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Evidence Based Practices: An Overview Desiree MacPhail-Crevecoeur, Ph.D. Integrated Substance Abuse Programs University of California, Los Angeles.

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Presentation on theme: "Evidence Based Practices: An Overview Desiree MacPhail-Crevecoeur, Ph.D. Integrated Substance Abuse Programs University of California, Los Angeles."— Presentation transcript:

1 Evidence Based Practices: An Overview Desiree MacPhail-Crevecoeur, Ph.D. Integrated Substance Abuse Programs University of California, Los Angeles

2 Overview Part One: Addiction as a Chronic Disease –The Addicted Brain –A chronic, relapsing disease Part Two: What are Evidence Based Practices? Part Three: Cognitive Behavioral Therapy Part Four: Motivational Interviewing Part Five: Medically Assisted Treatments

3 Part One: Addiction as a Chronic Brain Disease

4 4 Addiction = Brain Disease Addiction is a brain disease that is chronic and relapsing in nature.

5 5

6 6 How a neuron works

7 7

8 8 The Reward System Natural rewards –Food –Water –Sex –Nurturing

9 9 How the Reward System Works

10 10

11 11 Activating the System with Drugs

12 12 The Brain After Drug Use (1) (Source: McCann et al. (1998). Journal of Neuroscience, 18, 8417-8422.) Control Methamphetamine

13 Partial Recovery of Brain Dopamine Transporters in Methamphetamine Abuser After Protracted Abstinence Normal Control METH Abuser (1 month detox) METH Abuser (24 months detox) 0 3 ml/gm

14 14 The Brain After Drug Use (2) DA = Days Abstinent

15 15 Drugs Change the Brain After repeated drug use, “deciding” to use drugs is no longer voluntary because DRUGS CHANGE THE BRAIN!

16 IOM Quality Chasm Recommendations “Substance use disorder treatment should move toward building its standards of care, performance measurement and quality, information and cost measures upon a chronic illness model rather than the current, acute illness-based, fragmented and deficient system of health care.”

17 Treatment Substance Abusing Patient Non- Substance Abusing Patient Acute Care Treatment Model

18 18 Acute symptoms, Discontinuous treatment Crisis management Resource: Tom Kirk, Ph.D. Traditional Service Approach Symptoms Severe Remission Time

19 NQF Recommendations “Patients treated for Substance Use Disorders (SUD) should be engaged in long-term, ongoing management of their care. Primary medical care providers should support and monitor ongoing recovery in collaboration with the specialty provider who is managing their SUD.”

20 20 Severe Remission Symptoms A Recovery-Oriented Approach Resource: Tom Kirk, Ph.D Continuous Treatment Response Time

21 A Continuing Care Model Detox Substance Abusing Patient Continuing Care Recovering Patient Rehabilitation Duration Determined by Performance Criteria Duration Determined by Performance Criteria

22 1.Medications relieve symptoms but…. behavioral change is necessary for sustained benefit 2.Treatment effects usually don’t last very long after treatment stops. Lessons from Chronic Illness

23 3.Patients who are not in some form of treatment or monitoring are at elevated risk for relapse. In addiction this could include monitoring or AA Lessons from Chronic Illness

24 Summary Drugs affect the brain in ways that are long term but reversible. These brain changes profoundly influence cognition, emotions and behavior. There are multiple forms of treatment that can be effective in treating addicted individuals. Addiction and many psychiatric illnesses are chronic illnesses, and, like other chronic disorders, require continuous ongoing (not episodic) treatment and support.

25 Part Two: Evidence Based Practices

26 26 What are Evidence Based Practices? Interventions that show consistent scientific evidence of being related to preferred client outcomes.

