Alcohol and Offenders Treatable?

1. Alcohol and OffendersTreatable? Jonathan Chick

2. Is confrontation ethical............. or effective? • CONFRONTATION Miller WR, Benefield RG, Tonigan JS. Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. J Consult Clin Psychol 1993; 61: 455–61 • ‘DENIAL’ may be iatrogenic: Pomerleau O, Pertschuk M, Stinnett J. A critical examination of some current assumptions in the treatment of alcoholism. J Stud Alcohol 1976; 37: 849–67

3. Communications with spouse/ employer/Court Confidentiality and health workers: If asked by a spouse or an employer to comment on the patient’s condition, they must have permission to do so. Help the spouse, the employer, the Court to clarify for themselves what they expect, and give a clear, firm, but positive message.

4. Empathy in the ‘motivational interviewing’ style • Respect for individual differences • Patience with gradual approximations • Express interest/concern • Patient senses you are trying to get on their wavelength • Acceptance that ambivalence is normal

5. The use of coercion in the out-patient treatment of alcoholismRosenberg and Liftik (1976) J Stud Alc 37:58-65

6. Atlanta USA: repeat drunken offenders given a suspended sentence (30-60 days in prison)Bourne et al 1966 Q J Stud Alc,27:42-8 • Of 132, 78 chose to take disulfiram and abstained for the duration of the suspended sentence; • 61 continued voluntarily for a further 6 months (or more)

7. Colorado Springs: repeat drunken offenderswere offered EITHER usual 90-day imprisonmentOR suspension of sentence contingent on completing 1 year of disulfiram-linked treatment (Haynes,1973, J Behav Ther Exp Psy,4:31-2) • Of 141, 138 chose attendance twice weekly to take disulfiram • At 1 year: 66 still taking disulf. 35 left town without permission 17 in jail 14 left town with permission 3 hospitalised 3 lost • Mean arrest rate for whole group reduced from 3.8(preceding year) to 0.3 (year of study)

8. Outcome in 36 patients with drink-drive convictions in past year, attending a Washington state clinic Ward &Allwine,1979, Justice System Journal,5:107-11

9. Patients’ choice Many state they wish ‘to continue to drink but without any problems’

10. Sources of evidence for reduced drinking Outcome studies of abstinence goal treatments Epidemiological longitudinal studies of the natural history of alcohol use disorders Studies of natural recoveries (self-change) Experimental studies with an explicit reduction goal

11. There are good outcomes with low-risk drinking for some patients • Sobell MB, Sobell LC. Controlled drinking after 25 years: How important was the great debate? Addiction 1995; 90: 1149–53

12. South Dakota's 24/7 Sobriety Project twice-a-day breathalyzer tests, or continuous alcohol monitoring bracelets. Individuals who fail or skip required tests are immediately subject to a short jail term, typically a day or two. reduced county-level repeat DUI arrests by 12% and domestic violence arrests by 9%. DUI rate fell from double national average to similar Mixed evidence about whether the program reduced traffic crashes. (Kilmer et al (2013) Amer J Pub Hlth 103:37-43) Cf ‘Contingency management’

13. Mutual Help Groups • Proven effect of ‘12 step facilitation’ • Chits • (even a patient on compulsion order – escorted by staff, and two AA members) • AA in prison

14. Past-year status by interval since onset of dependence 100 90 Abstainer 80 70 Low-risk drinker 60 50 % PPY population Asymptomatic risk drinker (subclinical dependence) 40 30 Partial remission 20 Still dependent 10 0 <5 5 to 9 10 to 19 20+ Interval (years) Slide courtesy of Dr. Ting-Kai Li (NESARC data)

15. Why offer reduced drinking goals? • In the UK, fewer than 10% of those with alcohol problems ever enter treatment –why? • Stigma • Abstinence requirement • Overly intensive demands of treatment

16. Collaborative exploration • ‘Run the experiment’

17. You can’t learn to navigate in a ship that’s sinking: antabuse, acamprosate, naltrexone, future medications, help in early recovery

