Transcript Intensive Outpatient Treatment Programs

Evidence-Based
Intensive Outpatient
Treatment Programs
For Substance Use
Disorders
Definition and Diagnoses of
Substance Use Disorders
• DSM-IV-TR CRITERIA
Substance Abuse: a maladaptive pattern of
substance use leading to clinically significant
impairment or distress occurring in any of the
following areas, within a 12-month period
 Failure to fulfill major obligations at work, school,
or home
Substance Abuse Dx – Cont.
Recurrent substance use in hazardous
situations, such as driving or operating
heavy machines while impaired by the
substance use
Substance-related legal problems
Social and interpersonal problems caused
by or exacerbated by the substance
Substance Dependence Dx
A syndrome characterized by a maladaptive
pattern of substance use leading to clinically
significant impairment or distress, as manifested
by at least 3 of the following and occurring in a
12-month period:
 Tolerance
 Withdrawal
 Substance is taken in larger amounts or for
longer periods than intended (overdosing)
Substance Dependence Dx –
Cont.
 Persistent desire or unsuccessful efforts to cut
down or control substance use
 A significant amount of time is spent in activities
to obtain, use, and recover from the substance
 Important social, occupational, or recreational
activities are given up or reduced
 Continued substance use despite knowledge of
having a persistent or recurrent physical or
psychological problem
Definition of Addiction
American Society of Addiction Medicine defines
it as:
A primary, chronic, neurobiologic disease with
genetic, psychosocial, and environmental factors
influencing its development and manifestations.
Addiction is characterized by behaviors that
include one or more of the following: impaired
control over drug use, compulsive use,
continued use despite harm, and craving
(Graham et al., 2003).
U.S. Statistics on Drinking and
Substance Use Disorder rates:
NIAA 2001-2002 National Epidemiologic
Survey on Alcohol and Related Conditions
72% Never exceed the daily or weekly
limits
16% Exceed only the daily limit
10% Exceed both daily and weekly limits
CSAT 2006 data
 50% Americans age 12 and older report
drinking alcohol
 30% American adults drink at levels that
increase their risk for physical, emotional, and
social problems. Of these heavy drinkers, about
1 in 4 currently has an alcohol abuse or
dependence disorder
 More men report being current drinkers than do
women
 The rate of alcohol dependence is also lower for
women than for men
N-SSATS 2005
 The survey showed that on March 31, 2005,
1.08 million people were enrolled in substance
abuse treatment, an 8 percent increase from 1
million in 2000.
 Of them, 34 percent were in treatment for drug
abuse only, up from 29 percent in 2000.
 In contrast, patients enrolled in treatment only
for alcohol abuse declined from 23 percent in
2000 to 19 percent in 2005.
N-SSATS 2005 – Cont.
The proportion of patients in treatment for
both drug and alcohol abuse made up
nearly half of all patients (47 percent).
The 2005 national survey reported that the
number and proportion of patients
receiving methadone increased from 17
percent of all patients in 2000 to 22
percent in 2005.
N-SSATS 2005 – Cont.
The survey also indicated that opioid
treatment programs, which focus on
treating addiction to heroin and
prescription narcotic pain medications,
were available in 8 percent of all
substance abuse treatment programs.
http://wwwdasis.samhsa.gov/05nssats/nss
ats2k5web.pdf
SAMHSA's National Survey on
Drug Use and Health (NSDUH)
2006
 In 2003, of the estimated 25 million veterans
(93% were male) living in the United States,
8.4% were between the ages of 17 and 34;
30.1% between the ages of 35 and 54; 42.3%
between the ages of 55 and 74; and 19.2% were
aged 75 or older.
 SAMHSA's National Survey on Drug Use and
Health found that in 2003, an estimated 3.5% of
veterans used marijuana in the past month
compared with 3.0% of their nonveteran
counterparts.
NSDUH 2006 – Cont.
 Past month heavy use of alcohol was more
prevalent among veterans (7.5%) than
nonveterans (6.5%).
 Estimated rates of dependence on alcohol
and/or illicit drugs did not differ significantly
between veterans and nonveterans. Rates of
those dependent on alcohol and/or illicit drugs
but who did not receive treatment in the past
year were also comparable.
