Evidence-Based Intensive Outpatient Treatment Programs

1. Evidence-Based Intensive Outpatient Treatment Programs For Substance Use Disorders

2. Definition and Diagnoses of Substance Use Disorders • DSM-IV-TR CRITERIA Substance Abuse: a maladaptive pattern of substance use leading to clinically significant impairment or distress occurring in any of the following areas, within a 12-month period • Failure to fulfill major obligations at work, school, or home

3. Substance Abuse Dx – Cont. • Recurrent substance use in hazardous situations, such as driving or operating heavy machines while impaired by the substance use • Substance-related legal problems • Social and interpersonal problems caused by or exacerbated by the substance

4. Substance Dependence Dx A syndrome characterized by a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by at least 3 of the following and occurring in a 12-month period: • Tolerance • Withdrawal • Substance is taken in larger amounts or for longer periods than intended (overdosing)

5. Substance Dependence Dx – Cont. • Persistent desire or unsuccessful efforts to cut down or control substance use • A significant amount of time is spent in activities to obtain, use, and recover from the substance • Important social, occupational, or recreational activities are given up or reduced • Continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem

6. Definition of Addiction American Society of Addiction Medicine defines it as: A primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addiction is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving (Graham et al., 2003).

7. U.S. Statistics on Drinking and Substance Use Disorder rates: NIAA 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions • 72% Never exceed the daily or weekly limits • 16% Exceed only the daily limit • 10% Exceed both daily and weekly limits

8. CSAT 2006 data • 50% Americans age 12 and older report drinking alcohol • 30% American adults drink at levels that increase their risk for physical, emotional, and social problems. Of these heavy drinkers, about 1 in 4 currently has an alcohol abuse or dependence disorder • More men report being current drinkers than do women • The rate of alcohol dependence is also lower for women than for men

9. N-SSATS 2005 • The survey showed that on March 31, 2005, 1.08 million people were enrolled in substance abuse treatment, an 8 percent increase from 1 million in 2000. • Of them, 34 percent were in treatment for drug abuse only, up from 29 percent in 2000. • In contrast, patients enrolled in treatment only for alcohol abuse declined from 23 percent in 2000 to 19 percent in 2005.

10. N-SSATS 2005 – Cont. • The proportion of patients in treatment for both drug and alcohol abuse made up nearly half of all patients (47 percent). • The 2005 national survey reported that the number and proportion of patients receiving methadone increased from 17 percent of all patients in 2000 to 22 percent in 2005.

11. N-SSATS 2005 – Cont. • The survey also indicated that opioid treatment programs, which focus on treating addiction to heroin and prescription narcotic pain medications, were available in 8 percent of all substance abuse treatment programs. • http://wwwdasis.samhsa.gov/05nssats/nssats2k5web.pdf

12. SAMHSA's National Survey on Drug Use and Health (NSDUH) 2006 • In 2003, of the estimated 25 million veterans (93% were male) living in the United States, 8.4% were between the ages of 17 and 34; 30.1% between the ages of 35 and 54; 42.3% between the ages of 55 and 74; and 19.2% were aged 75 or older. • SAMHSA's National Survey on Drug Use and Health found that in 2003, an estimated 3.5% of veterans used marijuana in the past month compared with 3.0% of their nonveteran counterparts.

13. NSDUH 2006 – Cont. • Past month heavy use of alcohol was more prevalent among veterans (7.5%) than nonveterans (6.5%). • Estimated rates of dependence on alcohol and/or illicit drugs did not differ significantly between veterans and nonveterans. Rates of those dependent on alcohol and/or illicit drugs but who did not receive treatment in the past year were also comparable.

14. NSDUH 2006 – Cont. • An estimated 0.8% of veterans received specialty treatment for a substance use disorder (alcohol or illicit drugs) in the past year compared with 0.5% of nonveterans.

15. 1996 Veterans Affairs Report • Among veterans with drug diagnoses treated in specialized inpatient substance abuse units 65% abuse cocaine, 19% abuse opiates, and 35% have co-existing psychiatric diagnoses.

16. Veterans with Hepatitis C Source: HCV Clinical Case Registry

17. Veterans with Cirrhosis 33% increase in annual unique patients (HCV+ or -) with a diagnosis of cirrhosis from 2000-2006. Source: VA Liver Disease Database

18. HCV+ Veterans in care who ever had cirrhosis or HCC, 2004-2007 • Cirrhosis HCC

19. Risk of HCC increases with increasing alcohol intake but is greater in the presence of HCV infection Donato et al. Am J Epidemiol 2002;155:323

20. Brief Alcohol Intervention Initiative • Challenge: Need evidence-based alcohol reduction interventions to help HCV patients reduce or eliminate alcohol consumption • Response: Implement effective brief-intervention strategies and tools for providers to address heavy alcohol use in HCV clinical settings

21. Principles of Effective IOP Programs • Utilize evidence-based practices • Motivational Interviewing (Miller and Rollnick, 1991) • Relapse Prevention (Marlatt and Gordon, 1985; Marlatt,1998) • NIDA Matrix Model of IOP 20 year project • (Rawson et al. 1995) • Stages of Change (DiClemente and Prochaska, 1998) • Harm Reduction model • ( Sobell and Sobell, 1993b, 1993, 1998, 1999)

22. Evidence-Based Practices – Cont. • Brief Alcohol Interventions in primary care settings (Project TREAT (Trial for Early Alcohol Treatment), 1997; World Health Organization Brief Intervention Study, 1996; and TIP 24 A Guide to Substance Abuse Services for Primary Care Clinicians) • Cognitive-Behavioral Therapy (i.e. relapse prevention –Gorski, Marlatt & Gordon, Najavits - Seeking Safety)

23. Evidence-Based Practices – Cont. • SAMHSA/CSAT Treatment Improvement Protocols (TIPS 8, 13, 33 and 35 for IOP programs)

24. Websites for Evidence-based Practices • www.hepatitis.va.gov • www.modelprograms.samhsa.gov • www.nrepp.samhsa.gov • www.mentalhealthpractices.org • tie.samhsa.gov/Externals/tips.html • www.nida.nih.gov/PubCat/PubsIndex.html • www.niaaa.nih.gov/publications/guides.html

25. Principles of Effective IOP – Cont. • A continuum of care is more cost efficient care. • A multidisciplinary approach • Cross-trained Staff • Integration of treatment is essential. • Treatment should be individualized.

