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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

Desiree MacPhail-Crevecoeur, Ph.D.

Integrated Substance Abuse Programs

University of California, Los Angeles


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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


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Part One:

Addiction as a Chronic Brain Disease


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Addiction = Brain Disease

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

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5



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The Reward System

Natural rewards

Food

Water

Sex

Nurturing

8





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The Brain After Drug Use (1)

Control Methamphetamine

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


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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)


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The Brain After Drug Use (2) Methamphetamine Abuser

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DA = Days Abstinent


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Drugs Change the Brain Methamphetamine Abuser

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

DRUGS CHANGE THE BRAIN!

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IOM Quality Chasm Methamphetamine Abuser 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.”


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Acute Care Treatment Model Methamphetamine Abuser

Substance Abusing Patient

Treatment

Non- Substance Abusing Patient


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Traditional Service Approach Methamphetamine Abuser

Severe

Symptoms

Acute symptoms,

Discontinuous treatment

Crisis management

Remission

Time

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Resource: Tom Kirk, Ph.D.


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NQF Recommendations Methamphetamine Abuser

“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.”


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A Recovery-Oriented Approach Methamphetamine Abuser

Severe

Symptoms

Continuous

Treatment Response

Remission

Time

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Resource: Tom Kirk, Ph.D


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A Continuing Care Model Methamphetamine Abuser

Substance Abusing Patient

Detox

Duration

Determined by

Performance

Criteria

Rehabilitation

Duration

Determined by

Performance

Criteria

Continuing Care

Recovering Patient


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Lessons from Chronic Illness Methamphetamine Abuser

  • Medications relieve symptoms but…. behavioral change is necessary for sustained benefit

  • Treatment effects usually don’t last very long after treatment stops.


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Lessons from Chronic Illness Methamphetamine Abuser

  • Patients who are not insome form of treatment or monitoringare at elevated risk for relapse.

    In addiction this could include monitoring or AA


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Summary Methamphetamine Abuser

  • 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.


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Part Two: Methamphetamine Abuser

Evidence Based Practices


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What are Evidence Based Practices? Methamphetamine Abuser

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

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Evidence Based Practices Methamphetamine Abuser

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

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


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Principles of Effective Treatment Methamphetamine Abuser

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

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- NIDA (1999) Principles of Drug Addiction Treatment


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Principles of Effective Treatment Methamphetamine Abuser

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

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- NIDA (1999) Principles of Drug Addiction Treatment


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Principles of Effective Treatment Methamphetamine Abuser

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

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- NIDA (1999) Principles of Drug Addiction Treatment


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Examples of Evidence Based Practices Methamphetamine Abuser

Contingency management

Medically Assisted Treatment

Brief intervention

Cognitive–behavioral interventions

Community reinforcement

Behavioral contracting

Motivational enhancement therapy

12-step facilitation

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

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What is CBT and how is it used in Methamphetamine Abuser 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)

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What is relapse prevention (RP)? Methamphetamine Abuser

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

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Foundation of CBT: Methamphetamine Abuser 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

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Why is CBT useful? (1) Methamphetamine Abuser

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

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Why is CBT useful? (2) Methamphetamine Abuser

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

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Important concepts in CBT (1) Methamphetamine Abuser

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.

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Important concepts in CBT (2) Methamphetamine Abuser

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

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Important concepts in CBT (3) Methamphetamine Abuser

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

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Foundations of CBT Methamphetamine Abuser

The learning and conditioning principles involved in CBT are:

Classical conditioning

Operant conditioning

Modelling

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Classical conditioning: Addiction Methamphetamine Abuser

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

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Classical conditioning: Application to CBT techniques Methamphetamine Abuser

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

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Operant conditioning: Addiction Methamphetamine Abuser

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.

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Operant conditions (1) Methamphetamine Abuser

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.)

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Operant conditions (2) Methamphetamine Abuser

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.).

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Operant conditioning: Methamphetamine Abuser 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

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Modeling: Definition Methamphetamine Abuser

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.

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Basis of substance use disorders: Modeling Methamphetamine Abuser

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.

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Modeling: Application to CBT techniques Methamphetamine Abuser

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

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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.

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The 5 Ws (functional analysis) life?

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

When?

Where?

Why?

With / from whom?

What happened?

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The 5 Ws life?

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)

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Questions clinicians can use to learn life?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?

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“Triggers” (conditioned cues) & Triggers and Craving

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).

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“Triggers” for drug use & Triggers and Craving

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

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External triggers & Triggers and Craving

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

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Internal triggers & Triggers and Craving

Anxiety

Anger

Frustration

Sexual arousal

Excitement

Boredom

Fatigue

Happiness

Hunger

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Triggers & Cravings & Triggers and Craving

TriggerThoughtCravingUse

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The Clinician’s Role & Triggers and Craving

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

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The role of the clinician in CBT & Triggers and Craving

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.

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The role of the clinician in CBT & Triggers and Craving

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.

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Match material to client’s needs & Triggers and Craving

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

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Repetition & Triggers and Craving

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

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Practice & Triggers and Craving

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.

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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

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Communicate clearly in simple terms do a homework assignment without understanding

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

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Monitoring do a homework assignment without understanding

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.

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Praise approximations do a homework assignment without understanding

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.

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Example of praising approximations do a homework assignment without understanding

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.

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Develop a plan do a homework assignment without understanding

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!

