Week 13 - Review and specialist intervention

Question 1

Specialist interventions: Overview

Answer 1

• Treatment works!
  – The completion rate for all treatment types is around 65%
  – Relapse rate after treatment of about 50% (similar to other chronic health conditions e.g., asthma, high blood pressure and diabetes)
• Wide range of treatment settings and services to provide substance abuse treatment. Interventions usually target one of three different areas, all important

Question 2

What is Psychoeducation / drug information
(INTERVENTIONS TARGETING THE DRUG)

Answer 2

• Psychoeducation is a brief process of information provision
  focused on the communication of varied aspects of disease and treatment related information.
• Aim: to provide the client and families knowledge about
  various facets of the illness and its treatment to assist them
  to live more productive and fulfilling lives:

– To help understand their disorder,
– Understand the meaning of symptoms and what’s known about cause
– Harm minimisation / safety information
– Explore treatment options
– Early identify relapse risks

Question 3

In Psychoeducation / drug information it is important to provide the client with accurate information regarding..

Answer 3

– Effects and side effects, dosage, methods, and potential harms
– Correct inaccurate or dangerous information
– Explore treatment options

Question 4

Psychoeducation / drug information is particularly useful for pre contemplators because it…

Answer 4

– Avoids confrontation and argument
– Raises awareness

Question 5

Is Psychoeducation / drug information effective?

Answer 5

• Strong evidence base in clinical trials and community settings, particularly when delivered by clinicians
• Simply providing information about harms is ineffective as a sole intervention, and confrontation has nil or negative effects. Psychoeducation involves assessing consumption as well as substance-related behaviour, and providing normative feedback and information on the impact of use.
• Educating individuals on the impact of hazardous alcohol use on both mental and physical health may facilitate motivation to change behaviour; however, an additional component of psychoeducation (e.g., alternative coping strategies) may be necessary to modify coping motivated use and enhance confidence

Question 6

What is Withdrawal Management (previously detoxification or detox)

(INTERVENTIONS TARGETING THE DRUG)

Answer 6

• Withdrawal management refers to the medical and psychological care of a person experiencing withdrawal symptoms as a result of ceasing or reducing substance use

– assistance in the mitigation of withdrawal symptoms
through medical supervision and access to pharmacological treatment options
* Common ‘entry point’ into AOD treatment. In/out patient
* Generally speaking, withdrawal feels like the opposite of the drug. For example when withdrawing from a depressant like alcohol a person may feel restless and agitated, or have
tremors.

Question 7

What do withdrawal symptoms depend on during withdrawal management

Answer 7

• Symptoms experienced during withdrawal can be mild or
  severe, depending on:
• Duration of use
• Substance
• Age
• Physical health
• Psychological characteristics
• Method of withdrawal

Question 8

What is the outcome of withdrawal management?

Answer 8

• Withdrawal management can be a stand alone treatment –
  with limited effectiveness
• Treatment outcomes enhanced when people engage in
  further treatment such as counselling or rehabilitation services

Question 9

What is Pharmacotherapy (INTERVENTIONS TARGETING THE DRUG)

Answer 9

• Pharmacotherapy is the use of prescribed medication to
  assist in the treatment of addiction. Replacing a prescribed drug to treat a drug of dependence
• to reduce the intensity of withdrawal symptoms,
• to manage cravings, and
• to reduce the likelihood of a lapse or relapse by blocking a drug or addictive behaviour’s effect.

Question 10

What is the aim of Pharmacotherapy

Answer 10

• preventing physical withdrawal
• helps to stabilise the lives of people who are substance dependent
• to reduce the harms related to substance use.

Question 11

What are agonists?

Answer 11

Drugs that occupy receptors and activate them

Question 12

What are antagonists

Answer 12

Drugs that occupy receptors but do not activate them
Antagonist block receptor activation by agonist

Question 13

What is Naltrexone Maintenance Treatment

Answer 13

• Naltrexone is a long-lasting opioid antagonist.
• Naltrexone reduces both the rewarding effects of opioids /
  alcohol and craving for it

Question 14

What are the outcomes for Naltrexone Maintenance Treatment

Answer 14

– Safe treatment
– For alcohol, 54% completed the 12 weeks of the treatment study: 39% abstained; 86% were consuming less alcohol by
final visit than at baseline.
* Outcomes best if highly motivated, employed, with good social support, older and with prior treatment experience
* Risk of overdose – removes tolerance

