Evidence Based Practices: An Overview Desiree
MacPhail-Crevecoeur, Ph.D. Integrated Substance Abuse Programs
University of California, Los Angeles Slide 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 Slide 3 Part
One: Addiction as a Chronic Brain Disease Slide 4 4 Addiction =
Brain Disease Addiction is a brain disease that is chronic and
relapsing in nature. Slide 5 5 Slide 6 6 How a neuron works Slide 7
7 Slide 8 8 The Reward System Natural rewards Food Water Sex
Nurturing Slide 9 9 How the Reward System Works Slide 10 10 Slide
11 11 Activating the System with Drugs Slide 12 12 The Brain After
Drug Use (1) (Source: McCann et al. (1998). Journal of
Neuroscience, 18, 8417-8422.) Control Methamphetamine Slide 13
Partial Recovery of Brain Dopamine Transporters in Methamphetamine
Abuser After Protracted Abstinence Normal Control METH Abuser (1
month detox) METH Abuser (24 months detox) 0 3 ml/gm Slide 14 14
The Brain After Drug Use (2) DA = Days Abstinent Slide 15 15 Drugs
Change the Brain After repeated drug use, deciding to use drugs is
no longer voluntary because DRUGS CHANGE THE BRAIN! Slide 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. Slide 17 Treatment
Substance Abusing Patient Non- Substance Abusing Patient Acute Care
Treatment Model Slide 18 18 Acute symptoms, Discontinuous treatment
Crisis management Resource: Tom Kirk, Ph.D. Traditional Service
Approach Symptoms Severe Remission Time Slide 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. Slide 20 20 Severe Remission Symptoms A
Recovery-Oriented Approach Resource: Tom Kirk, Ph.D Continuous
Treatment Response Time Slide 21 A Continuing Care Model Detox
Substance Abusing Patient Continuing Care Recovering Patient
Rehabilitation Duration Determined by Performance Criteria Duration
Determined by Performance Criteria Slide 22 1.Medications relieve
symptoms but. behavioral change is necessary for sustained benefit
2.Treatment effects usually dont last very long after treatment
stops. Lessons from Chronic Illness Slide 23 3.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 Lessons
from Chronic Illness Slide 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. Slide 25
Part Two: Evidence Based Practices Slide 26 26 What are Evidence
Based Practices? Interventions that show consistent scientific
evidence of being related to preferred client outcomes. Slide 27 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 >1000 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 What Defines Evidence Based Practices and What Does it
Mean to Implement EBT? NIDA Blending Meeting,? November 2006 Slide
28 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 - NIDA
(1999) Principles of Drug Addiction Treatment Slide 29 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 - NIDA (1999) Principles of Drug Addiction Treatment
Slide 30 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 - NIDA (1999)
Principles of Drug Addiction Treatment Slide 31 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 Slide 32 32 Part 3:
Cognitive Behavioral Therapy (CBT) & Relapse Prevention
Strategies One Example of an Evidence Based Practice Slide 33 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) Slide 34 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 Slide 35 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 Slide 36 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 Slide 37 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 Slide 38 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. Slide
39 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 Slide 40 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 Slide 41 41 Foundations of CBT The learning and
conditioning principles involved in CBT are: Classical conditioning
Operant conditioning Modelling Slide 42 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 Slide
43 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 Slide 44 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.
Slide 45 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.) Slide 46 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.). Slide 47 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 Slide 48 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. Slide 49 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. Slide 50 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
Slide 51 51 CBT Techniques for Addiction Treatment: Functional
Analysis / The 5 Ws Slide 52 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. Slide 53 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? Slide 54 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) Slide 55 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? Slide 56 Functional Analysis or High-Risk Situations
Record Antecedent Situation ThoughtsFeelings and Sensations
BehaviourConsequences Where was I? Who was with me? What was
happening? What was I thinking? How was I feeling? What signals did
I get from my body? What did I do? What did I use? How much did I
use? What paraphernalia did I use? What did other people around me
do at the time? What happened after? How did I feel right after?
How did other people react to my behaviour? Any other consequences?
