Harm Reduction Approaches to Substance Use Problems

1. Harm Reduction Approaches to Substance Use Problems By Philip J. Pellegrino, Psy.D. Licensed Psychologist

2. Treatment Models Moral Model Spiritual Model Disease Model Social Learning Model AA/Abstinence Model

3. Moral Model Substance use is viewed as a problem of moral failing, character defect and sin. For the individual to get better, they must make changes in their moral character. Proponents also suggest that coercion and punishment are effective treatment tools (Brickman et al., 1992).

4. The Spiritual Model Substance use problems are viewed as a lack of belief in a higher power. Spiritual principles and belief in a higher power are used to help the person overcome their substance use difficulties (Hester & Miller, 2003).

5. Disease Model Takes a bio-medical approach. This model states that the user suffers from a disease of the brain that does not allow them to be able to control their drinking. Alcoholics and addicts are believed to have predispositions to the disease which is initiated upon the use of the substance.

6. Disease Model (Cont.) The individual is not considered to be responsible for the development of a problem, but is responsible for getting help. The solution is for the person to remain abstinent from substances. The disease model is not a part of the original philosophy of AA/NA. AA/NA are spiritual programs.

7. Social Learning Theory The behavior and attitude of substance use is learned through the individual’s personal experience. Substance use is viewed as a behavior that needs to be modified. Substance use is reinforced by positive feelings. Family/cultural messages about substance use.

8. Social Learning (Cont.) Observational Learning—Substance use is learned by watching others. Substance use can be seen as a learned coping mechanism. Negatively reinforced for the avoidance of negative emotions, which at times is created by use of the substance.

9. Abstinence Model Views any drug use as problematic. The only way to address drug and alcohol use problems is to completely avoid substance use altogether.

10. So What is Harm Reduction? • An approach that minimizes the risks and harm done by substance use. • Long-term goal can be abstinence, which is elimination of harm and risk. • Any steps towards change is an acceptable goal. • Reduction • Safer Use (i.e., clean needles, DD, vaporizors, hydration) • Using in Context

11. What is Harm Reduction? (Cont.) Student self-determination and choice is respected and fostered in this approach. The student is supported to make any positive changes. Harm-reduction attempts to break down barriers to treatment and attempts at making a change.

12. What is Harm Reduction? A biopsychosocial approach. Drug use is initially adaptive. Active users can participate in treatment. (This does not mean they are “high” in session.) This approach is sensitive, non-judgmental, and based on respect for the individual.

13. Harm Reduction is Multidisciplinary! • Harm reduction is not just an approach to drug and alcohol problems. • Exercise is Harm Reduction • Diet is Harm Reduction • DBT is Harm Reduction • Condoms are Harm Reduction • Insulin is Harm Reduction

14. Drug, Set, and Setting Drug—Pharmacology of the drug, route of administration. Set—The personality, mood, and attitude of the person. Setting—The context where use occurs (Who, what, when, and where).

15. Drug, Set, and Setting Drug use is a relationship that is more than the effects of the substance. Culture surrounding drug use has an impact. We must illicit details of the person’s experience. We use this to develop our interventions.

16. Harm Reduction Approaches • Moderation Management • Motivational Interviewing • Needle Exchange • CRAFT • Smart Recovery • Behavioral Self-Control Training • Moderation-oriented Cue Exposure • Guided Self-Change • Behavioral Couples Therapy • BASICS • SBIRT • Mindfulness-Based Relapse Prevention • Trial for Early Alcohol Tx • Medications • Methadone • Suboxone • Naltrexone

17. Moderation Management Both a self-help group and a treatment approach. Teaches moderate drinking strategies. Focuses on individuals who are not alcohol dependent. Participants are asked to sample sobriety. Specific drinking goals and strategies (Rotgers, Kern, & Hoetzel, 2002)

18. Moderation Management (Cont.) Most who choose moderation will later switch to abstinence (Hodgins, Leigh, Milne, & Gerrish, 1997). Provides a treatment option for those who would otherwise be turned off by treatment. Initial sobriety period. Researchers have found a 50% reduction in drinking with similar web-based moderation programs (Hester, et al., 2005).

19. Motivational Interviewing Meet the client where they are, let them set their treatment goals. Moving the individuals towards making any positive change. A non-judgmental, rogerian, client-centered approach.

20. Motivational Interviewing (Cont.) • MI approach • Reflections, open-ended questions, creating cognitive dissonance, enhancing self-efficacy. • MI has been shown to be effective with resistant individuals (Project MATCH Research Group, 1993). • Abundance of studies supporting its efficacy (Miller & Rollnick, 2002).

21. CRAFT Community Reinforcement Approach and Family Therapy Focuses on treating the family member. Goal is to get the individual into tx, reduce substance intake, and increase family member self-efficacy (Smith and Meyers, 2004).

22. Smart Recovery A cognitive-behaviorally based self-help group. Provides the support similar to AA, but is focused on making specific behavioral and cognitive changes related to substance use. Not very prevalent.

23. Behavioral Self-Control Training Focuses on teaching self-monitoring of drinking decisions based on functional analysis. Teaches drink refusal skills. Focuses on rewards and consequences as well as specific drinking goals. Relapse prevention skills.

24. Behavioral Self-Control Training A meta-analysis has shown this approach to be superior to other moderation approaches and abstinence approaches (Walters, 2000).

