Substance Use and Abuse Week 12

The numbers last year for disorders

- approximately 20.1 million people aged 12 or older had a substance use disorder (SUD) related to their use of alcohol or illicit drugs in the past year - 15.1 million people who had an alcohol use disorder - 7.4 million people who had an illicit drug use disorder - 4.0 million- marijuana use disorder - 2.1 million- opioid use disorder - 1.8 million people with a prescription pain reliever use disorder - .6 million people with a heroin use disorder

Stages of Change (Prochaska & DiClemente) 4. Action

-An actual change in behavior -for less than six months

Stages of Change (Prochaska & DiClemente) 5. Maintenance

-Behavior change for more than six months -Committed to continuing the change

Stages of Change (Prochaska & DiClemente) 3. Preparation

-Intend to take action soon -change as possible and will be good -becoming serious about changing

Stages of Change (Prochaska & DiClemente) 1. Precontemplation

-No intention of changing behavior -unaware of problem -not taking responsibility for the problem -avoiding the subject

Professional Treatment

-Professional treatments have specific aims or goals --goals typically follow through assessment The goals typically involve improving a person's use of alcohol and drugs and extends to other areas of life functioning

What does the scientific evidence suggest about self-help organizations like AA? -There is no significant advantage in successfully in abstaining by attending self-help groups. -Based on research with AA, attending self-help group induce a significant increases in number of days spent abstinent -There is a small increase in number of days spent abstinent among individuals who are active, but simply attending members of AA. -It has not been possible at all to scientifically study self-help groups due privacy issues.

-There is a small increase in number of days spent abstinent among individuals who are active, but simply attending members of AA.

Stages of Change (Prochaska & DiClemente) 2. Contemplation

-Thinking about changing behavior (within 6 months) -May procrastinate -realizing there are other options/possibilities

Key points learned from vietnam soldiers for the self-change study

-Treatment may not be necessary for recovery (for many people_ -Self-change seems to be common (even from narcotics) -We can learn much about recovery from samples of people who aren't in treatment (Yet most addiction studies focused on treatment samples) -Context and social networks seem to have been major factors influencing soldiers drug use

Assessment 1. AUDIT - what is it? -what's it designed for? -how's it administered?

1. AUDIT (The Alcohol Use Disorders Identification Test a. Brief questionnaire that can help identify alcohol dependence and some specific consequences of harmful drinking b. Designed for health care practitioners and a range of health settings c. Also can be self-administered or used by non-health professionals (with suitable instructions)

what are two examples of Assessment Treatment?

1. AUDIT (The Alcohol Use Disorders Identification Test 2. DAST-10 (Drug Abuse Screen Test)

Non-Pharmacological Treatment strategies of Substance Use Disorders - Name the 4

1. Assessment 2. Cognitive Behavioral Therapies 3. Motivational Interviewing 4. SBIRT (Screening, Brief Intervention, and Referral to Treatment)

Self-Change: Why Don't We Hear More About It?

1. Difficult to identify people have successfully changed on their own (People who don't use treatment or sell them the focus of research studies) 2. People who have less severe problems are the ones who are most likely to succeed at self change (What severe cases tend to be the focus of research studies) • Myths 1 - Common belief that people who are able to change on their own must not of had an addiction in the first place • Myth 2 - That true recovery requires total abstinence. But money self changes choose moderate drinking over abstinence

Assessment 2. DAST-10 -What is it? --how's it administered?

2. DAST-10 (Drug Abuse Screen Test) a. Questionnaire designed to provide a brief instrument for clinical screening and treatment evaluation b. Designed to be self-administered

Which assessment tool, seeks to identify substance users at risk for alcoholism, but is not sophisticated enough to make a diagnosis of alcohol use disorder or provide any intervention. Instead it is more of a fast assessment tool to identify those who may need professional treatment. DAST-10 AUDIT CBT SBIRT

AUDIT

Abstinence or Moderation? -what is the standard goal of treatment? -what might be a reasonable goal?

