Alaska Substance Abuse Prevention and Treatment System Effectiveness Study

Transcription

1 Alaska Substance Abuse Prevention and Treatment System Effectiveness Study Working Paper #3 Factors Related to Successful Prevention and Treatment Alaska Mental Health Trust Authority William Herman, Program Manager Jeff Jessee, Director Suzanne Womack Strisik, PhD Brian Saylor, PhD, MPH, Director University of Alaska Anchorage 3211 Providence Drive Anchorage, Alaska This project was supported by a contract from the Alaska Mental Health Trust Authority

2 TABLE OF CONTENTS TABLE OF CONTENTS... i I. Introduction... 1 II. Prevention... 1 III. Treatment... 2 A. Brief Interventions... 2 B. Family Systems Therapies... 2 C. Cognitive-Behavioral Therapy... 3 D. Treatment Based On 12 Steps of Alcoholics Anonymous... 3 E. Treatment of Dual Diagnosis Patients... 4 F. Adolescent Substance Abuse Treatment Outcomes... 4 G. Chemically Dependent Offenders... 4 H. Culturally Relevant Therapies... 5 IV. References... 6 Factors Related to Successful Prevention i

3 I. Introduction A major factor that distinguishes whether a treatment or prevention program for addictions is a best practice does not so much involve the nature of the treatment or the prevention but the competency of the provider. This is an important issue in Alaska: providers who lack clinical experience and training do not have easy or frequent access to the professional support and education that will strengthen their skills. Awareness of cultural complexities and culturally relevant treatment is a major part of clinical competency, and this is especially true in Alaska where Alaska Natives compose a significant portion of the state s population. Droby (2000) said the most qualified persons to treat Alaska Native mental health problems, including addiction, is a health practitioner from the same culture as the patient. Therefore, in thinking about best practices, consideration should be given to the limitations in the therapeutic work force. Initial training and continuing education opportunities in best practices should be considered as well as the development of programs that recruit and retain Alaska native people into academic clinical training. II. Prevention Community based prevention programs blend an educational approach and a public health policy approach, and are effective (NIAAA, 2000). In an educational approach, a community-level media campaign promoting education and health to individuals, particularly adolescents, is developed. These campaigns are most effective when multiple institutions, including families, churches, and social services, are linked to school-based programs. Such campaigns show reduced rates of alcohol use among middle school students, reduced rates of alcohol sales to minors, and reduced rates of traffic crashes involving alcohol (NIAAA, 2000). Another educational approach, the Harm Reduction Approach for college students, was developed by a authorities in addiction studies, Marlatt, Baer, and Larimer (1995). This brief intervention using motivational interviewing reduces the level of drinking and the risk of harm associated with drinking, including motor vehicle accidents, blackouts, reduced work and school attendance, and decreased attention to responsibilities. The objective of the Harm Reduction Model is to move the individual along a step-wise direction away from the harmful consequences of alcohol use to abstinence. The environmental or public health approach reaches a community through formal policy changes that affect the production, distribution, sales, and marketing of alcoholic beverages and drunk driving laws. In The National Institute of Alcohol Abuse and Alcoholism (NIAAA, 2000) study, key legislation targeted to adolescents and young people who drink and drive was studied. When the legal drinking age was increased to 21, the maximum legal blood alcohol level was raised to.02%, and taxes on beer were increased, deaths related to alcohol impaired driving were reduced significantly. Factors Related to Successful Prevention 1

4 III. Treatment Efficacious treatments, although cost effective, tend to require intensive training and carefully designed treatment programs. The stronger the evidence for a treatment s efficacy, the more expensive it is to administer (Miller, et al., 1995). Training in interventions with proven effectiveness is essential for program success (McCrady and Langenbucher, 1996). Research (Miller, et al., 1995; NIAAA, 2000) indicates that the following therapeutic treatments are significant best practices in the treatment of substance abuse and dependency. A. Brief Interventions Brief interventions, which consist of time-limited counseling administered by medical health practitioners in family practice or emergency care settings, are most effective for people with drinking problems but who are not alcohol dependent and who do not have co-occurring psychiatric problems (NIAAA, 2000; Miller et al. 1995). Time-limited counseling follows a specific protocol and employs three components: a) the practitioner states the medical concern related to the substance use; b) the patient is advised to reduce or to eliminate the substance use; c) a plan of action is agreed-upon by the practitioner and the client (Kahan, Wilson, & Becker, 1995). Motivational enhancement, another effective brief intervention, is a collaborative client-centered approach that reduces client resistance and increases client confidence and selfefficacy (Bien, Miller, Tonigan, 1993; Miller, 1995). B. Family Systems Therapies Family and couple therapies are designed to eliminate problem drinking and addiction by improving the quality of family and marital relationships (Miller et al, 1995). Family therapy approaches are complex, because multiple dynamics, including moderate to severe substance use-related problems, are addressed (Meyers et al., 2002). Family therapy is probably the most robust therapy currently in use today: it is effective for severe problems and addresses the complex array of difficulties experienced by people with substance-related disorders (Miller et al., 1995; Williams and Chang, 2000). The community reinforcement approach (CRA) is a systems or multi-dimensional treatment in which family members become agents of their own healing and engage the substance abusing family member into treatment (Meyers et al., 2002). This type of family systems therapy is superior to family education and group therapy. It also is useful for adolescent substance abusers who are living at home and whose substance using behavior is influenced by the family system (Meyers et al., 2002). CRA is a broad-spectrum intervention involving spouses, family members, and other individuals from the drinker s social networks in the treatment process. In a review of individual treatment studies versus CRA studies, CRA demonstrated superior outcomes in treatment engagement, low attrition, relapse and subsequent hospitalization, as well as increased employment and social and marital adjustment (Baucom, et al., 1998). CRA is cost-effective: it has lower reported cost and required staff time per participant than Factors Related to Successful Prevention 2