27 27 Evidence Based Practices Standards of Care are Changing It is abundantly clear that not all treatment works, some types show evidence of being more effective than others >1000 clinical trials published in Addiction Cities, states and other funding sources are increasingly demanding the use of EBPs Closer integration of behavior health with healthcare will apply same standards What Defines “Evidence Based Practices” and What Does it Mean to Implement EBT? NIDA Blending Meeting,? November 2006

28 28 Principles of Effective Treatment 1. No single treatment is appropriate for all 2. Treatment needs to be readily available 3. Effective treatment attends to the multiple needs of the individual 4. Treatment plans must be assessed and modified continually to meet changing needs 5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness - NIDA (1999) Principles of Drug Addiction Treatment

29 29 Principles of Effective Treatment 6. Counseling and other behavioral therapies are critical components of effective treatment 7. Medications are an important element of treatment for many patients 8. Co-existing disorders should be treated in an integrated way 9. Medical detox is only the first stage of treatment 10. Treatment does not need to be voluntary to be effective - NIDA (1999) Principles of Drug Addiction Treatment

30 30 Principles of Effective Treatment 11. Possible drug use during treatment must be monitored continuously 12. Treatment programs should assess for HIV/AIDS, Hepatitis B & C, Tuberculosis and other infectious diseases and help clients modify at-risk behaviors 13. Recovery can be a long-term process and frequently requires multiple episodes of treatment - NIDA (1999) Principles of Drug Addiction Treatment

31 31 Examples of Evidence Based Practices Contingency management Medically Assisted Treatment Brief intervention Cognitive–behavioral interventions Community reinforcement Behavioral contracting Motivational enhancement therapy 12-step facilitation

32 32 Part 3: Cognitive Behavioral Therapy (CBT) & Relapse Prevention Strategies One Example of an Evidence Based Practice

33 33 What is CBT and how is it used in addiction treatment? CBT is a form of “talk therapy” that is used to teach, encourage, and support individuals to reduce / stop their harmful drug use. CBT provides skills that are valuable in assisting people in gaining initial abstinence from drugs (or in reducing their drug use). CBT also provides skills to help people sustain abstinence (relapse prevention)

34 34 What is relapse prevention (RP)? RP is a cognitive-behavioral treatment (CBT) with a focus on the maintenance stage of addictive behaviour change that has two main goals: –To prevent the occurrence of initial lapses after a commitment to change has been made and –To prevent any lapse that does occur from escalating into a full-blow relapse Because of the common elements of RP and CBT, we will refer to all of the material in this training module as CBT

35 35 Foundation of CBT: Social Learning Theory Cognitive behavioral therapy (CBT) Provides critical concepts of addiction and how to not use drugs Emphasizes the development of new skills Involves the mastery of skills through practice

36 36 Why is CBT useful? (1) CBT is a counseling-teaching approach well- suited to the resource capabilities of most clinical programs CBT has been extensively evaluated in rigorous clinical trials and has solid empirical support CBT is structured, goal-oriented, and focused on the immediate problems faced by substance abusers entering treatment who are struggling to control their use

37 37 Why is CBT useful? (2) CBT is a flexible, individualized approach that can be adapted to a wide range of clients as well as a variety of settings (inpatient, outpatient) and formats (group, individual) CBT is compatible with a range of other treatments the client may receive, such as pharmacotherapy

38 38 Important concepts in CBT (1) In the early stages of CBT treatment, strategies stress behavioral change. Strategies include: planning time to engage in non-drug related behaviour avoiding or leaving a drug-use situation.

39 39 Important concepts in CBT (2) CBT attempts to help clients: –Follow a planned schedule of low-risk activities –Recognize drug use (high-risk) situations and avoid these situations –Cope more effectively with a range of problems and problematic behaviors associated with using

40 40 Important concepts in CBT (3) As CBT treatment continues into later phases of recovery, more emphasis is given to the “cognitive” part of CBT. This includes: –Teaching clients knowledge about addiction –Teaching clients about conditioning, triggers, and craving –Teaching clients cognitive skills (“thought stopping” and “urge surfing”) –Focusing on relapse prevention

41 41 Foundations of CBT The learning and conditioning principles involved in CBT are: Classical conditioning Operant conditioning Modelling

42 42 Classical conditioning: Addiction Repeated pairings of particular events, emotional states, or cues with substance use can produce craving for that substance Over time, drug or alcohol use is paired with cues such as money, paraphernalia, particular places, people, time of day, emotions Eventually, exposure to cues alone produces drug or alcohol cravings or urges that are often followed by substance abuse

43 43 Classical conditioning: Application to CBT techniques Understand and identify “triggers” (conditioned cues) Understand how and why “drug craving” occurs Learn strategies to avoid exposure to triggers Cope with craving to reduce / eliminate conditioned craving over time

44 44 Operant conditioning: Addiction Drug use is a behavior that is reinforced by the positive reinforcement that occurs from the pharmacologic properties of the drug. Once a person is addicted, drug use is reinforced by the negative reinforcement of removing or avoiding painful withdrawal symptoms.

