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Evidence Based Practices: An Overview. Desiree MacPhail-Crevecoeur, Ph.D. Integrated Substance Abuse Programs University of California, Los Angeles. Overview. Part One: Addiction as a Chronic Disease The Addicted Brain A chronic, relapsing disease

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evidence based practices an overview
Evidence Based Practices:An Overview

Desiree MacPhail-Crevecoeur, Ph.D.

Integrated Substance Abuse Programs

University of California, Los Angeles

overview
Overview
  • Part One: Addiction as a Chronic Disease
    • The Addicted Brain
    • A chronic, relapsing disease
  • Part Two: What are Evidence Based Practices?
  • Part Three: Cognitive Behavioral Therapy
  • Part Four: Motivational Interviewing
  • Part Five: Medically Assisted Treatments
slide3
Part One:

Addiction as a Chronic Brain Disease

addiction brain disease
Addiction = Brain Disease

Addiction is a brain disease that is chronic and relapsing in nature.

4

the reward system
The Reward System

Natural rewards

Food

Water

Sex

Nurturing

8

the brain after drug use 1
The Brain After Drug Use (1)

Control Methamphetamine

12

(Source: McCann et al. (1998). Journal of Neuroscience, 18, 8417-8422.)

slide12

Partial Recovery of Brain Dopamine Transporters in Methamphetamine Abuser

After Protracted Abstinence

3

0

ml/gm

METH Abuser

(1 month detox)

Normal Control

METH Abuser

(24 months detox)

the brain after drug use 2
The Brain After Drug Use (2)

14

DA = Days Abstinent

drugs change the brain
Drugs Change the Brain

After repeated drug use, “deciding” to use drugs is no longer voluntary because

DRUGS CHANGE THE BRAIN!

15

iom quality chasm recommendations
IOM Quality Chasm Recommendations

“Substance use disorder treatment should move toward building its standards of care, performance measurement and quality, information and cost measures upon a chronic illness model rather than the current, acute illness-based, fragmented and deficient system of health care.”

slide16

Acute Care Treatment Model

Substance Abusing Patient

Treatment

Non- Substance Abusing Patient

slide17

Traditional Service Approach

Severe

Symptoms

Acute symptoms,

Discontinuous treatment

Crisis management

Remission

Time

18

Resource: Tom Kirk, Ph.D.

nqf recommendations
NQF Recommendations

“Patients treated for Substance Use Disorders (SUD) should be engaged in long-term, ongoing managementof their care. Primary medical care providers should support and monitor ongoing recovery in collaboration with the specialty provider who is managing their SUD.”

slide19

A Recovery-Oriented Approach

Severe

Symptoms

Continuous

Treatment Response

Remission

Time

20

Resource: Tom Kirk, Ph.D

a continuing care model
A Continuing Care Model

Substance Abusing Patient

Detox

Duration

Determined by

Performance

Criteria

Rehabilitation

Duration

Determined by

Performance

Criteria

Continuing Care

Recovering Patient

lessons from chronic illness
Lessons from Chronic Illness
  • Medications relieve symptoms but…. behavioral change is necessary for sustained benefit
  • Treatment effects usually don’t last very long after treatment stops.
lessons from chronic illness22
Lessons from Chronic Illness
  • Patients who are not insome form of treatment or monitoringare at elevated risk for relapse.

In addiction this could include monitoring or AA

summary
Summary
  • Drugs affect the brain in ways that are long term but reversible.
  • These brain changes profoundly influence cognition, emotions and behavior.
  • There are multiple forms of treatment that can be effective in treating addicted individuals.
  • Addiction and many psychiatric illnesses are chronic illnesses, and, like other chronic disorders, require continuous ongoing (not episodic) treatment and support.
slide24
Part Two:

Evidence Based Practices

what are evidence based practices
What are Evidence Based Practices?

Interventions that show consistent scientific evidence of being related to preferred client outcomes.

