewarding activities that are not AOD-centred • assisting with job-seeking help or other satisfying social roles • providing accommodation (if necessary) • providing incentives for participation in the program (e.g., swap vouchers for goods compatible with a healthy lifestyle).
CRA: The Community Reinforcement Approach (3) • CRA is intensive and expensive, but it indicates some of the elements required for highly successful outcomes! • Shared care arrangements can approximate CRA if services are very well-coordinated.
Pharmacotherapies (1) ‘…while prescribing itself brings some benefits, the effectiveness of treatment is improved when combined with treatment addressing psychological and social issues that accompany dependence.’
Pharmacotherapies (2) • Are the mainstay of treatment and harm minimisation for those dependent on heroin • Play an increasingly important role in the treatment of alcohol dependence but only as an adjunct to psychosocial treatments • Limited evidence to date regarding the role of pharmacotherapies for other drug dependence (with the exception of tobacco).
Pharmacotherapies: Alcohol Greater evidence of efficacy for: • Naltrexone (a competitive opioid antagonist) and • Acamprosate (a GABA-receptor agonist) Less commonly used: • Disulfiram (results in a toxic build-up of acetaldehyde if alcohol consumed) • Antidepressant and anxiolytic drugs.
Pharmacotherapies: Opioids (1) Methadone (long-acting synthetic opioid) Indications: • withdrawal management • maintenance • stabilises patients • increases retention in treatment • improves psychosocial functioning (multiple indicators) • reduces death rate • individualised dose is critical to good outcomes • higher doses important for longer term effectiveness and retention in treatment.
Pharmacotherapies: Opioids (2) • Naltrexone • opiate antagonist • Buprenorphine • opioid analgesic, partial agonist and antagonist • Levo-alpha-acetylmethadol (LAAM) • synthetic opioid.
What Has Limited Evidence (1) • Aversion therapy • Relaxation therapy • Hypnosis • Acupuncture • Generic non-specific counselling • Psychodynamic therapies • Confrontational techniques.
What Has Limited Evidence (2) • In-patient over outpatient treatment • unless patients have severely dependent or major physical, psychological and social needs • Therapeutic Communities • without integration back into the community • 12-Step self-help groups • at the expense of recommended treatments • may be useful as an adjunct to ‘evidence-based’ treatments for some patients.
What is the Role of Generic Counselling? • There is no evidence that non-directive, traditional counselling results in a change in AOD use • i.e., it is not recommended as a stand-alone treatment • However, the micro-skills of good counselling should be utilised in assessment and treatment: • e.g., active listening, open-ended questions, reflection of feeling, paraphrasing, summarising.
Residential Programs • Residential and ‘therapeutic communities’ are indicated for patients • with few social supports • with long-standing severe dependence • who are enmeshed in AOD-using lifestyle • Occasionally advocated for some patients despite high attrition rates and high relapse rates on re-entry to society • Can have highly variable orientations / philosophies (some are CBT-oriented, others are 12-step based).
12-step Self-help Groups • Not well researched • Restricted to a goal of abstinence • Spiritual emphasis can be off-putting • Attendance less than weekly does not improve outcomes • High attrition rates • Some evidence that those who self-select into regular participationdo well, particularly if offered as an adjunct to other treatments • Positives • widespread availability • low cost.
It’s The Patient’s Choice! • GPs can discuss treatment options with patients and make recommendations, but ultimately it is the patient’s choice regarding selection of treatments and AOD goals (i.e., abstinence or controlled use) • Offer a ‘menu’ of treatment options • There is no clear evidence of better outcomes from ‘matching’ certain patients (based on their personal characteristics) to specific treatments.
Goal: To Give Up or Cut Down? • Reduced or controlled use is possible when the patient: • is not highly dependent • is younger, with a more malleable lifestyle • has plenty of social supports • has full cognitive abilities and no physical or psychological contraindications to AOD use • The converse of the above indicates abstention as a preferred goal • A period of abstinence may be recommended prior to attempting controlled use.
Patients with Special Needs (1) Women • very high rates of physical / sexual abuse in women presenting for help with AOD issues • contraindicates group therapy with male patients • female clinicians often preferred • female-oriented treatments with provision for childcare may be preferable for women The Cognitively Impaired • need highly structured treatments.
Patients with Special Needs (2) Young polydrug users • alienated from their families need intensive support regimes and an emphasis on harm minimisation strategies Indigenous patients • the culturally and linguistically diverse may be best helped by those from within their communities The socially isolated • require intensive, supportive treatments.
Patients with Special Needs (3) Concurrent AOD and psychiatric problems • people with comorbid psychiatric and drug use conditions have special treatment requirements • GPs are critically important in the screening and detection of comorbid disorders • the patients often are ‘bounced’ between mental health and AOD services • shared care is essential to provide effective treatment • the GP can play an important role in the shared care treatment of patients with comorbid disorders.