Key ideas in treatment Flashcards
1
Q
What are the 10 key ideas in the treatment of addiction?
A
- Who needs treatment?
- Dependence
- Harm reduction
- Motivation to change
- Maintenance and abstinence
- Organising treatment
- Failure to respond
- Coercion
- What is recovery?
- Who pays?
2
Q
What does the pyramid of treatment needs suggest?
A
> At the bottom:
- most people
- with infrequent use and no problems
- > little/no treatment need
> At the top:
- few people
- with frequent use and multiple problems
- > large treatment need
=> graded need for treatment
3
Q
What does the natural history of drug misuse tell us?
A
> Most problematic substance users stop using on their own
> People in treatment are stuck with their use and need help (large treatment need)
> Substance misuse is a relapse illness for some
(most still get better)
> Natural history is very variable and often not predictable
- hard to predict who. is gonna have problems and who won’t
4
Q
How do most problematic substance users stop using on their own?
A
- Reduced drug use with age
- Most people mature with age
5
Q
What makes substance misuse a relapse illness for some people?
A
Periods of small use, no use, or great use
6
Q
What is a spontaneous recovery in drug misuse?
A
Some people decide to stop using sometimes in their life
- range of personal reasons
7
Q
When does spontaneous recovery often occur?
A
At a time of change
- new job
- relationship
- newborn child
8
Q
What is the valid concept on spontaneous recovery among patients?
A
- You need to hit rock-bottom to stop
- Readiness for treatment
9
Q
How does the person’s environment and situation play a central role in helping them stop drug misuse?
A
Stable life helps recovery
- e.g. homeless vs. having a home and family
- However, a proper environment is not always necessary to help people stop
10
Q
Why is self-detoxification common?
A
There’s a population that isn’t in treatment and doesn’t want to be
- they’ll go in treatment when benefits of treatment outweigh benefits of no treatment
=> aim of treatment system is to engage as much people as possible
11
Q
Why do people need treatment?
A
- Stop drug misuse
- Reduce personal harm
- Help manage their lives
- Reduce risk to others
- Reduce risks to community
12
Q
What is the division of the different drugs used?
A
- Small number of people using harmful drugs
- High number of people using less harmful drugs
13
Q
Why is the type of drug important?
A
> Some drugs require particular treatment
- opiate substitution treatment specific to opiate use
> Some drugs cause harm
- any injected is harmful
> Propensity to cause dependence
> Spontaneous reduction more common with certain drugs
=> Assessment of problems is needed before treatment can be offered
14
Q
In which case is spontaneous reduction of drug misuse more common?
A
Often in people with high social support and social capital
15
Q
Why is lay people’s understanding of dependence and addiction important?
A
Because when you talk to people who use drugs you need to know what they think of it
16
Q
Why is the propensity of dependence important?
A
- Treatments differ wether people are dependent on the substance they use
- Presence of dependence increases risk of severe withdrawal symptoms (varies between chemical structure of substances)
17
Q
What does dependence as a continuum or a binary concept refer to?
A
The severity of the dependence and withdrawal symptoms
- physical or psychological dependence
18
Q
What is dependence as a binary concept?
A
You are either addicted or not
- binary understanding
19
Q
What makes the binary understanding of dependence attractive?
A
It provides a point in treatment when person needs to take medication to stop using
20
Q
What does the evidence reflected in the DSM-5 suggest is the nature of the concept of dependence?
A
Dependence as a continuum:
- you’re more or less addicted depending on where you are and the dosage used
21
Q
Who gave the first descriptions of dependence?
A
Edwards and Gross (1976):
- narrowing of repertoire
- salience of drinking
- increased tolerance to alcohol
- withdrawal symptoms
- relief or avoidance of withdrawal symptoms by further drinking
- subjective awareness of compulsion to drink
- reinstatement after abstinence
22
Q
Why is defining dependence important?
A
- Enables correct planning of treatment
- Look at prognosis / diagnosis
- Important for research
23
Q
How do the ICD-10 and DSM-5 characterise substance abuse and harmful use
A
> ICD-10: abuse has a single diagnostic category, dependent of harmful use
> DSM-5: combines mild harmful use AND severe dependence
24
Q
How does abuse differ from harmful use?
A
Harmful use is less severe than dependence
25
What does the ICD-10 describe as the qualifications for diagnosis of dependence or abuse?
Only if 3 of more have been present together during the previous year:
- strong desire or sense of compulsion to take substance
- difficulties in controlling substance-taking behaviour
- physiological withdrawal state
- evidence of tolerance
- progressive neglect of alternative pleasures or interests because of psychoactive substance use
- persisting with substance use despite clear evidence of overly harmful consequences
26
How is harmful use of substances described in ICD-10?
