Understanding the Journey into and out of Addiction Carlo C. DiClemente, Ph.D. University of Maryland Baltimore County Center for Community Collaboration (http://communitycollaboration.umbc.edu/) (www.umbc.edu/psyc/habits)
Shake Your Family Tree Most families can identify family members with a substance use or gambling disorder On a piece of paper write first names of extended family members who have of have had one (make sure you include alcohol, marijuana, nicotine, etc.) Most of us know addiction personally We need to keep in mind that we are talking about loved ones not Addicts Homeless Drug Abusers Substance Abusers
What are Addictions? Habitual patterns of intentional, appetitive behaviors Become excessive, problematic and produce serious consequences Stability of these problematic behavior patterns over time Interrelated physiological, psychological and social components Addicted individuals have difficulty modifying and stopping these patterns of behavior (smoking, alcohol, marijuana, heroin or process addictions like gambling, sex, etc.) Definition of a DMS 5 Severe Use Disorder
Addiction and Change Both acquisition of and recovery from an addiction require a personal journey Through an intentional change process marked by personal decisions and choices Each journey is influenced at various points by many biological, psychological, and social factors Defining Addiction Severity should describe the problematic nature of the pattern of involvement with the addictive behavior
As individuals move through stages of initiation they move from thinking about doing it, to experimenting, to developing a pattern of behavior (social drinker, binge drinker, daily drinker, non drinker) that becomes habitual or consistent over time. Many patterns are normative and socially acceptable, do not create problems or get judged excessive Addiction, however, is best represented as a well maintained, problematic pattern of engagement best equated with a severe use disorder or dependence Once an individual has created such a maintained, rather stable pattern of this nature, interventions move from prevention of initiation to recovery from addiction Addiction and Stages
Stage of Change Labels and Tasks Precontemplation Not interested Contemplation Considering Preparation Preparing Action Initial change Maintenance Sustained change Interested, concerned and willing to consider Risk-reward analysis and decision making Commitment and creating a plan that is effective/acceptable Implementing plan and revising as needed Consolidating change into lifestyle DiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. NY: Guilford Press; 2003. DiClemente. J Addictions Nursing. 2005;16:5.
* THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY ADDICTION Dependence PC C PA A M PROCESSES, CONTEXT AND MARKERS OF CHANGE PC C PA A M Dependence RECOVERY Sustained Change
Many of us have moved through stages of initiation to achieve a regular pattern of consuming alcohol, smoking, gambling Critical to be able to distinguish among engagement patterns: Use, Misuse, Abuse, Dependence, or DSM 5 - Mild, Moderate, Severe Use Disorders Trajectories of engagement can change over time (social use or medical use to misuse to dependence) and depend on developmental and contextual factors and influences (e.g., time limited heavy binge drinking pattern in college; money spent gambling) Motivation focuses on how individuals move into and out of these different patterns of behavior; Addiction focuses on the end state: a well maintained pattern of behavior Stages of Change are Pattern Neutral
Patient Safety and Addiction Obviously the safest way to avoid Addiction and its consequences is to never engage in an addictive behavior Second best is to interfere with initiation so never becomes moderate or severe use disorder Third if addicted, get them to stop the behavior Fourth, keep them safe from harm until we can get them to make a more significant behavior change
Understanding the Challenges Why do we need options: Addictions are chronic conditions that involve multiple risk and protective factors that we can influence but not always control Addicted individuals are often trapped in a vicious cycle where biology, behavior and social influences create a pattern that is hard to break
