Richard N Rosenthal, MD Professor of Clinical Psychiatry

1. Treatment: Options and EffectivenessNational Partnership On Alcohol Misuse and Crime Meeting on Treatment, Washington, DC Richard N Rosenthal, MD Professor of Clinical Psychiatry Columbia University College of Physicians & Surgeons Chairman, Dept of Psychiatry St. Luke’s-Roosevelt Hospital Center, NY June 2, 2009

2. Disclosure RESEARCH  GRANT  SUPPORT: 2006 - 2008  Forest Laboratories, Inc. Principal Investigator 2007 - 2008  Titan Pharmaceuticals, Inc. Principal Investigator 2007 - 2012  National Institute on Drug AbuseCo-Investigator 2008 - 2010  The National Institute of Diabetes, Co-Investigator Digestive and Kidney Disease AFFILIATIONS: 2008 -           Sequest Technologies, Lisle, IL. Advisory Board

3. Overview • Who needs Treatment? • What is the Treatment Process? • How does it begin? • Who is involved? • Importance of Screening and Assessment • Consideration of Prior Convictions • Pre-treatment • Brief Interventions/Motivational Interviewing

4. Overview • Treatment Options and Effectiveness • Counseling Models and Outcome Differences • Motivational Enhancement Therapy • Cognitive Behavioral Therapy • Patient Placement Criteria: settings and levels of care • Role of Detoxification • Role of residential rehabilitation/halfway house • Voluntary vs. Mandatory Treatment • Treatment Vs. Education • Role of 12-Step and Support Group

5. Who Needs Treatment? • Heavy/at Risk drinkers • Medical Impact even without a “diagnosis” • Diagnosis of Alcohol Abuse - where symptoms increase likelihood of further sanctions due to impaired judgment/control • DUI, assault, loss of external social supports, missed appointments • Diagnosis of Alcohol Dependence • Impairment, disability

6. The Scope of Alcohol Problems in the Criminal Justice System • 21.6 percent of victims of violent crimes thought or knew the offender had consumed alcohol; another 1.5 percent of the victims thought the offender had used either alcohol or another drug (Bureau of Justice Statistics 2003). • 40 percent of offenders on probation, in State prisons, or in local jails reported using alcohol at the time of their offense (Bureau of Statistics 1998). • 18 percent of Federal prison inmates and about 25 percent of State prison inmates reported having experienced problems consistent with a history of alcohol abuse and dependence (Knight et al. 2002). • 29 percent of Federal and 40 percent of State prisoners reported a previous domestic violence dispute involving alcohol (Knight et al. 2002). • There were 1.4 million DWI arrests in 2001, making DWI the number one crime, besides drug possession, for which Americans are arrested (NHTSA 2003). • About two-thirds of convicted DWI offenders are alcohol dependent (Lapham et al. 2001). http://pubs.niaaa.nih.gov/publications/arh28-2/85-93.htm

7. The Scope of Alcohol Problems in the Criminal Justice System • In a study of first-time DWI offenders interviewed 5 years after first being referred to screening following their DWI offense (Lapham et al. 2001): • 85% of female and 91% of male DWI offenders had met the criteria for alcohol abuse or dependence at some time in their lives. • 32% of female and 38% of male offenders had met criteria for abuse of or dependence on another drug at some time in their lives. • 50% of women with an alcohol use disorder and 33% of men with an AUD also had at least one psychiatric disorder (not drug-related), most commonly depression and post-traumatic stress disorder. http://pubs.niaaa.nih.gov/publications/arh28-2/85-93.htm

8. Why Are Alcohol Use Disorders (AUD) Underdiagnosed ≈ 50% time? Clinicians: • Typically lack proper training in screening and recognition • Miss diagnosis if presentation is not obvious, e.g. “skid row bum” “Alcohol on Breath,” etc. • Are practical professionals, spend time on “fixable problems” • Frequently believe alcohol dependence isn’t treatable, leading to professional denial

9. Why Are Alcohol Use Disorders Underdiagnosed ≈ 50% time? • Patients with AUD typically: • minimize or deny strongly problem use • deny physical and psychological problems could be related to drinking • rationalize work and interpersonal problems as cause of use, not result • Present with emotional complaints (anxiety, mood disturbance) without linking them to alcohol use. • Significant others/family/friends in best position to report problems with alcohol but not present at screening or evaluation Adapted from Waldinger RJ: Substance-Related Disorders and Eating Disorders, in Psychiatry for Medical Students. 3rd Ed. American Psychiatric Press, Inc. Washington DC, 1997.