Diagnosis requires that actual physical and mental damage have been caused
- pattern of psychoactive substances misuse that’s damaging to health
27
What is the most commonly used objective measure in the UK to assess service users on alcohol abuse?
Alcohol Use Disorders Identification Test (AUDIT)
| - questions on people’s drinking and how often they drink
28
What do you need to do for service users to fill in the AUDIT?
- Explain what a unit is
| - Help them understand how it will quantify how much they’re drinking
29
What is the AUDIT-C?
Shortened version of the AUDIT
- only contains three questions
- commonly used in screening
- part of preparing for a brief advise session
30
When is an objective measure of dependence useful (e.g. SADQ)?
When someone has a high AUDIT score, or is describing physical signs of withdrawal
31
What is the SADQ?
Severity of Alcohol Dependence Questionnaire
- objective measure of dependence
32
Why is the assessment of service users important?
- Helps to choose the right treatment
- Decisions on complexity can be made
- Helps evaluate prognosis
33
What is the idea of harm reduction?
Reducing the harm from substance misuse
- started in HIV epidemic mid 1980s
- more important than stopping people using drugs
34
What is harm reduction according to Newcombe (1992)?
Term that defines policies, programmes, services and actions that work to reduce the health/social/economic harms
- to individuals, communities, society
- associated with drug use
35
What are the steps in the hierarchy of goals in drug treatment?
1. Unsafe injecting of street drugs
2. Safe injecting of street drugs
- clean injecting paraphernalia
3. Smokable drugs
- rather than injection
- considerable step for many people
4. Prescribed drugs and street drugs
5. Prescribed drugs alone
6. Drug free
- for many these steps take years
- for many substances: similar move from unsafe using to abstinence
36
What are the four main harm reduction interventions?
1. Needle and syringe exchange
- give out clean ones, they bring them back
2. Provision of injecting paraphernalia and needle cleaning equipment
3. Provision of smoking paraphernalia (foils)
4. Provision of condoms and other items to reduce high risk sexual behaviour
37
What is the success of needle and syringe exchange interventions?
- Didn't help the most chaotic people
| - Returning needles helped reduce needle waste in communities
38
What does injecting paraphernalia consist of?
- Cups to cook heroin in
- Heroin filters
- Citric acid
- Sterile water
39
What can be provided to people for safer injecting, in countries where it's illegal to provide injecting paraphernalia?
Needle cleaning equipment
40
In which communities is it important to provide condoms and other items to reduce high risk sexual behaviour?
Communities associated with prostitution and sex related drug use/exchange
41
What did the government policy for needle and syringe exchange do in the UK?
Policy made early in HIV epidemic
| -> efficient reduction of HIV prevalence
42
What is the state of injecting rooms as a harm reduction approach?
- Not universally accepted
| - Popular amongst service users in countries who've adopted this approach
43
What is the key idea behind low threshold prescribing as a harm reduction approach?
Reducing the harm rather than make someone stop using the drug
- effective in opiate programmes
44
What is the goal behind take home naloxone?
- Reverse opiate deaths
| - To be used in case of overdose
45
What is the idea of Hepatitis B vaccination programmes?
Drug users are offered vaccination
46
What is the goal of the alcohol harm reduction approach?
- Move to beverages with lower percentage of alcohol
| - Using them in a safe environment
47
What does the approach of harm reduction for club drug users consist of?
- Provision of water
- Providing medical help in clubs
- Establishing drug knowledge amongst drug users
48
What are the controversies in harm reduction?
Moral rights object to any policy
- In North America: for many years no federal funding
- In Europe: no harm reduction policies
- > very high levels of HIV
49
What happened in Europe where harm reduction was introduced early in the HIV epidemic?
Low levels of HIV
50
What is the dilemma of hepatitis C?
Drug users still catch hepatitis C even if prevalence of HIV is low
- nature of the virus and its high transmissibility compared to HIV
-> harm reduction and interventions need to be tightly implemented
51
What is the idea of the motivation to change?
- Needs to come from individuals
- Help people to want to change
- People can be motivated by different goals which may not be shared by the service or people who treat them
- No legal framework to stop people using drugs in most parts of the world
- > motivation to use drugs more safely but not stopping to use them
- > motivation to stay out of prison rather than stop using drugs
52
What does the Transtheoretical Model of Change of Prochaska and DiClemente (1982) consist of?
