Transcript Evidence-Based Practice Scholar Program Initiatives 2012-2013

Evidence-Based Practice Scholar
Program Initiative
2013-2014
Identifying Readiness to Change in Veterans
with Opioid Dependence
L. Mann MSN, RN
Department of Veterans Affairs
Veterans Health Care System of the Ozarks
Harding University
Mental Health Clinic
Fayetteville, AR
Topic of Interest
Opioid Dependence and Readiness to Change
Cause for concern:
Over 7 million people are addicted or physically dependent to
some form of opiate or prescription pain killer in the United States.
Depressive, anxiety and drug abuse disorders are associated with
increased use of regular opioids in the general population.
Death and Dollars:
Retail sales of prescription drugs jumped 250 percent from $72
billion to $250 billion, while the average price of prescriptions has
more than doubled from $30 to $68.
Topic integrated with EBP
 Purpose
 VA scholar will implement an initiative through the
Evidenced Based Practice program for Veterans that
utilize the outpatient Mental Health Clinic in
Fayetteville, Arkansas.
 PICO Question:
 In an outpatient VA mental health clinic, is there
sufficient evidence to suggest that augmenting the
nursing intake process of Veterans with opiate
dependence through the use of a Socratic selfassessment tool can improve treatment alliance, and
provide subjective data critical in identifying Veterans’
levels of readiness for change?
PICO Question:
Breaking it down:
 Population: Veterans in an outpatient clinic with opioid dependence
as listed in the problem section of outpatient’s electronic chart
 Intervention: Mental health nurses will present to identified
Veteran the self assessment SOCRATES Form 8D during intake
 Comparison: To those Veterans with opioid dependence who do
not have option to complete self-assessment tool during intake
 Outcomes: identify specific stage for Veteran, and facilitate
recovery for treatment success, increase in treatment completion
data, and appropriate resource referrals
Evidenced Based Practice: Defined at VA level
 6. VISION
 All Veterans with PTSD, depression, and other mental and
behavioral health conditions must have access to specific
EBPs being nationally disseminated and implemented in
VHA when treatments are clinically appropriate.
 EBPs must be fully available to Veterans when clinically
indicated, and that there must be sufficient staff capacity to
provide these therapies, as they were designed and shown
to be effective, in a timely fashion.
 VHA is beginning to disseminate and implement EBP’s for
additional mental and behavioral health conditions,
including substance use disorders…These efforts will
continue to be an important focus within VHA and
EVOLVE OVER TIME. (Section 11, VHA Handbook 2012).
Current Practice
 No self assessment tool was being used by RN specific
for opioid abuse assessment
 AUDC screen for ETOH done by RN
 Depression screen PHQ9 or BDI done by RN
 Veterans admitted for substance abuse detox
 Referred to substance abuse treatment may or may not be ready for change
 Assessments for substance abuse done by social workers
 Possible integration of cognitive based therapy or other
individualized therapy can be offered
 Groups/Classes offered
 Process could be enhanced with SOCRATES and nursing dialogue
and facilitation
Understanding Change
 Behavior for change is rarely a discrete single event
 A patient moves from being uninterested or unaware to… considering
options, and then…. preparing to make a change.
 Relapses become part of process of working toward lifelong integration of
change
 Actual Stages of Change model has 5 stages
 1. Precomtemplation stage
 2. Contemplation stage
 3. Preparation stage
 4. Action stage
 5. Maintenance and Relapse Prevention stage
Methods of Literature Review
 Multiple online searches of literature were completed
 Use of EBSCHO, Medline, and PsychINFO
 Used key words:
 Opioid dependence
 Opiate use
 Readiness to change
 SOCRATES assessment
 Substance abuse
 Mental health self assessment tools
 Some articles eliminated if not directly related to topic
 i.e. Suboxone therapy
 PTSD/MST
Overall Evidence Summation
 A total of 12 different studies and
reviews were utilized
 Level I: Experimental studies-1
 Level II: Quasi experimental-0
 Level III: Non-experimental,
qualitative-2
 Level IV: Opinion of experts based
on research-8
 Level V: Opinion of experts based
on non-research-1
Details of Evidence Summation
 Level 1: One experimental study from Journal of Addiction (1992) was
reviewed.
