23/05/2015
The role of Brief Interventions in the
treatment of alcohol related
problems: an European view
Dr Antoni Gual
[email protected]
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
1
23/05/2015
Index
• What’s going on before a Brief Intervention (BI) is
delivered?
• What do we call a BI?
• When do BIs become motivational?
• What is the evidence of efficacy and effectiveness?
• Why do MBI work? Which are the core elements of MBI?
• Final remarks
Index
• What’s going on before a Brief Intervention (BI) is
delivered?
• What do we call a BI?
• When do BIs become motivational?
• What is the evidence of efficacy and effectiveness?
• Why do MBI work? Which are the core elements of MBI?
• Final remarks
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23/05/2015
1.
2.
3.
4.
5.
6.
7.
APC study – Regions and drinking
patterns
Germanya: East Germany
Hungaryb:
Latviab:
Italy 1c:
Italy 2c:
Polandb:
Spainc:
entire country
entire country
Friuli-Venezia Giulia
Tuscany
Łódź & Podkarpackie provinces
Catalonia
a
Central-western drinking style: frequent drinking partly with, partly
without food, beer is favourite beverage
b
Eastern European drinking style: drinking often irregular (almost no
daily drinking) with heavy drinking occasions; mostly outside of meals
c
Southern European Mediterranian drinking style: drinking often
daily, usually wine alongside with meals, few heavy drinking occasions
Prevalence of AD and AUD by type of assessment & sex
AD
diagnosis
by GP
AD
diagnosis
by CIDI
AD
diagnosis
by GP or
CIDI
Total
N=13,003
Total
N=7,901
Total
N=7,279
Male
8.7%
9.6%
14.4%
Female
2.5%
2.7%
4.5%
Total
5.1%
5.5%
8.5%
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23/05/2015
Prevalence of AD and AUD by type of assessment & sex
AD diagnosis AD diagnosis AD diagnosis
by GP
by CIDI
by GP & CIDI
Total
N=13,003
Total N=7,901 Total N=7,279
Male
8.7%
9.6%
14.4%
Female
2.5%
2.7%
4.5%
Total
5.1%
5.5%
8.5%
21.8%
13.5%
19.7%
Professional
help (sought
and received)
Treatment gap* (%)
Widest treatment gap among all mental disorders
High prevalence and low treatment rates indicate a huge unmet medical need
ESSEMED Study. Kohn et al. Bull World Health Organ 2004;82:858–866
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23/05/2015
Amphora study: Per cent of adults who would benefit from treatment for sustained heavy
alcohol use who actually receive treatment
0
10 20 30 40 50 60 70 80 90 100
Germany
England
Austria
Switzerland
Spain
Italy
Wolstenhome, Drummond et al, 2012
The need for early identification
Past Alcohol Dependence. Treatment History:
EVER had treatment
NEVER had treatment
25.5%
74.5%
Treatment Examples:
• Inpatient
• Outpatient
• Alcoholics Anonymous
Source: United States 2001-2002, NESARC data
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23/05/2015
Screening or early identification?
• Screening: Strategy used in a population to identify
an unrecognised disease in individuals without signs
or symptoms.
• Targeted screening: Screening limited to selected
population (because of high risk or high vulnerability)
• Early identification: Evaluation of patients in whom
signs of alcohol playing a negative role in a case
history are present
The AUDIT: Alcohol Use Disorders Inventory Test
1. How often do you have a drink containing alcohol?
2. How many standard drinks containing alcohol do you have on a typical day when drinking?
3. How often do you have six or more drinks on one occasion?
4. During the past year, how often have you found that you were not able to stop drinking once
you had started?
5. During the past year, how often have you failed to do what was normally expected of you
because of drinking?
6. During the past year, how often have you needed a drink in the morning to get yourself going
after a heavy drinking session?
7. During the past year, how often have you had a feeling of guilt or remorse after drinking?
8. During the past year, have you been unable to remember what happened the night before
because you had been drinking?
0) Never
1) Less than monthly
2) Monthly
3) Weekly
4) Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
10. Has a relative or friend, doctor or other health worker been concerned about your drinking or
suggested you cut down?
0) No
2) Yes, but not in the past year
4) Yes, during the past year
WHO, 1982
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The AUDIT: Alcohol Use Disorders Inventory Test
1. How often do you have a drink containing alcohol?
2. How many standard drinks containing alcohol do you have on a typical day when drinking?
3. How often do you have six or more drinks on one occasion?
4. During the past year, how often have you found that you were not able to stop drinking once
you had started?
