Screening, Identification, Counseling, and Treatment of ......Apisak Wittayanookulluk,MD...
Transcript of Screening, Identification, Counseling, and Treatment of ......Apisak Wittayanookulluk,MD...
Screening, Identification, Counseling, and
Treatment of Opioid Use Disorder
Apisak Wittayanookulluk,MD
Psychiatrist,ICAPIII,
Deputy director
Thanyarak Chiangmai hospital
1. What are screening/identification,
motivational counseling, and referral
to treatment?
2. Screening and identification of
unhealthy opioid use
3. Counseling to increase motivation
4. Planning for treatment
Why screen for and identify opioid
use disorders?
The v
indivi
coul
treat it
in a
ast majority of
duals with OUD who
d benefit from
ment are not receiving
ny given year.
Stein 1999; McLellan et al 2000; SAMHSA 2015
Why screen for and identify opioid
use disorders?
Untr
disor
signif
cons
over
eated, opioid use
ders can lead to
icant negative
equences, including
dose and death.
Stein 1999; McLellan et al 2000; SAMHSA 2015
Why screen for and identify opioid
use disorders?
Your brief intervention can help increase motivation to reduce risky use and initiate evidence-based treatments.
Stein 1999; McLellan et al 2000; SAMHSA 2015
Why screen for and identify opioid
use disorders?
Unive
oppor
are w
gener
like pr
hospi
rsal and
tunistic screenings
ell suited for
al medical settings
imary care and
tals.
Stein 1999; McLellan et al 2000; SAMHSA 2015
97
.5 m
illio
n p
eo
ple
(36
.4%
of to
tal p
op
12
+)
SA
MH
SA
NS
DU
H 2
01
5
OUD Unhealthy
Opioid Use
Misuse
No Misuse
Screening/ Identification
Brief Intervention/ Counseling
Treatment
Evidence to Support Screening, Identification,
Counseling, and Treatment in Primary Care
Screening Identification Brief Treatment
Intervention
Counseling
Alcohol ✔ ✔ ✔ ✔
Tobacco ✔ ✔ ✔ ✔
Illicit ✔ ✔ X ✔ drugs
SAMHSA 2011, Thomas et al Psychiatric Services 2014
Outline
1. What are screening/identification,
motivational counseling, and referral
to treatment?
2. Screening and identification of
unhealthy opioid use
3. Counseling to increase motivation
4. Planning for treatment
Tools for Screening and Identification
1) Alcohol use disorder(AUDIT)
2) Alcohol,smoking and substance
involvment screening tool
ASSIST
3) Drug Abuse Screening Test (DAST-
10)
ASSIST (1)
Sm
ith
et.
al 20
10
1. In your lifetime, which of the following
substances have you ever used?
2. In the past three months, how often have you used the
substances you mentioned?
3. In the past three months, how often have you
had a strong desire or urge to use?
4. During the past three months, how often has your use of
the drug led to health, social, legal, or financial problems?
ASSIST (2)
Sm
ith
et.
al 2
01
0
5. During the past three months, how often have
you failed to do what was normally expected of you
because of your use of drugs?
6. Has a friend, relative, or anyone else ever
expressed concern about your use of drugs?
7. Have you ever tried and failed to control, cut
down, or stop using the drug?
8. Have you ever used any drug by injection?
ASSIST: Results (1)
Level of risk Action required
htt
ps:/
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w.d
rug
ab
use
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ub
licatio
ns/r
eso
urc
e-g
uid
e-s
cre
en
ing
-
dru
g-u
se
-in
-gen
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ed
ica
l-se
ttin
gs/n
ida
-qu
ick-s
cre
en
Lower
Risk
Score 0-3
Moderate
Risk
Score 4-26
✓ Reinforce abstinence
✓ Offer continued support
✓ Provide feedback on the
screening results
✓ Provide counseling
✓ Offer or refer to further treatment
if clinically indicated
✓ Offer continuing support and
accountability
ASSIST: Results (2)
Level of risk Action required
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ps:/
/ww
w.d
rug
ab
use
.go
v/p
ub
licatio
ns/r
eso
urc
e-g
uid
e-s
cre
en
ing
-
dru
g-u
se
-in
-gen
era
l-m
ed
ica
l-se
ttin
gs/n
ida
-qu
ick-s
cre
en
High Risk
Score ≥ 27
✓ Provide feedback on the screening
results
✓ Provide counseling
✓ Offer or refer to further treatment
✓ Offer continuing support and
accountability
Outline
1. What are screening/identification,
motivational counseling, and referral
to treatment?
2. Screening and identification of
unhealthy opioid use
3. Counseling to increase motivation
4. Planning for treatment
The Goals of Counseling:
• Demonstrate respect for patient
autonomy
• Demonstrate empathy using reflective
listening
• Evoke and strengthen patient’s own
reasons for change (i.e., change talk)
• Probe the patient’s readiness and
willingness to engage in treatment
iSto
ck P
ho
to
However, there
should be no
expectation that a
brief encounter alone
is sufficient to
successfully engage
all patients into
treatment.
iSto
ck P
ho
tos
Once identified, multiple encounters over a
period of weeks or months may be needed
before the patient is willing to try further
treatment. Therefore, it is important to meet
patients at their degree of readiness.
