Evidence-Based Substance Abuse
Treatment
David A. Patterson, Ph.D.
Professor
UT College of Social Work
dpatter2@utk.edu
Learning Objectives
1. Participants will learn basic concepts of evidence-based
practice.
2. Participants will learn of the limitations of current substance
abuse treatment practices.
3. Participants will learn ten evidence-based principles of drug
use and problems.
4. Participants will learn the stages of change model
5. Participants will learn the basic principles of motivational
interviewing and motivation enhancement therapy.
6. Participants will learn the basic principles of the Screening,
Brief Intervention, Referral, and Treatment Model
7. Participants will acquire information on where to find
additional information on evidence-based substance abuse
treatment.
Global Scope of the Problem
• World Health Organization (2007)
–
–
–
–
76.3 million - alcohol use disorders
15.3 million - drug abuse disorders
People in 136 countries inject drugs
60 disease and injuries causally related to alcohol consumptions =
1.8 million deaths annually
– Heroin production tripled since 1985
– 13.5 million people take opiates/9.2 heroin
– European heroin injectors have 20 to 30 times the likelihood of
death compared to nonusers.
Evidence Based Practice
• Becoming the dominant paradigm in Western
medicine and social work
• SAMSHA (2007) has defined evidence-based
practice as,
– "a practice which, based on expert or consensus
opinion about available evidence, is expected to
produce a specific clinical outcome (measurable
change in client status)".
• The Institute of Medicine (2001) emphasizes the
notion of "multiple streams of evidence".
Evidence Based Practice
• Institute of Medicine (2001)
– (1) ”Best research evidence-the support of clinically
relevant research, especially that which is patients
centered",
– (2) ”Clinician expertise-the ability use clinical skills
and past experience to identify treat the individual
client"
– (3) ”Patient values-the integration into treatment
planning of the preferences, concerns and expectations
that each client brings to the clinical encounter".
Evidence-Based Practice
Evidence-Based Practice
Substance Abuse Treatment Effectiveness
Insufficient Evidence of Effectiveness
(two or less controlled studies)
•
•
•
•
•
•
Mandated attendance at Alcoholics Anonymous (AA)
Hypnosis
Psychedelic medication therapy
Non-SSRI antidepressant therapy
Standard treatment
Milieu Therapy
Insufficient Evidence of Effectiveness
(two or less controlled studies)
•
•
•
•
•
•
Antiolytic agent therapy
Relaxation training
Confrontational counseling
Psychotherapy
General alcoholism counseling
Educational lectures and films
Indeterminate Evidence of Effectiveness
•
•
•
•
•
•
•
•
Nonbehavioral marital therapy
Electrical aversion therapy
Placebo therapy
Lithium therapy
Functional analysis
Relapse prevention
Self-monitoring
Selective serotonin reuptake inhibitor (SSRI)
antidepressant therapy
Strong Evidence of Effectiveness
(consistent support from controlled research)
• Behavioral marital therapy (includes improving
problem solving, communication skills, and
increases in positive reinforcement)
• Motivational enhancement therapies
• Opioid antagonist therapy
• Behavior contracting
• Brief interventions, e.g., FRAMES
• Community reinforcement approach (CRA)
• Social skills training
• Stress management
Strong Evidence of Effectiveness Strong
Evidence of Effectiveness
(consistent support from controlled research)
•
•
•
•
•
Patient-centered therapy
Behavioral self control training
Cognitive therapy
Covert sensitization (a form of aversion therapy)
Covert sensitization Oral and implant disulfiram (placebo
effect has not been ruled out)
• Self-help manual
• Screening, Brief Intervention, Referral, and Treatment
Therapist Characteristics - Treatment
Outcome
• Level of therapist empathy is a major predictor of
treatment outcome.
• Treatment outcomes suffer secondary to aggressive
confrontation.
• Miller et al.(1980) found that when there was low
therapists’ empathy, the clients faired better with a selfhelp manuals.
• Motivational Interviewing is a strong alternative approach.
