1. © Alcohol Medical Scholars Program1 Motivational Interviewing Regarding Substance Use in the Medical Setting John M. Wryobeck, Ph.D

2. © Alcohol Medical Scholars Program2 SUD in the Medical Setting ~ 30 % ED Pts have AUD 50% trauma Pts, + for drugs 24% hospital admits have AUD 33% non-trauma admits related to AUD

3. © Alcohol Medical Scholars Program3 SUD in the Medical Setting ~ 20% medical clinic Pts have AUD SUD among top 3 diseases worldwide SUD related to many injuries/disease

4. © Alcohol Medical Scholars Program4 SUD Interventions External motivation Education – information motivates change Persuasion – logic motivates change Elicit internal motivation Explore Pts knowledge/thoughts about change

5. © Alcohol Medical Scholars Program5 This Lecture Reviews Definition & Principles Basic Skills of MI Basic Steps of MI Research supporting MI

6. © Alcohol Medical Scholars Program6 Definition & Principles Directing style 1 active participant –Manage –Lead –Take charge –Go along Guiding style 2 active participants –Enlighten –Encourage –Support –Elicit

7. © Alcohol Medical Scholars Program7 Principles - Ambivalence Ambivalence is normal Persuasion & confrontation avoided Elicit/reinforce own motivation Discuss how change relates to desires

8. © Alcohol Medical Scholars Program8 Principles - Empathy Express empathy  Understanding & honesty Communicates acceptance, support Non-verbal & “reflective” empathy State emotion underlying Pt statement Paraphrase Pt statement to show understanding

9. © Alcohol Medical Scholars Program9 Example: Empathy Pt: I say I am going to quit but don’t. Dr: It is frustrating not accomplishing what you want. Pt: Drinking is ruining my health but I can’t change. Dr: ?

10. © Alcohol Medical Scholars Program10 Principles – Roll w/ Resistance Resistance  when Pt feels unheard Ambivalence & self determination ≠ resistance  Resistance through reflective listening Requires “active listening” Invites Pt to view situation differently

11. © Alcohol Medical Scholars Program11 Example: Reflective Listening Pt: What do you know about drinking? Dr: It’s hard to imagine I could understand. Pt: My drinking really isn’t that bad. Dr: ?

12. © Alcohol Medical Scholars Program12 Principles – Confidence Develop confidence Pt must believe they can change Support small changes Any + change Pt willing to make is supported Elicit/reinforce statements of confidence Use reflection, evocative questions

13. © Alcohol Medical Scholars Program13 Principles - Confidence Evocative questions What might be a good first step? What gives you confidence that you might do this? Past success What change have you made successfully and what did you learn in making that change? When you last abstained, what worked for you?

14. © Alcohol Medical Scholars Program14 This Lecture Reviews Definition & Principles  Basic Skills of MI Basic Steps of MI Research supporting MI

15. © Alcohol Medical Scholars Program15 Basic Skills - Asking Asking Open-ended questions gain more information Skillful asking is element of guiding style What kind of change makes sense to you? vs Are you willing to make any changes? Open-ended questions are simple, focused, neutral

16. © Alcohol Medical Scholars Program16 Example: Asking Learning questions What went well and why? What would you do differently now? How might the outcome be improved? Other?

17. © Alcohol Medical Scholars Program17 Example: Asking Value Questions What are your priorities at this time in life? What matters to you? How does alcohol fit in your life? Other?

18. © Alcohol Medical Scholars Program18 Example: Asking Skill Questions What did you learn about your skills as you cut back on your drinking? Were there any surprises? What are you doing (behavior) when you find abstinence/reduction is going well? Other ?

19. © Alcohol Medical Scholars Program19 Basic Skills - Listening Listening Reflect resistance Reflect change-talk Desire Ability Reasons Resistance Status Quo

20. © Alcohol Medical Scholars Program20 Basic Skills - Informing Informing Information exchange vs receptacle Provide choice Inform skillfully Elicit-inform-elicit

21. © Alcohol Medical Scholars Program21 This Lecture Reviews Definition & Principles  Basic Skills of MI  Basic Steps of MI Research supporting MI

22. © Alcohol Medical Scholars Program22 Steps - Rapport Establish rapport Ask permission Non-threatening language

23. © Alcohol Medical Scholars Program23 Steps - Rapport I would like to spend a few minutes talking about how alcohol fits into your life. Would that be ok?

24. © Alcohol Medical Scholars Program24 Steps - Scaling Assess Pt motivation Importance Ruler Confidence Ruler 12345789106 Change TalkResistance

25. © Alcohol Medical Scholars Program25 Is important & I can change. Is important but I cannot change. Not important but I could change. Not important & I cannot change. ↑ Importance ↓ Importance ↑ Confidence ↓ Confidence

26. © Alcohol Medical Scholars Program26 Case Example - Scaling Dr: How important is it to make changes to your drinking? Dr: How confident are you that you would be successful if you tried to quit?

27. © Alcohol Medical Scholars Program27 Steps – Reflect Change talk Elicit Motivation When you hear change talk: Reflect it Use open-ended question to elicit more

28. © Alcohol Medical Scholars Program28 Case Example Pt: I sometimes drink too much. Dr: What makes you think that? Pt: I don’t know when to quit. Dr: You don’t feel you need to stop but drinking causes you problems.

29. © Alcohol Medical Scholars Program29 Steps – Resolve Ambivalence Resolve ambivalence = identify inconsistency Inconsistency between values & behaviors Discussion of pros and cons of change Identify for what Pt is motivated

30. © Alcohol Medical Scholars Program30 Case Example Pt: I need to cut down but I entertain clients. Dr: Client’s take precedence over your health. Pt: No, my health is important to me. Dr: You can entertain clients and be healthy by altering drinking.

31. © Alcohol Medical Scholars Program31 This Lecture Reviews Definition & Principles  Basic Skills of MI  Basic Steps of MI  Research supporting MI

32. © Alcohol Medical Scholars Program32 % of RCT’s Finding MI Effective in Medical Settings

33. © Alcohol Medical Scholars Program33 % Reduction in Use Medical/SUD Setting

34. © Alcohol Medical Scholars Program34 % Occurrence, Emergency Dept Setting 3 Years 6 Months

35. © Alcohol Medical Scholars Program35 Summary AUD’s will be seen in medical settings Guiding as alternative to directing Understand Pt ambivalence MI principles/skills/steps support Pt Research supports use in medical settings