The Hook, The Cage and the Empty Glass
Substance Use Disorders 101 for Primary Care Providers
Ariel Singer, MPH – Northwest Addiction Technology Transfer Center/OHSU
Anderson Rice, LPC, CADC I – Kaiser Permanente Addiction Medicine
The Voice of Addiction“I don’t have an ‘off’ switch…one is too many and a thousand is not enough.”
“Incomprehensible demoralization”
“It’s a disease that tells you you don’t have a disease.”
“I really did not get how I could be an addict when I had been successful in all other areas of my life – it didn’t make sense. However, no matter how hard I tried, I couldn’t moderate. I just couldn’t control it.”
“My addiction took everything from me.”
“My substance use was relief from the pain, but it quit working.”
Definitions of Addiction
ASAM: Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. http://www.asam.org/for-the-public/definition-of-addiction
Gabor Maté: Any repeated behavior, substance related or not, in which a person feels compelled to persist, regardless of its negative impact on his or her life and the lives of others.
Addiction in Clinical Practice• The 4 C’s
– Loss of Control– Compulsive use– Continued use despite harms– Craving
Savage SR, et al. J Pain Symptom Manage. 2003;26:655-667.
DSM V: 11 Criteria for SUDs Diagnosis on a Continuum of Severity
• Taking substance in larger amounts for longer than intended• Wanting to cut down or stop using, but not managing to• Spending a lot of time getting, using, or recovering from use • Cravings and urges to use the substance• Not managing to do what you should at work, home or school• Continuing to use, even when it causes problems in relationships• Giving up important social, occupational or recreational activities • Using again and again, even when it puts the you in danger• Continuing to use, when you have a physical or psychological problem that could have
been caused or made worse by use• Needing more of the substance to get desired effect (tolerance)*• Development of withdrawal symptoms; relieved by taking more of the substance.*
Mild (2-3) Moderate (4-5) Severe (6+)
*Not counted in SUD diagnosis if symptoms of tolerance or withdrawal occur during appropriate medical treatment with prescribed medications.
Physiologic Dependence Vs. Addiction
Physical Dependence Tolerance
Physiologic adaptations to chronic opioid therapy
AddictionMaladaptive behavior
associated with opioid misuse
Savage SR, et al. J Pain Symptom Manage. 2003 Jul;26(1):655-67.
The Spectrum of Substance Use Disorders
SAMHSA. Results from the 2013 National Survey on Drug Use and Health:Summary of National Findings
Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons
Aged 12 or Older
Policy Drivers of Substance Use Disorders and Treatment
Koob, CSAM Addiction Medicine Review Course, 2014
Policy/Environmental Drivers of SUD and Treatment
Alcohol Dependence was last among 30 medical conditions in proportion of care received as evidence would recommend
McGlynn E. et al. NEJM, 2003
Like other chronic illnesses…
• Genetic, personal-choice, and environmental factors • Behavioral change is an important part of treatment• Relapse and medication adherence issues• Comply with treatment and medications = better
outcomes• No reliable cure• Older, employed with stable families = better outcomes• Reasonably predictable course
McLellan A T, et al. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284(13):1689–1695
The Ups and Downs of Chronic Disease
Time
Dis
ease
Act
ivit
y
Asthma, Diabetes, HTN, HIV, etc.
Substance Use Disorder
O’Connor, JAMA 1998Lucas, JAIDS 2005
A Chronic Illness Exacerbated by Stigma
• People with SUDs have had a history of being ignored
• War on drugs = war on drug addicts
• Acute episodic response has been the historical treatment paradigm
• AA was a response to the lack of treatment options and sustains stigma and marginalization through its anonymity
We are moving from saying, “this is a personal failure...”
