The Language We Use in Addiction Treatment

The language we use related to alcohol and drug use disorders is often stigmatizing and misguided. Alltyr’s mission is to transform addiction treatment in America. Changing language is a necessary step in that process.

Here’s is Alltyr’s guide to addiction language for the 21^st Century.

Instead of saying:	Say:
alcoholic	person with an alcohol use disorder (AUD)
addict	person with a substance use disorder (SUD)
alcohol /drug abuse	risky use, heavy drinking, risky drinking
sober	abstaining, in remission
betrayer, liar, cheat, thief, selfish	addicted person, sick, ill
enabler	loved one
enabling	unhelpful or unskillful behavior
tough love	self-care, setting reasonable limits and expectations
unmotivated, denial	ambivalent about change, non-adherent, not yet able to overcome barriers to change, demoralized
dry drunk	irritable, moody, troubled, erratic, struggling
slip, lapse, relapse	use episode, recurrence, set-back
recovery (abstinence + spiritual growth)	remission (absence of illness once present)
relapse	recurrence, set-back
relapse prevention	recovery skills training
treatment program	rehab
Treatment (meaning rehab)	treatment (includes all levels of care)
MAT (medication assisted treatment)	treatment, pharmacotherapy, anti-relapse meds
compliance	adherence
non-compliant	non-adherent
harm reduction	treatment, chronic care management, partial response

Want to learn more about The Alltyr Model of Care™? Visit our website: www.alltyr.com 

Alltyr Clinic Featured on NPR's Weekend Edition!

Alltyr Clinic is featured on NPR's Weekend Edition Sunday today, June 8, 2014. We are positioned as an alternative to traditional rehab, in this case Hazelden. One of our patients, Shane Linehan, was brave enough to share his experience with both Hazelden (where he went first) and Alltyr Clinic (where he is being treated now.) I want to thank him and applaud his courage for speaking out. (For the record, Alltyr Clinic gave him no incentive; we simply offered the opportunity to many of our patients.) We are honored to be compared to arguably the best known traditional rehab in the country (if not the world.)

Unfortunately, in the summary on the program's landing page, our approach is described as being almost totally oriented around prescribing anti-relapse medications. Although we use every proven anti-relapse medication, we also use every evidence-based behavioral/psychosocial approach. This includes individual and group therapy using motivational, cognitive-behavioral, coping skills, 12-Step Facilitation, EMDR, CRAFT, DBT, psychodynamic, community reinforcement, couples and family approaches. Which we use depends on the needs of the patient. Our team includes addiction psychiatrists, addiction medicine specialists, psychologists, social workers, counselors and recovery coaches.

Furthermore, we fully integrate treatment for any co-existing mental health disorder, such as anxiety, depression, PTSD, personality disorders, bipolar disorder, cognitive disorders, as well as medical problems such as insomnia and chronic pain. We really aim to be a "one-stop shop." If sober housing is needed we work with community partners to help our patients secure it. 

The bottom line is this: coming to Alltyr Clinic is like coming to a mental health clinic or any other health care service using a multi-disciplinary approach. Each patient receives a comprehensive individual evaluation upon which the treatment recommendations are based. Selecting from a large menu of services, a truly individualized treatment plan is arrived at by the patient, the treatment team, and if appropriate, the family. After treatment is started, the plan is modified as needed. The length and intensity of treatment is also completely individual and flexible. We do whatever we can and we stay with you as long as it takes. We aren't a program, we're a clinic.

At Alltyr Clinic, "We Don't Just Call Addiction a Disease, We Treat It Like One."TM

Many Patients with Alcohol Use Disorders Not Offered Medications

An exhaustive and brand new meta-analysis and systematic review, published today in the Journal of the American Medical Association, paints a disappointing picture of medication access for those with alcohol use disorders (AUD) in the US. The authors included 123 studies, involving nearly 23,000 participants, and determined that while acamprosate and naltrexone have been shown to be effective treatments, fewer than 10% of those who might benefit are ever prescribed an AUD medication.

Here's the Abstract, via JAMA:

IMPORTANCE Alcohol use disorders cause substantial morbidity and early mortality yet

remain greatly undertreated. Medications are considerably underused.

