Substance Abuse. Heather Gotham, PhD, Licensed Clinical Psychologist September 9, TB Nurse Case Management September 7-9, 2016 San Antonio, TX

Transcription

1 Substance Abuse Heather Gotham, PhD, Licensed Clinical Psychologist September 9, 2016 TB Nurse Case Management September 7-9, 2016 San Antonio, TX EXCELLENCE EXPERTISE INNOVATION Heather Gotham, PhD, Licensed Clinical Psychologist, has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1

2 Prevalence: TB and Substance Use : 18.7% of TB patients in the US reported excessive substance use Patients who use substances are more contagious, more TB treatment failures Oeltmann et al., 2009, Arch Intern Med Main Points 1. Recognizing substance use what s the level of risk? 2. Screening, Brief intervention and Referral to Treatment (SBIRT) a) Quickly determine substance use risk b) Provide a method to intervene with patients c) Use a warm handoff to more effectively refer patients to treatment 3. Resources 2

3 1. RECOGNIZING SUBSTANCE USE WHAT S THE LEVEL OF RISK? Substance Use Along the Continuum Non-Use/ Low-Risk Use Positive Health Message Risky/Harmful Use Brief Intervention to Reduce Use Substance Use Disorder/Addiction Referral to Specialty Addiction Treatment 3

4 What is risky or harmful use? What does this mean? Non-Use/ Low-Risk Use Risky/Harmful Use Substance Use Disorder/Addiction What is ONE drink? 4

5 What is ONE drink? A drink is: One 12-ounce can/bottle of beer One 5-ounce glass of wine One shot of hard liquor (1 ½ oz) Low-Risk Drinking Guidelines National Institutes of Health *Women who are pregnant or may become pregnant should not drink alcohol. 5

6 Risky Drug Use Any use of a recreational drug Recreational drugs include methamphetamines (speed, crystal), cannabis (marijuana, pot), inhalants (paint thinner, aerosol, glue), tranquilizers (Valium), barbiturates, cocaine, ecstasy, hallucinogens (LSD, mushrooms), or narcotics (heroin) Using a prescription medication for nonmedical reasons What is a Substance Use Disorder? What does this mean? Non-Use/ Low-Risk Use Risky/Harmful Use Substance Use Disorder/Addiction 6

7 Pathological pattern of behaviors related to use of the substance DSM-5: Substance Use Disorder MILD 2 3 Symptoms MODERATE 4 5 Symptoms SEVERE 6+ Symptoms Can be applied to 10 classes of substances DSM-5: Symptoms of a Substance Use Disorder Impaired Control Take in larger amounts or over longer period than intended Repeatedly trying without success to decrease or discontinue substance use Spending much time obtaining, using, and recovering from substance Craving intense desire/urge for substance Social Impairment Failure to fulfill major obligations because of repeated substance use Continued use of substance despite persistent social and interpersonal problems caused or exacerbated by use Giving up important social, occupational, or recreational activities because of substance use Risky Use Recurrent use when it is physically hazardous Recurrent use despite knowing that it has probably caused ongoing physical or psychological problems Pharmacological Tolerance - need increased amount to achieve same effect Withdrawal experience withdrawal symptoms or continue using to keep from having withdrawal 7

8 Substance Use Disorders/Addiction Addiction is a chronic, relapsing disease characterized by compulsive drugseeking and use and by long-lasting chemical changes in the brain. NIDA, SCREENING, BRIEF INTERVENTION AND REFERRAL TO TREATMENT (SBIRT) 8

9 SBIRT: Evidence-based process to identify and intervene in patients substance use creening Standardized tools to quickly assess risk level Pre-screen - universal Full Screen - targeted rief ntervention Help patients understand their substance use and health impact; motivate behavior change eferral to reatment Help patients showing signs of a substance use disorder to access specialty care NWATTC SBIRT Slides, 2014 SBIRT: Screening creening Standardized tools to quickly assess risk level Pre-screen - universal Full Screen - targeted rief ntervention Help patients understand their substance use and health impact; motivate behavior change. eferral to reatment Help patients showing signs of a substance use disorder to access specialty care. 9

10 Two Levels of Screening Screening Pre-screen (universal = everyone) Full screen (patients who score positive on pre-screen) Pre-Screening: Two Questions Alcohol - NIAAA Drugs - NIDA National Institute on Alcohol Abuse and Alcoholism National Institute on Drug Use 10

11 Full Screening Tools AUDIT: Alcohol Use Disorder Identification Test DAST: Drug Abuse Screening Test ASSIST: Alcohol, Smoking, and Substance Abuse Involvement Screening Test GAINor GAIN-SS: Global Appraisal of Individual Needs CRAFFT: Car, Relax, Alone, Forget, Family or Friends, Trouble (adolescents) CAGE AUDIT and DAST 2-4 minutes to administer

12 Use AUDIT/DAST to Assess Risk & Plan Intervention ZONE OF USE: I: LOW RISK II: RISKY III: HARMFUL IV: SEVERE AUDIT Score: DAST Score: Explanation of Zone: Intervention: At low risk for health or social complications. Positive Health Message May develop health problems or existing problems may worsen. Brief Intervention to Reduce Use Has experienced negative effects from substance use. Brief Intervention to Reduce or Abstain Could benefit from more assessment and assistance. Brief Intervention to Accept Referral to Treatment Brief Intervention rief ntervention Help patients understand their substance use/possible health impact, motivate behavior change eferral to reatment 12

13 What is a Brief Intervention? A brief (as short as 5-15 minute) motivational interviewing based discussion Aim 1: Enhance a patient s motivation to change risky/harmful substance use Aim 2: Motivate patients with more severe risk to seek assessment/treatment Different Communication Styles Are Used for Different Purposes in Healthcare Directing Following Guiding Rollnick, Miller, & Butler,

