Transcript Addiction

The Hook, The Cage and the
Empty Glass
Substance Use Disorders 101 for Primary
Care Providers
Ariel Singer, MPH – Northwest Addiction Technology
Transfer Center/OHSU
Anderson Rice, LPC, CADC I – Kaiser Permanente
Addiction Medicine
The Voice of Addiction
“I don’t have an ‘off’ switch…one is too many and a thousand is not
enough.”
“Incomprehensible demoralization”
“It’s a disease that tells you you don’t have a disease.”
“I really did not get how I could be an addict when I had been successful
in all other areas of my life – it didn’t make sense. However, no matter
how hard I tried, I couldn’t moderate. I just couldn’t control it.”
“My addiction took everything from me.”
“My substance use was relief from the pain, but it quit working.”
Definitions of Addiction
ASAM: Addiction is a primary, chronic disease of brain reward,
motivation, memory and related circuitry. Dysfunction in these
circuits leads to characteristic biological, psychological, social
and spiritual manifestations. This is reflected in an individual
pathologically pursuing reward and/or relief by substance use
and other behaviors.
http://www.asam.org/for-the-public/definition-of-addiction
Gabor Maté: Any repeated behavior, substance related or
not, in which a person feels compelled to persist,
regardless of its negative impact on his or her life and the
lives of others.
Addiction in Clinical Practice
• The 4 C’s
– Loss of Control
– Compulsive use
– Continued use despite harms
– Craving
Savage SR, et al. J Pain Symptom Manage. 2003;26:655-667.
DSM V: 11 Criteria for SUDs
Diagnosis on a Continuum of Severity
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Taking substance in larger amounts for longer than intended
Wanting to cut down or stop using, but not managing to
Spending a lot of time getting, using, or recovering from use
Cravings and urges to use the substance
Not managing to do what you should at work, home or school
Continuing to use, even when it causes problems in relationships
Giving up important social, occupational or recreational activities
Using again and again, even when it puts the you in danger
Continuing to use, when you have a physical or psychological problem that could have
been caused or made worse by use
Needing more of the substance to get desired effect (tolerance)*
Development of withdrawal symptoms; relieved by taking more of the substance.*
Mild (2-3)
Moderate (4-5)
Severe (6+)
*Not counted in SUD diagnosis if symptoms of tolerance or withdrawal occur during appropriate
medical treatment with prescribed medications.
Physiologic
Dependence
Vs. Addiction
Physical
Dependence
Tolerance
Physiologic adaptations
to chronic opioid therapy
Addiction
Maladaptive behavior
associated with opioid misuse
Savage SR, et al. J Pain Symptom Manage. 2003 Jul;26(1):655-67.
The Spectrum of Substance Use
Disorders
Past Year Perceived Need for and Effort Made to
Receive Specialty Treatment among Persons
Aged 12 or Older
SAMHSA. Results from the 2013 National Survey on Drug Use and Health:
Summary of National Findings
Policy Drivers of Substance Use
Disorders and Treatment
Koob, CSAM Addiction Medicine Review Course, 2014
Policy/Environmental Drivers of SUD
and Treatment
Alcohol Dependence was last among 30 medical conditions in
proportion of care received as evidence would recommend
McGlynn E. et al. NEJM, 2003
Like other chronic illnesses…
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Genetic, personal-choice, and environmental factors
Behavioral change is an important part of treatment
Relapse and medication adherence issues
Comply with treatment and medications = better
outcomes
• No reliable cure
• Older, employed with stable families = better outcomes
• Reasonably predictable course
McLellan A T, et al. Drug dependence, a chronic medical illness:
Implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284(13):1689–1695
The Ups and Downs of Chronic Disease
Disease Activity
Asthma, Diabetes, HTN, HIV, etc.
Substance Use Disorder
Time
O’Connor, JAMA 1998
Lucas, JAIDS 2005
A Chronic Illness Exacerbated by Stigma
• People with SUDs have
had a history of being
ignored
• War on drugs = war on
drug addicts
• Acute episodic response
has been the historical
treatment paradigm
• AA was a response to the
lack of treatment options
and sustains stigma and
marginalization through
its anonymity
We are moving from
saying, “this is a
personal failure...”
