Lecture given in an Addiction workshop sponsored by the Lundbeck Institute in Copenhaguen, march 18th, 2015. Attended by psychiatrists from Germany, Belgium, Romania and France.
Counseling for alcohol use disorder: Adlerian and Rogerian approachesJeffrey Ahonen
This is a brief presentation on two well-known theoretical orientations in mental health counseling practice, with a focus on the use of these approaches in the treatment of alcohol use disorder. The theoretical approaches of Alfred Adler and Carl Rogers to the psychological conceptualization of the disorder are discussed, together with a sketch of the general shape of the treatment program prescribed by each of these counseling theories.
This presentation might be useful as an specific application of the Adlerian and Rogerian approaches to psychotherapeutic treatment, particularly within an undergraduate or lower-level graduate course in psychology, mental health counseling, or addiction counseling.
Mental Health Policy - Substance Abuse and Co-Occurring ConditionsDr. James Swartz
These slides are from a mental health policy lecture that focuses on substance use disorders and their relationship to mental health issues. The latter half of the lecture is devoted to discussing key points in the history of drug policy in the US and is based on information from the related text: Substance Abuse in America: A Documentary and Reference Guide
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This presentation is an overview of the collaborative care model of hypertension management for behavioral health providers, primary care doctors and health care teams. It explored social determinants of health, complex interaction of adverse childhood experiences and treatment and provides a map for integrated care.
A DSM 5 Update: Substance - Related And Addictive DisordersChat 2 Recovery
Within the next year, most insurance providers will be expecting all claims to include the new DSM-5 nomenclature. It is imperative for all mental health professionals to be comfortable with the new diagnostic criteria and recording procedures. This presentation provides participants with a clear understanding of the revisions made in the category of Substance - Related and Addictive Disorders from the DSM-IV to the DSM-5.
Topics presented by Nick Lessa, CEO of Inter-Care: an addiction treatment program in New York City.
Includes:
Changes in the diagnostic criteria from the DSM–IV to the DSM-5
The distinction between Substance Use Disorders and the Substance - Induced Disorders
Recording procedures for Substance Related Disorders
Counseling for alcohol use disorder: Adlerian and Rogerian approachesJeffrey Ahonen
This is a brief presentation on two well-known theoretical orientations in mental health counseling practice, with a focus on the use of these approaches in the treatment of alcohol use disorder. The theoretical approaches of Alfred Adler and Carl Rogers to the psychological conceptualization of the disorder are discussed, together with a sketch of the general shape of the treatment program prescribed by each of these counseling theories.
This presentation might be useful as an specific application of the Adlerian and Rogerian approaches to psychotherapeutic treatment, particularly within an undergraduate or lower-level graduate course in psychology, mental health counseling, or addiction counseling.
Mental Health Policy - Substance Abuse and Co-Occurring ConditionsDr. James Swartz
These slides are from a mental health policy lecture that focuses on substance use disorders and their relationship to mental health issues. The latter half of the lecture is devoted to discussing key points in the history of drug policy in the US and is based on information from the related text: Substance Abuse in America: A Documentary and Reference Guide
Team Based Care for Hypertension Management a biopsychosocial approachMichael Changaris
This presentation is an overview of the collaborative care model of hypertension management for behavioral health providers, primary care doctors and health care teams. It explored social determinants of health, complex interaction of adverse childhood experiences and treatment and provides a map for integrated care.
A DSM 5 Update: Substance - Related And Addictive DisordersChat 2 Recovery
Within the next year, most insurance providers will be expecting all claims to include the new DSM-5 nomenclature. It is imperative for all mental health professionals to be comfortable with the new diagnostic criteria and recording procedures. This presentation provides participants with a clear understanding of the revisions made in the category of Substance - Related and Addictive Disorders from the DSM-IV to the DSM-5.
Topics presented by Nick Lessa, CEO of Inter-Care: an addiction treatment program in New York City.
Includes:
Changes in the diagnostic criteria from the DSM–IV to the DSM-5
The distinction between Substance Use Disorders and the Substance - Induced Disorders
Recording procedures for Substance Related Disorders
Steps on How to Recover from Drugs and Alcohol AddicitionDr. Omer Hameed
When it comes to addiction recovery process, it is important to look for a program that is a good match for you. Treatment programs may vary depending on the level of addiction, the duration of substance abuse, and its effects on the affected individual.
