Download James Finch, MD

Motivation in Addiction
Medicine Practice
Psychotherapy in Small Doses
James Finch, MD
Governor’s Institute on Substance Abuse
Changes By Choice, Durham, NC
Objectives
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Define a time efficient, motivational approach
to the Addiction Medicine encounter.
Define a reasonable “standard of care” for
brief MAT follow-up visits.
Outline basic elements of “psychotherapy” as
they apply to this time-limited but longitudinal
setting.
Describe what we can learn and apply from
Cognitive Behavioral and Motivational
approaches.
“Two-year experience with buprenorphinenaloxone for maintenance treatment of opioiddependence within a private practice setting”
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Office based setting
Mid-size urban community sample in North Carolina
Mixed prescription opioid and illicit opioid dependent patients
Minimal staff resources (solo practice)
Standard visits: 45-60 min initial, 15-20 min follow-up
Used standard community referral resources
Finch JW, Kamien KB, Amass L, J of Addiction Medicine, 2007.
Clinical Sample (n=71)
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Patient Characteristics:
Age: 16-62 (mean 32)
Gender: 69% male
Employed: 70%
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Opioid dependence history:
Heroin: 51%
Prescription analgesics: 49%
Years of dependence: 1-18 (mean 4.3)
Mean Suboxone Maintenance Doses
14
Suboxone Dose (mg/day)
12
10
8
6
4
2
0
Months in Treatment 2
4
6
8
10
12
14
16
18
20
22
24
% Negative
Negative
%
100%
80%
2 tests/month
60%
40%
Rates of Opioid Abstinence
40%
20%
0%
0%
Treatment Month
Pre
20%
1
2
3 4 6
8
10 12 14 16 18 20 22 24
Participation in counseling
Overall rate of involvement in supportive psychosocial
therapy: 58%
Kinds of supportive counseling:
Individual or group: 68%
Psychiatric follow-up/med mgmt: 29%
Drug treatment program: 7%
Peer support/12 Step: 2%
The “COMBINE” Study
Combined Pharmacotherapies and Behavioral
Interventions for Alcohol Dependence: A
Randomized Controlled Trial
Anton, RF, O’Malley, SS, et al. JAMA, May 2006
Groups randomized to med management with
naltrexone, acamprosate, both and/or both
placebos, with or without a combined behavioral
intervention (CBI). One group with CBI only.
Evaluated for up to one year after treatment.
The Combine Study: Outcomes
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Patients receiving medical management with naltrexone,
CBI or both fared better on drinking outcomes.
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No combination produced better efficacy than naltrexone or
CBI alone in the presence of medical management.
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Placebo pills and meeting with a health care professional
had a positive effect above that of CBI alone during
treatment.
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Medical Management (MD, RN, PA): Initial 45 min visit,
followed by 20 min visits, on week 1 and 2 and then every
2 to 4 weeks.
Medication Assisted Treatment for
Primary Addiction Treatment
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Demonstrated efficacy and FDA approval:
 Alcohol:
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Nicotine:
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nicotine replacement, buproprion, varenicline
Opioids:
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disulfiram, naltrexone, acamprosate
agonist: methadone, buprenorphine/naloxone
antagonist: naltrexone
Investigational but preliminary findings of efficacy:
 Cannabinoids
 Cocaine and other stimulants
Routine Elements of Medication Assissted
Treatment (MAT) Follow-up
Assess response to med: Efficacy/Side-Effects
Assess abstinence (primary and other drugs)
Assess overall stability (bio/psycho/social)
Reinforce participation in counseling/peer-support
Problem solve/provide advice/support recovery
Roles of the Addiction Medicine Physician
in Relation to Counseling
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Apply knowledge of therapeutic alternatives
available for referral
Understand and support the elements of
cognitive behavioral therapy and peersupport
Apply counseling skills within the setting of
the medical encounter
Psychosocial Therapeutic
Support Alternatives
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Mutual peer-support groups
Faith-based support groups
Individual and/or group therapy
Cognitive Behavioral Therapy (CBT)
Motivational Enhancement Therapy
Incentive Based Therapy
Coping Skills Development (DBT)
Trauma Processing Therapies (EMDR)
Anger Management Therapies
Relaxation/Meditation
Common Elements of CBT
for Substance Abuse
1. Drug Refusal Skills Training
2. Managing Negative Thinking
3. Managing Thoughts About Using
4. Managing Negative Moods and Depression
5. Effective Problem Solving
7. Seemingly “Irrelevant” Decisions
8. Alcohol and Other Drug Use
9.Coping with Anger
10.Progressive Muscle Relaxation/Meditation
11.Managing Insomnia
12.Giving and Receiving Criticism
13.Sharing Feelings
14.Vocational Counseling
15.Financial Management
16.Time Management
17.Relationship Counseling
18.Taking Responsibility for Choices
Potential counseling roles
for the medical clinician
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Psychotherapist
Counselor
Coach
Guide
Do we want to take on a counseling role?
Do we want to stay in a traditional medical role?
