Alcohol Interventions : Successful and Innovative Intervention Strategies

1. Alcohol Interventions : Successful and Innovative Intervention Strategies John B Saunders MD, FRACP Professor of Alcohol and Drug Studies, University of Queensland, Director, Alcohol and Drug Service, Royal Brisbane and Women’s Hospital, Queensland Health, Co-Director, WHO Collaborating Centre on Substance Misuse and Mental Health; Member, Australian National Council on Drugs

2. The Spectrum of Use and Misuse Dependence Hazardous/Harmful Use/Substance Abuse Non-Hazardous Use Non-use

3. The Development of Substance Use Disorders • Repeated use of: • alcohol • certain medications • drugs Development of a repetitive behaviour Hazardous / Harmful Use/ Substance Abuse

4. Mechanisms of Substance Dependence • Repeated use of: • alcohol • certain medications • drugs Re-setting of dopamine reward centres Substance dependence syndrome

5. Alcohol’s Effects on Opioid Neurotransmission Dopaminergic neurone GABA Neurone Opioid (eg β endorphin) neurone Ventral tegmental area Nucleus accumbens

6. The Dependence Syndrome A psychobiological syndrome - a powerful internal driving force. Features of the dependence syndrome: • impaired control over substance use • a strong desire to take the particular substance • preoccupation with substance use (given greater priority than other activities) • increased tolerance • withdrawal symptoms on cessation of substance use, or relief of withdrawal symptoms by further use • continuation of use despite harmful effects

7. Dependence and the Reinstatement Phenomenon A FEW DAYS 5 - 10 YEARS } } ALCOHOL INTAKE AND SEVERITY OF DEPENDENCE TIME Implications If a person is physically dependent on alcohol to the extent that they repeatedly (>twice per week) suffer withdrawal symptoms, he/she is best advised to abstain rather than attempt moderated or controlled drinking.

8. Responses to Substance Misuse Tertiary intervention Brief intervention (Secondary prevention) Primary prevention

9. Rapid Assessment

10. Select from the answers below and place the number that corresponds with your answer in the box 1. How often do you have a drink containing alcohol? Score o 0 1 2 3 4 Never or less 2 to 4 2 to 3 4 or more times a month times a week times a week 2. How many standard drinks do you have on a typical day when you are drinking? o 0 1 2 3 4 1 or 2 2 to 4 5 or 6 7, 8 or 9 10 or more 3. How often do you have six or more drinks in one occasion? o 0 1 2 3 4 Never Less than monthly Monthly Weekly Daily or almost daily 4. How often during the last year have you found that you were not able to stop drinking once you had started? o 0 1 2 3 4 Never Less than monthly Monthly Weekly Daily or almost daily 5. How often during the last year have you failed to do what was normally expected from you because of drinking? o 0 1 2 3 4 Never Less than monthly Monthly Weekly Daily or almost daily 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? o 0 1 2 3 4 Never Less than monthly Monthly Weekly Daily or almost daily 7. How often during the last year have you had a feeling of guilt or remorse after drinking? o 0 1 2 3 4 Never Less than monthly Monthly Weekly Daily or almost daily 8. How often during the lst year have you been unable to remember what happened the night before because you had been drinking? o 0 1 2 3 4 Never Less than monthly Monthly Weekly Daily or almost daily 9. Have you or someone else been injured as a result of your drinking? o 0 2 4 No Yes, but not in the Yes, during the last last year year 10. Has a relative, a friend, a doctor or another health worker been concerned about your drinking or suggested you cut down? o 0 2 4 No Yes, but not in the Yes, during the last last year year o RECORD TOTAL OF SPECIFIC ITEMS HERE Audit

11. Interpretation of the AUDIT Score 0 Abstainer 1-7 Non-hazardous “safe” drinking 8-12 Hazardous or harmful alcohol use 13+ High risk of alcohol dependence

12. Non-hazardous range Hazardous or harmful range Alcohol dependent range Decision Tree Offer AUDIT questionnaire Review AUDIT score • Feedback, or no further action • Feedback • Brief intervention • Feedback • Referral to specialist • Need for detoxification? • Pharmacotherapy

13. Brief Alcohol Intervention

14. What is Brief Alcohol Intervention? • A brief and flexible form of therapy, comprising advice to reduce hazardous alcohol consumption and brief strategies to achieve this • Ranges from 4 - 5 minutes to 2 - 3 sessions of up to 30 - 60 minutes • Appropriate for people with hazardous alcohol use and a range of common mental health disorders • Can complement other treatments for people who have an alcohol dependence syndrome

