Addiction

From the 11th Annual Fundamentals of Addiction Medicine Conference,presented by Providence Regional Medical Center Everett, WA

Educational Objectives

The goal of this program is to improve care for addictions. After hearing and assimilating this program, the clinician will be better able to:

1.   Describe the advantages and disadvantages of using motivational interviewing (MI) in treatment of addictions.

2.   Define MI and discuss some of the changes that have occurred in its philosophy.

3.   State some of the principles involved in learning and practicing MI.

4.   Explain why addictions may be better served by treating them as chronic conditions that require long-term management.

5.   Describe a model for chronic disease management of addictions in an integrated care setting.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and plan­ning committee reported nothing to disclose.

Acknowledgements

Drs. Rosengren and Saitz were recorded at 11th Annual Fundamentals of Addiction Medicine, held March 5-6, 2009, in Seattle, WA, and sponsored by Providence Regional Medical Center Everett, WA. The Audio-Digest Foundation thanks the speakers and Providence Regional Medical Center Everett for their cooperation in the production of this program.

Motivational Interviewing in Addiction

David B. Rosengren, PhD, Research Scientist, Alcohol and Drug Abuse Institute, University of Washington, Seattle

Brief history of motivational interviewing (MI): since 1981, when MI introduced, extensive literature has ap­peared, and MI now used in many fields other than addiction (eg, in corrections); speaker credits growth to MI’s ev­idence-based approach; addiction trials included Matching Alcoholism Treatment to Client Heterogeneity (MATCH), United Kingdom Alcoholism Treatment Trial (UKATT), Combining Medications and Behavioral Inter­ventions for Alcoholism (COMBINE), and Marijuana Youth Treatment Study; in addition, several books available (see Suggested Reading); Motivational Interviewing Network of Trainers (MINT)  —established in 1993; now offers training in »45 countries on all continents, except Antarctica

Does MI work? meta-analyses have looked at MI in various formats, including stand-alone and combination inter­ventions; conclusions from these sources include 1) its effectiveness varies across studies, locations, counselors, and clients; 2) in general, effect sizes have been small to medium; 3) seems to work best in combination with other interventions; 4) effects tend to fade over time (but some of this phenomenon due to controls “catching up”); 5) more effective than educational, didactic, or persuasive interventions; 6) as effective as longer treatments; efficacy well supported as stand-alone treatment for alcohol dependence; for drug abuse and dependence, seems to work better in combination therapy; in 2007, National Registry of Evidence-based Practices agreed that MI meets their review criteria

Research on MI training: over time, focus of training has changed from including only content to including content and process; training available through meetings, videotapes, printed materials, and online

What is MI? original definition  —  “MI is a client-centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”; latest definition  —  “MI is a person-centered guiding method of communication used to elicit and strengthen motivation for change”; “client” changed to “person” because MI now used in variety of settings; communication methods among humans include guiding, directing, and follow­ing; MI “is really just a refined form of guiding”; ambivalence part of process of change and may never be fully resolved, but can be managed effectively to benefit of individual who seeks change

Mobilizing language: clients often talk about change; preparatory talk (eg, “I’d really like it if I wasn’t messing up my life,” “I think I can do it if I really made up my mind”) does not predict change, but does predict mobilizing language (which does predict change); stages of change include commitment, which requires that client say equivalent of “and I’m going to do it,” and taking steps, such as attending meeting or throwing out paraphernalia

Phases of MI: first phase involves building motivation and making commitment; second phase involves taking de­finitive action

Components of MI: technical component involves learning skills; relational component involves communicating with attitude and words that do not alienate client

Ten things MI is not (per Miller and Rollnick): 1) based on transtheoretical model; 2) “a trick (not a way to make people do things that they’re not interested in doing”); 3) “a technique” utilizing specific procedures; 4) decisional balance; 5) assessment feedback (not considered necessary or sufficient for intervention); recent article makes ex­ception for college students, who usually expect feedback; 6) form of cognitive behavioral therapy (MI more akin to humanistic psychotherapy); 7) simply client-centered therapy, but consciously directed towards goal with spe­cific guidelines; 8) easy; involves complex style and set of skills; 9) what “I’m already doing”; other therapies may involve elements of MI, but do not include whole process; 10) panacea; “you need to be able to do other [therapies] as well, but this can be a very effective tool in your toolbox”

Learning MI: complex intervention; concepts can be taught in relatively brief overviews, but skills more difficult to master; 2-day workshop can increase skills, but not sufficiently to attain expert level; requires follow-up training activities (without which, skills tend to return to baseline); coaching and feedback important, but not only consider­ations; in initial training, learning context at least as important as environment to which clinician will return

Factors that may matter: support at agency level (does whole agency get involved? does clinical director participate in training? time made for agency employees to talk about it?) people in organization willing to change? do prac­tioners in organization feel they have autonomy in making choices about which method of therapy they provide (negatively correlated with change)? how does staff feel about efficacy of their work? do organizational activities support maintaining skills?

