Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Clinical strategies in the
management of alcohol use
disorders
Antoni Gual
Addictions Unit.
Psychiatry Dept. Neurosciences...
Conflicts of interest
Interest Name of organisation
Current roles and
affiliations
Addictions Unit, Psychiatry Dept,
Neuro...
Index
•  Who is in front of us? A humanistic approach
to persons with AUD.
•  Is patient centered care needed?
•  The role...
Your opinion matters !!
•  What is the biggest challenge when
managing alcohol dependent patients at the
clinic?
Please, w...
Index
•  Who is in front of us? A humanistic
approach to persons with AUD.
•  Is patient centered care needed?
•  The role...
6
The case of Tom
Clinical Picture
Humanistic Picture
Index
•  Who is in front of us? A humanistic approach
to persons with AUD.
•  Is patient centered care needed?
•  The role...
Patient-Centered Care (PCC)
Providing care that is respectful of and
responsive to individual patient preferences,
needs, ...
Defining attributes of PCC
•  Holistic
•  Individualized
•  Respectful
•  Empowering
Morgan and Yoder (2012)
Expected outcomes of PCC
•  Increased satisfaction with
health care
•  Greater perceived quality of
care
•  Increased comm...
Clinicians and patients should discuss:
•  ambivalence toward change;
•  patient goals (eg, abstinence vs decreasing drink...
Index
•  Who is in front of us? A humanistic approach
to persons with AUD.
•  Is patient centered care needed?
•  The role...
Clinical	
  management	
  
Assessment
Goal setting
Abstinence oriented Reduced drinking
AUD. Assessment dimensions.
DIMENSION DIAGNOSTIC CRITERIA
Drinking Quantity & Frequency
Tolerance & Withdrawal
Craving
Med...
Assessment of drinking patterns
•  Use Standard Drinks (8-10gr in EU)
•  Measure in grams/week
•  Ask quantity & frequency...
Bio-psycho-social assessment (1)
Medical assessment (Why?)
•  Very high medical comorbidity
•  Improves adherence to treat...
Bio-psycho-social assessment (1)
Medical assessment (How?)
•  Physical examination
•  Blood tests (GGT, VCM, ASAT, ALAT, V...
Bio-psycho-social assessment (2)
Psychological / Psychiatric Assessment
•  Alcohol related distress
–  Feeling guilty
–  I...
Lifetime prevalence of psychiatric disorders and co-
occurrent alcohol dependence1,2
31%
Comorbid
alcohol
dependence
21%
2...
Social Assessment
•  Family status (divorce, ACOAs, etc)
•  Work (unemployment, unstability, etc)
•  Economical situation ...
How to do it
•  Empathic style
•  Avoid judgmental attitudes
•  Stick to facts. Do not discuss why.
•  Don’t ask just abou...
Index
•  Who is in front of us? A humanistic approach
to persons with AUD.
•  Is patient centered care needed?
•  The role...
Clinical management
Assessment
Goal setting
Abstinence oriented Reduced drinking
Shared decision making
•  Helping patients better understand
their medical conditions;
•  Providing information about bene...
Elwyn et al, 2014
Help patients
explore and form
their personal
preferences
Describe the
alternatives in
more detail (use
...
Clinical management
ASSESSMENT
Goal setting
Abstinence oriented Reduced drinking
DETOXIFICATION	
  
Indicated	
  when:	
  
•  Signs	
  or	
  symptoms	
  of	
  AW	
  are	
  present	
  
•  PaEent	
  drinks...
Clinical	
  Ins2tute	
  Withdrawal	
  Assessment	
  
(CIWA)	
  
•  Nausea	
  and	
  vomiEng	
  	
  
•  TacEle	
  disturban...
BENZODIAZEPINES	
  (BZD)	
  