Question 15

What is Methadone Maintenance Treatment

Answer 15

• Full opiate agonist
• For those unable to cease opiate use/manage withdrawal
  – Maintenance rather than abstinence
  – Often preferred choice for high levels of opiate dependence
  – Can be useful for chronic pain treatment
  – Protective treatment for released prisoners with opiate use histories
• Selected GP and Alcohol and Drug Services only – highly
  regulated
• High retention in treatment
  – Not as intensive
• Reduces/does not eliminate heroin use for all
• Reduces HIV risk behaviour, criminal behaviour, and risk of overdose

Question 16

What is Buprenorphine

Answer 16

• Partial agonist & partial antagonist
• Maintenance treatment
• Can be a detoxification aid
  – Detoxification and withdrawal from Buprenorphine better tolerated than from methadone or heroin
  – Less severe symptoms
• Higher doses improve retention in treatment and reduce
  heroin use
• Can be taken in one, two, or three day doses (Double/Triple
  dosing options); long acting injectables
• Compared to methadone maintenance treatment:
  – Similar/slightly less retention in treatment,
  – Reduces illicit drug use to an equivalent or greater extent

Question 17

How to treat alcohol –>What is Acamprosate (Campral)

Answer 17

– Decreases cravings for alcohol in people who have been
dependent on alcohol and are trying to abstain.
– Agonist and antagonist
– Maintenance: Does not prevent withdrawal symptoms
– Acamprosate significantly reduced the risk of returning to
any drinking by 86% (95% confidence interval [CI]: 81%–
91%) and increased the cumulative duration of abstinence
by 11% (95% CI: 5%–16%) compared with placebo during
treatment

Question 18

How to treat alcohol –> (What is Antabuse (Disulfiram)

Answer 18

• Maintenance Therapy - with abstinence as a goal
• Blocks enzyme that metablises alcohol - Reacts with alcohol to make client feel very ill
• Designed as a deterrent to drinking - Unpleasant side effects and sensitivity to alcohol
• Skinner et al (2014) – Meta analysis. Disulfiram is a safe and
  effective treatment. Produced an abstinence rate of more than 50%. Individuals who have taken Disulfiram for an average of 20 months have showed the highest rates of abstinence.
• More effective if used in conjunction with counselling and
  ongoing support

Question 19

How to treat alcohol

Answer 19

• Naltrexone
• Acamprosate (Campral)
  *Antabuse (Disulfiram)

Question 20

How to treat Nicotine

Answer 20

• Nicotine replacement therapy (NRT) – partial agonist
• Varenicline (Champix)

Question 21

How to treat Nicotine –> What is Nicotine replacement therapy (NRT)

Answer 21

• Temporarily replaces much of the nicotine from tobacco to
  reduce motivation to consume tobacco and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence.
• Evidence suggests the use of NRT increase chances of successfully stopping smoking by 50 - 70%
• Supports the reduction in amount of use by people not wanting to stop completely (Fagerstrom 2008)
• Most effective with counselling

Question 22

How to treat Nicotine –> What is Varenicline (Champix)

Answer 22

• Antagonist and partial agonist. Stimulates dopamine receptors
  whilst blocking nicotine receptors.
  – Reduces cravings
  – Lowers effects
• Cahill et al 2017 - meta-analysis suggested that varenicline is the most efficacious smoking cessation medicine at up to 12 months; odds ratio (and 95% confidence interval) were 1.6 (1.3 to 1.9)
• Best with counselling and support
• Not recommended for young people
• Can be used with NRT

Question 23

What is the Tina Trial (Methamphetamine treatment)

Answer 23

• There are currently no approved medications for treating
  methamphetamine dependence.
• Australian trial on the use of Mirtazapine
  – Two small trials conducted in the USA found mirtazapine reduced methamphetamine use and reduced symptoms of depression in people who use methamphetamine

Question 24

What are the treatments for cannabis?

Answer 24

• There are currently no approved pharmacotherapies approved for treatment of cannabis use disorders.
• Bahji et al (2021) – Meta analysis:
  – Some medications appeared to show promise for treating individual aspects of CUD. However, there is a lack of robust evidence to support any particular pharmacological treatment.
  – Psychosocial interventions should remain the first line given the limitations in the available evidence

Question 25

What is Drug screening (INTERVENTIONS TARGETING THE DRUG)

Answer 25

• Urinary drug screening and hair follicle testing can detect over- the-counter, prescription drugs, alcohol and illicit substances.
• Simple point-of-care tests; laboratory screens
• Can often provide evidence of previous drug consumption – ‘parent drug’ and metabolites
• Screening is useful in monitoring abstinence from drug use, use of drugs in the workplace and in legal disputes. May aid in relapse prevention.