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Stay on schedule, stay sober do a homework assignment without understanding

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

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Develop a plan: Dealing with resistance to scheduling do a homework assignment without understanding

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.

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Part Four: do a homework assignment without understanding

Motivational Interviewing

A second Example of an Evidence Based Practice


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Definition of Motivation do a homework assignment without understanding

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

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Motivational Interviewing do a homework assignment without understanding

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.

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Motivational Interviewing do a homework assignment without understanding

It seems surprising that…

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

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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

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Understanding How People Change: Models they want to stop using, but they simply don’t know how, are unable to, or are not fully ready to stop.

Traditional approach

Motivating for change


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Change is motivated by discomfort. they want to stop using, but they simply don’t know how, are unable to, or are not fully ready to stop.

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

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The Traditional Approach they want to stop using, but they simply don’t know how, are unable to, or are not fully ready to stop.

You better!

Or else!

If the stick is big enough,

there is no need for a carrot.

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Someone who continues to use is they want to stop using, but they simply don’t know how, are unable to, or are not fully ready to stop.

“in denial.”

The best way to “break through” the

denial is direct confrontation.

The Traditional Approach

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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

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Ambivalence empowering, and safe atmosphere

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Ambivalence: Feeling two ways about empowering, and safe atmosphere

something.

All change contains an element of ambivalence.

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

Ambivalence

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Why empowering, and safe atmospheredon’t people change?


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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…

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that experiencing the dehumanizing blackouts

privations of prison would

dissuade people from

re-offending.

You Would Think…

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

Yet…

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It is NOT that… blackouts

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?

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“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

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Motivation is influenced by the clinician’s style person will enter into, continue, and adhere to a specific change strategy”

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

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giving ADVICE person will enter into, continue, and adhere to a specific change strategy”

removing BARRIERS

providing CHOICE

decreasing DESIRABILITY

practicing EMPATHY

providing FEEDBACK

clarifying GOALS

active HELPING

General Motivation Strategies

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Ambivalence is normal person will enter into, continue, and adhere to a specific change strategy”

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

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What you person will enter into, continue, and adhere to a specific change strategy” 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?

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Prochaska & DiClemente person will enter into, continue, and adhere to a specific change strategy”

Precontem-

plation

Contemplation

Recurrence

Preparation

Maintenance

Action

Stages of Change

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People at this stage: person will enter into, continue, and adhere to a specific change strategy”

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

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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

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In this stage the patient is 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

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In this stage the patient is 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

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Definition is

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

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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

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Someone who has relapsed behaviour.

is NOT a failure!

Relapse is part of the recovery process.

Relapse

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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

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

Blaise Pascal


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“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)

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Strategy Goals intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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

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The Style intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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

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The Style intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)(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

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Important Considerations intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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

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Motivating for change intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

Motivational Interviewing

Maintenance

Action

Determination/ Preparation

Contemplation

Pre-contemplation

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Motivational interviewing is founded on 4 basic principles: intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

Express empathy

Develop discrepancy

Roll with resistance

Support self-efficacy

Principles of Motivational Interviewing

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Principle 1: Express Empathy intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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

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Examples of Expressing Empathy intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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!

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Principle 2: Develop Discrepancy intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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

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Example of Discrepancy intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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.

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Principle 3: Roll with Resistance intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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

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Example of intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)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.

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Example of Rolling with Resistance intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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.

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Principle 4: Support Self-Efficacy intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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

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Example of Supporting Self-Efficacy intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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.

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Part Five: intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

Medically Assisted Treatment

A Third Example of an Evidence Based Practice


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Considerations intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

  • 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.


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NQF Recommendations intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

  • 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.


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Pharmacotherapy intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

  • 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.


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Pharmacotherapy intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

  • 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


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Alcohol Dependence intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)


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Pharmacotherapy for Alcohol Dependence intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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


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Pharmacotherapy for Alcohol Dependence intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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 intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

  • FDA-Approved:

    • Disulfuram (Antabuse)

    • Oral naltrexone (Revia)

    • Intramuscular naltrexone (Vivitrol)

    • Acamprosate (Campral)


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IM Naltrexone (Vivitrol) intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

  • FDA approved 2006

  • Dose: 380 mg intramuscular once monthly

  • Mechanism: opioid receptor antagonist

  • Results: Decreased heavy drinking days, decreased frequency of drinking


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Opioid Dependence intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)


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Pharmacotherapy for Opioid Dependence intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

Target Outcome

  • Cessation of non-medical use of opioids

  • Retention in Treatment


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Pharmacotherapy for Opioid Dependence intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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.


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Opioid Pharmacotherapy intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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


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Opioid Detoxification intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

Medications used to alleviate withdrawal

symptoms:

  • Opioids (methadone, buprenorphine)

  • Clonidine

  • Other supportive meds

    • anti-diarrheals, anti-nausea agents, ibuprofen, muscle relaxants, anxiolytics


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Opioid Substitution Goals intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

  • 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


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Buprenorphine for Opioid Dependence intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

  • 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


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Buprenorphine Formulations intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

  • Subutex (Buprenorphine)

    -2mg, 8mg

  • Suboxone (4:1 Bup:naloxone)

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

  • Dose: 2mg-32mg/daysublingually


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Pharmacotherapy intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

Pharmacotherapy should be a standard component when effective drugs exist.


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What Pharmacotherapy Entails intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

  • 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 intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

  • 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 intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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 intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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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Questions? intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002)

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