26

evidence based practices
Evidence Based Practices

Standards of Care are Changing

It is abundantly clear that not all treatment works, some types show evidence of being more effective than others

>1000 clinical trials published in Addiction

Cities, states and other funding sources are increasingly demanding the use of EBPs

Closer integration of behavior health with healthcare will apply same standards

27

What Defines “Evidence Based Practices” and What Does it Mean to Implement EBT? NIDA Blending Meeting,? November 2006

principles of effective treatment
Principles of Effective Treatment

1. No single treatment is appropriate for all

2. Treatment needs to be readily available

3. Effective treatment attends to the multiple needs of the individual

4. Treatment plans must be assessed and modified continually to meet changing needs

5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness

28

- NIDA (1999) Principles of Drug Addiction Treatment

principles of effective treatment28
Principles of Effective Treatment

6. Counseling and other behavioral therapies are critical components of effective treatment

7. Medications are an important element of treatment for many patients

8. Co-existing disorders should be treated in an integrated way

9. Medical detox is only the first stage of treatment

10. Treatment does not need to be voluntary to be effective

29

- NIDA (1999) Principles of Drug Addiction Treatment

principles of effective treatment29
Principles of Effective Treatment

11. Possible drug use during treatment must be monitored continuously

12. Treatment programs should assess for HIV/AIDS, Hepatitis B & C, Tuberculosis and other infectious diseases and help clients modify at-risk behaviors

13. Recovery can be a long-term process and frequently requires multiple episodes of treatment

30

- NIDA (1999) Principles of Drug Addiction Treatment

examples of evidence based practices
Examples of Evidence Based Practices

Contingency management

Medically Assisted Treatment

Brief intervention

Cognitive–behavioral interventions

Community reinforcement

Behavioral contracting

Motivational enhancement therapy

12-step facilitation

31

slide31

Part 3: Cognitive Behavioral Therapy (CBT) & Relapse Prevention StrategiesOne Example of an Evidence Based Practice

32

what is cbt and how is it used in addiction treatment
What is CBT and how is it used in addiction treatment?

CBT is a form of “talk therapy” that is used to teach, encourage, and support individuals to reduce / stop their harmful drug use.

CBT provides skills that are valuable in assisting people in gaining initial abstinence from drugs (or in reducing their drug use).

CBT also provides skills to help people sustain abstinence (relapse prevention)

33

what is relapse prevention rp
What is relapse prevention (RP)?

RP is a cognitive-behavioral treatment (CBT) with a focus on the maintenance stage of addictive behaviour change that has two main goals:

To prevent the occurrence of initial lapses after a commitment to change has been made and

To prevent any lapse that does occur fromescalating into a full-blow relapse

Because of the common elements of RP and CBT, we will refer to all of the material in this training module as CBT

34

foundation of cbt social learning theory
Foundation of CBT: Social Learning Theory

Cognitive behavioral therapy (CBT)

Provides critical concepts of addiction and how to not use drugs

Emphasizes the development of new skills

Involves the mastery of skills through practice

35

why is cbt useful 1
Why is CBT useful? (1)

CBT is a counseling-teaching approach well-suited to the resource capabilities of most clinical programs

CBT has been extensively evaluated in rigorous clinical trials and has solid empirical support

CBT is structured, goal-oriented, and focused on the immediate problems faced by substance abusers entering treatment who are struggling to control their use

36

why is cbt useful 2
Why is CBT useful? (2)

CBT is a flexible, individualized approach that can be adapted to a wide range of clients as well as a variety of settings (inpatient, outpatient) and formats (group, individual)

CBT is compatible with a range of other treatments the client may receive, such as pharmacotherapy

37

important concepts in cbt 1
Important concepts in CBT (1)

In the early stages of CBT treatment, strategies stress behavioral change. Strategies include:

planning time to engage in non-drug related behaviour

avoiding or leaving a drug-use situation.