OBJECTIVE To conduct a systematic review and meta-analysis of the benefits and harms of

medications (US FDA-approved and others) for adults with alcohol use disorders.

DATA SOURCES PubMed, Cochrane Library, PsycINFO, CINAHL, EMBASE, FDA website, and

clinical trials registries (January 1, 1970, to March 1, 2014).

STUDY SELECTION Two reviewers selected randomized clinical trials (RCTs) with at least 12

weeks’ duration that reported eligible outcomes and head-to-head prospective cohort

studies reporting health outcomes or harms.

DATA EXTRACTION AND SYNTHESIS We conducted meta-analyses using random-effects

models and calculated numbers needed to treat for benefit (NNTs) or harm (NNHs).

MAIN OUTCOMES AND MEASURES Alcohol consumption, motor vehicle crashes, injuries,

quality of life, function, mortality, and harms.

RESULTS We included 122 RCTs and 1 cohort study (total 22 803 participants). Most assessed

acamprosate (27 studies, n = 7519), naltrexone (53 studies, n = 9140), or both. The NNT to

prevent return to any drinking for acamprosate was 12 (95% CI, 8 to 26; risk difference [RD],

−0.09; 95% CI, −0.14 to −0.04) and was 20 (95% CI, 11 to 500; RD, −0.05; 95% CI, −0.10 to

−0.002) for oral naltrexone (50 mg/d). The NNT to prevent return to heavy drinking was 12

(95% CI, 8 to 26; RD −0.09; 95% CI, −0.13 to −0.04) for oral naltrexone (50 mg/d).

Meta-analyses of trials comparing acamprosate to naltrexone found no statistically significant

difference between them for return to any drinking (RD, 0.02; 95% CI, −0.03 to 0.08) or

heavy drinking (RD, 0.01; 95% CI, −0.05 to 0.06). For injectable naltrexone, meta-analyses

found no association with return to any drinking (RD, −0.04; 95% CI, −0.10 to 0.03) or heavy

drinking (RD, −0.01; 95% CI, −0.14 to 0.13) but found an association with reduction in heavy

drinking days (weighted mean difference [WMD], −4.6%; 95% CI, −8.5% to −0.56%). Among

medications used off-label, moderate evidence supports an association with improvement in

some consumption outcomes for nalmefene (heavy drinking days per month: WMD, −2.0;

95% CI, −3.0 to −1.0; drinks per drinking day: WMD, −1.02; 95% CI, −1.77 to −0.28) and

topiramate (% heavy drinking days: WMD, −9.0%; 95% CI, −15.3% to −2.7%; drinks per

drinking day: WMD, −1.0; 95% CI, −1.6 to −0.48). For naltrexone and nalmefene, NNHs for

withdrawal from trials due to adverse events were 48 (95% CI, 30 to 112) and 12 (95% CI, 7 to

50), respectively; risk was not significantly increased for acamprosate or topiramate.

CONCLUSIONS AND RELEVANCE Both acamprosate and oral naltrexone were associated with

reduction in return to drinking. When directly compared with one another, no significant

differences were found between acamprosate and naltrexone for controlling alcohol

consumption. Factors such as dosing frequency, potential adverse events, and availability of

treatments may guide medication choice.

Would love to know what readers think about the results of this large study. What are the main drivers of this gap, and why aren't more patients requesting these medications? What needs to be done to improve access?

Computerized Vs In-Person Brief Intervention for Drug Misuse: RCT

We have written much about the challenges of widespread implementation of SBIRT in the US. Well, authors of a new study, published online this month in the journal, Addiction, have suggested a novel tool which they believe could help ensure that scores of additional patients are being screened: computerized brief intervention. And according to their study, it works as well and the in-person version:

Abstract

Background and aims

Several studies have found that brief interventions (BIs) for drug misuse have superior effectiveness to no-treatment controls. However, many health centers do not provide BIs for drug use consistently due to insufficient behavioral health staff capacity. Computerized BIs for drug use are a promising approach, but their effectiveness compared with in-person BIs has not been established. This study compared the effectiveness of a computerized brief intervention (CBI) to an in-person brief intervention (IBI) delivered by a behavioral health counselor.