NSDUH 2006 – Cont.
An estimated 0.8% of veterans received
specialty treatment for a substance use
disorder (alcohol or illicit drugs) in the past
year compared with 0.5% of nonveterans.
1996 Veterans Affairs Report
• Among veterans with drug diagnoses
treated in specialized inpatient substance
abuse units 65% abuse cocaine, 19%
abuse opiates, and 35% have co-existing
psychiatric diagnoses.
Veterans with Hepatitis C
250000
210698
215102
219590
217250
2003
2004
2005
2006
207798
200000
150000
100000
50000
0
2007
Source: HCV Clinical Case Registry
Veterans with Cirrhosis
55000
50000
49357
47428
45000
44533
42249
40000
40005
36801
38189
35000
30000
2000
2001
2002
2003
2004
2005
2006
33% increase in annual unique patients (HCV+ or -)
with a diagnosis of cirrhosis from 2000-2006.
Source: VA Liver Disease Database
HCV+ Veterans in care who ever had
cirrhosis or HCC, 2004-2007
•
Cirrhosis
HCC
19,200
18,800
18,400
18,000
17,600
17,200
16,800
16,400
16,000
15,600
2,400
2,000
1,600
1,200
800
400
0
FY 2004
FY 2005
Cirrhosis
FY 2006
HCC
CY 2007
Risk of HCC increases with increasing
alcohol intake but is greater in the
presence of HCV infection
Donato et al. Am J Epidemiol 2002;155:323
Brief Alcohol Intervention Initiative
• Challenge:
Need evidence-based alcohol reduction
interventions to help HCV patients reduce
or eliminate alcohol consumption
• Response:
Implement effective brief-intervention
strategies and tools for providers to
address heavy alcohol use in HCV clinical
settings
Principles of Effective IOP
Programs
Utilize evidence-based practices
Motivational Interviewing (Miller and Rollnick, 1991)
Relapse Prevention (Marlatt and Gordon, 1985;
Marlatt,1998)
NIDA Matrix Model of IOP 20 year project
(Rawson et al. 1995)
Stages of Change
(DiClemente and Prochaska, 1998)
Harm Reduction model
( Sobell and Sobell, 1993b, 1993, 1998, 1999)
Evidence-Based Practices –
Cont.
 Brief Alcohol Interventions in primary care
settings (Project TREAT (Trial for Early Alcohol
Treatment), 1997; World Health Organization
Brief Intervention Study, 1996; and TIP 24 A
Guide to Substance Abuse Services for Primary
Care Clinicians)
 Cognitive-Behavioral Therapy (i.e. relapse
prevention –Gorski, Marlatt & Gordon, Najavits Seeking Safety)
Evidence-Based Practices –
Cont.
SAMHSA/CSAT Treatment Improvement
Protocols (TIPS 8, 13, 33 and 35 for IOP
programs)
Websites for Evidence-based
Practices
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www.hepatitis.va.gov
www.modelprograms.samhsa.gov
www.nrepp.samhsa.gov
www.mentalhealthpractices.org
tie.samhsa.gov/Externals/tips.html
www.nida.nih.gov/PubCat/PubsIndex.html
www.niaaa.nih.gov/publications/guides.html
Principles of Effective IOP –
Cont.
A continuum of care is more cost
efficient care.
A multidisciplinary approach
Cross-trained Staff
Integration of treatment is essential.
Treatment should be individualized.
Components of IOP Treatment
Group Topics
 The neurochemistry of addiction and the
addiction process
 The role and process of treatment and recovery
 Medical aspects of addiction - PAWS symptoms
 The importance of abstinence from alcohol and
all other drugs
 Appropriate use of prescribed and over-thecounter drugs
 Powerlessness and unmanageability of AOD
use
Components of IOP – Cont.
Group Topics
 Maximizing the use of self-help and support
groups
 Spirituality and the development of an
externalized source of support
 The roles of nutrition, exercise, leisure, and
recreation in recovery
 Experiencing emotions and feelings without
AODs
 Relationship skills
 Conflict resolution and communication skills
Components of IOP – Cont.