> Different types of thinking depending on how close they are to making important behaviour
> In practice people change from stage to stage and back
Pre-contemplation, Contemplation, Preparation, Action, Maintenance, Relapse
53
In practice, how can you assess whether someone wants to change or is ready to change?
By observing whether they're actually doing it
54
What is motivational interviewing?
Style of patient-centred counselling developed to facilitate change in health-related behaviours
- style used by clinician or formal counselling method
- extremely researched and found effective
55
What does motivational interviewing consist in?
- Focuses on building report
- Focuses on exploring and resolving ambivalence
- Encourages conversations about change in a collaborative and evocative way
- > empathy, support self-efficacy
- Help individual understand resistance and progress towards changing it
56
What is the goal of making a decision balance matrix with a service-user?
Help individual identify pros and cons of giving up a drug or alcohol-using behaviour
- pros and cons of changing vs. not changing
57
What is motivational interviewing for practitioners?
- Core skill for anyone working with drug users
- Motivational style may override the main repertoire of interviewing techniques
- May be used for range of behaviours
- Has to be done face-to-face
- Training should be provided
58
What are the elements to enhance motivation in practice?
- Non-judgmental approach
- Make services accessible and welcoming
- Engagement hierarchies
- Understanding service user priorities (e.g. placement before treatment)
- Flexible opening hours
- Contingency management (e.g. giving vouchers for hepatitis vaccination)
- Allow time for change
59
What do engagement hierarchies to enhance motivation consist of?
Drop-in treatment for people who are ambivalent about treatment, so they can come and get other services (food, laundry)
-> hook people in so they accept formal counselling sessions that imply appointments
60
What are the four opiate substitution treatments?
> Methadone
> Burprenorphine
> Heroin
> Slow release morphine
61
What is the story of methadone?
- First used in NYC prisons in 60s
| - Several long term studies and RCTs supported its effectiveness as opiate substitution
62
What characterises Buprenorphine?
- Highly effective
| - Issues with dose induction and retention
63
What characterises heroin for opiate substitution?
- Good evidence from RCTs
| - Expensive treatment -> not available in all countries
64
What is the status of slow release morphine for opiate substitution?
Increasing evidence base
65
What are the negative aspects of opiate substitution?
> Does not solve addiction problem
> Does not provide solution for service users that want to stop using drugs
> In some countries:
- morally unacceptable
- viewed as opposite of recovery or total abstinence
> Different reactions in different service users
- often badly delivered
- poor access to intensive interventions that would help people stop long-term
66
What is the myth on methadone among users?
Methadone gets into your bones, takes your heart and is worse than heroin to come off
67
How is opiate substitution treatment often badly delivered?
- Low doses are used
- Inadequate social support
- Inadequate psychosocial interventions
68
What is the status of abstinence based treatment for opiates?
> History of ineffective but popular treatment
- e.g. rapid detox with anaesthetics
> High rates of post detoxification overdose
> High relapse rates
> Residential rehabilitation can be effective BUT not often available
> Many people who want to come off opiates are not ready and fail many times before being successful
69
What does the evidence suggest that provides better prognosis for achieving abstinence?
- Having good community support
| - Fewer co-morbities (e.g. long term physical damage, mental health pbs)
70
Which advice can be given to service users for opiate substitution treatment (i.e. methadone or buprenorphine)?
> Reduce crime, injection and drug use
> Increase dose of substitution substance
> Reduction of dosage when life situation is stable AND they have extensive post-detoxification support available (i.e. education, employment, peer support)
- e.g. 12-step programmes
71
Why do service users often don't like to increase the dose of substitution substance in treatment?
They want to stop faster than they're able to
-> advise reduction when life situation is stable
72
What is the purpose of the model of stepped care?
To organise treatment for complex populations with complex needs
73
What does stepped care consist of?
- Simple treatment as base
- if necessary: more intensive, complex treatment
- Treatment can be optimised to improve outcomes
Initial intervention -> assess effectiveness
- > increase intensity OR change treatment type
- > assess effectiveness...
74
What would stepped care resemble for opiate substitution with methadone as initial intervention?
Methadone treatment -> assess effectiveness
- > Increase intensity OR change to buprenorphine
- > assess effectiveness...
75
What are the sections in the treatment outcomes profile?
1. Substance use
2. Injecting risk behaviour
3. Crime
4. Health and Social functioning
76
What is the purpose of the treatment outcomes profile?
To assess the treatment response
77
What does a care planning consist of?
- Multiple domains
- Filled in by service user
- Goals are smart and have a review date (e.g. 3 months)
78
What constitutes the treatment journey?