Drawing the Science Together:
10 Broad Principles of Drug Use and Problems
Drug use is a chosen behavior
Drug problems emerge gradually and occur along a continuum of severity
Once well-established, drug problems tend to become self-perpetuating
Motivation is central to prevention and intervention
Drug use responds to reinforcement
Drug problems do not occur in isolation, but as part of behavior clusters
There are identifiable and modifiable risk and protective factors for problem
drug use
Drug problems occur within a family context
Drug problems are affected by a larger social context
Relationship matters
Drug Use is a Chosen Behavior
• Drug use is chosen from among behavioral options.
• “Most people who recover from drug problems do so on their own,
without formal treatment.”
• “Effective interventions facilitate and perhaps support natural
change processes.”
• Evidence suggests that change frequently involves a decision,
commitment, or turnabout.
• “Personal commitment appears to be a final common pathway
toward change in drug use.”
• “There is every reason to treat the individual drug user as an active
participant, responsible choosing agent, and a collaborator in
prevention and treatment interventions.”
Drug Problems Emerge Gradually and Occur
Along a Continuum of Severity
• Drug addiction happens gradually, with initial experimentation,
moving to more frequent use.
• There is no clear moment when a person “the commons”dependent
or addicted.
• “Dependence emerges over time as the person’s life becomes
increasingly centered on drug use.
• It is easier to back out of drug use at earlier and less severe stages of
problem development.
Once Well-Established, Drug Problems Tend to
Become Self-Perpetuating
• Addictive behaviors take on a life of their own, becoming “self organizing” and
robust.
• Addressing just one component of the system is often ineffective.
• It is important to understand for each individual what is maintaining the pattern of
drug use, and, more importantly, which components need to be addressed in order
to produce stable change.
• The pharmacological effects can lead to stable preference for drug use and
displacement of natural sources of reinforcement.
• An initial period of drug abstinence can be helpful in destabilizing dependent drug
use.
• Hospitalization, incarceration, antagonist medications and differential
reinforcement of nonuse can produce initial periods of abstinence.
Motivation Is Central to Prevention and
Intervention
• Motivational factors are central to understanding drug use, and also in preventing
and reversing drug problems.
• “People who stop drug use on their own without formal treatment, when later
asked how and why they did so, often referred to a choice or decision .”
• “Transtheoretical research points to a sequence of events or stages through which
people pass, starting with increased concern or motivation for change, decisional
consideration, commitment, planning, and taking action to change.”
• “Taking action also predicts change. Better outcomes follow from attending more
sessions or staying longer in treatment, going to more 12-step meetings, adhering
to treatment advice, or faithfully taking one’s medication.”
• “The idea that there is nothing one can do until a person “hits bottom” is simply
mistaken.”
• “Positive reinforcement, unilateral intervention to family members, and brief
motivational counseling and advice have all been shown to instigate change in
seemingly unmotivated individuals.”
Drug Use Responds to Reinforcement
• “Preferred drugs are powerful reinforcers, chosen from among
available options.”
• “Because stopping drug use simply eliminates one readily available
source of positive reinforcement, long-term change typically
involves finding competing reinforcers -in essence, developing a
rewarding life that does not rely on drug use.”
• Drug use tends to be associated with a foreshorting of time
perspective, so that longer term delayed rewards are discounted in
value.
• Providing clear incentives for abstinence often yields rapid
reductions in drug use.
Drug Problems Do Not Occur in Isolation,
but As Part of Behavior Clusters
• For adolescents, drug use occurs in conjunction with poor school performance,
precocious sexuality, mood problems (anxiety, depression), and antisocial
behavior.
• For adults, drug use occurs in conjunction with “elevated rates of family
discord, violence, health problems, unemployment, poverty and financial
problems, homelessness, crime, injury, child behavior problems, child abuse
and neglect, disability, and a host of psychological and mood problem.”
• “Drug use occurs in a context of life problems, and abstinence is often well
down on a client’s list of priorities.”
• “Interventions that target a broader range of life functioning are more
successful in resolving drug problems.”
There Are Identifiable and Modifiable
Risk and Protective Factors for Problem
Drug Use
• “Heredity contributes to risk for alcohol problems, and evidence is mounting for
genetic predispositions for or against other drug use.”
– “Some Asian groups inherit a metabolic abnormality… (that) decreases risk
for problem drinking.”
– People who are relatively insensitive to the intoxicating an adverse effects of
alcohol are greater risk of alcohol dependence.
