James Finch, MD, FASAM Director of Physician Education NC Governor s Institute on Alcohol and Substance Abuse Medical Director: Changes By Choice

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1 James Finch, MD, FASAM Director of Physician Education NC Governor s Institute on Alcohol and Substance Abuse Medical Director: Changes By Choice Durham, NC

2 ASAM Disclosure of Relevant Financial Relationships Content of Activity: ASAM Review Course 2014 Name Commercial Interests Relevant Financial Relationships: What Was Received Relevant Financial Relationships: For What Role No Relevant Financial Relationships with Any Commercial Interests James Finch, MD Reckitt Benckiser, Orexo, Pfizer Honoraria, Honoraria, Honoraria Speaker, Speaker, Speaker

3 12-step programs: Alcoholics Anonymous / Narcotic Anonymous Al Anon / Nar Anon ACOA (Adult Children of Alcoholics) Other national support groups: Smart Recovery Women for Sobriety Local and/or less formalized programs Church groups Treatment program groups

4 Can mean: Informal support and facilitation for regular involvement in organized peer support Structured, manual-driven process developed initially for Project MATCH Available through NIAAA: Twelve-step facilitation therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Nowinsky, Baker and Carroll. NIAAA 1992

5 Why need to be familiar with model: Widely available, inexpensive Traditional foundation of SA treatment in US Dominant model in influential treatment centers Works for many people Core concepts: Abstinence: From all drugs of abuse Acceptance: Working through denial and accepting powerlessness Spirituality: Surrender to higher power Pragmatism: Actively working the program

6 Widely accepted and reinforced as a core element of treatment. Quality of research on effectiveness has been variable. AA and other 12-step programmes for alcohol dependence. Cochrane Database Syst Rev. 2008; 3:1-25. Ferri, Amato, Davoli. Evidence does support that attendance at self-help groups is associated with better outcomes over time. Self-help organizations for alcohol and drug problems: toward evidence-based practice and policy. J Subst Abuse Treat 2004; 26: Humphreys, Wing, McCarty.

7 Readiness To Change Treatment Matching Assessment Pharmacotherapies Behavioral Therapies Adjust Plan Based on Outcome

8 Adequate assessment for: Diagnosis of abuse or dependence Withdrawal risk Medical and psychiatric co-morbidities Recovery environment Assess readiness to change: Commitment to sobriety Develop initial treatment goals and plan: collaboratively Assess readiness to change: Commitment to active/specific steps Monitor and adjust treatment plan as ongoing process over time.

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12 Monitor not just in terms of sobriety/abstinence Monitor in terms of functional improvement: -emotional -interpersonal -medical (Don t rely entirely on self-report) -occupational -legal Is there progress toward patient s identified goals? Is there active participation in treatment?

13 Increase level of care Improve recovery environment Joblessness / Homelessness Substance users in living environment Assess, access and integrate needed medical care Assess and access treatment for co-morbid psych problems Increase skills for tolerating negative affects Is there now a need for medication assisted treatment)? If on MAT, how is compliance? Can it be improved?

14 Reassess for ambivalence re change process What follow-up plans were followed / not followed? Rearrange or look for reinforcements Increase self-efficacy: build on successes What is going well, what not so well? Leverage what is different since last contact? Client-centered treatment strategies vs. confrontation

15 Take advantage of what we know: Utilize pharmacologic and non-pharmacologic treatment approaches that research shows are most effective Adapt treatments dependent on outcome/progress Take advantage of all opportunities to: Use motivational approach to keep patients engaged with treatment Adapt treatments to address patients at various stages of change

16 Maximizing medication management: It s not ALL about the medicine.

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18 Explore and define reasonable counseling expectations during brief clinical encounters, such as the typical med management visit. Outline common elements of addiction recovery that can be reinforced in these encounters. Provide concrete examples of using basic elements of CBT, MI and DBT to reinforce behavior change. No clinical encounter is too brief for a little counseling: Psychotherapy applied in small doses.

19 Potential roles in variety of settings: Management of acute withdrawal syndromes Treatment of medical and/or psychiatric co-morbidities. Providing medication assisted treatment (MAT). Non-pharmacologic/behavioral treatment: - Support and reinforce that provided by others - Provide therapy directly: formal or brief counseling

20 Assess response to medication/s: Efficacy/Side-Effects Assess abstinence from primary as well as other drugs Assess overall bio-psycho-social stability AND Reinforce steps toward engagement in recovery BY Exploiting opportunities to apply elements of MI and CBT

21 Medical clinician only Psychotherapist Counselor Coach Guide Do we want to stay in a traditional medical role? Do we want to accept and activate our counseling role?

22 Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence: A Randomized Controlled Trial Anton, RF, O Malley, SS, et al. JAMA, May 2006 Groups randomized to med management with naltrexone, acamprosate, both and/or both placebos, with or without a combined behavioral intervention (CBI). One group with CBI only. Evaluated for up to one year after treatment.

23 Patients receiving medical management with naltrexone, behavioral intervention or both fared better on drinking outcomes. No combination produced better efficacy than naltrexone or behavioral intervention alone in the presence of medical management. Placebo pills and meeting with a health care professional had a positive effect above that of behavioral intervention alone during treatment. Medical Management (MD, RN, PA) applied during: Initial 45 min visit, followed by 20 min visits; week 1 and 2 then every 2 to 4 weeks.