10. Screening in the Criminal Justice System • In 2002, Criminal justice/DWI referrals accounted for 40% of alcoholism treatment admissions to alone, and 34% of admissions to alcohol and other drugs treatment programs (SAMHSA 2004). • Court-ordered screening misses many people with AUD and other disorders • In N=1,078 convicted offenders, later voluntary screening reported proportionally more alcohol abuse or alcohol dependence compared to the court-ordered initial screening for alcohol problems (Lapham et al. 2004). Lapham, S.C et al., Drug and Alcohol Dependence 76:135–141, 2004

11. Screening in the Criminal Justice System • Limitations of screening procedures in the criminal justice system include: • No screening instruments are available that have proven validity to assess both AOD use and the range of mental health problems found in criminal justice populations. • Lack of screening instruments validated specifically for criminal justice offenders. • Most current screening instruments rely on self report. • Court-ordered screening is by definition coercive. • Screening and treatment programs have limited financial resources; costs may be passed on to people being screened or treated who may be unable to pay. Lapham, S.C et al., Drug and Alcohol Dependence 76:135–141, 2004

12. When to Implement Screening • A planned, purposeful and usually brief process that should occur soon after the offender enters the system. • Offenders screened at various stages of the judicial process, including at arrest or arraignment, at pretrial investigation, during interactions with court staff, or as a post-sentence action. • Screening and interventions with offenders who have AUD will probably be more effective if initiated soon after the offense, (laws are most likely to deter illegal behavior (e.g., DWI) if perceived to result in swift, certain, and severe sanctions (e.g., Morral et al. 2002). • National Commission on Correctional Health Care: • Comprehensive health assessment (including substance abuse history) within 7 days of arrival in prison, 14 days of arrival in jail Morral, A.R et al. Drug and Alcohol Dependence 66(Suppl.):S124–S125, 2002.

13. Screening and Assessment in Correctional Settings • Substance Use history: patterns of use, treatment, acute symptoms, need for detox • Criminal history • Personality traits related to criminality • Mental health issues, including suicide potential, acute symptoms, treatment history, psychiatric medications • Abuse and trauma history, as victim/perp • High-risk behaviors • Motivation for treatment • Education and literacy • Physical disabilities • Relationships with significant others, family, dependents • Physical health, acute conditions, infectious diseases including STD’s, HIV/AIDS, TB, and hepatitis

14. Screening for AUD • Screening: • determines the likelihood of alcohol use disorder • establishes the need for an in-depth assessment. • Begin at the earliest point of clinical contact with the offender and continue throughout treatment, if provided • Several screening tools can help determine the likelihood of the presence of problem alcohol use. • CAGE 4-item self report , scores 0-4, 2+ answers flag high risk • MAST 21-item self report, scores > 6 probable alcohol dependence • AUDIT 10 item self report, score > 8 in men, probable AUD > 4 in woman, probable AUD

15. Screening for AUD • CAGE – 4 Items • < 1 minute to administer • ≥ 2 “yes” answers = high risk for AUD • High sensitivity for AUD (60-95%) • No questions about frequency of use • No quantity of consumption questions • No frequency of heavy drinking questions • Because consequence-focused, won’t flag early problem drinkers

16. Screening for AUD • MAST – 25 Items • ≥ 7 Probable Alcohol Dependence • 5-6 Borderline Alcoholism • ≤ 4 No problem drinking • High Sensitivity for AUD (86-98%) • Questions elicit lifetime history rather than current drinking behavior (Magruder-Habib et al., 1991)

