Retooling! Treatment Practices! For Long Term Wellness

Transcription

1 Retooling! Treatment Practices! For Long Term Wellness Stephen J. Gumbley, MA, CAADC 1"

2 The present system of care" is strained." 2

3 TRIAGE The SUD care system does not effectively or efficiently use its resources for wellness. It says, Everyone needs treatment. Programs expect recoverees to fit the program rather than the program fitting the recoveree.

4 RESOURCES The SUD care system does not identify, develop and use all the resources at the recoveree s disposal. Assessments focus on pathology. Recovery/social capital is not assessed.

5 WELLNESS CHANGE DYNAMICS The SUD care system ignores the evidence of self correction. Many studies including broad Federal epidemiologic studies demonstrate that the most common pathway to recovery is self correction.

6 MEASURING SUCCESS The SUD care system does not demonstrate achievable, broadly-acknowledged, meaningful metrics for personal recovery or population health. An"effec(ve"system"of"care"must"be"able"to" demonstrate"(to"the"pa(ent,"payer"and"community)" that"improvement"has"been"gained"and"maintained"in" the"pa(ent s"ability"to"func(on." Although"it"has"become"more"evident"that"abs(nence" alone"is"no"longer"a"viable"marker"of"success," addi(onal"metrics"of"change"are"not"widely"iden(fied" and"used.""

7 What"message"are"we"conveying?" 7

8 SelfEEfficacy" Whether you think you can, or whether you think you can t, you re probably right. Henry"Ford" 8

9 CHRONIC (Once an addict, always an addict!) 9

10 SUDs are similar to other chronic disorders SUDs are similar to other chronic disorders such as arthritis, hypertension, asthma, and diabetes. Treatments for SUDs should be regarded as being long term, and a "cure" is unlikely from a single course of treatment. Other chronic illnesses that are generally accepted as requiring life-long treatment include adultonset diabetes, hypertension, and asthma. 10

11 Comparison to Other Chronic Disorders Like substance-use disorders, the onset of these three diseases is determined by multiple factors, and the contributions of each factor are not yet fully specified. Parenting practices, stress in the home environment, and other environmental factors are also important in determining whether these diseases actually get expressed, even among individuals who are genetically predisposed. Behavioral choices seem to be implicated in the initiation of each of them. Behavioral control continues to be a factor in determining their course and severity. 11

12 Treatment of Chronic Disorders 40%-60% of discharged AOD patients continuously abstinent at 1 year <60% adult patients with type 1 diabetes fully adhere to medication schedule <40% of patients with hypertension or asthma fully adhere to their medication regimens <30% of patients with adult-onset asthma, hypertension or diabetes adhere to prescribed diet and/or behavioral change McLellan et al. (2000) 12

13 PROGRESSIVE (Inevitably!!) 13

14 A" progressive "disorder" BOTTOM!& 14

15 15

16 Considerable evidence has accumulated showing that alcohol problems are not progressive. That is, they do not necessarily worsen if people do not stop drinking and do not get treated. 16

17 The traditional view had been that individuals with low-severity alcohol problems were in the early stages of an irreversible progression from mild to severe alcoholism. In practice, this view had led to the use of intensive (e.g., 28-day inpatient) treatment for everyone with an alcohol problem, whether mild or severe. 17

18 " " PROGRESSIVE Aging"out "contradicts"the"concept"of" inevitability." 18

19 RELAPSING (Of course.) 19

20 Success&rates&for&the&treatment&of&various&SUDs" Disorder (DSM-IV) Success rate (%)* Alcoholism 50 (40-70) Opioid dependence 60 (50-80) Cocaine dependence 55 (50-60) Nicotine dependence 30 (20-40) *Follow-up 6 mo. Data are median (range). 20

21 21

22 Compliance&and&relapse&in&selected&medical&disorders& & Insulin&Dependent&Diabetes&Mellitus& "Medica(on"regimen" " " " "<50%"" "Diet"and"foot"care"" " " " "<30%"" "Relapse"[a]" " " " " " "30E50%"" " Hypertension&[b]"" "Medica(on"regimen" " " " "<30%"" "Diet"" " " " " " " "<30%"" "Relapse"[a]" " " " " " "50E60%"" " Asthma&& "Medica(on"regimen" " " " "<30%"" "Relapse"[a]" " " " " " "60E80%"" " " a"retreatment"within"12"mo"by"physician"emergency"room"or"hospital." b"requiring"medica(on"" 22