Pearls for MI success: spirit, or attitude that clinician brings to encounter, predicts clinical skills; relational compo­nent must be present, and this may be first task clinicians need to learn; important to spend time cultivating attitude; clinical skills predict “change talk,” “sustained talk” (client’s reasons for not changing), and whether resistance in­creases or decreases; change talk predicts outcomes (the more people engage in change talk, the more likely they will change); change talk occurs in other forms of therapy, but only MI targets it; however, change occurs in ab­sence of change talk; therefore, unclear whether change talk causative or indicative; all change represents self-change (ie, process of change under way before client sought clinician; clinician simply facilitates change)

The Case for Treating Addiction as a
Chronic Disease

Richard Saitz, MD, MPH, Professor of Medicine and Epidemiology; and Director, Clinical Addiction Research and Educa­tion (CARE) Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA

Introduction: substance dependence similar in many ways to other chronic disorders (eg, asthma, diabetes, hyperten­sion); has genetic and environmental components and produces physiologic changes; has chronic relapsing course; no cure, but treatments can help control condition; adherence to care variable; medical and psychiatric comorbidity common and can be triggers for relapse

Long-term care for substance dependence: not needed by everyone with addiction; epidemiologic survey showed that three-fourths of patients with substance abuse or dependence have only one episode; median duration of depen­dence episodes 2 to 3 yr; however, those who have >1 episode have mean of 5 over lifetime and need long-term care

Comorbidity: more common in people with addictions; in Massachusetts Medicaid data, heart disease, asthma, gas­trointestinal disorders, skin infections, and acute respiratory disorders most common comorbidities; in another survey, most patients in detoxification reported depressive symptoms and moderate-to-severe pain associated with relapse

Effects of substance-abuse disorders on comorbid conditions: in survey of 7 Veterans Affairs (VA) sites, 66% of nondrinkers adherent to medication regimens for medical conditions, vs 55% for those with worst scores on Al­cohol Use Disorders Test-Consumption (AUDIT-C); in another VA survey, those with substance abuse disorders 20% to 30% less likely to meet quality-of-care measures for diabetes, asthma, and heart disease; similar effects noted with other conditions, including psychiatric illness

Coordination of care: despite high prevalence of comorbidities and their effect on outcome, care remains frag­mented, with limited coordination between medical care, psychiatric care, and addiction care; about half of pa­tients who have undergone detoxification do not seek further care; only half of those who do seek further care complete their (generally, short-term) treatment regimen

Barriers to care: separate systems for medical, psychiatric, and addiction care; separate insurance systems; barriers to sharing of information; characteristics of treatment programs (sometimes not customer-oriented)

Management of chronic disease: model of care for treatment of chronic illness proposed >10 yr ago; patient-cen­tered; uses community resources; focuses on chronic disease as priority; to be successful, model must include support for patient self-management, attention to design of delivery system, decision support for clinicians, and use of clinical information systems to facilitate high-quality care; management of chronic disease implemented by multidisciplinary teams with disease-specific skills; utilizes nurse, social worker, or physician to provide di­rect care, coordinate referrals, communicate with other caregivers, proactively arrange and facilitate follow-up, and facilitate access to community resources

Controlled studies of efficacy of chronic disease management: >100 done for medical and psychiatric conditions (but none for addictions); studies indicate disease management improves patient satisfaction, improves patients’ adherence to treatment regimens, improves clinical and functional outcomes and quality of life, and decreases acute care hospitalization; cost-effective

Case management and integrated care: studied in patients with addictions

Case management: single point of contact for assessment and care planning, and facilitates linkage to and coordina­tion of other needed services; studies show increased treatment retention, receipt of treatment when needed, in­creased receipt of medical, mental health, and social services, and decrease in relapse, intoxication, and medical, psychiatric, family, and legal problems

