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Evidence Based Practices: An Overview Desiree

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Title: Evidence Based Practices: An Overview Desiree


1
Evidence Based Practices An Overview
  • Desiree MacPhail-Crevecoeur, Ph.D.
  • Integrated Substance Abuse Programs
  • University of California, Los Angeles

2
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

3
  • Part One
  • Addiction as a Chronic Brain Disease

4
Addiction Brain Disease
  • Addiction is a brain disease that is chronic and
    relapsing in nature.

4
5
5
6
How a neuron works
6
7
7
8
The Reward System
  • Natural rewards
  • Food
  • Water
  • Sex
  • Nurturing

8
9
How the Reward System Works
9
10
10
11
Activating the System with Drugs
11
12
The Brain After Drug Use (1)
Control Methamphetamine
12
(Source McCann et al. (1998). Journal of
Neuroscience, 18, 8417-8422.)
13
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)
14
The Brain After Drug Use (2)
14
DA Days Abstinent
15
Drugs Change the Brain
  • After repeated drug use, deciding to use drugs
    is no longer voluntary because
  • DRUGS CHANGE THE BRAIN!

15
16
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.

17
Acute Care Treatment Model
Substance Abusing Patient
Treatment
Non- Substance Abusing Patient
18
Traditional Service Approach
Severe
Symptoms
Acute symptoms, Discontinuous treatment Crisis
management
Remission
Time
18
Resource Tom Kirk, Ph.D.
19
NQF Recommendations
  • Patients treated for Substance Use Disorders
    (SUD) should be engaged in long-term, ongoing
    management of their care. Primary medical care
    providers should support and monitor ongoing
    recovery in collaboration with the specialty
    provider who is managing their SUD.

20
A Recovery-Oriented Approach
Severe
Symptoms
Continuous Treatment Response
Remission
Time
20
Resource Tom Kirk, Ph.D
21
A Continuing Care Model
Substance Abusing Patient
Detox
Duration Determined by Performance Criteria
Rehabilitation
Duration Determined by Performance Criteria
Continuing Care Recovering Patient
22
Lessons from Chronic Illness
  • Medications relieve symptoms but. behavioral
    change is necessary for sustained benefit
  • Treatment effects usually dont last very long
    after treatment stops.

23
Lessons from Chronic Illness
  • Patients who are not in some form of treatment or
    monitoring are at elevated risk for relapse.
  • In addiction this could include monitoring or AA

24
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.

25
  • Part Two
  • Evidence Based Practices

26
What are Evidence Based Practices?
  • Interventions that show consistent scientific
    evidence of being related to preferred client
    outcomes.

26
27
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
  • gt1000 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
28
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
29
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
30
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
31
Examples of Evidence Based Practices
  • Contingency management
  • Medically Assisted Treatment
  • Brief intervention
  • Cognitivebehavioral interventions
  • Community reinforcement
  • Behavioral contracting
  • Motivational enhancement therapy
  • 12-step facilitation

31
32
Part 3 Cognitive Behavioral Therapy (CBT)
Relapse Prevention Strategies One Example of an
Evidence Based Practice
32
33
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
34
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 from
    escalating 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
35
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
36
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
37
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
38
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
39
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
40
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
41
Foundations of CBT
  • The learning and conditioning principles involved
    in CBT are
  • Classical conditioning
  • Operant conditioning
  • Modelling

41
42
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
43
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
44
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
45
Operant conditions (1)
  • Positive reinforcement strengthens a particular
    behaviour (e.g., pleasurable effects from the
    pharmacology of the drug peer acceptance)
  • Punishment is 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
46
Operant conditions (2)
  • Negative reinforcement occurs 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
47
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
48
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
49
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
50
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
51
CBT Techniques for Addiction Treatment
Functional Analysis / The 5 Ws
51
52
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 clients 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 clients life.
    Those details are critical to creating a useful
    treatment plan.

52
53
The 5 Ws (functional analysis)
  • The 5 Ws of a persons drug use (also called a
    functional analysis)
  • When?
  • Where?
  • Why?
  • With / from whom?
  • What happened?