14 Brief Intervention Uses a Guiding Communication Style, Based on Motivational Interviewing Directive Communication Explain why Tell how Emphasize importance Persuading Clinician is the expert Guiding Communication Respect for autonomy, goals, values Readiness to change Ambivalence Empathy, non-judgment, respect Patient is the expert A Guiding Communication takes some of the burden off of you, your patient is the expert because it s really his/her behavior that you re discussing. Oregon SBIRT Primary Care Curriculum Module II Motivational Interviewing Ambivalence Change Talk Sustain Talk Client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. Miller & Rollnick,

15 Motivational Interviewing/Motivational Enhancement Therapy Accept client s current motivation for change as starting point Enhance motivation by exploring and resolving ambivalence Engaging, focusing, evoking, planning Is especially important if a patient is ambivalent about changing substance use, or is in a pre-contemplation or contemplation stage of change about substance use Should be initial method used to explore substance use with any patient Accurate empathy is a major predictor of patient change, MI is an excellent method to engage a patient and show empathy Brief Intervention Motivational Interviewing-based, goal-directed conversation to enhance a patient s motivation to change Recognizes a patient s conflicting feelings about behavior change Raise the subject Provide feedback Enhance motivation Negotiate plan The Yale Brief Negotiated Interview Manual, D Onofrio et al.,

16 SBIRT Learning Tool Brief Intervention Steps Referral to Treatment eferral to reatment Help patients showing signs of a substance use disorder to access specialty care 16

17 Substance use disorders are treatable and recovery is possible. There are Many Paths to Recovery Specialty addiction treatment Psychosocial interventions Medication assisted treatment Support from families, friends, or schools Faith-based approaches Peer support Others 17

18 Kinds of Specialty Treatment: Psychosocial Interventions Counseling individual and/or group and other behavioral therapies are the most commonly used forms of addiction treatment Research has shown a number of approaches to have strong effectiveness and efficacy Motivational Interviewing Cognitive-behavioral Therapy Medication-Assisted Treatment When combined with counseling and other psychosocial therapies, medications are an important element of treatment for many patients Medications are used to: Treat withdrawal Stay in treatment Prevent relapse Opioid use disorders: methadone, buprenorphine, naltrexone Alcohol use disorders: naltrexone, acamprosate, disulfiram Resources BH Meds - app and booklet, Opiate Addiction: Understanding Replacement Therapy from HBO Addiction film: diction.html 18

19 Specialty Addiction Treatment - Modalities/Levels of Care Detoxification 2-3 days Medically-managed Social detox Residential Long-term: 6-12 months Short-term: 2 weeks 3 months Outpatient Intensive outpatient: 8-20 hrs/week Outpatient: 1-8 hrs/week Continuing Care Outpatient: 1-3 hrs/week Telephone monitoring Peer Support Peer-Support Groups Some people enter recovery solely through peer-support groups, but most need to begin with formal treatment Peer-support groups are a very effective component of recovery Increase abstinence, help to deal with relapse, provide social support There are multiple kinds of peer-support groups Alcoholics Anonymous (Narcotics, Cocaine, etc.) SMART Recovery Co-occurring mental health disorders (Dual Recovery Anonymous, Double Trouble in Recovery) 19

20 Relapse -Nota sign that treatment didn t work A defining feature of substance use disorders is the HIGH PROBABILITY OF RELAPSE Relapse rates for addiction are the same as other chronic, relapsing illnesses 40-60% McLellan et al., JAMA 2000 A Strong Referral to an Appropriate Treatment Provider Is Key 3 strategies to make a strong referral 20

21 1. Use the Brief Intervention to Prepare the Patient Patients often feel ambivalent about seeking addiction treatment. During the brief intervention, use motivational techniques to build the patient s confidence and willingness to go to a specialty provider before making the referral. 2. Plan for the Nuts and Bolts Who do you call? Maintain an up-to-date roster of public and private treatment and peer support resources in your community Make contact with the agencies beforehand, so you know their process What form do you fill out? Who on your team can help you set up an appointment? 21

22 Who do you call? SAMHSA s Behavioral Health Locator or HELP (4357) / (TDD) Facility Operation (e.g. Private, Public) Age groups, gender, language services Payment/Insurance Accepted Type of Care: mental health, substance abuse, health care centers Service Setting (e.g., Outpatient, Residential, etc.): Payment Assistance Available: Your state Department of Behavioral Health 3. Use a Warm Handoff A warm handoff is directlyintroducing the patient to the specialty addiction treatment provider or a behavioral health specialist during the visit. Introduce the patient to an addiction treatment provider or behavioral health specialist on staff at the end of their appointment Assist the patient to make an appointment; help them make the call Call or help the patient call the insurance company or local authority who oversees access 22

23 Pointers for Conducting a Referral to Treatment BI Goal: Enhance the patient s motivation to accept a referral to specialty addiction treatment for an initial appointment and assessment You can tailor each step of a regular brief intervention for use in referral to treatment lbum/ /vide o/ RESOURCES 23

24 If you want to try this at home Get training Online training on SBIRT Online or in-person training on Motivational Interviewing Practice the brief intervention ahead of time Gather your resources Patient education materials on substance use Provider information on treatment and referrals Plan for implementation SBIRT for Health and Behavioral Health Professionals: How to Talk to Patients about Substance Use or sbirt.care 4-hour, self-paced, FREE CNE, NASW, CHES, NAADAC, NBCC units Clinician tools, patient education materials, role plays 24

25 Videos posted at: Heather J. Gotham, PhD UMKC SBIRT Project Director Mid-America ATTC Associate Research Professor (816) University of Missouri-Kansas City School of Nursing and Health Studies 2464 Charlotte St, HSB Kansas City, MO