2. Initial MM Session (40 to 60 minutes)
Overview of Initial Session
Review the following eight areas with the patient at the initial session:
1. Go over the results from the patient’s intake evaluation. Address any medical concerns.
2. Explain the rationale, information, and prognosis on the patient’s diagnosis of alcohol dependence. Show how the results from the evaluation support the diagnosis of alcohol dependence. Advise abstinence.
3. Give the rationale and information on medications.
4. Provide the rationale for evaluating medication compliance at each session.
5. Establish the patient’s history of medication compliance, suggest strategies for enhancing compliance, and
develop an individualized compliance plan.
6. Discuss the benefits of participating in mutual-support groups.
7. Offer pamphlets on alcohol dependence, medications, and mutual-support groups.
8. Solicit and answer the patient’s questions or concerns about treatment.
2.2a. Reviewing Results From Patient’s Evaluation.
You will meet with the patient for the first time after he/she has undergone the intake evaluation. Introduce yourself, describe your role in the treatment plan, and explain how frequently you expect to see the patient over the course of treatment. The forms described in this section are in “Appendix A: Clinician Packet.”
If the patient has not had his/her BAC, vital signs, and weight taken, do so prior to giving him/her the first dose of medication. Record this information on Vital Signs and BAC (Form A–2).
Form A–2: Vital Signs and BAC
If the patient registers a positive breathalyzer reading, postpone the initial MM treatment visit until he/she can provide a negative reading. However, you or another on-site clinician should explain why the visit will be postponed. If the reading is above the legal limit, make arrangements to have the patient escorted from the facility to another unit capable of retaining the patient, or contact a family member who can take him/her home. Observe the same procedures for the MM treatment followup visits. (Note: some settings may permit the patient to continue the MM treatment visits as intended if his/her BAC reading is positive, as long as his/her blood alcohol concentration is extremely low.)
After introductions, begin the initial session by reviewing with the patient the results from the evaluation that support his/her diagnosis of alcohol dependence. Begin with the patient’s medical status and move into his/her lifetime and current drinking behavior. This discussion will go more smoothly if you review the results of the patient’s intake evaluation in a systematic format before you see him/her. The Clinician Report (Form A–1) is constructed so you can assemble, then quickly review a summary of the patient’s results. Record information from the measures listed below on this form prior to the initial session. (Note: It is important that you recognize the difference between this narrow-focused MM treatment report and broader-based reports, such as the one given with Motivational Enhancement Therapy.)
Form A–1: Clinician Report
Below is a list of the information to be obtained at the intake evaluation that you should summarize on the Clinician Report:
Blood pressure, laboratory results (blood and urine), and medical problems identified on the physical exam
Quantity/frequency of drinking in recent weeks (can use the Timeline Followback or Form–90 from COMBINE)1 (1 Form–90 is a series of instruments originally published in the Project MATCH manuals. For more information, see Miller, W.R. Form 90: A Structured Assessment Interview for Drinking and Related Behaviors (Test Manual). Project MATCH Monograph Series, Volume 5. DHHS Publication No. 96–4004. Bethesda, MD: Dept. of Health and Human Services, 1996.)
Self-report of alcohol-related problems (can use the Drinker Inventory of Consequences [DrInC] from COMBINE)
Symptoms of alcohol dependence (obtained from a diagnostic interview).
2.2b. Relaying Feedback From the Clinician Report. This section provides suggestions for discussing with patients aspects of the Clinician Report; tailor your own discussions to your patient’s particular situation and level of knowledge about the areas you are covering. Note that not all areas on the form are covered here.
The example below provides a suggestion for explaining to the patient his/her liver enzyme results:
CLINICIAN: Let’s begin today by reviewing your physical health and then move on to talking about your drinking. First, let’s review together your medical health, including the results of your blood and urine tests.
When we review your medical status, we pay particular attention to your blood tests because some of them tell us how your liver is working. This is what we look for in patients who we know are drinking heavily. Your liver is extremely important to your health. It is involved in producing energy, and it filters and neutralizes impurities and poisons in your bloodstream. Alcohol damages the liver by causing inflammation. In some cases, permanent scars can form, called cirrhosis. Prior to cirrhosis, physical changes in the liver caused by drinking begin as a leakage of chemicals called enzymes into the blood. When this happens, we see abnormally high values on these blood tests.