Mechanisms of Addiction Severity There seem to be a small set of mechanisms that characterize the end state of addiction that could be used to indicate severity and help understand the Opioid Crisis My candidates are the following: Neurobiological Adaptation brain and biological adaptations to frequent exposure to addictive behavior/substance (a brain disease) Reduced/Impaired Self-Regulation The sense of loss of control and compromised self-regulation despite consequences that are the hallmark of addictions (a behavioral control disease) Salience and Narrowing of Behavioral Repertoire The addictive behavior becoming so valued a reinforcer that the behavior becomes more ubiquitous and potent in the life of the individual
Anna Rose Childress UPENN In a vulnerable brain...the brain s frontal (STOP!) circuitry is not modulating downstream (GO!) systems the brain brakes may be bad or the connection between the brakes and the other regions may be broken. Result: poor decision-making poor impulse control greater risk-taking poor inhibition an over-reacting brain
Neurobiological Adaptation Ability to use more/tolerance Emotional/stress regulation tied to use State dependent learning Compulsive use Altered thresholds of stress & pleasure Increased strength and scope of cues Negative emotional states when use is blocked Possible withdrawal & other rebound effects FMRI indicators Mild Severe
Stages of the Addiction Cycle: Associations with Neurocircuits & Addictions Neurochemical Assessment Binge- Intoxication mpfc (AC) Insula DS VS VS GP Thal Hippo VTA VTA Delay Discounting Incentive Salience Cue Reactivity Task OFC Executive Function Negative Emotionality Preoccupation- Anticipation Withdrawal- Negative affect Facial Emotion Matching Task Adapted from George Koob. Curr Top Behav Neurosci. 2011 Jul 10. Modified from: Kwako LE et al. (2015)
Reduced Self-Regulation Use becomes more automatic Difficulty controlling or cutting back Using to cope and self-regulate Continued use despite consequences Impulsivity increases Upset if use is interfered with Underestimating consequences Both ECF and Affect Regulation effects Mild Severe
Increased Salience and Narrowing of Behavioral Repertoire More highly valued & meaningful; Alcohol/Drug Expectancies Integrated into lifestyle (related to life domains) Meets more basic needs Difficult to imagine life without it Feel conflicted when incongruent with other values Decreases in other important activities More time using; arranging for use Social interactions and networks narrowed to similar users Mild Severe
Opioid Crisis: the Search for Long Term Solutions Many overdoses are among individuals with severe use disorders. Brains compromised by neuroadaptation Severely impaired self-regulation Lives completely dominated by addiction Recovery not simply Resuscitation Medication and Motivation Intensity not simply brief Interventions Short and Long Term Perspectives Solution not simply Crisis Resolution
In a large study researchers at National Cancer Institute in the US have discovered that watching television more than 1 to 2 hours a week causes brain cancer. How many of you would stop watching TV immediately? Breaking News
How Do People Change? People change voluntarily only when They become interested and concerned about the need for change They become convinced the change is in their best interest or will benefit them more than cost them They organize a plan of action that they are committed to implementing They take the actions necessary to make the change and sustain the change
Clear Difference Between Pre Action and Action Stages The Key Link Pre Action Stages Action Stages What do individuals/organizations have to do in Pre Action Stages to be successful in Action Stages? What do they have to do in the Action stages to sustain success?
WHY DON T PEOPLE CHANGE? NOT CONVINCED OF THE PROBLEM OR THE NEED FOR CHANGE UNMOTIVATED NOT COMMITTED TO MAKING A CHANGE UNWILLING DO NOT BELIEVE THAT THEY CAN MAKE A CHANGE - UNABLE
Theoretical and Practical Considerations Related to Movement Through the Stages of Change Motivation Decision Making Self-efficacy Precontemplation Contemplation Preparation Action Maintenance Personal Concerns Environmental Pressure Decisional Balance Cognitive Experiential Processes Behavioral Processes Recycling Relapse What would help or hinder completion of the tasks of each of the stages and deplete the self-control strength needed to engage in the processes of change needed to complete the tasks?
