Assessment & Treatment of Alcohol and Other Drug Problems

Alta Bates Hospital

Berkeley, Ca. October 13, 2008

Joan E. Zweben, Ph.D.Executive Director: East Bay Community Recovery Project

Clinical Professor of Psychiatry; UC San Francisco

IN COLLABORATION WITH:

Arnold Washton, Ph.D.Recovery Options

New York, NY & Princeton, NJ

Recovery-Oriented Psychotherapy

An Integrative Approach

Stages of Recovery-Oriented Therapy

1. Assessment with motivational feedback

2. Engaging the client who is actively using

3. Negotiating an abstinence contract

4. Helping the client to stop using (early abstinence)

5. Consolidating abstinence, changing lifestyles, developing adaptive coping skills (relapse prevention)

6. Addressing developmental/interpersonal issues (psychotherapy)

Recovery-Oriented Psychotherapy

Framework that integrates disease model addiction treatment with abstinence-based psychotherapy

Individual, group, & couples therapy Supports, facilitates , and encourages but does not

mandate involvement in AA Therapist’s tasks shift according to the patient’s stage

of recovery Collaborative stance toward the patient

Therapist’s Role

Facilitate change Mobilize motivation Non-judgmental coach, advisor, and guide Educator Voice of reason and reality Safety net and backstop Steady, reliable resource Supply ego functions that the patient lacks

Integrative Approach

Stages of change Motivational interviewing Cognitive-behavioral techniques Disease model & AA Adaptive “self medication” model Psychodynamic, insight-oriented techniques

Using Different Strategies at Different Stages

1. Initially, focus on motivational issues and treatment engagement

2. Once the client becomes willing to change, utilize cognitive-behavioral strategies to facilitate transition from active use to stable abstinence

3. As recovery proceeds, incorporate insight-oriented techniques to address broader issues, but always keeping addiction issues in focus

Integrative Approach

Treatment must address more than the substance abuse itself:

Developmental arrest Interpersonal problems Managing feelings Self-esteem issues Co-existing Axis I & II disorders Other addictive/compulsive behaviors

Key Points

There is no single best pathway to recovery for everyone

Accept that you are powerless to control another’s drug use; let go of your control fantasies

Maintain an empathic connection; the single most important aspect of treatment is the therapeutic alliance

Key Points

Re-conceptualize resistance as ambivalence

Start where the patient is- NOT where you want him/her to be

Listen to your clients. They will tell you what they are ready or not ready to do.

Psychodynamic Issues at Different Stages

Psychodynamic Issues in the Early Phase

Therapeutic alliance Warmth, empathy, positive regard Trust, respect, concern Unconditional acceptance Consistency & availability Counteract internalized self-loathing, shame, guilt Support self-efficacy, autonomy, reduce dependency fears Environment of safety: accountability, limits, realistic

feedback, boundaries

Psychodynamic Issues in the Middle Phase

Ongoing ambivalence about giving up alcohol/drugs

“I’ve stopped using, but I’m still unhappy” Affect management: “self-medication” Defining interpersonal, self-esteem, and

boundary issues Shame and guilt issues

Psychodynamic issues in later stages

Intimacy with autonomy*Separation-individuation* Affect management: “self-medication” Grief and loss Early traumas Residual narcissistic & controlling behaviors

Relapse Dreams

Can occur at any stage Wake up not sure whether they have actually used Worst fear is that the dream is prophetic In early stage often due to ambivalence and self-doubt In middle stage often due to fears about relapse- “Is

there something moving me toward relapse??” In latter stages often stimulated by unresolved issues

and/or being overwhelmed with feelings

Relapse Dreams

What feelings were stimulated by the dream? Why did this dream occur at this particular point in

time? What could the dream be telling you about where you

need to strengthen your recovery plan? What issues/problems may have given rise to the

dream? Does the dream signal unresolved or renewed

ambivalence about giving up alcohol/drugs?

Motivational Interviewingand the Stages of Change

Facilitating Change

Motivational Interviewing offers a way to conceptualize and deal more effectively with problems of patient resistance and poor motivation

Stages of Change Model provides a framework for determining the readiness of patients to change their behavior and for matching treatment interventions accordingly

Stages of Change

Precontemplation- Not seeing the behavior as a problem or feeling a need to change (“in denial”)

Contemplation- Ambivalent, unsure, wavering about necessity and desirability of change

Preparation- Considering options for change Action- Taking specific steps to change behavior Maintenance- Relapse prevention Relapse- Returning to use or earlier stage of change

Stages of Change

Stages of Change Model

Facilitates empathy- patients seen as “stuck” in a particular stage of the process rather than “resistant”

Defines ambivalence as normal not pathological Leads to better patient-treatment matching by

defining the types of clinical interventions that work best with patients in each stage of change

Provides “roadmap” and sets the tone for more positive interaction with “resistant” patients

Motivational Approach Start where the patient is Roll with resistance Avoid arguments, power struggles Back off in the face of resistance Be persuasive not confrontive Reframe resistance as ambivalence Offer choices to increase patient acceptance and investment Negotiate, don’t pontificate Acknowledge positive drug effects Adjust interventions to stage of readiness for change

Diagnosis

Substance USE

Absence of problems/consequencesNo apparent or significant riskNo obsession or preoccupationUnder volitional control

Substance ABUSE

Use is associated with significant risks or consequences

Exceeds medical/cultural normsNo obsession or preoccupationUnder volitional control