17. Screening for AUD • AUDIT – 10 Items, assesses over past year • WHO Collaborative effort • Multicultural (Babor & Grant, 1989) • Designed to screen earlier-level problems in primary-care settings • Sensitivity – 92%, Specificity – 93% • Three Domains: amount & frequency; alcohol dependence; alcohol-induced problems • Cutoff score of 8 of 40 = probable AUD

18. Simple Screening for AUD • Ask the screening question about heavy drinking days: How many times in the past year have you had 5 or more drinks in a day? (for men) 4 or more drinks in a day? (for women) • One standard drink is equivalent to 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits — • 1 or more heavy drinking days, or • AUDIT score of ≥ 8 for men or ≥ 4 for women • If endorsed, then a clinical evaluation

19. Clinician’s Initial Evaluation • Document current and past use of alcohol and each other substance separately – pattern?, who with? • Log prior quit attempts & treatments • Medications: how used? how long ? • Psychosocial treatment? • Assess current motivation to quit (pros & cons; quit date) • Assess triggers, withdrawal, and dependence • Assess social support

20. NESARC Any AUD 17.6 M (8.46 %) SAMHSA HOUSEHOLD SURVEY, 2004 Total US Population Over 12 Years (~237 M) Current Alcohol Users: 50.3% (~121 M people) Binge Drinkers: 22.8 % (55 M) Heavy Drinkers: 6.9% (~16.7M) (NSDUH, 2005)

21. Hazardous Drinking A “standard drink” contains about 14 g alcohol • At-Risk or Heavy Drinking is defined as: • Men: >14 drinks/week or >4 drinks/occasion • Women: >7 drinks/week or >3 drinks/ occasion • Hazardous alcohol consumption = 60-90 g alcohol • Good predictor of alcohol-related problems • Negative Impact on chronic medical illness • Significant increased morbidity and mortality McGinnis JM, Foege WH. JAMA. 1993; 270(18):2207–2212. NIAAA (2004) Helping Patients With Alcohol Problems. DHHS, Wash., DC.

22. DSM -IV Substance Abuse • Substance use leading to clinically significant impairment manifested by one (or more): • Failure to fulfill major role obligations • Hazardous situations • Legal problems • Continued substance use despite having persistent or recurrent social or interpersonal problems • Never met the criteria for substance dependence

23. Addiction: Classical and Contemporary Constructs Classical (Peele 1985): • Craving • Increased tolerance • Physiologic withdrawal Contemporary: Behavioral Dysregulation • Compulsive behavior despite negative consequences, i.e., loss of control • Salience – primacy in a person’s life • Cognitive – dominates mental life • Behavioral – dominates activity • Functional Impairment

24. Loss of Control Salience Functional Impairment DSM -IV Substance Dependence Three (or more) of the following over 12 Months: • Tolerance • Withdrawal • Larger amounts or over longer period than intended • Persistent desire or unsuccessful efforts to cut down • Much time spent in acquiring, using, or recovering from effects • Abandonment/reduction of important social, work, or recreational activities • Continued use despite knowledge of having an alcohol-induced or exacerbated physical or mental problem

25. Targeting Heavy Drinking • Proxy for Impairment • Impact of Heavy Drinking • Differences in NESARC diagnoses rates and rates of binge and heavy drinking

26. 2000 National Household Surveys on Drug Abuse (NHSDA) • Highest rates binge, heavy drinking young adults aged 21 to 25 • Peak rate 65 % at age 21 (45 % binge drinking, 17 % heavy drinking) • Binge and heavy alcohol use rates decrease faster with age than rates of past month alcohol use http://www.samhsa.gov/oas/2k2/alcNS/alcNS.htm

27. Impact of Heavy Drinking • About 25% have alcohol dependence • Increased risk: • gastrointestinal bleeding,  • sleep disorders,  • major depression,  • hemorrhagic stroke, • cirrhosis of the liver, and  • several cancers Rehm J Addiction. 2003;98(9):1209-1228. NIAAA (2004) Helping Patients With Alcohol Problems. DHHS, Wash., DC.