Issues
– Timing
– False positives/negatives
– Masking agents. Focus can become on ‘beating’ the screen rather than treatment goals
– Impact on therapeutic relationships / family relationships

Question 26

What are the four interventions targeting the drug?

Answer 26

1. Psychoeducation / drug information
2. Withdrawal Management (previously detoxification or detox)
3. Pharmocotherapy
4. Drug Screening

Question 27

What are the four interventions targeting the individual

Answer 27

1. Controlled Drinking/Drug Use Training
2. Self Help Groups
3. Brief interventions
4. Psychological therapies

Question 28

What is Controlled Drinking/Drug Use Training (interventions targeting the individual)

Answer 28

• Controlled drinking is an approach to alcohol consumption that focuses on moderation, or setting limits on consumption, as opposed to abstinence, or refraining from consuming alcohol altogether.
• DOHA (2009):
  – Many people would like to continue drinking at ‘low levels’, or resume ‘moderate’ drinking soon after withdrawal.
  – Severity of dependence is a key factor when setting goals of controlled drinking or abstinence. Controlled drinking is usually more appropriate with lower levels of dependence, while higher levels of dependence indicate abstinence as the best option.
  – Controlled drinking may be attempted after a period of abstinence of at least 3-6 months for such individuals
• Challenges for long-standing addiction; Environmental factors often key to success; Strong social supports required
• Good science was devoted to the development and evaluation of behavioural self-control training to help people moderate their drinking
• Available evidence does not support abstinence as the only approach in the treatment of alcohol use disorder. Controlled drinking, particularly if supported by specific psychotherapy, appears to be a viable option where an abstinence-oriented approach is not applicable
  Process involves:
  – Self-monitoring
  – Develop limits and rules around consumption
  – Devise strategies for high-risk situations
  – Use rewards to maintain changes to behaviour

Question 29

What is Self Help Groups (interventions targeting the individual)

Answer 29

• A self-help group brings people together who are dealing with similar challenges to help build support and community around shared life experiences.
• Mutual self-help groups include a variety of programs, with 12-step programs (e.g., Alcoholics Anonymous, AA; or Narcotics Anonymous, NA) and Self-Management and Recovery Training (SMART Recovery) being the most common ones.
• 12 step groups regard addiction as a relapsing illness with complete abstinence as the only treatment goal
• Widely available
• Easy to set up and run – no/low cost
• 12 Step programs most common
  – Strong ‘spiritual’ based philosophy
  – Require abstinence as a goal

Question 30

What is the 12 step program?

Answer 30

Admission
Recognition
Submission
Understanding
Confession
Readiness
Humility
Reparation
Apology
Integrity
Meditation
Awakening

Question 31

What is SMART recovery (self help groups)

Answer 31

Self Management and Recovery Training

• CBT and MI based group program
• Trained facilitators
• 4-point program
  1. Build and maintain motivation
  2. Cope with urges
  3. Learn problem solving techniques
  4. Achieve lifestyle balance

Question 32

What are Peer workers (in self help groups)

Answer 32

• Long tradition in the AOD sector via groups and defined roles – community support, harm reduction and treatment.
• Many AOD clinicians and support workers have a lived
  experience of substance use and treatment that they draw on in their work.
• Consumer advocacy
• Supporting others with a similar lived experience to engage with services and attain their personal goals.
• Authentic connection with service users
• The evidence on how peers improve outcomes is limited

Question 33

What are Brief interventions (interventions targeting the individual)

Answer 33

• Time-limited efforts to provide information or advice, increase motivation to avoid substance use, or to teach behaviour change skills with the aim of reducing substance use and the likelihood of experiencing negative consequences
• The aim of the intervention is to help the patient understand that their substance use is putting them at risk and to encourage them to reduce or give up their substance use.
• Range from 5 min of brief advice to 15-30 min of brief counselling.
• They can be delivered opportunistically like when a patient presents in primary care, general hospital, inpatient and outpatient settings.
• If the patient is still drinking to excess following a brief intervention, more intensive treatment is indicated, and may involve referral to a specialist alcohol and drug service.