38

important concepts in cbt 2
Important concepts in CBT (2)

CBT attempts to help clients:

Follow a planned schedule of low-risk activities

Recognize drug use (high-risk) situations and avoid these situations

Cope more effectively with a range of problems and problematic behaviors associated with using

39

important concepts in cbt 3
Important concepts in CBT (3)

As CBT treatment continues into later phases of recovery, more emphasis is given to the “cognitive” part of CBT. This includes:

Teaching clients knowledge about addiction

Teaching clients about conditioning, triggers, and craving

Teaching clients cognitive skills (“thought stopping” and “urge surfing”)

Focusing on relapse prevention

40

foundations of cbt
Foundations of CBT

The learning and conditioning principles involved in CBT are:

Classical conditioning

Operant conditioning

Modelling

41

classical conditioning addiction
Classical conditioning: Addiction

Repeated pairings of particular events, emotional states, or cues with substance use can produce craving for that substance

Over time, drug or alcohol use is paired with cues such as money, paraphernalia, particular places, people, time of day, emotions

Eventually, exposure to cues alone produces drug or alcohol cravings or urges that are often followed by substance abuse

42

classical conditioning application to cbt techniques
Classical conditioning: Application to CBT techniques

Understand and identify “triggers”

(conditioned cues)

Understand how and why “drug craving” occurs

Learn strategies to avoid exposure to triggers

Cope with craving to reduce / eliminate conditioned craving over time

43

operant conditioning addiction
Operant conditioning: Addiction

Drug use is a behavior that is reinforced by the positive reinforcement that occurs from the pharmacologic properties of the drug.

Once a person is addicted, drug use is reinforced by the negative reinforcement of removing or avoiding painful withdrawal symptoms.

44

operant conditions 1
Operant conditions (1)

Positive reinforcement strengthens a particular behaviour (e.g., pleasurable effects from the pharmacology of the drug; peer acceptance)

Punishmentis a negative condition that decreases the occurrence of a particular behavior (e.g., If you sell drugs, you will go to jail. If you take too large a dose of drugs, you can overdose.)

45

operant conditions 2
Operant conditions (2)

Negative reinforcementoccurs when a particular behavior becomes stronger by avoiding or stopping a negative condition (e.g., If you are having unpleasant withdrawal symptoms, you can reduce them by taking drugs.).

46

operant conditioning application to cbt techniques
Operant conditioning: Application to CBT techniques

Functional Analysis – identify high-risk situations and determine reinforcers

Examine long- and short-term consequences of drug use to reinforce resolve to be abstinent

Schedule time and receive praise

Develop meaningful alternative reinforcers to drug use

47

modeling definition
Modeling: Definition

Modeling: To imitate someone or to follow the example of someone. In behavioral psychology terms, modeling is a process in which one person observes the behavior of another person and subsequently copies the behavior.

48

basis of substance use disorders modeling
Basis of substance use disorders: Modeling

When applied to drug addiction, modeling is a major factor in the initiation of drug use. For example, young children experiment with cigarettes almost entirely because they are modeling adult behavior.

During adolescence, modeling is often the major element in how peer drug use can promote initiation into drug experimentation.

49

modeling application to cbt techniques
Modeling: Application to CBT techniques

Client learns new behaviors through role-plays

Drug refusal skills

Watching clinician model new strategies

Practicing those strategies

Observe how I say “NO!”

NO thanks, I do not smoke

50

the first step in cbt how does drug use fit into your life
The first step in CBT: How does drug use fit into your life?

One of the first tasks in conducting CBT is to learn the details of a client’s drug use. It is not enough to know that they use drugs or a particular type of drug.

It is critical to know how the drug use is connected with other aspects of a client’s life. Those details are critical to creating a useful treatment plan.

52

the 5 ws functional analysis
The 5 Ws (functional analysis)

The 5 Ws of a person’s drug use (also called a functional analysis)

When?

Where?

Why?

With / from whom?

What happened?