Methods

Two-arm randomized clinical trial, conducted in two health centers in New Mexico, USA. Participants were 360 adult primary care patients with moderate-risk drug scores on the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) who were randomly assigned on a 1:1 basis to a computerized brief intervention (CBI) or to an in-person brief intervention (IBI) delivered by a behavioral health counselor. Assessments were conducted at baseline and 3-month follow-up, and included the ASSIST and drug testing on hair samples.

Results

The IBI and CBI conditions did not differ at 3 months on global ASSIST drug scores (b=-1.79; 95% CI=-4.37,-0.80) or drug-positive hair tests (OR=.97; 95% CI= 0.47,1.94). There was a statistically significant advantage of CBI over IBI in substance-specific ASSIST scores for marijuana (b=-1.73; 95% CI= -2.91,-0.55; Cohen's d=.26; p=.004) and cocaine (b= -4.48; 95% CI= -8.26,-0.71; Cohen's d=.50; p=.037) at 3 months.

Conclusions

Computerized brief intervention can be an effective alternative to in-person brief intervention for addressing moderate drug use in primary care.

What do you think - could computerized brief interventions be the key to widespread SBIRT implementation?

Source: http://onlinelibrary.wiley.com/doi/10.1111/add.12502/abstract 

Gaps in Clinical Prevention and Treatment for Alcohol Use Disorders

Dr W's article, "Gaps in Clinical Prevention and Treatment for Alcohol Use Disorders" was published this month online in the journal Alcohol Research: Current Reviews. Here's the abstract:

Abstract

Heavy drinking causes significant morbidity, premature mortality, and other social and economic burdens on society, prompting numerous prevention and treatment efforts to avoid or ameliorate the prevalence of heavy drinking and its consequences. However, the impact on public health of current selective (i.e., clinical) prevention and treatment strategies is unclear. Screening and brief counseling for at-risk drinkers in ambulatory primary care has the strongest evidence for efficacy, and some evidence indicates this approach is cost-effective and reduces excess morbidity and dysfunction. Widespread implementation of screening and brief counseling of nondependent heavy drinkers outside of the medical context has the potential to have a large public health impact. For people with functional dependence, no appropriate treatment and prevention approaches currently exist, although such strategies might be able to prevent or reduce the morbidity and other harmful consequences associated with the condition before its eventual natural resolution. For people with alcohol use disorders, particularly severe and recurrent dependence, treatment studies have shown improvement in the short term. However, there is no compelling evidence that treatment of alcohol use disorders has resulted in reductions in overall disease burden. More research is needed on ways to address functional alcohol dependence as well as severe and recurrent alcohol dependence.

And check out the full piece here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3908715/

Study: Healthcare Utilization Rates After Treatment Are Equivalent Among Abstinent and Low-Risk Drinkers

A fascinating new study will add to the small, but growing, treatment literature suggesting that low-risk drinking is a viable option for people receiving treatment for alcohol-use disorders. The paper, published this month in Alcoholism: Clinical and Experimental Research, measured healthcare utilization rates and associated costs over a 5-year period among clients receiving treatment in a large Northern California healthcare system. The results show that outcomes for abstainers and lower-risk drinkers were equivalent (and far better than the high-risk drinkers), despite the fact that the abstinence-based treatment received by all groups was the same.

According to the authors, "The finding that lower-risk drinkers did not differ from those of abstinent individuals, in inpatient use in particular, even when controlling for patient characteristics, suggests that a health policy perspective may consider benefits of lower-risk drinking."

Here's the abstract via Wiley:

Background

Lower-risk drinking is increasingly being examined as a treatment outcome for some patients following addiction treatment. However, few studies have examined the relationship between drinking status (lower-risk drinking in particular) and healthcare utilization and cost, which has important policy implications.

Methods

Participants were adults with alcohol dependence and/or abuse diagnoses who received outpatient alcohol and other drug treatment in a private, nonprofit integrated healthcare delivery system and had a follow-up interview 6 months after treatment entry (N = 995). Associations between past 30-day drinking status at 6 months (abstinence, lower-risk drinking defined as nonabstinence and no days of 5+ drinking, and heavy drinking defined as 1 or more days of 5+ drinking) and repeated measures of at least 1 emergency department (ED), inpatient or primary care visit, and their costs over 5 years were examined using mixed-effects models. We modeled an interaction between time and drinking status to examine trends in utilization and costs over time by drinking group.

