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.
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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 ClĂnic 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
â˘âŻ Who is in front of us? A humanistic approach
to persons with AUD.
â˘âŻ Is patient centered care needed?
â˘âŻ The role of assessment
â˘âŻ Setting goals through shared decision making
â˘âŻ Pharmacological treatments
â˘âŻ Psychosocial treatments
â˘âŻ Summary & Conclusions
4. Your opinion matters !!
â˘âŻ 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
â˘âŻ Who is in front of us? A humanistic
approach to persons with AUD.
â˘âŻ Is patient centered care needed?
â˘âŻ The role of assessment
â˘âŻ Setting goals through shared decision making
â˘âŻ Pharmacological treatments
â˘âŻ Psychosocial treatments
â˘âŻ Summary & Conclusions
10. Index
â˘âŻ Who is in front of us? A humanistic approach
to persons with AUD.
â˘âŻ Is patient centered care needed?
â˘âŻ The role of assessment
â˘âŻ Setting goals through shared decision making
â˘âŻ Pharmacological treatments
â˘âŻ Psychosocial treatments
â˘âŻ 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
âNo decision about me, without meâ.
13. Defining attributes of PCC
â˘âŻ Holistic
â˘âŻ Individualized
â˘âŻ Respectful
â˘âŻ Empowering
Morgan and Yoder (2012)
14. Expected outcomes of PCC
â˘âŻ Increased satisfaction with
health care
â˘âŻ Greater perceived quality of
care
â˘âŻ Increased commitment
â˘âŻ Better compliance
â˘âŻ Improved health outcomes.
15. Clinicians and patients should discuss:
â˘âŻ ambivalence toward change;
â˘âŻ patient goals (eg, abstinence vs decreasing drinking vs no
change);
â˘âŻ preference for group based or individual psychosocial treatment
â˘âŻ differences in the privacy and cost of the various options
â˘âŻ medication treatments
16. Index
â˘âŻ Who is in front of us? A humanistic approach
to persons with AUD.
â˘âŻ Is patient centered care needed?
â˘âŻ The role of assessment
â˘âŻ Setting goals through shared decision making
â˘âŻ Pharmacological treatments
â˘âŻ Psychosocial treatments
â˘âŻ 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
â˘âŻ Use Standard Drinks (8-10gr in EU)
â˘âŻ Measure in grams/week
â˘âŻ Ask quantity & frequency specifically
â˘âŻ Ask for labour & weekend days separately
â˘âŻ Identify binge drinking (>6 drinks pdo)
â˘âŻ The ânormal dayâ strategy
â˘âŻ 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
â˘âŻ Family status (divorce, ACOAs, etc)
â˘âŻ Work (unemployment, unstability, etc)
â˘âŻ Economical situation (debts, financial
problems, etc)
â˘âŻ Educational level (lower degree than expected,
children with low qualifications)
Bio-Ââpsycho-Ââsocial
 assessment
 (3)
Â
25. How to do it
â˘âŻ Empathic style
â˘âŻ Avoid judgmental attitudes
â˘âŻ Stick to facts. Do not discuss why.
â˘âŻ Donât ask just about alcohol. Tobacco, BZD
and illicit drugs are also relevant.
â˘âŻ Try to understand the story and the dilemma
behind
â˘âŻ Try to identify strengths of the patient
26. Index
â˘âŻ Who is in front of us? A humanistic approach
to persons with AUD.
â˘âŻ Is patient centered care needed?