26. Components of IOP TreatmentGroup Topics • The neurochemistry of addiction and the addiction process • The role and process of treatment and recovery • Medical aspects of addiction - PAWS symptoms • The importance of abstinence from alcohol and all other drugs • Appropriate use of prescribed and over-the-counter drugs • Powerlessness and unmanageability of AOD use

27. Components of IOP – Cont.Group Topics • Maximizing the use of self-help and support groups • Spirituality and the development of an externalized source of support • The roles of nutrition, exercise, leisure, and recreation in recovery • Experiencing emotions and feelings without AODs • Relationship skills • Conflict resolution and communication skills

28. Components of IOP – Cont.Group Topics • Family dynamics of addiction • Healthy relationships and family functioning • Relapse management skills • AOD refusal skills • Avoiding and defusing triggers for craving and relapse • Minimizing risks for HIV, AIDS, and sexually transmitted disease

29. Core and Enhanced Services for IOP programs • High quality leadership and administrative support • Comprehensive biopsychosocial screening and assessment • Program orientation and intake procedures • Routine and random urine drug screening • Individual treatment planning and review • 24-hour crisis management • Pharmacotherapy and medication management • Medical treatment

30. Core and Enhanced Services for IOP programs – Cont. • Individual counseling • Group therapy • Education about AOD issues • Family education and counseling • Self-help and support group orientation • Case management services • Discharge and transitional service planning

31. Core and Enhanced Services for IOP programs – Cont. • Program and outcome evaluation • Adult education • Adjunctive therapies • Transportation services • Housing and food • Smoking cessation treatment • Aftercare • Specialty groups

32. Model Programs and Evidence-Based Practices • Brief Interventions/Motivational Interviewing for Hazardous Drinking

33. Brief Interventions/Motivational Interviewing for Hazardous Drinking • Strengths: • Uses Motivational Interviewing -Uses change talk -Roadmap for BI

34. Brief Interventions/Motivational Interviewing for Hazardous Drinking • Uses feedback to raise readiness • Discuss change options with patients • Solution-Focused • Structured • Harm Reduction

35. Brief Interventions for Hazardous Drinking • Weaknesses: • Is not a pancea for every difficult or unmotivated patient • (see Ten Things Motivational Interviewing is not by Miller & Rollnick, 2009)

36. AUDIT-C “Triangle” Card

37. Counseling Card: Back

38. Prototype FLO Card

39. Raise importance • On a scale of 0-10, how important is it for you to change your drinking? • Why did you give it a (patient’s number) and not a lower higher number? • What would it take to give it a higher number? • I m p o r t a n c e • 0 1 2 3 4 5 6 7 8 9 10 Rollnick, Health Behavior Change, 1999

40. Build confidence • On a scale of 0-10, how confident are you that you can change your drinking? • Why did you give it a (patient’s number) and not a lower higher number? • What would it take to give it a higher number? • C o n f i d e n c e • 0 1 2 3 4 5 6 7 8 9 10 • Rollnick, Health Behavior Change, 1999

41. Drinking Diary Card(Wallet Card)

42. Drinking Diary Card • Measuring behavior is an intervention • Good for patients in early stages of change • Self-monitoring can reveal: • Drinking patterns • Social/emotional contexts • Antecedents/consequences (A, B, C’s) • Can promote harm reduction

43. Change Plan Template(Wallet Card)

44. Change Plan Template • For patients who appear ready to attempt behavior change • Goals most likely successful when they are: • Explicit (measurable) • Achievable (realistic) • Public (verbal commitment) • Facilitates problem-solving, identifying resources & support

45. Model Programs and Evidence-Based Practices • 12-Step Facilitation Approach "Minnesota Model“

46. 12-Step Facilitation Model • Strengths: • 12-Step meetings are a free, widely available, ongoing source of support. • The 12-Step approach emphasizes an array of recovery tasks in cognitive, spiritual, and health realms. • The 12-Step approach is effective with patients from diverse backgrounds (Tonigan 2003).

47. 12-Step Facilitation Model • Weaknesses: • It can be difficult to monitor accurately patients' compliance with assigned step tasks, including meeting attendance. • 12-Step groups' emphasis on a higher power may be unacceptable to some patients. • Some communities may not be large enough to sustain 12-Step meetings or appropriate meetings for people with significant psychiatric disorders.

48. Model Programs and Evidence-Based Practices • Cognitive Behavioral Therapy (CBT)

49. Cognitive Behavioral Therapy (CBT) • Strengths: • CBT actively engages patients in therapy and experiential learning. • Numerous manuals on CBT are available. • CBT is suitable for patients from diverse backgrounds and with varying histories of alcohol and drug use. • CBT provides structured methods for understanding relapse triggers and preparing for relapse situations.

50. CBT • Weaknesses: • Patients with poor reading or cognitive skills may need alternatives to written assignments. • The approach requires counselor training in CBT principles and techniques. • Patient motivation is critical because of the extent of homework assignments. • CBT was developed as an individual, not group, counseling approach.