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Dual Diagnosis describes the co-occurring problems of mental illness and substance misuse. However, the term 'dual' is something of a misnomer - the needs of this client group are often highly complex and extend beyond the relatively simplistic scenario implied by the term 'dual diagnosis'. This course uses realistic scenarios to enable participants to look at the reasons why mentally ill clients are so prone to drug and alcohol problems, the potential consequences of dual diagnosis, and current assessment and treatment approaches
Duration: half-day. one day, or two day options
Experience: None required
This course is suitable for: all staff currently working within health and social care settings in the United Kingdom. The course is designed to meet the training needs of domiciliary care agencies, care home or hospital settings and all staff. The course is also ideal for carers.
Number of Trainees: 15 maximum
Course Standard: Certificate of attendance
Equipment Needed: Hand-outs will be provided
Candidates will cover:
•Definitions of dual diagnosis and co-morbidity.
•Possible reasons for substance misuse in those with mental health difficulties
•Effects of substance misuse on those with mental health difficulties
By the end of the course Candidates will be able to:
•Discuss the relationship between substance misuse and mental health problems
•Describe the risk factors associated with these behaviours
•Understand the skills that are necessary to effectively work with clients who have dual diagnosis
Integrated Behavioral Health: Approaches to hypertension, toxic stress, ment...Michael Changaris
•TEAM BASED CARE: Team-based care incorporates a multidisciplinary team, centered on the patient, to optimize the quality of hypertension care. •TEAM PLAYERS: Team-based care includes the patient, the primary care clinician, and other professionals such as nurses, pharmacists, physician assistants, dieticians, social workers, and community health workers, each with pre-defined responsibilities in care. •OUTCOMES: Review and Meta-analysis of 100 randomized trials determined that team-based care is highly effective compared with other strategies for BP control.
Integrated Primary Care Assessment SBIRT (Substance Use) and Mental and Refer...Michael Changaris
This is an overview of triage pathway for those with mental health and substance use conditions with clinical cutoffs and referral options based on screening.
Alcohol Addiction Treatment - An Ultimate Guide to Overcome Your AddictionInspire Change Wellness
>> Psychological Conditions Depicting Alcohol Addiction.
>> Alcohol Addiction Treatment in 3 steps.
>> Alcohol Addiction Treatment through Group Therapies.
>> Social Life and Alcohol Addiction Treatment.
Addiction treatment at Positive Sobriety Institute emphasizes not just short-term abstinence, but lifelong recovery.
Positive Sobriety Institute’s continuum of care:
Comprehensive evaluation and diagnosis
Inpatient and ambulatory detox
https://www.positivesobrietyinstitute.com
Joshua Riley presented for the Kolmac School in Silver Spring, MD on Friday, April 24, 2015. "Working with LGBT Substance Abuse Users and the Persistence of Methamphetamine Use Among Gay and Bi-Sexual Men" was adored by all. Enjoy his slides!
Inhalant disorders are induced by inhaling the aliphatic and aromatic hydrocarbons found in substances such as fuels, solvents, adhesives, aerosol propellants, and paint thinners. When inhaled, they cause euphoria, sedation, emotional lability, and impaired judgment.
Steps on How to Recover from Drugs and Alcohol AddicitionDr. Omer Hameed
When it comes to addiction recovery process, it is important to look for a program that is a good match for you. Treatment programs may vary depending on the level of addiction, the duration of substance abuse, and its effects on the affected individual.
Training innovations dual diagnosis cambian fountains march 16Patrick Doyle
Dual Diagnosis describes the co-occurring problems of mental illness and substance misuse. However, the term 'dual' is something of a misnomer - the needs of this client group are often highly complex and extend beyond the relatively simplistic scenario implied by the term 'dual diagnosis'. This course uses realistic scenarios to enable participants to look at the reasons why mentally ill clients are so prone to drug and alcohol problems, the potential consequences of dual diagnosis, and current assessment and treatment approaches
Duration: half-day. one day, or two day options
Experience: None required
This course is suitable for: all staff currently working within health and social care settings in the United Kingdom. The course is designed to meet the training needs of domiciliary care agencies, care home or hospital settings and all staff. The course is also ideal for carers.
