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

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Presentation on theme: "Harm Reduction Approaches to Substance Use Problems By Philip J. Pellegrino, Psy.D. Licensed Psychologist."— Presentation transcript:

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

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

3  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). Moral Model

4  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). The Spiritual Model

5  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. Disease Model

6  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. Disease Model (Cont.)

7  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. Social Learning Theory

8  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. Social Learning (Cont.)

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

10  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 So What is Harm Reduction?

11  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. What is Harm Reduction? (Cont.)

12  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. What is Harm Reduction?

13  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 Harm Reduction is Multidisciplinary!

14  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). Drug, Set, and Setting

15  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. Drug, Set, and Setting

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  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) Moderation Management

18  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). Moderation Management (Cont.)

19  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. Motivational Interviewing

20  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). Motivational Interviewing (Cont.)

21  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). CRAFT

22  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. Smart Recovery

23  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. Behavioral Self-Control Training

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

25  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). Moderation-Oriented Cue Exposure

26  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). Guided Self Change

27  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). Behavioral Couples Therapy

28  A brief two session intervention for college students.  First session-assessment  2 nd 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). BASICS

29  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). SBIRT

30  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. Harm Reduction in Job Corps

31  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. Alcohol

32  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! How Do Students See Drug Use?

33  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. Applying to Job Corps

34  Naltrexone  Acamprosite  Methadone  Suboxone Medications

35  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. References

36  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 (2 nd ed.). New York: Guilford Press. References

37  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). References

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