Your laboratory results showed the following (show patient the results).
(If the patient’s liver function tests are within normal ranges) Your liver function tests show no significant elevations yet. Although normal results on these tests do not always guarantee that your liver is functioning normally, this is a positive sign that with treatment, you may be able to change your heavy alcohol drinking habits before you do any permanent damage to your body. A healthy liver will also help you make a quicker, more complete recovery.
(If the patient’s liver function tests are abnormal) This elevated value in the abnormal range on one or more of these blood tests is likely reflecting unhealthy changes in your body that have resulted from your excessive use of alcohol and/or other drugs. It is possible that you can improve your medical status and return these values to normal ranges if you stop drinking. The longer you continue drinking, however, the more difficult it is to reverse the physical damage.
Consequences of Drinking
When reviewing the patient’s drinking information, do not focus primarily on the patient’s quantity of drinking, because some people can drink fairly heavily with few consequences and other people may have serious adverse consequences despite drinking amounts of alcohol that do not cause problems for other people. Since discussions of quantity and frequency may lead to fruitless debates with the patient about safe levels of drinking, focus more on consequences of drinking.
The example below provides a suggestion for discussing the consequences of the patient’s drinking:
CLINICIAN: I see that you drink very heavily when you drink, and that you have reported several things that are related to having a serious problem with alcohol, such as getting DUIs.
(If the patient is a binge drinker who may abstain for days or weeks and then drink large amounts) Although you report going days without drinking, you drink a great deal when you do drink. People who drink this much at one time have what we call high tolerance for alcohol. This is a warning sign, because it means that you have a high blood alcohol level and don’t feel drunk, sick, or sleepy—any of which would ordinarily lead you to stop drinking for the night. You need to know that you are not protected like most people from being harmed by drinking; rather, damage is more likely.
Review the responses on the DrInC in advance and select up to three items that the patient has endorsed for the Clinician Report. Note that some people will only report a single adverse consequence from drinking, but the consequence may be quite serious (e.g., an arrest for DUI or significant liver disease). In any case, discuss with the patient, as shown in the example below.
CLINICIAN: I see you reported several things that we know are related to having a serious problem with alcohol, such as DUIs. We refer to these experiences as “negative consequences” because they are harmful events that happened as a direct result of drinking alcohol. Taken together, we use these events as warning signs that drinking for you is destructive to your health and/or well-being.
Inform the patient that according to the diagnostic assessment, he/she has X number of symptoms of alcohol dependence. Review each of the symptoms reported with the patient. Provide basic information on what is currently known about alcohol and the disorder. Emphasize that alcohol may be a toxin for some people, and unless the patient stops drinking, the problems he/she has already experienced will continue and new, additional problems are likely to occur in the future, such as hypertension, cancer, heart and brain disease, or decreased life expectancy.
In a nonjudgmental way, emphasize the importance of abstinence. Tell the patient that although any reductions in the amount of his/her drinking will help, the only way to be sure that alcohol is not going to cause any further damage is to stop drinking alcohol entirely.
The example below provides suggestions for discussing the patient’s diagnostic information and recommending abstinence:
CLINICIAN: Let’s look at the facts. The results of your evaluation point to a clear diagnosis of alcohol dependence. Here is the list of your symptoms: you have a history of excessive drinking, likely coupled with alcohol-related problems; you have made previous unsuccessful attempts to cut down or quit drinking; and you drink more than you intend to drink on a regular basis.
Therefore, I strongly suggest that you stop drinking altogether. Let me explain. Alcohol may be a toxin to the body. Consistent heavy alcohol drinking puts you at risk for physical harm and negative social consequences. If you have difficulties in reducing drinking or stopping entirely, this is not a sign of weakness, immoral self-indulgence, or deviance. If your goal is only to “cut down” your amount of drinking, there is a good probability that you will return to heavy drinking. If you continue to drink, your dependence will get worse and it will be even harder to stop. Given your current condition, I cannot guarantee you that there is a level of drinking that will cause you no harm.
