Detalle del Riesgo

BACKGROUND

The provider in general healthcare settings can and should provide evidence-based medical management to reduce substance use. A structured, focused format can provide an initial pathway towards recovery. Brief interventions are effective in the initial phase and may be repeated as part of medical monitoring. For patients who do not respond to brief intervention, comprehensive medical management and monitoring as well as opportunistic referral to specialty SUD care are the emphases of general healthcare treatment. In some cases, medical management will lead to remission of the SUD or referral for specialty SUD care, while in others it serves a more palliative function.

RECOMMENDATIONS

1. Provide a brief intervention (counseling) for Unhealthy Alcohol Use , which includes the following components: [A]

a. Express concern that the patient is drinking at unhealthy levels known to increase his/her risk of alcohol-related health problems

b. Provide feedback linking alcohol use and health, including:

• Personalized feedback (i.e., explaining how alcohol use can interact with the patient’s medical concerns [e.g., hypertension, depression/anxiety, insomnia, injury, diabetes, breast cancer risk, interactions with medications]) OR

• General feedback on health risks associated with drinking. c. Advise:

• To abstain (if there are contraindications to drinking) OR

• To drink below recommended limits (specified for the patient by gender, age and health status)

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2. Provide medical management in the treatment of alcohol use disorder and consider medical management for other substance use disorders that includes: [C]

• Monitoring self-reported use, laboratory markers and consequences

• Use of medication, adherence monitoring, response to treatment and adverse effects

• Education and referral to community support for recovery (e.g., Alcoholics Anonymous). 3. Offer referral to a specialty addictions program when indicated.

RATIONALE

A number of modalities of psychosocial therapy have been studied and validated for treatment of SUDs (McCaul & Petry, 2003). Referral to specialty care is an ongoing consideration for arranging access to more extensive evidence-based psychosocial therapy interventions. In the context of the primary care setting, delivering particular psychosocial therapies may be difficult due to time constraints, patient population, and lack of training. Brief interventions and comprehensive medical management and monitoring have been shown to be the most studied (and effective) interventions in the context of non-specialty care settings (Anton et al. 2006).

Brief interventions (see discussion Module A, Annotation F).

Medical Management strategy was developed as part of the NIAAA-supported COMBINE study to

provide a basic form of clinical intervention supporting effective pharmacotherapy (Anton et al., 2006). Medical Management is a manualized treatment designed to approximate a primary care

approach to alcohol dependence () (Pettinati

et al., 2000). The treatment, delivered by a medical professional (e.g., nurse or physician), provides strategies to increase medication adherence and monitoring of substance use and consequences as well as supporting abstinence through education and referral to support groups.

The initial session (40–60 minutes) involves discussion of the alcohol dependence diagnosis and negative consequences from drinking, a recommendation to abstain, medication information, strategies to enhance medication adherence, and referral to support groups such as Alcoholics Anonymous. In the subsequent monitoring visits, the clinician assesses the client’s drinking, monitoring lab or physiologic measures, assesing overall functioning, medication adherence, and any medication side effects. Session structure varies according to the client’s drinking status and treatment compliance. When the client does not adhere to the medication regime, the clinician evaluates the reasons and helps the client devise plans to address the problem(s). Clinicians urge clients who drink to attend support groups and offer common sense recommendations, such as avoiding bars. If the client suffers from medical side effects, the clinician specifies procedures for using concomitant medication to ameliorate them or reduces the dosage of either one or both study agents, resuming the study agents if side effects remit. If a client discontinues medication because he or she cannot tolerate it, the clinician schedules a monthly 15- to 25-minute “medical attention” meeting, during which the clinician employs a similar approach that focuses on the client’s drinking and overall health, omitting the medication adherence component.

In COMBINE, Medical Management appeared to be an excellent treatment to reduce alcohol

consumption even when the medication prescribed was placebo. Medical management can be adapted to help treat substances other than alcohol use and alcohol use disorders, although further studies will be required to support its effectiveness.

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EVIDENCE TABLE

Evidence Source QE Overall Quality

SR

1 Medical monitoring and placebo are as effective as acamprosate or a combined behavioral intervention for alcohol

Anton , 2006 I Good C

QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A)

I. Treatment: Psychosocial Support for Recovery

BACKGROUND

Psychosocial rehabilitation services can be an important part of the treatment of SUD when indicated. Negative life events and stressful circumstances may contribute to the onset or relapse of a substance use disorder. They also may influence treatment adherence and outcome.

RECOMMENDATIONS

1. Referral to psychosocial rehabilitation services should be offered to individuals with identified, unmet psychosocial needs, regardless of the population or setting, and regardless of the type of pharmacotherapy or psychotherapy being administered.

2. Prioritize and address other coexisting biopsychosocial problems with services targeted to these problem areas, rather than increasing intensity of addiction-focused psychosocial treatment alone. [B]

a. Address transitional housing needs to facilitate access to treatment and promote a supportive recovery environment

b. Provide social/vocational/legal services in the most accessible setting to promote engagement and coordination of care

c. Address deferred problems as part of treatment plan updates and monitor emerging needs d. Coordinate care with other social service providers or case managers.

DISCUSSION

The Guideline for Detoxification and Substance Abuse Treatment: An Overview of the Psychosocial and Biomedical Issues during Detoxification (SAMHSA, 2006) recommends the following:

“Patients are more likely to engage in treatment if they believe the full array of their problems will be addressed, including those needs typically addressed by social services (e.g., housing, vocational assistance, childcare, and transportation). Moreover, patients receiving needed services remain in substance abuse treatment longer and improve more than people who do not receive such services.

As the individual passes through acute intoxication and withdrawal, it is important to ensure that the basic needs of the patient are met after discharge. These needs include access to a safe, stable, and drug-free living environment if possible; physical safety; food and clothing; ongoing health and prenatal care; financial assistance; and childcare.

Providers should be familiar with available resources for legal assistance, dental care, support groups, interpreters, housing assistance, trauma treatment, recovery-sensitive parenting groups, spiritual and cultural support, employment assistance, and other assistance programs

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for basic needs. Family and other support systems also can be helpful to the patient in accessing services and should take part in the services planning as often as possible, always with the patient's consent.

To address the needs of homeless and indigent patients, providers should be familiar with emergency shelters, cash assistance, and food programs in their communities and should have established referral relationships. Assessing women, teenagers, older adults, and other vulnerable individuals for victimization by another member of the household also is important. Patients should be linked with prenatal and primary healthcare for domestic violence. Ideally, linkage to these programs includes more than a phone number; and should assist patients in scheduling initial appointments and arranging for transportation.”