Number of Trainees: 15 maximum
Course Standard: Certificate of attendance
Equipment Needed: Hand-outs will be provided
Candidates will cover:
•Definitions of dual diagnosis and co-morbidity.
•Possible reasons for substance misuse in those with mental health difficulties
•Effects of substance misuse on those with mental health difficulties
By the end of the course Candidates will be able to:
•Discuss the relationship between substance misuse and mental health problems
•Describe the risk factors associated with these behaviours
•Understand the skills that are necessary to effectively work with clients who have dual diagnosis
Integrated Behavioral Health: Approaches to hypertension, toxic stress, ment...Michael Changaris
•TEAM BASED CARE: Team-based care incorporates a multidisciplinary team, centered on the patient, to optimize the quality of hypertension care. •TEAM PLAYERS: Team-based care includes the patient, the primary care clinician, and other professionals such as nurses, pharmacists, physician assistants, dieticians, social workers, and community health workers, each with pre-defined responsibilities in care. •OUTCOMES: Review and Meta-analysis of 100 randomized trials determined that team-based care is highly effective compared with other strategies for BP control.
Integrated Primary Care Assessment SBIRT (Substance Use) and Mental and Refer...Michael Changaris
This is an overview of triage pathway for those with mental health and substance use conditions with clinical cutoffs and referral options based on screening.
Alcohol Addiction Treatment - An Ultimate Guide to Overcome Your AddictionInspire Change Wellness
>> Psychological Conditions Depicting Alcohol Addiction.
>> Alcohol Addiction Treatment in 3 steps.
>> Alcohol Addiction Treatment through Group Therapies.
>> Social Life and Alcohol Addiction Treatment.
Addiction treatment at Positive Sobriety Institute emphasizes not just short-term abstinence, but lifelong recovery.
Positive Sobriety Institute’s continuum of care:
Comprehensive evaluation and diagnosis
Inpatient and ambulatory detox
https://www.positivesobrietyinstitute.com
Joshua Riley presented for the Kolmac School in Silver Spring, MD on Friday, April 24, 2015. "Working with LGBT Substance Abuse Users and the Persistence of Methamphetamine Use Among Gay and Bi-Sexual Men" was adored by all. Enjoy his slides!
Inhalant disorders are induced by inhaling the aliphatic and aromatic hydrocarbons found in substances such as fuels, solvents, adhesives, aerosol propellants, and paint thinners. When inhaled, they cause euphoria, sedation, emotional lability, and impaired judgment.
Evaluation and Management of Behaviors in Persons with Cognitive ImpairmentVITAS Healthcare
The goal of this webinar is to enable healthcare clinicians to implement a comprehensive approach to non-pharmacologic and pharmacologic management of dementia-related behaviors for the benefit of patients and their caregivers.
Closing the treatment gap in alcohol dependence thessalonika 2015Antoni Gual
Lecture on the treatment gap (underdiagnose & undertreatment) of alcohol use disorders. Presented at the 5th Conference of the Greek Psychiatric society in Thessalonika, march 21st, 2015.
Addiction is a disease that impacts millions of Americans. Drug addiction often leads to problematic behavioral patterns, overdose, and death. Treatment and rehab are key to overcoming addiction. Get more information at FindRehabCenters.org or call (877) 322-2450.
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Key Opinion Leaders talk on Alcohol. Thessalonika 2015Antoni Gual
Workshop for Key opinion leaders in the field of alcohol, psychiatrists from Bulgaria, Rumania and Greece. The meeting was held in Thessalonika in march 20, 2015
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De las intervenciones breves a los farmacos. malaga 2015 Antoni Gual
Conferencia sobre los problemas derivados del alcoholismo y su tratamiento, impartida el 6 de marzo del 2015 en la reunión de la Red de Trastornos Adictivos, realizada el Hospital Universitario de Málaga
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Are There Any Natural Remedies To Treat Syphilis.pdf
Clinical strategies in the management of Alcohol Use Disorders. Lundbeck Institute, Copenhague march 2015
1. Clinical strategies in the
management of alcohol use
disorders
Antoni Gual
Addictions Unit.
Psychiatry Dept. Neurosciences Institute.
