1 MOVING TOWARD EVIDENCE-BASED PRACTICE FOR ADDICTION TREATMENT June, 2014 Dean L. Babcock, LCAC, LCSW Associate Vice President Eskenazi Health Midtown Community Mental Health Centers
2 Why is Evidence-Based Practice Critically Important?
3 ADDICTION: ACUTE ILLNESS OR CHRONIC ILLNESS?
4 13 Principles of Effective Treatment
5 No Single Treatment Is Appropriate For All Individuals Matching treatment setting, interventions and services to each individual's particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family,workplace, and society. treatment Problem
6 Treatment Needs To Be Readily Available Individuals who are addicted to drugs may be uncertain about entering treatment, taking advantage of opportunities when they are ready for treatment is crucial. Potential treatment applications can be lost if treatment is not immediately available or is not readily accessible.
7 Effective Treatment Attends To Multiple Needs Of The Individual, Not Just His or Her Drug Use To be effective: Treatment must address the individual s drug use. - AND - Any associated,medical, physiological, social, vocational, and legal problems.
8 Individual Treatment and Service Plans Must Be Assessed and Continually Modified As Necessary To Ensure The Plan Meets The Person s Changing Needs Varying treatment components and other medical services. Family counseling, parenting, vocational rehabilitation, social and legal services. Medication. Appropriate to the individual s age, gender, ethnicity, and culture.
9 Remaining In Treatment For An Adequate Period Of Time Is Critical For Treatment Effectiveness Duration depends on his/her problems/needs. Significant improvement is reached in about 3 months for most patients. Additional treatment is often needed. Include strategies to engage and keep patients in treatment.
10 Counseling and Behavioral Therapy Critical Components Of Effective Treatment For Addiction: Address issues of motivation Build skills to resist use Replace with constructive activities Improve problem solving abilities Behavior therapy facilitates interpersonal relationships and the individual's ability to function in the family and community.
11 Medication Is An Important Element Of Treatment For Many Patients Especially When Combined With Counseling And Other Behavioral Therapies
12 Addicted or Drug-Abusing Individuals With Coexisting Mental Disorders Should Have Both Disorders Treated In An Integrated Way Because addictive disorders and mental disorders often occur in the same individual, patients presenting for either condition should be assessed and treated for the co-occurrence of the other type of disorder.
13 Medical Detoxification Is A Stage Of Addiction Treatment And By Itself Does Little To Change Long-Term Drug Use Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug use. Detox alone is rarely sufficient to help achieve long-term abstinence. For some individuals it is a strongly indicated precursor to effective drug addiction treatment.
14 Treatment Does Not Need To Be Voluntary To Be Effective Strong motivation can facilitate treatment process. Sanctions or enticements in the family, employment setting or criminal justice system can significantly increase both treatment entry and retention rates and the success of drug treatment interventions.
15 Drug Use During Treatment Must Be Continually Monitored Lapses to drug use can occur during treatment. Objective monitoring through urinalysis or other tests can help the patient withstand urges to use. Can also provide early evidence of drug use so the individuals treatment plan can be adjusted.
16 Treatment Programs Should Provide Assessment For HIV/AIDS, Hepatitis B & C, Tuberculosis, and Other Infectious Diseases
17 Recovery Can Be A Long-Term Process That Frequently Requires Multiple Episodes Of Treatment Relapses can occur during or after May require prolonged treatment Participation in self-help support programs
19 National Standards for the Treatment of Substance Use Conditions: Evidence- Based Practices FOUR sections are: I. Identification of Substance Use Conditions II. III. IV. Initiation and Engagement in Treatment Therapeutic Interventions to Treat Substance Use Illness Continuing Care Management of Substance Use illness
20 Section I Identification of Substance Use Conditions
21 Screening and Case Finding During new patient encounters and at least annually, patients in general and mental healthcare settings should be screened for atrisk drinking, alcohol use problems and illnesses, and any tobacco use. Healthcare providers should employ a systematic method to identify patients who use drugs that considers epidemiologic and community factors, and the potential health consequences of drug use for their specific population.