To saying, “there is a light at the end of this tunnel…”
“And if you want to, we can walk towards it together…”
The Hook, the Cage and the Empty Glass
The Hook• The pharmacologic explanation of addiction• Addiction attributable to intrinsic property of
the substanceThe Cage• Family history of SUD• Co-occurring MH Disorders• ACES• Social Determinants of HealthThe Empty Glass• Unquenchable need for relief• Often substituted
The Cage - Rat Park
www.brucekaleander.com, Addiction: The View from Rat Park, ,Professor Emeritus, Simon Fraser University
“Nothing is addictive within itself” Gabor Mate’
Remedy Seeking• Addictive behaviors are a way of controlling an experience
through external remedies• No external remedy improves a condition without internal or
external consequences• Differentiate between the disease model vs a normal
response to pain
“We must acknowledge what is right about addiction, not what is wrong…”
Gabor Maté
Remedies provide…1. A sense of control2. A sense of fulfillment3. Relief from real pain4. A way to increase the threshold for tolerance
Remedy-Seeking and the Thin Line• Seen as a way towards love and vitality• Replaces genuine intimacy, compassion or honest
endeavors to thrive• Paramount to other ways to self remedy• Compulsiveness • Impairment • Persistence
The question to be asking is not “why the addiction….”
But, “why the pain?” (Maté)
• Marginalization• Racism• Poverty• Lack of access• Adverse history• Socio-economic inequality• Distress of daily living• Loss• Physical pain• Emotional pain
SUD Treatment: Check the Cage, Minimize the Hooks and Fill the Glass
• Behavioral Treatments: CBT, DBT, ACT, Seeking Safety, Contingency Management, etc
• Medication Assisted Treatment (MAT) for Opioid and Alcohol Use Disorders
• Recovery-Oriented Systems of Care
And when treatment is not an option…• Harm Reduction – a palliative approach
Substance Use Disorder MedicationsUnderutilized because of Stigma
Alcohol Use Disorder1.Naltrexone2.Acamprosate3.Disulfiram
Opioid Use Disorder1.Methadone2.Buprenorphine3.Naltrexone
Barriers to MAT• Lack of understanding of the medications• Organizational philosophy/staff beliefs about use of
medications; • Cost of medications• Lack of appropriate staffing in treatment centers
Harm Reduction
• Meeting our patients where they are at
• Medication Assisted Treatment is not harm reduction
• Respect• Honoring personal
autonomy• Reduction in drug
related harm • Comfort Care
Before any treatment can occur a full Biopsychosocial assessment must take place.
Data is gathered in 6 dimensions to determine the appropriate level of care: ↓Dimension 1 – Acute Intoxication and/or Withdrawal PotentialDimension 2 – Biomedical Conditions and ComplicationsDimension 3 – Emotional, Behavioral or Cognitive Conditions and ComplicationsDimension 4 - Readiness to ChangeDimension 5 – Relapse, Continued Use or Continued Problem PotentialDimension 6 – Recovery Environment
Is there a DSM – 5 diagnosis based on a thorough assessment?
Example: Alcohol Use Disorder – Mild, Moderate, or Severe
Inside the Black Box: What Treatment Looks Like
Continuum of Care – patients enter treatment at a level appropriate for their needs and step up for more
intense treatment or down for less intense treatment.
• Level 1
• Level 2
• Level 3
• Outpatient Treatment 1 treatment encounter/week• Intensive Outpatient
Treatment 3-5 treatment encounters/week• Residential/Inpatient 2 weeks to one year
Residential Treatment- may need detox before residential
Focus on:StabilizationAcceptanceSkill building Becoming relationalRelapse prevention planningPossible housing/job skills
Group Focus
Education • Alcohol/Drug education• Relapse Prevention• Mindfulness/Stress Reduction• DBT/CBT• Neuroscience of Addiction• Diet/Sleep/Daily living activities• Co-Occurring MH education
Anxiety, Depression, ADD, PTSD, etc.• Family Education
Therapeutic Process Groups
What was important about residential?
“It gave me a safe and structured place to go through withdrawal. It gave me the first glimpse of myself sober – the good and the not so good – that I had had in over a decade. I went in to residential thinking my only problem was an addiction to meth. I came out convinced I was an addict.
Writing a list of ten insane behaviors, which had to be whittled down from about ten thousand, convinced me that addiction was a disease, because there is no way any sane person could have done all the things I did and made all the choices I did, night after night, year after year, for my next hit.
Residential treatment also gave me a first taste of what it means to follow direction, trust in my counselors and guides, and to connect to other addicts.