Group Topics
 Family dynamics of addiction
 Healthy relationships and family functioning
 Relapse management skills
 AOD refusal skills
 Avoiding and defusing triggers for craving and
relapse
 Minimizing risks for HIV, AIDS, and sexually
transmitted disease
Core and Enhanced Services for
IOP programs
 High quality leadership and administrative
support
 Comprehensive biopsychosocial screening and
assessment
 Program orientation and intake procedures
 Routine and random urine drug screening
 Individual treatment planning and review
 24-hour crisis management
 Pharmacotherapy and medication management
 Medical treatment
Core and Enhanced Services for
IOP programs – Cont.
 Individual counseling
 Group therapy
 Education about AOD issues
 Family education and counseling
 Self-help and support group orientation
 Case management services
 Discharge and transitional service planning
Core and Enhanced Services for
IOP programs – Cont.
 Program and outcome evaluation
 Adult education
 Adjunctive therapies
 Transportation services
 Housing and food
 Smoking cessation treatment
 Aftercare
 Specialty groups
Model Programs and
Evidence-Based Practices
Brief Interventions/Motivational
Interviewing for Hazardous Drinking
Brief Interventions/Motivational
Interviewing for Hazardous
Drinking
• Strengths:
• Uses Motivational Interviewing
-Uses change talk
-Roadmap for BI
Brief Interventions/Motivational
Interviewing for Hazardous Drinking
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Uses feedback to raise readiness
Discuss change options with patients
Solution-Focused
Structured
Harm Reduction
Brief Interventions for
Hazardous Drinking
• Weaknesses:
• Is not a pancea for every difficult or
unmotivated patient
• (see Ten Things Motivational Interviewing
is not by Miller & Rollnick, 2009)
AUDIT-C “Triangle” Card
Counseling Card: Back
Prototype FLO Card
Raise importance
• On a scale of 0-10, how important is it for you to change
your drinking?
• Why did you give it a (patient’s number) and not a lower
higher number?
• What would it take to give it a higher number?
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• 0
I
1
m
2
p
3
o
4
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5
t
a
6
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Rollnick, Health Behavior Change, 1999
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9
10
Build confidence
• On a scale of 0-10, how confident are you that you can
change your drinking?
• Why did you give it a (patient’s number) and not a lower
higher number?
• What would it take to give it a higher number?
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• 0
1
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2
o
3
n
4
f
i
5
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• Rollnick, Health Behavior Change, 1999
c
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10
Drinking Diary Card
(Wallet Card)
Drinking Diary Card
• Measuring behavior is an intervention
• Good for patients in early stages of
change
• Self-monitoring can reveal:
– Drinking patterns
– Social/emotional contexts
– Antecedents/consequences (A, B, C’s)
• Can promote harm reduction
Change Plan Template
(Wallet Card)
Change Plan Template
• For patients who appear ready to attempt
behavior change
• Goals most likely successful when they
are:
– Explicit (measurable)
– Achievable (realistic)
– Public (verbal commitment)
• Facilitates problem-solving, identifying
resources & support
Model Programs and EvidenceBased Practices
12-Step Facilitation Approach
"Minnesota Model“
12-Step Facilitation Model
• Strengths:
• 12-Step meetings are a free, widely available,
ongoing source of support.
• The 12-Step approach emphasizes an array of
recovery tasks in cognitive, spiritual, and health
realms.
• The 12-Step approach is effective with patients
from diverse backgrounds (Tonigan 2003).
12-Step Facilitation Model
• Weaknesses:
• It can be difficult to monitor accurately patients'
compliance with assigned step tasks, including
meeting attendance.
• 12-Step groups' emphasis on a higher power
may be unacceptable to some patients.
• Some communities may not be large enough to
sustain 12-Step meetings or appropriate
meetings for people with significant psychiatric
disorders.
Model Programs and EvidenceBased Practices
Cognitive Behavioral Therapy
(CBT)
Cognitive Behavioral Therapy
(CBT)
• Strengths:
• CBT actively engages patients in therapy and
experiential learning.
• Numerous manuals on CBT are available.