53

the 5 ws
The 5 Ws

People addicted to drugs do not use them at random. It is important to know:

The time periods whenthe client uses drugs

The places where the client uses and buys drugs

The external cues and internal emotional states that can trigger drug craving (why)

The people with whom the client uses drugs or the people from whom she or he buys drugs

The effects the client receives from the drugs ─ the psychological and physical benefits (whathappened)

54

questions clinicians can use to learn the 5 ws
Questions clinicians can use to learn the 5 Ws

What was going on before you used?

How were you feeling before you used?

How / where did you obtain and use drugs?

With whom did you use drugs?

What happened after you used?

Where were you when you began to think about using?

55

triggers conditioned cues
“Triggers” (conditioned cues)

One of the most important purposes of the 5 Ws exercise is to learn about the people, places, things, times, and emotional states that have become associated with drug use for your client.

These are referred to as “triggers” (conditioned cues).

58

triggers for drug use
“Triggers” for drug use

A “trigger” is a “thing” or an event or a time period that has been associated with drug use in the past

Triggers can include people, places, things, time periods, emotional states

Triggers can stimulate thoughts of drug use and craving for drugs

59

external triggers
External triggers

People: drug dealers, drug-using friends

Places: bars, parties, drug user’s house, parts of town where drugs are used

Things: drugs, drug paraphernalia, money, alcohol, movies with drug use

Time periods: paydays, holidays, periods of idle time, after work, periods of stress

60

internal triggers
Internal triggers

Anxiety

Anger

Frustration

Sexual arousal

Excitement

Boredom

Fatigue

Happiness

Hunger

61

triggers cravings
Triggers & Cravings

TriggerThoughtCravingUse

62

the clinician s role
The Clinician’s Role

To teach the client and coach her or him towards learning new skills for behavioral change and self-control.

63

the role of the clinician in cbt
The role of the clinician in CBT

CBT is a very active form of counseling.

A good CBT clinician is a teacher, a coach, a “guide” to recovery, a source of reinforcement and support, and a source of corrective information.

Effective CBT requires an empathetic clinician who can truly understand the difficult challenges of addiction recovery.

64

the role of the clinician in cbt64
The role of the clinician in CBT

The clinician is one of the most important sources of positive reinforcement for the client during treatment. It is essential for the clinician to maintain a non-judgemental and non-critical stance.

Motivational interviewing skills are extremely valuable in the delivery of CBT.

65

match material to client s needs
Match material to client’s needs

CBT is highly individualized

Match the content, examples, and assignments to the specific needs of the client

Pace delivery of material to insure that clients understand concepts and are not bored with excessive discussion

Use specific examples provided by client to illustrate concepts

66

repetition
Repetition

Habits around drug use are deeply ingrained

Learning new approaches to old situations may take several attempts

Chronic drug use affects cognitive abilities, and clients’ memories are frequently poor

Basic concepts should be repeated in treatment (e.g., client’s “triggers”)

Repetition of whole sessions, or parts of sessions, may be needed

67

practice
Practice

Mastering a new skill requires time and practice. The learning process often requires making mistakes, learning from mistakes, and trying again and again. It is critical that clients have the opportunity to try out new approaches.

68

give a clear rationale
Clinicians should not expect a client to practice a skill or do a homework assignment without understanding whyit might be helpful.

Clinicians should constantly stress the importance of clients practicing what they learn outside of the counseling session and explain the reasons for it.

Give a clear rationale

69

communicate clearly in simple terms
Communicate clearly in simple terms

Use language that is compatible with the client’s level of understanding and sophistication

Check frequently with clients to be sure they understand a concept and that the material feels relevant to them

70

monitoring
Monitoring

Monitoring: to follow-up by obtaining information on the client’s attempts to practice the assignments and checking on task completion. It also entails discussing the client’s experience with the tasks so that problems can be addressed in session.

71

praise approximations
Praise approximations

Clinicians should try to shape the client’s behavior by praising even small attempts at working on assignments, highlighting anything that was helpful or interesting.

72

example of praising approximations
Example of praising approximations

I did not work on my assignments…sorry.

Well Anna, you could not finish your assignments but you came for a second session. That is a great decision, Anna. I am very proud of your decision! That was a great choice!

