Motivation in Addiction Medicine Practice

Psychotherapy in Small Doses

James Finch, MD

Governor’s Institute on Substance Abuse

Changes By Choice, Durham, NC

Objectives

Define a time efficient, motivational approach to the Addiction Medicine encounter.

Define a reasonable “standard of care” for brief MAT follow-up visits.

Outline basic elements of “psychotherapy” as they apply to this time-limited but longitudinal setting.

Describe what we can learn and apply from Cognitive Behavioral and Motivational approaches.

“Two-year experience with buprenorphine-naloxone for maintenance treatment of opioid-dependence within a private practice setting”

• Office based setting • Mid-size urban community sample in North Carolina• Mixed prescription opioid and illicit opioid dependent patients• Minimal staff resources (solo practice)• Standard visits: 45-60 min initial, 15-20 min follow-up• Used standard community referral resources

Finch JW, Kamien KB, Amass L, J of Addiction Medicine, 2007.

Clinical Sample (n=71)

Patient Characteristics: Age: 16-62 (mean 32) Gender: 69% male Employed: 70%

Opioid dependence history: Heroin: 51% Prescription analgesics: 49% Years of dependence: 1-18 (mean 4.3)

Mean Suboxone Maintenance Doses

Months in Treatment0

2

4

6

8

10

12

14

2 4 6 8 10 12 14 16 18 20 22 24

Su

boxon

e D

ose (

mg

/day)

Rates of Opioid Abstinence

0%

20%

40%

% N

eg

ati

ve

0%

20%

40%

60%

80%

100%

1 2 3 4 6 8 10 12 14 16 18 20 22 24Treatment Month

% N

eg

ati

ve 2 tests/month

Pre

Participation in counseling

Overall rate of involvement in supportive psychosocial therapy: 58%

Kinds of supportive counseling:

Individual or group: 68% Psychiatric follow-up/med mgmt: 29% Drug treatment program: 7% Peer support/12 Step: 2%

The “COMBINE” Study

Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence: A Randomized Controlled Trial

Anton, RF, O’Malley, SS, et al. JAMA, May 2006

Groups randomized to med management with naltrexone, acamprosate, both and/or both placebos, with or without a combined behavioral intervention (CBI). One group with CBI only.

Evaluated for up to one year after treatment.

The Combine Study: Outcomes

Patients receiving medical management with naltrexone, CBI or both fared better on drinking outcomes.

No combination produced better efficacy than naltrexone or CBI alone in the presence of medical management.

Placebo pills and meeting with a health care professional had a positive effect above that of CBI alone during treatment.

Medical Management (MD, RN, PA): Initial 45 min visit, followed by 20 min visits, on week 1 and 2 and then every 2 to 4 weeks.

Medication Assisted Treatment for Primary Addiction Treatment

Demonstrated efficacy and FDA approval: Alcohol:

disulfiram, naltrexone, acamprosate Nicotine:

nicotine replacement, buproprion, varenicline Opioids:

agonist: methadone, buprenorphine/naloxone antagonist: naltrexone

Investigational but preliminary findings of efficacy: Cannabinoids Cocaine and other stimulants

Routine Elements of Medication Assissted Treatment (MAT) Follow-up

Assess response to med: Efficacy/Side-Effects

Assess abstinence (primary and other drugs)

Assess overall stability (bio/psycho/social)

Reinforce participation in counseling/peer-support

Problem solve/provide advice/support recovery

Roles of the Addiction Medicine Physician in Relation to Counseling

Apply knowledge of therapeutic alternatives available for referral

Understand and support the elements of cognitive behavioral therapy and peer-support

Apply counseling skills within the setting of the medical encounter

Psychosocial Therapeutic Support Alternatives

Mutual peer-support groups Faith-based support groups Individual and/or group therapy Cognitive Behavioral Therapy (CBT) Motivational Enhancement Therapy Incentive Based Therapy Coping Skills Development (DBT) Trauma Processing Therapies (EMDR) Anger Management Therapies Relaxation/Meditation

Common Elements of CBT for Substance Abuse

1. Drug Refusal Skills Training 2. Managing Negative Thinking 3. Managing Thoughts About Using 4. Managing Negative Moods and Depression 5. Effective Problem Solving 7. Seemingly “Irrelevant” Decisions 8. Alcohol and Other Drug Use 9.Coping with Anger 10.Progressive Muscle Relaxation/Meditation11.Managing Insomnia12.Giving and Receiving Criticism 13.Sharing Feelings 14.Vocational Counseling 15.Financial Management 16.Time Management 17.Relationship Counseling18.Taking Responsibility for Choices

Potential counseling roles for the medical clinician

Psychotherapist Counselor Coach Guide

Do we want to take on a counseling role? Do we want to stay in a traditional medical role?