Abstinence from alcohol or drugs: has been standard goal of treatment • Non-problem, moderate use of alcohol: some argue that this is a reasonable outcome goal for some patients

Non-NRT Drugs for Smoking Cessation

Bupropion (Wellbutrin/Zyban) -originally used as an antidepressant -similar effectiveness to NRT Varenicline (Chantix) -Primary uses for smoking cessation -Binds to nicotine receptors -Reduces cravings them across symptoms and makes smoking less pleasurable -slightly more effective than NRT short term or bupropion overall -nauseates some women

What does CBT stand for? Cognitive Behavioral Therapy Contemplation needs Before Treatment Couples Behavioral Therapy Counselling problem Behaviors in Therapy

Cognitive Behavioral Therapy

Non Pharmacological Professional Treatment

Cognitive-behavioral therapies appear effective, as are Structured behavioral contracting programs: apply positive reinforcers for desired behavior (ex. abstinence from drugs) rather than punishment for undesired behavior; has been effective-- drug court Couples/family treatment has been effective treatment for illicit drug users

Alcohol Pharmacological Treatment- -List the 3 drug names and chart

Disulfiram Naltrexone Acamprosate none are started until absitenance occurs, but research on naltrexone may reduce wanting the drug after long term use

Treatment Settings and Services: Alcohol -General treatment settings: Variety of services may be offered within each setting, including:

General treatment settings: hospital, intermediate, outpatient Variety of services may be offered within each setting, including: • Hospital / nursing care • Halfway houses / Milieu treatment • Outpatient counseling

Treatment of Polysubstance Abusers •What is there a need for?

Large percentage of patients abuse multiple substances -There's a need for setting that accommodate users of multiple substances, increased understanding of common aspects of the addictive behavior

Which professional treatment focuses on improving the substance users desire to change their behavior? CBT MI ABCT IDK

MI

Which film in this lecture illustrated why moderation is not for everyone? Richard Burton's interview Moby's interview Oprah's interview Daniel's interview

Moby's interview

Of the many self-help groups which one does not help individuals seek abstinence and which one focuses on spirituality to support abstinence? Rational Recovery; Women for Sobriety Women for Sobriety; Secular Organization for Sobriety Moderation Management; Alcoholics Anonymous Smart Recovery; Rational Recovery

Moderation Management; Alcoholics Anonymous

Providing normative statistics about substance use and abuse and negative consequences, to help the substance user reflect upon their disorder is a common strategy in which professional treatment Motivational Interviewing Cognitive Behavioral Therapy Alcohol Behavioral Couples Therapy Assessment Therapy

Motivational Interviewing

Pharmacological Treatment: Nicotine

Nicotine Replacement Therapy (NRT) for Smoking Cessation • Harm reduction approach • Reduces cravings related to physical withdrawal • Success rate is double as compared to placebo • Several routes of administration • Success rate is similar regardless of route of administration • Less health risks than smoking • NRT combined with behavioral treatment results in greater success rates than either one alone

Which statement below is NOT a concern for therapist who provide professional treatment for substance use disorder? Many, if not most, individuals with substance use disorder are poly-substance users. Whether treatment for abstinence or moderation is the best strategy for their client How to manage their practice so that pharmacological and non-pharmacological treatment can be administered at the same time None of the above answer the question

None of the above answer the question

Relapse

One of the most important topics in substance abuse treatment and research There are many models to try to explain the problem, but no single one addresses the complete problem • Relapse prevention has become an important focus of treatment

AA (Alcoholics Anonymous) Research Participants, setting and intervention- Measurements- Findings- Conclusions-

Participants, setting and intervention- A total of 169 alcoholic out-patients (57 women) assigned randomly to one of three conditions: a directive approach to facilitating AA, a motivational enhancement approach to facilitating AA or treatment as usual, with no special emphasis on AA. ▪ Measurements- Self-report of AA meeting attendance and involvement, alcohol consumption (percentage of days abstinent, percentage of days heavy drinking) and negative alcohol consequences. Findings- Participants exposed to the 12-Step directive condition for facilitating AA involvement reported more AA meeting attendance, more evidence of active involvement in AA and a higher percentage of days abstinent relative to participants in the treatment-as-usual comparison group. ▪ Conclusions- These results suggest that treatment providers can use a 12- Step-based directive approach to effectively facilitate involvement in AA and thereby improve client outcome.

