Week 6 Lecture 6 - substance use and MH comorbidity 2

Question 1

What is early remission?

Answer 1

Early remission from a DSM-5 substance use disorder is defined as at least 3 but less than 12 months without substance use disorder criteria (except craving)

Question 2

What is sustained remission?

Answer 2

Sustained remission is defined as at least 12 months without criteria (except craving).

Question 3

What are abstinence programmes (inc. examples)

Answer 3

• Based on the idea that there is no “safe” amount of use.
• Aim = complete cessation of use

e.g.:
- Detoxification programmes (opioid treatment programmes)

• 12 step self-help programmes (e.g. Alcoholics Anonymous)
• Pharmacological interventions. Medications such as:
  —- Disulfiram - interferes with alcohol
  metabolism causing nausea & vomiting
  —- Naltrexone – reduces craving for alcohol / blocks effects of opioids in the brain (reducing pleasure)
  —- Methadone – reduces withdrawal symptoms

Question 4

What are the success rates of abstinence programmes?

Answer 4

• Success rates variable
• Detox/12 step approaches highly dependant on motivation to change; sometimes based on coercion /mandatory
• Relapse may lead to discharge from treatment
• Good evidence for pharmacological aids but they are not available for all types of substance use (e.g. cannabis; amphetamines)

Question 5

What is harm reduction? What is the goals of harm reduction?

Answer 5

• Aim of treatment at individual level is to reduce the risks associated with substance use (e.g. from needle sharing, drinking when driving) and to reduce/prevent excess morbidity+mortality.
• Attempts to meet people “where they are at” with their drinking or drug use.
• Pragmatic approach, assuming small changes better than none

Goals:
- Reduce negative consequences of substance use for the individual
- Promote recovery (whilst accepting relapse)
- Improve quality of life

Question 6

What are the NICE guidelines for helping people with Psychosis and Coexisting Substance Misuse?

Answer 6

AIM: To help healthcare professionals guide people with psychosis and coexisting substance misuse to stabilise, reduce or stop their substance misuse, to improve treatment adherence and outcomes, and to enhance their lives

Question 7

What do most health care professionals assume when helping people who misuse substances?

Answer 7

1. Abstinence (total cessation) is not necessary - reducing and stabilising substance use also a desirable outcome
2. Reducing substance use will lead to improved outcomes (greater treatment adherence; fewer relapses & hospitalisations etc.)

Question 8

According to NICE guidelines:

Healthcare professionals in all settings should routinely ask adults and young people with known or suspected psychosis about their use of alcohol and/or prescribed and non-prescribed drugs.

If the person has used substances what should they be asked about?

Answer 8

• The particular substance(s) used
• The quantity, frequency and pattern of use
• The route of administration
• Duration of current level of use

Question 9

What do the NICE guidelines recommend as treatment for both psychosis and substance use?

Answer 9

Psychosis:
- Antipsychotic medication, CBT and Family Intervention.
- Discuss use of substances with the service user, and carer if appropriate

Substance use:
- Motivational interventions; CBT; contingency management; family involvement

Question 10

Generally, what are psychosocial interventions for dual disorders?

Answer 10

Typically involve a combination of the recommended interventions (“integrated therapy”):

• Motivational interviewing;
• CBT (including relapse prevention);
• Psychoeducation;
• Family therapy /systemic therapy

Modalities:
- Individual (one to one)
- Group (with strangers / partner / family members)
- Combination of above
- Increasingly, mHealth (use of internet and mobile apps to deliver therapy)

Question 11

What do psychological assessments determine?

Answer 11

• Patterns of use (what substances; when used; where; how much?)
• History of use; previous treatment
• Motives for use
• Consequences (negative AND positive) – impact of use
• Motivation to address problems
• Personal strengths

Question 12

What do psychological assessments seek to do?

Answer 12

To understand role played by substances in client’s life; identify factors maintaining substance use and obstacles to change / relapse risks

Question 13

How long does a psychological assessment take?

