Substance Use Disorders 101 for Primary Care Providers Ariel Singer MPH Northwest Addiction Technology Transfer CenterOHSU Anderson Rice LPC CADC I Kaiser Permanente Addiction Medicine ID: 800698
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Slide1
The Hook, The Cage and the Empty GlassSubstance Use Disorders 101 for Primary Care ProvidersAriel Singer, MPH – Northwest Addiction Technology Transfer Center/OHSUAnderson Rice, LPC, CADC I – Kaiser Permanente Addiction Medicine
Slide2The Voice of Addiction“I don’t have an ‘off’ switch…one is too many and a thousand is not enough.”“Incomprehensible demoralization”
“It’s a disease that tells you
you
don’t have a disease.”
“I really did not get how I could be an addict when I had been successful in all
other
areas of my life – it didn’t make sense. However, no matter how hard
I
tried, I couldn’t moderate. I just couldn’t control it.”
“
My addiction took everything from me
.”
“My substance use was relief from the pain, but it quit working.”
Slide3Definitions of AddictionASAM: Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.http://www.asam.org/for-the-public/definition-of-addiction
Gabor
Maté
:
Any
repeated behavior, substance related or not, in which a person feels compelled to persist, regardless of its negative impact on his or her life and the lives of others
.
Slide4Addiction in Clinical PracticeThe 4 C’sLoss of ControlCompulsive use
C
ontinued use despite harms
C
raving
Savage SR, et al. J Pain Symptom Manage. 2003;26:655-667.
Slide5DSM V: 11 Criteria for SUDs Diagnosis on a Continuum of SeverityTaking substance in larger amounts for
longer than
intended
Wanting to cut down or stop
using,
but not managing to
Spending a lot of time getting, using, or recovering from use
Cravings and urges to use the substance
Not managing to do what you should at work, home or
school
Continuing to use, even when it causes problems in relationships
Giving up important social, occupational or recreational activities
Using again and again, even when it puts the you in dangerContinuing to use, when you have a physical or psychological problem that could have been caused or made worse by useNeeding more of the substance to get desired effect (tolerance)*Development of withdrawal symptoms; relieved by taking more of the substance.*
Mild (2-3 ) Moderate (4-5) Severe (6+)
*Not counted in SUD diagnosis if symptoms of tolerance or withdrawal occur during appropriate medical treatment with prescribed medications.
Slide6Physiologic Dependence Vs. Addiction
Physical Dependence
Tolerance
Physiologic adaptations
to chronic opioid therapy
Addiction
Maladaptive behavior
associated with opioid misuse
Savage
SR,
et al. J Pain Symptom Manage. 2003 Jul;26(1):655-67.
Slide7The Spectrum of Substance Use Disorders
Slide8SAMHSA. Results from the 2013 National Survey on Drug Use and Health:Summary of National FindingsPast Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older
Slide9Policy Drivers of Substance Use Disorders and TreatmentKoob, CSAM Addiction Medicine Review Course, 2014
Slide10Policy/Environmental Drivers of SUD and TreatmentAlcohol Dependence was last among 30 medical conditions in proportion of care received as evidence would recommendMcGlynn
E. et al.
NEJM,
2003
Slide11Like other chronic illnesses…Genetic, personal-choice, and environmental factors Behavioral change is an important part of treatmentRelapse and medication adherence issuesComply with treatment and medications = better outcomesNo reliable cureOlder, employed with stable families = better outcomesReasonably predictable course
McLellan A T
, et al.
Drug dependence, a chronic medical illness:
Implications
for treatment, insurance, and outcomes evaluation.
JAMA
. 2000;284(13):1689–1695
Slide12The Ups and Downs of Chronic DiseaseTimeDisease Activity
Asthma, Diabetes, HTN, HIV, etc.
Substance Use Disorder
O’Connor, JAMA 1998
Lucas, JAIDS 2005
Slide13A Chronic Illness Exacerbated by StigmaPeople with SUDs have had a history of being ignored War on drugs = war on drug addictsAcute episodic response has been the historical treatment paradigmAA was a response to the lack of treatment options and sustains stigma and marginalization through its anonymity
Slide14We are moving from saying, “this is a personal failure...”