That’s why abstinence is the safest choice for you. If you stop drinking, you can be sure that you won’t have any more problems related to drinking. After some time of no drinking, your ability to think, complete tasks, and get along with others will all likely improve. When you are abstinent, you may discover things about yourself that you have forgotten.
If it is apparent that the patient is unwilling or unable to commit to abstinence, offer a trial of abstinence. The example below provides a suggestion of how to mention this:
CLINICIAN: If you are thinking that lifelong abstinence is too difficult of a goal for you to commit to right now, you could try a brief period of abstinence of say, a month, to find out what it’s like to live without alcohol. Would you be willing to try this out? (You could also suggest other reasons for abstinence, such as experiencing a change, building some confidence, or pleasing a spouse or other family members.)
2.2c. Providing Rationale and Information on Medications. Begin by asking your patient what he/she already knows about the medications that will be prescribed, and if necessary, clear up any myths or misinformation. Tell the patient the purpose of the medications being prescribed. Distinguish them from medications used for detoxification. In particular, distinguish these medications from disulfiram (Antabuse), because your patient may have heard that when combined with alcohol, disulfiram makes the user violently sick, and he/she may have negative feelings or images about taking medications to treat alcohol dependence.
Review the Concurrent Medications form (Form A–3) that the patient completed during the medical exam prior to seeing you at the initial MM session, and inquire about medication that he/she might have started since completing that form. Use the Modified SAFTEE form (Form A–7) to evaluate the patient’s status of current somatic complaints.
Appendix A includes medication information sheets about the medications you will be prescribing—Naltrexone Information Sheet: Clinician Version (Form A–4) and Acamprosate Information Sheet: Clinician Version (Form A–5). Review with the patient information about these medications, focusing on the following four categories:
Proposed mechanism of action
Potential side effects
Form A–3: Concurrent Medications
Form A–7: Modified SAFTEE
Form A–4: Naltrexone Information Sheet: Clinician Version
Form A–5: Acamprosate Information Sheet: Clinician Version
Appendix C has patient versions of these forms—Forms C–1 and C–2; give them to the patient to review and take home.
Tell the patient that if he/she experiences side effects, there are things he/she can try to manage them before calling you. Go over the Patient Instructions for Managing Side Effects (Form C–5) and point out the ways to cope with adverse events such as nausea, vomiting, and diarrhea. Advise the patient also to contact you if he/she is concerned with any symptoms in between visits.
Form C–1 Naltrexone Information Sheet: Patient Version
Form C–2 Acamprosate Information Sheet: Patient Version
Form C–5: Patient Instructions for Managing Side Effects
Show the patient the blister card containing the pills and review the dosing regimen, storage of the medication, and return of the blister cards, empty or containing unused pills. Tell the patient what to do if he/she skips a dose, loses a blister card, or runs out of medications before returning for the next visit, and review what procedures to follow in case of an emergency. Review the information on the Medication Instructions Summary (Form A–6) while the patient looks over the patient version, Medication Instructions Summary (Form C–3) as well as the Quick Reference Medication Information Grid (Form C–4), and answer any questions.
Form A–6: Medication Instructions Summary
Form C–3: Medication Instructions Summary
Form C–4: Quick Reference Medication Information Grid
Observe the patient taking the morning dose of medication no matter what time of day the session takes place. Do this only at the initial session.
Form C–6: Sample Medical Emergency Card
If the patient is taking naltrexone (as in the COMBINE study), give him/her two emergency cards (one for his/her wallet and one for a significant other) (Sample Medical Emergency Card, Form C–6). The emergency card is designed to inform medical personnel if the patient seeks medical treatment elsewhere; it states that the patient is taking naltrexone (or may be, depending on the situation) and suggests a treatment plan for naltrexone users. The card includes space on the back for information, including the date treatment began and will end, name of medical clinician, and a 24-hour emergency telephone contact.
