Structured intervention in preparing dependent drinkers towards abstinence Windmill Team Alcohol Care Pathway evaluation. May 2014

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1 45 Structured intervention in preparing dependent drinkers towards abstinence Windmill Team Alcohol Care Pathway evaluation. May 2014 E. Sharma, A. Smith, K.J. Charge and C. Kouimtsidis Windmill Drug & Alcohol Team, Surrey & Borders Partnership NHS Foundation Trust Introduction There is a strong consensus that medically assisted withdrawal from alcohol should be planned and part of a structured treatment package for alcohol dependence (NICE, 2011). Group interventions of diverse theoretical basis share the same benefits and challenges and are considered to be more cost-effective than one to one interventions (Bieling et al, 2006). Relapse Prevention interventions based on Cognitive Behaviour Therapy (CBT) put emphasis on regaining control over the decision making process involved in resisting or lapsing into alcohol use (Marlatt and Donovan, 2005; Monti et al, 1989). Key components include identifying high risk situations, reducing positive expectancies and developing negative expectancies from drinking, developing self-efficacy and coping skills and finally developing overall lifestyle changes compatible with an abstinent way of living (Raistrick et al, 2006). Empirical evidence though suggests that less that 60% of people attend aftercare interventions, which demonstrates the importance of starting CBT interventions while people are still drinking (Kouimtsidis et al, 2012). There is accumulating evidence that repeated detoxification attempts might have a negative impact on cognitive functioning. As people with alcohol dependence experience more detoxifications (medically assisted or not) and their alcohol dependence increases, they show withdrawal induced impairment in prefrontal subfields and inability to perform a task that captures two of the basic features of addictive behaviour cue-induced motivation to seek a reward, and failure to inhibit such motivation when reward seeking is inappropriate. Furthermore, under emotional challenge, multiple detoxified alcohol dependent people show increase in integration of neural networks in sub-cortical regions, underlying a bottom up emotional input. These changes may confer inability in conflict resolution and increased sensitivity to stress, both of which may contribute to relapse (Duka et al., 2004; Duka et al., 2011). Methodology Evaluation study from 2005 was used to structure the methodology for current evaluation. In 2005 a three staged treatment programme for alcohol dependence was used. (Kouimtsidis & Ford, 2011; Kouimtsidis et al., 2012). This programme included an innovative preparation stage consisting of six (CBT group sessions) Preparation for Alcohol Detoxification (PAD) group, alongside three structured individual sessions. Progress to the second stage for detoxification was dependent on successful completion of preparation stage as defined by full attendance, stabilisation of drinking (and if possible gradual reduction), initiation of lifestyle changes and preparation of an aftercare plan. The third stage consisted of ten open Relapse Prevention Group sessions. The Surrey adapted version and evaluation An adapted version of the above three staged programme was piloted in the North West part of Surrey, covered by Windmill Community Drug and Alcohol Team, in July The pathway had to be delivered in a

2 flexible way due to the large geographical area (groups and individual sessions). The content of the Abstinence Preparation Group (APG) was reviewed and modified using all the quantitative and qualitative evidence from the evaluation of the PAD groups described above (see box 1). All clients referred to the team and assessed to be dependent on alcohol and seeking abstinence between 1 July and 31 December 2013 entered the pathway and were included in this evaluation. Data was collected from HALO, a substance misuse specific electronic data management system and a database developed to monitor group attendance and client s progress. Box 1: List of APG sessions Abstinence Preparation Group Session 1 Understanding dependency Session 2 Control your drink Session 3 Alcohol reduction Session 4 Detoxification Session 5 Lifestyle changes Session 6 Relapse prevention Results 64 out of 94 (68%) new referrals with alcohol dependence entered the pathway. Four disengaged before entering stage one. 46 out of the 60 people (77%) who entered stage one, completed APG, (72% of overall cohort). 18 were able to complete a guided gradual withdrawal during stage two (51% of those entered stage two). Almost all the clients finishing stage two (32/35) entered stage three (aftercare), mostly having group interventions (28/32), either Relapse Prevention Group, peer facilitated groups or both. Abstinence rate one month post stage two (detoxification of any type) was very high for those clients achieving guided self-detox (94%). Overall only 33% disengaged at any stage, 9% had to repeat stage one and 40% maintained abstinence one month post withdrawal, which is 57% of those who completed stage one. This success rate is comparable to the 60% abstinence rate reported for those clients completing residential rehabilitation, which is the more expensive type of aftercare, only available to a small proportion of clients. 46