To saying, “there is a light at the end of this tunnel…”
Slide15“And if you want to, we can walk towards it together…”
Slide16The Hook, the Cage and the Empty Glass
Slide17The HookThe pharmacologic explanation of addictionAddiction attributable to intrinsic property of the substance
The Cage
Family history of SUD
Co-occurring MH Disorders
ACES
Social Determinants of Health
The Empty Glass
Unquenchable
need for
relief
Often
substituted
Slide18The Cage - Rat Parkwww.brucekaleander.com, Addiction: The View from Rat Park
, ,Professor Emeritus, Simon Fraser University
Slide19“Nothing is addictive within itself” Gabor Mate’
Slide20Remedy SeekingAddictive behaviors are a way of controlling an experience through external remediesNo external remedy improves a condition without internal or external consequencesDifferentiate between the disease model vs a normal response to pain
“We must acknowledge what is right about addiction, not what is wrong…”
Gabor
Maté
Remedies provide…
A
sense of control
A sense of fulfillment
Relief from real pain
A way to increase the threshold for tolerance
Slide21Remedy-Seeking and the Thin LineSeen as a way towards love and vitalityReplaces genuine intimacy, compassion or honest endeavors to thriveParamount to other ways to self remedyCompulsiveness Impairment Persistence
The question to be asking is not “why the addiction….”
Slide22But, “why the pain?” (Maté)Marginalization
Racism
Poverty
Lack of access
Adverse history
Socio-economic inequality
Distress of daily living
Loss
Physical
pain
Emotional pain
Slide23SUD Treatment: Check the Cage, Minimize the Hooks and Fill the GlassBehavioral Treatments: CBT, DBT, ACT, Seeking Safety, Contingency Management, etcMedication Assisted Treatment (MAT) for Opioid and Alcohol Use DisordersRecovery-Oriented Systems of CareAnd when treatment is not an option…Harm Reduction – a palliative approach
Slide24Substance Use Disorder MedicationsUnderutilized because of StigmaAlcohol Use DisorderNaltrexoneAcamprosate
Disulfiram
Opioid Use Disorder
Methadone
Buprenorphine
Naltrexone
Barriers to MAT
Lack of understanding of the medications
Organizational philosophy/staff beliefs about use of medications;
Cost of medications
Lack of appropriate staffing in treatment
centers
Slide25Harm ReductionMeeting our patients where they are atMedication Assisted Treatment is not harm reductionRespectHonoring personal autonomyReduction in drug related harm Comfort Care
Slide26Before any treatment can occur a full Biopsychosocial assessment must take place. Data is gathered in 6 dimensions to determine the appropriate level of care: ↓Dimension 1 – Acute Intoxication and/or Withdrawal PotentialDimension 2 – Biomedical Conditions and ComplicationsDimension 3 – Emotional, Behavioral or Cognitive Conditions and ComplicationsDimension 4 - Readiness to ChangeDimension 5 – Relapse, Continued Use or Continued Problem PotentialDimension 6 – Recovery Environment
Is there a DSM – 5 diagnosis based on a thorough assessment?
Example: Alcohol Use Disorder – Mild, Moderate, or Severe
Inside the Black Box: What Treatment Looks Like
Slide27Continuum of Care – patients enter treatment at a level appropriate for their needs and step up for more intense treatment or down for less intense treatment. Level 1Level 2Level 3Outpatient Treatment 1 treatment
encounter/week
Intensive Outpatient Treatment
3-5 treatment encounters/week
Residential/Inpatient
2 weeks to one year
Slide28Residential Treatment - may need detox before residentialFocus on:
Stabilization
Acceptance
Skill building
Becoming relational
Relapse prevention planning
Possible housing/job skills
Slide29Group FocusEducation Alcohol/Drug educationRelapse Prevention
Mindfulness/Stress Reduction
DBT/CBT
Neuroscience of Addiction
Diet/Sleep/Daily living activities
Co-Occurring MH education
Anxiety, Depression, ADD, PTSD, etc.
Family Education
Therapeutic Process Groups
Slide30What was important about residential?“It gave me a safe and structured place to go through withdrawal. It gave me the first glimpse of myself sober – the good and the not so good – that I had had in over a decade. I went in to residential thinking my only problem was an addiction to meth. I came out convinced I was an addict. Writing a list of ten insane behaviors, which had to be whittled down from about ten thousand, convinced me that addiction was a disease, because there is no way
any
sane person could have done all the things I did and
made
all the choices I did, night after night,
year
after year, for my next hit.