53
54
The 5 Ws
  • People addicted to drugs do not use them at
    random. It is important to know
  • The time periods when the 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 (what
    happened)

54
55
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
56
Functional Analysis or High-Risk Situations
Record
57
CBT Techniques for Addiction Treatment
Functional Analysis Triggers and Craving
57
58
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
59
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
60
External triggers
  • People drug dealers, drug-using friends
  • Places bars, parties, drug users 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
61
Internal triggers
  • Anxiety
  • Anger
  • Frustration
  • Sexual arousal
  • Excitement
  • Boredom
  • Fatigue
  • Happiness
  • Hunger

61
62
Triggers Cravings
62
63
The Clinicians Role
  • To teach the client and coach her or him towards
    learning new skills for behavioral change and
    self-control.

63
64
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
65
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
66
Match material to clients 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
67
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., clients triggers)
  • Repetition of whole sessions, or parts of
    sessions, may be needed

67
68
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
69
Give a clear rationale
  • Clinicians should not expect a client to practice
    a skill or do a homework assignment without
    understanding why it 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.

69
70
Communicate clearly in simple terms
  • Use language that is compatible with the clients
    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
71
Monitoring
  • Monitoring to follow-up by obtaining information
    on the clients attempts to practice the
    assignments and checking on task completion. It
    also entails discussing the clients experience
    with the tasks so that problems can be addressed
    in session.

71
72
Praise approximations
  • Clinicians should try to shape the clients
    behavior by praising even small attempts at
    working on assignments, highlighting anything
    that was helpful or interesting.

72
73
Example of praising approximations
I did not work on my assignmentssorry.
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
74
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
75
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
76
Develop a plan Dealing with resistance to
scheduling
  • Clients might resist scheduling (Im not a
    scheduled person or In our culture, we dont
    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
77
  • Part Four
  • Motivational Interviewing
  • A second Example of an Evidence Based Practice

78
Definition of Motivation
The probability that a person will enter into,
continue, and comply with change-directed
behavior
78
78
79
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
80
Motivational Interviewing
  • It seems surprising that
  • people dont simply stop using drugs,
    considering that drug addiction creates so many
    problems for them and their families.

80
81
Motivational Interviewing
  • People who engage in harmful drug or alcohol use
    often say they want to stop using, but they
    simply dont know how, are unable to, or are not
    fully ready to stop.

81
82
Understanding How People Change Models
  • Traditional approach
  • Motivating for change

83
The Traditional Approach
The Stick
  • 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 dont change if they havent
    suffered enough

83
84
The Traditional Approach
You better! Or else!
If the stick is big enough, there is no need for
a carrot.
84
85
The Traditional Approach
  • Someone who continues to use is
  • in denial.
  • The best way to break through the
  • denial is direct confrontation.

85
86
Another Approach Motivating
  • 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

The carrot
86
87
Ambivalence
87
88
Ambivalence
  • 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

88
89
Why dont people change?

90
You Would Think
  • that hangovers, damaged relationships, an auto
    crash, memory blackouts - or even being pregnant
    - would be enough to convince a woman to stop
    drinking.

90
91
You Would Think
  • that experiencing the dehumanizing
  • privations of prison would
  • dissuade people from
  • re-offending.

91
92
Yet
  • Harmful drug and alcohol use persist despite
    overwhelming evidence of their destructiveness.

92
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What is the Problem?
  • It is NOT that
  • They dont want to see (denial)
  • They dont care (no motivation)
  • They are just in the early stages of change.

93
94
  • Why DO people change?

95
The Concept of Motivation
  • 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

95
96
The Concept of Motivation
  • Motivation is influenced by the clinicians style
  • Motivation can be modified
  • The clinicians task is to elicit and enhance
    motivation
  • Lack of motivation is a challenge for the
    clinicians therapeutic skills, not a fault for
    which to blame our clients

96
97
General Motivation Strategies
  • giving ADVICE
  • removing BARRIERS
  • providing CHOICE
  • decreasing DESIRABILITY
  • practicing EMPATHY
  • providing FEEDBACK
  • clarifying GOALS
  • active HELPING

97
98
The Concept of Ambivalence
  • Ambivalence is normal
  • Clients usually enter treatment with fluctuating
    and conflicting motivations
  • Clients want to change and dont want to change
  • working with ambivalence is working with the
    heart of the problem