Types of Power for Behavior Change
Inherent in the Clinical Encounter
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Reward: ability to give people what they want or need
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Coercive: disapproval, denying requests, not seeing
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Referent: the “admired other”, role-model
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Legitimate: validated authority
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Expert: access to knowledge, training, information
5 Basic Elements of Psychotherapy
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Expectation of receiving help
Therapeutic relationship
Obtaining external perspective
Encouraging corrective experiences
Opportunity to test reality
“Psychotherapy means a form of treatment of mental
illness or emotional disorders which is based primarily
on verbal interaction with the client.”
NC Dept MH/DD/SAS
“the efficacy of psychotherapeutic methods lies in the
shared belief of the participants that these methods will
work.”
JD Frank
Core Elements of CBT:
Recognize/Avoid/Cope
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Recognize: triggers/cues (external/internal)
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Anticipate/Avoid: (situations/people/places)
“People/Places/Things”
“Playmates/Playgrounds/Playthings”
“Play the tape to the end.”
“It is easier to avoid temptation,
than to resist temptation”.
Core Elements of CBT:
Recognize/Avoid/Cope
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Cope: develop or reinforce skills:
Explore other ways to relax/deal with stress/problem solve
Re-expand dormant behavioral options to socialize/have fun
Connect/re-connect with sources of reward
and “hedonic tone”
“Who needs life when you’ve got heroin.” (Trainspotting)
Rebuild/Reward
“How come if alcohol kills millions of brain
cells, it never killed the ones that made
me want to drink?”
Anonymous
Editing the Patient’s “Story”
The language of the story:
generalizations/delitions/distortions
Therapeutic interventions:
Challenging “learned helplessness”
Reinforcing the power of “yet”
Supporting “self-efficacy”
MotivationaI Interviewing (MI) aims to
help the client…
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Enhance intrinsic motivation for change
(mobilize client’s own change resources)
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Recognize the need to do something about
the current or potential problem
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Resolve ambivalence and reach a decision
for change
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Build commitment to change
Transtheoretical Model
Pre-contemplation
Relapse
Contemplation
Maintenance
Determination
Action
Termination
Synonyms
Determination = Preparation
Termination = Exit
Prochaska and DiClemente
Continuum of Communication Styles
Directing
Guiding
Following
Directing
Prescribe
Tell
Show the way
Lead
Manage
Point toward
Conduct
Steer
Determine
Take command
Preside
Rule
Take charge
Authorize
Govern
Take the reins
Push
Administer
Following
Listen
Attend
Understand
Observe
Take in
Be responsive
Trust
Go along
Be with
Shadow
Permit
Allow
Support
Have faith in
Guiding
Enlighten
Encourage
Motivate
Awaken
Lay before
Collaborate
Involve
Take along
Look after
Accompany
Elicit
Evoke
Offer options
Invite
In practice and in management…
There is an appropriate role for directing
There is an appropriate role for following
But when your goal is behavior change, the optimal style
is usually guiding
William Miller
A Guiding Style…
Reduces resistance (relative to a directing style)
Improves working alliance
Enhances openness to consider change
Facilitates behavior change
Increases self-regulation and internalization of
change
“More like dancing than wrestling.” William Miller
Two Stages of Motivational Interviewing
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Phase 1: Building Motivation for Change
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Phase 2: Strengthening Commitment to
Change
Four Basic Principles
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Express Empathy
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Roll with Resistance
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Focus on understanding the person’s dilemma
Don’t be the one arguing for change
Develop Discrepancy
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Evoke the person’s own arguments for change
Support Self-Efficacy
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Encourage belief that change is possible
Change Talk
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Change talk is any client speech that favors
movement in the direction of change
Previously called “self-motivational
statements”
Change talk is by definition linked to a
particular behavior change target
Preparatory Change Talk
 DESIRE to change (want, like, wish . . )
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ABILITY to change (can, could . . )
REASONS to change (if . . then)
NEED to change (need, have to, got to)
Sustain Talk
The other side of ambivalence.
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I really like alcohol/oxy/weed
I don’t see how I could give it up
I need to use to be social
I intend to keep using/no one can stop me
I don’t think I have to quit
I can drink/use once in a while
Implementing Change Talk
Reflects resolution of ambivalence.
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COMMITMENT (intention, decision,
readiness)
ACTIVATION (willing, trying, preparing)
TAKING STEPS
Resources
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Motivational Interviewing by William Miller
CSAT TIP 35: Enhancing Motivation for Change in
Substance Abuse Treatment
The 15 Minute Hour by Stuart and Lieberman
Treating Alcohol Dependence: A Coping Skills
Training Guide by Monti, et al.
www.SA4Docs website
ASAM trainings and involvement
“…alcoholics recover not because we
treat them but because they heal
themselves.”
George Vaillant
The Natural History of Alcoholism, 1983
You can’t always get
what you want…
But if you try
sometimes…
You get what you
need.
JWF: The Vintage Image Gallery
Mick Jagger,
The Rolling Stones,
1969