Hospital Clínic de Barcelona. IDIBAPS.
tgual@clinic.cat
2. Conflicts of interest
Interest Name of organisation
Current roles and
affiliations
Addictions Unit, Psychiatry Dept,
Neurosciences Institute, Hospital Clinic,
University of Barcelona; IDIBAPS; RTA; Vice
President of INEBRIA, President of EUFAS
Grants Lundbeck, D&A Pharma, FP7, SANCO
Honoraria Lundbeck, D&A Pharma, Servier, Lilly, Abbvie
Advisory board/
consultant
Lundbeck, D&A Pharma, Socidrogalcohol
(Alcohol Clinical Guidelines) 2013
3. Index
• Who is in front of us? A humanistic approach
to persons with AUD.
• Is patient centered care needed?
• The role of assessment
• Setting goals through shared decision making
• Pharmacological treatments
• Psychosocial treatments
• Summary & Conclusions
4. Your opinion matters !!
• What is the biggest challenge when
managing alcohol dependent patients at the
clinic?
Please, write down in a piece of paper a
short answer to this question
4
5. Index
• Who is in front of us? A humanistic
approach to persons with AUD.
• Is patient centered care needed?
• The role of assessment
• Setting goals through shared decision making
• Pharmacological treatments
• Psychosocial treatments
• Summary & Conclusions
10. Index
• Who is in front of us? A humanistic approach
to persons with AUD.
• Is patient centered care needed?
• The role of assessment
• Setting goals through shared decision making
• Pharmacological treatments
• Psychosocial treatments
• Summary & Conclusions
11.
12. Patient-Centered Care (PCC)
Providing care that is respectful of and
responsive to individual patient preferences,
needs, and values, and ensuring that patient
values guide all clinical decisions.
Institute of Medicine, 2001
“No decision about me, without me”.
13. Defining attributes of PCC
• Holistic
• Individualized
• Respectful
• Empowering
Morgan and Yoder (2012)
14. Expected outcomes of PCC
• Increased satisfaction with
health care
• Greater perceived quality of
care
• Increased commitment
• Better compliance
• Improved health outcomes.
15. Clinicians and patients should discuss:
• ambivalence toward change;
• patient goals (eg, abstinence vs decreasing drinking vs no
change);
• preference for group based or individual psychosocial treatment
• differences in the privacy and cost of the various options
• medication treatments
16. Index
• Who is in front of us? A humanistic approach
to persons with AUD.
• Is patient centered care needed?
• The role of assessment
• Setting goals through shared decision making
• Pharmacological treatments
• Psychosocial treatments
• Summary & Conclusions
18. AUD. Assessment dimensions.
DIMENSION DIAGNOSTIC CRITERIA
Drinking Quantity & Frequency
Tolerance & Withdrawal
Craving
Medical harm Continued use despite medical problems
Recurrent drinking (physically hazardous)
Behavioural Uncontrolled intake
Unsuccessful efforts to stop
Time spent around alcohol
Social harm Given up or reduced activities
Use despite social or interpersonal problems
Failure to fulfil major role obligations
19. Assessment of drinking patterns
• Use Standard Drinks (8-10gr in EU)
• Measure in grams/week
• Ask quantity & frequency specifically
• Ask for labour & weekend days separately
• Identify binge drinking (>6 drinks pdo)
• The ‘normal day’ strategy
• Use standard tools whenever possible: AUDIT
23. Lifetime prevalence of psychiatric disorders and co-
occurrent alcohol dependence1,2
31%
Comorbid
alcohol
dependence
21%
21%
Comorbid
alcohol
dependence
26%
Anxiety disorder Mood disorder
Lifetime prevalence
of psychiatric disorder2
Lifetime prevalence
of co-occurrent alcohol dependence
and psychiatric disorder1
12%
24%
7%
28%
6%
30%
17%
26%
4%
28%
GAD Phobia PTSD
Major
depressive disorder
Bipolar
disorder
1. Kessler et al. American Journal of Orthopsychiatry 1996; 66(1): 17-31
2. National Comorbidity Survey Replication NCS-R. Lifetime prevalences estimates www.hcp.med.harvard.edu/ncs/index.php
24. Social Assessment
• Family status (divorce, ACOAs, etc)
• Work (unemployment, unstability, etc)
• Economical situation (debts, financial
problems, etc)
• Educational level (lower degree than expected,
children with low qualifications)
Bio-‐psycho-‐social
assessment
(3)
25. How to do it
• Empathic style
• Avoid judgmental attitudes
• Stick to facts. Do not discuss why.