28. Hazardous Drinking • Defined as AUDIT scores: 8+ (Babor et al., 2001) • Sample Patient: • drank 2 – 3 times a week (3 points) • drank  2 drinks/day typically (1 point) • had  6 drinks on one occasion at least monthly (2 points) • “had a relative or friend, a doctor or other health worker” say that they have “been concerned about your drinking or suggested you cut down” in past year (4 points) • Total score = 10. Mertens, JR et al., Alc Clin Exp Res. 2005;29(6):989-998

30. Impact of Hazardous Drinking • 1,419 HMO primary care clinic patients, 13.9 K comparison group; AUDIT screen • Hazardous drinking prevalence of 7.5% • Alcohol abuse prevalence was only 0.38% • ↑prevalences of 8 medical conditions: • Pneumonia, COPD • Costly conditions such as injury and hypertension • Depression, anxiety disorders, and major psychoses Mertens, JR et al., Alc Clin Exp Res. 2005;29(6):989-998

32. Systematic Review Findings: Alcohol and Hypertension • 11 randomized controlled trials • Dose related effects • < 2 drinks/day or 10/week – usually decreases • > 3 drinks/day or 14/week – significant increase • Magnitude of effect about the same as salt intake • Effect of alcohol greatest in subjects with pre-existing hypertension McFadden et al. Am J Hypertension. In press. Slide courtesy A.T. McLellan, PhD

33. Systematic Review Findings: Alcohol and Diabetes • 32 studies • U-shaped association • Moderate alcohol (1-3 drinks/ day) • 33-56% lower incidence of diabetes • 34-55% lower incidence of diabetes-related coronary heart disease • Heavy alcohol (>3 drinks/day): up to 43% increased risk of diabetes Howard, A.A. et al. Ann Int. Med. 2004;140:211-219

34. Interventions for Heavy Drinkers

35. Screening as a Brief Intervention • In various medical settings, brief interventions are recommended for patients who misuse alcohol and are at risk for dependence, but who are not alcohol dependent. • These interventions typically: • Involve four or fewer sessions • Are not conducted in a specialized alcoholism treatment facility, and • Are performed by health care providers and others who are not specialized in addiction treatment.

36. Impact of Brief Physician Advice for Heavy Drinkers • TrEAT study (Trial for Early Alcohol Treatment) • RCT N=723 subjects, 12 and 48-month follow-up, 64 MDs in 17 primary care offices • Two 10-15’ physician-delivered, counseling visits • Review drinking norms, patient-specific effects, • Worksheet on drinking cues, diary cards • Drinking agreement as a prescription Fleming MF, et al. Alcohol Clin Exp Res. 2002(Jan);26(1):36-43

37. Impact of Brief Physician Advice for Problem Drinkers • 2 nurse follow-up calls • Measures: • Alcohol use, • ER visits and • Hospital days Fleming MF, et al. Alcohol Clin Exp Res. 2002(Jan);26(1):36-43

38. Impact of Brief Physician Advice for Problem Drinkers Baseline Control 12-month Control BaselineIntervention 12-month Intervention # drinks 7 d 18.9 15.5 19.1 11.5* # binges 30 d 5.3 4.2 5.7 3.1* % excessive use ETOH 7 d 48.1 32.5 47.5 17.8* *p<0.001 Fewer hospitalization days in Exp group, χ2(P < 0.01) Fleming MF, et al. JAMA 1997;277:1039-1045

39. Impact of Brief Physician Advice for Problem Drinkers • Significant reductions • 7-day alcohol use • Number of binge episodes • Frequency of excessive drinking • Effects by 6 months, sustained at 48 months • Fewer hospital days and ER visits • For every $10K invested in early intervention, $43K future health cost reduction (without including MVA and crime costs) Fleming MF, et al. Alcohol Clin Exp Res. 2002(Jan);26(1):36-43

40. Targeting Heavy Drinking • Psychosocial interventions that reduce alcohol intake have important clinical effects • Why not use medications that might accomplish the same? • Proxy diagnosis “hazardous or heavy drinkers” versus categorical one • Drinkers without diagnoses might not want to be abstinent • Large potential social utility • Naltrexone’s main effect is reduction in heavy drinking

