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DR CHRISTOS KOUIMTSIDIS - ALCOHOL MISUSE IN SPECIAL POPULATIONS: INTELLECTUAL DISABILITIES AND PEOPLE WITH TRAUMATIC BRAIN INJURY.

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There is little and con icting evidence on the prevalence of alcohol misuse and treatment available for people with Intellectual Disabilities (also referred as Learning Disabilities). As is similar to other vulnerable populations, adults with ID have increasingly lived more independently in the community following the closure of long-stay hospitals. This has increased their exposure to environmental stressors and substance and alcohol misuse, negatively impacting on their functioning, relationships, physical and mental health, and safety. Traumatic Brain Injury (TBI) is the most common cause of disability in younger adults. Yet the community care for patients with TBI varies hugely in the UK. There is a well-established link between TBI and alcohol misuse, with both TBI leading to increased levels of alcohol misuse and alcohol misuse contributing to risk of TBIs. The effects of neuronal damage have been shown to increase after TBI accompanied by alcohol intoxication.This presentation is based on the experience gained from the rst in the UK feasibility study on this topic, and draws from the experience of setting up and running the first ever pilot of a combined TBI and alcohol brief intervention service in London.

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DR CHRISTOS KOUIMTSIDIS - ALCOHOL MISUSE IN SPECIAL POPULATIONS: INTELLECTUAL DISABILITIES AND PEOPLE WITH TRAUMATIC BRAIN INJURY.