23 Treatment conformity for chronic disorders " As with the treatment of SUDs, treatments for hypertension, diabetes, and asthma heavily depend on behavioral change and medication regimen to achieve their potential effectiveness. Lack of conformity with treatment regimen is a major contributor to reoccurrence and to the development of more serious and more expensive "disease-related" conditions, e.g., limb amputations and blindness are all too common consequences of treatment non-response among diabetic patients. Stroke and cardiac disease are often associated with exacerbation of hypertension. 23

24 Making an effort I#only#lost#one#pound#before#I#quit#my#diet.# But#if#I#can#do#that#50#times,#I ll#lose#50#pounds! # 24

25 POTENTIALLY FATAL 25

26 THE SPECTRUM OF ALCOHOL USE Continuum of care for excessive drinking and alcohol use disorders. (Percentages represent the approximate proportion of the U.S. population age 18 and older in each category in any given year.) [Mark Willenbring, MD]

27 Incidence"and"Prevalence" Incidence Current SUD prevalence rate is about 8.2% of the population 27

28 Substance Dependence or Abuse in the Past Year among Persons Aged 12 or Older:

29 Incidence"and"Prevalence" US"popula(on"growth" approximately"2,215,500/ yr" " 8.2%"="181,671" " " Incidence"="181,671/year"input" 8.2% ="181,671/year"outgo" 29

30 " 18% 25% Dependent Partial remission 18% Asymptomic risk drinkers 12% 27% 25.5% ever received treatment Low risk Abstainers Prior-to-past-year (PPY) Dawson et al (2005) 30

31 SUD"status"is"fluid" Michael"Dennis" 31

32 A" Typical "Course"of"Recovery" [A] typical course of recovery might consist of continued drinking, accompanied by symptoms of alcohol use disorders, that would persist for 5 10 years before resolving into asymptomatic risk drinking and, ultimately, into either low-risk drinking or abstinence. 32

33 Most persons who develop alcohol dependence have mild to moderate disorder. They primarily experience impaired control." Na(onal"Epidemologic"Survey"on"Alcohol"and"Related"Condi(ons"2001E2002" 33

34 34

35 Many"heavy"drinkers"do&not&have"alcohol"dependence."" " Na(onal"Epidemiologic"Survey"on"Alcohol"and"Related"Condi(ons" 2001E2002"

36 About 70% of affected persons have of less than 4 years. " The remainder experience an average of 5 episodes. Na(onal"Epidemologic"Survey"on"Alcohol"and"Related"Condi(ons"2001E2002" 36

37 Alcohol"dependence"and"full"recovery" 20 years after onset of alcohol dependence, About 3/4 of individuals are in full recovery more than ½ of those who have fully recovered drink at low-risk levels without symptoms of alcohol dependence. 37

38 HighEfunc(oning"alcoholic " 38

39 Conclusions CLINICALLY: We treat SUDs as monolithic disorders with little regard to the individual level of severity and level of functioning We use a moral rather than science base to describe and interact with persons with SUDs We don t identify and develop indigenous client resources SYSTEMICALLY: We do not use available science about typologies to help design effective responses We identify all persons with SUDs as needing treatment, creating an enormous, unrealistic and unnecessary service burden 39

40 Self Correction: The Most Common Pathway 40

41 SELF CORRECTION NO"TREATMENT" NO"MUTUAL"AID Na$onal!Epidemologic!Survey!on!Alcohol!and! Related!Concerns!2001>2002! 41

42 Self"Correc(on"Sta(s(cs" 80%" 77%" 42

43 The"dynamics"of"this"" selfecorrec(on"process" " Mostly"those"with"less"severe"diagnosis,"less" complicated"situa(ons" Ac(ve"cogni(ve"appraisal" Access"to"and"use"of"recovery"capital" 43

44 Less Severe 44

45 Cognitive Appraisal Self-change is strongly associated with the ability to reflect on the costs and benefits of continued use. 45

46 Smaller trigger for correction 46

47 Self-correction recovery patterns APPROACH-ORIENTED CUMULATIVE CONSEQUENCES (Avoidance-oriented) MATURING OUT 47

48 Geographic"Cures" 48

49 More social capital 49

50 Solo Alone

51 RECOVERY CAPITAL Availability Accessibility " " " " "

52 Knowing how to use recovery capital is important 52

53 Based on the dynamics of the most common pathway to recovery, the purpose of specialized treatment is to enhance a person s capacity for self correction. 53

54 The"goals"of"specialty"treatment" Reduce risks/vulnerabilities Increase recovery capital/ resilience 54

55 SPECIALTY TREATMENT STRATEGIES Decrease complications /Increase stabilization (care manager) Enhance cognitive appraisal (counselor) Develop and use resources (peer support)