24 Basic Elements of Psychotherapy: Expectation of receiving help Therapeutic relationship Obtaining external perspective Encouraging corrective experiences Opportunity to test reality All available in the medical encounter.

25 Reward: ability to give people what they want or need Coercive: disapproval, denying requests, not seeing Referent: the admired other, role-model Legitimate: validated authority Expert: access to knowledge, training, information All are inherent in the medical encounter.

26 the efficacy of psychotherapeutic methods lies in the shared belief of the participants that these methods will work. JD Frank That is If you believe that what you re doing when you talk to your patients is helpful it is more likely that it will be.

27 Your patients already expect it of you And they are already responding to you as if you are doing it. So, for better or worse, you are already in a therapist role. The only real question is how can you do better at what you re already doing!

28 Applying and adapting core elements of CBT and DBT Incorporating a Motivational Interviewing (MI) style in the clinical encounter Supporting the patient s self-efficacy through attention to language and behavioral reinforcement

29 1. Recognize: triggers-cues: external-internal 2. Anticipate/Avoid: high risk situations-people-places 3. Cope: skills for relaxing-dealing with stress-dysphoria 4. Connect: options for support-socializing-fun-meaning

30 External: Internal: People/Places/Things Playmates/Playgrounds/Playthings HALT: Hungry-Angry-Lonely-Tired I slipped again I don t know what happened I just started craving I don t know why Play the tape back: Where were you, who were you with, how did you feel how is that like other slips?

31 I get paid and cash in hand is a huge trigger to go buy some dope (Plan ahead direct deposit, etc) I just ended up at this party...and when it s in front of me I can t say no (Play the tape back: When did you still have control?) If an old using buddy calls and wants to hang out, what s the harm? (Play the tape to the end: What s likely to happen?) It is easier to avoid temptation, than to resist temptation.

32 Re-expand dormant options to socialize and have fun: Really, everybody uses? Any old, non-using old friends to contact? What did you use to do to have fun? Re-connect with sources of reward: hedonic tone : What do you want out of life? What were your goals before you got into drugs? What else gives you a charge or a buzz?

33 Attention to basics: Sleep-diet-exercise-having fun Skills to relax/deal with stress: What s a different option next time you re upset? Who can you call who can you talk to? Mindfulness: Simple exercises to be in the moment To turn off the wheels To put space between feeling and acting Thoughts are only thoughts you don t have to act on them.

34 Can help to: Enhance intrinsic motivation for change Mobilize person s own resources Resolve ambivalence and reach a decision Build commitment to change

35 Express Empathy Focus on understanding the person s dilemma Roll with Resistance Don t be the one arguing for change Develop Discrepancy Evoke the person s own arguments for change Support Self Efficacy: Change is Possible

36 Listen to the language of the patient s story: Listen for generalizations/deletions/distortions: I always screw up. I can t stop using. I m just an addict. My life is a mess...

37 Challenging learned helplessness : Really you always screw up what s something you did right? Reinforcing the power of yet you haven t stopped yet you haven t re-earned peoples trust yet your life isn t where you want it to be yet.

38 You slipped with cocaine but you haven t used dope in 3 months. You thought about using every day but you only used once what worked on those other days How about instead of just an addict, try thinking of yourself as a person with an addiction who s working hard to get better? You may have to accept that you re not a total screw-up after all. Find some positive behavior to reinforce every visit!.

39 If that sounds like first grade it is kind of. If you feel like you re repeating yourself that s ok. If you feel like a coach or a parent that s ok too.

40 Directing Guiding Following when your goal is behavior change, the optimal style is usually guiding. William R Miller

41 Reduces resistance Improves working alliance Enhances openness to consider change Increases self-regulation and internalization of change More like dancing than wrestling. William R Miller

42 Phase 1: Building Motivation for Change Phase 2: Strengthening Commitment to Change Reinforcing positive changes Listening to language can also help assess the patient s ambivalence or commitment to needed change

43 Change talk is speech linked to a particular behavior change. Three types: Sustaining talk Preparatory talk Implementing talk

44 Supporting ambivalence or resistance toward change: I really like getting high I couldn t give up I need to use to be social I don t think I need to stop I can use once in a while I m just too busy to get to any meetings

45 Implies continuing ambivalence but contemplation: DESIRE: I want to would like to wish I could... ABILITY: Maybe I can maybe I could... REASONS: If I stopped.. then... NEED: I need to have to I should I really should try to find time to make it to a meeting

46 Reflects resolution of ambivalence and decision: COMMITMENT (intention, decision, readiness) ACTIVATION (willing, trying, preparing) SPECIFIC (steps, actions) I have decided to I am ready to I will I will go to at least 2 meetings before my next appointment.

47 Do you will you

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61 alcoholics recover not because we treat them but because they heal themselves. George Vaillant, MD The Natural History of Alcoholism, 1983

62 Motivational Interviewing by William Miller Medication Management Techniques and Collaborative Care: Integrating Behavioral with Pharmacologic Interventions in Addiction Treatment: ASAM Principles of Addiction Medicine, Fifth Edition: Chapter 67: Rosenthal, Ries, Zweben CSAT TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment The 15 Minute Hour by Stuart and Lieberman Treating Alcohol Dependence: A Coping Skills Training Guide by Monti, et al. Medication Management Manual: Project COMBINE 12-Step Facilitation Manual: Project Match