– “Escapist reasons for drug use and avoided styles of coping are both
associated with increased risk for drug involvement.”
• “Protective factors include…
– Nondrug positive reinforcement, stimulating environments, stress-buffering
resources, close, high-quality positive relationships with nondrug involved
people.
Drug Problems Occur Within a Family Context
• “Parental drug use is the risk factor for children’s drug use, and is linked to a
host family problems and more general risk factors.”
• “Children of drug impaired parents are, less likely to develop self-regulation
skills particularly if parenting is disrupted before the child is age 6, the critical
period for learning self-control.”
• “Domestic violence and child abuse are greatly increased with parental alcohol
and other drug problems.”
• Protective family factors include…
– Parental disapproval of drug use, consistent, supportive and authoritative
parenting style, parental monitoring of child whereabouts, family
involvement in religion and other conventional activities.
• Effective family interventions include (1) strengthening family skills for
constant communication and monitoring, and (2) building family reciprocity in
exchanging in sharing positive reinforcement.
Drug Problems Are Affected by a Larger
Social Context
• “There are large regional differences in the problems of drug use and problems.”
• Social modeling can promote or deter use.
• “Criminal sanctions for use are relatively ineffective in suppressing drug use,
particularly once it is an established pattern.”
• Clear norms and modeling of moderation influence drinking rates.
• “Adding one heavy drinker can increase the consumption rate at a table, whereas
adding one moderate drinker has little effect.”
• “Having a meaningful role in society is a protective factor, while the loss of
significant role increases the risk of drug problems.”
• “Social isolation is both a promoter and a consequence of the progression of drug
dependence, and social bonding with non-users can be the antidote.”
Relationship Matters
• “There is something therapeutic about certain
relationships.”
• “Counselors who are higher in warmth and accurate
empathy have clients who showed greater improvements
in drug use and problems.”
• “As early as the second session, clients’ ratings of their
working relationship with the counselor are predictive of
treatment outcome.”
• “A confrontational style that puts clients on the defensive
appears to be counterproductive… producing
significantly worse outcomes.”
National Longitudinal Alcohol
Epidemiologic Survey
• NLAES DATA ON ALCOHOL DEPENDENT SUBJECTS
• Outcome categories
Treated
Untreated
•
(n=1,233) (n=3,309)
• < 5 years since onset dependence
•
•
•
alcohol abuse
70%
abstinent
11%
drinking w/o abuse 19%
53%
5%
41%
National Longitudinal Alcohol
Epidemiologic Survey
• NLAES DATA ON ALCOHOL DEPENDENT SUBJECTS
• Outcome categories
•
Treated
Untreated
•
(n=1,233)
(n=3,309)
• 20+ years since onset dependence
•
•
•
alcohol abuse
abstinent
drinking w/o abuse
• Source: Dawson (1996)
20%
55%
24%
10%
30%
60%
Long-Term Residential (LTR)Treatment
Changes from Before to After Treatment
100
Pre
Post
88
77
80
66
60
41
40
40
22
24
19
17
20
16
13
6
0
Cocaine
(Weekly)*
Heroin
(Weekly)*
Heavy
Alcohol*
Illegal
Activity*
No FT
Work*
Suicidal
Ideation*
*p<.001
% of DATOS Sample (N=676)
Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997 (PAB)
Outpatient Drug-Free (ODF) Treatment
Changes from Before to After Treatment
Pre
100
Post
82
76
80
60
42
40
31
25
22
18
20
15
19
14
11
9
0
Cocaine
(Weekly)*
Marijuana
(Weekly)*
Heavy
Alcohol*
Illegal
Activity*
No FT
Work*
Suicidal
*p<.001
Ideation*
% of DATOS Sample (N=764)
Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997 (PAB)
Short-Term Inpatient (STI) Treatment
Changes from Before to After Treatment
100
80
Pre
Post
67
67
60
64
48
40
31
30
26
21
20
20
11
16
11
0
Cocaine
(Weekly)*
Marijuana
(Weekly)*
Heavy
Alcohol*
Illegal
Activity*
No FT
Work
Suicidal
Ideation*
*p<.001
% of DATOS Sample (N=799)
Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997 (PAB)
Outpatient Methadone Treatment (OMT)
Changes from Before to After Treatment
100
Pre
89
Post
85
82
80
60
42
40
29
28
22
15 16
20
17
14
13
0
Cocaine
(Weekly)*
Heroin
(Weekly)*
Heavy
Alcohol
Illegal
Activity*
No FT
Work
Suicidal
Ideation
*p<.001
% of DATOS Sample (N=727)
Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997 (PAB)
Transtheoretical Model
• The Transtheoretical Model (Prochaska & DiClemente)
• An integrative model of behavior change.