Residential
treatment also gave
me a
first taste of what it means to follow
direction
, trust in my counselors and guides, and to connect to other addicts. - Kaiser patient/38 yr old male
Slide311-5 treatment encounters per weekGroup education and processIndividual counseling and treatment planning
Integration of recovery efforts with daily life
Consistent support and structure through changes
Outpatient Treatment
Slide32Ongoing Relapse Prevention skillsMindfulnessCognitive Behavioral TherapyDialectical Behavioral Therapy
Motivational Enhancement
Seeking Safety/Mental Health
Slide33What was your treatment experience in an outpatient program?“Well, obviously it provided a safe space for the months it took for my emotions and brain to calm down, and to engage many of the issues and problems that fueled my using in the first place. It taught me what it means to be honest and to value and respect the honesty of others, to let everyone have their own process and honor that. It has been the most thorough schooling in addiction I can imagine; every day in group brings a list of lessons about how this disease works,
the
different forms it can take with different drugs of choice or different people, the unique challenges addicts face,
the
skills they can use, and the stages of addiction or recovery. It provided needed structure and a more directly
engaged process
than twelve-step groups, though I think those groups are absolutely necessary for developing community,
finding
support, and rebuilding a new way of life.”
- Kaiser Patient/38 yr old male
Slide34Integration of community supports:AA, NA, MA, CA, CMA, HA, GA, DAA, SAA, SA, SMART, Alcoholics Victorious, Celebrate Recovery,
WFS
, Refuge Recovery, etc.
Many options – all road tested by others
Slide35One of the biggest challenges in early recovery is ________ ? Staying focused. Making it through the emotions. And the confusion. Being told again and again, “More will be revealed.” - Kaiser patient/38 yr old male
Slide36Strong System SupportBiopsychosocial AssessmentMotivational InterviewingAdvocacy Psycho-educationCare CoordinationFollow upRx Adherence & SupportCommunity resource educationTx planning and goal settingMulti-systemic settings and multidisciplinary assessments
Slide37What can you do about it?Screening
Referral to Treatment
Brief Intervention
“A public
health approach to the delivery of early intervention and treatment services for people with substance use disorders and those at risk of developing these
disorders.”
SAMHSA
Slide38SBIRT implementedNo SBIRT
Routine and universal screening, regardless of medical complaint
Inconsistent and selective screening
Validated, standardized screening tools
Non‐systematized narrative
questions
Alcohol use seen as a continuum
Alcohol use seen as dichotomous
Evidence-based, patient-centered change talk
Ineffective, directive style of communication
Ongoing transition between primary care and treatment
Discoordinate/unclear referrals and
follow up
SBIRT vs. business as usual
Slide39Brief Intervention at a Glance
Slide40Feeling Two Ways about SomethingNon-compliant
Ambivalent
Slide41Does this look familiar?
Slide42What Change Actually Looks Like
Slide43Whose life is it anyway?
Slide44Resist the Righting Reflex
Slide45How to “FRAME” What You SayF – FeedbackR – ResponsibilityA – AdviseM – MenuE – EmpathyS – Self-efficacy
Slide46How to “FRAME” What You SayF RA ME
S
“The results of your questionnaire indicate that your use of alcohol puts you at risk from problems due to drinking.
Of course, any decisions regarding a change are yours to make.
As your doctor,
I
would like to share some advice with you on modifying
your drinking
habits – would that be ok?
I want you to know that we have a lot of options to help you, should you decide to make a change.. I know that change can be difficult and at the same time, I am confident that if you decide to change you will be able to do so. Would you like to talk about some options that we have for supporting you in this?”
Slide47How to “FRAME” What You SayF – FeedbackR – ResponsibilityA – AdviseM – MenuE – EmpathyS – Self-efficacy
What they’ve told you
It’s their choice
Be clear, you’re the
medical
expert
Lots of options
Give them hope
Be genuine
Slide48F. What do you already know about how ______ affects your health? Would it be ok if I share some information with you about ______? How does this affect your thinking?R. These are always your choices to make and I am very interested to hear your thoughts.A.
From a medical standpoint, it would be better for your health to_______.
M.
What are some things you have considered for making this change? Why
might you want to _______?
E.
What
are the three most important benefits for you to
____? How
important is it for
you, on a scale of 0-10, to
make this
change? Why are you at a ___ and not a lower number? If you did decide to ______, how would you do it?S. Your willingness to talk about this today shows how important this is to you and I am confident that you can make progress towards the goals that you have for your health. What do you think your next step might be?
Let’s Practice!