Emphasize that it takes time for the medications to be effective. Remind the patient that some people feel the medication’s effectiveness more slowly than others and that it is important to keep taking the medications as prescribed and to continue trying to maintain abstinence. Encourage the patient’s use by telling him/her that the medications are thought to increase abstinence by improving his/her ability to resist drinking, making it easier to choose not to drink.
2.2d. Providing Rationale and Information on Medication Compliance. It is vital that your patient comply with taking the medication as you prescribe it so that you can evaluate how effective the medication is and how the patient is able to tolerate it.
Explain to the patient the importance of consistently taking the medications as prescribed. For example, you could refer to research that showed that subjects who complied with their prescribed naltrexone doses were able to reduce their drinking more than subjects who did not do so (see Pettinati et al. Journal of Addictive Diseases, 2000, 19:71–83).
It could help prevent noncompliance if you educate your patient about alcohol dependence, the nature of the medications, and the time course of the medication effects (e.g., the fact that they do not work immediately).
The example below suggests a way to explain the expected time course of the medication’s effects:
CLINICIAN: For you to get the benefit of these medications to support your treatment goal of abstinence, you must take them consistently and as prescribed. It can take several days to achieve a steady therapeutic level in your blood. And once you have the right amount of medication in your blood, it can still take some time for the medications to have their full effect on helping you change your drinking behaviors.
The medications can only help you to maintain abstinence if you take them consistently, as you would with blood pressure medicine or insulin. These medications do not work like aspirin does, which you take only when you feel you need it.
2.2e. Designing a Patient-Tailored Medication Compliance Plan. Follow the format outlined in the Medication Compliance Plan (Form A–13) to design a concrete plan for regularly taking medications to minimize the number of missed doses. This section refers to different areas of this form.
Form A–13: Medication Compliance Plan
Examine Patient’s History of Medication-Taking Practices
Ask the questions on Form A–13 or paraphrase them, as suggested below:
Have you ever been asked or tried on your own to take pills on a daily basis?
Have you ever been asked or tried on your own to take four or more pills at one time on a daily basis?
Have you ever been asked or tried on your own to take pills in the evening or at bedtime on a daily basis?
Have you ever taken pills from blister cards?
Do you typically carry your pills with you?
Have you ever been asked to take prescribed medications until all the pills are gone?
Determine from the patient’s answers if he/she had enough opportunities in the past to take several medications at once, in both the morning and evening, and if he/she has a good record of consistently following this regimen.
If you find that the patient has been successful in remembering mundane but necessary day-to-day pill-taking, ask about the strategies he/she found useful for keeping up such a record. If possible, use these routine strategies for taking pills in formulating the Medication Compliance Plan for adding new medications (see more details about this in “Pill-Taking Strategies,” below).
If you find that the patient has not had enough experience taking medication on a regular basis or has a record of taking medications inconsistently, skipping doses, or quitting medication early, discuss examples of the common reasons for medication noncompliance, such as those listed here. This may prompt the patient to say that this could happen to him/her. (See Chapter 4, “Medication Compliance and Treatment Session Attendance,” for suggested techniques for dealing with each of these reasons for medication noncompliance.)
Common Reasons for Pill Noncompliance
The list below is similar to the one on the Medication Compliance Plan:
Forgets to take medications
misplaces one or more dose
misplaces blister card
Reports troublesome side effects from the medications
Believes he/she is taking placebo
Has misconceptions about what the medications will or will not do
expects instant change in drinking
expects elimination of pleasure
Is uneasy about taking medications
has never liked taking pills, even aspirin
is convinced by members of an AA mutual-support group to stop medications
Sometimes just wants to drink or “get high”
Refuses to accept a diagnosis of alcohol dependence
disagrees that he/she has a disorder or that it is serious enough to warrant taking medications
believes he/she is “cured” and no longer needs medications.
If your patient has been successful in taking pills in the past, solicit strategies he/she used to maintain compliance, and write them on the Medication Compliance Plan (Form A–13).