Oh, thanks!

Yes, you are right. I will do my best to get all assignments done by next week.

73

develop a plan
Develop a plan

A specific daily schedule:

Enhances your client\'s self-efficacy

Provides an opportunity to consider potential obstacles

Helps in considering the likely outcomes of each change strategy

Nothing is more motivating than being

well prepared!

74

stay on schedule stay sober
Stay on schedule, stay sober

Encourage the client to stay on the schedule as the road map for staying drug-free.

Staying on schedule = Staying sober

Ignoring the schedule = Using drugs

75

develop a plan dealing with resistance to scheduling
Develop a plan: Dealing with resistance to scheduling

Clients might resist scheduling (“I’m not a scheduled person” or “In our culture, we don’t plan our time”).

Use modeling to teach the skill.

Reinforce attempts to follow a schedule, recognizing perfection is not the goal.

Over time, let the client take over responsibility for the schedule.

76

slide76
Part Four:

Motivational Interviewing

A second Example of an Evidence Based Practice

slide77

Definition of Motivation

The probability that a person will enter into, continue, and comply with change-directed behavior

78

78

motivational interviewing
Motivational Interviewing

Many people who engage in harmful substance use do not fully recognize that they have a problem or that their other life problems are related to their use of drugs and/or alcohol.

79

motivational interviewing79
Motivational Interviewing

It seems surprising that…

people don’t simply stop using drugs, considering that drug addiction creates so many problems for them and their families.

80

slide80
People who engage in harmful drug or alcohol use often say they want to stop using, but they simply don’t know how, are unable to, or are not fully ready to stop.

Motivational Interviewing

81

understanding how people change models

Understanding How People Change: Models

Traditional approach

Motivating for change

slide82
Change is motivated by discomfort.

If you can make people feel bad enough, they will change.

People have to “hit bottom” to be ready for change

Corollary: People don’t change if they haven’t suffered enough

The Traditional Approach

The Stick

83

slide83

The Traditional Approach

You better!

Or else!

If the stick is big enough,

there is no need for a carrot.

84

slide84
Someone who continues to use is

“in denial.”

The best way to “break through” the

denial is direct confrontation.

The Traditional Approach

85

slide85
Motivation for change can be fostered by an accepting, empowering, and safe atmosphere

People are ambivalent about change

People continue their drug use because of their ambivalence

Another Approach: Motivating

The carrot

86

slide87
Ambivalence: Feeling two ways about

something.

All change contains an element of ambivalence.

Resolving ambivalence in the direction of change is a key element of motivational interviewing

Ambivalence

88

slide89
that hangovers, damaged relationships, an auto crash, memory blackouts ─ or even being pregnant ─ would be enough to convince a woman to stop drinking.

You Would Think…

90

slide90
that experiencing the dehumanizing

privations of prison would

dissuade people from

re-offending.

You Would Think…

91

slide91
Harmful drug and alcohol use persist despite overwhelming evidence of their destructiveness.

Yet…

92

slide92
It is NOT that…

They don’t want to see (denial)

They don’t care (no motivation)

They are just in the early stages of change.

What is the Problem?

93

slide94
“Motivation can be defined as the probability that a person will enter into, continue, and adhere to a specific change strategy”

(Council of Philosophical Studies, 1981)

Motivation is a key to change

Motivation is multidimensional

Motivation is dynamic and fluctuating

The Concept of Motivation

95

slide95
Motivation is influenced by the clinician’s style

Motivation can be modified

The clinician’s task is to elicit and enhance motivation

“Lack of motivation” is a challenge for the clinician’s therapeutic skills, not a fault for which to blame our clients

The Concept of Motivation

96

slide96
giving ADVICE

removing BARRIERS

providing CHOICE

decreasing DESIRABILITY

practicing EMPATHY

providing FEEDBACK

clarifying GOALS

active HELPING

General Motivation Strategies

97

slide97
Ambivalence is normal

Clients usually enter treatment with fluctuating and conflicting motivations

Clients “want to change and don’t want to change”

“working with ambivalence is working with the heart of the problem”

The Concept of Ambivalence

98

slide98
What you do depends on where the client is in the process of changing

The first step is to be able to identify where the client is coming from

Where Do I Start?