25. Moderation-Oriented Cue Exposure Based on classical conditioning. Involves exposure to alcohol cues without access to alcohol. The hope is to decrease those cues with drinking. Found to have similar impact as BSCT (Dawe, Reese, Mattick, Sitharthan and Heather, 2002; Heather et al., 2000).

26. Guided Self Change Combines MI and CBT approaches. Is a short, brief intervention that focuses on getting individuals to make their own changes. Emphasizes the self-determination approach to harm reduction. One session found to be as effective as four (Andreasson, Hansagi, and Osterlund, 2002).

27. Behavioral Couples Therapy Couples therapy based on behavioral strategies. Contracting not to drink with SO. Another CBT based approach. Found to be more effective than individualized treatments (Marlatt and Winkiewitz, 2002).

28. BASICS • A brief two session intervention for college students. • First session-assessment • 2nd session-feedback and MI • Found to reduce frequency and amount of drinking. • Also a reduction in harmful drinking behaviors (i.e., driving, shots, binge drinking) (Dimeff, L.A., et al, 1999).

29. SBIRT Conducted by physicians to get patients to enter treatment or reduce use of alcohol and other drugs. Uses the CRAFFT assessment tool. Gives feedback using basic MI skills (Clark et al., 2010).

30. Harm Reduction in Job Corps This is tricky due to the illegality of drugs. We are a Federal Program, therefore we fall under Federal rules. Goal is employability. Positive drug tests lead to employability issues. Alcohol is also a major concern. We can follow the rules, let the guidelines be known, while our interventions can reflect a harm-reduction approach.

31. Alcohol Most of these interventions we reviewed are for alcohol use. Students referred to alcohol infractions may respond well to SBIRT and BASICS. Alcohol is something that students may choose to engage when they turn 21. Addressing how drinking affects employability with harm reduction is highly pragmatic.

32. How Do Students See Drug Use? Some may not be ready to make complete changes. Those who are sober may not be committed to long-term sobriety. Harm-reduction approaches emphasize internal motivation and not abstinence based on avoidance of punishment (What we see in Job Corps). Or avoidance of getting caught!

33. Applying to Job Corps • When our only message is to stop, how does this affect those students who are not ready to make changes? • Do they give us lip service? • Does this close them off to us? • HEALs is about making good decisions and reducing unhealthy behaviors to minimize their harm on the body. • Not only 1 way to change. • Gives TEAP more options when working with students.

34. Medications Naltrexone Acamprosite Methadone Suboxone

35. References Andreasson, S., Hansagi, H., & Osterlund, B. (2002). Short-term treatment for alcohol related problems: Four session guided self-change versus one session of advice. A randomized, control trial. Alcohol, An International Biomedical Journal, 28, 57-62. Brickman, P., Babinowitz, V.C., Karuza J., Jr., Coates, D., Cohn, E. & Kidder, L. (1992). Models of helping and coping. American Psychologist, 37, 368-384. Clark, D.B., Gordon, A.J., Ettaro, L.R., Owens, J.M., & Moss, H.B. (2010). Screening and brief intervention for underage drinkers. Mayo Clinic Proceedings, 85, 380-391. Dawe, S., Reese, V., Mattick, R., Sitharthan, T., & Heather, N. (2002). Efficacy of moderation-oriented cue exposure for problem drinkers: A randomized control trial. Journal of Consulting and Clinical Psychology, 70, 1045-1050. Denning, P. (2000). Practicing harm reduction psychotherapy. New York: Guilford Press. Dimeff, L.A., Baer, J.S., Kivlahan, D.R., Marlatt, A.G. (1999). Brief alcohol screening and intervention for college students: A harm reduction approach. New York: Guilford Press.

36. References Heather, N., Brodie, J., Wale, S., Wilkonson, G., Luce, A., Webb. E. et al. (2000). A randomized control trial of moderation oriented-cue exposure. Journal of Studies on Alcohol, 61, 551-570. Hester, R.K. & Miller, W.R. (2003). Handbook of alcoholism treatment approaches: Effective alternatives, (3rd ed.). New York: Pearson Education Inc. Hester, R.K., Squires, D.D., & Delaney, H.D. (2005). The drinkers check-up: 12 month outcomes of a controlled clinical trial of stand alone software program for problem drinkers. Journal of Substance Abuse Treatment, 28, 159-169. Hodgins, D., Leigh, G., Milne, R., & Gerrish, R. (1997). Drinking goals election in behavioral self-management treatment of chronic alcoholics. Addictive Behaviors, 22, 247-255. Marlatt, A.G. & Witkiewitz, K. (2002). Harm reduction approaches to alcohol use: Health promotion, prevention, and treatment. Addictive Behaviors, 27, 867-886. Miller, W.R. & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nded.). New York: Guilford Press.

37. References Project MATCH Research Group. (1993). Project MATCH: Rationale and method for a multisite clinical trial matching patients to alcoholism treatment. Alcoholism: Clinical and Experimental Research, 6, 1130-1145. Rotgers, F., Kern, M.F., & Hoeltzel, R. (2002). Responsible drinking: A moderations management approach for problem drinkers. Oakland, CA: New Harbinger Publications. Smith, J.E. & Meyers, R.J. (2004). Motivating substance abusers to enter treatment: Working with family members. New York: Guilford Press. Walters, G.D. (2000). Behavioral self-control training for problem drinkers: A meta-analysis of randomized control studies. Behavioral Therapy, 31, 135-149. Witkiewitz, K., and Marlatt, A.G. (2006). Overview of harm reduction treatments for alcohol. International Journal of Drug Policy, 17, 285-294).