To saying, “there is a light
at the end of this
tunnel…”
“And if you want to, we can
walk towards it together…”
The Hook, the Cage and the Empty
Glass
The Hook
• The pharmacologic explanation of addiction
• Addiction attributable to intrinsic property of
the substance
The Cage
• Family history of SUD
• Co-occurring MH Disorders
• ACES
• Social Determinants of Health
The Empty Glass
• Unquenchable need for relief
• Often substituted
The Cage - Rat Park
www.brucekaleander.com, Addiction: The View from Rat Park, ,Professor Emeritus, Simon Fraser University
“Nothing is addictive within itself”
Gabor Mate’
Remedy Seeking
• Addictive behaviors are a way of controlling an experience
through external remedies
• No external remedy improves a condition without internal or
external consequences
• Differentiate between the disease model vs a normal
response to pain
“We must acknowledge what is right about addiction,
not what is wrong…”
Gabor Maté
Remedies provide…
1. A sense of control
2. A sense of fulfillment
3. Relief from real pain
4. A way to increase the threshold for tolerance
Remedy-Seeking and the Thin Line
• Seen as a way towards love and vitality
• Replaces genuine intimacy, compassion or honest
endeavors to thrive
• Paramount to other ways to self remedy
• Compulsiveness
• Impairment
• Persistence
The question to be asking is not “why
the addiction….”
But, “why the pain?”
(Maté)
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Marginalization
Racism
Poverty
Lack of access
Adverse history
Socio-economic inequality
Distress of daily living
Loss
Physical pain
Emotional pain
SUD Treatment: Check the Cage, Minimize
the Hooks and Fill the Glass
• Behavioral Treatments: CBT, DBT, ACT, Seeking Safety,
Contingency Management, etc
• Medication Assisted Treatment (MAT) for Opioid and
Alcohol Use Disorders
• Recovery-Oriented Systems of Care
And when treatment is not an option…
• Harm Reduction – a palliative approach
Substance Use Disorder Medications
Underutilized because of Stigma
Alcohol Use Disorder
1.Naltrexone
2.Acamprosate
3.Disulfiram
Opioid Use Disorder
1.Methadone
2.Buprenorphine
3.Naltrexone
Barriers to MAT
• Lack of understanding of the medications
• Organizational philosophy/staff beliefs about use of
medications;
• Cost of medications
• Lack of appropriate staffing in treatment centers
Harm Reduction
• Meeting our patients
where they are at
• Medication Assisted
Treatment is not harm
reduction
• Respect
• Honoring personal
autonomy
• Reduction in drug
related harm
• Comfort Care
Inside the Black Box: What Treatment
Looks Like
Before any treatment can occur a full Biopsychosocial assessment must take
place.
Data is gathered in 6 dimensions to determine the appropriate level of care:
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Dimension 1 – Acute Intoxication and/or Withdrawal Potential
Dimension 2 – Biomedical Conditions and Complications
Dimension 3 – Emotional, Behavioral or Cognitive Conditions and
Complications
Dimension 4 - Readiness to Change
Dimension 5 – Relapse, Continued Use or Continued Problem Potential
Dimension 6 – Recovery Environment
Is there a DSM – 5 diagnosis based on a thorough assessment?
Example: Alcohol Use Disorder – Mild, Moderate, or Severe
Continuum of Care – patients enter treatment at a
level appropriate for their needs and step up for more
intense treatment or down for less intense treatment.
• Level 1
• Level 2
• Level 3
• Outpatient Treatment
1 treatment
encounter/week
• Intensive Outpatient
Treatment
3-5 treatment
encounters/week
• Residential/Inpatient
2 weeks to one year
Residential Treatment
- may need detox before residential
Focus on:
Stabilization
Acceptance
Skill building
Becoming relational
Relapse prevention planning
Possible housing/job skills
Group Focus
Education
• Alcohol/Drug education
• Relapse Prevention
• Mindfulness/Stress Reduction
• DBT/CBT
• Neuroscience of Addiction
• Diet/Sleep/Daily living activities
• Co-Occurring MH education
Anxiety, Depression, ADD, PTSD, etc.
• Family Education
Therapeutic Process Groups
What was important about residential?
“It gave me a safe and structured place to go through withdrawal.
It gave me the first glimpse of myself sober – the good and the not so good –
that I had had in over a decade. I went in to residential thinking my only
problem was an addiction to meth. I came out convinced I was an addict.
Writing a list of ten insane behaviors, which had to be whittled down from
about ten thousand, convinced me that addiction was a disease, because
there is no way any sane person could have done all the things I did and
made all the choices I did, night after night, year after year, for my next hit.