99

99

prochaska diclemente
Prochaska & DiClemente

Precontem-

plation

Contemplation

Recurrence

Preparation

Maintenance

Action

Stages of Change

100

100

slide100
People at this stage:

Are unaware of any problems related to their drug use

Are unconcerned about their drug use

Ignore anyone else’s belief that they are doing something harmful

Primary task– Raising Awareness

Precontemplation Stage

101

slide101

In this stage the patient sees the possibility of change but is ambivalent and uncertain

They enjoy using drugs, but:

Worried about the increasing problems of their use.

Debating with themselves whether or not they have a problem.

Primary task: Resolving ambivalence and helping the client choose to make the change

Contemplation Stage

102

102

slide102

In this stage the patient is committed to changing but is still considering exactly what to do and how to do it

Primary task: Help client identify appropriate change strategies

Determination Stage

103

103

slide103

In this stage the patient is taking steps toward change but hasn’t stabilized in the process

Primary task: Help implement the change strategies and learn to limit or eliminate potential relapses

Action Stage

104

104

slide104
Definition

A stage in which the patient has achieved the primary tx goals and is working to maintain them

Primary task

Patient needs to develop new skills for maintaining recovery

Maintenance Stage

105

105

slide105
People at this stage have reinitiated the identified behaviour.

People usually make several attempts to quit before being successful.

The process of changing is rarely the same in subsequent attempts. Each attempt incorporates new information gained from the previous attempts.

Relapse

106

slide106
Someone who has relapsed

is NOT a failure!

Relapse is part of the recovery process.

Relapse

107

slide107
Helping people change involves increasing their awareness of their need to change and helping them to start moving through the stages of change.

Start “where the client is”

Positive approaches are more effective than confrontation – particularly in an outpatient setting.

Helping People Change

108

slide108

“People are better persuaded by the reasons they themselves discovered than those that come into the minds of others”

Blaise Pascal

slide109
“MI is a directive, client-centered method for enhancing intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

“MI is a way of being with a client, not just a set of techniques for doing counseling” (Miller and Rollnick, 1991)

Motivational Interviewing (MI)

110

slide110
Strategy Goals

Resolve ambivalence

Avoid eliciting or strengthening resistance

Elicit “Change Talk” from the client

Enhance motivation and commitment for change

Help the client go through the Stages of Change

Motivational Interviewing

111

slide111
The Style

Nonjudgmental and collaborative

based on client and clinician partnership

gently persuasive

more supportive than argumentative

listens rather than tells

communicates respect for and acceptance for clients and their feelings

Motivational Interviewing

112

slide112
The Style (Continued)

Explores client’s perceptions without labeling or correcting them

No teaching, modeling, skill-training

Resistance is seen as an interpersonal behavior pattern influenced by the clinician’s behavior

Resistance is met with reflection

Motivational Interviewing

113

slide113
Important Considerations

The clinician’s counseling style is one of the most important aspects of motivational interviewing:

- Use reflective listening and empathy

- Avoid confrontation

- Work as a team against “the problem”

Motivational Interviewing

114

slide114
Motivating for change

Motivational Interviewing

Maintenance

Action

Determination/ Preparation

Contemplation

Pre-contemplation

115

slide115
Motivational interviewing is founded on 4 basic principles:

Express empathy

Develop discrepancy

Roll with resistance

Support self-efficacy

Principles of Motivational Interviewing

116

slide116
Principle 1: Express Empathy

The crucial attitude is one of acceptance

Skilful reflective listening is fundamental to the client feeling understood and cared about

Client ambivalence is normal; the clinician should demonstrate an understanding of the client’s perspective

Labeling is unnecessary

Principles of Motivational Interviewing

117

slide117

Examples of Expressing Empathy

I am so tired, but I cannot even sleep… So I drink some wine.

