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!