Incorporating Medications and Motivational Interviewing Jennie Wei MD MPH Gallup Indian Medical Center Gallup NM Assistant Clinical Professor of Medicine University of California San Francisco ID: 921263
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Slide1
Inpatient Treatment of Alcohol Use Disorders: Incorporating Medications and Motivational Interviewing
Jennie Wei, MD, MPH
Gallup Indian Medical Center, Gallup, NM
Assistant Clinical Professor of Medicine, University of California, San Francisco
Slide2ObjectivesDefine Alcohol Use Disorders (AUDs)Describe the pathogenesis and prevalence of AUDsReview the FDA approved medications for the treatment of AUDsSummarize other non-FDA approved medications for the treatment of AUDsDescribe motivational interviewing and brief interventions in the inpatient setting
Slide3Recurrent drinking resulting in failure to fulfill role obligationsRecurrent drinking in hazardous situationsContinued drinking despite alcohol-related social or interpersonal problemsEvidence of tolerance Evidence of alcohol withdrawal or use of alcohol for relief or avoidance of withdrawalDrinking in larger amounts or over longer periods than intendedPersistent desire or unsuccessful attempts to stop or reduce drinkingGreat deal of time spent obtaining, using, or recovering from alcoholImportant activities given up or reduced because of drinkingContinued drinking despite knowledge of physical or psychological problems caused by alcoholAlcohol cravingDefinition of Alcohol Use Disorders (AUDs)
Disorder severity:
Mild: 2-3 symptoms
Moderate: 4-5 symptoms
Severe: 6 or more symptoms
DSM-5 diagnostic criteria for alcohol use disorder:
Slide4Development of alcohol use disorder is a complex interplay of:Environmental influences family/peer influences, prenatal exposuresPersonality traits neuroticism, impulsivity, extroversionGenetics (responsible for ~50% of vulnerabilities related to AUDs)Responsiveness to alcohol, personality characteristics, GABA, dopamine, opioid receptorsPathogenesisSher KJ, Grekin ER, Williams NA. The development of alcohol use disorders. Annu Rev Clin Psychol. 2005; 1: 493-523.
Slide5Substance Use Disorder in the Past Year among People Aged 12 or Older: 2016National Survey on Drug Use and Health: Summary of National Findings, 2016. Substance Abuse and Mental Health Services Administration
75% of those with SUD have an AUD
Slide6Treatment for alcohol use disordersLocations where alcohol treatment was receivedNational Survey on Drug Use and Health: Summary of National Findings, 2016. Substance Abuse and Mental Health Services Administration.Of those with an alcohol use disorder, 10.9% (2.2 million/20.1 million) of patients received treatment
Slide7Past-Year Alcohol Use Treatment in New Mexico (2009-2013)National Survey on Drug Use and Health: Summary of National Findings, 2009-2013. Substance Abuse and Mental Health Services Administration.
Slide8Provider Attitudes around PharmacotherapyVA Healthcare System of 331,000 veterans with alcohol use disorder1.9% were prescribed pharmacotherapy (2003)3.0% were prescribed pharmacotherapy (2012)Survey of 1388 US physicians on pattern of prescribing3-13% of physicians use pharmacotherapy for treatment of alcohol dependence Seen in general practitioners, internal medicine physicians, family physicians, VA physicians, and addiction psychiatrists Lack of awareness of medications, lack of knowledge about efficacy, lack of time, and lack of reimbursement sited as main reasons for low usePetrakis, I. L., Leslie, D., & Rosenheck, R. (2003). Use of naltrexone in the treatment of alcoholism nationally in the Department of Veterans Affairs. Alcoholism: Clinical and Experimental Research, 27, 1780–1784. Harris, A.H., Oliva E, et al. (2012). Pharmacotherapy of alcohol use disorders by the Veterans Health Administration: patterns of receipt and persistent. Psychiatr Serv. 63(7): 679-85.Mark, T. L., Kranzler, H. R., & Song, X. (2003b). Understanding U.S. addiction physicians’ low rate of naltrexone prescription. Drug and Alcohol Dependency, 71(3), 219–228.
