Understanding Substance Abuse & Addiction: What Research, Psychology & Medicine Have to Teach Us TRUST Clinic Speaker Series Oakland, Ca. June 20, 2014 Joan Zweben, Ph.D. Executive Director, East Bay Community Recovery Project www.EBCRP.org Clinical Professor of Psychiatry, UCSF
84
Embed
Understanding Substance Abuse & Addiction: What Research, Psychology & Medicine Have to Teach Us TRUST Clinic Speaker Series Oakland, Ca. June 20, 2014.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Understanding Substance Abuse & Addiction:What Research, Psychology & Medicine Have to Teach Us
TRUST Clinic Speaker SeriesOakland, Ca. June 20, 2014
Joan Zweben, Ph.D. Executive Director, East Bay Community Recovery
Projectwww.EBCRP.org
Clinical Professor of Psychiatry, UCSF
Disclosures Dr. Zweben has no conflict of interest to
disclose. Dr. Zweben’s bias is that evidence-
supported, safe treatment for SUDS should be equally available throughout our system of care, including medication treatment.
Dr. Zweben’s bias is that evidence-based interventions are only one component of individualized treatment planning, not a substitute for comprehensive care.
Evolution of Substance Abuse Treatment in the U.S.
How Did We Get Here?
National Institute on Alcoholism & Alcohol Abuse (NIAAA)
Founded 1970 as a center within NIH
Research on the biology of alcoholism, psychosocial issues, treatment (1990’s)
Produced educational materials for prevention, but initially not a leader in the treatment field.
Pressure from community groups led to more treatment research
National Institute on Drug Abuse (NIDA)
Founded 1972 to promote creation of tx system + research on clinical issues
Goal: what programs were contributing to reducing social costs of addiction
Tx system developed for the indigent (uninsured), funded by federal, state and local entities
Research emphasis on tx modalities
Chronology AA – 1935. Bill Wilson, Dr. Bob Smith in
“Harm reduction is a set of strategies that encourage substance users and service providers to reduce the harm done to drug users, their loved ones and communities by their licit and illicit drug use.”
The Harm Reduction Working Group & Coalition, 1995
Arenas for Harm ReductionArenas for Harm Reduction
HIV/ STD outreach and education needle exchange homeless populations: wet, damp housing SMI clients - Harborview model methadone maintenance (damage control
component) drop in centers users’ support groups money management/payee community HR education
Pitfalls of Abstinence-Oriented TreatmentPitfalls of Abstinence-Oriented Treatment Failure to assess motivation level before
pushing abstinence commitment Failure to understand factors promoting
continued use Unrealistic timetables Power struggle vs clinical approach Failure to recognize fluctuating
motivation Inappropriate termination of treatment
Pitfalls of Harm Reduction ApproachPitfalls of Harm Reduction Approach
Inappropriately low expectations for what client can achieve
Difficulty setting clear goals Reluctance to ask client to abstain
completely Underestimate risks/lethality Clinician alcohol and/or illicit drug
use
The Substance Abuse Treatment System: Finding Good Care
The Substance Abuse Treatment System: Finding Good Care
Paradigm Shift
Chronic Care Model: When treated as a chronic illness, relapse rates are as good or better than other chronic illnesses (McLellan et al. 2005)
Recovery Oriented System of Care (ROSC): Support person centered and self-directed approaches to care that build on the strengths and resilience of individuals, families and communities to take responsibility for their sustained health, wellness and recovery from alcohol and drug problems (CSAT)
(Rawson & Freese. 2010)25
Recovery Oriented System of Care (ROSC)
ROSCs are founded on a chronic care model of substance use treatment and recovery services that use recovery management approaches to engage and treat, and provide recovery support services that help individuals/families sustain their recovery.
(Rawson & Freese. 2010)
26
Broadening Our Target Population
The Changing Health Care Landscape
Different policies for different levels of
Severity
Addiction ~ 25,000,000(Focus on Treatment)
“Harmful Use” – 68,000,000(Focus on Early Intervention))
Little or No Use(Focus on Prevention))
Diabetes ~24,000,000
LITTLE
LOTS In Treatment ~ 2,300,000
Distribution of AOD Problems
2M people (.08%) receiving treatment
21M people (7%) have problems but are not receiving treatment 1.1% made effort to get tx 3.7% felt they needed tx but made no
effort to get it 95.2% did not feel they needed tx
60-80 M (20-25%) using at risky levels
(UCLA/ATTC
2013)
Using at Risky Levels (60-80 million)
Do not meet diagnostic criteria Level of use indicates risk of
developing problems Examples:
Drinks 3-4 glasses of wine several times per week Pregnant woman occasionally uses vodka to relieve
stress Adolescent to smokes mj with friends on weekends Occasionally takes 1-2 extra vicodin to help with pain
(UCLA/ATTC 2013)
ImplicationsAs long as the specialty care programs (AOD treatment programs) are the only places which address SUD: most people with severe problems will
not receive treatment. virtually all with risky use will not
receive professional attention.(UCLA-ATTC 2013)
Value of Behavioral Health
Source: Wyatt Matas, 2013
Value of Behavioral Health
49% of Medicaid Beneficiaries with disabilities have a psychiatric illness. Top 3 behavioral dyads: 1. Psychiatric/Cardiovascular 2. Psychiatric/Central Nervous System 3. Psychiatric/ Pulmonary
Healthcare Settings for Locating Individuals with SUD Primary care settings Emergency rooms/
Trauma centers Prenatal clinics/OB/Gyn offices Medical specialty settings for
diabetes, liver and kidney disease, transplant programs
Pediatrician offices College health centers Mental health settings
(UCLA-ATTC 2013)
Workforce Implications MH/AOD clinicians will be working in
many different settings where teamwork is key
Holistic, integrative perspective and approach; Sick care + wellness care
Screening & brief intervention integral
MI principles and skills essential Availability for drop in or scheduled
meetings; “hallway consults”
Evidence-Based Practices and Treatment Interventions
Evidence-Based Practices and Treatment Interventions
Rationale, Challenges & Perils
Why Use Evidence-Based Principles and Practices?Why Use Evidence-Based Principles and Practices?
