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 Interviewing and 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/consequences  No apparent or significant risk  No obsession or preoccupation  Under volitional control

Substance ABUSE  Use is associated with significant risks or consequences  Exceeds medical/cultural norms  No obsession or preoccupation  Under volitional control

Substance DEPENDENCE  Continued use despite adverse consequences  Impaired control  Preoccupation/obsession  Exaggerated importance/priority  Tolerance/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 beer  One 5 oz. glass of wine  1.5 oz of distilled spirits

“Low Risk” Qualifiers PRESUMES ABSENCE OF:  Pregnancy  Medical or psychiatric conditions likely to be exacerbated by ETOH use  Medication that interacts adversely with ETOH  Prior personal or family history of substance abuse  Hypersensitivity to alcohol

“At Risk” Drinking  Frequently exceeds recommended limits  No 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  Medical  Job, Financial  Relationships  Legal  Psychological  Sexual

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