If your patient has never had a successful routine for pill-taking, assist him/her in tailoring an individualized plan for taking the medication as prescribed. Prompt the patient to think of ideas, or suggest some of the following:
Take the medications while brushing teeth in the morning and evening.
Take medications with morning coffee or vitamins.
Take medications while watching a particular TV show every morning or evening.
Involve others to witness him/her taking the pills or to administer the medications.
Place notes or other reminders in prominent places.
Wear an alarm watch that rings when it is time to take the pills.
Write these suggestions in section II of the Medication Compliance Plan form, “Personalized Medication Compliance Plan.”
Explain that you will routinely go over the success of this plan at the beginning of each visit. Tell the patient to bring back the blister card(s) at each visit because you will use pill counts of the returned blister card(s) to verify his/her medication compliance.
Be sure to tell the patient that if his/her plan proves unsuccessful at any point, you will help revise the plan to develop one he/she feels more comfortable following.
2.2f. Reviewing Benefits of Participating in Mutual-Support Groups. Describe mutual-support groups, such as AA and SMART Recovery, as a way that many people with alcohol dependence find they can secure the alcohol-free lifestyle they know they need to adopt. Mutual-support groups allow the patient to quickly acquire a social network of friends who have found ways of living their lives without alcohol. Mention that the medication treatment is time-limited and that many patients find the importance of mutual-support groups increases when they stop taking the medications.
Let the patient know that he/she is not required to attend a mutual-support group to participate in this treatment. However, tell him/her that it is important for you to keep track of whether or not he/she has attended mutual-support group meetings, so you will be asking about it from time to time. Unless the patient is adamantly opposed, provide a list of telephone numbers, times, and locations of meetings of local mutual-support groups (Form C–8). Choose a location or a specific meeting from those listed and suggest that the patient just try it out and report back later on.
Provide the patient with pamphlets on mutual-support groups. An example of a mutual-support group pamphlet is listed in Appendix C. Feel free to substitute pamphlets available in your region.
The official position of AA is that members should take medications prescribed in good faith. Nonetheless, some AA members (as opposed to the AA organization) may discourage any use of medications to stop drinking. Prepare the patient to cope with some mutual-support group members’ objections to psychotropic medications.
Form C–8: Listing of Local Mutual-Support Groups
Form C–7: Name and Location of AA
Pamphlet Relevant to Pharmacotherapy
The examples below suggest ways to discuss aspects of AA that your patient may find problematic:
CLINICIAN: (If the patient is reluctant to attend a meeting for the first time) Attending a mutual-support group is an excellent way of meeting people who don’t drink. There are also people there who have been through what you are about to go through and may be able to help you with the hardest parts in ways you can’t imagine at this time. Would you be willing to try just one meeting before our next session? Next time we can talk about what you thought of it.
(If the patient has attended a meeting before and was uncomfortable) I know you are saying that your experiences in the past with AA meetings have been disappointing. Who makes up the group really matters, and not all groups are alike. It is likely that you will need to try out several groups before finding one that feels right—kind of like looking for a new restaurant. Would you be willing to let me suggest a group for you to start with? Try the group out and tell me at our next session what you did or did not like about it. Sometimes talking out the problem can help pinpoint the type of group you might feel more comfortable in.
(If the patient is concerned about members disapproving of his/her medications) Some members of mutual-support groups believe that it isn’t possible to get over an addiction by taking a pill. If you choose to reveal at a meeting that you are taking medications, you may run into a member who objects and tries to discourage you or other members from taking medications. It is important to remember, however, that the medications you are taking as part of your treatment are tools you will use in your efforts not to drink. They have been shown to help others stop drinking and remain abstinent. Also, these medications are not addicting. And the official policy of AA is supportive of people taking nonaddicting medications prescribed by a doctor. This policy is described in this pamphlet, “The AA Member—Medications and Other Drugs.”
Summarize the diagnosis and recommendation for abstinence.
Summarize the dosage regimen the patient will follow until the next visit.
Remind the patient that he/she is to bring back the blister card at the next visit.
Ask about remaining questions or concerns.
Schedule the next visit.
Tell the patient that in 3 days, you will contact him/her.