Slide9Patient Attitudes around PharmacotherapySurvey of hospitalized patients on an internal medicine service in a university public hospital84% agreed that they needed to stop drinking66% agreed that they would like to receive an effective medication to help prevent drinkingStewart, S. H., & Connors, G. J. (2007). Interest in pharmacotherapy and primary care alcoholism treatment among medically hospitalized, alcohol dependent patients. Journal of Addictive Diseases, 26(2), 63–69.
Slide10Slide11Wouldn’t it be great if there was something that could help…Lengthen periods of abstinencePrevent a lapse from becoming a full-blown relapseRelieve symptoms of protracted withdrawalAllow brain cells to readapt to a normal nonalcoholic state, helping patients stabilize, think more clearly, strengthen coping mechanisms, and increase motivational readiness for changeSupport the effects of psychosocial treatment and sustain the gains of intervention
Slide12Slide13FDA Approved Medications for the Treatment of Alcohol Use DisordersDisulfiram1951Naltrexone
1994
Extended Release Naltrexone
2006
Acamprosate
2004
Slide14FDA Approved Medications for the Treatment of Alcohol Use DisordersDisulfiram1951Naltrexone
1994
Extended Release Naltrexone
2006
Acamprosate
2004
Slide15Disulfiram: Mechanism of ActionAlcohol
Acetaldehyde
Acetic Acid
Disulfiram
Alcohol Dehydrogenase
Acetaldehyde Dehydrogenase
Flushing
Nausea
Headache
Slide16Disulfiram: EvidenceReview of all 18 RCTs with disulfiram under direct supervision 17 of 18 showed improved abstinence, treatment retention and/or proportion of days of alcohol consumptionMost comprehensive review of literature covering 1937-2005 concluded that supervised disulfiram is effective treatment for alcohol dependenceDisulfiram similar to placebo when not under close supervision1. Brewer, C., Meyers, R. J., & Johnsen, J. (2000). Does disulfiram help to prevent relapse in alcohol abuse? CNS Drugs, 14(5), 329–341.2. Suh, J. J., Pettinati, H. M., Kampman, K. M., & O’Brien, C. P. (2006). The status of disulfiram: A half of a century later. Journal of Clinical Psychopharmacology, 26(3),290–302.
Slide17When to Use Disulfiram?Use in motivated patients with good supervision/strong support system (court ordered, inpatient rehab)Use as adjunct to other medications or to support abstinence if attending events that involve alcoholMay not be a viable option in primary care settings given limited ongoing supervisionContraindications: Severe cardiovascular diseaseMonitoring: Baseline LFTs then ~14 days of treatmentPatient info: Take 250mg/day, if no effect with alcohol, can increase to 500mg/day Avoid alcohol at least 12 hours prior to initiation and at least 2 weeks after last dose
Slide18FDA Approved Medications for the Treatment of Alcohol Use DisordersDisulfiram1951Naltrexone
1994
Extended Release Naltrexone
2006
Acamprosate
2004
Slide19Naltrexone: Mechanism of ActionNicholas, W. Neurobiology of Alcohol Dependence. NIAAA 2007.
Slide20Naltrexone: EvidenceMulti-center COMBINE study has proven usefulness of naltrexone in the primary care setting (JAMA 2006)Largest RCT to date, 11 academic sites in the US, N=1383Naltrexone reduced heavy drinking (HR 0.72, p =0.02) and improved “good clinical outcome” (OR 2.16, p <0.001)Cochrane Review published which evaluated 27 randomized control trials from 1992-2001 in N. America, Europe, Asia, Australia, N = 3048 (2008)Short term (16 week) treatment of naltrexone decreased the chance of alcohol relapses by 36% (NNT = 7). NTX can lower the risk of withdrawal in alcohol dependent patients by 28% (NNT = 13)Treatment up to 1 year gave no benefit for relapse prevention, but decreased overall alcohol consumption and diminished cravings
Anton, R. F., COMBINE Study Research Group. (2006). Combined pharmacotherapies and behavioral interventions for alcohol dependence: The COMBINE study, A randomized controlled trial.
JAMA, 295
(17), 2003–2017.
Srisurapanont
M,
Jarusuraisin N. Opioid antagonists for alcohol dependence (Review). Cochrane Database Syst Rev. 2005;2(1):CD001867.
