How The Two Pillars of Recovery Promote Patient Responsibility Geoff Kane, MD, MPH HUB Teleconference April 14, 2014 Themes VulnerabilityVulnerability EmpathyEmpathy ResponsibilityResponsibility AccountabilityAccountability HonestyHonesty Feelings / EmotionsFeelings / Emotions AuthenticityAuthenticity SpiritualitySpirituality Outline RecidivismRecidivism Laws of Nature NeurobiologyLaws of Nature Neurobiology Two Pillars of RecoveryTwo Pillars of Recovery MotivationMotivation Eliciting StoryEliciting Story DiscussionDiscussion RELAPSE RATE OVER TIME Abstainers (%) Time (Months) Weeks Heroin Smoking Alcohol Kane, MD 2013 Abstinence results from Skill Power not Will Power Recidivism happens Two universal mistakesTwo universal mistakes Two Pillars of RecoveryTwo Pillars of Recovery Relapse The Usual Mistakes Individuals take insufficient responsibility for:Individuals take insufficient responsibility for: u The details of recovery management u Honest self-disclosure Nature: Cause and Effect You either take responsibility You either take responsibility or take natures consequences. or take natures consequences. Addiction is like gravity; it is governed by the laws of nature and never takes time off. Laws of Nature Neurobiology BehaviorBehavior AddictionAddiction RecoveryRecovery There is more to who we are and more to why we do the things we do than what meets our own minds. Lower centers of the Central Nervous System can, and routinely do, act independently of higher centers. New research shows that emotions have a separate system of nerve pathways, through the limbic system to the cortex, allowing emotional signals to avoid conscious control. -Robert Ornstein, 1991 -Robert Ornstein unconscious decisions for action go on constantly inside the head. go on constantly inside the head. -Robert Ornstein Were worse off than Freud thought, because many actions proceed without our knowing anything about them. Addictive chemical substances change the brain and change behavior. Addiction Positive reinforcementPositive reinforcement Negative reinforcementNegative reinforcement ConditioningConditioning Altered motivational hierarchiesAltered motivational hierarchies the essence of addiction: uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences. - Alan Leshner, PhD AddictionAddiction Subjective: Powerlessness (loss of control)Subjective: Powerlessness (loss of control) Objective: Persistent use despite adverse consequencesObjective: Persistent use despite adverse consequences Subjective: Powerlessness (loss of control)Subjective: Powerlessness (loss of control) Objective: Persistent use despite adverse consequencesObjective: Persistent use despite adverse consequences neurobiology of behavior plus neurobiology of addiction equals neurobiology of powerlessness I have a passion for alcohol. - 25 year old female Any addict knows, youll do anything to get it. - 23 year old male Pillar of Recovery It is the nature of addiction that you cant trust yourself, so Keep Your Distance! Positive interpersonal relationships change the brain and change behavior. 27 Neural repatterning comes as we enter into and sustain new types of relationships that allow us to reregulate our sense impressions slowly and over time. - Tian Dayton, PhD Interpersonal experience shapes the mind as it continues to develop throughout the lifespan Interactions with the environment, especially relationships with other people, directly shape the development of the brains structure and function. of the brains structure and function. - Daniel J. Siegel, MD the amygdala, along with related areas, plays a crucial role in coordinating perceptions with memory and behavior. These regions are and behavior. These regions are especially sensitive to social interactions. especially sensitive to social interactions. - Daniel J. Siegel, MD Our limbic system sets the minds emotional tone and stores our highly charged emotional memories. - Tian Dayton, PhD RELAPSE RATE OVER TIME Abstainers (%) Time (Months) Weeks Heroin Smoking Alcohol Kane, MD 2013 The treatment of addiction is [still] people. Suggestions Made in Addiction Treatment 90 meetings in 90 days90 meetings in 90 days Obtain and use sponsorObtain and use sponsor Do some Step workDo some Step work Participate in an aftercare groupParticipate in an aftercare group Participate in counseling/Participate in counseling/ psychotherapy psychotherapy Some Recovery Skills/Tips Be honestBe honest Embrace your painEmbrace your pain Mistrust yourselfMistrust yourself Keep your distanceKeep your distance Seek people, not chemicalsSeek people, not chemicals Pay attention!Pay attention! Pillar of Recovery It is the nature of recovery that you cant do it alone, so Ask for Help! Messages for Patients The only way out of embarrassment and shame is through it.The only way out of embarrassment and shame is through it. Honesty is more important than image.Honesty is more important than image. Replace What can I take? with Who can I talk to?Replace What can I take? with Who can I talk to? The Two Pillars of Addiction Recovery Keep your distance!Keep your distance! (avoid the negatives) Ask for help!Ask for help! (chase the positives) Motivation n A state not a trait n You are a brain treatment Professionals Influence Client Motivation Expectations influence outcomesExpectations influence outcomes Differences in drop-out ratesDifferences in drop-out rates Differences in outcome ratesDifferences in outcome rates Simple actions decrease drop outSimple actions decrease drop out Empathic professionals have better outcomesEmpathic professionals have better outcomes -Obert and Farentino Determinants of Client Change Client factors40%Client factors40% Relationship factors30%Relationship factors30% Expectancy & Hope15%Expectancy & Hope15% Model/technique15%Model/technique15% - Michael Clark, MSW Counseling Tips Be Empathic, NonconfrontationalBe Empathic, Nonconfrontational Offer ChoicesOffer Choices Emphasize Patients ResponsibilityEmphasize Patients Responsibility Convey Confidence In PatientsConvey Confidence In Patients Ability To Change people will forget what you said, people