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Module III: Refining your intervention

Detailed guide on making recommendations for reducing or abstaining from substance use based on patient zones. Includes referral criteria and stages of change intervention.

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Module III: Refining your intervention

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  1. Module III: Refining your intervention

  2. Making recommendations Making recommendations • Reducing use • Abstaining • Referral Your recommendation to your patient is often based on your patient’s zone of use Dependent IV III Harmful II Risky I

  3. Making recommendations Illicit drug use Recommendation: abstinence Dependent IV III Harmful II Risky I

  4. Exceptions: Prior history of substance dependence Serious mental illness, pregnancy Taking medications that require total abstinence Medical condition complicated by use Alcohol use, Zone II: Making recommendations Recommendation: reduce use IV III II Risky I

  5. Alcohol use, Zone III Making recommendations Recommendation: Abstinence or reduce use IV • Individuals who abuse alcohol are more likely to succeed at abstaining than reducing use • It may be helpful to discuss a trial period of abstinence with your patient III Harmful II I

  6. Making recommendations Alcohol use, Zone III Factors that point to referral: • You strongly suspect pt dependence based on other factors • Prior history of alcohol/drug dependence or liver damage • Persons with prior or current serious mental illness • Patients who have failed to achieve their goals through BI IV III Harmful II I

  7. Alcohol use, Zone IV Making recommendations Recommendation: abstinence Dependent IV This usually means advising outside assessment and/or treatment. III II I

  8. Referring your patient Zone IV referral • Although AUDIT is not a formal diagnostic tool, studies support that patients in Zone IV reflect DSM-IV criteria for dependence. • Goal: enhance patient’s motivation for seeking further assessment and help • Provide clear feedback about the risks and information about treatment services • Provide follow-up and monitoring on this condition Dependent IV III II I

  9. Operators can identify facilities based on level of care, insurance, gender, location, etc. Referring your patient Making the referral • Alcohol and Drug Addiction treatment phone number, sponsored by Oregon Addictions and Mental Health Division: 1-800-923-4357

  10. Purpose: determine diagnosis and appropriate level of care: Level I: Outpatient treatment Level II: Intensive outpatient treatment Level III: Residential/inpatient treatment Level IV: Medically managed intensive inpatient treatment Detoxification can be delivered at all levels of care – typically delivered at Level III. Referring your patient Levels of substance abuse treatment

  11. Stages of change The Journal of the American Medical Association Would you change your behavior? Watching TV Causes Brain Cancer How ready are you to change your behavior?

  12. Stages of change Stages of change Pre- contemplation Relapse Contemplation Maintenance Preparation Action

  13. Stages of change The patient is not thinking about changing and perhaps is unaware that a problem exists. Pre- contemplation It isn’t that they can’t see the solution. It is that they can’t see the problem.

  14. Stages of change Pre- Contemplation Intervention:

  15. Stages of change In the contemplation stage, people acknowledge that they have a problem and begin to think seriously about solving it. Contemplation • “I want to stop feeling so stuck” • Contemplators are struggling to understand their problem, see its causes, wonder about solutions • They may be far from making a commitment to taking action about their problem

  16. Stages of change Intervention: Contemplation

  17. Stages of change Preparation takes your patient from decision making in the contemplation stage to the specific steps for solution in the action phase. Preparation • Preparation is the cornerstone of effective action • Commitment is the most important change process in the preparation stage

  18. Stages of Change Intervention: Preparation

  19. Stages of change Effective action begins with commitment. Once the commitment to change is made, it is time to move. Action • The process of action includes: • Countering, control & reward • Continued reliance on helping relationships

  20. Stages of change Intervention: Action

  21. Stages of change • The first two months of maintenance is the most likely time for relapse. Maintenance • Acknowledge vulnerability to the problem behavior, even while building a new life-style • Develop confidence in ability to succeed • Find few, if any, temptations to misuse substances

  22. Stages of change Intervention: Maintenance

  23. Case #1 Case examples Bob is a 26 yr. old and he has an AUDIT score of 12 and is being seen for his yearly physical. No other medical complications are evident at this time. He is in pre-contemplation relative to changing his substance use. • What zone did Bob score in? • What is your recommendation? • What elements of the brief intervention will you focus on?

  24. Case #1 Case examples • What zone did Bob score in? • Zone II (Risky) • What is your recommendation? • Reduce use to safe drinking amounts. • What elements of the brief intervention will you focus on? • Provide feedback and information to Bob about the risks of being in Zone II and discuss the safe drinking limits. Explore possible reasons for making a change.

  25. Case #2 Case examples Jennifer is a 30 yr. old being seen for an ulcer and her AUDIT score is a 18. She is in the contemplative stage of change, she is unsure if she can successfully cut-down her use. • What zone did Jennifer score in? • What is your recommendation? • What elements of the brief intervention will you focus on?

  26. Case #2 Case examples • What zone did Jennifer score in? • Zone III – (Harmful) • What is your recommendation? • Abstinence • What elements of the brief intervention will you focus on? • Provide feedback and explore with Jennifer what some of her own reasons are for wanting to cut down. Explore pros and cons. Support her self-efficacy and explore options for making a change.

  27. Case #3 Case examples Jessie is 45 and he is being seen for hypertension and anxiety. His AUDIT score is a 24. He is in the preparation stage of change • What zone did Jessie score in? • What is your recommendation? • What elements of the brief intervention will you focus on?

  28. Case #3 Case examples • What zone did Jessie score in? • Zone IV - Dependent • What is your recommendation? • Abstinence & referral for an evaluation • What elements of the brief intervention will you focus on? • Provide feedback and state concerns regarding the interaction between Jessie’s medical problems and alcohol use. Explore with Jessie his interest in making a change. Enhance motivation for accepting a referral.

  29. Case #4 Case examples Larry scores a 15 on the AUDIT. He is being seen for allergies. He is in the Action Stage as he has already started to cut down his use and drink fewer days per week. • What zone did Larry score in? • What is your recommendation? • What elements of the brief intervention will you focus on?

  30. Case #4 Case examples • What zone did Larry score in? • Level II – High-end of risky drinking • What is your recommendation? • Cut down to within safe drinking limits. • What elements of the brief intervention will you focus on? • Explore with Larry his reasons for cutting down and previous strategies to successfully change his drinking. Discuss possible barriers. Negotiate a plan and schedule a follow-up.

  31. Medications Meds for substance dependence, in general • The most powerful role a primary care provider can fill in treating alcohol and drug problems is that of a motivator, an educator, and a provider of referrals to treatment – SBIRT. • Should they choose, providers may enhance the services they provide through the use of medications for substance dependence

  32. Medications Meds for treating EtOH dependence Meds

  33. Medications Meds for treating opiate dependence • Methadone maintenance • Treatment is highly effective • Must be prescribed in a federally licensed clinic • Buprenoprhine treatment • Also highly effective • Requires 8 CME hours of specialty training (easily available on-line or at in-person trainings) • Psychosocial treatment alone • Not very effective • Illicit drugs other than opiates (marijuana, cocaine, etc): • No medication treatments are proven to enhance sobriety

  34. Role play: Jill Practice • Form groups of three: • Physician • Patient • Observer • Observer: Use the observation sheet and keep track of time

  35. Brief intervention: “Jill” Practice http://www.youtube.com/watch?v=MaxHuf17A44

  36. Role play: “Tom” Practice • Form groups of three: • Physician • Patient • Observer • Observer: Use the observation sheet and keep track of time

  37. Brief intervention: “Tom” Practice http://www.youtube.com/watch?v=1kalMZCelNw&feature=related

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