Substance Abuse MI

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Substance Abuse Treatment in Health Care Settings
From Jeff Temple, Ph.D. - UTMB
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Overview

• Background
• Motivational Interviewing
• Cognitive Behavior Therapy
• Functional analysis
• Skills training
• Assessment
• Alcoholics Anonymous

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Diagnosis

• Abusea maladaptive pattern of substance use
  leading to clinically significant impairment or
  distress, as manifested by one (or more) of the
  following, occurring within a 12-month period.
• Recurrent substance use resulting in a failure to
  fulfill major role obligations.
• Recurrent substance use in situations in which it
  is physically hazardous
• Recurrent substance-related legal problems
• Continued substance use despite having persistent
  or recurrent social or interpersonal problems
  caused or exacerbated by the effects of the
  substances
• Dependencea maladaptive pattern of substance use
  leading to clinically significant impairment or
  distress, as manifested by three (or more) of the
  following, occurring at any time in the same 12
  month period.
• Tolerance
• Withdrawal
• Increased amounts and longer duration
• Persistent desire or unsuccessful attempts to cut
  down or control
• Time consuming (obtaining or recovering)
• Give up important social, occupational, or
  recreational activities
• Substance use continued despite problems caused
  by substances (continue drinking despite
  Pancreatitis)

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Magnitude of the Problem
Current, Binge, and Heavy Alcohol Use among
Persons Aged 12 or Older, by Age 2006
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Current, Binge, and Heavy Alcohol Use among
Persons Aged 12 or Older, by Race/Ethnicity 2006
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Past Month Cigarette Use among Persons Aged 12 or
Older, by Age 2006
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Past Month Use of Selected Drugs among Persons
Aged 12 or Older, by Gender 2006
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Past Month Illicit Drug Use among Persons Aged 12
or Older, by Age 2002-2006
SAMHSA
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Comorbidity

• Precipitates, compounds, or results from
• Mental Health Problems
• Anxiety
• Depression
• Suicidality
• PTSD
• Psychoticism
• Physical Health problems
• Social problems
• Interpersonal relationships
• Work

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TREATMENT

• Motivational Interviewing
• CBT

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Motivational Interviewing

• Motivational interviewing is a directive,
  client-centered counseling style for eliciting
  behavior change by helping clients to explore and
  resolve ambivalence (Rollnick Miller, 1995
  Miller Rollnick, 2002)
• Developed through experience in treating problem
  drinkers
• Roots are Rogerian
• Its a counseling style
• Also a stand alone intervention (e.g.,
  motivational enhancement therapy (4 session),
  brief motivational interviewing (1 session)

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The Basics of MI

• Non confrontational
• The therapeutic relationship is collaborative
• Relies upon identifying and mobilizing the
  client's intrinsic values and goals to stimulate
  behavior change
• Motivation to change is elicited from the client
• It is the client's task to articulate and resolve
  his or her ambivalence (not the counselors)
• The counselor facilitates the expression of both
  sides of the ambivalence and guides the client
  toward an acceptable resolution that triggers
  change
• Readiness to change is not a client trait, but a
  fluctuating product of interpersonal interaction
• The therapist respects the client's freedom of
  choice (and consequences) regarding his or her
  own behavior

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Assumptions regarding behavior change

• Direct persuasion, aggressive confrontation, and
  argumentation increase client resistance and
  diminish the probability of change. 
• Ambivalence or lack of resolve is the principal
  obstacle to be overcome in triggering change.
•  
• Readiness to change is not a client trait, but a
  fluctuating product of interpersonal interaction.
  
• Resistance is often a signal that the counselor
  is assuming greater readiness to change.

