Enhancing Substance Use Interventions in Tertiary Care: Addressing Alcohol Misuse in the U.S.

1. MTF Toolkit for CoRC Implementation:Bucket 3/Tertiary Care Insert your name here

2. We need more emphasis, outside of ADAPT, on substance use because….

3. U.S. Statistics • 63% U.S population are current drinkers (CDC, 2002) • 5% U.S. adults heavy drinkers • 20% adults, 5+ drinks 1x/past year • 3 of 10 adults in the U.S. engage in risky drinking (NIAAA) • 40% traffic fatalities due to alcohol (50% for age 18-24) • “1700 college students die each year from alcohol related injuries” (Wake Forest Univ, O’Brien 2005) • 400,000 students between 18-24 had unprotected sex • 100,000 were too intoxicated to know if they consented to having sex (Hingson, et al., 2002)

4. Alcohol Misuse in the Air Force: A Clear and Present Danger • Alcohol misuse is involved in: • 33% of suicides • 57% sexual assaults • 28.5% domestic violence cases • 44% PMV accidents

5. Heavy Alcohol Use* Past 30 Days, Ages 18–55 *standardized 2001 NHSDA Note: 18-25 yr estimate significantly different from civilian estimate at 95% confidence

6. Alcohol-Related Effects Total DoD * * * Statistically significant increase from 1998 Source: 2002 HRB Survey

7. The best model for change…

8. CoRC’s Success Requires Collaboration: Research Says…. • Comprehensive community approach ideal: • Leadership Driven, Environmental Change, Information, Early Identification and Intervention, Policy/Deterrence, & Alternative Activities • Key: Identify those at of risk • Population based screening/assessment • Good evidence for brief interventions • Tailored feedback (in-person and mailed), Brief Interventions, Primary Care, Web-based programs, etc… Based on SAMHSA and NIAAA recommendations for prevention and early intervention in youth & young adults

9. The role of LSSC and FAP…

10. Why Bother? • Many alcohol problems aren’t seen in ADAPT • We need to screen and treat in all clinics 82% of AF heavy drinkers Receive NO Intervention Source: DoD WorldWide Survey, 2002

11. Co-morbidity Co-morbid D/O Alcohol Abuse Alcohol Dependence Mood D/Os 12.3 29.2 Maj Depression 11.3 27.9 Bipolar D/O 0.3 1.9 Anxiety D/O 29.1 36.9 GAD 1.4 11.6 Panic D/O 1.3 3.9 PTSD 5.6 7.7 From: National Co morbidity Survey (Keesler et al. 1996) All data is 1-year rate: the percent of people who met the criteria for the disorder during the year prior to the survey

12. Treatment Research Says…. • Alcohol Treatment (all)—1 year outcomes Miller et al, 2000 • 1 in 4 clients remain continuously abstinent • 1 in 10 use alcohol in moderation without problems • Mortality about 1.5% • Remaining clients abstained an avg. of 3 out of 4 days • Remaining clients reduced overall consumption by 87% • Reduced from avg. of 77/wk to 10/wk

13. Treatment Research Says…. • Alcohol Review “ Mesa Grande” Miller and Wilbourne, 2002 • 361 controlled studies-weighted on methodological strength • Strongest Efficacy: • Brief Interventions • Social Skills Training • Community Reinforcement • Behavioral Contracting • Behavioral Marital Therapy • Opiate antagonists (naltrexone, nalmefone) and acamprosate • Least Efficacy: • Education, Confrontation, Shock or Insight Driven Methods, Mandatory AA, etc..

14. Treatment Research Says…. • Brief interventions for alcohol problems (15 min- 4 sessions) (Moyers et al, 2002 meta-analysis) • Non-treatment seeking populations: • Brief interventions better than control conditions • Treatment seeking populations: • Brief interventions as good as more extended treatment • No difference in response by gender

15. Surgeon General’s Toolkit:Bucket 3 Targeted/Tertiary Prevention • Screening, Assessment & Brief Intervention • For behavioral health outside of ADAPT • Family Advocacy and Life Skills Support Centers • Recommend screening at each new intake • Identify and treat “sub-clinical” alcohol misuse • Identify substance use disorders (Abuse and Dependence) • Refer these cases to ADAPT for assistance with treatment • When not an abuse or dependence diagnosis, it is generally appropriate to incorporate hazardous drinking into the existing treatment plan at FAP or LSSC

16. Surgeon General’s Toolkit:Bucket 3 • Step 1: Include screening as part of intake process • They drink and • Had problems with alcohol in the past • Had at least 1 binge episode within the past year • 4 or more drinks in a sitting for women • 5 or more drinks in a sitting for men

17. Surgeon General’s Toolkit:Bucket 3 • Step 2: Assess further • Recommend standardized screening (e.g. AUDIT) • DSM-IV-TR checklist also included in tool kit • If positive for Abuse or Dependence Diagnosis • Refer to ADAPT • If not positive for Abuse or Dependence Diagnosis • Consider and act on any fitness fro duty issues, if any • Consider incorporating reduction of hazardous drinking into existing treatment plan

18. Recommended Screening Tool:Alcohol Use Disorders Test (AUDIT) • The AUDIT is a 10-item questionnaire assessing the patient’s drinking habits and risk for developing alcohol related problems in the future • Aggregate score has predictive value as a screener for alcohol problems • Cut Off Scores • > 8 men/7women = High risk • > 15 = Warrant additional assessment, counseling

19. Surgeon General’s Toolkit:Bucket 3 • Step 3: Assess Readiness for Change • “Are you interested in reducing your drinking level?” • Use Readiness to Change Questionnaire in Toolkit • Step 4: If ready, develop a treatment and follow-up plan tailored to the patient’s needs • Consider using Motivational interviewing approach • Brief Intervention Resources in Toolkit • Recommended: NIAAA’s Helping Patients Who Drink to MUCH: A Clinician’s Guide, 2005 Edition • Consider ordering SAMHSA’s free TIPS (website on info sheet): • TIP 34: Enhancing Motivation for Change in Substance Abuse Treatment • TIP 35: Brief Interventions and Brief Therapies for Substance Abuse

20. Surgeon General’s Toolkit:Bucket 3 For more specialized training and guidance, please consult with your local ADAPT staff

21. See Surgeon General’s Toolkit for Details about Bucket 3