 One research report by Rollnick, Heather et al. used a questionnaire based on
Prochaska and DiClemente’s stages of change model using 141 alcohol consumers
recruited through a disguised screening method and psychometric analysis of a 20
item scale. This questionnaire provides a short, convienient measure of readiness
to change which may be used with interventions in excessive drinkers.
 Level 2: As of yet, no Level II studies examined.
 Level 3: There were two studies in this category.
 The first report by Sklar & Turner from 1999 took place at an addiction facility in
Ontario, Canada. The authors used a measure of coping self-efficacy in substance
users and administered a tool at intake to treatment. It was determined the
Socrates tool is useful for the assessment and monitoring of confidence levels
during treatment and is a promising research tool for outcome evaluation.
 The second Level 3 study was completed in England within 54 treatment agencies
using a longitudinal prospective cohort design with structured interviews at intake
and then 1 year follow up collecting data about illicit drug use.
Details of Evidence Summation
 Level 4: The majority of studies were assigned level IV A, B or C. A total of 6 unique
studies/reviews were examined.
 Comprehensive review applying the Transtheoretical Model to substance abuse using a
Change Assessment scale and Socrates (Stages of Change Readiness and Treatment
Eagerness scale) that offers a promising ambitious approach but leaving unanswered
questions
 Written by DiClemente himself, Schlundt & Gemmell a review examining current
perspectives on readiness, criticisms and clinical applications for future use
 Predictors of Initiation & Engagement in VA patients as a systematic review involving
270,877 veterans identified with substance abuse**main effects for gender were not
significant and were removed from model: patient who are younger than 30, not married
and have substance use disorder identified were more likely to engage
 Article review by DiClemente distinguishing change vs. readiness for treatment and
impact
 A cognitive behavioral intervention and case report of its use with a cocaine dependent
patient (component of Level 5)
 One Clinical Practice Guideline on Management of Opioid Therapy for Chronic Pain
which included addressing misuse and discontinuation of therapy
 Level 5: One comparing buprenorphine and methadone by the National Institute
on Drug Abuse that lists benefits and research highlights of use
About SOCRATES
(The Stages of Change Readiness and Treatment Eagerness Scale)
 An experimental instrument designed to assess readiness for
change in a simplified three scale score:
1.
Recognition (Re) (Range = 7-35)
2.
Ambivalence (Am) (Range = 4-20)
3.
Taking Steps (Ts) (Range = 8-40)
 Different forms of the SOCRATES have been developed
 Form 8D is a 19 item drug/alcohol questionnaire for clients and the one of
interest for this EBP project
 Others are 32 item drug/alcohol questionnaires for significant others and
will not be used for this EBP project
Self Assessment Tools
 University of Rhode Island Change Assessment
 This tool differs from SOCRATES in that it asks about “problems” in a
general manner and not as specific as SOCRATES about substance use
 Brief Addiction Monitor (BAM)
 17 item questionnaire currently used by substance abuse
counselors in mental health for only those patients enrolled in
SAC program
 A pilot study on BAM found that a 5 minute assessment can
monitor progress in multiple areas
 However- it is not done by nurses on all patients
Project Planning
 Literature Review
Created a 10 page outline from which to create an abstract on
literature review and EBP
 Submission for Approval
 Abstract, Request for EBP, and CITI training forms were
submitted to Little Rock IRB to proceed
 Development
 Included mentors, substance abuse team and nurses
 Formed an initiative to educate on Socrates model and use of
self assessment tool in outpatient clinic
 Goals
 To implement this model upon nursing intake in a mental health
clinic
 To identify the Veteran’s stage and readiness to change
Methods of Implementation
 Education
 Nursing service and mental health staff
 Biweekly, monthly meetings & updates
 Questionnaire/self assessment
 Use of Socrates tool, a self-assessment for Veterans
with history of opioid abuse/dependence
 Done by Veterans at nursing intake
Results
o Received approval for project on: September 23,
2013
o Nurses and staff were then educated at Mental
Health Staff meetings and nursing meetings
o Nursing service initiated SOCRATES assessments:
10/15/13
o Stop date 3/17/2014
o Total of 33 unique assessments were collected from
RN’s in Mental Health
Barriers
o Incomplete forms
o Due to Veteran not filling out back of Form 8D
o Incorrect information
o Not having opioid dependence listed in
Diagnoses (i.e. ETOH)
o Family members
o Veteran attempted to fill out and deferred to
wife to answer questions
o Nursing barriers:
o RN misplacing the original form, but could
not be evaluated by Initiative Leader
Improving Outcomes
 Potential for future research project
 Evaluation of treatment success and resources used or not used after 3 - 6 months
 Feedback from SAC team if referred
 Feedback from psychotherapist if referred
 What could be measured in future
 Treatment success
 Best use of resources

Success for this project defined
 Completion of Form 8D by Veteran and discuss with nurses
 Documentation in chart
 Provider acknowledgement and appropriate referrals
 Resource options for Veterans
 Replacement therapy-Suboxone
 Outpatient follow up
 Groups/Individual therapy
References
Diclemente, C. (1999.) Motivation for Change: Implications for Substance Abuse Treatment.