45 45 Operant conditions (1) Positive reinforcement strengthens a particular behaviour (e.g., pleasurable effects from the pharmacology of the drug; peer acceptance) Punishment is a negative condition that decreases the occurrence of a particular behavior (e.g., If you sell drugs, you will go to jail. If you take too large a dose of drugs, you can overdose.)

46 46 Operant conditions (2) Negative reinforcement occurs when a particular behavior becomes stronger by avoiding or stopping a negative condition (e.g., If you are having unpleasant withdrawal symptoms, you can reduce them by taking drugs.).

47 47 Operant conditioning: Application to CBT techniques Functional Analysis – identify high-risk situations and determine reinforcers Examine long- and short-term consequences of drug use to reinforce resolve to be abstinent Schedule time and receive praise Develop meaningful alternative reinforcers to drug use

48 48 Modeling: Definition Modeling: To imitate someone or to follow the example of someone. In behavioral psychology terms, modeling is a process in which one person observes the behavior of another person and subsequently copies the behavior.

49 49 Basis of substance use disorders: Modeling When applied to drug addiction, modeling is a major factor in the initiation of drug use. For example, young children experiment with cigarettes almost entirely because they are modeling adult behavior. During adolescence, modeling is often the major element in how peer drug use can promote initiation into drug experimentation.

50 50 Modeling: Application to CBT techniques Client learns new behaviors through role-plays Drug refusal skills Watching clinician model new strategies Practicing those strategies Observe how I say “NO!” NO thanks, I do not smoke

51 51 CBT Techniques for Addiction Treatment: Functional Analysis / The 5 Ws

52 52 The first step in CBT: How does drug use fit into your life? One of the first tasks in conducting CBT is to learn the details of a client’s drug use. It is not enough to know that they use drugs or a particular type of drug. It is critical to know how the drug use is connected with other aspects of a client’s life. Those details are critical to creating a useful treatment plan.

53 53 The 5 Ws (functional analysis) The 5 Ws of a person’s drug use (also called a functional analysis) –When? –Where? –Why? –With / from whom? –What happened?

54 54 The 5 Ws People addicted to drugs do not use them at random. It is important to know: –The time periods when the client uses drugs –The places where the client uses and buys drugs –The external cues and internal emotional states that can trigger drug craving (why) –The people with whom the client uses drugs or the people from whom she or he buys drugs –The effects the client receives from the drugs ─ the psychological and physical benefits (what happened)

55 55 Questions clinicians can use to learn the 5 Ws What was going on before you used? How were you feeling before you used? How / where did you obtain and use drugs? With whom did you use drugs? What happened after you used? Where were you when you began to think about using?

56 Functional Analysis or High-Risk Situations Record Antecedent Situation ThoughtsFeelings and Sensations BehaviourConsequences Where was I? Who was with me? What was happening? What was I thinking? How was I feeling? What signals did I get from my body? What did I do? What did I use? How much did I use? What paraphernalia did I use? What did other people around me do at the time? What happened after? How did I feel right after? How did other people react to my behaviour? Any other consequences?

57 57 CBT Techniques for Addiction Treatment: Functional Analysis & Triggers and Craving

58 58 “Triggers” (conditioned cues) One of the most important purposes of the 5 Ws exercise is to learn about the people, places, things, times, and emotional states that have become associated with drug use for your client. These are referred to as “triggers” (conditioned cues).

59 59 “Triggers” for drug use A “trigger” is a “thing” or an event or a time period that has been associated with drug use in the past Triggers can include people, places, things, time periods, emotional states Triggers can stimulate thoughts of drug use and craving for drugs

60 60 External triggers People: drug dealers, drug-using friends Places: bars, parties, drug user’s house, parts of town where drugs are used Things: drugs, drug paraphernalia, money, alcohol, movies with drug use Time periods: paydays, holidays, periods of idle time, after work, periods of stress

61 61 Internal triggers Anxiety Anger Frustration Sexual arousal Excitement Boredom Fatigue Happiness Hunger

62 62 Triggers & Cravings TriggerThoughtCravingUse

63 63 The Clinician’s Role To teach the client and coach her or him towards learning new skills for behavioral change and self-control.

