Archives for September 2017

A Guide for Clinicians to Initial Treatment for Alcohol Use Disorder

“Evidence-based treatment” refers to specific treatment protocols that research scientists, through rigorous research methodology, have found work for most people most of the time, better than other treatments, and better than no treatment. Research, by design, reports on groups, not on individuals.

This guide is comprised of evidence-based treatment components, rather than belief-based or theory-based components. This guide, as a whole, has not been tested by research scientists, and therefore it cannot be termed “evidence-based.” It is, however, meticulously researched to include what the latest research reports is most effective. It is intended for informational purposes only and is not a substitute for individualized medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

The intended audience is counselors and clinicians who provide care for people with alcohol use disorders. Individuals and family members investigating current, evidence-informed alcohol use disorder (AUD) treatment may find the content useful as well.

Given that only one in ten Americans with substance use disorder receives treatment, and the contact a clinician has with a client may be brief, even one-time only, this guide is intentionally brief. It is a work in progress. It is updated as the latest research on AUD is published and the author reviews it.

Introduction

The Surgeon General’s report, Facing Addiction in America, released in November, 2016, recommends a multi-pronged approach to addiction treatment, in this priority order:

1) medical care, initially from a primary care physician (PCP), to be assessed for a) suitability for medications, b) co-occurring or underlying physical conditions that may be causing stress or distress, including physical pain, and c) co-occurring mental illnesses that may be causing stress, distress, or instability.

2) individual counseling;

3) recovery support services (RSS) to reduce life stressors. Based on clients’ individual preferences, recovery-specific support group attendance may be part of RSS.

Alcohol use disorder (AUD) is defined as a disorder of the organ of the brain which requires medical treatment. Given the nature of the substance, abstinence, rather than harm reduction, is the recommended long-term treatment goal for AUD. Unfortunately, unlike with opioids, no safe dosing of ethyl alcohol exists.

The cognitive functions a person with AUD and other substance use disorders would need for abstention are the very ones impaired by the disorder itself: choice, decision-making, and recognizing the need for change, planning for it, and executing it. The neurobiology of addiction compromises the brain’s basal ganglia, extended amygdala, and prefrontal cortex and, thus, under-sensitizes one to pleasure, over-sensitizes one to pain, automates use of the substance to feel normal, weakens decision-making abilities, magnifies emotional highs and lows and incapacitates the ability to regulate them, interferes with recognizing cause-and-effect relationships, and confounds the ability to make a plan and follow through with it.

“People suffering from addictions are not morally weak; they suffer a disease that has compromised something that the rest of us take for granted: the ability to exert will and follow through with it.”
– Nora D. Volkow, M.D, Director of the National Institute on Drug Abuse (NIDA), quoted in What We Take for Granted

Other than with 1) medication and 2) time without exposure of the brain to the substance, brain structures and pathways impaired by AUD currently cannot be directly, immediately and efficiently treated for AUD. Therefore, individuals’ self-care efforts and counselors’ therapeutic efforts will focus on supporting abstinence rather than on attempting to directly treat the brain for addiction.

Alcohol use, even in small amounts, can compromise brain functioning and physical health. In those with alcohol use disorder, physical and behavioral symptoms can be life-threatening to themselves and others. Alcohol withdrawal can be a dangerous, deadly medical condition. Even nurses can be challenged by the symptoms. If a client needs emergency care, call 911. If a client needs urgent care, arrange for it.

The following guide applies to clients who are stable and not in need of urgent or emergency care.

Medical Care

Assist individuals with procuring health insurance and making appointments with medical professionals, beginning with the primary care physician (PHP). If the client does not have health insurance, query community sources for assistance.

(This is normally in the realm of case management rather than traditional clinical sessions, but helping the individual make the phone calls and appointments accommodates possible cognitive impairments associated with use and/or early abstinence. If it’s a personal fit for clinicians, they may consider accompanying individuals to medical appointments.)

Ask non-abstaining clients to keep a log of their consumption of alcohol.

Ask clients to make a rank-ordered list of physical symptoms that cause them stress or distress. (Include physical pain and issues with sleeping and/or eating.)

Ask clients to make a rank-ordered list of mental or psychiatric symptoms that cause them stress or distress.

Help clients compile this data: 1) consumption log (if applicable), 2) physical symptoms, 3) mental or psychiatric symptoms.

Coach clients in advocating for evidence-based treatment when they meet with their PCP. Few PCPs have time to stay up-to-date on the latest in addiction treatment given most work overtime to meet the demand for health care which exceeds capacity. Unfortunately, many PCPs continue to hold the belief that alcoholism is a personal, moral or mental problem rather than a medical one.

In the brief appointment clients will have with PCPs, they need to try to make these things happen:

1) Ask to be assessed for medical management of tapering and for medical management of potentially dangerous withdrawal symptoms, including a cost-benefit analysis of the risks of outpatient detox vs. highly stressful and disruptive inpatient detox.

Evidence-based guides to self-tapering from alcohol do not exist. This source, however, may be a place to begin for patient and physician to co-create a tapering plan based on the individual’s alcohol consumption log. Attending rehab is not an evidence-based method for achieving abstinence from substances.

