Evidence-Based Substance Abuse Treatment

1. Evidence-Based Substance Abuse Treatment David A. Patterson, Ph.D. Professor UT College of Social Work dpatter2@utk.edu

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

3. 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.

4. 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".

5. 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".

6. Evidence-Based Practice

7. Evidence-Based Practice

8. Substance Abuse Treatment EffectivenessInsufficient 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

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

10. 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

11. 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

12. Strong Evidence of Effectiveness 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

13. 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 self-help manuals. • Motivational Interviewing is a strong alternative approach.

14. 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

15. 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.”

16. 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.

17. 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.

18. 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.”

19. 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.

20. 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.”

21. 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.

22. 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.

23. 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.”

24. 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.”

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

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

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

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

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

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

31. Transtheoretical Model • The Transtheoretical Model (Prochaska & DiClemente) • 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)

32. Stages of Change Model

33. 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.

34. 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.

35. 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.

36. 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.

37. 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.

38. 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

39. 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.

40. Transtheoretical Model

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

42. 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 high-risk 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.

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

44. Transtheoretical Model • HelpingRelationships 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.

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

46. 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.

47. Motivational Interviewing

48. 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.

49. 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

50. 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