Surrey Health Partners 1 Structured preparation in the treatment of Alcohol Dependence; is there...

Surrey Health Partners

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Structured preparation in the treatment of Alcohol Dependence; is there enough evidence

to support a change of the treatment paradigm? Results of a prospective cohort evaluation.

Christos Kouimtsidis, Ekta Sharma; Avril Smith; Kelly-Jo Charge

Consultant Psychiatrist in Addictions, Surrey & Borders Partnership NHS Foundation TrustLead Mental Health Clinical Academic Group, SHP

Hon. Senior Research Associate UCL


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Why is this important?


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background

Current treatment guidelines:

Planned detox and emphasis on structured aftercare. CBT interventions and family interventions good evidence for relapse prevention

Challenge 1:<60% completing detoxification engage in structured aftercare.


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Challenge 2


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Multiple detoxifications (medically assisted or not):

• Are related to withdrawal induced impairment in ‐mental functioning. Changes may confer inability in conflict resolution and increased sensitivity to stress (both relapse risk factors).

• Can exacerbate craving, impacting on subsequent attempts at achieving abstinence such that repeated attempts may be less likely to result in positive outcomes.


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referencesDuka T, Townshend JM, Collier K, Stephens DN. Kindling of Withdrawal: A Study of Craving and Anxiety After Multiple Detoxifications in Alcoholic Inpatients. Alcoholism: Clinical and Experimental Research. 2002;26(6):785-95.

Duka T, Townshend JM, Collier K, Stephens DN. Impairment in Cognitive Functions After Multiple Detoxifications in Alcoholic Inpatients. Alcoholism: Clinical and Experimental Research. 2003;27(10):1563-72.

Duka, Theodora, Gentry, John, Malcolm, Robert, Ripley, Tamzin L, Borlikova, Gilyana, Stephens, Dai N, Veatch, Lynn M, Becker, Howard C and Crews, Fulton T (2004) Consequences of multiple withdrawal from alcohol. Alcoholism: Clinical and Experimental Research, 28 (2). pp. 233-246. ISSN 0145-6008

Stephens, David N and Duka, Theodora (2008) Cognitive and emotional consequences of binge drinking: role of amygdala and prefrontal cortex. Philosophical Transactions B: Biological Sciences, 363 (1507). pp. 3169-3179. ISSN 1471-2970

Loeber S, Duka T, Welzel H, Nakovics H, Heinz A, Flor H, et al. Impairment of Cognitive Abilities and Decision Making after Chronic Use of Alcohol: The Impact of Multiple Detoxifications. Alcohol and Alcoholism. 2009;44(4):372-81.

Loeber S, Duka T, Welzel Márquez H, Nakovics H, Heinz A, Mann K, et al. Effects of Repeated Withdrawal from Alcohol on Recovery of Cognitive Impairment under Abstinence and Rate of Relapse. Alcohol and Alcoholism. 2010;45(6):541-7.

Duka, Theodora, Trick, Leanne, Nikolaou, Kyriaki, Gray, Marcus A, Kempton, Matthew J, Williams, Hugh, Williams, Steven C R, Critchley, Hugo D and Stephens, David N (2011) Unique brain areas associated with abstinence control are damaged in multiply detoxified alcoholics. Biological Psychiatry, 70 (6). pp. 545-552. ISSN 1873-2402

http://sro.sussex.ac.uk/13792/




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What should we change in medically assisted withdrawal?

• Duration?• Method? Are the observed symptoms the tip

of the iceberg? • Frequency of attempts? • Medication used?


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Orshould we change our overall approach?

How is this similar to the change of practice regarding antibiotics?


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Structured preparation


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Intervention

• APG groups bring forward and initiate prior detoxification a modified version of the Relapse Prevention Groups, a post detoxification intervention supported by evidence.

• APG groups are based on principles of Learning theory and PRIME theory

• APG groups use Cognitive Behaviour Therapy (CBT) techniques


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Intervention aims

• Stabilise the amount and pattern of drinking

• Devise and implement lifestyle changes that support regaining of control over drinking

• Increase coping skills and self-efficacy, which are considered necessary for the maintenance of abstinent lifestyle.


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Hertfordshire experience2005-2012


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Surrey cohortJuly-December 2013


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25/60=42% abstinent & 49% PDA

9 outstanding:19/60=32% abstinent & 48% PDA


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17 (94%) abstinent at 1 month post detox

18 (51%) guided self- detox during stage 1

11 (61%) abstinent at 3 months post detox

10 (55.5%) abstinent at 6 months post detox

Guided self detoxification


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Kouimtsidis C, Kolli S. 2014. Preparation for alcohol detoxification group programme. Service users’ evaluation of individual sessions. Journal of Substance Use, Vol. 19, No. 1-2, 184-187.

Kouimtsidis C. Drabble K & Ford L. 2012. Implementation and evaluation of a three stages community treatment programme for alcohol dependence. A short report. Drugs: Education, Prevention and Policy, 19 (1), 81-83.

Kouimtsidis C. 2013. Community alcohol detoxification; the challenge of changing service provision. Short report. Journal of Substance Use, 18(2), 166-169.

Kouimtsidis C. & Ford L. 2011. A staged programme approach for alcohol dependence: Cognitive Behaviour Therapy groups for detoxification preparation and aftercare; preliminary findings. Short report. Drugs: Education, Prevention and Policy, 18 (3),237-239.

Croxford A, Notley C, Maskrey V, Holland R, Kouimtsidis C. 2014. An exploratory qualitative study seeking participant views evaluating group Cognitive Behavioural Therapy preparation for alcohol detoxification. Journal of Substance Use (in print).


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SPADe

A randomised controlled trial of Structured Preparation for Detoxification in moderate and severe Alcohol dependence, within specialist

treatment services. SPADe

Collaborators: SABP, C&I, Surrey U, Sussex U, Imperial UL.42 monthsFunding proposal to NIHR/HTA; January 2015


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SPADe

Multi-centre, single blind, pragmatic, two-arm parallel RCT, comparing intervention as an adjunct to treatment as usual vs TAU. Specialist community alcohol services, publicly funded (Surrey, Hounslow, Camden & Islington). Adults with moderate to severe alcohol dependence (SADQ> 16); seeking abstinence; wishing to participate in group intervention.


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SPADe objectives

Does participation in SPADe groups • Improve long term abstinence compared to a control group

receiving treatment as usual (no group preparation prior detoxification) ?

• Reduce the hypothesised adverse cognitive effect of the medically assisted withdrawal on the brain?

• Reduce the experience of cravings, which have an adverse impact on subsequent attempts at achieving abstinence?

Does the addition of SPADe groups in the existing treatment pathways reduce the overall treatment cost by improving treatment outcomes?


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SPADe

We are looking for 2 more recruiting partners. If you would like to join us

please get in touch


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Thank [email protected]

[email protected]

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