Regression, Relapse and Recycling through the Stages Regression represents movement backward through the stages Slips are brief returns to the prior behavior that represent a some problems in the action plan Relapse is a return or re-engaging to a significant degree in the previous behavior after some initial change After returning to the prior behavior, individuals most often Recycle back into pre-action stages
Relapse is Not a Substance Abuse Problem Relapse is probable with any health behavior change Often at same rates as addictive behaviors A problem of starting and sustaining behavior change A problem of adequately completing the critical tasks of the stages of change
Stages of Change Model Precontemplation Increase awareness of need to change Contemplation Motivate and increase confidence in ability to change Relapse Assist in Coping Preparation Negotiate a plan Maintenance Encourage active problem-solving Action Reaffirm commitment and follow-up Termination
Cyclical Model for Intervention Most addicted individuals will recycle through multiple quit attempts and multiple interventions To accomplish each stage task well enough to support recovery However successful recovery occurs for a large number of addicted individuals over time (if they live long enough) Keys to successful recycling Persistent efforts Repeated attempts Helping individuals take the next step Enhance motivation and support self-efficacy Support for impaired self-regulation (scaffolding) Match strategy to stage of change
Recovery represents a series of tasks that are critical to moving through the stages to sustained change Motivation is behavior and goal specific so pattern of use and severity are critical to goal setting Severity impairs self-regulation and self-control which are critical to coping needed to manage addictive behavior and reduce use Severity interacts with ambivalence, decision making, commitment, support, planning, and implementation of action plan as well as relapse and recycling How does Severity interact with Motivation
Motivation Challenges Intrinsic and Extrinsic Motives External forces (stop not necessarily change) Internal values and reasons Incentives Imposed versus Intentional (Chosen) Change Motivated to do What? Take medications Enter treatment Abstinence Harm Reduction Continue doing what I am doing
Helping Change Happen Focus on where person is in stages For what change (cutting down, sharing needles, getting methadone, quitting opiates) Readiness ruler ( On a scale of 1 to 10) Create conversations about change (when sober or least impaired) Help person with current stage tasks Focus on important personal values and possibility of change Offer support to scaffold severity mechanisms (impaired brain, loss of self-control, loss of pleasure and functional lifestyle
Families and Friends Experience disappointment, burnout, betrayal, and despair about change when facing addiction Often offering help, getting frustrated and angry, threatening, confronting, and supporting Families cannot be motivated for the individual suffering from an addiction BUT Can make a difference with caring concern, setting limits/boundaries, promising only what they are willing to do, doing everything they promise, helping consequences teach, and support for completing tasks of the stages of change and making positive steps toward recovery
Some Solution Focused Suggestions Use a model that focus on patient needs and desires, motivation, and self-regulation Create systems of care not treatment programs Build Integrated Care training capacity not just learning about what other specialists do Create a system of communication among professionals that focuses on client and is used to coordinate interventions and treatment
Harm Reduction Getting the change you can while promoting the change you want. Myths of Harm Reduction Promotes Heroin Use (Promotes concern about HIV; promotes interest and concern for change Interferes with Recovery and Abstinence (opens a door to recovery) We promote harm reduction all the time (prom promise, uber when drinking, screening and brief interventions, pill returns)
The Role of Harm Reduction in Combating the Opioid Epidemic Kip Castner, MPS, Chief Center for HIV/STI Integration and Capacity Infectious Disease Prevention and Health Services Bureau Prevention and Health Promotion Administration
CURRENT LANDSCAPE FOR PWID Public Health: Prevention Law Enforcement: Arrest Incarceration Public Health: Treatment PWID = People Who Inject Drugs 36