5 individual treatment or traditional substance abuse treatment programs. Also, alcoholics exposed to CRA were more likely to start treatment than those in individual treatment; a small-scale study aimed at treatment found CRA to be superior to usual recruitment efforts (Baucom, et al., 1988, p. 74). Social skills training, when embedded in an individual treatment program, is similar to CRA in efficacy and may be useful for treating patients who have no family networks. In social skills training, life and social problems related to drinking problems, dependency, and relapse are addressed, and the capacity to cope with difficulties and stress inherent in sober living is increased (Miller et al, 1995). Behavioral marital therapy (BMT) has strong support as an efficacious intervention for treating distressed couples as superior to wait-list control and non-specific treatment participants (Baucom, et al., 1998). BMT has its roots in social learning theory and provides positive communication skills, effective problem-solving, and couple behavior change. O Farrell (1995) reported that behavioral marital therapy (BMT) in which the substance use and the marital relationship are treated, produces better long-term outcomes than individual treatment during the 12 months after the treatment is terminated. In a study by O Farrell (1985), 100% of BMT clients versus 58% of the interactional and treatment-as-usual control groups met the criterion for abstinence (maintaining abstinence for 95% of the treatment period). The 58% abstinence rates for the two non- BMT groups translates to 2 3 drinking days per month, versus the less than half a day of drinking per month for the BMT clients. These two or three days of drinking by a problem drinker or an alcohol-dependent drinker can have a serious impact at the community level, which is a dynamic that occurred in O Farrell & Murphy s (1985) study. O Farrell and Murphy (1995) claimed that clients who remitted after BMT were much less likely to be involved in marital violence than substance users who went through programs in interactional or individual therapy. C. Cognitive-Behavioral Therapy Three cognitive-behavioral approaches are suited especially for substance abuse treatment and are effective for individuals whose drinking is not severe or dependent and who can take responsibility for their treatment (NIAAA, 2000; Miller et al., 1995). Behavior contracting combined with relapse prevention is a process in which a series of successive and specific goals for recovery are set and achieved. Behavioral self control training (BSCT) is a treatment in which clients learn how to monitor, to take responsibility for, and to modify their drinking behavior. D. Treatment Based On 12 Steps of Alcoholics Anonymous Professional treatment modeled on the 12 steps of Alcoholics Anonymous (AA) is as effective as motivational enhancement and cognitive behavioral techniques in reducing or eliminating drinking. It also may be more effective than those treatments in helping Factors Related to Successful Prevention 3

6 recovering problem drinkers to sustain sobriety over a long period, such as three years (Project Match, 1998b). Treatment modeled on AA is especially efficacious for people without adequate social support for maintaining abstinence. E. Treatment of Dual Diagnosis Patients Solid research on treatment of individuals with a dual diagnosis of a mental disorder and a substance-related disorder is limited (Johnson, 2000). Dual diagnosis patients are resistive to treatments that are effective for people with a substance-related disorder alone. Preliminary results from a federally funded study indicate that the most cost and treatment effective approach is a combination of medication management, education, and individual therapy. This combination reduces the risk of relapse and psychiatric hospitalization (Johnson, 2000). Psychosocial services, in which meaningful activities such as vocational services and personal health seminars are offered to replace selfdestructive activities, is an expensive treatment but shows beneficial, long-term success in integrating these people into the community (Johnson, 2000). Formulating treatment to serve clients with a dual diagnosis is likely to improve treatments for those clients with a single diagnosis of a substance-related disorder. Substance users who receive standard alcoholism counseling plus psychological interventions for related problems show better employment rates, fewer family conflicts, and less interaction with the legal system than those who receive standard alcoholism counseling alone (McLellan, et al., 1997). F. Adolescent Substance Abuse Treatment Outcomes For adolescents, family systems treatment is more effective than individual treatment in reducing relapse and increasing functional, healthy behaviors (Williams & Chang, 2000). The following variables, which are listed as significant predictors of successful treatment outcome, portray the importance of multi-dimensional treatment: Pretreatment variables are low substance use, peer and parental social support for not using substances, and good school functioning. Treatment variables are treatment completion, programs with experienced therapists and comprehensive services, and large programs with large budgets. Post-treatment variables were attendance in aftercare and peer and parental social support. Family behavioral therapy combined with behavioral self control therapy (BSCT) or on its own is more effective than individually-oriented therapies (Azrin et al., 1994; Hennggeler, et al., 1991; Joanning, et al., 1992; Szapocznik, Kurtines, Foote, Perez-Vidal, & Hervis, 1986). G. Chemically Dependent Offenders Treatment Alternatives to Street Crimes (TASC) is composed of cooperatively-based referral, monitoring, and management services. TASC was created as an alternative to treatment strategies shown as ineffective with chemically dependent offenders. Such treatment models tended to be confrontational or authoritarian and non-supportive (Chanhatasilpa, MacKenzie, & Hickman (2000). Chanhatasilpa et al. (2000) claim that Factors Related to Successful Prevention 4