64 64 The role of the clinician in CBT CBT is a very active form of counseling. A good CBT clinician is a teacher, a coach, a “guide” to recovery, a source of reinforcement and support, and a source of corrective information. Effective CBT requires an empathetic clinician who can truly understand the difficult challenges of addiction recovery.

65 65 The role of the clinician in CBT The clinician is one of the most important sources of positive reinforcement for the client during treatment. It is essential for the clinician to maintain a non-judgemental and non-critical stance. Motivational interviewing skills are extremely valuable in the delivery of CBT.

66 66 Match material to client’s needs CBT is highly individualized Match the content, examples, and assignments to the specific needs of the client Pace delivery of material to insure that clients understand concepts and are not bored with excessive discussion Use specific examples provided by client to illustrate concepts

67 67 Repetition Habits around drug use are deeply ingrained Learning new approaches to old situations may take several attempts Chronic drug use affects cognitive abilities, and clients’ memories are frequently poor Basic concepts should be repeated in treatment (e.g., client’s “triggers”) Repetition of whole sessions, or parts of sessions, may be needed

68 68 Practice Mastering a new skill requires time and practice. The learning process often requires making mistakes, learning from mistakes, and trying again and again. It is critical that clients have the opportunity to try out new approaches.

69 69 Clinicians should not expect a client to practice a skill or do a homework assignment without understanding why it might be helpful. Clinicians should constantly stress the importance of clients practicing what they learn outside of the counseling session and explain the reasons for it. Give a clear rationale

70 70 Communicate clearly in simple terms Use language that is compatible with the client’s level of understanding and sophistication Check frequently with clients to be sure they understand a concept and that the material feels relevant to them

71 71 Monitoring Monitoring: to follow-up by obtaining information on the client’s attempts to practice the assignments and checking on task completion. It also entails discussing the client’s experience with the tasks so that problems can be addressed in session.

72 72 Praise approximations Clinicians should try to shape the client’s behavior by praising even small attempts at working on assignments, highlighting anything that was helpful or interesting.

73 73 Example of praising approximations Oh, thanks! Yes, you are right. I will do my best to get all assignments done by next week. I did not work on my assignments…sorry. Well Anna, you could not finish your assignments but you came for a second session. That is a great decision, Anna. I am very proud of your decision! That was a great choice!

74 74 Develop a plan A specific daily schedule: Enhances your client's self-efficacy Provides an opportunity to consider potential obstacles Helps in considering the likely outcomes of each change strategy Nothing is more motivating than being well prepared!

75 75 Stay on schedule, stay sober Encourage the client to stay on the schedule as the road map for staying drug-free. –Staying on schedule = Staying sober –Ignoring the schedule = Using drugs

76 76 Develop a plan: Dealing with resistance to scheduling Clients might resist scheduling (“I’m not a scheduled person” or “In our culture, we don’t plan our time”). Use modeling to teach the skill. Reinforce attempts to follow a schedule, recognizing perfection is not the goal. Over time, let the client take over responsibility for the schedule.

77 Part Four: Motivational Interviewing A second Example of an Evidence Based Practice

78 78 The probability that a person will enter into, continue, and comply with change-directed behavior Definition of Motivation

79 79 Motivational Interviewing Many people who engage in harmful substance use do not fully recognize that they have a problem or that their other life problems are related to their use of drugs and/or alcohol.

80 80 Motivational Interviewing It seems surprising that… people don’t simply stop using drugs, considering that drug addiction creates so many problems for them and their families.