You drink wine to help you sleep.

…When I wake up…it is too late already…

Yesterday my boss fired me.

So you’re concerned about not having a job.

...but I do not have a drinking problem!

118

slide118
Principle 2: Develop Discrepancy

Clarify important goals for the client

Explore the consequences or potential consequences of the client’s current behaviors

Create and amplify in the client’s mind a discrepancy between their current behavior and their life goals

Principles of Motivational Interviewing

119

slide119

Example of Discrepancy

I enjoy having some drinks with my friends…that’s all. Drinking helps me relax and have fun…I think that I deserve that for a change…

So drinking has some good things for you…now tell me about the not-so-good things you have experienced because of drinking.

Well…as I said, I lost my job because of my drinking problem…and I often feel sick.

120

slide120
Principle 3: Roll with Resistance

Avoid arguing against resistance

If it arises, stop and find another way to proceed

Avoid confrontation

Shift perceptions

Invite, but do not impose, new perspectives

Value the client as a resource for finding solutions to problems

Principles of Motivational Interviewing

121

slide121

Example of NOT Rolling with Resistance

I do not want to stop drinking…as I said, I do not have a drinking problem…I want to drink when I feel like it.

But, Anna, I think it is clear that drinking has caused you problems.

You do not have the right to judge me. You don’t understand me.

122

slide122

Example of Rolling with Resistance

I do not want to stop drinking…as I said, I do not have a drinking problem…I want to drink when I feel like it.

You do have a drinking problem

Others may think you have a problem, but you don’t.

That’s right, my mother thinks that I have a problem, but she’s wrong.

123

slide123
Principle 4: Support Self-Efficacy

Belief in the ability to change (self-efficacy) is an important motivator

The client is responsible for choosing and carrying out personal change

There is hope in the range of alternative approaches available

Principles of Motivational Interviewing

124

slide124

Example of Supporting Self-Efficacy

I am wondering if you can help me. I have failed many times. . .

Anna, I don’t think you have failed because you are still here, hoping things can be better. As long as you are willing to stay in the process, I will support you. You have been successful before and you will be again.

I hope things will be better this time. I’m willing to give it a try.

125

slide126
Part Five:

Medically Assisted Treatment

A Third Example of an Evidence Based Practice

considerations
Considerations
  • If addiction is a chronic, relapsing, sometimes fatal illness, why are we still treating it like an academic deficit?
  • If addiction is a disease and there is effective medication for it, then to withhold it is malpractice.
nqf recommendations128
NQF Recommendations
  • Pharmacotherapy: Medications should be recommended and available to all adult patients with:
    • opioid or alcohol dependence and directly linked with comprehensive clinical services
    • nicotine dependence and directly linked with brief counseling.
pharmacotherapy
Pharmacotherapy
  • Psychosocial therapy is often integral to the success of pharmacotherapy, addressing psychological and social issues that might, if left untreated, contribute to relapse after pharmacotherapy is complete.
pharmacotherapy130
Pharmacotherapy
  • A variety of classes of drugs are effective in treating SUD through multiple mechanisms including:
    • Suppressing withdrawal and discomfort and pain that accompany it
    • Reduce craving
    • Blocking the effects of substance use
pharmacotherapy for alcohol dependence
Pharmacotherapy for Alcohol Dependence

Target Outcome

  • Reduction of alcohol consumption with the goal of cessation
  • Retention in treatment

Goals

  • Treatment of withdrawal (“detox”)
  • Reduction of cravings and urges
  • Substitution therapy
pharmacotherapy for alcohol dependence133
Pharmacotherapy for Alcohol Dependence