15. Aims of Brief Alcohol Intervention • Advice is usually to reduce drinking, rather than abstinence • Aims to prevent exacerbation of drinking and alcohol-related harm and progression to dependence • Can complement the treatment of alcohol dependence but is not appropriate as the sole treatment

16. WHO Brief Intervention Study - findings from Australian Centre I Aim: To determine the effectiveness of three types of brief intervention to assist persons with hazardous or harmful alcohol consumption reduce their intake and risk of harm Design: Controlled clinical trial with random assignment to: (1) No treatment control (2) Simple advice (5 minutes and leaflet) (3) Advice and brief counselling (20 minutes + manual) (4) Advice and extended counselling (40 minutes over 2 - 3 sessions) Saunders et al (1998)

17. WHO Brief Intervention Study - findings from Australian Centre II Subjects: Males and females aged 17 - 70 years, fulfilling mean intake or binge drinking criteria Settings: General practice, general outpatient clinics, health screening programs Follow Up: at 9 months, 2 years and 10 years Measures: Average weekly alcohol intake, frequency of drinking to intoxication, occurrence of hazardous drinking, alcohol-related problems score, laboratory test results Evaluation: By repeated measures analysis of variance and regression modelling Saunders et al (1998)

18. WHO - RPAH Early Intervention TrialResults at nine months Average weekly alcohol intake (grams) Condition Intake at Intake at % reduction Recruitment Follow up Control 402 402 0 Simple advice 424 307 27.5 Advice and 480 341 29.0 counselling Extended 460 285 38.0 counselling

19. Aggregate Effect Sizes for Brief Intervention versus Control in Non-Treatment-Seeking Populations Moyer et al (2002)

20. Conclusions for Meta-analyses • Brief interventions lead to a reduction in hazardous alcohol use, alcohol-related problems and biochemical abnormalities for at least 12 months • No differential response according to gender or age

21. Four-year Outcome after Brief Intervention Fleming et al (2002)

22. Drink-less: getting started

23. The Drink-less Program -how it works • Screening • Receptionist gives AUDIT questionnaire to patient • Patient brings questionnaire to consultation

28. NSW Alcohol Interlock Program • Voluntary means of reducing a lengthy disqualification • Combines brief alcohol intervention and fitting an interlock device to the motor vehicle • Operates on a ‘user pays’ basis • Interlock Driver Licence holders are subject to a BAC < 0.02 • Failure to comply with requirements of Program results in loss of licence

31. The Treatment of Alcohol Dependence

32. Alcohol Withdrawal SYNDROME TIME OF ONSET DURATION Simple 6 - 48 hours 24 hours - 5 days Complicated 4 - 48 hours Usually single by fits Delirium Tremens 48 hours - 7 days 3 - 10 days

33. Alcohol 2 Protocol - Regular Diazepam

34. Pharmacotherapies for Alcohol Dependence • Acamprosate (Campral) • Naltrexone (Revia) • Disulfiram (Antabuse) • Topiramate • Ondansetron • Buspirone (for alcohol dependence and comorbid social anxiety) • SSRIs (for underlying or residual depression)

35. Acamprosate • A derivative of the amino-acid, taurine. Chemically calcium bis acetyl homotaurine • Complex pharmacological actions • Interacts with the GABAA receptor, facilitating GABAergic inhibitory neurotransmission • Inhibits glutamate excitatory neurotransmission by interacting with NMDA glutamate receptor

36. Alcohol’s Actions on Glutamate Neurotransmission

37. Controlled trials of Acamprosate in Alcohol Dependence. II AuthorsCountryNo. DurationOutcome Abstinence % abstinent days Biochemistry Paille et al. (1995 ) France 538 1 year A: 61% Biological markers C: 47% showed greater improvement in acamprosate group Sass et al. (1997) Germany 272 1 year A: 43% 62% C: 21% 45% Tempesta et al. (1998) Italy 330 6 months A: 58% 66% No difference C: 45% 54% Besson et al. (1998) Switzerland 110 1 year A: 25% 40% C: 5% 21% Ritson,Chick et al. U.K. 581 6 months A: 12% No difference (1999) C: 11%

38. Naltrexone • A specific antagonist of opioids • Introduced in Australia in 1999 for the treatment of alcohol dependence