Residential treatment also gave me a first taste of what it means to follow
direction, trust in my counselors and guides, and to connect to other addicts.
- Kaiser patient/38 yr old male
Outpatient Treatment
• 1-5 treatment encounters per week
• Group education and process
• Individual counseling and treatment planning
• Integration of recovery efforts with daily life
• Consistent support and structure through changes
Ongoing Relapse Prevention skills
• Mindfulness
• Cognitive Behavioral Therapy
• Dialectical Behavioral Therapy
• Motivational Enhancement
• Seeking Safety/Mental Health
What was your treatment experience in an outpatient
program?
“Well, obviously it provided a safe space for the months it took for my emotions
and brain to calm down, and to engage many of the issues and problems that
fueled my using in the first place. It taught me what it means to be honest and
to value and respect the honesty of others, to let everyone have their own
process and honor that. It has been the most thorough schooling in addiction I
can imagine; every day in group brings a list of lessons about how this disease
works, the different forms it can take with different drugs of choice or different
people, the unique challenges addicts face, the skills they can use, and the
stages of addiction or recovery. It provided needed structure and a more
directly engaged process than twelve-step groups, though I think those groups
are absolutely necessary for developing community, finding support, and
rebuilding a new way of life.”
- Kaiser Patient/38 yr old male
Integration of community supports:
Many options – all road tested by others
One of the biggest challenges in early
recovery is ________ ?
Staying focused. Making it through the emotions.
And the confusion.
Being told again and again, “More will be
revealed.”
- Kaiser patient/38 yr old male
Strong System Support
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Biopsychosocial Assessment
Motivational Interviewing
Advocacy
Psycho-education
Care Coordination
Follow up
Rx Adherence & Support
Community resource
education
• Tx planning and goal setting
• Multi-systemic settings and
multidisciplinary assessments
What can you do about it?
Screening
Brief
Intervention
Referral to
Treatment
“A public health approach to the delivery of
early intervention and treatment services for
people with substance use disorders and those
at risk of developing these disorders.”
SAMHSA
SBIRT vs. business as usual
SBIRT implemented
• Routine and universal screening,
regardless of medical complaint
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Validated, standardized screening
tools
No SBIRT
• Inconsistent and selective screening
• Non‐systematized narrative
questions
• Alcohol use seen as a continuum
• Alcohol use seen as dichotomous
• Evidence-based, patient-centered
change talk
• Ineffective, directive style of
communication
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Ongoing transition between primary
care and treatment
• Discoordinate/unclear referrals and
follow up
Brief Intervention at a
Glance
Feeling Two Ways about
Something
Ambivalent
Non-compliant
Does this look familiar?
What Change Actually Looks Like
Whose life is it anyway?
Resist the Righting Reflex
How to “FRAME” What You Say
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F – Feedback
R – Responsibility
A – Advise
M – Menu
E – Empathy
S – Self-efficacy
How to “FRAME” What You Say
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“The results of your questionnaire indicate that
your use of alcohol puts you at risk from
problems due to drinking. Of course, any
decisions regarding a change are yours to make.
As your doctor, I would like to share some
advice with you on modifying your drinking
habits – would that be ok? I want you to know
that we have a lot of options to help you,
should you decide to make a change.. I know
that change can be difficult and at the same
time, I am confident that if you decide to
change you will be able to do so. Would you like
to talk about some options that we have for
supporting you in this?”
How to “FRAME” What You Say
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What they’ve told you
F – Feedback
It’s their choice
R – Responsibility
Be clear, you’re the medical
A – Advise
expert
M – Menu Lots of options
E – Empathy Be genuine
Give them hope
S – Self-efficacy
Let’s Practice!
F. What do you already know about how ______ affects your health?
Would it be ok if I share some information with you about ______? How
does this affect your thinking?
R. These are always your choices to make and I am very interested to hear
your thoughts.
A. From a medical standpoint, it would be better for your health
to_______.
M. What are some things you have considered for making this change?
Why might you want to _______?
E. What are the three most important benefits for you to ____? How
important is it for you, on a scale of 0-10, to make this change? Why are
you at a ___ and not a lower number? If you did decide to ______, how
would you do it?
S. Your willingness to talk about this today shows how important this is to
you and I am confident that you can make progress towards the goals that
you have for your health. What do you think your next step might be?