Target Population

  • All non pregnant (18 and older), current alcohol dependent patients
  • Special considerations should be given before using pharmacotherapy with selected populations
    • Those with medical contradictions, pregnant/breast feeding women, adolescents and the elderly.
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Pharmacotherapy for Alcohol Dependence
  • FDA-Approved:
    • Disulfuram (Antabuse)
    • Oral naltrexone (Revia)
    • Intramuscular naltrexone (Vivitrol)
    • Acamprosate (Campral)
im naltrexone vivitrol
IM Naltrexone (Vivitrol)
  • FDA approved 2006
  • Dose: 380 mg intramuscular once monthly
  • Mechanism: opioid receptor antagonist
  • Results: Decreased heavy drinking days, decreased frequency of drinking
pharmacotherapy for opioid dependence
Pharmacotherapy for Opioid Dependence

Target Outcome

  • Cessation of non-medical use of opioids
  • Retention in Treatment
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Pharmacotherapy for Opioid Dependence

Target Population

  • All adult (and adolescents 16 and older) patients diagnosed with opioid dependence who meet clinical and regulatory indications; may consider for adolescents as clinically indicated
  • Special considerations should be given before using pharmacotherapy with selected populations
    • Those with medical contradictions, pregnant/breast feeding women, adolescents and the elderly.
opioid pharmacotherapy
Opioid Pharmacotherapy

Goals

  • Detoxification:
    • Opioid-based agonist (methadone, buprenorphine)
    • Non-opioid based (clonidine, supportive meds)
  • Relapse prevention:
    • Agonist maintenance (methadone)
    • Partial agonist maintenance (buprenorphine)
    • Antagonist maintenance (naltrexone)
  • Lifestyle and behavior change
opioid detoxification
Opioid Detoxification

Medications used to alleviate withdrawal

symptoms:

  • Opioids (methadone, buprenorphine)
  • Clonidine
  • Other supportive meds
    • anti-diarrheals, anti-nausea agents, ibuprofen, muscle relaxants, anxiolytics
opioid substitution goals
Opioid Substitution Goals
  • Reduce symptoms and signs of withdrawal
  • Reduce or eliminate craving
  • Block effects of illicit opioids
  • Restore normal physiology
  • Promote psychosocial rehabilitation and non-drug

lifestyle

buprenorphine for opioid dependence
Buprenorphine for Opioid Dependence
  • FDA approved 2002, age 16+
  • Mandatory certification from DEA (100 pt. limit)
  • Mechanism: partial opioid agonist
  • Office-based, expands availability
  • Analgesic properties
  • Ceiling effect
  • Lower abuse potential
  • Safer in overdose
buprenorphine formulations
Buprenorphine Formulations
  • Subutex (Buprenorphine)

-2mg, 8mg

  • Suboxone (4:1 Bup:naloxone)

-2mg/0.5 mg , 8mg/2mg

  • Dose: 2mg-32mg/daysublingually
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Pharmacotherapy

Pharmacotherapy should be a standard component when effective drugs exist.

what pharmacotherapy entails
What Pharmacotherapy Entails
  • Medications that have been proven to be effective for ongoing treatment of
    • Opioid dependence (buprenorphine, methadone, etc)
    • Alcohol dependence (naltrexone, acamprosate, etc.)
    • Tobacco Cessation (nicotine replacement therapy, bupropion, etc)
  • Provided in adequate doses to control cravings
  • Controlled dispensing of doses (for opioid dependence)
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What Pharmacotherapy Entails
  • Regular biological monitoring of illicit drug use.
  • Monitoring response/side effects
  • Adjusting of doses when indicated.
  • Monitoring of medical status, including coexisting conditions and medications.
  • Provisions of empirically validated psychosocial treatment or psychosocial support (including medical management).
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Pharmacotherapy

Who Should Perform It?

  • Health care workers licensed to prescribe medication
  • Healthcare workers authorized to initiate and guide the treatment of alcohol and opioid dependent patients should offer pharmacotherapy
  • Providers who do not prescribe pharmacotherapy should have formal arrangements to refer patients for pharmacotherapy treatment.
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Pharmacotherapy

Where Should It be Performed?

  • Substance use illness specialty settings.
  • General and mental healthcare settings where patients are treated for substance use and illness.
  • If dispensing medications, must been regulatory requirements at the state and federal levels.
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