Question 34

Key features of a brief intervention

Answer 34

• Focused on reduced substance use
• Address motivation
• Remain individualised
• Have the features of:
  – Give feedback of risk
  – Encourage responsibility for change
  – Give options
  – Demonstrate empathy
  – Enhance self efficacy

Question 35

What does FRAMES stand for in Brief interventions

Answer 35

a acronym for 6 key aspects of Brief interventions

F - Feedback of personal risk of impairment
R - Responsibility for change
A - Advice for change
M - Menu of alternative change options
E - Empathy on behalf of the practitioner
S - Self-efficiency or optimism in client facilitated by practioner

Question 36

More on Brief Interventions…

Answer 36

• They do not work with dependent drinkers who are seeking help for alcohol problems
  –They are effective for people who are ambivalent about change but ineffective for people who are motivated to change and already receiving treatment.
  – Kaner et al (2018) moderate-quality evidence to reduce alcohol use in hazardous and harmful drinkers compared to minimal or no intervention.
• They generally result in a 20-30% reduction in excessive drinking. Effective in multiple settings
• Highly cost-effective. Significant effect at follow-up after BI is found for up to 2 years
• Evidence for cannabis and amphetamine use
• BIs can be an effective first level of treatment offered because of their cost-effectiveness and fit with public health treatment approach in substance use disorders.

Question 37

What are Psychological therapies (interventions targeting the individual)

Answer 37

– Overall psychosocial interventions have been found to be
effective.

– Some interventions, such as cognitive behaviour therapy,
motivational interviewing and relapse prevention, appear to be effective across many drugs of abuse.

– Psychological treatment is more effective when prescribed
with substitute prescribing than when medication or psychological treatment is used alone, particularly for opiate users.
– Psychological interventions are an essential part of the
treatment regimen and efforts should be made to integrate
evidence-based interventions in all substance use disorder
treatment programs

Question 38

What are Psychological therapies –> Cognitive behavioural therapy
(interventions targeting the individual)

Answer 38

• CBT is a focused approach based on the premise that cognitions influence feelings and behaviours, and that subsequent behaviours and emotions can influence cognitions. The clinician works with individuals to identify unhelpful thoughts, emotions, and behaviours.
• CBT is often rated as the most effective approach to treatment with a drug and alcohol population

– Evidence for the efficacy of CBT exists for a range of substances including alcohol, cannabis, amphetamines, cocaine, heroin and injecting drug use.

– Benefits may extend beyond the treatment period and protects against relapse or recurrence after treatment termination

Question 39

What are Psychological therapies –> Acceptance and Commitment Therapy (ACT)
(interventions targeting the individual)

Answer 39

• Focuses on the context and function of psychological experiences (e.g., thoughts, feelings, and sensations) as the
  target of interventions, rather than on the actual form or
  frequency of particular symptoms.

– Individuals increase their acceptance of the full range of subjective experiences, in an effort to promote desired behaviour change that will lead to improved quality of life.
– attempts to control unwanted subjective experiences (e.g., anxiety) are often not only ineffective but even counterproductive in that they can result in increased distress and significant psychological costs.
– ACT also helps individuals to identify their values and translate them into specific behavioural goals

• Systematic review: Strong evidence for ACT either as
  monotherapy or in combination for treatment of individuals with
  SUD

Question 40

What are Psychological therapies –> Dialectical behaviour therapy (DBT)
(interventions targeting the individual)

Answer 40

• DBT is designed to serve five functions: enhance capabilities, increase motivation, enhance generalisation to the natural environment, structure the environment, and improve clinician capabilities and motivation to treat effectively.
  – The overall goal is the reduction of ineffective action tendencies linked with deregulated emotions
  – Skill based and intensive
  – Key areas: mindfulness, distress tolerance, emotional regulation and interpersonal effectiveness
• Strong evidence for DBT treatment for substance use
  disorders and addictions

Question 41

What are Psychological therapies –> Relapse prevention
(interventions targeting the individual)

Answer 41

• The emphasis on developing skills:
  – to identify high-risk situations and triggers for craving,
  – skills to manage cravings and other painful emotions without using substances
  – learning to cope with lapses and
  – attaining a life-style balance (Carroll and Onken, 2005).
• Effective treatment. It can be enhanced by adding CBT,
  motivational enhancement therapy and/or pharmacotherapy

Question 42

What are Psychological therapies –> Contingency management
(interventions targeting the individual)

Answer 42

• Aimed at encouraging positive behaviour by providing positive reinforcement when a client progresses toward treatment goals (e.g., no drug use), often includes vouchers, privileges, prizes or modest financial incentives that are of value to the client.
• Strong evidence:
  – for treatment of substance use disorders, particularly, opioids, tobacco and polysubstance use
  – improves adherence to opiate substitution programs. However, it has not been used widely in clinical practice due to perceived high costs of provision of such interventions
  – has been found to improve medication compliance and encourage treatment attendance at AOD services

Question 43

What are Psychological therapies –> Social Skills Training
(interventions targeting the individual)