5. During the past year, how often have you failed to do what was normally expected of you
because
of drinking?
Cut
off points:
6. During the past year, how often have you needed a drink in the morning to get yourself going
after a heavy drinking session?
7. During theor
past
year, how oftendrinking:
have you had8aor
feeling
of guilt or remorse after drinking?
Harmful
Hazardous
more
8. During the past year, have you been unable to remember what happened the night before
because you had been drinking?
Alcohol Dependence: 13 or more in women, and 15 or more in men
0) Never
1) Less than monthly
2) Monthly
3) Weekly
4) Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
10. Has a relative or friend, doctor or other health worker been concerned about your drinking or
suggested you cut down?
0) No
2) Yes, but not in the past year
4) Yes, during the past year
WHO, 1982
The AUDIT-C
1. How often do you have a drink containing
alcohol?
2. How many standard drinks containing alcohol
do you have on a typical day when drinking?
3. How often do you have six or more drinks on
one occasion
0) Never
3) Weekly
1) Less than monthly
4) Daily or almost daily
2) Monthly
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23/05/2015
The AUDIT-C
1. How often do you have a drink containing
alcohol?
2. How many standard drinks containing alcohol
do you have on a typical day when drinking?
3.CutHow
often
do you
have six or more drinks on
off point
for Hazardous
drinking:
one
occasion
• 4 or more in women
5 or more in men 1) Less than monthly
0)• Never
3) Weekly 4) Daily or almost daily
2) Monthly
The AUDIT 3
• How often do you have six or more drinks on
one occasion?
Cut off point for Hazardous drinking:
If yes in the last 12 months, continue with full AUDIT
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Attitudes of PHC professionals towards alcohol
Attitudes of PHC professionals towards alcohol
Concept
Number of countries studied
Data
8
Total Sample
8672
Responses (response rate)
2345
(27%)
Hours of postgraduate education (SD)
10,2 (4,7)
Mean number (SD) of patients / week
127 (44,2)
Mean number (SD) of patients managed for heavy
drinking / last year
10,7 (4,9)
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Attitudes of PHC professionals towards
alcohol
Index
• What’s going on before a Brief Intervention (BI) is
delivered?
• What do we call a BI?
• When do BIs become motivational?
• What is the evidence of efficacy and effectiveness?
• Why do MBI work? Which are the core elements of MBI?
• Final remarks
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23/05/2015
What is a Brief Intervention?
It usually consists of a package involving:
• information on drinking risk levels,
• the status of the patient’s own drinking in
relation to those levels,
• encouragement to cut down and set a date for
doing so
• and perhaps a few simple hints on how cutting
down might best be achieved
Heather, N., 2010
What is brief??
•
•
•
•
one contact as ‘minimal’,
one to three sessions as ‘brief ’
five to seven sessions as ‘moderate’
eight or more sessions as ‘intensive’ treatment.
• However, what is considered a ‘brief’
intervention in one study might be considered an
‘extended’ intervention in another.
Babor & Grant (1994)
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23/05/2015
Just one type of BI?
• Heather has argued that two broad types of
brief interventions should be considered
separately.
• ‘Opportunistic Brief Interventions’
• ‘Specialist Brief Interventions’
Heather (1995; 1996)
Opportunistic Brief Interventions
• Interventions typically designed for and evaluated among
individuals not seeking help
• Generated through opportunistic screening in health care
settings.
• Subjects often have less severe problems and lower
motivation for change.
• These interventions are typically shorter, less structured,
less theoretically based and delivered by a non-specialist.
• They are usually compared to a no-treatment control
condition
Heather (1995; 1996)
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23/05/2015
Opportunistic Brief Interventions (2)
• SIMPLE ADVICE. Very Brief (or “Minimal”)
interventions consisting of not much more than
simple but structured advice, taking no more than
a few (five) minutes to deliver.
• BRIEF COUNSELLING. More intensive brief
interventions, taking perhaps 20-30 minutes to
deliver and often involving a few repeat sessions
Heather (1995; 1996)
Specialist Brief Interventions
• Originated as a control condition in evaluations of
traditional treatment
• Have typically been evaluated among individuals
seeking or being persuaded to seek treatment
• These interventions are usually longer, more
structured, theoretically based and delivered by a
specialist.