81 81 People who engage in harmful drug or alcohol use often say they want to stop using, but they simply don’t know how, are unable to, or are not fully ready to stop. Motivational Interviewing

82 Understanding How People Change: Models Traditional approach Motivating for change

83 83 Change is motivated by discomfort. If you can make people feel bad enough, they will change. People have to “hit bottom” to be ready for change Corollary: People don’t change if they haven’t suffered enough The Stick The Traditional Approach

84 84 If the stick is big enough, there is no need for a carrot. You better! Or else! The Traditional Approach

85 85 Someone who continues to use is “in denial.” The best way to “break through” the denial is direct confrontation. The Traditional Approach

86 86 Motivation for change can be fostered by an accepting, empowering, and safe atmosphere People are ambivalent about change People continue their drug use because of their ambivalence The carrot Another Approach: Motivating

87 87 Ambivalence

88 88 Ambivalence: Feeling two ways about something. All change contains an element of ambivalence. Resolving ambivalence in the direction of change is a key element of motivational interviewing Ambivalence

89 Why don’t people change?

90 90 that hangovers, damaged relationships, an auto crash, memory blackouts ─ or even being pregnant ─ would be enough to convince a woman to stop drinking. You Would Think…

91 91 that experiencing the dehumanizing privations of prison would dissuade people from re-offending. You Would Think…

92 92 Harmful drug and alcohol use persist despite overwhelming evidence of their destructiveness. Yet…

93 93 It is NOT that… They don’t want to see (denial) They don’t care (no motivation) They are just in the early stages of change. What is the Problem?

94 Why DO people change?

95 95 “Motivation can be defined as the probability that a person will enter into, continue, and adhere to a specific change strategy” (Council of Philosophical Studies, 1981) Motivation is a key to change Motivation is multidimensional Motivation is dynamic and fluctuating The Concept of Motivation

96 96 Motivation is influenced by the clinician’s style Motivation can be modified The clinician’s task is to elicit and enhance motivation “Lack of motivation” is a challenge for the clinician’s therapeutic skills, not a fault for which to blame our clients The Concept of Motivation

97 97 giving ADVICE removing BARRIERS providing CHOICE decreasing DESIRABILITY practicing EMPATHY providing FEEDBACK clarifying GOALS active HELPING General Motivation Strategies

98 98 Ambivalence is normal Clients usually enter treatment with fluctuating and conflicting motivations Clients “want to change and don’t want to change” “working with ambivalence is working with the heart of the problem” The Concept of Ambivalence

99 99 What you do depends on where the client is in the process of changing The first step is to be able to identify where the client is coming from Where Do I Start?

100 100 Prochaska & DiClemente Stages of Change

101 101 People at this stage: Are unaware of any problems related to their drug use Are unconcerned about their drug use Ignore anyone else’s belief that they are doing something harmful Primary task– Raising Awareness Precontemplation Stage

102 102 In this stage the patient sees the possibility of change but is ambivalent and uncertain They enjoy using drugs, but: –Worried about the increasing problems of their use. –Debating with themselves whether or not they have a problem. Primary task: Resolving ambivalence and helping the client choose to make the change 102 Contemplation Stage

103 103 In this stage the patient is committed to changing but is still considering exactly what to do and how to do it Primary task: Help client identify appropriate change strategies 103 Determination Stage

104 104 In this stage the patient is taking steps toward change but hasn’t stabilized in the process Primary task: Help implement the change strategies and learn to limit or eliminate potential relapses 104 Action Stage

105 105 Definition A stage in which the patient has achieved the primary tx goals and is working to maintain them Primary task Patient needs to develop new skills for maintaining recovery Maintenance Stage

106 106 People at this stage have reinitiated the identified behaviour. People usually make several attempts to quit before being successful. The process of changing is rarely the same in subsequent attempts. Each attempt incorporates new information gained from the previous attempts. Relapse

107 107 Someone who has relapsed is NOT a failure! Relapse is part of the recovery process. Relapse

108 108 Helping people change involves increasing their awareness of their need to change and helping them to start moving through the stages of change. –Start “where the client is” –Positive approaches are more effective than confrontation – particularly in an outpatient setting. Helping People Change

109 “People are better persuaded by the reasons they themselves discovered than those that come into the minds of others” Blaise Pascal

110 110 “MI is a directive, client-centered method for enhancing intrinsic motivation for change by exploring and resolving ambivalence” (Miller and Rollnick, 2002) “MI is a way of being with a client, not just a set of techniques for doing counseling” (Miller and Rollnick, 1991) Motivational Interviewing (MI)

111 111 Strategy Goals Resolve ambivalence Avoid eliciting or strengthening resistance Elicit “Change Talk” from the client Enhance motivation and commitment for change Help the client go through the Stages of Change Motivational Interviewing

