Transcript What is Treatment and What is it Supposed to Do?

Evidence Based Practices:
An Overview
Desiree MacPhail-Crevecoeur, Ph.D.
Integrated Substance Abuse Programs
University of California, Los Angeles
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
Part One:
Addiction as a Chronic Brain Disease
Addiction = Brain Disease
Addiction is a brain disease that is chronic and
relapsing in nature.
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How a neuron works
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The Reward System
Natural rewards
–
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Food
Water
Sex
Nurturing
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How the Reward System Works
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Activating the System with Drugs
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The Brain After Drug Use (1)
Control Methamphetamine
(Source: McCann et al. (1998). Journal of Neuroscience, 18, 8417-8422.)
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Partial Recovery of Brain Dopamine
Transporters in Methamphetamine Abuser
After Protracted Abstinence
3
0
ml/gm
Normal Control
METH Abuser
(1 month detox)
METH Abuser
(24 months detox)
The Brain After Drug Use (2)
DA = Days Abstinent
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Drugs Change the Brain
After repeated drug use, “deciding” to use
drugs is no longer voluntary because
DRUGS CHANGE THE
BRAIN!
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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.”
Acute Care Treatment Model
Substance Abusing Patient
Treatment
Non- Substance Abusing Patient
Traditional Service Approach
Symptoms
Severe
Acute symptoms,
Remission
Discontinuous treatment
Crisis management
Time
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Resource: Tom Kirk, Ph.D.
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.”
A Recovery-Oriented Approach
Symptoms
Severe
Continuous
Treatment Response
Remission
Time
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Resource: Tom Kirk, Ph.D
A Continuing Care Model
Substance Abusing Patient
Detox
Duration
Determined by
Performance
Criteria
Rehabilitation
Duration
Determined by
Performance
Criteria
Continuing Care
Recovering Patient
Lessons from Chronic Illness
1. Medications relieve symptoms but….
behavioral change is necessary for sustained
benefit
2. Treatment effects usually don’t last very long
after treatment stops.
Lessons from Chronic Illness
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
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.
Part Two:
Evidence Based Practices
What are Evidence Based Practices?
Interventions that show consistent scientific
evidence of being related to preferred
client outcomes.
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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
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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
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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
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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
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Examples of Evidence Based Practices
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Contingency management
Medically Assisted Treatment
Brief intervention
Cognitive–behavioral interventions
Community reinforcement
Behavioral contracting
Motivational enhancement therapy
12-step facilitation
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Part 3: Cognitive Behavioral Therapy
(CBT) & Relapse Prevention
Strategies
One Example of an Evidence Based
Practice
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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)
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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
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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
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Why is CBT useful? (1)
•
CBT is a counseling-teaching approach wellsuited 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
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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
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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.
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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
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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
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Foundations of CBT
The learning and conditioning principles
involved in CBT are:
•Classical
•Operant
conditioning
conditioning
•Modelling
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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
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Classical conditioning: Application to CBT
techniques
•
•
•
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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
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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.
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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.)
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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.).
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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
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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.
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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.
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Modeling: Application to CBT techniques
•
•
•
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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
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CBT Techniques for
Addiction Treatment:
Functional Analysis /
The 5 Ws
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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 client’s 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 client’s life.
Those details are critical to creating a useful
treatment plan.
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The 5 Ws (functional analysis)
The 5 Ws of a person’s drug use (also called a
functional analysis)
– When?
– Where?
– Why?
– With / from whom?
– What happened?
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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)
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Questions clinicians can use to learn
the 5 Ws
•
What was going on before you used?
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How were you feeling before you used?
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How / where did you obtain and use drugs?
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With whom did you use drugs?
•
What happened after you used?
•
Where were you when you began to think about
using?
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Functional Analysis or High-Risk Situations Record
Antecedent
Situation
Thoughts
Feelings and
Sensations
Behaviour
Consequences
Where was I?
What was I
thinking?
How was I
feeling?
What did I do?
What happened
after?
What did I use?
Who was with
me?
What was
happening?
What signals did I
get from my
body?
How much did I
use?
What
paraphernalia did
I use?
What did other
people around me
do at the time?
How did I feel
right after?
How did other
people react to
my behaviour?
Any other
consequences?
CBT Techniques for
Addiction Treatment:
Functional Analysis &
Triggers and Craving
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“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).