56 Lessen complicated situations: STABILIZE Reduce complications and barriers Be able to make a resolution to change

57 Cognitive Appraisal: ENHANCE MOTIVATION FOR CHANGE Increase"selfEefficacy"" Expand"understanding"of"problems"and" solu(ons" Ar(culate"commitment"to"change"

58 Access to and use of recovery capital: BUILD CAPITAL Develop assets Practice

59 Specialty"treatment" 59

60 THE SPECTRUM OF ALCOHOL USE SPECIALISTS Continuum of care for excessive drinking and alcohol use disorders. (Percentages represent the approximate proportion of the U.S. population age 18 and older in each category in any given year.) [Mark Willenbring, MD]

61 What is SPECIALTY treatment? 61

62 THE SPECTRUM OF ALCOHOL USE NON-SPECIALISTS Continuum of care for excessive drinking and alcohol use disorders. (Percentages represent the approximate proportion of the U.S. population age 18 and older in each category in any given year.) [Mark Willenbring, MD]

63 NonEspecialty"Interven(ons" 63

64 Mutual aid is not treatment 64

65 Some people need some treatment some of the time in order to achieve recovery 65

66 Who needs What treatment for substance use disorders 66"

67 NEED FOR TREATMENT = SEVERITY People who enter treatment are a distinct subgroup of substance users whose problems are particularly severe and intractable. Dennis & Scott " For most people, SUD treatment alone does not provide the breadth and depth of support to sustain change.

68 In"2012,"2.5"million"people"received"" specialty"addic(on"treatment" Diagnosis"of" 'moderate'"and" 'severe'" 50%" No"diagnosis" 36%" Diagnosis"of" 'mild'" 14%" (SAMHSA,"2013)" 68

69 Percent"of"US"popula(on"with"a" substance"use"disorder"2013" Mild" Moderate" Severe" None"" Johnson,"K.A."(2014)" 69

70 Percentage"of"severity"category"of" persons"diagnosed"with"sud"2013" 19.5" 20.7" 59.7" Mild" Moderate" Severe" Johnson,"K.A."(2014)" 70

71 What"characteris(cs"do"the"25E30%"have?"! Loss"or"absence"of"selfEmo(va(on" (resilience)"! Lack"of"having"or"knowing"resources"! "Overwhelmed"by"circumstances" Personal vulnerability Problem severity and intensity AOD-related consequences William"White" Trauma Co-morbid conditions Significant personal problems

72 The"spectrum"of"alcohol"use"

73 The"right& treatment" 73

74 Bill"White"on" choice " And yet long-term recovery is not possible without choice. If there is no rehabilitation of the power to choose and encouragement of choice, we are left with, not sustainable recovery, but superficial treatment compliance. 74

75 Making Choices In Self Correcting Where is my recovery starting? (Level of functioning) Where do I want it to end up? (Level of functioning? How much recovery is enough?) Steve Gumbley Consulting 75 & Training!!!!!

76 Recovery-focused assessment Identifying What s right? not What s wrong? Recovery&& Capital& 76

77 Current assessment: dark side of the moon 77

78 A"complete"assessments"need"to"include" Problem"severity/level"of"func(oning" Typology" What"needs"to"be"stabilized?" What"is"the"level"of"moDvaDon&to&change" and"its"difficul(es?" What"resources"are"available"and" accessible;"what"resources"are"not"available" and"accessible?" 78

79 Assessment"1" Motivation 79

80 Assessment"2" Motivation 80

81 Assessment"3" Motivation 81

82 Identify level of functioning 82

83 Agree on goals based on level of functioning 83

84 Lessen complicated situations: STABILIZE Reduce complications and barriers Be able to make a resolution to change

85 Stabiliza(on" Substance Use Disorder Mental Health Disorder Basic needs 85

86 Basic Needs 86

87 PHARMACOLOGIC THERAPIES 87

88 Moderation-based Abstinence-based Medication(s) Medication(s) 88

89 Medications that support recovery create a level playing field 89

90 Cognitive Appraisal: ENHANCE MOTIVATION FOR CHANGE Increase"selfEefficacy"" Expand"understanding"of"problems"and" solu(ons" Ar(culate"commitment"to"change"

91 Change Process 91

92 Access to and use of recovery capital: BUILD CAPITAL Develop assets Practice

93 Recovery"must"be"portable" 93

94 Scanning my environment What s around me? What are my resources? 94

95 Outside support Family/friends Professional Mutual aid Knowledge Recovery practices Recovery resources Skills Relaxation Refusal Internal resources Self-change Self-efficacy Some"essen(als " 95