Behavioral Health and Opioid Related Disorders Alex Nelson MSW, CDP

What to do? Many individuals who have a ORD would like to stop using but struggle with maladaptive coping skills. Individuals learn to use opioids not just for pain but for other ailments. Anxiety/Depression Fatigue Trepidation Unwanted emotions

What to do? (continued) However, the benefits of opioid use cannot be separated from the detrimental effects that accompany them. Thus individuals find themselves struggling to reconcile the benefits they receive from opioid use while trying to mitigate the negative effects. The problem isn’t that opioid use is not beneficial, the problem is that it is very difficult to remember the negative effects of opioid use when struggling with an unpleasant issue in the present.

Cognitive Behavioral Therapy (CBT) CBT is a structured, short-term, present oriented psychotherapy directed at solving current problems and modifying dysfunctional thinking and behaviors. (Beck, 1964) CBT theory states that many of our dysfunctional behaviors or unhealthy emotions are a direct result of irrational beliefs or irrational thinking. (Beck, 1964) CBT seeks to help individuals recognize their irrational beliefs or thoughts, and by doing so eliminate dysfunctional behavior.

Cognitive Behavioral Therapy (Continued) While this therapy was developed to initially address depression, in the decades since its inception, CBT, or therapies which rely on the CBT model, have proven to be effective in addressing: Depression (Beck, 1964) PTSD (Foa & Rothbaum, 1998) Anxiety (Foa & Rothbaum, 1998) Substance Use Disorders (Hettema, Steele, and Miller, 2005) Relationships Issues (Hayes, Follette, and Linehan, 2004) Some Personality Disorders (Linehan, 1993)

Stages of Change Pre-contemplation: The individual does not notice there is a problem. Contemplation: The individual notices there is a problem but is unsure how to address this issue. Preparation: The individual is preparing to address the issue, gathering resources or developing a plan to move forward. Action: The individual is actively addressing the issue which they have identified. Maintenance: A new homeostasis is reached and the individual becomes accustom to this “new normal.”

Motivational Interviewing Developed by William Miller. A branch of CBT. Motivational Interviewing seeks to develop the desire to change which is present in every individual. (Hettema et al., 2005) This is therapy relies on the stages of change model, nonconfrontation to help individuals develop their own reasons to change their behavior. (Hettema et al., 2005)

Motivational Interviewing Principles Tools used in Motivational Interviewing Nonconfrontation Rolling with resistance Reductio ad absurdum Reflective listening Summarizing Unconditional positive regard

Motivational Interviewing (continued) If using MI correctly, the facilitator should not… Develop goals for the patient Become frustrated with the patient Should not focus on the past, unless it is directly related to a present issue. Should not use “why” questions. If using MI correctly, the facilitator should… Only ask opened questions. Use “How” “When” and “What” questions frequently Use reflective listening

Case Study (Han) 52 year old male, history of low back pain treated at a local pain management clinic for 4 years with escalating doses of short acting opioids.  His provider became uncomfortable with the dose he needed to achieve "pain control" so he was abruptly discharged from the practice.  Unable to obtain prescription opiates at the dose necessary for achieve the desired affect he began using heroin.  Prior to treatment he reports having a12 year history of using 2-3 grams of IV heroin per day.   He is currently receiving MAT with buprenorphine.  Your patient has been relapsing on oxycodone and valium off and on for the last few months.  He seems to be very motivated during appointments and you believe that he really does want to stop using opioids.  What is the best approach to treatment?

Case Study (Leia) 31 year female, began using opioids after a very bad car accident and continued to seek out opioid medication for 6 years after the accident.  She has no history of iv drug use but admits to buying the "pills she needs" from friends.  She is now wanting to stop using opioids and would like to begin Suboxone treatment because her friend told her it would help her get off the pills.  Urine drug test today is negative for all substances except for oxycodone.  Urine pregnancy positive.  What is the best course of action?

Sources Beck, A.T. (1964). Thinking and depression: II. Theroy and therapy. Archives of General Psychiatry, 10, 561-571 Beck, J. S., & Beck, J. S. (2011). Cognitive therapy: basics and beyond. New York: Guilford Press. Foa, E.B., & Rothbaum, B.O. (1998) Treating the trauma of rape: Cognitive-behavioral therpay for PTSD. New York: Gilford Press. Hayes, S.C., Follette, V.M., Linehan, M.M. (Eds.). (2004) Mindfulnessand acceptance: Expanding the cognitive-behavioral tridition. New York: Guilford Press. Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational Interviewing. Annual Review of Clinical Psychology, 1(1), 91-111. doi:10.1146/annurev.clinpsy.1.102803.143833 Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.