39. Alcohol’s Effects on Opioid Neurotransmission Dopaminergic neurone GABA Neurone Opioid (eg ß endorphin) neurone Ventral tegmental area Nucleus accumbens

40. Controlled Trials of Naltrexone in Alcohol Dependence. I AuthorsCountryNo. DurationOutcome Abstinence Relapse free Biochemistry O’Malley et al. (1992 ) USA 104 3 months N: 51% 69% C: 23% 40% Volpicelli et al. (1992) USA 70 3 months N: 77% 79% C: 46% 59% Chick et al. (1999) UK 175 3 months N: 18% C: 19% Anton et al. (1999) USA 131 3 months N: 62% % with heavy C: 40% drinking days less in those on naltrexone Morris et al. (2001) Australia 111 3 months N: 51% Improvement in those C: 25% on naltrexone

41. Combined Pharmacotherapies for Alcohol Dependence. I :Naltrexone and Acamprosate Kiefer et al (2003) Study • Randomised, controlled trial of 160 alcohol dependent patients • Assigned, following detoxification, to one of four treatments • placebo drug • naltrexone • acamprosate • naltrexone + acamprosate • In addition, participants were encouraged to attend group therapy in a clinic setting • Follow up at weekly intervals for three months

42. Combined Pharmacotherapies for Alcohol Dependence. I :Naltrexone and Acamprosate Results of Kiefer et al (2003) Study As judged by time to first drink and time to relapse, • Naltrexone was superior to placebo • Acamprosate was superior to placebo • Combination of naltrexone and acamprosate was superior to acamprosate alone • There was a trend for of naltrexone and acamprosate combined to be superior to naltrexone alone

43. Alcohol-sensitising Drugs • Aldehyde dehydrogenase inhibitors Examples - disulfiram (“Antabuse”) 250 - 500mg daily • Result in an unpleasant flush reaction when alcohol is taken • Indications: - alcohol dependence - accepts goal of abstinence - need for external aid to abstinence - high risk situations for drinking imminent • Controlled trials indicate the abstinence rate is higher in the first 3-6 months when patients take these drugs • Best results are when given under supervision with contingency management strategies

44. Topiramate in the Treatment of Alcohol Dependence • Inhibits glutamate hypersensitivity and facilitates GABAergic function • 150 patients assigned to either topiramate or placebo • Greater reduction in quantity and intensity of alcohol consumption compared with placebo • Reduction in GGT in topiramate-treated group compared with placeboJohnson et al., 2003

45. Ondansetron • Early indications that ondansetron may be a useful treatment for early-onset alcohol dependence (likely to be those with a positive family history) • No support for its use in later onset alcohol dependence • More evidence needed from controlled trials • Not approved for the treatment of alcohol dependence in Australia

46. Buspirone • A 5HTIA partial agonist • An anti-anxiety drug • Shown in some small-scale trials to increase cumulative days of abstinence in people with alcohol dependence and comorbid social anxiety compared with placebo

47. SSRIs • Trialled (with high hopes) in the 1980s • Reduce alcohol consumption by 20% in low dependence drinkers, but effect wears off after 1-2 months • Do not increase abstinence rates in alcohol dependent people • No change in overall alcohol intake in alcohol dependent people • Reserved for patients with persistent depression after detoxification

48. Treatments for Alcohol Misuse Best practice Bad practice Available Brief interventions Just say no! CBT (limited) MET (limited) 12 -step approaches 12-step approaches Acamprosate (limited, if at all) Naltrexone (limited) Analytic psychotherapy Analytic psychotherapy Confrontation therapy Confrontation therapy Supportive counselling Supportive counselling Aversion therapy Hypnosis Benzodiazepines Benzodiazepines (post-detox) for detox and beyond Anti-depressants Anti-depressants Residential treatment

49. Cost-effectiveness of Treatment for Hazardous Alcohol Use and Alcohol Dependence • Cost-effectiveness of brief alcohol interventions: $3 to $7 return for each $1 invested • Cost-effectiveness of treatment for alcohol dependence: $4 to $5 return for each $1 invested

50. Treatments for Alcohol Misuse: Looking to the Future • Correspondence-based, CD-ROM and Internet therapies • Combined CBT/motivational therapy and pharmacotherapy • Combined pharmacotherapies  Acamprosate and naltrexone  Acamprosate and disulfiram  Naltrexone and ondansetron • Depot preparations