Chapter Eight: Evaluation and Treatment Overview

1. Chapter Eight: Evaluation and TreatmentOverview

2. what is treatment? • Treatment of what ? • Multiple potential targets: • problems of chronic heavy use • problems of acute use • efforts to avoid harmful use

3. chronic disease framework • Framework to address diverse alcohol problems • Entails • identification of risk factors • risk reduction • monitoring status • patient education

4. screening and evaluation • Rationale for broad based screening • high rates of morbidity and mortality if untreated • condition is wide spread • treatment is available • treatment is effective • Two screening approaches • laboratory tests & interview

5. laboratory tests • Laboratory measures • limited utility • BAC only when alcohol in system • liver function generally identify liver disorders related to heavy drinking • Carbohydrate-deficient transferrin exception tied to recent drinking

6. screening tests • Variety of tests available • Differ in terms of — • format • focus of screening (high risk use, alcoholism, alcohol problems) • utility with special populations • should not be considered diagnostic

7. major screening tests • CAGE • TRAUMA Index • AUDIT Alcohol Use Disorder Identification Test • MAST Michigan Alcohol Screening Test • DAST Drug Abuse Screening Test • TWEAK • DALI Dartmouth Assessment of Lifestyle

8. CAGE • Four questions • Have you ever tried to Cut down • Have you ever gotten Annoyed by comments on your drinking • Have you ever felt Guilty about your drinking? • Have you ever had an Eye opener

9. Alcohol Use Disorders Identification Test (AUDIT) • developed by World Health Organization • goals: • identify high risk drinkers • instrument for primary care • valid in different cultures • 10 questions — drinking patterns signs of dependence social consequences self-concerns

10. AUDIT questions 1. How often do you have a drink containing alcohol? never = 0 2-3 times per wk = 3 1or less per month.=1 4 or more per week = 4 2. How many drinks do you have on a typical day when you are drinking? 1 or 2 = 0 5 or 6 = 2 10 or more = 4 3 or 4 =1 7 to 9 = 3

11. AUDIT questions (cont.) How often — 3. do you have 6 or more drinks per occasion? 4 have you found yourself unable to stop drinking in the past year 5. have you failed to do what was normally expected due to drinking, in past year? never = 0 <monthly = 1 monthly = 2 daily or almost = 4

12. AUDIT questions (cont.) How often during the past year have you ... 6. needed a drink in the morning after drinking the night before? 7. had a feeling of guilt about your drinking? 8. been unable to remember what happened the night before, when you were drinking? never = 0 <monthly = 1 monthly = 2 daily or almost = 4

13. AUDIT questions (cont.) 9. How often during the past year have you or someone else been injured as a result of your drinking? never = 0 <monthly = 1 monthly = 2 daily or almost = 4 10. Has a relative or friend, or doctor or health worker been concerned about your drinking or suggested cutting down? no = 0 yes, but not past year = 2 yes, in last year = 4

14. Trauma Index • To identify early-stage problem drinkers • Since your 18th birthday have you — • “Had any fractures or dislocations?” • “Been injured in a traffic accident?” • “Had a head injury?” • “Been injured in an assault or fight?” • “Been injured after drinking?”** only alcohol specific question

15. Trauma Index (cont.) • Scoring: 2 or more positive answerslikelihood of alcohol problem • Basis: Accidents and injury statistically more common among those with alcohol problems • Identifies 2/3rds of problem drinkers

16. TWEAK • Developed for pregnant women • 5 questions • Modification of CAGE • Acronym: Tolerance, Worry, Eye-opener, Amnesia (blackouts), K/cut down

17. MASTMichigan Alcohol Screening Test • Introduced in 1971, to identify alcoholics • Questions touch on medical, interpersonal, and legal problems • Different formatsMAST (original) = 25 questionsShort MAST = 13 questionsBrief MAST = 10 questions

18. MAST (cont.) • Scoring: Nonalcoholic = 3 or less pointsSuggestive of alcoholism = 4 pointsAlcoholism = 5 or more points

19. DAST (Drug Abuse Screening Test) • adaptation of MAST • 28 questions • largely substitutes “drug use” for “alcohol use” in questions • focus on interpersonal, social,legal and medical problems of druguse, and concerns of self or others • score of 5 or more, suggests need for further evaluation