Types of Power for Behavior Change Inherent in the Clinical Encounter

Reward: ability to give people what they want or need

Coercive: disapproval, denying requests, not seeing

Referent: the “admired other”, role-model

Legitimate: validated authority

Expert: access to knowledge, training, information

5 Basic Elements of Psychotherapy

Expectation of receiving help Therapeutic relationship Obtaining external perspective Encouraging corrective experiences Opportunity to test reality

“Psychotherapy means a form of treatment of mental illness or emotional disorders which is based primarily on verbal interaction with the client.”

NC Dept MH/DD/SAS

“the efficacy of psychotherapeutic methods lies in the shared belief of the participants that these methods will work.”

JD Frank

Core Elements of CBT: Recognize/Avoid/Cope

Recognize: triggers/cues (external/internal)

Anticipate/Avoid: (situations/people/places)

“People/Places/Things”

“Playmates/Playgrounds/Playthings”

“Play the tape to the end.”

“It is easier to avoid temptation,

than to resist temptation”.

Core Elements of CBT:Recognize/Avoid/Cope

Cope: develop or reinforce skills:

Explore other ways to relax/deal with stress/problem solve

Re-expand dormant behavioral options to socialize/have fun

Connect/re-connect with sources of reward

and “hedonic tone”

“Who needs life when you’ve got heroin.” (Trainspotting)

Rebuild/Reward

“How come if alcohol kills millions of brain cells, it never killed the ones that made

me want to drink?”

Anonymous

Editing the Patient’s “Story”

The language of the story: generalizations/delitions/distortions

Therapeutic interventions:

Challenging “learned helplessness”

Reinforcing the power of “yet”

Supporting “self-efficacy”

MotivationaI Interviewing (MI) aims to help the client…

Enhance intrinsic motivation for change (mobilize client’s own change resources)

Recognize the need to do something about the current or potential problem

Resolve ambivalence and reach a decision for change

Build commitment to change

Nn

Transtheoretical Model

Determination

Relapse

Pre-contemplation

Contemplation

Maintenance

Action

Termination

SynonymsDetermination = Preparation

Termination = ExitProchaska and DiClemente

Continuum of Communication Styles

Directing Guiding

Following

Directing

PrescribeTellShow the wayLeadManagePoint towardConduct SteerDetermine

Take commandPresideRuleTake chargeAuthorizeGovernTake the reinsPushAdminister

Following

ListenAttendUnderstandObserveTake inBe responsiveTrustGo along

Be withShadowPermitAllowSupportHave faith in

Guiding

EnlightenEncourageMotivateAwakenLay beforeCollaborateInvolve

Take alongLook afterAccompanyElicitEvokeOffer optionsInvite

In practice and in management…

There is an appropriate role for directingThere is an appropriate role for followingBut when your goal is behavior change, the optimal style

is usually guiding

William Miller

A Guiding Style…

Reduces resistance (relative to a directing style)Improves working allianceEnhances openness to consider changeFacilitates behavior changeIncreases self-regulation and internalization of

change

“More like dancing than wrestling.” William Miller

Two Stages of Motivational Interviewing

Phase 1: Building Motivation for Change

Phase 2: Strengthening Commitment to Change

Four Basic Principles

Express Empathy Focus on understanding the person’s dilemma

Roll with Resistance Don’t be the one arguing for change

Develop Discrepancy Evoke the person’s own arguments for change

Support Self-Efficacy Encourage belief that change is possible

Change Talk

Change talk is any client speech that favors movement in the direction of change

Previously called “self-motivational statements”

Change talk is by definition linked to a particular behavior change target

Preparatory Change Talk

DESIRE to change (want, like, wish . . ) ABILITY to change (can, could . . ) REASONS to change (if . . then) NEED to change (need, have to, got to)

Sustain Talk

The other side of ambivalence.

I really like alcohol/oxy/weed I don’t see how I could give it up I need to use to be social I intend to keep using/no one can stop me I don’t think I have to quit I can drink/use once in a while

Implementing Change Talk

Reflects resolution of ambivalence.

COMMITMENT (intention, decision, readiness)

ACTIVATION (willing, trying, preparing) TAKING STEPS

Resources

Motivational Interviewing by William Miller CSAT TIP 35: Enhancing Motivation for Change in

Substance Abuse Treatment The 15 Minute Hour by Stuart and Lieberman Treating Alcohol Dependence: A Coping Skills

Training Guide by Monti, et al. www.SA4Docs website ASAM trainings and involvement

“…alcoholics recover not because we treat them but because they heal

themselves.”

George Vaillant

The Natural History of Alcoholism, 1983

You can’t always get what you want…

But if you try sometimes…

You get what you need.

Mick Jagger, The Rolling Stones, 1969

JWF: The Vintage Image Gallery

JWF: The Vintage Image Gallery