• Don’t ask just about alcohol. Tobacco, BZD
and illicit drugs are also relevant.
• Try to understand the story and the dilemma
behind
• Try to identify strengths of the patient
26. Index
• Who is in front of us? A humanistic approach
to persons with AUD.
• Is patient centered care needed?
• The role of assessment
• Setting goals through shared decision making
• Pharmacological treatments
• Psychosocial treatments
• Summary & Conclusions
28. Shared decision making
• Helping patients better understand
their medical conditions;
• Providing information about benefits
and adverse effects of treatment
options;
• Supporting patients while they clarify
their values and preferences;
• Providing support while patients
implement their decisions
• working with family and caregivers
when patients have impaired
decisional capacities
29.
30. Elwyn et al, 2014
Help patients
explore and form
their personal
preferences
Describe the
alternatives in
more detail (use
decision support
tools if appropriate)
Explain the need
to consider
alternatives as a
team
This strategy fits well with an integrated care approach
32. DETOXIFICATION
Indicated
when:
• Signs
or
symptoms
of
AW
are
present
• PaEent
drinks
above
120gr
of
alcohol
daily
Not
indicated
when:
• PaEent
is
absEnent
>72h
and
no
signs
of
AW
are
present
• PaEent
does
not
agree
to
an
absEnence
goal
33. Clinical
Ins2tute
Withdrawal
Assessment
(CIWA)
• Nausea
and
vomiEng
• TacEle
disturbances
• Tremor
• Auditory
disturbances
• Paroxysmal
sweats
• Visual
disturbances
• Anxiety
• Headache,
fullness
in
head
• AgitaEon
• OrientaEon
and
clouding
of
sensorium
34. BENZODIAZEPINES
(BZD)
• Long
half-‐life
BZD
are
preferred:
Diazepam
and
chlordiazepoxide
are
the
golden
standard
• Loading
dose
Technique:
a
standard
dose
of
the
BZD
is
given
every
2
hours
unEl
light
sedaEon
is
reached.
• Tapering
technique:
iniEal
dose
of
BZD
based
on
history.
Then
adjust
and
taper.
• Lorazepam
and
oxazepam
are
indicated
in
paEents
with
impared
liver
funcEon
• BZD
should
only
be
used
short
term
to
prevent
risk
of
addicEon
38. Index
• Who is in front of us? A humanistic approach
to persons with AUD.
• Is patient centered care needed?
• The role of assessment
• Setting goals through shared decision making
• Pharmacological treatments
• Psychosocial treatments
• Summary & Conclusions
39. • Avoid withdrawal signs
• Treat comorbid conditions (mental & physical)
• Accept and understand his disease
• Reduce his desire & craving for alcohol
• Reduce the priming effects of alcohol if drinking
• Promote abstinence or reduction of alcohol
• Improve coping skills
• Improve quality of life
TREATMENT: Group of therapeutic processes
designed to help the patient to:
H
S
S
S
S
S
H
H
S
-‐
pSychosocial
H
-‐
pHarmacological
H
H
S
S
44. Target of Pharmacological
treatments
Goal Example
Decrease craving Acamprosate
Decrease priming Nalmefene
Decrease impulsivity Topiramate
Aversive reaction Disulfiram
45. 45
Jonas, D. E., Amick, H. R., Feltner, C., et al (2014). Pharmacotherapy for
adults with alcohol use disorders in outpatient settings: a systematic review
and meta-analysis. Jama, 311(18), 1889–900. doi:10.1001/jama.2014.3628
Abstinence Oriented
Pharmacological treatments
46. • Similar efficacy worldwide
• Discontinuation of treatment lower in Europe
than in the rest of the world (acamprosate)
46
48. Efficacy of acamprosate in Japan
• RCT in 327 Japanese patients with alcohol dependence
assigned to treatment with either acamprosate (1,998 mg/d
orally) or placebo for 24 weeks.