18. Antabuse : The Partnership Approach • A partner is a person whom the patient asks to observe him/her taking the Antabuse • So that the tablets cannot be substituted, genuine Antabuse is marked ‘C J O’ • To ensure the tablets are not put under the tongue and removed later, they are dispersed in water • Either daily, or 3 times/week e,g 2 on Monday, 2 on Wednesday, 3 on Friday • If vomiting the tablet is suspected, partner stays with patient for 30 minutes • If patient decides to stop Antabuse, patient or partner phones clinic to discuss the reason

19. The assessment:non-judgemental, empathic, collaborative Start with the offender’s own concerns • ‘What is your current main concern?’ • ‘Help me understand how this came about’ • What are the various factors in your view? • Your offending- Where does your use of alcohol fit in? • Your health Have you used alcohol to help with stress/insomnia • What would your partner say if he/she were here?

20. COURT REPORTSDeferred sentence ‘…If the Court deferred sentence, then I would report in 3-6 months on whether the offender has complied with the treatment undertakings he has agreed to.’

21. Structured Deferred Sentence • Scottish Government, 2008: this approach is to be extended to cover courts across two Community Justice Authorities areas - Glasgow and Tayside. The total funding amounts to £667,000 per year. • a low-tariff intervention providing structured social work intervention for offenders post-conviction, but prior to final sentencing. It is primarily aimed at offenders with underlying problems such as drug or alcohol dependency, mental health or learning difficulties or unemployment. It is not used for violent, serious or sex offenders.

22. When there’s no wish to change. • Keep the dialogue open...

23. Prison and Retoxification • AA in prisons • Start Antabuse during custody or by the last week

24. CHILD PROTECTION

25. CHILD PROTECTION O’Brien report Oct 2003 35 recommendations Number 20 “That steps are taken to clarify when medical duties of confidentiality towards a patient who is caring for a child can be waived”

27. “At Risk” as defined in the Children (Scotland) Act 1995 ………….suffering, or likely to suffer significant harm because of abuse or neglect. Abuse is defined as ‘a deliberate act of ill treatment that can harm or is likely to cause harm to a child’s safety, well-being and development’. Neglectis the ‘failure to provide for, or to secure for a child the basic needs of food, warmth, clothing, emotional security, physical safety and well-being’.

28. ‘At risk’ • A child living in a household where adults misuse substances will be seen as potentially ‘in need’ and possibly ‘at risk’ • Practitioners should ensure that their approach to care is non-judgmental so that it does not deter parents and pregnant women with alcohol/drug related problems from engaging with services • “If a child may be at risk of harm this will always override….”

29. Confidentiality is conditional and not absolute • Assessment for children “at risk” • Generic • Substance use related • Consent to share information

30. Adults with Incapacity (Scotland) Act 2000 and ARBD(alcohol-related brain damage) ‘Incapable’ means incapable of • acting; or • making decisions; or • communicating decisions; or • understanding decisions; or • retaining the memory of decisions, in relation to any particular matter, by reason of mental disorder … An adult shall not be treated as suffering from mental disorder by reason only of ……dependence on alcohol or drugs…or acting as no prudent person would act

31. In practice: use objective measures • Even when no sanctions apply, client does not want to disappoint the therapist • The client wants to try his experiment in ‘controlled drinking’ Make the breath alcohol test routine Test at the beginning of the interview, before the patient gives self-report Use blood test markers

32. Assessment when patient claims he takes Disulfiram (Antabuse) Biological markers less essential if the disulfiram is supervised by an objective 3rd party e.g. at work, for the Court, at a Clinic,

33. Supervised disulfiram • 200mg daily • or 400mg Mon and Wed, 600 mg Friday • ‘Dispersed in 50 ml water’ • Check with the supervisor regularly that the drug is still being taken • Encourage supervisor • Motivate the patient – review his/her rationale for choosing this method; check on side effects, be prepared to adjust slightly the dose • Watch for neuropathy

34. FAST: stage 2 How often during the last year………… ……have you been unable to remember what happened the night before because you had been drinking? ……failed to do what was normally expected of you because of drink? ….has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

35. fini