Psychological Sciences. Vol. 10 No. 3. 209-213.
DiClemente, C. C., Schlundt, D., & Gemmell, L. (2004). Readiness and stages of change in
addiction treatment. The American journal on addictions/American Academy of
Psychiatrists in Alcoholism and Addictions, 13(2), 103.
Gossop, M., Stewart, D. and Marsden, J. (2007), Readiness for change and drug use
outcomes after treatment. Addiction, 102: 301–308. doi: 10.1111/j.1360-0443.2006.01681.x
Harris, Alex H. S.; Bowe, Tom. (2008). Predictors of initiation and engagement in VA
substance use disorder (SUD) treatment. Psychological Services, Vol 5(3), 22810.1037/1541-1559.5.3.228
238. doi:
Jakupcak, M., Hoerster, K., Blais, R., Malte, Hunt, Seal. (2013). Readiness for Change Predicts
VA Mental Healthcare Utilization Among Iraq and Afghanistan War Veterans VA
Puget Sound Health Care System, Journal of Traumatic Stress. 26, 165–168.
References pg. 2
Migneault, J., Adams, T., & Read, J.(2005). Application of the Transtheoretical Model to
substance abuse: historical development and future directions. Drug and Alcohol
Review, 24(5), 437-448.
Mitchell & Angelone, 2006 Military Medicine, 171. 9:900, 2006 Assessing the Validity of
the Stages of Change Readiness and Treatment Eagerness Scale with TreatmentSeeking Behaviors
Morasco BJ, Duckart JP, Carr TP, Deyo RA, Dobscha SK. Clinical characteristics of
veterans prescribed high doses of opioid medications for chronic non-cancer pain.
Pain. 2010; 151(3):625-632.
Okie, S. (2010). A Flood of Opioids, a Rising Tide of Deaths. New England Journal of
Medicine 363:1981-1985 November 18, 2010 DOI: 10.1056/NEJMp1011512\
Rollnick, S., Heather, N., Gold, R. and Hall, W. (1992), Development of a short
‘readiness to change’ questionnaire for use in brief, opportunistic interventions
among excessive drinkers. British Journal of Addiction, 87: 743–754. doi:
10.1111/j.1360-0443.1992.tb02720.x
References pg.3
Seal KH, Shi Y, Cohen G, et al. (2012). Association of Mental Health Disorders with
Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan.
JAMA. 307(9):940-947. doi:10.1001/jama.2012.234.
Sklar, S. M. and Turner, N. E. (1999), A brief measure for the assessment of coping self- efficacy
among alcohol and other drug users. Addiction, 94: 723–729. doi: 10.1046/j.13600443.1999.94572310.x
Veterans Affairs/DoD Clinical Practice Guideline for Management of Opioid Therapy for
Chronic Pain. (2010). Guideline Summary. Prepared by The Management of Opioid
Therapy for Chronic Pain Working Group. Version 2.0. 2-73.
Zimmerman GL, Olsen CG, Bosworth MF (2000) A 'stages of change' approach to helping
patients change behavior. American Family Physician 61: 1409–1416. [PubMed]