7 effective treatment involves the implementation of a socially supportive non-substance using community in prison and a TASC-like model of follow-up after release from prison. H. Culturally Relevant Therapies Family therapy, with its emphasis on familial and community connections, is more relevant to Alaska native cultures than individual therapies or treatments (Droby, 2000; Reimer, 1999). The incorporation of culturally sensitive approaches, including cultural awareness and education activities, and increased contact with mentors and therapists from one s own culture increases retention in alcohol treatment program. Increased retention in a substance treatment program increases the likelihood of recovery from dependency and abuse (Fisher, Lankford, & Galea, 1996). Network Therapy, conceived by Carolyn Attneave (1969; 1990), has been cited on an anecdotal level as successful and is worthy of notice. She describes three components as successful in bringing together an existing network of interconnected families and individuals or creating a new network to reduce individual and group pathology: first, the need to treat social pathology by an application of skills and insights derived from family and group therapy; second, the need for individual therapeutic skills both in crisis interaction and on a long-term basis; and third, the need for providing linkages with the institutions and external community as is seen in community psychiatry (Attneave, 1969, p. 209). These treatments vary in terms of the demographics of the populations best served. But they all have in common demonstrated efficacy in the prevention and treatment of substance-related disorders. Factors Related to Successful Prevention 5

8 IV. References Individual-Adult Brief Treatment Akeela House. (1996). Therapeutic community retention among Alaska Natives. Journal of Substance Abuse Treatment, 13,3, Bernstein, E., Bernstein, J. & Levenson, S. (1997). Project Assert: An ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system. Annals of Emergency Medicine, 30,(2), Bien, T. H., Miller, W. R., & Tonigan, J. S. (1993). Brief interventions for alcohol problems: A review. Addiction, 88,(3), Need this one to explicate on brief interventions. Burge, S. K., Amodei, N., Elkin, B., Catala, S., Andrew, S. R., Lane, P. A., & Seale, J. P. (1997). An evaluation of two primary care interventions for alcohol abuse among Mexican-American patients. Addiction, 92,(12), Chick, J., Ritson, B., Connaughton, J., Stewart, A. & Chick, J. (1988). Advice versus extended treatment for alcoholism: A controlled study. British Journal of Addiction, 83,(2), Davis, D. A., Thomson, M. A., Oxman, A. D., & Haynes, R. B. (1995). Changing physician performance: A systematic review of the effect of continuing medical education strategies. Journal of the American Medical Association, 274,(9), Drummond, D. C. (1997). Alcohol interventions: Do the best things, come in small packages? Addiction, 92,(4), Dunn, C., Deroo, L., Rivara, F. (2001). The use of brief interventions adapted from motivational interviewing across behavioral domains: A systematic review. Addiction, 96, 12, Fleming, M. F., Barry, K. L., Manwell, L. B., Johnson, K., & London, R. (1997). Brief physician advice for problem alcohol drinkers: A randomized controlled trial in community based primary care practices. JAMA, 277,(13), Fleming, M. F., Manwell, L. B., Barry, K. L., Adams, W., & Stauffacher, E. A. (1999). Brief physician advice for alcohol problems in older adults: A randomized community based trial. Journal of Family Practice, 48,(5), Galanter, M., Dermatis, H., Keller, D., & Trujillo, M. (2002). Network therapy for cocaine abuse: Use of family and peer supports. American Journal on Addictions,11,(11), Gentilello, L. M., Rivara, F. P., Donovan, D. M., Jurkovich, G. J., Daranciang, E., Dunn, C. W., Villavoces, A., Copass, M., & Ries, R. R. (1999). Alcohol interventions in a Community trauma center as a means of reducing the risk of injury recurrence. Annals of Surgery, 230,(4), Factors Related to Successful Prevention 6

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14 O'Farrell, T. J. (Ed.) (1993). A behavioral marital therapy couples' group program for alcoholics and their spouses. Treating alcohol problems: Marital and family interventions ((pp ). New York: Guilford Press) O'Farrell, T. J. & Murphy, C. M. (1995). Marital violence before and after alcoholism treatment. Journal of Consulting and Clinical Psychology, 63, O'Farrell, T. J., Choquette, K. A., Cutter, H. S. G., Brown, E. D., Bayog, R., McCourt, W., Lowe, J., Chan, A. & Deneault, P. (1996). Cost-benefit and costeffectiveness analyses of behavioral marital therapy with and without relapse prevention sessions for alcoholics and their spouses. Behavior Therapy, 27, 7-24.) Factors Related to Successful Prevention 12