To go beyond our preferences and biases
To improve the effectiveness of what we do: what works best, for whom
Because funders will increasingly insist on optimum utilization of inadequate resources
Evidence Based Principles & Practices vs Evidence Based Treatment Interventions
Evidence Based Principles & Practices vs Evidence Based Treatment Interventions
Principles and practices are derived from different types of research.
Rigor often trumps relevance in determining what type of research is valued.
Policy makers must be educated on these issues.
Important DistinctionsImportant Distinctions Evidence-based principles and
practices guide system development Example: care that is appropriately
comprehensive and continuous over time will produce better outcomes
Evidence-based treatment interventions are important elements in the overall picture. They are not a substitute for overall adequate care.
Types of StudiesTypes of Studies
Quasi-experimental studies – some control over confounding factors; less rigorous than RCT’s
Correlational studies – systematic observation across cases or programs
Longitudinal studies Naturalistic studies
Evidence-Based PrinciplesEvidence-Based Principles Retention improves outcomes; we need to
engage people, not discharge them prematurely.
Addicts/alcoholics are a heterogeneous population, not a particular personality type.
Addiction behaves like other chronic disorders Problem-service matching strategies improve
Harm reduction approaches yield benefits in terms of public health and safety.
Pts in methadone maintenance show a higher reduction in morbidity and mortality and improvement in psychosocial indicators than heroin users outside treatment or not on MAT.
Policies and Practices Not Supported by ResearchPolicies and Practices Not Supported by Research Requiring abstinence as a condition of
access to substance abuse or mental health treatment
Denying access to AOD treatment programs for people on prescribed medications
Arbitrary prohibitions against the use of certain prescribed medications
are usually investigated in random assignment studies using manualized treatments in carefully controlled trials. Samples and settings are homogeneous and treatment is standardized. Specific procedures assure fidelity to the model.
Random Assignment Controlled Trials (RCT’s)Random Assignment Controlled Trials (RCT’s)
Gold standard for pharmacological and many psychosocial interventions
Examples with strong efficacy: Cognitive behavioral therapy Motivational enhancement therapy Behavioral marital therapy Community reinforcement approach Relapse prevention Social skills training
“…experimental studies indicate that dissemination of information does not result in positive implementation outcomes (changes in practitioner behavior) or intervention outcomes (benefits to consumers)”
(Fixsen et al, 2005)
Opinion Leaders:A Key to Knowledge Adoption
Opinion Leaders:A Key to Knowledge Adoption Identified by peers as respected for
their knowledge in a particular area Trained in the use of an evidence-based
curriculum They then train their peers and
supervise the application of the curriculum
Changes in counselor behaviors and attitudes are measured to determine the effectiveness of the implementation process
(Rugs D, Hills HA, Peters R, 2004 at www.seekingsafety.org)
methadone pts to BPN and taper them off”) Using EBT’s takes precedence over
individualizing care Funders adopting a “pick from this list”
approach Achieving fidelity takes labor intensive
supervision, and many states don’t fund supervision.
Marketing Impostors
Distinguishing evidence from marketing“We have some of the highest success rates in the country”“You should only have to do this once.”
Presenting multiple anecdotes with no comparison or control groups as “proof”
Research to Practice IssuesResearch to Practice Issues
Inadequate effectiveness studies Huge gaps in the research literature
(s.g., group interventions, therapist variables)?
High training fees for “proven” practices Fidelity vs cultural competence: What is
the tradeoff between fidelity and the need to adapt interventions for specific populations? How can we make cultural adaptations and maintain the treatment effects?
Infrastructure DevelopmentInfrastructure Development
The existing infrastructure cannot handle the expectation for data collection
Funders want data but do not want to pay the costs
Data collected by funders is often not used to improve services
Workforce crisis is a huge problem and an opportunity. Must supply resources for training.
Stay Focused on Basic PrinciplesStay Focused on Basic Principles
Maintain commitment to the principle of individualizing treatment
When an evidence-based treatment doesn't work for an individual, some staff members conclude that the problem is that the treatment isn't being implemented correctly, rather than examining the possibility that it does not fit the needs of the client.
Example from Dual Dx listserve: dualdx.treatment.org
Is There Another Way?Is There Another Way?
Fund programs to develop the infrastructure to examine how they are doing with whom
Draw on EBT’s to improve in areas where there are problems
Clarify realistic performance standards
APA DefinitionAPA DefinitionEvidence-based psychotherapy is
resources-based: best practices are built on a foundation of empirical research, comprehensible and reasoned theories, clinical observation and expertise, and patients' values, contributions and responses.