112 112 The Style Nonjudgmental and collaborative based on client and clinician partnership gently persuasive more supportive than argumentative listens rather than tells communicates respect for and acceptance for clients and their feelings Motivational Interviewing

113 113 The Style (Continued) Explores client’s perceptions without labeling or correcting them No teaching, modeling, skill-training Resistance is seen as an interpersonal behavior pattern influenced by the clinician’s behavior Resistance is met with reflection Motivational Interviewing

114 114 Important Considerations The clinician’s counseling style is one of the most important aspects of motivational interviewing: - Use reflective listening and empathy - Avoid confrontation - Work as a team against “the problem” Motivational Interviewing

115 115 Motivating for change Pre-contemplation Contemplation Determination/ Preparation Action Maintenance Motivational Interviewing

116 116 Motivational interviewing is founded on 4 basic principles: 1.Express empathy 2.Develop discrepancy 3.Roll with resistance 4.Support self-efficacy Principles of Motivational Interviewing

117 117 Principle 1: Express Empathy The crucial attitude is one of acceptance Skilful reflective listening is fundamental to the client feeling understood and cared about Client ambivalence is normal; the clinician should demonstrate an understanding of the client’s perspective Labeling is unnecessary Principles of Motivational Interviewing

118 118 I am so tired, but I cannot even sleep… So I drink some wine. You drink wine to help you sleep. …When I wake up…it is too late already… Yesterday my boss fired me. So you’re concerned about not having a job....but I do not have a drinking problem! Examples of Expressing Empathy

119 119 Principle 2: Develop Discrepancy Clarify important goals for the client Explore the consequences or potential consequences of the client’s current behaviors Create and amplify in the client’s mind a discrepancy between their current behavior and their life goals Principles of Motivational Interviewing

120 120 Well…as I said, I lost my job because of my drinking problem…and I often feel sick. I enjoy having some drinks with my friends…that’s all. Drinking helps me relax and have fun…I think that I deserve that for a change… So drinking has some good things for you…now tell me about the not-so-good things you have experienced because of drinking. Example of Discrepancy

121 121 Principle 3: Roll with Resistance Avoid arguing against resistance If it arises, stop and find another way to proceed Avoid confrontation Shift perceptions Invite, but do not impose, new perspectives Value the client as a resource for finding solutions to problems Principles of Motivational Interviewing

122 122 You do not have the right to judge me. You don’t understand me. I do not want to stop drinking…as I said, I do not have a drinking problem…I want to drink when I feel like it. But, Anna, I think it is clear that drinking has caused you problems. Example of NOT Rolling with Resistance

123 123 That’s right, my mother thinks that I have a problem, but she’s wrong. I do not want to stop drinking…as I said, I do not have a drinking problem…I want to drink when I feel like it. You do have a drinking problem Others may think you have a problem, but you don’t. Example of Rolling with Resistance

124 124 Principle 4: Support Self-Efficacy Belief in the ability to change (self-efficacy) is an important motivator The client is responsible for choosing and carrying out personal change There is hope in the range of alternative approaches available Principles of Motivational Interviewing

125 125 I hope things will be better this time. I’m willing to give it a try. I am wondering if you can help me. I have failed many times... Anna, I don’t think you have failed because you are still here, hoping things can be better. As long as you are willing to stay in the process, I will support you. You have been successful before and you will be again. Example of Supporting Self-Efficacy


127 Part Five: Medically Assisted Treatment A Third Example of an Evidence Based Practice

128 Considerations If addiction is a chronic, relapsing, sometimes fatal illness, why are we still treating it like an academic deficit? If addiction is a disease and there is effective medication for it, then to withhold it is malpractice.

129 NQF Recommendations Pharmacotherapy: Medications should be recommended and available to all adult patients with: –opioid or alcohol dependence and directly linked with comprehensive clinical services –nicotine dependence and directly linked with brief counseling.

130 Pharmacotherapy Psychosocial therapy is often integral to the success of pharmacotherapy, addressing psychological and social issues that might, if left untreated, contribute to relapse after pharmacotherapy is complete.