MEETING PEOPLE WHERE THEY ARE Stages of Change Pre- Contemplation Contemplation Preparation Action Maintenance OVERDOSE REVERSAL WITH NALOXONE SYRINGE SERVICES PROGRAMS OVERDOSE REVERSAL WITH NALOXONE TREATMENT ENTRY: MAT, DETOX, INTENSIVE OUTPATIENT, MAT, RECOVERY SUPPORTS, AA, NA, OTHER OP GROUPS P E E R S 37
REIMAGINED LANDSCAPE FOR PWID Public Health: Harm Reduction Public Health: Prevention Law Enforcement: Arrest Incarceration Public Health: Treatment 38
HARM REDUCTION Harm Reduction is a public health philosophy operationalized as a set of interventions designed to reduce the harms associated with drug use, such as: Infectious Disease education, testing, and linkage to prevention and care (e.g., HIV PrEP, HCV treatment) Wound care and education on safe injection practices Naloxone, condom use, and syringe distribution Linkage to substance abuse treatment and other needed services 39
SCOTT COUNTY, INDIANA 190 people were diagnosed with HIV in Scott County, Indiana, in 2015 after HIV was introduced into a network of Injection Drug Users (IDU)
THAT That sign was acute Hepatitis C, a virus whose national incidence--driven by injection drug use--has risen sharply in recent years The cluster of cases of HCV pointed to widespread injection drug use
VULNERABILITY INDEX CDC followed up to the Scott County, Indiana outbreak by studying the variables (e.g., overdose deaths, poverty, unemployment) that made the county so vulnerable to an HIV outbreak CDC analyzed and scored all the counties in the U.S. on these variables CDC estimates that 50% of the counties in West Virginia are at highest risk of an HIV outbreak
HCV PREVALENCE & VULNERABILITY Co-infection rate of HCV and HIV in Scott County Indiana, was upwards of 90% Rising overdose deaths and inadequate surveillance infrastructure suggested a silent epidemic of HCV among Persons Who Inject Drugs (PWID) in Maryland Better capture of HCV prevalence can be a predictor of HIV outbreak vulnerability
SYRINGE SERVICES PROGRAMS (SSP) ARE LEGAL As part of his response to the heroin epidemic, Governor Hogan signed SB97 into law on May 10, 2016.
REQUIRED SSP COMPONENTS Collection and safe disposal of used syringes Distribution of sterile injection equipment HIV/HCV education Naloxone education Condom distribution Linkage to needed services, e.g. treatment for substance use disorders
OPTIONAL SSP COMPONENTS HIV, HCV, STI testing Wound care Naloxone training Reproductive health services Substance use disorder treatment planning HIV Pre-Exposure Prophylaxis (PrEP)
SSP SAVE LIVES
SSP SAVE $$ The lifetime cost of treating HIV is approximately $600,000 The cost of curing Hepatitis C (once) ranges from $54,600 to $94,500 The cost of a liver transplant ranges from $100,000 to $575,000 A sterile syringe costs about 10 cents
SSP BRIDGE USERS TO HELP When properly structured, syringe exchange programs provide a unique opportunity for communities to reach out to the active drug injecting population and provide for the referral and retention of individuals in local substance abuse treatment and counseling programs and other important health services. -- Surgeon General s Review of SSP Effectiveness In Seattle, SSP users were 5 times more likely to enter treatment than PWID who didn t use the SSP
PROGRESS Baltimore County approved for implementation in August, has completed hiring, slated to launch Washington County in final draft stage Anne Arundel, Cecil, Frederick, Howard and St. Mary s (Tri-County w/ Charles and Calvert) County Health Departments are developing applications; Family Medical and Counseling Services developing application in Prince George s County First Training Cohort completed
Syringe Service Programs Being Developed Garrett Allegany Washington Frederick Carroll Baltimore Harford Cecil Howard Baltimore City Kent Montgomery Anne Arundel Queen Anne's Prince George's Talbot Caroline The Baltimore City Health Department has operated an SSP since 1994. The Baltimore County Health Department s application to implement SSP was approved this summer. They will go live in 2018. Lighter-shaded jurisdictions are developing their applications to operate SSP. (St. Mary s for Southern) Charles Calvert St. Mary's Dorchester Wicomico Somerset Worcester
MARYLAND / WEST VIRGINIA BORDER
YOU CAN HELP Share these key messages: Maryland is at risk for a new outbreak of HIV due to injection drug use SSP establish trust between users and public health, making it easier for users to seek help when they re ready SSP reduce the costs and harms related to using keeping patients safe 53
CONTACT INFORMATION Kip Castner, Chief Andrew Bell, SSP Coordinator HIV/STI Center for Integration and Capacity Infectious Disease Prevention and Health Services Bureau Maryland Department of Health Kip.Castner@Maryland.gov Andrew.Bell@Maryland.gov