Integrated care: model would deliver primary medical care and addictions care at same site; study of individuals with alcoholism and medical illness (mostly liver disease); found having both services available at same site in­creased abstinence; similar study of individuals with any chemical dependency found same results, whether or not medical condition related to substance use

Proposed model of integrated care for substance abuse: considers conceptual elements for chronic disease man­agement reviewed above; uses case management to link people to community resources; plans long-term care for addiction and medical problems; provides routine assessment and feedback; encourages patients to participate in their management; provides psychosocial support

Delivery-system design: ensures planned visits over long term; provides multidisciplinary teams to address issues that arise; reminds patients of their appointments; has specialty expertise available; uses electronic medical re­cords for monitoring outcomes, providing reminders to clinician and patient, and assuring clinician’s attention to needs of patients not physically present

Primary care: may be ideal setting for integrated care; in studies, receipt of primary care significantly associated with decrease in severity of alcohol and drug addiction; once patients in recovery, “they need a place to come back to” for support and follow-up

Patient-centered medical home: Medicare and Medicaid have done some demonstration projects on this model and considering paying for it; team-based and patient-centered; provides continuous comprehensive care; involves hav­ing personal physician and addresses prevention and long-term management of conditions; coordinates services needed to do that; provides services in as few locations as possible (ideally, all in same location)

Speaker’s study: site has nurse care manager, internist with addiction expertise, psychiatrist, and social worker; has close relationship with city addiction-treatment services; uses electronic medical records to coordinate care be­tween primary care physician and all other providers, and to generate reminders for clinicians and patients; sub­stance-specific programs include motivational enhancement therapy, medications, and referrals to mutual health groups and specialists; first noticeable outcome  —  after several treatment sessions, patients often disappear for several months, then call or return to clinic for care

Structure of intervention: first 2 visits include assessment, feedback, and determination of services needed; patient connected to primary care physician and provided with other treatment and referrals, as needed; nurse care man­ager manages contacts and ongoing referrals, and with social worker, available for drop-in care

Early results: 59% of patients in study homeless, 17% employed full-time, and most have psychiatric comorbidity; of those randomized to intervention group, 281 of 282 completed first visit, and 75% returned for second visit; of 158 patients scheduled for visit with primary care physician, 79% kept first appointment; patients referred by de­toxification facility and did not necessarily want treatment for addiction; however, most accepted treatment for psychiatric disorders

Conclusions: chronic disease management has promise for improving treatment of substance dependence; patients with substance dependence appear to be willing to initiate and engage with chronic disease management addic­tion care

Suggested Reading

Britt E et al: Motivational interviewing in health settings: a review. Patient Educ Couns 53:147, 2004; Burke BL et al: The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. J Consult Clin Psychol 71:843, 2003; Friedman DP: Drug addiction: a chronically relapsing brain disease. N C Med J 70:35, 2009; Hodgins DC et al: Strength of commitment language in motivational interviewing and gambling outcomes. Psychol Addict Behav 23:122, 2009; Joosten EA et al: Shared decision-making reduces drug use and psychiatric severity in substance-dependent patients. Psy­chother Psychosom 78:245, 2009; Kritz S et al: Opioid dependence as a chronic disease: the interrelationships between length of stay, methadone dose, and age on treatment outcome at an urban opioid treatment program. J Addict Dis 28:53, 2009; Loeber S et al: Attentional bias in alcohol-dependent patients: the role of chronicity and executive functioning. Addict Biol 14:194, 2009; McKay JR et al: Extending the benefits of addiction treatment: practical strategies for continuing care and recovery. J Subst Abuse Treat 36:127, 2009; McKay JR, Carise D: State of the science: Extending the benefits of addic­tion treatment. J Subst Abuse Treat 36:172, 2009; McKay JR: Continuing care research: what we have learned and where we are going. J Subst Abuse Treat 36:131, 2009; McMurran M: Motivating Offenders to Change: A Guide to Enhancing Engagement in Therapy. Hoboken, NJ: Wiley, 2002; Moyer A et al: Brief interventions for alcohol problems: a meta-ana­lytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 97:279, 2002; Passik SD: Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clin Proc 84:593, 2009; Roll­nick S, Miller W: Motivational Interviewing: Preparing People for Change. New York: Guilford Press, 2002.