Evidence-Based Substance Abuse Treatment David A Patterson Ph

Evidence-Based Substance Abuse Treatment David A. Patterson, Ph. D. Professor UT College of Social Work dpatter 2@utk. edu

Learning Objectives 1. Participants will learn basic concepts of evidence-based practice. 2. Participants will learn of the limitations of current substance abuse treatment practices. 3. Participants will learn ten evidence-based principles of drug use and problems. 4. Participants will learn the stages of change model 5. Participants will learn the basic principles of motivational interviewing and motivation enhancement therapy. 6. Participants will learn the basic principles of the Screening, Brief Intervention, Referral, and Treatment Model 7. Participants will acquire information on where to find additional information on evidence-based substance abuse treatment.

Global Scope of the Problem • World Health Organization (2007) – – 76. 3 million - alcohol use disorders 15. 3 million - drug abuse disorders People in 136 countries inject drugs 60 disease and injuries causally related to alcohol consumptions = 1. 8 million deaths annually – Heroin production tripled since 1985 – 13. 5 million people take opiates/9. 2 heroin – European heroin injectors have 20 to 30 times the likelihood of death compared to nonusers.

Evidence Based Practice • Becoming the dominant paradigm in Western medicine and social work • SAMSHA (2007) has defined evidence-based practice as, – "a practice which, based on expert or consensus opinion about available evidence, is expected to produce a specific clinical outcome (measurable change in client status)". • The Institute of Medicine (2001) emphasizes the notion of "multiple streams of evidence".

Evidence Based Practice • Institute of Medicine (2001) – (1) ”Best research evidence-the support of clinically relevant research, especially that which is patients centered", – (2) ”Clinician expertise-the ability use clinical skills and past experience to identify treat the individual client" – (3) ”Patient values-the integration into treatment planning of the preferences, concerns and expectations that each client brings to the clinical encounter".

Evidence-Based Practice

Substance Abuse Treatment Effectiveness Insufficient Evidence of Effectiveness (two or less controlled studies) • • • Mandated attendance at Alcoholics Anonymous (AA) Hypnosis Psychedelic medication therapy Non-SSRI antidepressant therapy Standard treatment Milieu Therapy

Insufficient Evidence of Effectiveness (two or less controlled studies) • • • Antiolytic agent therapy Relaxation training Confrontational counseling Psychotherapy General alcoholism counseling Educational lectures and films

Indeterminate Evidence of Effectiveness • • Nonbehavioral marital therapy Electrical aversion therapy Placebo therapy Lithium therapy Functional analysis Relapse prevention Self-monitoring Selective serotonin reuptake inhibitor (SSRI) antidepressant therapy

Strong Evidence of Effectiveness (consistent support from controlled research) • Behavioral marital therapy (includes improving problem solving, communication skills, and increases in positive reinforcement) • Motivational enhancement therapies • Opioid antagonist therapy • Behavior contracting • Brief interventions, e. g. , FRAMES • Community reinforcement approach (CRA) • Social skills training • Stress management

Strong Evidence of Effectiveness (consistent support from controlled research) • • • Patient-centered therapy Behavioral self control training Cognitive therapy Covert sensitization (a form of aversion therapy) Covert sensitization Oral and implant disulfiram (placebo effect has not been ruled out) • Self-help manual • Screening, Brief Intervention, Referral, and Treatment

Therapist Characteristics - Treatment Outcome • Level of therapist empathy is a major predictor of treatment outcome. • Treatment outcomes suffer secondary to aggressive confrontation. • Miller et al. (1980) found that when there was low therapists’ empathy, the clients faired better with a selfhelp manuals. • Motivational Interviewing is a strong alternative approach.

Drawing the Science Together: 10 Broad Principles of Drug Use and Problems Drug use is a chosen behavior Drug problems emerge gradually and occur along a continuum of severity Once well-established, drug problems tend to become self-perpetuating Motivation is central to prevention and intervention Drug use responds to reinforcement Drug problems do not occur in isolation, but as part of behavior clusters There are identifiable and modifiable risk and protective factors for problem drug use Drug problems occur within a family context Drug problems are affected by a larger social context Relationship matters

Drug Use is a Chosen Behavior • Drug use is chosen from among behavioral options. • “Most people who recover from drug problems do so on their own, without formal treatment. ” • “Effective interventions facilitate and perhaps support natural change processes. ” • Evidence suggests that change frequently involves a decision, commitment, or turnabout. • “Personal commitment appears to be a final common pathway toward change in drug use. ” • “There is every reason to treat the individual drug user as an active participant, responsible choosing agent, and a collaborator in prevention and treatment interventions. ”

Drug Problems Emerge Gradually and Occur Along a Continuum of Severity • Drug addiction happens gradually, with initial experimentation, moving to more frequent use. • There is no clear moment when a person “the commons”dependent or addicted. • “Dependence emerges over time as the person’s life becomes increasingly centered on drug use. • It is easier to back out of drug use at earlier and less severe stages of problem development.