• The model describes how people modify a problem
behavior or acquire a positive behavior.
• The central organizing construct of the model is the
Stages of Change. Material adapted : Velicer, W. F, Prochaska, J. O., Fava, J. L., Norman, G. J., &
Redding, C. A. (1998)
Stages of Change Model
Transtheoretical Model
• Stages of Change: The Temporal
Dimension
–
–
–
–
–
Stage is a key organizing construct of the model.
Represents a temporal dimension.
Change implies phenomena occurring over time.
Largely ignored by alternative theories of change.
Behavior change was often construed as an event,
such as quitting smoking, drinking, or over-eating.
– The Transtheoretical Model construes change as a
process involving progress through a series of five
stages.
Stages of Change Model
• Precontemplation Stage– Individuals typically deny having a problem with drugs or alcohol
and commonly resist change
– Therapeutic goal • Increase their consideration of the possibility that they may have a
problem while avoiding any attempt to coerce the individual into
accepting a diagnosis or substance abuse label.
• Increase the individual's awareness that the behavior, problematic
substance use, and its consequences may merit his/her attention and
consideration.
Stages of Change Model
• Contemplation Stage
– Individuals begin to think about changing use of drugs/alcohol
– Commonly express ambivalence about changing their behavior.
– Benefit from a discussion of the pros and cons of changing their
behavior.
– Referred to as a "decisional balance" discussion.
– Individual may be considering change, in this stage they have not
committed to change.
Stages of Change Model
• Preparation/determination stage
– Individuals appear ready for and committed to action.
– Have decided to stop the problematic behavior and
initiate positive behavior.
– Ambivalence about change may not be fully resolved in
this stage.
– Commitment to change does not necessarily mean that
change is automatic but instead requires action by the
individual.
Stages of Change Model
• Action stage of change
– Individual is actively engaged in modifying the target behavior and
their environment.
– Typically they have developed a plan for change with their social
worker.
– Seeking support of family and friends facilitates success in this
stage of change.
– Clients publicly stating their commitment to take action can
solidify this effort.
– Typically requires three to six months, but the actual length will
vary depending on the severity of the problem.
Stages of Change Model
• Maintenance phase
–
–
–
–
Therapeutic focuses on maintaining the new behaviors.
Behavioral patterns generally require time to emerge and stabilize.
Clients may seek additional treatment for supporting recovery.
Always the threat of relapse or return to the old problematic
behavior.
– It is sometimes said that individuals go back to doing that which
they do not wish to do in order to remember why they made the
change
Stages of Change Model
• Relapse or recycling stage of change
– Does not occur for all individuals, but relapse is very common in
substance abuse in populations.
• People can regress from any stage to an earlier stage.
• The bad news is that relapse tends to be the rule when action is taken for
most health behavior problems.
• Relapse may occur secondary to
– (1) unexpected urges or temptations,
– (2) the individual relaxing their guard about the dangers of substance
abuse,
– (3) individuals may test their ability to resist the temptations of drugs or
alcohol and fail, and
– (4) there may be an erosion of their sense of self-efficacy or commitment
to change.
Transtheoretical Model
Transtheoretical Model
• The Relationship between Stage and the Decisional
Balance for a Healthy Behavior
Transtheoretical Model
• Self-efficacy/Temptations.
• The Self-efficacy construct represents the
situation specific confidence that people have
that they can cope with high-risk situations
without relapsing to their unhealthy or highrisk habit.
• The Situational Temptation Measure reflects
the intensity of urges to engage in a specific
behavior when in the midst of difficult
situations.
– It is the converse of self-efficacy and the same set
of items can be used to measure both, using
different response formats.
