Effective Treatment: Doing the Right Thing in the Right Way

Terrence D Walton, MSW, ICADC

Treatment

MoralityModal

TemperanceModel

Disease Concept

Alcoholics Anonymous

EBT

Manuals

BestPractice

Outcomes

Science

OUT IN

Efficacy

Outcomes

Evidence

Anecdotes

Instincts

Process

Practice

EffectiveTreatment

Process

Full Continuum of Care

Adequate Duration Sufficient Intensity Stage of Recovery-

based Design Policies & Procedures Team Interactions Evaluation

Practice

Culturally-appropriate evidenced based treatment practices

Practitioners trained and coached in manual-guided delivery

Services dominated by those that have been rigorously tested

Good

Drug Courts

AlcoholTreatment

BetterDUI

Courts

DUI Offender Treatment

Sources of Information

More

Drug Courts

AlcoholTreatment

Less

DUI Courts

DUI Offender Treatment

Sources of Information

• Randomized Controlled Trials• Project MATCH• COMBINE Study• UK Alcohol Treatment Trials• Mesa Grande Project (361

clinical trials analyzed)

Four Big Alcohol Studies

A Big Resource

National Registry of Evidenced-based Programs and Practices:

www.nrepp.samhsa.gov.

1. Behavioral Couples Therapy (BCT)– Not well tested in an offender population

2. Brief Interventions (5 or fewer sessions)– Not appropriate for an addicted DUI offender

Other Evidence Based Practices

Not Evidence Based

1. Generic Counseling2. AOD Education3. Confrontational

Interventions4. Psychodynamic Therapy5. Solution-focused

Therapy6. Mindfulness-based

Stress Reduction7. Acupuncture

Goals of Cognitive Behavioral Therapy (CBT) Approaches

1. Analyzes thoughts, feelings, and actions (behavior)

2. Thoughts drive emotions

3. Emotions drive behavior

4. Identify thinking patterns and stop thinking “errors” from leading to emotional reactions that produce problem behaviors.

Key Question

SHOW ME THE MANUALS!

Be Skeptical

• Nearly every evidenced based intervention is manual-based.

• However not every intervention that is manual-based is evidenced based.

1. To increase and maintain the person’s motivation to change his or her life

2. Motivate those who don’t want to change

3. Help increase the motivation of the people who aren’t sure

4. Help the motivated maintain their readiness to change

Motivational Approaches

1. Motivational Interviewing: Preparing People for Change– William Miller & Stephen

Rollnick (2002)

2. Addiction and Change: How Addictions Develop and Addicted People Recover– Carlo C. DiClemente

(2003)

Pre-Contemplation Contemplation

Preparation

Action

Maintenance

Assessing Readiness to Change

1. To provide relief from withdrawal symptoms

2. To prevent drugs from working (antagonist)

3. To reduce craving

4. To provide replacement (agonist)

5. To provide aversive reactions

Medication-Assisted Treatment

• Naltrexone – Interrupts actions of alcohol and opiates; reduces cravings (Vivitrol)

• Acamprosate – reduction of alcohol cravings

• Disulfiram/Antabuse – produces adverse reaction with alcohol use

Medication-Assisted Treatment

• Methadone – Opiate addiction – reduces craving, mediates withdrawal symptoms, helps restore normal functioning (agonist)

• Buprenorphine (Subuxone) – similar to methadone, may be prescribed by an MD with special training (partial agonist)

Driving while usinga legally prescribed medication,

including methadone taken according to doctor’s orders,

can still trigger a DUI charge in all 50 states

Medication-Assisted Treatment

Combining Medications and Behavioral Interventions for Alcoholism

THE COMBINE

STUDY

• Finding: Naltrexone in combination with medication management sessions delivered by health professionals was at least as effective as psychosocial interventions

• Side note: Pathology of multiple DUI offenders will likely require psychosocial interventions in addition to medications

Those Missed

92.9% with bipolar disorder 68.4% with depression 100.0% with OCD

1. Blended Screening and Assessment Approaches?

2. Education on Co-Occurring Disorders?3. Medication Monitoring and Management

Sessions?4. Heavy Utilization of Positive

Reinforcement and Flexible Application of Graduated Sanctions?

5. Mental Health Specialists?6. Agreements with Community Mental

Health Services Agencies?

Does Program include:

Twelve Step

Groups

What About Alcoholics Anonymous?

What about coerced AA participatio

n?

What About Alcoholics Anonymous?

“Attendance” versus

“Involvement” (active participatio

n)

What About Alcoholics Anonymous?

Seek Alternative

s to Mandating

AA

Using Support Groups in Therapy

“The 12 Step Facilitation Therapy Manual”Offer choice (types, spiritual & secular)Be selective regarding approved groupsTry to match demographics, lifestyles, and level of substance involvementwww.smartrecovery.org

1. Identify and adopt evidence-based practices2. Incorporate medication-assisted treatment3. Utilize alcoholics anonymous and provide

secular alternatives for those with religious-based objections

4. Treat the hard, core alcohol-dependent impaired driver

5. Modify (lessen) treatment requirements if treating non-addicted participants in DWI Court.

6. Stay abreast of latest DUI Court treatment-related research findings

Next Steps