Once Well-Established, Drug Problems Tend to Become Self-Perpetuating • Addictive behaviors take on a life of their own, becoming “self organizing” and robust. • Addressing just one component of the system is often ineffective. • It is important to understand for each individual what is maintaining the pattern of drug use, and, more importantly, which components need to be addressed in order to produce stable change. • The pharmacological effects can lead to stable preference for drug use and displacement of natural sources of reinforcement. • An initial period of drug abstinence can be helpful in destabilizing dependent drug use. • Hospitalization, incarceration, antagonist medications and differential reinforcement of nonuse can produce initial periods of abstinence.

Motivation Is Central to Prevention and Intervention • Motivational factors are central to understanding drug use, and also in preventing and reversing drug problems. • “People who stop drug use on their own without formal treatment, when later asked how and why they did so, often referred to a choice or decision. ” • “Transtheoretical research points to a sequence of events or stages through which people pass, starting with increased concern or motivation for change, decisional consideration, commitment, planning, and taking action to change. ” • “Taking action also predicts change. Better outcomes follow from attending more sessions or staying longer in treatment, going to more 12 -step meetings, adhering to treatment advice, or faithfully taking one’s medication. ” • “The idea that there is nothing one can do until a person “hits bottom” is simply mistaken. ” • “Positive reinforcement, unilateral intervention to family members, and brief motivational counseling and advice have all been shown to instigate change in seemingly unmotivated individuals. ”

Drug Use Responds to Reinforcement • “Preferred drugs are powerful reinforcers, chosen from among available options. ” • “Because stopping drug use simply eliminates one readily available source of positive reinforcement, long-term change typically involves finding competing reinforcers -in essence, developing a rewarding life that does not rely on drug use. ” • Drug use tends to be associated with a foreshorting of time perspective, so that longer term delayed rewards are discounted in value. • Providing clear incentives for abstinence often yields rapid reductions in drug use.

Drug Problems Do Not Occur in Isolation, but As Part of Behavior Clusters • For adolescents, drug use occurs in conjunction with poor school performance, precocious sexuality, mood problems (anxiety, depression), and antisocial behavior. • For adults, drug use occurs in conjunction with “elevated rates of family discord, violence, health problems, unemployment, poverty and financial problems, homelessness, crime, injury, child behavior problems, child abuse and neglect, disability, and a host of psychological and mood problem. ” • “Drug use occurs in a context of life problems, and abstinence is often well down on a client’s list of priorities. ” • “Interventions that target a broader range of life functioning are more successful in resolving drug problems. ”

There Are Identifiable and Modifiable Risk and Protective Factors for Problem Drug Use • “Heredity contributes to risk for alcohol problems, and evidence is mounting for genetic predispositions for or against other drug use. ” – “Some Asian groups inherit a metabolic abnormality… (that) decreases risk for problem drinking. ” – People who are relatively insensitive to the intoxicating an adverse effects of alcohol are greater risk of alcohol dependence. – “Escapist reasons for drug use and avoided styles of coping are both associated with increased risk for drug involvement. ” • “Protective factors include… – Nondrug positive reinforcement, stimulating environments, stress-buffering resources, close, high-quality positive relationships with nondrug involved people.

Drug Problems Occur Within a Family Context • “Parental drug use is the risk factor for children’s drug use, and is linked to a host family problems and more general risk factors. ” • “Children of drug impaired parents are, less likely to develop self-regulation skills particularly if parenting is disrupted before the child is age 6, the critical period for learning self-control. ” • “Domestic violence and child abuse are greatly increased with parental alcohol and other drug problems. ” • Protective family factors include… – Parental disapproval of drug use, consistent, supportive and authoritative parenting style, parental monitoring of child whereabouts, family involvement in religion and other conventional activities. • Effective family interventions include (1) strengthening family skills for constant communication and monitoring, and (2) building family reciprocity in exchanging in sharing positive reinforcement.

