Copyright Alcohol Medical Scholars Program1 Substance Use Disorders: Does Treatment Work? Christina M. Delos Reyes, MD Department of Psychiatry CWRU School

Copyright Alcohol Medical Scholars Program 1

Substance Use Disorders:Does Treatment Work?

Christina M. Delos Reyes, MDDepartment of PsychiatryCWRU School of Medicine


Topics to be covered

• Clinician hopelessness • Medical model of SUDs• Treatment effectiveness• Increasing clinician optimism


Clinician Hopelessness

• Society’s attitudes• Personal experiences• Exposure to severe, late stage

disease• Negative reactions are reinforcing

and self-fulfilling• Inadequate training of clinicians


Inadequate SUD Training

• Attitudes learned and internalized• Medical school

– 75% “little or no training in SUDs”

• Residency programs– 44% with no required curriculum

• Clinicians in practice– 33% fail to screen for SUDs


Substance Dependence

• 3 of 7 criteria in 12-month period- Tolerance- Withdrawal- More than intended- Cut down- Time spent using- Limit activities- Use despite consequences


Substance Abuse

• Never met criteria for dependence• 1 of 4 criteria in 12-month period

- Role failures- Hazardous use- Legal problems- Interpersonal problems


Explanatory Models

• Moral wrong• Spiritual empty• Psychological impulse control• Behavioral habit• Medical disease


Medical Model

• Sick person seeking wellness• SUDs as chronic diseases

– Biological basis– Identifiable signs and symptoms– Predictable course and outcome

• Treatment improves outcomes


Biological Basis of SUDs

• Genetic influences– 4x risk in children of alcoholics Concordance in identical twins

• Biochemical correlates– Dopamine and the reward system– CRF and craving


Predictable Course of Alcohol Dependence

• Onset by age 31• Present for Rx by age 41• Fluctuating course• 10-30% spontaneous remission


Predictable Course of Alcohol Dependence

• Life span decreased by 10-15 yrs• Leading causes of death

1. Cardiovascular2. Stroke3. Cancers4. Accidents5. Suicide


What is treatment?

• Comprehensive approach to a chronic disease

• Four basic goals– Enhance function– Optimize motivation toward

abstinence– Restructure life without substances– Relapse prevention


Treatment Structure

• Detox is not always needed • Several forms of rehab

– Short-term inpatient – Outpatient drug-free – Long-term residential– Outpatient maintenance– Aftercare


Treatment Components

• Educational lectures• Counseling

– Group– Individual– Family

• AA and other 12-Step groups• Vocational rehabilitation• Pharmacotherapy


Does Treatment Work?

• Outcomes –Functioning at followup after treatment

• Efficacy–Comparing outcomes in treatment group vs. control group


Treatment Outcomes

• Continuous abstinence• Amount of use• Criminal activity• Employment• Relationships• Health


Patient Factors Predicting Better Outcomes

• Severity of substance dependence

• Motivation• No psychiatric disorders• Social supports• Criminal involvement• Treatment completion


Program Factors Predicting

Better Outcomes

Range, frequency, intensity of services

• Flexible, individualized treatment

Length of time in treatment


National Multi-site Outcome Research

Study Name Date published• TOPS 1989• CATOR 1991• NTIES 1997• DATOS 1997• Project MATCH 1997


Treatment Outcome Prospective Study

• % Reduction in weekly cocaine use– 1-year post-treatment 35%– 2-years post-treatment 56%

• % Reduction in weekly heroin use– 1-year post-treatment 60%– 2-years post-treatment 70%


Treatment Outcome Prospective Study

• Increase in % of clients working– Before treatment 31%– After treatment 45%

• % Reduction in predatory crime– 1 year post-treatment 27%– 2 years post-treatment 45%


Chemical Abuse Treatment Outcome

Registry

• Total abstinence at followup–1 year 40% –2 years 33%


National Treatment Improvement Evaluation

StudyDRUG USE

YEAR BEFORE RX

YEAR AFTER RX

Crack Cocaine 50% 25%

PowderCocaine 40% 18%

Heroin 24% 13%



Study% Decrease in criminal behavior

51% drug possession64% arrests78% assault78% selling drugs82% shoplifting



Study% Reduction in health problems

AOD-related medical visits 54%Suicide attempts +AOD 40%Suicide attempts –AOD 48%Inpatient MH visits 57%Panic symptoms+AOD 96%


Drug Abuse Treatment Outcome Study

% Reduction at 1 year followup

Heavy drinking 52%Weekly cocaine use ~ 60%Weekly heroin use 69%


Drug Abuse Treatment Outcome Study

% Spending time in jail

Year prior to treatment 70% Year after treatment

30%


Matching Alcoholism Treatment to Client

HeterogeneityCan certain patients be matched

to different treatments?

• CBT: Cognitive Behavioral Therapy• TSF: Twelve Step Facilitation• MET: Motivational Enhancement

Therapy


Matching Alcoholism Treatment to Client

Heterogeneity

• ~50% abstinent or significantly reduced drinking at 1-year and 3-year followup

• All 3 approaches were effective


Comparison to Other Chronic Diseases

Med compliance

Required hospital stay annually

Follow diet & behaviorchange

DM I <60 % ~40 % <30 %

HTN <40 % ~60 % <30 %

Asthma <40 % ~60 % <30 %


Redefining Success

Appropriate comparisons– Treat SUDs as chronic diseases– Comparable to other chronic

diseases• Reasonable expectations

– Complete abstinence is not the only successful outcome


Reasonable Expectations

• Higher expectations for SUD treatment

• “Relapse” = Failure in SUDs• “Relapse” = Effectiveness in

other chronic diseases


IncreasingClinician Optimism

• Improved training – Increase recognition and

treatment of SUDs – Enhance clinician confidence– Share hope of recovery with

patient


Treatment is Worthwhile!

• SUDs common and easily identified

• Effective treatment exists• Similar outcomes to other

chronic diseases• Transform hopelessness into

optimism

Documents

Copyright Alcohol Medical Scholars Program1 Substance Use Disorders: Does Treatment Work? Christina M. Delos Reyes, MD Department of Psychiatry CWRU School