• They are usually compared to TAU or other
treatments
Heather (1995; 1996)
13
23/05/2015
Index
• What’s going on before a Brief Intervention (BI) is
delivered?
• What do we call a BI?
• When do BIs become motivational?
• What is the evidence of efficacy and effectiveness?
• Why do MBI work? Which are the core elements of MBI?
• Final remarks
Which are the esential components of
opportunistic BIs?
• Assess consumption with a brief screening
tool
• Advise patients to reduce their consumption
• Agree on individual goals
• Assist patients with acquiring the motivations,
self-help skills, or supports needed for
behaviour change
• Arrange follow-up
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23/05/2015
When do opportunistic BIs become motivational?
• Ask for permission to Assess consumption with a
brief screening tool
• Ask for permission to give Advise to patients to
reduce their consumption
• Agree on individual goals through negotiation
• Assist patients with acquiring the motivations, selfhelp skills, or supports needed for behaviour change
using MI microskills
• Offer to Arrange follow-up
30
A Brief Intervention is..
A short advice given by a health
professional to a patient
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23/05/2015
But a Brief Motivational Intervention
is
A short conversation between a health
professional and a patient
Two different MBI approaches
Assessment feedback
• Feedback of assessment as
the primary means of
structuring the conversation
and as the basis to elicit
change talk
Opportunistic MBI
Conversational style
• Series of conversational
exercises expected to be
helpful in eliciting change
talk on relevant material
Specialist MBI
McCambridge J, 2002
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23/05/2015
Components of MBI
Communicate
empathy
Evaluate stage of change
Give feed back on health status
Promote
self-efficacy
Give advice (Ask for permission)
Negotiate aims and strategies
Monitor progress
Respect his/her
responsibility
Modified from Etheridge RM & Sullivan E. http://www.alcoholcme.com
Opportunistic MBI
Communicate
empathy
Evaluate stage of change
Give feed back on health status
Promote
self-efficacy
Give advice (Ask for permission)
Negotiate aims and strategies
Monitor progress
Respect his/her
responsibility
Modified from Etheridge RM & Sullivan E. http://www.alcoholcme.com
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23/05/2015
Specialized MBI
Communicate
empathy
Evaluate stage of change
Give feed back on health status
Promote
self-efficacy
Give advice (Ask for permission)
Negotiate aims and strategies
Monitor progress
Respect his/her
responsibility
Modified from Etheridge RM & Sullivan E. http://www.alcoholcme.com
Index
• What’s going on before a Brief Intervention (BI) is
delivered?
• What do we call a BI?
• When do BIs become motivational?
• What is the evidence of efficacy and effectiveness?
• Why do MBI work? Which are the core elements of MBI?
• Final remarks
18
23/05/2015
What is the evidence ?
• Do brief interventions work? Efficacy studies on brief
alcohol interventions.
• Do brief interventions work in the real world of primary
care? Effectiveness trials.
• What factors promote widespread adoption of brief
interventions into routine practice? Implementation trials.
• Wider roll-out work: Demonstration studies.
O’Donnell et al, 2014
Efficacy studies
• 23 trials
• Best evidence for 10-15 min BIs and multicontacts
• Compared to controls:
• Consumption decreased by 3,6 drinks per week from
baseline
• Heavy drinking episodes reduced by 12%
• 11% reported drinking below recommended limits
• No evidence of impact in Alcohol Related Problems
Jonas et al, 2012
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23/05/2015
Effectiveness trials
• 24 systematic reviews
• Brief alcohol interventions are effective when delivered in
primary healthcare
• Brief alcohol intervention equally effective across different
countries and different health care systems?
• Insuficient evidence in young and older adults
• Optimum length, frequency and content unknown
O’Donnell et al, 2013
Implementation trials
Keurhorst et al, 2014
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23/05/2015
Implementation trials
1.
Two hours of training led to more interventions being
delivered. Repeating elements facilitate long-term
implementation
2.
Modest financial reimbursement led to more
interventions being delivered. Work optimally when
fine-tuned to county-specific contexts
3.
A combination of training and support and financial
reimbursement led to more interventions being
delivered than either strategy alone
Anderson et al, 2014. Submitted
Demonstration studies: screening in PHC
70
60
Lleida
Tarragona
50
Barcelona
40
Girona
Metropolitana Sud
30
Metropolitana Nord
Caralunya central
20
Alt Pirineu
Terres de l'Ebre
10
Total
0
2005
2006
2007
2008
2009
2010
2011
Health areas
in Catalonia
Colom et al, 2014. Data on file
21
23/05/2015
Index
• What’s going on before a Brief Intervention (BI) is
delivered?