Drug Problems Are Affected by a Larger Social Context • “There are large regional differences in the problems of drug use and problems. ” • Social modeling can promote or deter use. • “Criminal sanctions for use are relatively ineffective in suppressing drug use, particularly once it is an established pattern. ” • Clear norms and modeling of moderation influence drinking rates. • “Adding one heavy drinker can increase the consumption rate at a table, whereas adding one moderate drinker has little effect. ” • “Having a meaningful role in society is a protective factor, while the loss of significant role increases the risk of drug problems. ” • “Social isolation is both a promoter and a consequence of the progression of drug dependence, and social bonding with non-users can be the antidote. ”

Relationship Matters • “There is something therapeutic about certain relationships. ” • “Counselors who are higher in warmth and accurate empathy have clients who showed greater improvements in drug use and problems. ” • “As early as the second session, clients’ ratings of their working relationship with the counselor are predictive of treatment outcome. ” • “A confrontational style that puts clients on the defensive appears to be counterproductive… producing significantly worse outcomes. ”

National Longitudinal Alcohol Epidemiologic Survey • NLAES DATA ON ALCOHOL DEPENDENT SUBJECTS • Outcome categories Treated Untreated • (n=1, 233) (n=3, 309) • < 5 years since onset dependence • • • alcohol abuse abstinent drinking w/o abuse 70% 11% 19% 53% 5% 41%

National Longitudinal Alcohol Epidemiologic Survey • NLAES DATA ON ALCOHOL DEPENDENT SUBJECTS • Outcome categories • Treated Untreated • (n=1, 233) (n=3, 309) • 20+ years since onset dependence • • • alcohol abuse abstinent drinking w/o abuse • Source: Dawson (1996) 20% 55% 24% 10% 30% 60%

Long-Term Residential (LTR)Treatment Changes from Before to After Treatment *p<. 001 % of DATOS Sample (N=676) Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997 (PAB)

Outpatient Drug-Free (ODF) Treatment Changes from Before to After Treatment *p<. 001 % of DATOS Sample (N=764) Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997 (PAB)

Short-Term Inpatient (STI) Treatment Changes from Before to After Treatment % of DATOS Sample (N=799) *p<. 001 Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997 (PAB)

Outpatient Methadone Treatment (OMT) Changes from Before to After Treatment % of DATOS Sample (N=727) *p<. 001 Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997 (PAB)

Transtheoretical Model • The Transtheoretical Model (Prochaska & Di. Clemente) • An integrative model of behavior change. • The model describes how people modify a problem behavior or acquire a positive behavior. • The central organizing construct of the model is the Stages of Change. Material adapted : Velicer, W. F, Prochaska, J. O. , Fava, J. L. , Norman, G. J. , & Redding, C. A. (1998)

Stages of Change Model

Transtheoretical Model • Stages of Change: The Temporal Dimension – – – Stage is a key organizing construct of the model. Represents a temporal dimension. Change implies phenomena occurring over time. Largely ignored by alternative theories of change. Behavior change was often construed as an event, such as quitting smoking, drinking, or over-eating. – The Transtheoretical Model construes change as a process involving progress through a series of five stages.

Stages of Change Model • Precontemplation Stage– Individuals typically deny having a problem with drugs or alcohol and commonly resist change – Therapeutic goal • Increase their consideration of the possibility that they may have a problem while avoiding any attempt to coerce the individual into accepting a diagnosis or substance abuse label. • Increase the individual's awareness that the behavior, problematic substance use, and its consequences may merit his/her attention and consideration.

Stages of Change Model • Contemplation Stage – Individuals begin to think about changing use of drugs/alcohol – Commonly express ambivalence about changing their behavior. – Benefit from a discussion of the pros and cons of changing their behavior. – Referred to as a "decisional balance" discussion. – Individual may be considering change, in this stage they have not committed to change.

Stages of Change Model • Preparation/determination stage – Individuals appear ready for and committed to action. – Have decided to stop the problematic behavior and initiate positive behavior. – Ambivalence about change may not be fully resolved in this stage. – Commitment to change does not necessarily mean that change is automatic but instead requires action by the individual.

Stages of Change Model • Action stage of change – Individual is actively engaged in modifying the target behavior and their environment. – Typically they have developed a plan for change with their social worker. – Seeking support of family and friends facilitates success in this stage of change. – Clients publicly stating their commitment to take action can solidify this effort. – Typically requires three to six months, but the actual length will vary depending on the severity of the problem.

