Screening, Identification, Counseling, and Treatment of ......Apisak Wittayanookulluk,MD Psychiatrist,ICAPIII, Deputy director Thanyarak Chiangmai hospital . 1. What are screening/identification,

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:/

/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

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

htt

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