•  Long	
  half-­‐life	
  BZD	
  are	
  preferred:	
  Diazepam	
  and	
  
chlordiazepoxide	
 ...
Clinical management
ASSESSMENT
Goal setting
Abstinence oriented Reduced drinking
Timeline
followback
•  Retrospective
assessment of drinking
behaviour.
•  Reliable and valid for a
variety of populations
...
Index
•  Who is in front of us? A humanistic approach
to persons with AUD.
•  Is patient centered care needed?
•  The role...
•  Avoid withdrawal signs
•  Treat comorbid conditions (mental & physical)
•  Accept and understand his disease
•  Reduce ...
Pharmacological treatments
70
Alcohol useAbstinence - low risk - hazardous use - harmful use
-- dependence
Alcohol related
problems
Recommended psych...
70
Alcohol useAbstinence - low risk - hazardous use - harmful use
-- dependence
Alcohol related
problems
Recommended psych...
Widening the scope of
pharmacological treatments
•  Classical approach: Abstinence oriented
(disulfiram*, acamprosate*, na...
Target of Pharmacological
treatments
Goal Example
Decrease craving Acamprosate
Decrease priming Nalmefene
Decrease impulsi...
45
Jonas, D. E., Amick, H. R., Feltner, C., et al (2014). Pharmacotherapy for
adults with alcohol use disorders in outpati...
•  Similar efficacy worldwide
•  Discontinuation of treatment lower in Europe
than in the rest of the world (acamprosate)
...
47
Efficacy of acamprosate in Japan
•  RCT in 327 Japanese patients with alcohol dependence
assigned to treatment with either...
Other drugs for abstinence oriented
treatments
Baclofen
•  Very controversial
•  Ongoing research just about to be publish...
Reduced drinking
Pharmacological treatments
•  Nalmefene
•  Naltrexone?
•  Topiramate?
•  Gabapentin?
52
§  12-week, double-blind, RCT of naltrexone vs placebo in 221
individuals with AUD.
§  Participants randomly assigned...
53
Reduction of alcohol drinking in
young adults
•  A RCT conducted in an outpatient research center with 140 patients
aged 1...
55
Topiramate vs placebo at week 14th
60
61
62
Pivotal Nalmefene RCTs
HDD: change from baseline in the 6-month studies
– patients with at least high DRL at baseline and
randomisation
23 HDDs
1...
TAC: change from baseline in the 6-month studies
– patients with at least high DRL at baseline and
randomisation
113 g/day...
Putting the efficacy of psychiatric and general medicine
medication into perspective: review of meta-analyses
Leucht et al...
Index
•  Who is in front of us? A humanistic approach
to persons with AUD.
•  Is patient centered care needed?
•  The role...
Psychosocial treatments
The confrontational model
•  Review of four decades of treatment outcome research.
•  A large body of trials found no ther...
MoEvaEonal	
  Interviewing	
  
•  New	
  golden	
  standard	
  for	
  the	
  psychological	
  
approach	
  to	
  addicEve	...
Summary
•  Statistically significant,
modest but robust effect:
Odds ratio = 1.55
•  Effective: HIV viral load,
dental out...
A continuum of communication
styles …
73
Informing	
   Asking	
   Listening	
  
… that depends on how we use our
communica...
Communication styles
74
Directing Guiding Following
Informing
Listening
Asking
Informing with
choices
Empathic goal -
orie...
A continuum of styles
Goal Indications
Directing
Getting precise
information
Emergency
Making a diagnosis
Guiding
Elicitin...
A Brief psychosocial approach:
BRENDA
Volpicelli JR, Pettinati HM, McLellan AT, O’Brien CP. Combining medication and psych...
77
Reduction in drinking using
Brenda & TLFB (Sense study)
ChangefrombaselineinHDDspermonth
ChangefrombaselineinTAC(g/day)...
The Spirit of MI
Partnership
Collaboration
Acceptance
Evocation
Compassion
Spirit of
MI
Acceptance
Acceptance
Accurate	
  
empathy	
  
Autonomy	
  
support	
  
Affirma2on	
  
Absolute	
  worth	
  
Basic skills
Open
questions
Reflective
listening
Information /
Advice
Affirming
Summarizing
80
Strategical approach to promote
behaviour change (4 basic processes)
Engaging
Focussing
Evoking
Planning
Miller & Rollnick...
Index
•  Who is in front of us? A humanistic approach
to persons with AUD.
•  Is patient centered care needed?
•  The role...
Summary & Conclusions
•  AUD	
  is	
  a	
  disease	
  highly	
  prevalent	
  and	
  with	
  important	
  medical,	
  
psyc...
84
Clinical strategies in the
management of alcohol
dependence
Antoni Gual
Addictions Unit
Psychiatry Dept. Neurosciences ...
Clinical strategies in the management of Alcohol Use Disorders. Lundbeck Institute, Copenhague march 2015
Clinical strategies in the management of Alcohol Use Disorders. Lundbeck Institute, Copenhague march 2015
Clinical strategies in the management of Alcohol Use Disorders. Lundbeck Institute, Copenhague march 2015
Clinical strategies in the management of Alcohol Use Disorders. Lundbeck Institute, Copenhague march 2015
Clinical strategies in the management of Alcohol Use Disorders. Lundbeck Institute, Copenhague march 2015
Clinical strategies in the management of Alcohol Use Disorders. Lundbeck Institute, Copenhague march 2015
Clinical strategies in the management of Alcohol Use Disorders. Lundbeck Institute, Copenhague march 2015
Clinical strategies in the management of Alcohol Use Disorders. Lundbeck Institute, Copenhague march 2015
Clinical strategies in the management of Alcohol Use Disorders. Lundbeck Institute, Copenhague march 2015
Upcoming SlideShare
Loading in …5
×

Clinical strategies in the management of Alcohol Use Disorders. Lundbeck Institute, Copenhague march 2015

412 views

Published on

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.