Transtheoretical Model
• The Relationship between Stage and both Self-efficacy and Temptation
Transtheoretical Model
• Helping Relationships combine caring, trust, openness and
acceptance as well as support for the healthy behavior change.
Rapport building, a therapeutic alliance, counselor calls and
buddy systems can be sources of social support.
• Counter Conditioning requires the learning of healthier behaviors
that can substitute for problem behaviors. Relaxation can
counter stress; assertion can counter peer pressure; nicotine
replacement can substitute for cigarettes, and fat free foods can
be safer substitutes.
Transtheoretical Model
•
The Relationship between Stage and two sample Processes, Consciousness
Raising and Stimulus Control
Motivational Interviewing
• Motivational interviewing is an evidence-based
intervention designed to enhance client motivation
for change.
• Tested in a variety of clinical intervention
modalities including
–
–
–
–
brief 30-minute interventions,
multiple sessions,
ongoing counseling, and
client assessment.
Motivational Interviewing
Motivation Enhancement Therapy (MET)
(Miller, 2005)
There are four key assumptions of MET (Miller, 2005).
– 1. Ambivalence about substance use (and change) is normal
and constitutes an important motivational obstacle in
recovery.
– 2. Ambivalence can be resolved by working with your
client’s intrinsic motivations and values.
– 3. The alliance between you and your client is a
collaborative partnership to which you each bring
important expertise.
– 4. And empathetic, supportive, yet direct, counseling style
provides conditions under which change can occur. (Direct
argument and aggressive confrontation may tend to
increase clients defensiveness and reduces the likelihood of
behavior change.) p. 39.
Motivational Enhancement Therapy:
• A systematic intervention to evoke change in
problem drinkers.
• Based on the principles of motivational
psychology.
• Designed to produce rapid, internally motivated
change.
• Does not attempt to guide and train the client, step
by step, through recovery.
• Employs motivational strategies to mobilize the
client’s own change resources.
•
Miller, Chap. 5, Handbook of Alcoholism Treatment Approaches, 1995
Opening Strategies
•
•
•
•
•
1. Ask Open Questions
2. Listen Reflectively
3. Affirm – Compliments or statements of appreciation
4. Summarization –used to link together and reinforce material
5. Eliciting Self- Motivating Statements
–
–
–
–
Recognizing disadvantages of the status quo (problem recognition)
Recognizing advantages of change
Expressing optimism about change
Expressing intention to change
Motivation Enhancement Therapy
• Five Basic Principles of MET
–
–
–
–
Express Empathy
Develop Discrepancy
Avoid Argumentation
Roll with Resistance
•
•
•
•
Arguing
Interrupting
Denying
Ignoring
– Support Self-efficacy
Express Empathy
• Communications that imply a superior/inferior relationship
are avoided.
• The therapist’s role is a blend of supportive companion and
knowledgeable consultant.
• The client’s freedom of choice and self-direction is respected.
• Persuasion is gentle, subtle, always with the assumption that
change is up to the client. Miller, Chap. 5, Handbook of Alcoholism Treatment
Approaches, 1995
Avoid Argumentation:
• If handled poorly, raising of discrepancies can
create defensiveness.
• The MET style explicitly avoids direct
argumentation, which tends to evoke resistance.
• No attempt is made to have the client accept or
“admit” a diagnostic label.
• “The client, not the therapist voices the arguments
for change.”
• “What makes you think that maybe you should do
something about your drinking?” Miller, Chap. 5, Handbook
of Alcoholism Treatment Approaches, 1995
Roll with Resistance:
• MET strategies do not meet resistance head on, but rather
“roll with” the momentum, with a goal of shifting client
perceptions in the process.
• New ways of thinking about the problem are invited, but not
imposed.
• Ambivalence is viewed as normal, not pathological, and is
explored openly.
• Solutions are usually evoked from the client rather than
provided by the therapist. Miller, Chap. 5, Handbook of Alcoholism Treatment
Approaches, 1995
Support Self-Efficacy:
• Self -efficacy - the belief that one can perform a particular
behavior or accomplish a particular task..
• The person must believe he or she can change (Rogers &
Mewborn, 1976).
• Optimism can also be found in the menu of different
approaches available.
• A therapist’s own optimism may also powerfully influence
client motivation and outcome.