Self-help or mutual-help groups are best described as group counselling session change without assistance from anyone. Recovery programs where substance users come together to change problem behaviors spiritual revivals

Recovery programs where substance users come together to change problem behaviors

What is the most common long-term outcome of any treatment (self-change, self-help, or professional treatment)? Recovery Relapse Institutionalization Overcoming substance use disorder

Relapse

Effectiveness of Drug Treatment • Research: Drug treatment research:

Research: staying in residential or non-methadone outpatient drug treatment is associated with reduced substance use, a more productive lifestyle • Drug treatment research: • Needs to understand the length of treatment better (i.e., taper vs. ongoing maintenance) • Needs more studies of patient-treatment matching • The general success here does not really address relapse

Core Sessions for CBT In order to provide patients with effective cognitive-behavioral coping skills, therapists need to be sure to cover all eight core topics and to do so thoroughly. "Introduction" must be presented firt, and the fin a l session in the 12-week intervention must be "Termination." List the core sessions

Session 1: Introduction to Coping Skills Training Session 2: Coping With Cravings and Urges to Drink Session 3: Managing Thoughts About Alcohol and Drinking Session 4: Problem Solving Session 5: Drink Refusal Skills Session 6: Planning for Emergencies and Coping With a Lapse Session 7: Seemingly Irrelevant Decisions After thesfirt seven core sessions have been completed, the therapist may move on to one or more elective topics. Final Session: Termination

Treatment of Substance Use Disorders • -what do we start looking at?

Start looking at the topics of treatment and how people recover from problematic substance use

What barrier to professional treatment, or even self-help groups, seems to be in play for individuals that seek self-change for substance use disorders? Unaware they have a substance use problem No insurance Stigmatization Lack of education on how to get help

Stigmatization

Which non-pharmcological therapy uses the strategy of positive reinforcement and negative reinforcement to reduce substance use disorder behaviors? Cognitive-behavioral therapy Couples/family intervention Group counselling program Structured behavior contracting

Structured behavior contracting

Dick Cavett interviews Richard Burton about his drinking problems: What are the main notes of the film?

There is a constant struggle, constant fear, constant presence, and there is important need for social contacts for recovery

Effectiveness of Alcohol Treatment

Treatment is associated with better outcomes No one treatment for alcohol problem seems to be superior to others Individual treatments may be more effective if they are match to patient's characteristics

Cognitive Behavioral Therapies -how many sessions? -what is the goal? -what do the skills provide? -what can we address that will prove most effective ?

Typically consist of 12 sessions Goal is training the individual to use active behavioral or cognitive coping methods to deal with problems, rather than relying on alcohol is a maladaptive coping strategy The skills also provide a means of obtaining social support critical to the maintenance of sobriety Addressing this broad spectrum of problems will prove more effective than focusing on drinking alone

What take-home message about self-change was uncovered from research on returning Vietnam veterans? Under circumstances of great contextual and social change, professional treatment is necessary to break the narcotic use habit. Under circumstances of great contextual and social change, self-change methods can break even narcotic abuse for most people. Under circumstances of great contetual and social change, most people engage in marijuana abuse None of the above, many soldiers rturned with both a narcotic and marijuana habit

Under circumstances of great contextual and social change, self-change methods can break even narcotic abuse for most people.

Can CBT be used with spouse/significant other therapy? What is ABCT ?