Slide 57 57 CBT Techniques for Addiction Treatment: Functional
Analysis & Triggers and Craving Slide 58 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). Slide
59 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 Slide 60 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 Slide 61 61 Internal triggers Anxiety Anger Frustration
Sexual arousal Excitement Boredom Fatigue Happiness Hunger Slide 62
62 Triggers & Cravings TriggerThoughtCravingUse Slide 63 63 The
Clinicians Role To teach the client and coach her or him towards
learning new skills for behavioral change and self-control. Slide
64 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. Slide 65 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. Slide 66 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 Slide 67 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
Slide 68 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. Slide
69 69 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. Give a clear rationale
Slide 70 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
Slide 71 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. Slide 72 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. Slide 73 73 Example of praising approximations Oh,
thanks! Yes, you are right. I will do my best to get all
assignments done by next week. 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! Slide 74
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! Slide
75 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 Slide
76 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. Slide 77 Part Four: Motivational Interviewing A
second Example of an Evidence Based Practice Slide 78 78 The
probability that a person will enter into, continue, and comply
with change-directed behavior Definition of Motivation Slide 79 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. Slide 80 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. Slide 81 81 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. Motivational
Interviewing Slide 82 Understanding How People Change: Models
Traditional approach Motivating for change Slide 83 83 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 The
Stick The Traditional Approach Slide 84 84 If the stick is big
enough, there is no need for a carrot. You better! Or else! The
Traditional Approach Slide 85 85 Someone who continues to use is in
denial. The best way to break through the denial is direct
confrontation. The Traditional Approach Slide 86 86 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 Another Approach:
Motivating Slide 87 87 Ambivalence Slide 88 88 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 Ambivalence Slide 89 Why
dont people change? Slide 90 90 that hangovers, damaged
relationships, an auto crash, memory blackouts or even being
pregnant would be enough to convince a woman to stop drinking. You
Would Think Slide 91 91 that experiencing the dehumanizing
privations of prison would dissuade people from re-offending. You
Would Think Slide 92 92 Harmful drug and alcohol use persist
despite overwhelming evidence of their destructiveness. Yet Slide
93 93 It is NOT that They dont want to see (denial) They dont care
(no motivation) They are just in the early stages of change. What
is the Problem? Slide 94 Why DO people change? Slide 95 95
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 The Concept of Motivation Slide 96 96 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 The Concept of
Motivation Slide 97 97 giving ADVICE removing BARRIERS providing
CHOICE decreasing DESIRABILITY practicing EMPATHY providing
FEEDBACK clarifying GOALS active HELPING General Motivation
Strategies Slide 98 98 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 The Concept of Ambivalence
Slide 99 99 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 Where Do I Start? Slide 100 100 Prochaska
& DiClemente Stages of Change Slide 101 101 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
Precontemplation Stage Slide 102 102 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 Contemplation Stage Slide 103 103 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 Determination
Stage Slide 104 104 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 Action Stage Slide 105 105
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 Maintenance Stage Slide
106 106 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. Relapse Slide 107 107 Someone
who has relapsed is NOT a failure! Relapse is part of the recovery
process. Relapse Slide 108 108 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. Helping People Change Slide
109 People are better persuaded by the reasons they themselves
discovered than those that come into the minds of others Blaise
Pascal Slide 110 110 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) Motivational Interviewing
(MI) Slide 111 111 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 Motivational Interviewing Slide 112
112 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 Motivational
Interviewing Slide 113 113 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 Motivational Interviewing Slide 114 114
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 Motivational Interviewing Slide 115 115
Motivating for change Pre-contemplation Contemplation
Determination/ Preparation Action Maintenance Motivational
Interviewing Slide 116 116 Motivational interviewing is founded on
4 basic principles: 1.Express empathy 2.Develop discrepancy 3.Roll
with resistance 4.Support self-efficacy Principles of Motivational
Interviewing Slide 117 117 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
Principles of Motivational Interviewing Slide 118 118 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! Examples of Expressing Empathy
Slide 119 119 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 Principles of Motivational Interviewing Slide 120
120 Wellas I said, I lost my job because of my drinking problemand
I often feel sick. 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. Example of Discrepancy Slide 121 121 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 Principles
of Motivational Interviewing Slide 122 122 You do not have the
right to judge me. You dont understand me. 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. Example of NOT Rolling with Resistance
Slide 123 123 Thats right, my mother thinks that I have a problem,
but shes wrong. 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. Example of Rolling with Resistance Slide 124 124
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 Principles of
Motivational Interviewing Slide 125 125 I hope things will be
better this time. Im willing to give it a try. 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.
Example of Supporting Self-Efficacy Slide 126 Slide 127 Part Five:
Medically Assisted Treatment A Third Example of an Evidence Based
Practice Slide 128 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.
Slide 129 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. Slide 130 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. Slide 131
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 Slide 132 Alcohol Dependence
Slide 133 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 Slide 134
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. Slide
135 Pharmacotherapy for Alcohol Dependence FDA-Approved: Disulfuram
(Antabuse) Oral naltrexone (Revia) Intramuscular naltrexone
(Vivitrol) Acamprosate (Campral) Slide 136 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 Slide 137 Opioid
Dependence Slide 138 Pharmacotherapy for Opioid Dependence Target
Outcome Cessation of non-medical use of opioids Retention in
Treatment Slide 139 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. Slide
140 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 Slide 141
Opioid Detoxification Medications used to alleviate withdrawal
symptoms: Opioids (methadone, buprenorphine) Clonidine Other
supportive meds anti-diarrheals, anti-nausea agents, ibuprofen,
muscle relaxants, anxiolytics Slide 142 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 Slide 143
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
Slide 144 Buprenorphine Formulations Subutex (Buprenorphine) -2mg,
8mg Suboxone (4:1 Bup:naloxone) -2mg/0.5 mg, 8mg/2mg Dose:
2mg-32mg/day sublingually Slide 145 Pharmacotherapy Pharmacotherapy
should be a standard component when effective drugs exist. Slide
146 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) Slide 147
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). Slide 148 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. Slide
149 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. Slide 150 Questions? Comments?