â˘âŻ The role of assessment
â˘âŻ Setting goals through shared decision making
â˘âŻ Pharmacological treatments
â˘âŻ Psychosocial treatments
â˘âŻ Summary & Conclusions
28. Shared decision making
â˘âŻ Helping patients better understand
their medical conditions;
â˘âŻ Providing information about benefits
and adverse effects of treatment
options;
â˘âŻ Supporting patients while they clarify
their values and preferences;
â˘âŻ Providing support while patients
implement their decisions
â˘âŻ 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
Â
Indicated
 when:
Â
â˘âŻ Signs
 or
 symptoms
 of
 AW
 are
 present
Â
â˘âŻ PaEent
 drinks
 above
 120gr
 of
 alcohol
 daily
Â
Â
Not
 indicated
 when:
Â
â˘âŻ PaEent
 is
 absEnent
 >72h
 and
 no
 signs
 of
 AW
 are
Â
present
Â
â˘âŻ PaEent
 does
 not
 agree
 to
 an
 absEnence
 goal
Â
33. Clinical
 Ins2tute
 Withdrawal
 Assessment
Â
(CIWA)
Â
â˘âŻ Nausea
 and
 vomiEng
Â
Â
â˘âŻ TacEle
 disturbances
Â
â˘âŻ Tremor
Â
Â
â˘âŻ Auditory
 disturbances
Â
Â
â˘âŻ Paroxysmal
 sweats
Â
â˘âŻ Visual
 disturbances
Â
â˘âŻ Anxiety
Â
â˘âŻ Headache,
 fullness
 in
 head
Â
Â
â˘âŻ AgitaEon
Â
Â
â˘âŻ OrientaEon
 and
 clouding
 of
 sensorium
Â
Â
34. BENZODIAZEPINES
 (BZD)
Â
â˘âŻ Long
 half-Ââlife
 BZD
 are
 preferred:
 Diazepam
 and
Â
chlordiazepoxide
 are
 the
 golden
 standard
Â
â˘âŻ Loading
 dose
 Technique:
 a
 standard
 dose
 of
 the
 BZD
 is
Â
given
 every
 2
 hours
 unEl
 light
 sedaEon
 is
 reached.
Â
Â
â˘âŻ Tapering
 technique:
 iniEal
 dose
 of
 BZD
 based
 on
Â
history.
 Then
 adjust
 and
 taper.
Â
â˘âŻ Lorazepam
 and
 oxazepam
 are
 indicated
 in
 paEents
Â
with
 impared
 liver
 funcEon
Â
Â
â˘âŻ BZD
 should
 only
 be
 used
 short
 term
 to
 prevent
 risk
 of
Â
addicEon
Â
38. Index
â˘âŻ Who is in front of us? A humanistic approach
to persons with AUD.
â˘âŻ Is patient centered care needed?
â˘âŻ The role of assessment
â˘âŻ Setting goals through shared decision making
â˘âŻ Pharmacological treatments
â˘âŻ Psychosocial treatments
â˘âŻ Summary & Conclusions
39. â˘âŻ Avoid withdrawal signs
â˘âŻ Treat comorbid conditions (mental & physical)
â˘âŻ Accept and understand his disease
â˘âŻ Reduce his desire & craving for alcohol
â˘âŻ Reduce the priming effects of alcohol if drinking
â˘âŻ Promote abstinence or reduction of alcohol
â˘âŻ Improve coping skills
â˘âŻ Improve quality of life
TREATMENT: Group of therapeutic processes
designed to help the patient to:
H
Â
S
Â
S
Â
S
Â
S
Â
S
Â
H
Â
H
Â
S
 -Ââ
 pSychosocial
 H
 -Ââ
 pHarmacological
Â
H
Â
H
 S
Â
S
Â
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), 1889â900. doi:10.1001/jama.2014.3628
Abstinence Oriented
Pharmacological treatments
46. â˘âŻ Similar efficacy worldwide
â˘âŻ Discontinuation of treatment lower in Europe
than in the rest of the world (acamprosate)
46
48. Efficacy of acamprosate in Japan
â˘âŻ RCT in 327 Japanese patients with alcohol dependence
assigned to treatment with either acamprosate (1,998 mg/d
orally) or placebo for 24 weeks.
â˘âŻ The primary endpoint was complete abstinence after 24
weeks of administration.
â˘âŻ 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
â˘âŻ Very controversial
â˘âŻ Ongoing research just about to be published
â˘âŻ Low doses are not effective. High doses likely to be
effective
Sodium Oxibate
â˘âŻ Registered in Austria and Italy
â˘âŻ Efficacy established for withdrawal
â˘âŻ Main trial results confidential and shortly available
52. 52
§ď§âŻ 12-week, double-blind, RCT of naltrexone vs placebo in 221
individuals with AUD.
§ď§âŻ 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 (2ââŻĂââŻ2 cell design).
§ď§âŻ There was no evidence of a genotypeââŻĂââŻtreatment interaction
on the primary outcome of heavy drinking
54. Reduction of alcohol drinking in
young adults
â˘âŻ A RCT conducted in an outpatient research center with 140 patients
aged 18-25, who reported ⼠4 HDD in the prior 4 weeks.
â˘âŻ 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.
â˘âŻ 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 ⼠0.08 g/dL.