YES! • ABCT (Alcohol Behavioral Couples Therapy) is based on four assumptions: 1. Couple behaviors and interactions can be triggers for drinking 2. Intimate partners can reward abstinence 3. A positive intimate relationship is a key source of motivation to change drinking behavior 4. Reducing relationship distress lessens risk for relapse

AA (Alcoholics Anonymous) • Research Project: Can you encourage AA attendance? -what is the aim? -what is the design?

Yes, helpful when the treatment message is consistent with AA message ▪ Aim This study evaluated two strategies to facilitate involvement in Alcoholics Anonymous- 12 step motivational enhancement approach ▪ Design Randomized controlled trial with assessments at baseline, end of treatment and 3, 6, 9 and 12 months after treatment.

Recovery is defined as sustained abstinence of (previous) substance-related problems a voluntary, sustained period of abstinence after a previous substance-related problem a brief return to problem behavior after a period of voluntary remission change in the pattern of substance use without assistance

a voluntary, sustained period of abstinence after a previous substance-related problem

The current causal model of substance use disorders is called the... biological model sociocultural model moral model biopsychosocial model social learning theory model

biopsychosocial model

Which pharmacological treatment is approved for the treatment of nicotine use disorder from the list below? naltrexone buprenorphine bupropion none of the above are correct

bupropion

Adult behavioral Couples Therapy is built on which other professional non pharmacological therapy? motivational interviewing cognitive behavioral therapy counselling problem behaviors in treatment SBIRT

cognitive behavioral therapy

A brief return to problem behavior after a period of voluntary abstinence: lapse relapse self-change abstinence

lapse

Which statement below is true about the process of recognizing you have a substance use problem? most often it requires an intervention from friends most often it involves 'stepping in' to the stages of change cycle and moving toward the action stage most often it involves 'stepping in' to the stages of change cycle and moving toward the action stage most often it requires a diagnosis by your family phycisian

most often it involves 'stepping in' to the stages of change cycle and moving toward the action stage

Biopsychosocial Model ______________________ model in psychology to understand mental disorders -what is it? -what does it simultaneously take into account?

most widely accepted • Biopsychosocial model: combination of disciplines into one perspective; used as basis of treatment design -Simultaneously takes into account through major variable domains that are known to influence human health and behavior (biological, psychological, social factors)

Which pharmacological treatment is approved for the treatment of alcoholism from the list below? naltrexone methadone bupropion none of the above

naltrexone

Abstinence is defined as: sustained recovery of (previous) substance-related problemssustained recovery of (previous) substance-related problems no consumption of alcohol (or illicit substances) a brief return to problem behavior after a period of voluntary remission change in the pattern of substance use without assistance

no consumption of alcohol (or illicit substances)

Considering all illicit substances, except marijuana, which substance has the highest amount of substance use disorders? hallucinogen users heroin users cocaine users prescription opioid users

prescription opioid users

Change occuring- what is spontaneous remission? what is an underlying assumption?

when you quit on your own -outcome can be moderation of use or abstinence Self-Change or Spontaneous Remission: -People change problem behaviors on their own frequently -In fact, more people solve their problems on their own then join self-help groups or enter formal treatment -The majority of these individuals said change occurred because of pros of quitting and cost of continued use Underlying assumption: people go through stages of change on their own, that is sufficient for their behavior change

Motivational Interviewing -What is it? -What's the Goal? -Whats the focus? -What is the therapist role?