• CBT is suitable for patients from diverse
backgrounds and with varying histories of
alcohol and drug use.
• CBT provides structured methods for
understanding relapse triggers and preparing for
relapse situations.
CBT
• Weaknesses:
• Patients with poor reading or cognitive skills may
need alternatives to written assignments.
• The approach requires counselor training in CBT
principles and techniques.
• Patient motivation is critical because of the
extent of homework assignments.
• CBT was developed as an individual, not group,
counseling approach.
Model Programs and EvidenceBased Practices
Motivational Approaches
Motivational Approaches
• Strengths
• MI and MET are patient centered and relevant to
patients' personal interests.
• MI and MET focus on realistic, attainable goals.
• MI and MET encourage patient self-efficacy and
self-sufficiency.
• MI and MET emphasize positive, empathic
support that does not undermine or elicit anger
from patients.
Motivational Approaches – Cont.
• Weaknesses:
• MI and MET rely heavily on patients' capabilities
and level of self-awareness.
• Commonly used problem-oriented assessment
instruments are incompatible with a motivational
approach.
• Although MET provides some guidance about
effective interpersonal strategies for treating
ambivalent patients, the approach does not
specify session content.
Motivational Approaches – Cont.
• Motivational approaches require significant staff
training, reorientation, and ongoing supervision.
• Motivational approaches may be difficult to
combine with disease- or therapeutic
community-oriented approaches that expect
adherence to program-imposed goals.
• MI and MET were developed as individual
approaches; their effectiveness for use with
groups is unproved.
Motivational Approaches – Cont.
• MET was developed for, and has been effective
with, patients exhibiting varying severities of
alcohol-related problems. Court-mandated
patients appear to benefit as much from MET as
do self-referred patients.
Model Programs and EvidenceBased Practices
The Matrix Model
The Matrix Model
• Strengths
• The model integrates a cognitive-behavioral approach
with family involvement, psychosocial education, 12-Step
support, and urine testing.
• The model follows a manual, providing therapists with
specific instructions and practical exercises. A version of
the Matrix materials is available free from NCADI (CSAT
2006c, 2006d).
• The model has been used extensively with people
dependent on stimulants and has been shown to be
effective.
The Matrix Model – Cont.
• Weaknesses:
• Some materials may need to be modified for
patients whose cognitive functioning is impaired.
• The program requires special staff training and
supervision.
• The highly structured content may not appeal to
all patients.
• The tight structure and schedule may not leave
time for identification and stabilization of other
non-drug-specific problems.
CONTROLLED DRINKING
RESEARCH FINDINGS
Controlled Drinking Research
(Sternberg, 2005)
• Some alcohol-dependent individuals choose
and achieve moderation even while participating
in abstinence-based treatment programs.
• Studies of abstinence-based treatment
outcomes consistently report reduced,
moderated, or non-problematic drinking among
participants of these programs. Long-term
moderate consumption appears to be as
prevalent as continuous abstinence.
Controlled Drinking Research –
Cont.
• The combined evidence from multiple studies
finds that 20-40% of patients report long-term
abstinence or stable moderate-drinking following
treatment.
• When given a choice between controlleddrinking or abstinence treatment goals, many
problem drinkers choose abstinence.
• On the other hand, other individuals who start
out with the goal to achieve moderate drinking,
eventually choose to become abstinent.
Controlled Drinking Research –
Cont.
• Sobell and Sobell recommend that patients be
treated in a stepwise fashion. For those who
have substance abuse rather than dependence,
work towards moderate drinking (if patient
desires this), if patient is unable to achieve
moderation then focus on abstinence and more
intensive interventions.
• Permitting a choice of treatment goals (e.g.,
controlled drinking vs. abstinence) increases
recruitment and lowers attrition, without
increasing the rate of relapse.
Controlled Drinking Research –
Cont.
• Numbers of studies have found several factors
to be associated with controlled drinking success
– including psychological and social stability,
steady employment, higher levels of education,
and fewer pre-treatment periods of abstinence.
• Generally, speaking patients with more severe
alcohol problems tend to fare better in
abstinence-oriented programs.