Web-based Interventions: A stepped care approach for problem drinkers

1. Reid K. Hester, Ph.D. Director, Research Division Behavior Therapy Associates, LLC www.behaviortherapy.com reidhester@behaviortherapy.com Tel. 505.345.6100 Web-based Interventions: A stepped care approach for problem drinkers

2. ASAM Disclosure of Relevant Financial Relationships Content of Activity: 2013 State of the Art Course in Addiction Medicine

3. Thanks • NIAAA for funding • Research staff (RAs, T. Haney, H. Delaney, Bo & Bill Miller, consultants) • Study participants

4. Overview • Problem drinkers: The big picture • Stages of Change & matched interventions • Stepped care: only as much as needed • BMIs • Action-oriented protocols • Management issues

5. Consumption & alcohol related problems Consumption None Mild Moderate Substantial Severe Severe Substantial Moderate Mild None Alcohol Problems IOM, 1990

6. Spectrum of interventions Brief intervention, moderation training Abstinence focused treatment Threshold for action Severe Substantial Moderate Mild None Alcohol Problems

7. Stages of Change Permanent exit Precontemplation

8. 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

9. Detecting & screening • Screen as integral part of lifestyle assessment • Consider drinking from health standpoint, not disease standpoint

10. Will (non-dependent) heavy drinkers be interested?

12. 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)

13. 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).

14. Average Peak BAC per Drinking Day

15. 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)

16. 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.

17. 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.)

18. 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)

19. Resources • Moderation Management (www.moderation.org) • Moderation training protocols (e.g., www.moderatedrinking.com)

20. 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

21. Baseline Data

22. Baseline Data

23. Median Peak BAC/Drinking Day

24. Percent Days Abstinent

25. DrInC Recent Total Scores

26. 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

27. 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

28. 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

29. 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)

30. 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

31. SMART Recovery • www.smartrecovery.org • 1,000+ face-to-face meetings • 30 Online meetings/week • Forum for support • Manuals, etc. on their web site

32. Baseline characteristics

33. Percent Days Abstinent

34. Drinks per Drinking Day

35. Alcohol Problems

36. 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

37. 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

38. 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.

39. 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.

40. 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.