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Clinical strategies in the management of Alcohol Use Disorders. Lundbeck Institute, Copenhague march 2015

  1. 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. 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. 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. 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. 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
  6. 6. 6 The case of Tom
  7. 7. Clinical Picture
  8. 8. Humanistic Picture
  9. 9. 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. 10. 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”.
  11. 11. Defining attributes of PCC •  Holistic •  Individualized •  Respectful •  Empowering Morgan and Yoder (2012)
  12. 12. Expected outcomes of PCC •  Increased satisfaction with health care •  Greater perceived quality of care •  Increased commitment •  Better compliance •  Improved health outcomes.
  13. 13. 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
  14. 14. 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
  15. 15. Clinical  management   Assessment Goal setting Abstinence oriented Reduced drinking
  16. 16. 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
  17. 17. 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
  18. 18. Bio-psycho-social assessment (1) Medical assessment (Why?) •  Very high medical comorbidity •  Improves adherence to treatment •  Reduces stigma
  19. 19. Bio-psycho-social assessment (1) Medical assessment (How?) •  Physical examination •  Blood tests (GGT, VCM, ASAT, ALAT, VHC, etc) •  Focussed Anamnesis –  Accidents –  A&E and hospital admissions –  Alcohol-related diseases
  20. 20. Bio-psycho-social assessment (2) Psychological / Psychiatric Assessment •  Alcohol related distress –  Feeling guilty –  Irritability –  Insomnia –  Antisocial behaviour •  Psychiatric comorbidity –  Depression –  Suicidal behaviour –  Anxiety disorders –  Personality disorders
  21. 21. 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
  22. 22. 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)  
  23. 23. 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
  24. 24. 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
  25. 25. Clinical management Assessment Goal setting Abstinence oriented Reduced drinking
  26. 26. 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
  27. 27. 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
  28. 28. Clinical management ASSESSMENT Goal setting Abstinence oriented Reduced drinking
  29. 29. 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  
  30. 30. 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    
  31. 31. 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  
  32. 32. Clinical management ASSESSMENT Goal setting Abstinence oriented Reduced drinking
  33. 33. Timeline followback •  Retrospective assessment of drinking behaviour. •  Reliable and valid for a variety of populations for time frames of up to one year. (Sobell & Sobell, 1992, 1996)
  34. 34. 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
  35. 35. •  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  
  36. 36. Pharmacological treatments
  37. 37. 70 Alcohol useAbstinence - low risk - hazardous use - harmful use -- dependence Alcohol related problems Recommended psychosocial interventions Primary prevention -- Brief interventions -- Specialized treatment Pharmacological interventions
  38. 38. 70 Alcohol useAbstinence - low risk - hazardous use - harmful use -- dependence Alcohol related problems Recommended psychosocial interventions Primary prevention -- Brief interventions -- Specialized treatment Pharmacological interventions
  39. 39. Widening the scope of pharmacological treatments •  Classical approach: Abstinence oriented (disulfiram*, acamprosate*, naltrexone*, topiramate) •  Substitution therapy: BZD, sodyum oxibate, baclofen •  Reduction approach: nalmefene*, naltrexone, topiramate, gabapentine. * Registered indication
  40. 40. Target of Pharmacological treatments Goal Example Decrease craving Acamprosate Decrease priming Nalmefene Decrease impulsivity Topiramate Aversive reaction Disulfiram
  41. 41. 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
  42. 42. •  Similar efficacy worldwide •  Discontinuation of treatment lower in Europe than in the rest of the world (acamprosate) 46
  43. 43. 47
  44. 44. 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
  45. 45. 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
  46. 46. Reduced drinking Pharmacological treatments •  Nalmefene •  Naltrexone? •  Topiramate? •  Gabapentin?
  47. 47. 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
  48. 48. 53
  49. 49. 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.
  50. 50. 55
  51. 51. Topiramate vs placebo at week 14th
  52. 52. 60
  53. 53. 61
  54. 54. 62
  55. 55. Pivotal Nalmefene RCTs
  56. 56. 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
  57. 57. 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
  58. 58. 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
  59. 59. 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
  60. 60. Psychosocial treatments
  61. 61. 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
  62. 62. 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
  63. 63. 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
  64. 64. A continuum of communication styles … 73 Informing   Asking   Listening   … that depends on how we use our communication abilities Directing Guiding Following
  65. 65. Communication styles 74 Directing Guiding Following Informing Listening Asking Informing with choices Empathic goal - oriented Listening Asking open questions Informing Empathic listening Asking
  66. 66. 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
  67. 67. 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
  68. 68. 77 Reduction in drinking using Brenda & TLFB (Sense study) ChangefrombaselineinHDDspermonth ChangefrombaselineinTAC(g/day) Monthly period Monthly period HDDs TAC Results from the control group
  69. 69. The Spirit of MI Partnership Collaboration Acceptance Evocation Compassion Spirit of MI
  70. 70. Acceptance Acceptance Accurate   empathy   Autonomy   support   Affirma2on   Absolute  worth  
  71. 71. Basic skills Open questions Reflective listening Information / Advice Affirming Summarizing 80
  72. 72. Strategical approach to promote behaviour change (4 basic processes) Engaging Focussing Evoking Planning Miller & Rollnick; 2013
  73. 73. 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
  74. 74. 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  
  75. 75. 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.

×