22 Diagnosis and Assessment Patients who have a positive screen for - or an indication of a substance use problem or illness should receive further assessment to confirm that a problem exist and determine a diagnosis. Patients diagnosed with a substance use illness should receive a multidimensional, biopsychosocial assessment to guide patient-centered treatment planning and any coexisting conditions.
23 Section II Initiation and Engagement in Treatment
24 Brief Intervention All patients identified with alcohol use in excess of National Institute on Alcohol Abuse and Alcoholism guidelines and/or any tobacco use should receive a brief motivational counseling intervention by a healthcare worker trained in this technique.
25 Promotion Engagement in Treatment for Substance Use Illness Healthcare providers should systematically promote patient initiation of care and engagement in ongoing treatment for substance use illness. Patients with substance use illness should receive supportive services to facilitate their participation in ongoing treatment.
26 Withdrawal Management Supportive pharmacotherapy should be available and provided to manage the symptoms and adverse consequences of withdrawal. Withdrawal management alone does not constitute treatment for dependance and should be linked with ongoing treatment for substance use illness.
27 Section III Therapeutic Interventions to Treat Substance Use Illness
28 Psychological Interventions Empirically validated psychosocial treatment interventions should be initiated for all patients with substance use illness.
29 Pharmacotherapy Pharmacotherapy should be recommended and available to all adult patients diagnosed with: opioid alcohol nicotine dependence and without medical contradictions. Pharmacotherapy, if prescribed, should be provided in addition to and directly linked with psychosocial treatment/support.
30 Section IV Continuing Care Management of Substance Use Illness
31 Patients with substance use illness should be offered long-term care. Coordinated management of their care for substance use illness and any coexisting conditions. Care management should be adapted ongoing monitoring for their progress.
32 INEFFECTIVE TREATMENTS The following practices or treatment approaches are generally ineffective and should not be provided as a routine component of treatment: Any of the following as a stand alone treatment for SUD s Acupuncture Relationship therapy Didactic group education, or Biological monitoring of substance use
33 INEFFECTIVE TREATMENTS (con t) Detoxification as a stand alone treatment for substance dependence syndromes Individual psychodynamic therapy Unstructured group therapy Confrontation as a principle treatment approach Discharge from a treatment program in response to relapse
34 Evidence Based Approaches to Addiction and Mental Illness Treatment for Adults Cognitive Behavioral Interventions Community Reinforcement Motivational Enhancement Therapy 12-Step Facilitation Contingency Management Pharmacological Therapy Systems Treatment Integrated Dual Disorders Treatment
35 Evidence Based Approaches to Addiction and Mental Illness Treatment for Adults (con t) Illness Management and Recovery Assertive Community Treatment (ACT), Intensive Care Management (ICM) Family Psycho-education Supported Employment Trauma Services
36 Evidence Based Practices for Children and Adolescents Evidence-Based Prescribing Practices Family Education and Support Services Functional Family Therapy (FFT) Home-Based Crisis Intervention (HBCI) Home and Community-Based Services (HCBS) Intensive Care Management (ICM) School-Based Mental Health Services Post Traumatic Stress Disorder (PTSD) Treatment
37 1. Generations of Clinical Care David Mee-Lee, MD Senior VP, The Change Companies, VP, Institute for Wellness Education
38 2. Generations of Clinical Care David Mee-Lee, MD Senior VP, The Change Companies, VP, Institute for Wellness Education
39 3. Individualized, Clinically-driven Treatment Patient/Participant Assessment BIOPSYCHOSOCIAL Dimensions Progress Severity of Illness/LOF Problems/Priorities Severity of Illness/LOF Plan INTENSITY OF SERVICE - Modalities and Levels of Service David Mee-Lee, MD Senior VP, The Change Companies, VP, Institute for Wellness Education
40 4. Client-directed, Outcome-informed Patient/Participant Assessment BIOPSYCHOSOCIAL Dimensions Progress Treatment Response Proximal Outcomes e.g., Session Rating Scale (SRS) Outcome Rating Scale (ORS) Problems/Priorities Build alliance working with Multidimensional Assessment Plan INTENSITY OF SERVICE - Modalities and Levels of Service (Clinical and wrap-around services) David Mee-Lee, MD Senior VP, The Change Companies, VP, Institute for Wellness Education
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