Stages of Change Model • Maintenance phase – – Therapeutic focuses on maintaining the new behaviors. Behavioral patterns generally require time to emerge and stabilize. Clients may seek additional treatment for supporting recovery. Always the threat of relapse or return to the old problematic behavior. – It is sometimes said that individuals go back to doing that which they do not wish to do in order to remember why they made the change

Stages of Change Model • Relapse or recycling stage of change – Does not occur for all individuals, but relapse is very common in substance abuse in populations. • People can regress from any stage to an earlier stage. • The bad news is that relapse tends to be the rule when action is taken for most health behavior problems. • Relapse may occur secondary to – (1) unexpected urges or temptations, – (2) the individual relaxing their guard about the dangers of substance abuse, – (3) individuals may test their ability to resist the temptations of drugs or alcohol and fail, and – (4) there may be an erosion of their sense of self-efficacy or commitment to change.

Transtheoretical Model

Transtheoretical Model • The Relationship between Stage and the Decisional Balance for a Healthy Behavior

Transtheoretical Model • Self-efficacy/Temptations. • The Self-efficacy construct represents the situation specific confidence that people have that they can cope with high-risk situations without relapsing to their unhealthy or highrisk habit. • The Situational Temptation Measure reflects the intensity of urges to engage in a specific behavior when in the midst of difficult situations. – It is the converse of self-efficacy and the same set of items can be used to measure both, using different response formats.

Transtheoretical Model • The Relationship between Stage and both Self-efficacy and Temptation

Transtheoretical Model • Helping Relationships combine caring, trust, openness and acceptance as well as support for the healthy behavior change. Rapport building, a therapeutic alliance, counselor calls and buddy systems can be sources of social support. • Counter Conditioning requires the learning of healthier behaviors that can substitute for problem behaviors. Relaxation can counter stress; assertion can counter peer pressure; nicotine replacement can substitute for cigarettes, and fat free foods can be safer substitutes.

Transtheoretical Model • The Relationship between Stage and two sample Processes, Consciousness Raising and Stimulus Control

Motivational Interviewing • Motivational interviewing is an evidence-based intervention designed to enhance client motivation for change. • Tested in a variety of clinical intervention modalities including – – brief 30 -minute interventions, multiple sessions, ongoing counseling, and client assessment.

Motivational Interviewing

Motivation Enhancement Therapy (MET) (Miller, 2005) There are four key assumptions of MET (Miller, 2005). – 1. Ambivalence about substance use (and change) is normal and constitutes an important motivational obstacle in recovery. – 2. Ambivalence can be resolved by working with your client’s intrinsic motivations and values. – 3. The alliance between you and your client is a collaborative partnership to which you each bring important expertise. – 4. And empathetic, supportive, yet direct, counseling style provides conditions under which change can occur. (Direct argument and aggressive confrontation may tend to increase clients defensiveness and reduces the likelihood of behavior change. ) p. 39.

Motivational Enhancement Therapy: • A systematic intervention to evoke change in problem drinkers. • Based on the principles of motivational psychology. • Designed to produce rapid, internally motivated change. • Does not attempt to guide and train the client, step by step, through recovery. • Employs motivational strategies to mobilize the client’s own change resources. • Miller, Chap. 5, Handbook of Alcoholism Treatment Approaches, 1995

Opening Strategies • • • 1. Ask Open Questions 2. Listen Reflectively 3. Affirm – Compliments or statements of appreciation 4. Summarization –used to link together and reinforce material 5. Eliciting Self- Motivating Statements – – Recognizing disadvantages of the status quo (problem recognition) Recognizing advantages of change Expressing optimism about change Expressing intention to change

Motivation Enhancement Therapy • Five Basic Principles of MET – – Express Empathy Develop Discrepancy Avoid Argumentation Roll with Resistance • • Arguing Interrupting Denying Ignoring – Support Self-efficacy

Express Empathy • Communications that imply a superior/inferior relationship are avoided. • The therapist’s role is a blend of supportive companion and knowledgeable consultant. • The client’s freedom of choice and self-direction is respected. • Persuasion is gentle, subtle, always with the assumption that change is up to the client. Miller, Chap. 5, Handbook of Alcoholism Treatment Approaches, 1995

Avoid Argumentation: • If handled poorly, raising of discrepancies can create defensiveness. • The MET style explicitly avoids direct argumentation, which tends to evoke resistance. • No attempt is made to have the client accept or “admit” a diagnostic label. • “The client, not therapist voices the arguments for change. ” • “What makes you think that maybe you should do something about your drinking? ” Miller, Chap. 5, Handbook of Alcoholism Treatment Approaches, 1995