Slide21Number Needed to Treat (NNT) for Common Medical Problems1. Dickerson, L. Prevention of Recurrent Ischemic Stroke. Am Fam Physician. 2007 Aug 1;76(3):382-388.2. Sanmagunathan, P. Aspirin for primary prevention of coronary heart disease. Heart. 2001 Mar; 85(3): 265-271.3. Wang, W. Effects of proton-pump inhibitors on functional dyspepsia. Clin Gastroenterol Hepatol. 2007 Feb; 5(2): 178-85.4. Cochrane Briefs: Effectiveness of Antidepressants Compared with Placebo for Depression in Primary Care. Am Fam Physician. 2010 Jul 1: 81(1).
Slide22When to Use Naltrexone?First line treatment (unless severe liver disease or opioid use)Decreases cravings, reduces heavy drinkingContraindications: severe liver disease (AST, ALT or GGT > 6xULN), acute or chronic opioid useMonitoring: baseline LFTs, then q3-6months Black Box Warning for hepatocellular injury REMOVED in 2013Patient Info:Take 25mg per day for 1 week, then 50mg dailySafe to use in supervised withdrawal or concomitant alcohol use
Slide23Extended Release Naltrexone380mg IM injection every 4 weeksDoes not go through first pass liver metabolismIndicated for patients who have not responded to other treatments, or have trouble with adherence (ie poor memory, mental illness)RCTs show effectiveness in decreasing heavy drinkingNo definitive head to head trials between oral and extended release naltrexoneCost prohibitive
Slide24FDA Approved Medications for the Treatment of Alcohol DependenceDisulfiram1951Naltrexone
1994
Extended Release Naltrexone
2006
Acamprosate
2004
Slide25Acamprosate: Mechanism of ActionNicholas, W. Neurobiology of Alcohol Dependence. NIAAA 2007.
Slide26Acamprosate: Evidence17 RCTs in 12 countries with 5000 patients measuring 3 months to over a year14 of 17 showed increased abstinence, time to first drink and decreased LFT levelsCombined abstinence rate at the end of treatment was 35% in acamprosate versus 21% in placebo groupsOf 3 studies that failed, only 2 month treatment period was usedLarge US RCT COMBINE in 2006 did not show evidence of efficacy for acamprosateOutcomes only measured for 4 monthsMann K, Lehert P, Morgan MY. The efficacy of acamprosate in the maintenance of abstinence in alcohol-dependent individuals: results of a meta-analysis. Alcohol Clin Exp Res. 2004;28(1):51–63.
Slide27When to Use Acamprosate?First line treatment if contraindication to naltrexone, second line if partial/no response to naltrexoneSafe in liver disease, no medication interactions, no abuse potentialContraindications: CrCl <30, suicidality (1.4% vs 0.5% suicidal ideation, no difference in completion 0.1% overall)Monitoring: Baseline renal functionPatient Info: Take two 333mg tablets three times per dayBest to abstain from alcohol for 3 days, but safe to use in supervised withdrawal or concomitant alcohol use
Slide28Topiramate: Mechanism: Glutamate antagonist and GABA inhibitorEfficacy: Meta-analysis (JAMA 2014) showed decreased alcohol consumption compared to placebo Dose: 50mg daily -150mg BIDGabapentinMechanism: GABA regulationEfficacy: Increased abstinence, decreased use, dysphoria, cravings, some concern for abuse potential in patients with a SUDDose: 900-1800mg/dayOther drugs for the treatment of Alcohol Use Disorders (Non-FDA Approved)Jonas DE. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014 May;311(18):1889-900.
Slide29BaclofenMechanism: GABA regulationEfficacy: mixed resultsDose: 30mg/dayAntidepressants (sertraline, desipramine, imipramine)Mechanism: Serotonin regulationEfficacy: Only effective in treating alcohol use disorder in patients who have comorbid depressive/anxiety disorderOndansetronMechanism: Serotonin regulationEfficacy: May be selectively effective in patients with early onset subtype of alcohol use disorder or those with a specific genetic variant of the serotonin transporter gene.Other drugs for the treatment of Alcohol Use Disorders (Non-FDA Approved)
Slide30Medication and Psychosocial TreatmentReview of clinical trials on interactions of pharmacotherapy and psychosocial treatmentAdding medication to psychosocial therapy improves outcomesInterventions ranging from brief interventions to intensive psychotherapy have all been shown to be produce positive outcomesWeiss, R. D., & Kueppenbender, K. D. (2006). Combining psychosocial treatment with pharmacotherapy for alcohol dependence. Journal of Clinical Psychopharmacology, 26(Suppl 1), S37–S42.
