Embed Size (px)
Citation preview
WEB-BASED INTERVENTIONS: A STEPPED CARE APPROACH FOR PROBLEM DRINKERS
Reid K. Hester, Ph.D. Director, Research Division Behavior Therapy Associates, LLC www.behaviortherapy.com [email protected]. 505.345.6100
ASAM Disclosure of Relevant Financial Relationships
Content of Activity: 2013 State of the Art Course in Addiction MedicineName Commercial
InterestsRelevant Financial
Relationships: What Was Received
Relevant Financial
Relationships: For What Role
No Relevant Financial
Relationships with Any
Commercial Interests
Reid K Hester, Ph.D.
DCU Owns copyright
CDCU Owns copyright, patent pend.
ModerateDrinking app
Owns copyright
Overcoming Addictions app
Owns copyright
Checkup & Choices app
Owns copyright, patent pending
Thanks
NIAAA for funding Research staff (RAs, T. Haney, H.
Delaney, Bo & Bill Miller, consultants) Study participants
Overview
Problem drinkers: The big picture Stages of Change & matched
interventions Stepped care: only as much as needed BMIs Action-oriented protocols Management issues
Consumption & alcohol related problems
NoneMild
Moderate
Substantial
Severe
Alcohol Problems
None Mild
Moderate
Substantial
Severe
Consumption
IOM, 1990
Spectrum of interventions
NoneMild
Moderate
Thresholdfor action
Brief intervention, moderation training
Abstinence focused treatment
Substantial
Severe
Alcohol Problems
Stages of Change
Contemplation (Should I change
my drinking?) [DCU/CDCU]
Preparation (Goals, What Would it look like? [DCU/CDCU]
Action (How do I change my drink-
ing?) [MD.com/OA]
Maintenance
Relapse
Precontemplation
Permanent exit
Using a stepped care model for screening & intervention Using the minimal amount of
intervention needed to resolve problems (Sobell & Sobell, 2000). Screening (1 question) BMIs Action-oriented protocols
Moderation programs Abstinence programs
Detecting & screening
Screen as integral part of lifestyle assessment
Consider drinking from health standpoint, not disease standpoint
Will (non-dependent) heavy drinkers be interested?
When Patient Screens Positive
Assess extent of drinking & for heavy drinkers answer question, “Should I change my drinking?”
BMIs The Drinker’s Check-up (25+ y/o) The College Drinker’s Check-up (<25 y/o)
The Drinker’s Check-ups (DCU & CDCU)
Web version www.drinkerscheckup.com
Randomized clinical trial: moderate drinking outcomes far more common than abstinence (10%) (Hester et al., 2005).
Average Peak BAC per Drinking Day
0
50
100
150
200
Immediate 193.9 102.8 108.4 66.7
Delayed 150.8 115 75
Baseline 4 weeks 8 weeks 12 mo
Preparation State: Goals of Change
Cut back or abstain Natural recovery literature (Sobell et al.)
Most people w/alcohol problems reduce their drinking w/o any professional or self-help Tend to be the less dependent drinkers
Relationship of hx. alcohol problems & success in reducing alcohol problems w/moderation (Miller et al., 1992)
Non-Dependent Problem Drinkers
Prevalence is increasing (NIAAA, 2004) Tend to not seek abstinence-oriented
treatment. Constitute the majority of those who
recover w/o formal treatment (i.e. natural recovery) At same time they have long histories of
alcohol-related problems.
Are moderation protocols effective?
Outcome summary from Hester & Miller (2003) www.behaviortherapy.com/whatworks.htm More controlled clinical trials of BSCT than
any other treatment until recently Variety of ways to provide the tx. (face-to-
face, bibliotherapy, web app.)
Moderate Drinking
2-3 Std drinks for men, 1-2 for women 3-4 days/wk Peak BACs <.055 Maximum limits 3/7 day/week women,
4/14 day/week men (<65 y/o)
Resources
Moderation Management (www.moderation.org)
Moderation training protocols (e.g., www.moderatedrinking.com)
Moderate Drinking & Moderation Management: Results of a randomized clinical trial
80 heavy drinkers randomly assigned to: a) MD + MM or b) MM alone
Follow-ups at 3, 6, & 12 mo. 73% had outcome data at all 3 f-
up points
Baseline DataGroup
MD +MM MM only
Age 48.7 52.1
Education in Years 15.7 15.1
MAST score 14.1 13.2
Drinks (SECs)/Week 33.0 35.4
Percent Days Abstinent (PDA)
16.3 16.2
Mean Drinks per Drinking Day
5.5 6.1
Group
MD +MM MM only
Mean Peak BAC per Drinking Day
111mg% 119mg%
Hours BAC > 80 mg% (in prior week, descending curve)
21.9 26.1
DrInC Recent Total score 24.3 21.3
AUDIT score 17.7 18.3
Baseline Data
Median Peak BAC/Drinking Day
40
50
60
70
80
90
100
Baseline 3 Mo F-up 6 Mo F-up 12 Mo F-up
MD + MM MM only
Percent Days Abstinent
0
10
20
30
40
50
Baseline 3 Mo F-up 6 Mo F-up 12 Mo F-up
MD + MM MM only
DrInC Recent Total Scores
0
10
20
30
Baseline 3 Mo F-up 6 Mo F-up 12 Mo F-up
MD + MM MM only
Parameters for Moderation
AUDIT score over 8 MAST score under 20 Medical hx to screen for
contraindications Clients with less severe alcohol-related
problems Clients who refuse abstinence without
first trying moderation
Ethical and practical issues
Moderation achievable by many, but not all
Predictors of success not perfect Lack of success by 6-8 weeks not good
sign for chances of long term success in moderation
What to do with the clearly dependent client?
