Substance Use Disorders A Primer on Treatment Kirk

Substance Use Disorders: A Primer on Treatment Kirk A. Weaver, Ph. D. , LCPC, LCAC, MAC, NCC Certified Clinical Mental Health Counselor Director of Clinical Services CKF Addiction Treatment

Addiction Defined, Part 1 • Primary, chronic disease of • Brain reward • Motivation • Memory • Related circuitry

Addiction Defined, Part 2 • Leading to dysfunction • Biological • Psychological • Spiritual • Social

Addiction Defined, Part 3 • Resulting in • Inability to abstain • Impairment in behavioral control • Craving • Trouble in recognizing significance of behavior • Dysfunctional emotional response

Two Broad Categories of Addiction • Substance Use Disorders (SUD), or chemical addiction • Process or behavioral addiction

Examples Substance Process • Alcohol • Gaming • Heroin • Gambling • Tobacco • Food

Today’s focus is on substance addiction.

Addiction is a disease of the brain.

The addicted brain is damaged in three areas: • Positive motivation and “reward circuit” (basal ganglia) • Emotion modulation and “stress circuit” (extended amygdala) • Executive function and “deliberation circuit” (prefrontal cortex)

Damage to the prefrontal cortex means • Decreased ability in solving problems • Increased likelihood of making poor decisions • Higher probability of acting without thinking

People struggling with addiction • Lose their ability to manage their own behavior • Impaired autonomy

Is choice involved? • Of course! • But what starts as a choice • Can become a compulsion

One’s understanding of addiction is important • Lack of willpower? • Solution: more resolve • Lack of faith? • Solution: more spirituality • Lack of conscience? • Solution: more incarceration

If addiction is a disease, then treat it as such.

Everything changes. Perspective matters.

Even the language is different “Traditional” Model Disease Model • Addict • Person with Addiction • Relapse • Flare-Up • Sobriety • Recovery • Relapse Prevention • Recovery Management

As a disease, addiction must be managed • 2000 issue of Journal of the American Medical Association • The following flare-up rates were compared for patients with • Hypertension (50 -70%) • Asthma (50 -70%) • Substance use disorders (40 -60%)

Success rates for CKF are within that range.

An important difference between • ADDICTION • PHYSICAL DEPENDENCE • Inability to stop use • Tolerance • Failure to meet obligations • Withdrawal • MAYBE tolerance and withdrawal

Diagnostics Using the DSM-5 • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Substance-Related and Addictive Disorders • Substance Use Disorders • Substance-Induced Disorders • Substance Intoxication and Withdrawal • Substance/Medication-Induced Mental Disorders

Ten Categories of Substances • Alcohol • Opioid • Caffeine • Sedative/Hypnotic/Anxiolytic • Cannabis • Stimulant • Hallucinogen • Tobacco • Inhalant • Other (or Unknown)

DSM-5 Diagnostic Criteria Groups • Impaired Control (Criteria 1 -4) • Social Impairment (Criteria 5 -7) • Risky Use (Criteria 8 -9) • Pharmacological (Criteria 10 -11)

DSM-5 Diagnostic Criteria Severity • Mild: Presence of 2 -3 symptoms • Moderate: Presence of 4 -5 symptoms • Severe: Presence of 6 or more symptoms

So let’s talk about treatment.

What needs to be said here? • Money better spent on prevention • But people are suffering • Major assumption • People want relief from suffering

People use • To get high/intoxicated • To get symptom relief • E. g. , from pain (emotional or physical) • Stress • To avoid withdrawal symptoms

So when you encounter a patient, you must • Determine context and severity of substance use • Examine medical, psychological, social history • Understand treatment history • Factor in your underlying assumptions • Remember our discussion in the first part of this presentation?

AND • Determine • Level • Of • Patient • Motivation

Most providers in KS utilize a simple rubric • Transtheoretical Model of change (TTM) • Developed by Prochaska and Di Clemente et al. in 1977 • Five-stage model of change based on • Specific stages • Identifiable processes between stages • Decisional balance • Self-efficacy

TTM Stages • Precontemplation • Contemplation • Preparation • Action • Maintenance

Treatment options depend on • Availability • Provider preferences • Patient choice (most important)

Four choices • Medication-assisted treatment (MAT) • Other professional-partnered treatment • Community support treatment • Combination of any of the above

MAT • Only available for alcohol, opioid, and nicotine use disorders • “Available” meaning approved by FDA • Alcohol (acamprosate, naltrexone, disulfiram, topiramate) • Opioids (naloxone, buprenorphine, naltrexone, methadone) • Lofexidine hydrochloride (non-opioid)