• What do we call a BI?
• When do BIs become motivational?
• What is the evidence of efficacy and effectiveness?
• Why do MBI work? Which are the core elements of MBI?
• Final remarks
Why do MBI work?
•
•
•
•
Life events (raise awareness)
Assessment (raise awareness)
Internal discrepancies (importance)
Taking steps - planning (confidence)
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23/05/2015
Why do MBI work?
•
•
•
•
Life events (raise awareness)
Assessment (raise awareness)
Internal discrepancies (importance)
Taking steps - planning (confidence)
RCT with 12-month follow-up. Patients were randomized into:
– BAI group (n = 310)
– control group with screening and assessment (n = 342)
– control group with screening only (n = 335)
Results: Assessment didn’t influence drinking outcomes, but
one third of the patients were low risk drinkers 1 year later
Daeppen et al; Addiction, 102, 1224-33; 2007
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Changes in drinking before a mandated
BI (college students)
• OBJECTIVE: To assess the extent to which students
significantly reduce their drinking between the time of an
alcohol-related violation and the sanctioned intervention.
• METHOD: 175 (70% male) students mandated to a Drug
& Alcohol Program for Students. At intake, students
reported on their alcohol consumption for the 30 days
before the violation and the 30 days before the intake
assessment.
Morgan et al, J Stud Alcohol Drugs; 69(2):286-90; 2008
Changes in drinking before a mandated
BI (college students)
RESULTS
Mandated students significantly reduced before any
intervention:
– peak blood alcohol concentration (BAC) levels,
– total weekly drinks,
– frequency of alcohol use
Those who received a legal or medical referral (i.e., a serious
infraction) reduced their alcohol consumption significantly
more.
Morgan et al, J Stud Alcohol Drugs; 69(2):286-90; 2008
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23/05/2015
Why do MBI work?
•
•
•
•
Life events (raise awareness)
Assessment (raise awareness)
Internal discrepancies (importance)
Taking steps - planning (confidence)
Reduction after assessment: studies
ESENSE
Baseline
Visit1
Screening visit
Month 1
V2
Month 6
V5
V10
V11
V12
Randomisation
30% of patients reduced
consistently their drinking
before they actually initiated
any dose of study drug
Mann et al. Biol Psychiatry 2013;73(8):706–713; Gual et al. Eur Neuropsychopharmacol 2013
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23/05/2015
Change from baseline
in HDDs per month
Reduced prior to
randomisation
Did not reduce
0
0
-2
-2
-4
-4
-6
-6
-8
-8
-10
-10
-12
-12
-14
-14
-16
-16
-18
*
*
*
*
*
*
5
6
-18
B
R
1
2
3
4
5
6
B
Monthly period
R
1
2
3
4
Monthly period
Nalmefene
Placebo
Data on file
Why do MBI work?
•
•
•
•
Life events (raise awareness)
Assessment (raise awareness)
Internal discrepancies (importance)
Taking steps - planning (confidence)
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23/05/2015
Internal discrepancies
• Internal confrontation as a goal, instead of
external confrontation as a technique
• Help patients to see the mismatch between
their goals & values and their actual behaviour
Why do MBI work?
•
•
•
•
Life events (raise awareness)
Assessment (raise awareness)
Internal discrepancies (importance)
Taking steps - planning (confidence)
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23/05/2015
Taking steps - Planning
•
•
•
•
Help to overcome main barriers
Identify supports
Build internal confidence
Agree on a plan
Index
• What’s going on before a Brief Intervention (BI) is
delivered?
• What do we call a BI?
• When do BIs become motivational?
• What is the evidence of efficacy and effectiveness?
• Why do MBI work? Which are the core elements of MBI?
• Final remarks
28
23/05/2015
Final remarks
• Double gap: identification and treatment rates
are very low
• BIs efficacy and effectiveness stablished.
• Implementation is scarce
• BIs work through raising awareness, increasing
internal discrepancies and helping to plan
changes.
THANKS FOR YOUR ATTENTION !!!
Brief Interventions in
Alcohol Use Disorders
Dr Antoni Gual
[email protected]
29