131 Pharmacotherapy A variety of classes of drugs are effective in treating SUD through multiple mechanisms including: –Suppressing withdrawal and discomfort and pain that accompany it –Reduce craving –Blocking the effects of substance use

132 Alcohol Dependence

133 Pharmacotherapy for Alcohol Dependence Target Outcome Reduction of alcohol consumption with the goal of cessation Retention in treatment Goals Treatment of withdrawal (“detox”) Reduction of cravings and urges Substitution therapy

134 Pharmacotherapy for Alcohol Dependence Target Population All non pregnant (18 and older), current alcohol dependent patients Special considerations should be given before using pharmacotherapy with selected populations –Those with medical contradictions, pregnant/breast feeding women, adolescents and the elderly.

135 Pharmacotherapy for Alcohol Dependence FDA-Approved: –Disulfuram (Antabuse) –Oral naltrexone (Revia) –Intramuscular naltrexone (Vivitrol) –Acamprosate (Campral)

136 IM Naltrexone (Vivitrol) FDA approved 2006 Dose: 380 mg intramuscular once monthly Mechanism: opioid receptor antagonist Results: Decreased heavy drinking days, decreased frequency of drinking

137 Opioid Dependence

138 Pharmacotherapy for Opioid Dependence Target Outcome Cessation of non-medical use of opioids Retention in Treatment

139 Pharmacotherapy for Opioid Dependence Target Population All adult (and adolescents 16 and older) patients diagnosed with opioid dependence who meet clinical and regulatory indications; may consider for adolescents as clinically indicated Special considerations should be given before using pharmacotherapy with selected populations –Those with medical contradictions, pregnant/breast feeding women, adolescents and the elderly.

140 Opioid Pharmacotherapy Goals Detoxification: –Opioid-based agonist (methadone, buprenorphine) –Non-opioid based (clonidine, supportive meds) Relapse prevention: –Agonist maintenance (methadone) –Partial agonist maintenance (buprenorphine) –Antagonist maintenance (naltrexone) Lifestyle and behavior change

141 Opioid Detoxification Medications used to alleviate withdrawal symptoms: Opioids (methadone, buprenorphine) Clonidine Other supportive meds –anti-diarrheals, anti-nausea agents, ibuprofen, muscle relaxants, anxiolytics

142 Opioid Substitution Goals Reduce symptoms and signs of withdrawal Reduce or eliminate craving Block effects of illicit opioids Restore normal physiology Promote psychosocial rehabilitation and non-drug lifestyle

143 Buprenorphine for Opioid Dependence FDA approved 2002, age 16+ Mandatory certification from DEA (100 pt. limit) Mechanism: partial opioid agonist Office-based, expands availability Analgesic properties Ceiling effect Lower abuse potential Safer in overdose

144 Buprenorphine Formulations Subutex (Buprenorphine) -2mg, 8mg Suboxone (4:1 Bup:naloxone) -2mg/0.5 mg, 8mg/2mg Dose: 2mg-32mg/day sublingually

145 Pharmacotherapy Pharmacotherapy should be a standard component when effective drugs exist.

146 What Pharmacotherapy Entails Medications that have been proven to be effective for ongoing treatment of –Opioid dependence (buprenorphine, methadone, etc) –Alcohol dependence (naltrexone, acamprosate, etc.) –Tobacco Cessation (nicotine replacement therapy, bupropion, etc) Provided in adequate doses to control cravings Controlled dispensing of doses (for opioid dependence)

147 What Pharmacotherapy Entails Regular biological monitoring of illicit drug use. Monitoring response/side effects Adjusting of doses when indicated. Monitoring of medical status, including coexisting conditions and medications. Provisions of empirically validated psychosocial treatment or psychosocial support (including medical management).

148 Pharmacotherapy Who Should Perform It? Health care workers licensed to prescribe medication Healthcare workers authorized to initiate and guide the treatment of alcohol and opioid dependent patients should offer pharmacotherapy Providers who do not prescribe pharmacotherapy should have formal arrangements to refer patients for pharmacotherapy treatment.

149 Pharmacotherapy Where Should It be Performed? Substance use illness specialty settings. General and mental healthcare settings where patients are treated for substance use and illness. If dispensing medications, must been regulatory requirements at the state and federal levels.

150 Questions? Comments?

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