Roll with Resistance: • MET strategies do not meet resistance head on, but rather “roll with” the momentum, with a goal of shifting client perceptions in the process. • New ways of thinking about the problem are invited, but not imposed. • Ambivalence is viewed as normal, not pathological, and is explored openly. • Solutions are usually evoked from the client rather than provided by therapist. Miller, Chap. 5, Handbook of Alcoholism Treatment Approaches, 1995

Support Self-Efficacy: • Self -efficacy - the belief that one can perform a particular behavior or accomplish a particular task. . • The person must believe he or she can change (Rogers & Mewborn, 1976). • Optimism can also be found in the menu of different approaches available. • A therapist’s own optimism may also powerfully influence client motivation and outcome. • Leake and King (1977) demonstrated experimentally that therapist expectations of good prognosis are predictive of favorable outcomes among alcoholic clients. Miller, Chap. 5, Handbook of Alcoholism Treatment Approaches, 1995

Develop Discrepancy: • Motivation for change occurs when people perceive a discrepancy between where they are and where they want to be. • M. E. T. seeks to enhance and focus the client’s attention on such discrepancies. • In certain cases (the pre-contemplator), it may be necessary to first develop such discrepancy by raising client’s awareness of the personal consequences of abuse. Miller, Chap. 5, Handbook of Alcoholism Treatment Approaches, 1995 – Play video - Part B-2 Chapter 2 - Case Example Opening Session

Screening, Brief Intervention, Referral and Treatment (SBIRT) • SBIRT is an evidence based public health approach providing early intervention in treatment for individuals with substance abuse disorders and those at risk of developing problematic substance use (SAMSHA, 2007 a). • SBIRT reduces the frequency and severity of alcohol and drug use, reduces the risk of trauma associated with alcohol and drug use, and increases the number of clients to enter substance abuse treatment. • Screening in brief interventions have been shown to reduce hospital days and decrease emergency room visits, resulting in net cost savings from the interventions.

Screening, Brief Intervention, Referral and Treatment (SBIRT) • Screening – Identification of client seen in medical and public health settings who require further assessment for treatment for substance abuse disorders. – Integration substance abuse screening into regular medical and public health care. – Two elements of screening include • attention to biomarkers/client reports and • the use of screening instruments. • www. sbirt. samhsa. gov/core_comps/screening. htm

Screening, Brief Intervention, Referral and Treatment (SBIRT) • Brief Intervention – Single session or multiple sessions employing motivational strategies, – The intention is to increase the client's motivation toward positive behavioral changes. – Brief interventions can be structured either towards single sessions for clients at risk or as a means to increase motivation and engagement in treatment over the course of several sessions. – Targeted brief intervention protocols are available at www. sbirt. samhsa. gov/core_comps/brief. htm.

Screening, Brief Intervention, Referral and Treatment (SBIRT) • Brief Treatment – Treatment of increased intensity and is delivered over a shorter time. – Goal to eliminate hazardous and/or harmful substance use. – Brief treatment is delivered in a limited number of sessions that are highly structured and focused. – Brief interventions are typically less costly than alternative approaches, yet have been shown to be effective in substance abuse treatment. – FRAMES Model

Screening, Brief Intervention, Referral and Treatment (SBIRT) • Referral to Treatment – Treatment referrals used for individuals who, because of the severity of their substance abuse problem, need more extensive treatment than can be offered through SBIRT. – Effectiveness of referral to treatment is dependent upon the proactive and collaborative efforts of the medical and public health agency offering SBIRT and the specialized substance abuse treatment providers to which the SBIRT clinician will refer clients. – The intention is to appropriately match the client’s current substance abuse problems with the appropriate level of care necessary to address the needs of client.

http: //nrepp. samhsa. gov/

Drug Abuse Treatment Core Components and Comprehensive Services Medical Financial Housing & Transportation Core Treatment Intake Assessment Child Care Treatment Plans Group/Individual Counseling Abstinence Based Pharmacotherapy Mental Health Urine Monitoring Case Management Continuing Care Self-Help (AA/NA) Family AIDS / HIV Risks Vocational Legal Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB) Educational

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Treatment Process Model: Client & Program Predictors Hierarchical Linear Modeling (HLM) Session Attendance (Mos 1 -3) Trt Confidence (Mo 3) Client Ratings Rapport w/ Counselor Trt Commitment (Mo 3) (Mo 1) Treatment Readiness Client factors Program factors 2/3 1/3 • Referred services • Missed sessions • Diversity of needs LTR ODF OMT Joe, Simpson, & Broome, 1999 (Drug & Alcohol Dependence)