2) Ask to be assessed for medications that assist with abstinence, based on use as recorded in the log. For some patients, naltrexone can be prescribed prior to abstinence, potentially improving progress towards abstinence.. (Here’s an NPR story on naltrexone for AUD.)

3) Ask to be assessed for blood work and for other diagnostic assessments to begin to treat the top items on the list of physical symptoms, or to begin to find the origins of the physical symptoms that are most problematic. Present a copy of the physical symptoms list for reference.

4) Ask for a referral to a psychiatrist now to get on the wait list for an appointment (local wait is 6-12 months). Present a copy of the psychiatric symptoms list for reference.

5) Keep the end in mind, i.e. accomplishing the tasks above, and stay self-regulated if – unfortunately possible – moralistic, judgmental, admonishing, shaming or dismissive statements are made by medical professionals during the appointment, or if follow-up treatment is delayed.

6) Make an appointment now for a follow-up visit with the PCP.

“Do not attempt to take away a person’s main means of trying to cope with pain and suffering until you have another effective coping strategy in place.”
– Alan Marlatt

Prior to the appointment with the PCP, provide clients with copies of these summary reports on first-line medications for AUD to take with them to offer as reference material if needed:

Fewer than 10% of people with AUD are offered or receive medications to treat the illness. Scientifically sound studies of the comparative efficacy of naltrexone, acamprosate, disulfram and gabapentin do not exist, although one study does compare naltrexone and camprosate. Finding the right medication, or combinations of medications, for each individual takes time.

At risk for premature death from an acute state of AUD, many clients do not have time for trial-and-error experimentation. They may have complicating physical and mental disorders as well. An expert medical opinion, ideally from a physician or psychiatrist, is crucial. We may only have one chance to medically assist a client so we need the most informed, experienced medical advice we can access on the client’s behalf.

Counseling

According to research, individual counseling is more effective than group counseling in helping people with substance use disorders achieve and maintain abstinence. Cognitive behavior therapy (CBT) and related dialectical behavior therapy (DBT), are the therapeutic modalities associated with abstinence. (Here’s a helpful self-directed guide to DBT.) Stress, distress, and exposure to environmental cues are the primary precursors for a return to use.

A fundamental skill a person with AUD needs to acquire to increase the likelihood of maintaining abstinence can be termed “self-regulation.” Individuals who can self-regulate emotions, cognitions, attention, as well as moderate ways of relating to self and others, may limit or prevent the escalation of stress or distress to the state of near-dissociation in which a return may occur.

Trained counselors can assist clients with AUD by assisting them with developing self-regulation skills. Therapeutic rapport can help mitigate the stress and distress inherent in therapy and treatment.

In individual counseling sessions, or group sessions if individual sessions are not available – taking into account cognitive limitations resulting from recent use and/or early abstinence – clinicians can assist clients increase responsiveness (vs. reactivity) to stress and distress, thus to decrease the likelihood of a return to use. Helping clients develop self-regulation requires a shift from focusing on anticipated “people, places and things,” “triggers,” or “choices,” to focusing on using self-regulation in highly unpredictable circumstances, whether with a person, a trigger, or otherwise (see Kaye, et al., 2017).

Since an estimated 70% of people with substance use disorder have experienced trauma, clinicians need to assess for trauma and, if present, given the likelihood of only a few therapy sessions, attempt to provide evidence-based, brief trauma therapy. (Brief interventions are few in number and are still being researched.)

Since approximately half of people with substance use disorder have co-occurring mental illnesses, clinicians need to assess for co-occurring disorders, particularly severe mental illnesses (SMIs) which may qualify clients for additional services.

Since substance use disorder is a 24-7 condition and manifests outside the clinical setting, inform and coach clients on self-care practices that support abstinence.

Recovery Support Services

Query clients about what external factors cause stress and distress in their lives. Ask clients to rank order them, then ask what small improvement would decrease stress or distress in the top three. Take steps to make the improvements happen that are beyond the client’s personal resources or network of connections, or help the client to make them happen.

Assist clients with exploring diverse interest groups, clubs, religious groups, support groups and/or other sources of social connection based on their individual interests and preferences.

Invite clients to attend support groups. (Choices in the author’s locale for recovery-specific support groups, in order of estimated numbers of attendees per year, are Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery and Celebrate Recovery. Information on local groups is here.)

On a case-by-case basis, support group attendance may be helpful to some individuals with maintaining abstinence. Support group attendance is not, however, an evidence-based treatment for the medical condition of addiction, any more than support group attendance would be treatment for the medical condition of cancer, diabetes, or other dangerous medical conditions.

Connect clients with social services agencies to assist with current stressors and needs such as employment, housing, transportation, child care, and legal issues.

“Love, evidence & respect.”
– Maia Szalavitz, via Twitter, in response to the question, “What fights addiction?”

Disclaimer: The views expressed are the author’s alone and do not necessarily reflect the positions of the author’s employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Reports on substance use disorder research and treatment by Handshake Media are here.