Commonly-Used Formulations, Part 1 • Naltrexone extended-release (Vivitrol injection) for both alcohol and opioids • Methadone hydrochloride (Methadose, Dolophine) for opioids • Buprenorphine (Probuphine injection) for opioids • Buprenorphine/naloxone (Suboxone, Sublocade, Zubsolv, Cassipa, Bunavail) for opioids

Commonly-Used Formulations, Part 2 • Acamprosate (Campral) for alcohol • Disulfiram (Antabuse) for alcohol • Naltrexone (including Vivitrol injections) for alcohol • Topiramate (Topamax) for alcohol

Commonly-Used Formulations, Part 3 • Nicotine replacement therapies • Transdermal nicotine patch • Nicotine spray • Nicotine gum • Nicotine lozenges

Commonly-Used Formulations, Part 4 • Bupropion hydrochloride (Zyban, Wellbutrin) for nicotine • Varenicline (Chantix) for nicotine

Notice how nicotine was included? • Part of a nationwide effort toward tobacco-free treatment facilities • CKF started in August 2018 with promising results

MAT means just that: • Medication that is • Prescribed • Dispensed • Managed • Under supervision from a qualified med provider

Any MAT-related treatment • Should include • Behavioral health (BH) interventions • Provided by • Qualified BH practitioner(s)

BH Treatment for SUD Is not • Ignoring presenting problem(s) Is • Providing symptom relief • Dictating “the” solution • Exploring options to heal • Focusing solely on deficits • Promoting wellness • Solving the issue • Teaching how to be creative • Non-directional • Joint alliance with a definite goal

Whatever the BH treatment approach, • The goal is disease management (remember our discussion? ) • To manage the disease is to manage the self • People with impaired autonomy need help • The key is to develop a realistic, actionable recovery managment plan • In older parlance, a “relapse prevention” plan

What is a realistic goal? • Abstinence? • Harm reduction?

It depends. • On the patient • On the practitioner • On the context

Know your values • Know your practice location and its strengths/limitations • Know your referral sources

Once that goal is set • A recovery management plan can be developed • Realistic • Actionable

Recovery Management Plan (RMP) • Similar to managing other chronic diseases • Requires thinking and planning • Involves others • Family • Friends • Specialists

Development of a good RMP • Self-awareness and reflection • Flare-ups (relapse) as a process vs. an event • Recognition requires willingness to learn

Elements of a good RMP (ADAPT) • Acknowledge early warning signs and triggers • Detail the worst possible scenario(s) and how to cope • Accept help from “emergency recovery team” • Play on strengths • Trend healthward

Working with persons in recovery • Social support (family and friends) • Community support groups (12 -step, other) • Professional support

Community support groups • 12 -step groups • E. g. , AA, NA, CA, SA, Celebrate Recovery, DRA • Alternative groups • E. g. , SMART Recovery, Moderation Management, Life. Ring

BH treatment can include • Recovery Coach • Case Manager • Medical professional (physician, nurse, etc. ) • Licensed BH provider

BH treatment can include • Coaching • Case management • Didactic/psychoeducation • Counseling/therapy • Usually individual and group • Occasionally couples and/or family

Types of BH interventions • Evidence-based interventions are fashionable • Cf managed care • Almost any approach can be used when treating SUD • BUT the gold standards include • Motivational Interviewing (MI) and Motivational Enhancement Therapy (MET) • Cognitive-behavioral therapy (CBT)

Examples of Behavioral Treatments, Part 1 • Mindfulness-based interventions • Rational-Emotive Therapy, cognitive-behavioral therapy • Acceptance and commitment therapy (ACT) • Exposure therapies (EMDR, aversion therapy) • Programs: T 4 C; Moral Reconation Therapy • Dialectical behavioral therapy (DBT) can apply as well

Examples of Behavioral Treatments, Part 2 • Functional analytic psychotherapy (FAP) • Contingency Management/Motivational Incentives

Examples of Other BH Interventions • Community Reinforcement Approach (CRA) • Twelve-Step Facilitation (TSF) • Brief Eclectic Psychotherapy (BEP)

CKF offers many ways to help patients • Assessments (substance use, mental health, BIP) • Interventions (anger management, ADIS, Pathfinder) • Treatment (residential and outpatient SUD treatment; BIP) • Medication-Assisted Treatment (MAT) for alcohol and opioids

Thank you for coming!

Sources and Resources • American Association of Addiction Medicine (www. asam. org) • CKF Addiction Treatment (www. ckfaddictiontreatment. org) • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) • National Institute on Drug Abuse (www. drugabuse. gov) • Pro-Change Behavior Systems (www. prochange. com) • Substance Abuse and Mental Health Services Administration (www. samsha. gov)