41. MotivationaI Interviewing • Definition: Motivational Interviewing is • a client-centered, directive method • for enhancing intrinsic motivation to change • by exploring and resolving ambivalence, • typically in a particular direction of change. Miller R, Rollnick S. Motivational Interviewing: Preparing People for Change, New York: Guilford, 2002

42. Stages of Change Model • Precontemplation • Contemplation • Preparation • Action • Maintenance • Prochaska, J.O.; DiClemente, C.C. & Norcross, J.C. Am Psychol 47(9):1102-1114, 1992.

43. Stages of Change Model • Precontemplation- Overestimates costs of change and underestimates benefits. No intention to take action due to: • lack of information • not understanding consequences of not changing • demoralization after repeated failures • No inherent motivation (e.g. crawling to walking) – progress due to events, differential processing • Developmental, e.g., hitting 39th birthday, taking stock • Environmental: Beloved dog dies of lung cancer • Heavy-smoking wife quits smoking • Heavy-smoking husband buys new dog! • Prochaska, J.O. in: Ries R. et al. Eds, Principles of Addiction Medicine, 4th Ed. • Lippincott, Williams & Wilkins, 2009, pp 745-755.

44. Stages of Change Model • Contemplation– More aware of the benefits of change, acutely aware of the costs • Can present as profound ambivalence • Client can entertain the reality of a problem • Preparation– Decisional balance has tipped in favor of change, which is being planned for in next 30 days • Plan of action: go to AA, talk to physician, buy a self-help book, etc. • Action– Client makes specific, overt changes in lifestyle • Only modifications of behavior that results in reduction of disease risk is deemed effective action • Maintenance– Working to prevent relapse • Prochaska, J.O. in: Ries R. et al. Eds, Principles of Addiction Medicine, 4th Ed. • Lippincott, Williams & Wilkins, 2009, p 745-755.

45. Clinical Impact: Change Model Precontemplation Maintenance slip relapse + drop out relapse Contemplation Action Preparation

46. Principles of Motivational Interviewing • MI differs from traditional counseling in that it is client-centered: • Collaborates rather than confronts • Evocates rather than educates • Respects autonomy rather than imposing authority • Not focused on: • teaching new coping skills • reshaping cognitions • exploring the past • A way of being with rather than to do something to • Elicits intrinsic motivation rather than using extrinsic ones (coercion such as legal sanction, punishment, social pressure, or reward such as financial gain). • Negative contingency frequently doesn’t work (as you well know). Miller R, Rollnick S. Motivational Interviewing: Preparing People for Change, New York: Guilford, 2002

47. Clinical Assessment/Intervention • Integrate Motivational Interviewing into the clinical assessment interview for treatment seeking clients: • understand the motives clients have for addressing their substance use problems • gather the clinical and administrative information needed to plan their care • build and strengthen their readiness for change Martino, S. et al. (2006) Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency. Salem, OR: Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University. http://www.motivationalinterview.org/library/MIA-STEP.pdf

48. Motivational Interviewing • Identifying substance-related losses important for motivating people with comorbid psychiatric disorders contemplating behavior change (Blume & Marlatt, Addict Behav, 2000) • Pilot data: one-session preadmission 45-60’ motivational interview more effective than standard preadmission interview - partial hospital program. (Martino et al., Am J Addict, 2000)

49. High-Grade Evidence of MI Efficacy • http://www.motivationalinterview.org/library/index.html • Dunn C, Deroo L, Rivara FP. The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review. Addiction 2001;96:1725–42. • Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. J Consult Clin Psychol 2003;71:843–61. • Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and metaanalysis. Br J Gen Pract 2005;55:305–12.

50. Motivational Enhancement Therapy • View of the patient as self-directed and responsible for and capable of changing his or her behavior. • The clinician assists the patient in mobilizing his or her own inner resources. • MET allows the patient to determine treatment goals and encourages movement from one motivational stage to the next.