• A method of addiction counseling that focuses on the client • Goal-oriented and emphasizes results • Seeks to help alcoholics increase self motivation for change • Focuses on the desire to change within the client Therapist uses supportive reflection, don't say "you're wrong" but rather help the client find the discrepancy to their behavior and provide the norms

Terms to know • Abstinent-- • Recovery- • Remission- • Lapse- • Relapse- • Self-Help/Mutual Help Groups- • Self Change-

• Abstinent-- no consumption of alcohol (or illicit substances) • Recovery- a voluntary, sustained period of abstinence after a previous substance-related problem • Remission- sustained absence of (previous) substance-related problems, longer period of time than recovery • Lapse- a brief return to problem behavior after a period of voluntary abstinence (single instance) • Relapse- return to previous level of problem behavior after a period of voluntary abstinence • Self-Help/Mutual Help Groups- recovery programs where people come together to change a problem behavior (such as substance abuse) • Self Change- change without assistance (i.e., no treatment or self-help)

Self-Help Groups- name 2

• Alcoholics Anonymous and Narcotics Anonymous: major self help groups for alcohol drug use problems • Other self-help groups gaining in popularity: SMART Recovery, WFS, Secular Organizations for Sobriety (SOS)

AA (Alcoholics Anonymous)

• Attendance at Alcoholics Anonymous meetings is the most popular self-help method for changing drinking behaviors in the United States

Cognitive Behavioral Therapies -Based on: -Views drinking behavior relative to: -Emphasis is placed on:

• Based on the principles of social learning theory • Views drinking behavior related to major problems in the person's life • Emphasis is placed on overcoming skill deficits and increasing the person's ability to cope with high-risk situations -Can also address anger or depression

Drug Treatment - Naltrexone

• Blocks the brain's opiate receptors (antagonist) • Because of this, individuals must be completely opioid‐free before taking Naltrexone -Otherwise, the medication can bring about severe withdrawal symptoms • Following treatment with extended-release injectable Naltrexone, tolerance of opioids returns to pretreatment levels -taking previously tolerated or smaller amounts of opioids may result in overdose

Drug Treatment - Buprenorphine

• Buprenorphine is a semi synthetic opioid -It helps people reduce or quit their use of heroin or other opiates such as pain relievers like morphine • It helps treat opioid dependence by preventing withdrawal symptoms, but does not induce a "high" in patients (although it will in people who have never taken opioids)

Self-Change: What does it describe? What are other terms? What is the goal? 3 primary barriers to formal treatment

• Describes change without assistance (i.e., no treatment or self-help) • Other terms (for self-change) natural or spontaneous recovery, untreated remission • Most self-changers have a goal of moderate drug use (not abstinence) but end up abstinent 3 primary barriers to formal treatment (that promote self-change) • Stigma • Problem not severe enough to warrant treatment • Wanting to change on one's own

AA (Alcoholics Anonymous) Research • Is AA effective? If so, why?

• Difficult to assess -AA is cautious about conducting research because of privacy of members -it's anonymous

Four major tenets of Motivational Interviewing:

• Express empathy • Develop discrepancy • Navigate resistance • Encourage self-efficacy

Pharmacological Treatment: Alcohol • FDA-________ pharmacological treatment of alcohol problems: -What are the goals of the tx?

• FDA-approved pharmacological treatment of alcohol problems: • Medication to manage withdrawal from alcohol • Alcohol-sensitizing drugs • Medication that alters the reinforcing properties of alcohol • Medication that manages alcohol craving

Pharmacotherapy of Other Drug Problems • FDA-approved pharmacotherapy of dependence on opiate drugs includes:

• FDA-approved pharmacotherapy of dependence on opiate drugs includes: • Managing drug withdrawal • Replacing one opiate (e.g., heroin) with another one that is less addictive (Methadone) • Using antagonist drugs (e.g., Naltrexone for opioids)

Substance Use in Vietnam - Research for self change

• Few had used any illicit substances prior to Vietnam • ~80% of soldiers reported using marijuana • ~50% report using narcotics (heroin or opium) • ~50% used narcotics used at least weekly for more than 6 months • Started before combat exposure • Use attributed to boredom and to make life more enjoyable • 20% of soldiers reported being addicted to narcotics in Vietnam • 10% of general sample and 1/3 of drug test positive group reported some narcotic use in year after return to the US • Only 7% of drug test positive and 12% of addicted reported any signs of addiction after returning stateside • In other words, of those who were addicted to narcotics when they left Vietnam, 88% were no longer addicted one year later!!! (very few -less than 6%- had any type of tx after returning to the US) • Among those who were addicted in Vietnam and who used substances during the year after return to the US, researchers noticed