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“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
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External triggers
•
People: drug dealers, drug-using friends
•
Places: bars, parties, drug user’s 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
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Internal triggers
•
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Anxiety
Anger
Frustration
Sexual arousal
Excitement
Boredom
Fatigue
Happiness
Hunger
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Triggers & Cravings
Trigger
Thought
Craving
Use
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The Clinician’s Role
To teach the client and coach her or him
towards learning new skills for behavioral
change and self-control.
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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.
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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.
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Match material to client’s 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
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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.,
client’s “triggers”)
•
Repetition of whole sessions, or parts of sessions,
may be needed
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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.
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Give a clear rationale
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.
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Communicate clearly in simple terms
•
Use language that is compatible with the client’s
level of understanding and sophistication
•
Check frequently with clients to be sure they
understand a concept and that the material feels
relevant to them
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Monitoring
Monitoring: to follow-up by obtaining
information on the client’s attempts to
practice the assignments and checking on task
completion. It also entails discussing the
client’s experience with the tasks so that
problems can be addressed in session.
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Praise approximations
Clinicians should try to shape the client’s
behavior by praising even small attempts at
working on assignments, highlighting
anything that was helpful or interesting.
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Example of praising approximations
I did not work on my
assignments…sorry.
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!
Oh, thanks!
Yes, you are right. I
will do my best to
get all assignments
done by next week.
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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!
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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
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Develop a plan: Dealing with resistance
to scheduling
•
Clients might resist scheduling (“I’m not a
scheduled person” or “In our culture, we
don’t 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.
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Part Four:
Motivational Interviewing
A second Example of an Evidence Based
Practice
Definition of Motivation
The probability that a person
will enter into, continue,
and comply with
change-directed behavior
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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.
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Motivational Interviewing
It seems surprising that…
people don’t simply stop using drugs,
considering that drug addiction creates so
many problems for them and their families.
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Motivational Interviewing
People who engage in harmful drug or alcohol
use often say they want to stop using, but they
simply don’t know how, are unable to, or are
not fully ready to stop.
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Understanding How
People Change: Models
• Traditional approach
• Motivating for change
The Traditional Approach
The Stick
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•
•
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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 don’t change if they haven’t suffered
enough
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The Traditional Approach
You better!
Or else!
If the stick is big enough,
there is no need for a carrot.
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The Traditional Approach
Someone who continues to use is
“in denial.”
The best way to “break through” the
denial is direct confrontation.
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Another Approach: Motivating
•
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
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Ambivalence
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Ambivalence
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
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Why don’t people change?
You Would Think…
that hangovers, damaged
relationships, an auto crash, memory
blackouts ─ or even being pregnant ─
would be enough to convince a
woman to stop drinking.
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You Would Think…
that experiencing the dehumanizing
privations of prison would
dissuade people from
re-offending.
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Yet…
Harmful drug and alcohol use persist despite
overwhelming evidence of their destructiveness.
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What is the Problem?
It is NOT that…
•
•
They don’t want to see (denial)
They don’t care (no motivation)
They are just in the early stages of change.
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Why DO people change?
The Concept of Motivation
“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
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The Concept of Motivation
• Motivation is influenced by the clinician’s style
• Motivation can be modified
• The clinician’s task is to elicit and enhance
motivation
• “Lack of motivation” is a challenge for the
clinician’s therapeutic skills, not a fault for which
to blame our clients
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General Motivation Strategies
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•
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giving ADVICE
removing BARRIERS
providing CHOICE
decreasing DESIRABILITY
practicing EMPATHY
providing FEEDBACK
clarifying GOALS
active HELPING
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The Concept of Ambivalence
• Ambivalence is normal
• Clients usually enter treatment with
fluctuating and conflicting motivations
• Clients “want to change and don’t want to
change”
“working with ambivalence is working with
the heart of the problem”
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Where Do I Start?
• 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
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Stages of Change
Prochaska & DiClemente
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Precontemplation Stage
People at this stage:
• Are unaware of any problems related to their drug
use
• Are unconcerned about their drug use
• Ignore anyone else’s belief that they are doing
something harmful
• Primary task– Raising Awareness
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Contemplation Stage
• 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
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Determination Stage
• 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
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Action Stage
• In this stage the patient is taking steps
toward change but hasn’t stabilized in the
process
• Primary task: Help implement the change
strategies and learn to limit or eliminate
potential relapses
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Maintenance Stage
• 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
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Relapse
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.