Substance DEPENDENCE

Continued use despite adverse consequences

Impaired controlPreoccupation/obsessionExaggerated importance/priorityTolerance/withdrawal (optional)

NIAAA “Low Risk” Drinking

MEN

No more than 14 drinks per week (2 per day) and no more than 4 drinks per occasion

WOMEN

No more than 7 drinks per week (1 per day) and no more than 3 drinks per occasion

SENIORS- OVER AGE 65

No more than one drink per day

One “Standard” Drink

One 12 oz. bottle of beerOne 5 oz. glass of wine1.5 oz of distilled spirits

“Low Risk” Qualifiers

PRESUMES ABSENCE OF:PregnancyMedical or psychiatric conditions likely to be

exacerbated by ETOH useMedication that interacts adversely with ETOHPrior personal or family history of substance abuseHypersensitivity to alcohol

“At Risk” Drinking

Frequently exceeds recommended limitsNo evidence yet of adverse consequences Drinking exposes the individual to

significant risk Prime target for preventive efforts

“Problem Drinking” ALCOHOL ABUSE

Evidence of recurrent medical, psychiatric, interpersonal, social, or legal consequences related to alcohol use; OR

Being under the influence of alcohol when it is clearly hazardous to do so (e.g., operating a vehicle or other machinery, delivering health care services)

No evidence of physiological dependence No prior history of alcohol dependence

“Alcoholism” ALCOHOL DEPENDENCE

BEHAVIORAL syndrome characterized by: Compulsion to drink Preoccupation or obsession Impaired control (amount, frequency, stop/reduce)

Alcohol-related medical, psychosocial, or legal consequences

Evidence of withdrawal- not required Evidence of tolerance- not required

Assessment Techniques

Assessment Goals

Assess nature and extent of substance use Assess nature and extent of substance-related

problems and consequences Assess patient’s stage of readiness for change Formulate an initial diagnosis Provide motivation-enhancing feedback based

on assessment results

Assessment Domains Typology of use Positive benefits Negative consequences Need for medical detoxification Other addictive behaviors Prior attempts to stop or cut down Prior treatment and self-help experience Diagnostic signs of substance dependence disorder Family history of alcohol/drug problems Stage of readiness for change

Typology of Use Types of substances Amount/frequency Administration route (oral, intranasal, pulmonary, i.v., i.m.) Temporal pattern (continuous, episodic, binge) Environmental precursors (external “triggers”) Emotional precursors (internal “triggers”) Settings and circumstances linked with use (people, places..) Linkage with use of other substances (e.g., cocaine-alcohol) Linkage with other compulsive behaviors (sex, gambling,

spending, eating, etc)

Positive Benefits of Use

What first attracted you to this drug? How has it helped you? Does it still work as well? What would be the potential downside of not

using it?

Negative Consequences

MedicalJob, FinancialRelationshipsLegalPsychologicalSexual

Medical “Red Flags- ALCOHOL

Hypertension Blackouts Injuries Chronic abdominal pain Liver problems Sexual dysfunction Sleep problems Depression/anxiety

Medical “Red Flags” COCAINE

Chronic nasal/sinus problems (snorting) Chronic respiratory problems (smoking crack) Sexual dysfunction Labile moods, paranoia, suicidal ideation Sleep problems Seizures Abuse of alcohol and sedatives

Medical “Red Flags”OPIOIDS

For Rx opioids: requests for increased doses, frequent refills, multiple prescribers, “lost” prescriptions

Sexual dysfunction Amenorrhea Sleep problems Constipation Liver problems

Biochemical Indicators of Alcohol Abuse

Most markers are late stage and not very reliable indicators of alcohol problems

Best used in combination to confirm diagnosis & establish baseline for follow up GGT gamma-glutamyltransferase MCV mean corpuscular volume AST aspartate aminotransferase

Urine Toxicology- Drugs

Detects only recent use (past few days) No information about amount, frequency, or

chronicity of use No information about problem severity Best used as a clinical tool to monitor

treatment progress

Psychosocial Consequences

Vocational: Work life adversely affected? Relationships: Family/marital relationships or home

life been adversely affected? Legal: Any legal trouble? (e.g., DWI) Psychological: Mood or mental functioning been

adversely affected? Suicidal thoughts or actions? Sexual: Sex drive or performance been adversely

affected? Cocaine or amphetamine-related hypersexuality and acting out behavior?

Need for Medical Detoxification

Benzodiazepines, alcohol, opioids Abrupt withdrawal from alcohol/benzos can be

life threatening and must be managed medically

Opioid withdrawal is uncomfortable, but not life threatening, except when another medical condition could be exacerbated (e.g., heart problems)

The Specialty Treatment System

Inpatient – hospital based Therapeutic Communities (TCs) Residential treatment with less structure Outpatient – varying levels of intensity;

varying levels of capability to address co-occurring disorders

Opioid maintenance treatment system

Utilizing The Self-Help System

Provides a community that supports the recovery process

Provides a process for personal development with no financial barriers

Offers a wide range of role models Research shows benefits of short and long term

participation

Resources

Treatment Improvement Protocols (TIPS) www.samhsa.gov

East Bay Community Recovery Project: www.ebcrp.org

Washton, A. M., & Zweben, J. E. (2006). Treating Alcohol and Drug Problems in Psychotherapy Practice: Doing What Works. New York: Guilford Press.