will forget what you did, but people will never forget how you made them feel. - Maya Angelou Motivational Interviewing Elicits Behavior ChangeElicits Behavior Change Respects AutonomyRespects Autonomy Tolerates Patient AmbivalenceTolerates Patient Ambivalence Explores ConsequencesExplores Consequences - Obert and Farentino Four Principles of Motivational Interviewing Express empathyExpress empathy Develop discrepancyDevelop discrepancy Avoid argumentationAvoid argumentation Support self-efficacySupport self-efficacy What Motivational Interviewing is not: Giving informationGiving information Giving adviceGiving advice Using logic to persuadeUsing logic to persuade WarningWarning ConfrontingConfronting AgreeingAgreeing Theresa Moyers, PhD Style AcceptingAccepting Non-judgmentalNon-judgmental EmpoweringEmpowering SupportiveSupportive UnderstandingUnderstanding Patient- elicited Collaborative Ambivalence normal Facilitative -Obert and Farentino Building Motivation Open-ended questioningOpen-ended questioning AffirmingAffirming Reflective listeningReflective listening SummarizingSummarizing - Obert and Farentino Reflective Listening: Key-Concepts Listen to what patient says and to what patient meansListen to what patient says and to what patient means Check out assumptionsCheck out assumptions Create an environment of empathy (non judgmental)Create an environment of empathy (non judgmental) Patient and change agent do not have to agreePatient and change agent do not have to agree Be aware of intonation (statement, not question)Be aware of intonation (statement, not question) - Obert and Farentino Providers help ensure recovery success when they promote continuity of: HealthcareHealthcare CaringCaring AccountabilityAccountability Influences on Cognitive and Emotional Responses to Pain Pain IntensityIntensity CharacterCharacter LocationLocation DurationDuration PrecipitantsPrecipitants Treatments/Treatments/pharmacology Relevant factors Current contextCurrent context MeaningMeaning Past experiences/Past experiences/ expectations expectations FatigueFatigue Depression/anxietyDepression/anxiety DistractionDistraction StressStress Coping techniquesCoping techniques AddictionAddiction - Adapted from Compton et al. 2009 Contributors to Increased Opioid Dependence AvailabilityAvailability Decreased price/Increased purityDecreased price/Increased purity Removal of the injection barrierRemoval of the injection barrier Speed of physical dependenceSpeed of physical dependence Truth n Unreliability of memory n Vagaries of psychopathology n What is historically untrue may be emotionally true be emotionally true n Conflicts of interest create distortions distortions When the only treatment that has ever provided a patient relief happens to be a controlled substance; much more often than not, the patients complaint is motivated by addiction. Consider telling the patient that the more they push for that treatment, the more they push for that treatment, the more concerned you must be about addiction. Turning the Tables - Adapted from Ted Parran, MD 1997 If you are convinced the only treatment that can help you is an addictive medication: is an addictive medication: worry and ask for help because thats a sign of addiction. thats a sign of addiction. If You Have an Addictive Illness: Avoid These Medications BenzodiazepinesBenzodiazepines OpioidsOpioids Barbiturates (esp. Butalbital)Barbiturates (esp. Butalbital) StimulantsStimulants Meprobamate (including carisoprodol or Soma)Meprobamate (including carisoprodol or Soma) AlcoholAlcohol BenzodiazepinesBenzodiazepines OpioidsOpioids Barbiturates (esp. Butalbital)Barbiturates (esp. Butalbital) StimulantsStimulants Meprobamate (including carisoprodol or Soma)Meprobamate (including carisoprodol or Soma) AlcoholAlcohol And Be Cautious Taking Any of These: AntihistaminesAntihistamines Muscle relaxantsMuscle relaxants Sedating medications (psychiatric and other)Sedating medications (psychiatric and other) AntihistaminesAntihistamines Muscle relaxantsMuscle relaxants Sedating medications (psychiatric and other)Sedating medications (psychiatric and other) Your Responsibilities With Prescribers Look for alternatives before accepting an addictive medicationLook for alternatives before accepting an addictive medication Tell them you have an addictive disorder even if the problem was a long time agoTell them you have an addictive disorder even if the problem was a long time ago Its best to tell them this before you are sickIts best to tell them this before you are sick Remember you have no brakes when it comes to addictive substancesRemember you have no brakes when it comes to addictive substances Ask the prescriber to set a time limitAsk the prescriber to set a time limit Have someone else control the supply of medicationHave someone else control the supply of medication Biomedical Ethics: Basic Principles Respect for AutonomyRespect for Autonomy NonmaleficenceNonmaleficence BeneficenceBeneficence JusticeJustice Spirituality Involves Relationships With: SelfSelf Other Human BeingsOther Human Beings NatureNature Creator, God, Higher PowerCreator, God, Higher Power Patients help ensure recovery success when they embrace: AbstinenceAbstinence Mental and emotional changesMental and emotional changes Spiritual changesSpiritual changes Daily spiritual practiceDaily spiritual practice A Model for Recovery Emotional ArousalEmotional Arousal Sense of HopeSense of Hope Sense of MasterySense of Mastery Love and HumorLove and Humor - Modified from Jerome Frank, MD Additional Information addictiontreatmentbareessentials. comaddictiontreatmentbareessentials. com The Two Pillars of RecoveryThe Two Pillars of RecoveryThe Two Pillars of RecoveryThe Two Pillars of Recovery Keep Your Distance!Keep Your Distance!Keep Your Distance!Keep Your Distance! Ask for Help!Ask for Help!Ask for Help!Ask for Help! Adverse Childhood ExperiencesAdverse Childhood ExperiencesAdverse Childhood ExperiencesAdverse Childhood Experiences Can I have just one?Can I have just one?Can I have just one?Can I have just one? Sedative-hypnoticsSedative-hypnoticsSedative-hypnotics