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Inappropriate assumptions regarding behavior
change

• The person ought to change
• The person wants to change
• This patients health is the prime motivation
  factor for him/her
• If he/she does not decide to change, the
  consultation has failed
• Patients are either motivated to change, or not
• Now is the right time to consider change
• A tough approach is always best
• Im the expert. He or she must follow my advice
• A negotiation-based approach is best
• Taken from Emmons and Rollnick (2001)

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General Therapeutic Principles

• Express Empathy Understanding the clients
  experience facilitates change. Skillful
  reflective listening is fundamental.
• Support Self-Efficacy Belief that change is
  possible is essential to motivation. Confidence
  ruler.
• Roll with Resistance Statements demonstrating
  resistance are not challenged but used to explore
  the clients views
• Develop Discrepancy Motivation for change occurs
  when people perceive a discrepancy between where
  they are and where they want to be

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But I dont have very long with my patients

• Health care provider Your diabetes is really
  unstable, and youve got to stop playing Russian
  roulette with sweets and insulin.
• Patient Its not that bad, really. I know what
  Im doing.
• OR
• Health care provider It may be that the freedom
  to eat whatever you want, whenever you want, is
  so important to you that youre willing to put up
  with the consequences, no matter how severe.
• Patient Well, I dont know if its that
  important. I dont want to go blind or lose my
  feet or anything like that.
• From Miller and Rollnick, 2002

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Components of a brief intervention
Taken from Emmons and Rollnick, 2001
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What not to do

• Patient (PT) I just dont know whether to leave
  him or not
• Health care provider (HCP) You should do
  whatever you think is best
• PT But thats the point! I dont know whats
  best!
• HCP Yes, you do, In your heart
• PT Well, I just feel trapped, stifled in our
  relationship
• HCP Have you thought about separating for a
  while to see how you feel
• PT But I love him, and it would hurt him so much
  if I left
• HCP Yet if you dont do it, you could be wasting
  your life
• Pt But isnt that kind of selfish?
• HCP Its just what you have to do to take care
  of yourself
• PT I just dont know how I could do it, how Id
  manage
• HCP Im sure youll be fine
• From Miller and Rollnick, 2002

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Practice

• Reframing
• Patient Ive tried to quit smoking three times
  now and failed every time. I dont think I can do
  it.
• Simple reflection
• Patient I just dont want to take pills. I ought
  to be able to handle this on my own.
• Emphasizing personal choice
• Patient What if I tell you I like smoking and
  dont want to quit.
• From Miller and Rollnick, 2002

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MI for Specific Problem Areas

• Good for alcohol and illicit drugs
• Good for promoting treatment engagement,
  retention, and adherence
• Encouraging effects for HIV risk, diet/exercise,
  gambling.
• Less support for smoking bulimia

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CBT

• Functional Analysis
• Working together, the therapist and client try to
  identify the thoughts, feelings, and
  circumstances of the client before and after s/he
  drank or used drugs.
• Helps clients determine the risks that are likely
  to lead to a relapse.
• Give the client insight into why they drink or
  use drugs in the first place and identify
  situations in which s/he has coping difficulties.

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CBT
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CBT
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CBT

• Skills Training
• A major goal of CBT for substance use is to get
  the client to learn or relearn better coping
  skills and unlearn old habits.
• Interpersonal Skills (assertiveness dealing with
  conflict giving and receiving criticism)
• Managing Negative Emotions (including preparing
  for upcoming situations that may provoke negative
  emotions)
• Relapse Prevention (slip vs. relapse coping with
  high risk situations refusal skills goal
  setting/alternative activities)

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CAGE

• C - Have you ever thought you should CUT DOWN on
  your drinking?
• A - Have you ever felt ANNOYED by others'
  criticism of your drinking?
• G - Have you ever felt GUILTY about your
  drinking?
• E - Have you ever had a drink first thing in the
  morning (as an EYE OPENER) to steady your
  nerves or get rid of a hangover?
• Ewing, 1984

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Alcoholics Anonymous

• Estimated A.A. Membership and Group Information
• Groups in U.S. . . . . . . . . . . . . . . 52,651
• Members in U.S. . . . . . . . . . . . . 1,190,637
• Groups in Canada . . . . . . . . . . . 4,872
• Members in Canada . . . . . . . . . . 95,984
• Groups Outside of
• U.S./Canada . . . . . . . . . . . . . . . . . .
  45,209
• Members Outside of
• U.S./Canada . . . . . . . . . . . . . . . . .
  729,097