Motivation to Change - What's the first step? What is The Stages of change model:

• First step is Readiness or commitment to change is an important consideration in treatment Stages of change model- Applies to people who change on their own or who use outside resources to change • Stages of change model: • Five stages: (1) precontemplation (2) contemplation (3) preparation (4) action (5) maintenance

Stages of Change (Prochaska & DiClemente) 6. Termination

• Former behaviors no longer a problem or desirable • End of the change process

The Opiate Patient Will...

• Generally be unable to encode meaningful insights for retrieval for 90 days • Be focused on craving until the brain 'heals' from opiate injury or those cravings are blocked • Be afraid of being off their "medicine" to the point of panic • May be unable to remember treatment experience at all after a short period

Relapse Prevention Strategies

• In clinical practice, teach patients strategies to: • Understand relapse as a process • Identify and cope effectively with high-risk situations • Cope with urges and craving • Implement damage control procedures during a lapse • Stay engaged in treatment even after a relapse • Learn how to create a more balanced lifestyle

Pharmacological Treatments - List the three SUD's that have FDA approved txs

• In the US, the FDA has approved pharmacological treatments for the following substance use disorders: • Alcohol • Nicotine • Opiates

Drug Treatment - Methadone

• Is an opioid used to treat pain and as maintenance therapy or to help with detoxification in people with opioid dependence • Detoxification using methadone can either be done relatively rapidly in less than a month or gradually over as long as six months

Drug Treatment - Buprenorphine/Naloxone (Suboxone®)

• It helps treat opioid dependence by preventing withdrawal symptoms, but does not induce a "high" in patients • Like methadone • Naloxone is present in to discourage misuse; it does not serve any other purpose • Primary opioid treatment

Harm Reduction

• It is an approach that places emphasis on reducing the negative consequences of using a substance rather than on reducing the quantity or frequency of its consumption ex. using a designated driver when social occasions occur involving alcohol

Treatment of Dual-Diagnosis Patients -What is the treatment?

• Many in alcohol or drug treatment have major psychiatric disorders -Treatment: psychotropic medication to combat self medication. Use of alcohol and other drugs to decrease psychological symptoms such as anxiety or depression

SBIRT (Screening, Brief Intervention, and Referral to Treatment) • Screening — • Brief Intervention — • Referral to Treatment —

• Screening — Assess a patient for risky substance use behaviors using standardized screening tools • Brief Intervention — Engage a patient showing risky substance use behaviors in a short conversation, providing feedback and advice • Referral to Treatment — Provide a referral to brief therapy or additional treatment to patients who screen in need of additional service

SBIRT

• Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs • The SBIRT model was cited by an Institute of Medicine recommendation that called for community-based screening for health risk behaviors, including substance use

Self-Change is a Major Recovery Path - • Seems to be the most prevalent route to recovery for:

• Seems to be the most prevalent route to recovery for: -Alcohol / cigarette / drug problems (esp. cocaine and marijuana) • About ¾ of ex-smokers and former alcohol abusers report that they recovered on their own (without help) MC METHOD OF RECOVERY FOR ALCOHOL / POT / COCAINE

Specific Treatment Settings & Services: other drugs -• Traditionally defined by: -• Traditional drug treatment settings include:

• Traditionally defined by treatment of heroin abuse, but abusers of other drugs also appear in most of these settings • Traditional drug treatment settings include: • Detoxification • Methadone maintenance • Residential (Long and Short Term) • Outpatient

Models of Substance Use Disorders • Treatment is based on: • Five models:

• Treatment is based on: Based on model of etiology (cause) of alcohol and drug use • Five models: 1. Moral 2. American disease 3. Biological 4. Social learning 5. Sociocultural