> Standard / enhanced / intensive treatment
> Phases:
- Engagement and stabilisation
- Preparation for change
- Active change
- Completion
> Journey varies according to the individual
79
What are the various contexts of treatment for substance misuse?
> Community/outpatient
- what most service users need
> Inpatient
- medically managed/monitored
- > detoxification where doctor oversees treatment
> Residential rehabilitation
- service user goes live in residential setting
80
What is characteristic of a failure to respond?
> Patient uses substance on top of methadone
> Alcohol user who relapses every few months
> User of party drugs who fails to attend appointments
81
Which factors may explain why some opiate users fail?
- Service goals differ from patient goals
- the "Buzz" that users seek is not provided by opiate substitution
- Dose of opiate substitution is too low
- Poor compliance with medication
- Psychiatric/physical problems
- Poor social support
- Housing / employment: no meaningful social activity
82
What is key against a failure to respond?
Getting the basics right:
- housing
- social and community support
- treat psychiatric and physical problems (they mediate treatment outcome)
83
What are the six key factors in treatment?
1. Expectations
2. Goals
3. Care plan
- measures to assess progress
4. Dosage and choice of medication
5. Compliance
6. Monitoring and feedback
- risk of additional drug misuse
84
What is coercion in treatment?
Treatment choice is forced or manipulated by negative consequence of failing in treatment
e.g. choice between treatment and prison or community treatment order
85
Why is coercion in treatment not simple?
> Coercion or compulsion?
> Informal vs. formal
-> Criminal Justice coercion may not be the most important
> Family pressure may be more effective than threat of imprisonment
> Employee assistance programmes
> Child care removal threat
-> most effective coercive treatment intervention
86
What is the status of coercive treatment?
> Civil commitment programmes in the US
> Coerced treatment may be as effective BUT evidence is poor
87
What do employee assistance programmes consist of in treatment of substance misuse?
Employer offers treatment in exchange for the employee becoming drug free and keeping their job
88
What do drug and alcohol rehabilitation requirements consist of?
Time off sentence if person complies with drug rehab
89
What is the purpose of Drug Courts (mostly in the US)?
Individuals present themselves to a judge who offers possibility to participate in treatment provided by the court
90
What is the purpose of Family Drug and Alcohol Courts?
Same as Drug Courts: judge offers treatment provided by the Court
- risk of losing child care
91
What characterises the process of recovery from problematic substance misuse?
Voluntarily-sustained control over substance use
- which maximises health and wellbeing, participation in the rights, roles and responsibility of society
- sobriety, personal health and citizenship
92
Where does recovery from problematic substance misuse find its basis?
In 12-step programmes
93
What are the common elements found in the various definitions of recovery?
- Abstinence and maintenance
- Abstinence, recently medication-assisted
- Creating a fulfilling life (ad rather than take): employment, housing, social relationships
- Individual at heart of recovery
- Wider world is part of the process
94
What are three key factors in recovery?
1. Hope
2. Agency
3. Opportunity
95
What is the role of hope in recovery?
Essential to sustaining motivation
| AND supporting expectations of an individually-fulfilled life
96
What does agency refer to in recovery?
Sense of control over one's own problems and lifestyle
- self-control
- self-determination
- choice
- responsibility
97
What is the role of opportunity in recovery?
Social inclusion:
| - people with mental health problems wish to have access to the opportunities that exist within communities
98
What is controversial about recovery?
> Emergence of harm reduction vs. recovery
> Can polarise abstinence vs. maintenance debate
> Raise expectations un-realistically (services users, family, carers)
> May stigmatise current users
-> risk of reinforcing failures
> Not evidence-based
- difficult concept to evaluate
- no evidence that recovery-based approach is useful
99
What is the status of costs in drug treatment?
- Evidence that drug treatment saves money
- Requires funding
- Some elements are user-led and free
100
How does investment in treatment save money?
> Keeps people out of prisons
> Prevents blood-born virus epidemics
> Gets people employed
> Some basic drug treatments are the most cost-effective (e.g. opiate substitution, harm reduction)
101
How is the health system funded in England?
From the Public Health budgets
102
What is the issue in public health fundings in drug treatment?
Alcohol users are an unpopular group
- public do not want to fund treatment, never prioritised
- > constant need to get continuous funding
- > small group of self or family-funded people
103
Which elements of drug treatment are free, or nearly free?
> 12-step treatment
- delivered by service users themselves
> Peer support
> Recovery communities
> Brief interventions in primary care
> Harm reduction