Spirit of Motivational Interviewing
Acceptance
Compassion Partnership
Evocation
Spirit of MI Must Be Demonstrated (1)
iSto
ck P
ho
to
• Avoiding the impulse to immediately offer
solutions and fixes
• Asking permission before giving advice or
information
• Demonstrating accurate empathy
Miller and Rollnick 2015
Spirit of MI Must Be Demonstrated (2)
• Respecting patient’s decisions, even if
you disagree
• Reinforcing personal choice and
responsibility
• Affirming positive qualities and efforts to
change
• Respecting autonomy does not mean
agreeing with their decisions
Miller and Rollnick 2015
Some Strategies for Starting the Conversation about Behavior Change
• “Would it be ok if we spent a few
minutes talking about the results of the
questionnaire?”
• “Tell me a little bit about how your
heroin use fits into your life?”
• “What do you like about heroin? What
are some of the drawbacks?”
Using Reflective Listening to
Demonstrate Accurate Empathy
What the
patient is
trying to
communicate
What the
patient
said
Reflection
What you
heard
Your interpretation
of what the patient
was trying to say
I need to
stop using
heroin.
You need to
stop using
heroin.
I need to
stop using
heroin.
You want to cut
back on how much
heroin you use.
Complex reflections go deeper and
add substantial meaning
I need to
stop using
heroin.
You’ve decided to get
professional help.
Complex reflections go deeper and
add substantial meaning
I need to
stop using
heroin.
The overdose was a
real wake-up call.
Double-sided reflections reflect ambivalence
I need to
stop using
heroin.
On one hand, heroin has
helped with your pain,
and on the other hand,
it’s led to a lot of physical
and social problems.
Change Talk (DARN-CAT)
D : Desire → I want to…, I wish…, I’d like to…
A : Ability → I could…, I know I can…, I could try…
R : Reason → I want to change because…
N : Need → I should…, I need to…, I must…
C : Commitment → I will…, I promise to.., I guarantee…
A : Activating → I am ready to…, I am willing to…
T : Steps Taken → I’ve tried…
https://www.porticonetwork.ca/treatments/treatment-
methods/motivational-interviewing/mi-change-talk
The vast majority of patients are ambivalent
to some extent about their drug use
I want to
change. I don’t want
to change.
This side of the
ambivalence is
called Change Talk
This side of the
ambivalence is
called Sustain Talk
The vast majority of patients are ambivalent
to some extent about their drug use
I want to
change. I don’t want
to change.
Clinicians often argue for
ambivalence.
The vast majority of patients are ambivalent
to some extent about their drug use
I want to
change. I don’t want
to change.
Clinicians typically focus more on
addressing the “excuses” and
barriers to change.
The vast majority of patients are ambivalent
to some extent about their drug use
I want to
change. I don’t want
to change.
The goal of MI is for the patient
to argue for change, not the
clinician. The clinician should
work to evoke and strengthen
change talk.
Examples of Questions to Evoke Change Talk (1)
• If you were to stop using pills, how would you be
successful?
• What are the most important reasons for you to
cut back on using pills?
• On a scale of 1-10, 10 being completely ready,
and 1 being not at all ready, how ready are you
to stop using pills?
- Follow-up: Why did you pick that number,
and not a lower number?
Examples of Questions to Evoke Change Talk (2)
• Why did you decide to stop using
completely last year?
• How were you successful in not using for
an entire month last year?
Engaging OUD Patients in Further Treatment
SA
MH
SA
201
1
Patient’s Willingness Intervention
Patient is
willing to
engage
in treatment
• Explore appropriate treatment
options
• Affirm and recognize efforts to
seek treatment
• Offer treatment on-site or refer to
off-site programs
Engaging OUD Patients in Further Treatment
SA
MH
SA
201
1
Patient’s
Willingness Intervention
Patient is
not yet
willing
to engage
in treatment
• Continue to engage patient to
increase motivation
• Continue to explore ambivalence
• Demonstrate empathy
• Avoid coercive strategies
• Agree to provide ongoing support
and accountability
• Offer information on naloxone
rescue
Referral to Further Treatment
For patients willing to consider treatment for
OUD and other substances, the following are
options to consider in addition to medications:
1) Outpatient treatment
2) Intensive outpatient, partial hospital programs,
residential programs
3) Acute treatment services (medical withdrawal
or detoxification)
4) Peer-support programs (AA, NA, SMART
Recovery)** **Used supplemental to other treatment options
Screening/ Identification
Motivational
Counseling Treatment
Unit Resources:
• Physician/Patient Communication Skills Videos
• Reports and Detailed Tables From the 2015 National
Survey on Drug Use and Health (NSDUH)
• Instrument: TAPS Tool
• Instrument: The NIDA Quick Screen
• Instrument: NIDA Modified ASSIST (pdf)
• Instrument: Drug Abuse Screening Test (DAST-10)
• Portico, Canada’s Mental Health & Addiction Network -
MI: Change Talk