• The primary endpoint was complete abstinence after 24
weeks of administration.
• Acamprosate demonstrated superior efficacy vs placebo on
the primary endpoint: abstinence was 47.2% in the
acamprosate group compared with 36.0% in the placebo
group (P = .039).
48
49. Other drugs for abstinence oriented
treatments
Baclofen
• Very controversial
• Ongoing research just about to be published
• Low doses are not effective. High doses likely to be
effective
Sodium Oxibate
• Registered in Austria and Italy
• Efficacy established for withdrawal
• Main trial results confidential and shortly available
52. 52
§ 12-week, double-blind, RCT of naltrexone vs placebo in 221
individuals with AUD.
§ Participants randomly assigned to study treatment based on
the presence of 1 or 2 copies of the Asp40 allele compared
with those homozygous for the Asn40 allele (2 × 2 cell design).
§ There was no evidence of a genotype × treatment interaction
on the primary outcome of heavy drinking
54. Reduction of alcohol drinking in
young adults
• A RCT conducted in an outpatient research center with 140 patients
aged 18-25, who reported ≥ 4 HDD in the prior 4 weeks.
• Intervention: naltrexone 25 mg daily plus 25 mg targeted (at most
daily) in anticipation of drinking (n = 61) or daily/targeted placebo (n =
67). All participants received brief counseling every other week.
• Primary outcomes were percent of HDD and percent days abstinent
over 8 weeks. Secondary outcomes included number of DDD and
percentage of days with estimated blood alcohol concentration (BAC)
levels ≥ 0.08 g/dL.
• Percent HDD (21.60 vs 22.90) and percent days abstinent (56.60 vs
62.50) did not differ by group.
• Naltrexone significantly reduced the number of DDD (4.90 vs 5.90; P
= .009) and percentage of drinking days with estimated BAC ≥ 0.08 g/
dL (35.4 vs 45.7; P = .042).
• There were no serious adverse events.
64. HDD: change from baseline in the 6-month studies
– patients with at least high DRL at baseline and
randomisation
23 HDDs
11 HDDs
23 HDDs
10 HDDs
Difference:
-3.7 HDDs,
p=0.0010
Difference:
-2.7 HDDs,
p=0.0253
ESENSE 2ESENSE 1
van den Brink et al. Alcohol Alcohol 2013;48(5):570–578; Data on file
MMRM (OC) FAS estimates and SE; *p<0.05, **p<0.01, ***p≤0.001;
MMRM=mixed-effect model repeated measure;
OC=observed cases; FAS=full analysis set; SE=standard error
65. TAC: change from baseline in the 6-month studies
– patients with at least high DRL at baseline and
randomisation
113 g/day
43 g/day
102 g/day
44 g/day
Difference:
-18.3 g/day,
p<0.0001
Difference:
-10.3 g/day,
p=0.0404
ESENSE 2ESENSE 1
MMRM (OC) FAS estimates and SE; *p<0.05, **p<0.01, ***p<0.001;
MMRM=mixed-effect model repeated measure;
OC=observed cases; FAS=full analysis set; SE=standard error van den Brink et al. Alcohol Alcohol 2013;48(5):570–578; Data on file
66. Putting the efficacy of psychiatric and general medicine
medication into perspective: review of meta-analyses
Leucht et al. Br J Psychiatry 2012;200:97–106
Nalmefene
standardised effect size range
Standardized effect size (Cohen’s d)
Nalmefene1 HDDs TAC
ESENSE 1 0.37 0.46
ESENSE 2 0.27 0.25
Alcohol
treatment2,3 0.12 to 0.33
Antidepressants4 0.24 to 0.35
Antipsychotics4 0.30 to 0.53
1. Data on file;
2. Kranzler & Van Kirk. Alcohol Clin Exp Res 2001;25:1335–1341;
3. NICE. CG115. Alcohol dependence and harmful alcohol use: appendix 17d –
pharmacological interventions forest plot. 2011;
4. Leucht et al. Br J Psychiatry 2012;200:97–106
67. Index
• Who is in front of us? A humanistic approach
to persons with AUD.
• Is patient centered care needed?