â˘âŻ Percent HDD (21.60 vs 22.90) and percent days abstinent (56.60 vs
62.50) did not differ by group.
â˘âŻ Naltrexone significantly reduced the number of DDD (4.90 vs 5.90; P
= .009) and percentage of drinking days with estimated BAC ⼠0.08 g/
dL (35.4 vs 45.7; P = .042).
â˘âŻ There were no serious adverse events.
64. HDD: change from baseline in the 6-month studies
â 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):570â578; Data on file
MMRM (OC) FAS estimates and SE; *p<0.05, **p<0.01, ***pâ¤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
â 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):570â578; 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;200:97â106
Nalmefene
standardised effect size range
Standardized effect size (Cohenâs 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;25:1335â1341;
3. NICE. CG115. Alcohol dependence and harmful alcohol use: appendix 17d â
pharmacological interventions forest plot. 2011;
4. Leucht et al. Br J Psychiatry 2012;200:97â106
67. Index
â˘âŻ Who is in front of us? A humanistic approach
to persons with AUD.
â˘âŻ Is patient centered care needed?
â˘âŻ The role of assessment
â˘âŻ Setting goals through shared decision making
â˘âŻ Pharmacological treatments
â˘âŻ Psychosocial treatments
â˘âŻ Summary & Conclusions
69. The confrontational model
â˘âŻ Review of four decades of treatment outcome research.
â˘âŻ A large body of trials found no therapeutic effect relative to
control or comparison treatment conditions.
â˘âŻ Several have reported harmful effects including increased
drop-out, elevated and more rapid relapse.
â˘âŻ This pattern is consistent across a variety of confrontational
techniques tested.
â˘âŻ 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
Â
â˘âŻ New
 golden
 standard
 for
 the
 psychological
Â
approach
 to
 addicEve
 behaviours
Â
â˘âŻ Radical
 change:
Â
Â
ââŻexternal
 confrontaEon
 as
 a
 technique
Â
 vs
 internal
Â
confrontaEon
 as
 a
 goal
Â
ââŻPaEent
 centered
Â
ââŻSpirit:
 partnership,
 compassion,
 evocaEon
 and
Â
acceptance
Â
WR. Miller, S. Rollnick; 2012
71.
72. Summary
â˘âŻ Statistically significant,
modest but robust effect:
Odds ratio = 1.55
â˘âŻ 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.
â˘âŻ Not particularly effective:
eating disorder and some
medical outcomes
Lundahl et al, 2013
73. A continuum of communication
styles âŚ
73
Informing
 Asking
 Listening
Â
⌠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, OâBrien 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;12:80â89
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 patientâs 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
â˘âŻ Who is in front of us? A humanistic approach
to persons with AUD.
â˘âŻ Is patient centered care needed?
â˘âŻ The role of assessment
â˘âŻ Setting goals through shared decision making
â˘âŻ Pharmacological treatments
â˘âŻ Psychosocial treatments
â˘âŻ Summary & Conclusions
83. Summary & Conclusions
â˘âŻ AUD
 is
 a
 disease
 highly
 prevalent
 and
 with
 important
 medical,
Â
psychiatric
 and
 social
 comorbidiEes
Â
â˘âŻ Assessment
 should
 be
 conducted
 in
 an
 empathic
 style,
 from
 a
Â
bio-Ââpsycho-Ââsocial
 perspecEve
 and
 paEent
 centered
Â
â˘âŻ Brief
 intervenEons,
 psychosocial
 treatments
 and
 various
 drugs
Â
have
 shown
 eďŹcacy
 in
 the
 treatment
 of
 alcohol
 dependence
Â
â˘âŻ Combined
 medical
 and
 psychosocial
 treatments
 are
 the
Â
preferred
 treatment
 strategy
 for
 alcohol
 dependence,
 within
 an
Â
Integrated
 Care
 approach
Â
â˘âŻ Integrated
 Care
 must
 be
 oďŹered
 with
 a
 PaEent
 Centered
Â
approach,
 which
 implies
 the
 use
 of
 Shared
 Decision
 Making
 in
 a
Â
moEvaEonal
 style
Â
84. 84
Clinical strategies in the
management of alcohol
dependence
Antoni Gual
Addictions Unit
Psychiatry Dept. Neurosciences Institute
Hospital ClĂnic de Barcelona. IDIBAPS
tgual@clinic.cat
Thanks for your attention.
Questions are welcome.