Answer 43

• Premise that deficient social skills
• Leads to poor adjustment and dysfunction
• Substance abuse as a coping strategy
• Focus is training in areas of deficiency
• Teaching new social skills
• Group therapy can be a good setting for this
• Assertiveness training, anger management, relaxation training, modelling, role playing etc…
• Social skills training is effective in substance abuse treatment, designed to give clients new skills that will allow them to maintain their abstinence

Question 44

What are the five interventions targeting the environment

Answer 44

1. Community Development
2. Employment, educational and recreational
   opportunities
3. Family Therapy
4. Case Management
5. Residential rehabilitation

Question 45

What is Community Development (interventions targeting the environment)

Answer 45

• Engaging the local community in the design and implementation of prevention programs has the potential to improve individual and collective health and well-being.
• Generates and disseminates drug-related resources to the
  community
• Prevention and intervention strategies
• Can raise awareness of drug issues
• Useful if linked to the development of more comprehensive strategies for the community
  – e.g. liquor licensing interventions, support groups, school-
  based interventions

Question 46

What are Employment, educational and recreational
opportunities (interventions targeting the environment)

Answer 46

• Recognises role of social disadvantage in substance abuse
  problems
• If successful, are strong protective factors against drug misuse
• Opportunities to develop skills and social networks outside the drug using lifestyle
• Can improve self-worth and self-esteem
• Introduces alternatives and healthy lifestyle

Question 47

What is Family Therapy (interventions targeting the environment)

Answer 47

• Focus on treating the ‘family’
• Family inclusive practice
• Better treatment outcomes
  – Can improve compliance with treatment and earlier engagement
  – Can alleviate distress for significant others
• Family members need to agree to be involved
• Confidentiality issues
• Multiple needs need to be managed
  – Individuals may need own counsellin

Question 48

What is Case Managment (interventions targeting the environment)

Answer 48

• Single point of contact with health and social services
• Client driven
• Advocacy
• Community based
• Flexible and culturally sensitive
• Link clients with appropriate services
• Monitor clients’ progress in treatment

Question 49

What is Residential rehabilitation (interventions targeting the environment)

Answer 49

• Long term programs (usually 1 to 12 months) where people live in a community of other substance users, ex-users and
  professional staff.
• The aim is to help people develop the skills and attitudes to
  make long-term changes toward an alcohol- and drug-free life- style.
• Programs usually include counselling, employment, education and skills training, life skills training (e.g., budgeting, cooking), group work, relapse prevention, and a ‘re-entry’ phase assisting return to the community.
• Generally suited for moderate to severely dependent people who require structured social supports.
• Abstinence as a goal
• ‘Day-hab’

Question 50

What are the outcomes of residential rehabilitation

Answer 50

• Moderate quality evidence that residential rehabilitation improves outcomes across various domains, including substance use, mental health, social outcomes (including criminal justice involvement) and mortality
• The Australian Treatment Outcomes Study (ATOS)
  – residential rehabilitation was 16 times more effective in achieving abstinence at the three-year follow-up when compared with MAT and inpatient withdrawal management
• de Andrade (2019) systematic review
  – noted that outcomes were notably better for those who engaged with 12- step support on leaving residential rehabilitatio

Question 51

What are the challenge’s of residential rehabilitation

Answer 51

• Treatment drop out
• High relapse risk on leaving residential
• Expensive
• Impact on relationships, family, employment

Question 52

Matching clients to treatment (why is the therapeutic relationship important for treatment?)

Answer 52

• There are factors common across all treatments - the therapeutic relationship and what happens outside of the therapy session.
• The quality and strength of the collaborative relationship between client and therapist has a modest but consistent
  impact on AOD treatment outcomes
• Client ratings of the therapeutic alliance are better predictors of treatment outcomes, than therapist therapeutic alliance ratings

Question 53

What is a significant factor that contributes to the therapeutic alliance

Answer 53

• A significant factor that contributes to the therapeutic alliance is matching the appropriate therapy to the client.
  – each psychotherapeutic intervention works in different ways with individual factors most likely influencing the suitability of different therapies
• Different problems require different types or combinations of interventions at different levels – DRUG, INDIVIDUAL or ENVIRONMENT
• Goal is to place client into least intensive treatment that will most likely facilitate treatment goals

Question 54

Summary

Answer 54

• AOD is a dynamic and ever changing field
  – Changing substances
  – Legislation
  – Treatments
• AOD use and issues are prevalent – not just in AOD services
• Treatment works!
• Always consider: What is the evidence for best practice?