Results

Heavy drinkers and lower-risk drinkers were not significantly different from the abstainers in their cost or utilization at time 0 (i.e., 6 months postintake). Heavy drinkers had increasing odds of inpatient (p < 0.01) and ED (p < 0.05) utilization over 5 years compared with abstainers. Lower-risk drinkers and abstainers did not significantly differ in their service use in any category over time. No differences were found in changes in primary care use among the 3 groups over time. The cost analyses paralleled the utilization results. Heavy drinkers had increasing ED (p < 0.05) and inpatient (p < 0.001) costs compared with the abstainers; primary care costs did not significantly differ. Lower-risk drinkers did not have significantly different medical costs compared with those who were abstinent over 5 years. However, post hoc analyses found lower-risk drinkers and heavy drinkers to not significantly differ in their ED use or costs over time.

Conclusions

Performance measures for treatment settings that consider treatment outcomes may need to take into account both abstinence and reduction to nonheavy drinking. Future research should examine whether results are replicated in harm reduction treatment, or whether such outcomes are found only in abstinence-based treatment.

Figure 1 shows Adjusted odds ratios of utilization by 6-month drinking group over time:

Figure 2 shows Adjusted average costs per member month by 6-month drinking group over time:

                                               






As mentioned above, these are the results from patients who attended abstinence-based treatment. It will be
interesting to see if these results are replicated among patients who are instructed on low-risk drinking. What experience do readers have with this issue? Do results like these make those directing abstinence-based programs think twice about the policy? It would be great to hear from you.

Hat tip: Thanks, Dr Reid Hester, for bringing this study to our attention.

Source: Kline‐Simon, A. H., Weisner, C. M., Parthasarathy, S., Falk, D. E., Litten, R. Z., & Mertens, J. R. (2013). Five‐Year Healthcare Utilization and Costs Among Lower‐Risk Drinkers Following Alcohol Treatment. Alcoholism: Clinical and Experimental Research.
http://onlinelibrary.wiley.com/doi/10.1111/acer.12273/abstract

Study: Burden of Disease Associated with Alcohol-use Disorders Higher Than Previously Thought

In a paper published online last week in the journal, Alcoholism: Clinical and Experimental Research, a group of international researchers have brought fresh eyes to a familiar data set: the NIAAA's NESARC. Whereas past studies have estimated the alcohol-attributable global burden of disease, or rates of alcohol-attributable deaths and years of life lost, no study has focused specifically on the burden of disease in the United States associated with alcohol-use disorders (AUD). This is important, the authors note, because alcohol-use disorders (including "abuse" and "dependence" from DSM or "the harmful use of alcohol" from ICD) "were identified as the largest disease category contributing to the alcohol-attributable global burden of disease for the year 2004, making up approximately one-third of this burden." By using US-specific data, including population and death statistics as well as Waves 1 and 2 of the NESARC, the authors were able to estimate the burden of disease from AUD in the US in 2005.


Results

"In the United States in 2005, 65,000 deaths, 1,152,000 years of life lost due to premature mortality (YLL), 2,443,000 years of life lost due to disability (YLD), and 3,595,000 disability-adjusted life years (DALYs) lost were associated with AUD. For individuals 18 years of age and older, AUD were associated with 3% of all deaths (5% for men and 1% for women), and 5% of all YLL (7% for men and 2% for women). The majority of the burden of disease associated with AUD stemmed from YLD, which accounted for 68% of DALYs associated with AUD (66% for men and 74% for women). The youngest age group had the largest proportion of DALYs associated with AUD stemming from YLD."

Some figures from the article:

Prevalence of alcohol use disorders by category, sex, and age in 2005. 

And:

Proportion of all deaths associated with alcohol use disorders in 2005, by sex and age


You can read the abstract of the paper by Rehm, et al. here:

http://onlinelibrary.wiley.com/doi/10.1111/acer.12331/abstract

Would love to hear readers reactions to these numbers.