Harm Reduction for Managing High Risk Behaviors

1. Supported in part by Arkansas Blue Cross and Blue Shield and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501-406-0076 Event ID: 30121-24581

2. AR-IMPACT Team Members • Michael Cucciare, PhD • Johnathan Goree, MD • Corey Hayes, PharmD • Teresa Hudson, PharmD, PhD • Shona Ray-Griffith, MD • Leah Tobey, PT, DPT • Graduate Student: Andrea Melgar-Castillo

3. Flow of the Case Conferences • General Information: 5 minutes • Topic Presentation: 20 minutes • Case Conference: 25 minutes • Feedback and Thoughts on Future Sessions: 5 minutes

4. AR-IMPACT website: arimpact.uams.edu • AR-IMPACT email address: AR-IMPACT@uams.edu • Twitter: @ArkansasImpact • Joining the Conference: • Click to join: https://join.uams.edu/invited.sf?secret=YtVKQkHsoWTgJaguonymZw&id=415081971 • Or call in: 1-844-885-1319, then enter 415081971

5. Faculty Disclosure of Financial Relationships: The planners of this RSS, Corey Hayes, Michael Cucciare, Johnathan Goree, Leah Tobey, Teresa Hudson, Marti Morrison and Cathy Buzbee have no financial relationships with commercial interests to disclose. A planner of this RSS, Shona Ray-Griffith, MD, has a financial relationship with a commercial interest to disclose: Neuronetics, Inc. – Contracted Research. The speaker of this RSS has no financial relationships with commercial interests to disclose. The accreditation compliance reviewers of this RSS, Karen Fleming and Courtney Bryant, have no financial relationships with commercial interests to disclose.

6. Continuing Education • Accreditation: In support of improving patient care, University of Arkansas for Medical Sciences is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. • Credit Designation: The University of Arkansas for Medical Sciences designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. • The University of Arkansas for Medical Sciences designates this live activity for a maximum of 1 ANCC contact hour. Nurses must attend the entire session in order to receive credit. • This knowledge-based activity will provide pharmacists up to 1.0 contact hours or 0.1 CEU. ACPE# JA0000298-0000-18-040-L01-P • AAFP Credit: Submit your AMA credit • Pharmacists: Please email us your NABP number and month and day of birth

7. Other General Information CISCO IPhone App CISCO Meeting Information Please mute your microphone in CISCO Able to ask questions through CISCO Chat

8. Harm Reduction for Managing High Risk Behaviors Michael A. Cucciare, PhD Psychologist/Associate Professor University of Arkansas for Medical Sciences Text MCUCCIARE737 to 22333 join

9. Disclosures • I have no disclosures to report

10. Today’s Goals • Provide a brief overview of harm reduction • Describe who might (and might not) benefit from this counseling approach and how it works • Describe its main components and strategies used See Blume and Marlatt (2003) Harm Reduction. In W. O’Donohue, J. E. Fisher, and S. C. Hayes (Eds.) Cognitive Behavior Therapy: Applying Empirically Supported Techniques in Your Practice. John Wiley & Sons.

12. Overview • Goals are to: • reduce health risks of a target behavior • focus is not on stopping the behavior (but can be) but modifying the behavior to reduce risks • Developed in the area of substance use due to some substance users feeling marginalized by strict abstinence requirements • Need to develop counseling strategies to reduce consequences associated with people unwilling/able to abstain

13. Examples • Methadone or buprenorphine as an alternative to heroin use • CBT pain management techniques to reduce reliance on opioids • Needle exchange programs that incorporate education

14. Who Might (and Might not) Benefit? • May be helpful for: • People who are unable or unwilling to abstain from substance use • Those who have not done well with therapies that demand abstinence (e.g., those with comorbid disorders or hx of relapses) • May not be helpful for: • Those willing and able to abstain • Those without sufficient skills (e.g., cognitive) to engage in self-directed strategies

15. How Does it Work? • Goal is to protect patient’s health while respecting their goals for behavior change • Provider aids the patient in reaching their goals by teaching appropriate skills/strategies • Success is measured by successive approximations toward reduced health risks

16. Procedures • Step 1: Determine behavior change goal • Identify behavioral target • Assess motivation to change (readiness ruler) • May require Motivational Interviewing (pros and cons)

17. Procedures Cont’d… • Step 2: Self-monitoring • Ask patient to keep daily diaries to monitor substance use • Daily diaries can track time, type, amount, cues and consequences of substance use • Provides data on risky behaviors and suggest points of intervention • Allows patients to objectively reflect on their substance use - can be an intervention in and of itself

18. Procedures Cont’d… • Step 3: Education about the target behavior and its consequences • Exposure to new information about consequences of the risky behavior • Challenge positive expectancies and myths related to drug use - • e.g., walking person through an episode of drug use from taking that “first pill” to the consequences of withdrawal • e.g., for high risk sex, challenging the “that won’t happen to me” myth with data related to infection rates

19. Procedures Cont’d… • Step 4: Agreed-upon intervention strategies • Development of a patient-centered modification plan (including goals for change and strategies used) • In-session, successive approximations toward reduced health risks are reinforced • Harm reduction strategies are introduced and practiced

20. Example Harm Reduction Strategies • Switching - switch to less harmful alternative behavior • Tapering - emphasizing moderate substance use • Pharmacotherapy - help with tapering by alleviating other uncomfortable symptoms (e.g., anxiety or depression) • Structuring time – engage in activities incompatible with drug use; teaching when and where to use drugs more safely • Trial cessation – trial period of abstinence to understand drug use habits, allows cognitive abilities to improve to make better choices

21. Procedures Cont’d… • Step 5 and 6: Monitoring and reevaluating goals, and maintenance • Assess whether goals are being achieved, discuss progress, and change strategies if needed • Teach maintenance strategies (e.g., relapse prevention) once goals are reached

23. In Closing… • Harm reduction may serve as a first step toward abstinence • Pragmatic approach that uses different evidence-based strategies • It is effective, patient-centered and collaborative • May broaden the appeal of counseling for substance use

24. Thank you! Questions/comments?

25. Questions about the Topic Continuing Education Credit: TEXT: 501-406-0076 Event ID: 30121-24581

26. Case Conference and Feedback Continuing Education Credit: TEXT: 501-406-0076 Event ID: 30121-24581