- Kaiser patient/38 yr old male
• 1-5 treatment encounters per week
• Group education and process
• Individual counseling and treatment planning
• Integration of recovery efforts with daily life
• Consistent support and structure through changes
Outpatient Treatment
Ongoing Relapse Prevention skills
• Mindfulness
• Cognitive Behavioral Therapy
• Dialectical Behavioral Therapy
• Motivational Enhancement
• Seeking Safety/Mental Health
What was your treatment experience in an outpatient program?“Well, obviously it provided a safe space for the months it took for my emotions and brain to calm down, and to engage many of the issues and problems that fueled my using in the first place. It taught me what it means to be honest and to value and respect the honesty of others, to let everyone have their own process and honor that. It has been the most thorough schooling in addiction I can imagine; every day in group brings a list of lessons about how this disease works, the different forms it can take with different drugs of choice or different people, the unique challenges addicts face, the skills they can use, and the stages of addiction or recovery. It provided needed structure and a more directly engaged process than twelve-step groups, though I think those groups are absolutely necessary for developing community, finding support, and rebuilding a new way of life.”
- Kaiser Patient/38 yr old male
Integration of community supports:
AA, NA, MA, CA, CMA, HA, GA, DAA, SAA, SA, SMART, Alcoholics Victorious, Celebrate Recovery, WFS, Refuge Recovery, etc.
Many options – all road tested by others
One of the biggest challenges in early recovery is ________ ?
Staying focused. Making it through the emotions. And the confusion. Being told again and again, “More will be revealed.”
- Kaiser patient/38 yr old male
Strong System Support• Biopsychosocial Assessment• Motivational Interviewing• Advocacy • Psycho-education• Care Coordination• Follow up• Rx Adherence & Support• Community resource
education• Tx planning and goal setting• Multi-systemic settings and
multidisciplinary assessments
What can you do about it?
Screening
Referral to Treatment
Brief Intervention
“A public health approach to the delivery of early intervention and treatment services for
people with substance use disorders and those at risk of developing these disorders.”
SAMHSA
SBIRT implemented No SBIRT
• Routine and universal screening, regardless of medical complaint • Inconsistent and selective screening
• Validated, standardized screening tools
• Non systematized narrative ‐questions
• Alcohol use seen as a continuum • Alcohol use seen as dichotomous
• Evidence-based, patient-centered change talk
• Ineffective, directive style of communication
• Ongoing transition between primary care and treatment
• Discoordinate/unclear referrals and follow up
SBIRT vs. business as usual
Brief Intervention at a Glance
Feeling Two Ways about Something
Non-com
pliant
Ambivalent
Does this look familiar?
What Change Actually Looks Like
Whose life is it anyway?
Resist the Righting Reflex
How to “FRAME” What You Say• F – Feedback• R – Responsibility• A – Advise• M – Menu• E – Empathy• S – Self-efficacy
How to “FRAME” What You Say
• F • R• A • M• E• S
“The results of your questionnaire indicate that your use of alcohol puts you at risk from problems due to drinking. Of course, any decisions regarding a change are yours to make. As your doctor, I would like to share some advice with you on modifying your drinking habits – would that be ok? I want you to know that we have a lot of options to help you, should you decide to make a change.. I know that change can be difficult and at the same time, I am confident that if you decide to change you will be able to do so. Would you like to talk about some options that we have for supporting you in this?”
How to “FRAME” What You Say
• F – Feedback• R – Responsibility• A – Advise• M – Menu• E – Empathy• S – Self-efficacy
What they’ve told you
It’s their choice
Be clear, you’re the medical expert
Lots of options
Give them hope
Be genuine
F. What do you already know about how ______ affects your health? Would it be ok if I share some information with you about ______? How does this affect your thinking?
R. These are always your choices to make and I am very interested to hear your thoughts.
A. From a medical standpoint, it would be better for your health to_______.
M. What are some things you have considered for making this change? Why might you want to _______?
E. What are the three most important benefits for you to ____? How important is it for you, on a scale of 0-10, to make this change? Why are you at a ___ and not a lower number? If you did decide to ______, how would you do it?
S. Your willingness to talk about this today shows how important this is to you and I am confident that you can make progress towards the goals that you have for your health. What do you think your next step might be?
Let’s Practice!
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