20. DALIDartmouth Assessment of Lifestyle Instrument • Purpose: to assess alcohol and other drug use problems • Population: persons with chronic mental illness • Structure — • social rather than physical criteria • computer self-administration

21. when screening is positive • Engage individual • Substance use history • Identify medical concerns • Assess withdrawal risk • Identify indications for immediate medical evaluation

22. engaging patient • Ask about person not the alcohol • Motivational interviewing • Stages of Change • pre-contemplation • contemplation • determination • action • maintenance

23. stages of change: pre- contemplation • Characteristics • no recognition of need for change • problem identified by someone else • Clinical tasks • foster awareness of dangers of behavior • raise doubts about status quo

24. stages of change: contemplation • Characteristics • ambivalence • perceives plus and minuses to change • Clinical tasks • try to tip scale in favor of change • promote risk-benefit analysis • focus on undermining the “pluses”

25. stages of change: determination • Characteristics • ambivalence  • eager to do something • Clinical tasks • focus on specific things to be done • provide an expert’s opinion • provide support for action

26. stages of change: action • Characteristics • engaged in implementing a plan • may be formal treatment • Clinical tasks • provide assistance and direction • provide support for action

27. stages of change: maintenance • Characteristics • actions to sustain changes • may be formal treatment • Clinical tasks • provide assistance and direction • identify trouble spots • provide support for action

28. factors prompting change • Studies of “spontaneous remission” suggest factors prompting change • “ Spontaneous remission” misnomer • usually not spontaneous • not true remission • Actually, improvement without treatment

29. Illness or accident 33% Extraordinary event 29% such as pregnancy suicide attempt humiliation Religious or conversion experience 26% Financial problems 22% Family intervention 18% Friends’ alcohol death or illness, 14% Alcohol education 12% Alcohol-caused legal problem, 8% factors cited as prompting change

30. criteria for selecting treatment services ASAM guidelines of dimensions to assess • acute intoxication and/or withdrawal risk • medical conditions • emotional/psychiatric status • recognition of need for treatment • risks of continued use • recovery environment

31. levels of care • ASAM defined • Based on assessment of 6 dimensions • Levels of care 0.5 Early intervention I Out-patient treatment II Intensive outpatient or partial hospitalization III Inpatient/residential care IV Medically managed inpatient care

32. treatment of alcohol incident • Definition“ negative consequences of drinking but does not meet criteria for alcohol abuse or dependence • Clinical tasks • harm reduction • client education • follow-up/monitoring

33. brief treatment • Non-alcohol/drug settings • Goal: reduce harmful use • Typically one or two 15 min. sessions • Common elements • clear advice • patient education • contract • Stepped care if not effective

34. brief treatment key elements • Feedback about risk • Responsibility lies with patient • Advice to change • Menu of ways to reduce drinking • Empathetic counseling style • Self-efficacy/optimism of patientAcronym = FRAMES

35. treatment: alcohol abuse • Characteristics • chronic condition • pattern of high risk use • negative consequences • may be difficult to assess loss of control • Treatment • formal treatment, patient education, monitor ability to moderate use

36. treatment: alcohol dependence • Goals • establish abstinence as a pre-requisite • develop skills to live without alcohol • Setting: determined by client status • Treatment phases • each with distinct tasks

37. treatment of dependence factors to address • Dysfunctional lifestyle • Drinking as a major method of coping • Psychological wounds • Physical problems • Chronic nature of alcohol dependence • Deterioration in family functioning

38. relapse • Common in all chronic illnesses • “Relapse” versus “break in sobriety” • Planning response to drinking incident • Anticipatory guidance relapse prevention during treatment

39. treatment outcome • Positive outcomes compared to other chronic illnesses • Multi-site center study (2001) One year post treatment • 10 % drinking, no problems • 25 % continuously abstinent • remaining two-thirds consumption  87% problems  60%

40. treatment outcome (cont.) • Points to consider result of single treatment episode higher rates of continued abstinence in special populations • Client characteristics more significant factorthan program type

41. treatment outcome clinician impact • Outcome not related to clinician age, race, education, gender, personal alcohol history • Outcome is related to clinician’s • therapeutic alliance • positive emotional responses • adherence to manual-ized approaches • interpersonal style, and • client evaluation of clinician’s competence