3 Figure 1: Evaluation flowchart Service Evaluation 47

4 Conclusion The results from 2005 evaluation study showed an increase in treatment capacity by 123%, increase in assisted withdrawal outcome from 57% to 85%, and reduction in drop outs by 55% (Kouimtsidis and Ford, 2010). Further evaluation in 2009 suggested that, 90% of the 70% who attended and completed PAD groups, completed community or residential detox and 74.5% were abstinent at one month post withdrawal. Those attended the groups had significantly higher abstinence rates at one month (p<0.01) and at three months post withdrawal (p<0.05) (Kouimtsidis et al., 2012). The Surrey pilot evaluation of the first six months implementation of the three stages alcohol pathway for dependent drinkers indicates that the three stages pathway could be the main treatment pathway. It is expected that with time the experience of staff to both promoting and using the pathway will improve and the percentage of those treated within the pathway will increase about 75%. This depends on regular supervision of staff and ongoing education on the evidence behind this major innovation on treatment provision for alcohol dependence. It seems also that not only the pathway achieves success rates comparable to residential rehabilitation as measured by abstinence rates at one month post detox, but it might empower people to complete guided self-detox during the group, which is considered the best type of alcohol withdrawal. From those who completed guided selfdetox, 94% maintained their abstinence for one month following completion of withdrawal. This finding was never reported before in the literature. It is also important to note that a very high proportion of people completing stage one and two entered stage three, making excellent use of the aftercare facilities provided. Improvement of uptake of aftercare provision is considered to be a major challenge for any alcohol pathway. This project did not look into quality of groups or client feedback however Kouimtsidis and Kolli (2013) evaluated the content of individual PAD sessions using a structured feedback form completed at the end of each session showing that the majority of clients felt welcome to participate and found all sessions enjoyable. Importance of controlling alcohol, reducing gradually, preparing for after the withdrawal programme and understanding triggers of relapse were the learning points which were consistent across different sessions despite the style of the session (educational/ therapeutic) (Kouimtsidis and Kolli, 2013). A qualitative study, funded by Alcohol Research UK (ARUK), provided a client centred evaluation. There was a reported strong sense of group belonging and empathy. Specific to the CBT underlying theoretical approach of the groups, clients demonstrated high self-efficacy through reducing their drinking with the positive belief that they could continue to reduce down, or maintain abstinence after detox (Croxford et al, 2014). Future work should focus on follow up of this cohort for three and six months post stage two. There is very limited data to support the success of any treatment intervention. It would be important to consider facilitating access to the APG groups for those clients with limited access not only because groups are considered more cost-effective but because previous evaluation supports the treatment benefits of the group therapy. Furthermore, previous implementation suggests that the existing pathway could be easily expanded to services in A&E and the General Hospital. Common treatment policies across acute hospital and alcohol services needs to be established to overlook and coordinate that alcohol services are provided within the acute hospital. References Bieling P.J., McCabe R.E., Antony M.M. eds. (2006). Cognitive-Behavioral Therapy in Groups. Guilford Press, New York,

5 Croxford A, Notley C, Maskrey V, Holland R, Kouimtsidis C. An exploratory qualitative study seeking participant views evaluating group Cognitive Behavioural Therapy preparation for alcohol detoxification. Journal of Substance Use (in press 2014). Duka T, Gentry J, Ripley T. (2004). Consequences of multiple withdrawal from alcohol. Alcoholism: Clin & Exp Research 28(2): Duka T, Trick L, Nikolaou K, Gray MA, Kempton MJ, Williams H, et al. (2011). Unique Brain Areas Associated with Abstinence Control Are Damaged in Multiply Detoxified Alcoholics. Biol Psychiatry 70(6): Kouimtsidis C, Ford L. (2010). A staged programme approach for alcohol dependence: Cognitive Behaviour Therapy groups for detoxification preparation and aftercare; preliminary findings. Short report. DEPP19 (1): Kouimtsidis C, Drabble K, Ford L. (2012). Implementation and evaluation of a three stages community treatment programme for alcohol dependence. A short report. DEPP 19(1): Kouimtsidis C, Kolli S. (2013). Preparation for alcohol detoxification group programme. Service users evaluation of individual sessions. Journal of Substance Use (available on line, May 2013). Marlatt AG, Donovan DM. (eds). (2005). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviours. New York: The Guildford Press. Monti P.M., Abrams D.B., Kadden R.M. & Cooney N.L. (1989) Treating Alcohol Dependence: A Coping Skills Training Guide. Guilford Press, London. National Institute for Health and Clinical Excellence. (2011). Alcohol use disorders: guidelines on diagnosis, assessment and management of harmful drinking and alcohol dependence. The British Psychological Society and The Royal College of Psychiatrists. Raistrick D, Heather N, Godfrey C. (2006). Review of the effectiveness of treatment for alcohol problems. National treatment Agency for Substance Misuse. London: Department of Health. 49

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