98
99
Where Do I Start?
  • 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

99
99
100
Prochaska DiClemente
Stages of Change
100
100
101
Precontemplation Stage
  • People at this stage
  • Are unaware of any problems related to their drug
    use
  • Are unconcerned about their drug use
  • Ignore anyone elses belief that they are doing
    something harmful
  • Primary task Raising Awareness

101
102
Contemplation Stage
  • 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

102
102
103
Determination Stage
  • 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

103
103
104
Action Stage
  • In this stage the patient is taking steps toward
    change but hasnt stabilized in the process
  • Primary task Help implement the change
    strategies and learn to limit or eliminate
    potential relapses

104
104
105
Maintenance Stage
  • 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

105
105
106
Relapse
  • 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.

106
107
Relapse
  • Someone who has relapsed
  • is NOT a failure!
  • Relapse is part of the recovery process.

107
108
Helping People Change
  • 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.

108
109
People are better persuaded by the reasons
they themselves discovered than those that come
into the minds of others
  • Blaise Pascal

110
Motivational Interviewing (MI)
  • 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)

110
111
Motivational Interviewing
  • 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

111
112
Motivational Interviewing
  • 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

112
113
Motivational Interviewing
  • The Style (Continued)
  • Explores clients perceptions without labeling or
    correcting them
  • No teaching, modeling, skill-training
  • Resistance is seen as an interpersonal behavior
    pattern influenced by the clinicians behavior
  • Resistance is met with reflection

113
114
Motivational Interviewing
  • Important Considerations
  • The clinicians 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

114
115
Motivational Interviewing
  • Motivating for change

Maintenance
Action
Determination/ Preparation
Contemplation
Pre-contemplation
115
116
Principles of Motivational Interviewing
  • Motivational interviewing is founded on 4 basic
    principles
  • Express empathy
  • Develop discrepancy
  • Roll with resistance
  • Support self-efficacy

116
117
Principles of Motivational Interviewing
  • 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
    clients perspective
  • Labeling is unnecessary

117
118
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 upit is too late already Yesterday
my boss fired me.
So youre concerned about not having a job.
...but I do not have a drinking problem!
118
119
Principles of Motivational Interviewing
  • Principle 2 Develop Discrepancy
  • Clarify important goals for the client
  • Explore the consequences or potential
    consequences of the clients current behaviors
  • Create and amplify in the clients mind a
    discrepancy between their current behavior and
    their life goals

119
120
Example of Discrepancy
I enjoy having some drinks with my friendsthats
all. Drinking helps me relax and have funI
think that I deserve that for a change
So drinking has some good things for younow tell
me about the not-so-good things you have
experienced because of drinking.
Wellas I said, I lost my job because of my
drinking problemand I often feel sick.
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Principles of Motivational Interviewing
  • 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

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Example of NOT Rolling with Resistance
I do not want to stop drinkingas I said, I do
not have a drinking problemI 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 dont
understand me.
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Example of Rolling with Resistance
I do not want to stop drinkingas I said, I do
not have a drinking problemI want to drink when
I feel like it.
You do have a drinking problem
Others may think you have a problem, but you
dont.
Thats right, my mother thinks that I have a
problem, but shes wrong.
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Principles of Motivational Interviewing
  • 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

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Example of Supporting Self-Efficacy
I am wondering if you can help me. I have failed
many times. . .
Anna, I dont 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. Im
willing to give it a try.
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127
  • Part Five
  • Medically Assisted Treatment
  • A Third Example of an Evidence Based Practice

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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.

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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.

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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.

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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

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Alcohol Dependence
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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

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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)

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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

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Opioid Dependence
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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.

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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

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Opioid Detoxification
  • 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
  • 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
  • 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
  • Subutex (Buprenorphine)
  • -2mg, 8mg
  • Suboxone (41 Bupnaloxone)
  • -2mg/0.5 mg , 8mg/2mg
  • Dose 2mg-32mg/day sublingually

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Pharmacotherapy
  • Pharmacotherapy should be a standard component
    when effective drugs exist.

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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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  • Questions?
  • Comments?
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