Slide31Evidence: Inpatient Brief Interventions14 RCTs, n=4041, heavy alcohol use, US&UKBrief interventions: 1-4 sessions, each 5-15 minutes each, with the goal of providing information and feedback, enhancing motivation to change and giving adviceCompared to control groups, brief interventions had:Greater reduction in alcohol consumption at 6 and 9 months (MD -69.43, 95% CI -128.14 to -10.72)Fewer deaths (RR 0.42, 95% CI 0.19 to 0.94)McQueen, Jean et al. Brief interventions for heavy alcohol users admitted to general hospital wards. Cochrane Database of Systematic Reviews 2011, Issue 8.
Slide32Motivational Interviewing (MI) PrinciplesTherapeutic style to help patients address ambivalence, find internal motivations to change behaviorEmpathic, nonjudgmental, non-argumentative collaborative, supports self-efficacyFour strategies - OARSOpen ended questionsAffirmReflective listeningSummarizeMiller, W. R., Rollnick, S. Motivational Interviewing: Helping People Change. New York, NY: Guilford Press, 2013.
Slide33Traditional vs MotivationalCorrect patient perceptionsConvincing patient there is a problemDenial met with argumentation
Exploring patient perceptions
Eliciting patients own concerns
Denial met with reflection
Miller, W. R., Rollnick, S.
Motivational Interviewing: Helping People Change
. New York, NY: Guilford Press, 2013.
Slide34Stages of ChangeBring awareness, instill hope, provide information to decrease riskMiller, W. R., Rollnick, S. Motivational Interviewing: Helping People Change. New York, NY: Guilford Press, 2013.
Slide35Stages of ChangeExplore pros and cons, Develop discrepancyMiller, W. R., Rollnick, S. Motivational Interviewing: Helping People Change. New York, NY: Guilford Press, 2013.
Slide36Stages of ChangeOffer menu of choices, identify supports and barriers to changeMiller, W. R., Rollnick, S. Motivational Interviewing: Helping People Change. New York, NY: Guilford Press, 2013.
Slide37Stages of ChangeIdentify unexpected hurdles, new sources of support, coping strategies, decrease barriersMiller, W. R., Rollnick, S. Motivational Interviewing: Helping People Change. New York, NY: Guilford Press, 2013.
Slide38Stages of ChangeHighlight gains from healthy change, identify triggers to relapse Miller, W. R., Rollnick, S. Motivational Interviewing: Helping People Change. New York, NY: Guilford Press, 2013.
Slide39Stages of ChangeNormalize as common part of chronic disease, not failure, re-engage, avoid becoming discouraged Miller, W. R., Rollnick, S. Motivational Interviewing: Helping People Change. New York, NY: Guilford Press, 2013.
Slide40Brief Negotiated InterviewProject ED Health, D’Onofrio, Pantalon, et al. NIAAA RO1 AA12417-03
Slide41Summary of Inpatient Treatment of Alcohol Use Disorders Medication Assisted Treatment:Naltrexone: First line therapy (unless severe liver disease or opioid use)Acamprosate: First line if contraindication to naltrexone, second line if partial or no response to other medsDisulfiram: Must be motivated with close supervision, Use as adjunct therapy to other meds or to support abstinence if attending events that involve alcoholBrief interventions in the inpatient setting decrease alcohol use and mortalityUse motivational interviewing principles to move through stages of change
Slide42An Inpatient Treatment and Discharge Planning Protocol for Alcohol DependenceWei, J. Defries, T. et al. J Gen Intern Med, Mar 2015.