• The role of assessment
• Setting goals through shared decision making
• Pharmacological treatments
• Psychosocial treatments
• Summary & Conclusions
69. The confrontational model
• Review of four decades of treatment outcome research.
• A large body of trials found no therapeutic effect relative to
control or comparison treatment conditions.
• Several have reported harmful effects including increased
drop-out, elevated and more rapid relapse.
• This pattern is consistent across a variety of confrontational
techniques tested.
• In sum, there is not and never has been a scientific evidence
base for the use of confrontational therapies.
WR. Miller, W. White; 2007
70. MoEvaEonal
Interviewing
• New
golden
standard
for
the
psychological
approach
to
addicEve
behaviours
• Radical
change:
– external
confrontaEon
as
a
technique
vs
internal
confrontaEon
as
a
goal
– PaEent
centered
– Spirit:
partnership,
compassion,
evocaEon
and
acceptance
WR. Miller, S. Rollnick; 2012
71.
72. Summary
• Statistically significant,
modest but robust effect:
Odds ratio = 1.55
• Effective: HIV viral load,
dental outcomes, death
rate, body weight, alcohol
and tobacco use, sedentary
behavior, self-monitoring,
confidence in change, and
approach to treatment.
• Not particularly effective:
eating disorder and some
medical outcomes
Lundahl et al, 2013
73. A continuum of communication
styles …
73
Informing
Asking
Listening
… that depends on how we use our
communication abilities
Directing Guiding Following
74. Communication styles
74
Directing Guiding Following
Informing
Listening
Asking
Informing with
choices
Empathic goal -
oriented Listening
Asking open
questions
Informing
Empathic
listening
Asking
75. A continuum of styles
Goal Indications
Directing
Getting precise
information
Emergency
Making a diagnosis
Guiding
Eliciting and
reinforcing motivation
to change
Where there is some
ambivalence
Following
Letting them express
an emotional
experience
Emotional event
75
76. A Brief psychosocial approach:
BRENDA
Volpicelli JR, Pettinati HM, McLellan AT, O’Brien CP. Combining medication and psychosocial treatments for addictions; the BRENDA
Approach. New York, NY: The Guilford Press; 2001; Starosta et al. J Psychiatr Pract 2006;12:80–89
Needs expressed by the patient that
should be addressed
Direct advice on how
to meet those needs
Report to the patient
on assessment
Empathetic understanding
of the patient’s problem
Biopsychosocial
evaluation
Assessing response/behaviour of the
patient to advice and adjusting treatment
recommendations
77. 77
Reduction in drinking using
Brenda & TLFB (Sense study)
ChangefrombaselineinHDDspermonth
ChangefrombaselineinTAC(g/day)
Monthly period Monthly period
HDDs TAC
Results from the control group
78. The Spirit of MI
Partnership
Collaboration
Acceptance
Evocation
Compassion
Spirit of
MI
81. Strategical approach to promote
behaviour change (4 basic processes)
Engaging
Focussing
Evoking
Planning
Miller & Rollnick; 2013
82. Index
• Who is in front of us? A humanistic approach
to persons with AUD.
• Is patient centered care needed?
• The role of assessment
• Setting goals through shared decision making
• Pharmacological treatments
• Psychosocial treatments
• Summary & Conclusions
83. Summary & Conclusions
• AUD
is
a
disease
highly
prevalent
and
with
important
medical,
psychiatric
and
social
comorbidiEes
• Assessment
should
be
conducted
in
an
empathic
style,
from
a
bio-‐psycho-‐social
perspecEve
and
paEent
centered
• Brief
intervenEons,
psychosocial
treatments
and
various
drugs
have
shown
efficacy
in
the
treatment
of
alcohol
dependence
• Combined
medical
and
psychosocial
treatments
are
the
preferred
treatment
strategy
for
alcohol
dependence,
within
an
Integrated
Care
approach
• Integrated
Care
must
be
offered
with
a
PaEent
Centered
approach,
which
implies
the
use
of
Shared
Decision
Making
in
a
moEvaEonal
style
84. 84
Clinical strategies in the
management of alcohol
dependence
Antoni Gual
Addictions Unit
Psychiatry Dept. Neurosciences Institute
Hospital Clínic de Barcelona. IDIBAPS
tgual@clinic.cat
Thanks for your attention.
Questions are welcome.