Share info about likelihood of success with moderating drinking (Miller, et al., 1992)
Discourage abstinent alcoholics from trying moderation
Urge "vacation" from drinking Agree to moderation trial w/contract to
abstain if unsuccessful
Moderation issues
Most significantly dependent clients won't opt for moderation, especially once it is explained to them
Clients will always choose their own goal (see Sanchez-Craig's BSCT study w/abstinence & moderation gps)
Abstinence Oriented protocol
Overcoming Addictions, A SMART Recovery web application (www.overcomingaddictions.net)
A 4-step, CB-T & MET protocol Build, maintain motivation Dealing w/urges, cravings Managing thoughts, feelings, actions Lifestyle balance for relapse prevention
SMART Recovery
www.smartrecovery.org 1,000+ face-to-face meetings 30 Online meetings/week Forum for support Manuals, etc. on their web site
Variable Overall Group
SR SR + OA OA
(n = 86) (n = 83) (n = 19)
Female n (%) 114 (60.6%)
52 (61%) 50 (60%) 12 (63%)
Age M (SD) 44.3 (10.9) 43.4 (10.6) 44.6 (11.1) 48.3 (8.4)
Ethnicity n (%)
White 170 (90.4%) 76 (88.4%) 77 (92.8%) 17 (89.5%)
Hispanic 5 (2.7%) 3 (3.5%) 1 (1.2%) 1 (5.3%)
Other 7 (6.9%) 7 (8.1%) 5 (6.0%) 1 (5.3%)
Education M (SD)
16.1 (2.4) 15.93 (2.5) 16.0 (2.3) 17.3 (2.1)
AUDIT M (SD)a 24.7 (8.1) 24.8 (8.1) 23.95 (8.2) 27.4 (7.2)
BSI M (SD)b 17.4 (12.9) 19.35 (12.5) 15.95 (13.6) 14.8 (11.0)
InDUC M (SD)c 41.4 (17.9) 42.2 (19.0) 40.6 (17.5) 40.8 (15.6)
Baseline characteristics
Percent Days Abstinent Baseline 3 months 6 months
OA only 36.46 59.24 54
OA + SR 46.63 82.47 77.2
SR only 41.72 71.5 74.48
40
50
60
70
80
OA onlyOA + SRSR only
Drinks per Drinking Day
Baseline 3 months 6 months
OA only 8.7 4.7 6.2
OA + SR
6.8 3.6 4.2
SR only 8.6 4.7 3.8
0.5
2.5
4.5
6.5
8.5
OA onlyOA + SRSR only
Alcohol Problems
Baseline 3 months 6 months
OA only 40.8 19.5 22.1
OA + SR 35.4 17.8 15.4
SR only 41.2 18.6 17.8
5
15
25
35
45
OA onlyOA + SRSR only
www.CheckupandChoices.com
Our newest web app integrates: DCU, CDCU, MD, & OA
Designed for use with patients in primary care
Screens for heavy drinking, drug use Provides BMI Segues to MD & OA
Clinical Management
For many problem drinkers, BMI is sufficient
Some will benefit from moderation protocols, some will need abstinence-oriented protocols
Brief follow-ups key to knowing how much has been enough
References
Hester, R.K., Delaney, H.D., & Campbell, W. (2012). The College Drinker’s Check-up: Outcomes of two randomized clinical trials of a computer-based brief motivational intervention. Psychology of Addictive Behaviors,
Hester, R.K., Delaney, H.D., & Campbell, W., (2011). Moderatedrinking.com and Moderation Management: 12-month outcomes of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 79, 215-224. Abstract at http://psycnet.apa.org/psycinfo/2011-03047-001
Hester, R.K., Delaney, H.D., Campbell, W., & Handmaker, N.(2009). A web application for moderation training: Initial results of a randomized clinical trial. Journal of Substance Abuse Treatment, 37(3), 266-276.
Hester, R.K., Lenberg, K.L., Campbell, W., & Delaney, H.D.D. (2013). Overcoming Addictions, a web-based application, and SMART Recovery, an online and in-person mutual help group for problem drinkers Part 1: Three-Month Outcomes of a Randomized Controlled Trial. Journal of Medical Internet Research, 15(7):e134.
Hester, R.K., Squires, D.D., & Delaney, H.D. (2005). The Computer-based Drinker’s Check-up: 12 month outcomes of a controlled clinical trial with problem drinkers. Journal of Substance Abuse Treatment, 28(2), 159-169.
Miller, W. R., Leckman, A. L., Delaney, H. D., & Tinkcom, M. (1992). Long-term follow-up of behavioral self-control training. Journal of Studies on Alcohol, 53, 249-261.
National Institute on Alcohol Abuse and Alcoholism. (2004a). Alcohol abuse increases, dependence declines across decade. www.niaaa.nih.gov/press/2004/NESARCNews.htm
Sobell, M. B., & Sobell, L. C. (2000). Stepped care as a heuristic approach to the treatment of alcohol problems. Journal of Consulting and Clinical Psychology, 68, 573–579.