Slide43Discharge Planning Tool
Slide44Pre Intervention
June 2011 Chart Review
Slide45Post Intervention
March 2012 Chart Review
Slide46“He's been sober since his hospitalization with you guys. He looks great and is feeling well and is very happy about being sober. It's still a day at a time process for him to stay sober, but having you guys care so much made an impact on him. Sometimes it feels like we're fighting an uphill battle taking care of alcohol withdrawal patients, so I wanted to make sure you know that the extra effort you took in caring for him seems to have paid off.”- UCSF Internal Medicine R3
Slide47ReferencesSher KJ, Grekin ER, Williams NA. The development of alcohol use disorders. Annu Rev Clin Psychol. 2005; 1: 493-523.US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality; 2009-2013Petrakis IL, Leslie D, Rosenheck R. Use of naltrexone in the treatment of alcoholism nationally in the Department of Veterans Affairs. Alcohol Clinc Exp Res. 2003;27:1780–4. Harris, A.H., Oliva E, et al. (2012). Pharmacotherapy of alcohol use disorders by the Veterans Health Administration: patterns of receipt and persistent. Psychiatr Serv. 63(7): 679-85.Mark TL, Kranzle HR, Song X. Understanding U.S. addiction physicians’ low rate of naltrexone prescription. Drug Alcohol Depend. 2003;71(3):219–228.Stewart SH, Connors GJ. Interest in pharmacotherapy and primary care alcoholism treatment among medically hospitalized, alcohol dependent patients. J Addict Dis. 2007;26(2):63–69.
Brewer C, Meyers RJ, Johnsen J. Does disulfiram help to prevent relapse in alcohol abuse? CNS Drugs. 2000; 14(5), 329–341.
Suh JJ,
Pettinati
HM,
Kampman
KM, O’Brien CP. The status of disulfiram: a half of a century later. J Clin Psychopharmacol. 2006;26(3):290–302.Jorgensen CH, Pederson B, Tonnesen H. The efficacy of disulfiram for the treatment of alcohol use disorder. Alcohol Clin Exp Res. 2011;35(10): 1749-58.Nicholas, W. Neurobiology of Alcohol Dependence. NIAAA 2007.Anton RF, O’Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006;295(17):2003–17.Anton RF. Combined pharmacotherapy and behavioral interventions for alcohol dependence: the COMBINE study. JAMA 2006; 295:2003-17.
Slide48ReferencesAnton R. Naltrexone for the management of alcohol dependence. N Engl J Med. 2008;359(7):715–21.Srisurapanont M, Jarusuraisin N. Opioid antagonists for alcohol dependence (Review). Cochrane Database Syst Rev. 2005;2(1):CD001867.Dickerson L. Prevention of Recurrent Ischemic Stroke. Am Fam Physician. 2007 Aug 1;76(3):382-388.Sanmagunathan P. Aspirin for primary prevention of coronary heart disease. Heart. 2001 Mar; 85(3): 265-271.Wang W. Effects of proton-pump inhibitors on functional dyspepsia. Clin Gastroenterol Hepatol. 2007 Feb; 5(2): 178-85.Cochrane Briefs: Effectiveness of Antidepressants Compared with Placebo for Depression in Primary Care. Am Fam Physician. 2010 Jul 1: 81(1).Yen MH, et al. Study of hepatotoxicity of naltrexone in the treatment of alcoholism. 2006; 38:117-120.
Mann K,
Lehert
P, Morgan MY. The efficacy of
acamprosate
in the maintenance of abstinence in alcohol-dependent individuals: results of a meta-analysis. Alcohol
Clin Exp Res. 2004;28(1):51–63.Jonas DE. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014 May;311(18):1889-900.Weiss RD, Kueppenbender, KD. Combining psychosocial treatment with pharmacotherapy for alcohol dependence. Journal of Clinical Psychopharmacology. 2006; 26(Suppl 1), S37–S42.McQueen, Jean et al. Brief interventions for heavy alcohol users admitted to general hospital wards. Cochrane Database of Systematic Reviews 2011, Issue 8.Miller, W. R., Rollnick, S. Motivational Interviewing: Helping People Change. New York, NY: Guilford Press, 2013. Project ED Health, D’Onofrio, Pantalon, et al. NIAAA RO1 AA12417-03Wei J. Defries T. Lozada M. et al. An inpatient treatment and discharge planning protocol for alcohol dependence: efficacy in reducing 30-day readmissions and emergency department visits. J Gen Intern Med. 2015 Mar;30(3): 365-370.