• Leake and King (1977) demonstrated experimentally that
therapist expectations of good prognosis are predictive of
favorable outcomes among alcoholic clients. Miller, Chap. 5,
Handbook of Alcoholism Treatment Approaches, 1995
Develop Discrepancy:
• Motivation for change occurs when people
perceive a discrepancy between where they are
and where they want to be.
• M.E.T. seeks to enhance and focus the client’s
attention on such discrepancies.
• In certain cases (the pre-contemplator), it may be
necessary to first develop such discrepancy by
raising client’s awareness of the personal
consequences of abuse. Miller, Chap. 5, Handbook of Alcoholism
Treatment Approaches, 1995
– Play video - Part B-2 Chapter 2 - Case Example Opening Session
Screening, Brief Intervention,
Referral and Treatment (SBIRT)
• SBIRT is an evidence based public health approach
providing early intervention in treatment for individuals
with substance abuse disorders and those at risk of
developing problematic substance use (SAMSHA, 2007a).
• SBIRT reduces the frequency and severity of alcohol and
drug use, reduces the risk of trauma associated with alcohol
and drug use, and increases the number of clients to enter
substance abuse treatment.
• Screening in brief interventions have been shown to reduce
hospital days and decrease emergency room visits, resulting
in net cost savings from the interventions.
Screening, Brief Intervention,
Referral and Treatment (SBIRT)
• Screening
– Identification of client seen in medical and public health settings
who require further assessment for treatment for substance abuse
disorders.
– Integration substance abuse screening into regular medical and
public health care.
– Two elements of screening include
• attention to biomarkers/client reports and
• the use of screening instruments.
• www.sbirt.samhsa.gov/core_comps/screening.htm
Screening, Brief Intervention,
Referral and Treatment (SBIRT)
• Brief Intervention
– Single session or multiple sessions employing motivational
strategies,
– The intention is to increase the client's motivation toward positive
behavioral changes.
– Brief interventions can be structured either towards single sessions
for clients at risk or as a means to increase motivation and
engagement in treatment over the course of several sessions.
– Targeted brief intervention protocols are available at
www.sbirt.samhsa.gov/core_comps/brief.htm.
Screening, Brief Intervention,
Referral and Treatment (SBIRT)
• Brief Treatment
– Treatment of increased intensity and is delivered over a shorter
time.
– Goal to eliminate hazardous and/or harmful substance use.
– Brief treatment is delivered in a limited number of sessions that are
highly structured and focused.
– Brief interventions are typically less costly than alternative
approaches, yet have been shown to be effective in substance
abuse treatment.
– FRAMES Model
Screening, Brief Intervention,
Referral and Treatment (SBIRT)
• Referral to Treatment
– Treatment referrals used for individuals who, because of the
severity of their substance abuse problem, need more extensive
treatment than can be offered through SBIRT.
– Effectiveness of referral to treatment is dependent upon the
proactive and collaborative efforts of the medical and public health
agency offering SBIRT and the specialized substance abuse
treatment providers to which the SBIRT clinician will refer clients.
– The intention is to appropriately match the client’s current
substance abuse problems with the appropriate level of care
necessary to address the needs of client.
http://nrepp.samhsa.gov/
Drug Abuse Treatment Core Components
and Comprehensive Services
Medical
Financial
Housing &
Transportation
Core
Treatment
Intake
Assessment
Child
Care
Treatment
Plans
Group/Individual
Counseling
Abstinence
Based
Pharmacotherapy
Mental
Health
Urine
Monitoring
Case
Management
Continuing
Care
Self-Help
(AA/NA)
Family
AIDS /
HIV Risks
Vocational
Legal
Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB)
Educational
Thank you!
Treatment Process Model:
Client & Program Predictors
Hierarchical Linear Modeling (HLM)
Session
Attendance
(Mos 1-3)
Trt Confidence (Mo 3)
Client Ratings
Rapport
w/ Counselor
Trt Commitment (Mo 3)
(Mo 1)
Program factors
Treatment
Readiness
Client
factors
2/3
1/3
• Referred services
• Missed sessions
• Diversity of needs
LTR ODF OMT
Joe, Simpson, & Broome, 1999 (Drug & Alcohol Dependence)