  1. 1. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine ALCOHOL MISUSE IN SPECIAL POPULATIONS; People with Intellectual Disabilities and people with Traumatic Brain Injury Christos Kouimtsidis, FRCPsych, MSc, PhD Consultant Psychiatrist in Addictions, Surrey & Borders Partnership NHS Foundation Trust Chair of Mental Health Clinical Academic Group, Surrey Health Partners Honorary Clinical Senior Lecturer Imperial College London
  2. 2. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Conflict  Executive Director of  Private Practice at The London Psychiatry Centre
  3. 3. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Why special populations  Magnitude of the problem  Special risks  Special barriers to access treatment  People  Services  Treatment might require modifications  Treatment content  Staff skills
  4. 4. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine People with Intellectual Disabilities IQ<70
  5. 5. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Why People with Intellectual Disabilities?  Now live in the community  Are more likely to be exposed to substances and to consume them  Are more vulnerable to adverse effect
  6. 6. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Special barriers to access treatment  History of Paternalism & Restricted Choice  Extent of problem drinking among people with ID poorly understood and not addressed Before when I was in supported care, the carer said “no, that’s not allowed, we’re not allowed to come with you, if you’re having an alcoholic drink”. And that stopped me, stopped my freedom of going out.
  7. 7. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Magnitude of the problem  Any substance misuse: 0.5% to 2.5% (McGillicuddy & Blane, 1999).  Alcohol misuse by 50% of adults with ID who are drinkers (Westermeyer et al, 1996)  Alcohol 17.8% (men), 15.2% (women) (Adult Psychiatric Morbidity Survey: England, 2014)  Alcohol in ID NHS service: 22.5% (Pezzoni, Kouimtsidis, 2015).  Approximately 5% of youths in D&A services have a degree of ID (Barrett & Paschos, 2006)
  8. 8. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Why such diversity?
  9. 9. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Special risks  Screening tools used  People with ID may have reduced verbal communication skills (Burnip, 2002), may be more suggestible (Everington & Fuller, 1999). may try to mask their difficulties in understanding and communication (Hassiotis at al, 2012).  Barriers associated with care providers
  10. 10. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Screening tools need to be modified Need to be administered by trained personnel Carers support is crucial
  11. 11. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Treatment modifications
  12. 12. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Clinical trials
  13. 13. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine ID psychosocial interventions People with LD have cognitive deficits that impair their ability to learn or generalise new learning and therefore may require interventions to last longer, to include maintenance sessions and to be supported to seek help and attend appointments.
  14. 14. A feasibility study of a psychological intervention to address alcohol misuse for people with mild to moderate learning disabilities living in the community (EBI-LD) This presentation presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-1111-26022). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Team: Chief Investigator: Dr Christos Kouimtsidis Prof Angela Hassiotis, University College London Dr Katrina Scior, Reader in Psychology, UCL Dr Gianluca Baio, Reader in Medical Statistics, UCL Ms Rachael Hunter, Senior Research Associate, Health Economics, UCL Dr Vittoria Pezzoni, Consultant Psychiatrist HPFT Dr Eileen McNamara, Consultant Psychiatrist HPFT
  15. 15. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine EBI-LD  A feasibility study (RCT, economic evaluation & qualitative study)  Funded by NIHR (RfPB)  30 months  Collaboration between 2 NHS trusts & UCL
  16. 16. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Participants Adults Mild to moderate ID Known to ID professionals as possibly having an alcohol problem Screening  Full Scale IQ <70 (based on WASI or previous results)  Alcohol Use Disorder Identification Test (AUDIT) 8-20  Participant and carer recruited in pairs
  17. 17. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Feasibility study in England RCT: EBI versus TAU 30 participants (15 each arm) 5 weekly, 40 mins sessions + 60 mins at week 8 Assessments: Baseline, 2/12 and 3/12
  18. 18. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Intervention  Delivered by trained therapist within ID services  Combination of Motivational Enhancement Therapy (MET-UKATT) & coping skills training (UK-CBT) Motivational assessment Link amount & problems Coping skills Healthy life style
  19. 19. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Qualitative study  7 participants from intervention arm (6 M), aged 39-70 years; 5 completed all sessions, 1 declined treatment and 1 attended four sessions.  Identified themes: being part of the research project, having therapy sessions, impact of therapy on drinking, reasons of dropping out from therapy.  6 carers (4 paid carers, and 2 family carers) and 1 health professional.
  20. 20. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Lessons learned for future RCT  Involvement of service users, family and paid carers in the design, and execution of the research may increase understanding of the problem.  Induction of researchers to aid recall in the participants  A carer rated primary/secondary measure of the outcome of interest could provide an additional perspective.  Health and social care professionals’ buy-in of the study could augment their support in identifying potential participants.
  21. 21. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine EBI-LD publications  Kouimtsidis C, Hassiotis A, Scior K, Hunter R, Baio G, Pezzoni V. 2015. A feasibility study of a psychological intervention to address alcohol misuse for people with mild to moderate learning disabilities living in the community (EBI-LD); study protocol for a randomized controlled trial. Trials DOI: 10.1186/s13063-015-0629-x  Kouimtsidis C, Bosco A, Scior K, Baio G, Hunter R, Pezzoni V, Mcnamara E, Hassiotis A. 2017. A feasibility randomised controlled trial of extended brief intervention for alcohol misuse in adults with mild to moderate intellectual disabilities living in the community. TRIALS, 12;18(1):216. DOI: 10.1186/s13063-017-1953-0  Kouimtsidis C, Scior K, Baio G, Hunter R, Pezzoni V, Hassiotis A. 2017. Development of a manual for Extended Brief Intervention for alcohol misuse for adults with mild to moderate intellectual disabilities living in the community. Journal of Applied Research in Intellectual Disabilities. (DOI: 10.1111/jar.12409
  22. 22. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Kouimtsidis C, Scior K, Hassiotis A. A Manual for Extended Brief Intervention for Alcohol Misuse by People with Learning Disabilities; http://www.sabp.nhs.uk/research/news-and-events/alcohol-misuse-pld
  23. 23. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine People with Traumatic Brain Injury
  24. 24. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Magnitude of the problem
  25. 25. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Special risks for people with TBI  43-68% of mild TBI have normal MRI  Primary BI not adequate to explain subsequent deterioration  Frontal lobe damage is the most common problem 1/3 of people with post-concussion syndrome (headaches, dizziness, concentration difficulties, low mood) difficulties persist: memory loss occurs in up to 80% impaired attention, judgment, reduced processing speed depression, anxiety disorders; 2-3x ↑ suicide rate ‘organic personality disorder’; disinhibition, aggression, impulsiveness, lack of initiative, inappropriateness, poor social judgment
  26. 26. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Special barriers to access treatment
  27. 27. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Link between AUD and TBI
  28. 28. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine AUD pre TBI 43-66% of TBI have prior alcohol abuse/dependence 38-53% of alcohol dependents have TBI history Consequences People with AUD ↑ risk of TBI 60% in any year & ↑risk multiple TBIs TBI compromises the AUD treatment; ↑ risk of disengagement
  29. 29. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Intoxication at the time of TBI 35-50% TBI incidents involve alcohol intoxication From those 75% intoxicated when TBI have preinjury AUD Consequences more severe TBI, medical complications, ↑ neuronal damage •3x ↑ ITU days •2.5x ↑ benzodiazepines •2x ↑ opioids
  30. 30. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine AUD post TBI
  31. 31. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Treatment challenges  No evidence-based algorithm for treatment  Cognitive barriers ↓ Attention, judgment, insight, language ↓ Sort term memory, behavioural control  Interpersonal barriers  System barriers  Inpatient AUD programs may exclude TBI  Physical disabilities, antidepressants, analgesics
  32. 32. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine
  33. 33. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine Summary  Magnitude of the problem  Special risks  Special barriers to access treatment  Treatment might require modifications
  34. 34. https://gaiahealthcare.co/Trainers, Researchers and Interventionists in Addiction and Mental Health Medicine

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