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Relapse
Someone who has relapsed
is NOT a failure!
Relapse is part of the recovery process.
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Helping People Change
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.
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“People are better persuaded by the reasons
they themselves discovered than those that
come into the minds of others”
Blaise Pascal
Motivational Interviewing (MI)
• “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)
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Motivational Interviewing
Strategy Goals
•
•
•
•
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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
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Motivational Interviewing
The Style
•
•
•
•
•
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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
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Motivational Interviewing
The Style (Continued)
• Explores client’s perceptions without labeling or
correcting them
• No teaching, modeling, skill-training
• Resistance is seen as an interpersonal behavior
pattern influenced by the clinician’s behavior
• Resistance is met with reflection
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Motivational Interviewing
Important Considerations
• The clinician’s 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”
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Motivational Interviewing
Motivating for change
Maintenance
Action
Determination/ Preparation
Contemplation
Pre-contemplation
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Principles of Motivational Interviewing
Motivational interviewing is founded on 4
basic principles:
1. Express empathy
2. Develop discrepancy
3. Roll with resistance
4. Support self-efficacy
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Principles of Motivational Interviewing
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 client’s
perspective
•
Labeling is unnecessary
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Examples of Expressing Empathy
You drink wine
to help you
sleep.
So you’re
concerned
about not
having a job.
I am so tired,
but I cannot
even sleep…
So I drink some
wine.
…When I wake
up…it is too late
already…
Yesterday my
boss fired me.
...but I do not
have a
drinking
problem!
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Principles of Motivational Interviewing
Principle 2: Develop Discrepancy
•
Clarify important goals for the client
•
Explore the consequences or potential
consequences of the client’s current behaviors
•
Create and amplify in the client’s mind a
discrepancy between their current behavior and
their life goals
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Example of Discrepancy
So drinking has some
good things for
you…now tell me
about the not-so-good
things you have
experienced because
of drinking.
I enjoy having some drinks with
my friends…that’s all. Drinking
helps me relax and have fun…I
think that I deserve that for a
change…
Well…as I said, I
lost my job
because of my
drinking
problem…and I
often feel sick. 120
Principles of Motivational Interviewing
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
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Example of NOT Rolling with Resistance
I do not want to stop
drinking…as I said, I do not
have a drinking problem…I
want to drink when I feel like it.
But, Anna, I think it
is clear that
drinking has
caused you
problems.
You do not have
the right to judge
me. You don’t
understand me.
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Example of Rolling with Resistance
You do
have a
drinking
problem
Others may think
you have a
problem, but you
don’t.
I do not want to stop
drinking…as I said, I do not
have a drinking problem…I
want to drink when I feel like it.
That’s right, my
mother thinks that I
have a problem, but
she’s wrong.
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Principles of Motivational Interviewing
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
124
Example of Supporting Self-Efficacy
I am wondering if
you can help me. I
have failed many
times. . .
Anna, I don’t 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.
I hope things will
be better this
time. I’m willing to
give it a try.
125
Part Five:
Medically Assisted Treatment
A Third Example of an Evidence Based
Practice
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.
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.
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.
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
Alcohol Dependence
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
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.
Pharmacotherapy for Alcohol Dependence
• FDA-Approved:
–
–
–
–
Disulfuram (Antabuse)
Oral naltrexone (Revia)
Intramuscular naltrexone (Vivitrol)
Acamprosate (Campral)
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
Opioid Dependence
Pharmacotherapy for Opioid Dependence
Target Outcome
• Cessation of non-medical use of opioids
• Retention in Treatment
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.
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
Opioid Detoxification
Medications used to alleviate withdrawal
symptoms:
• Opioids (methadone, buprenorphine)
• Clonidine
• Other supportive meds
– anti-diarrheals, anti-nausea agents, ibuprofen,
muscle relaxants, anxiolytics
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
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
Buprenorphine Formulations
• Subutex (Buprenorphine)
-2mg, 8mg
• Suboxone (4:1 Bup:naloxone)
-2mg/0.5 mg , 8mg/2mg
• Dose: 2mg-32mg/day sublingually
Pharmacotherapy
Pharmacotherapy should be a standard
component when effective drugs exist.
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)
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).
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.
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.
Questions?
Comments?