Answer 13

May take several sessions and involve significant others (e.g. family members)

Question 14

What should a treatment plan using psychosocial interventions for dual disorders do?

Answer 14

• Be person centred: take individual’s needs and preferences into account
• address problems and goals identified during assessment
• take into account clients motivation to address substance use and obstacles to change
• Identify treatment goals and target behaviours (abstinence?)
• Identify measurable outcomes

Question 15

What do most psychological approaches take account of?

Answer 15

• the stages of change
• target treatment accordingly (stage of change dictating which methods are appropriate at a particular time

Question 16

What are the stages of change?

Answer 16

• Precontemplation –> Clients are not thinking about changing substance abuse behaviour and may not consider their substance abuse to be a problem
• Contemplation –> still using substances, but they begin to think about cutting back or quitting substance use
• Preparation –> still using substances, but intend to stop. Planning for change begins
• Action –> Clients choose a strategy for discontinuing substance use and begin to make the changes needed to carry out their plan
• Maintenance –> Clients work to sustain abstinence (or maintain reduction) and evade relapse
• Relapse –> Many clients will relapse and return to an earlier stage, but they will hopefully have gained new insights into problems

Question 17

In the pre-contemplation stage of change, what options are there? What method should be used?

Answer 17

Options:
- To not address substance use
- To persuade the client to change/ challenge their position
- To enhance motivation to change (emphasis placed here)

Method: Motivational Interviewing

Question 18

What is motivational interviewing?

Answer 18

• A person-centred counselling method for addressing the common problem of ambivalence about change
• A collaborative conversation to strengthen a person’s own motivation for and commitment to change
• Seeks to elicits and explore an individual’s own arguments for change
• Views ambivalence as normal
• Resolving ambivalence key to change
• Responsibility for change is with the client
• Accepts that clients goal unlikely to be abstinence (or even reduction)
• Emphasis: helping clients to understand how their substance use keeps them from achieving their goals

Question 19

In motivational interviewing, what do the reasons for change need to be?

Answer 19

Reasons for change (reducing / stopping substance use) need to be stronger than the reasons for staying the same in order to “tip the balance” for change

Question 20

How does motivational interviewing try to change people’s “reasons for using” into “reasons to change”

Answer 20

• Aim of MI: to enhance motivation to change; get client ready to make changes
• Typically brief, delivered as a stand alone intervention or can be integrated with another (e.g. CBT)

Question 21

What is psychoeducation?

Answer 21

Psychoeducation typically included in MI and other individual interventions:

• provision of information about the impact of substance use on mental health
• information sheets; leaflets; computer resources; DVDs
• Psychoeducation groups designed to educate clients about substance abuse, and related behaviours and consequences; identify resources; counteract denial
• Useful adjunct but not sufficient as treatment in own right

Question 22

What is CBT in substance abuse?

Answer 22

• Identifies antecedents of drug use (‘high risk situations’)
• Focus on teaching substance user new / more effective skills for dealing with high risk situations and craving
• CBT aims to change learned behaviour by changing thinking patterns, beliefs, and perceptions and assumptions.
• Cognitive restructuring around alcohol and drug expectancies e.g., Diaries, Behavioural experiments
• Assists making lifestyle changes so as to decrease need /urges for substance or to increase healthy alternatives

Question 23

What are relapse prevention techniques?

Answer 23

• Similar to CBT with focus on coping skills in high risk situations but specific to relapse (avoiding temptation in the threatening situation)

Clients taught to:
- Understand relapse as a process
- Implement damage control procedures during a lapse to minimize negative consequences / chances of relapse
- Stay engaged in treatment even after a relapse

• Longer term intervention, 6 – 26 sessions

Question 24

Under NICE guidelines, in family/systemic therapy family and carers should…?

Answer 24

• have the opportunity to be involved in decisions about treatment and care
• be given information and support
• be offered family intervention
• be offered information about local family or carer support groups and voluntary organisations

Question 25

What is family/systemic therapy?

Answer 25

Large psychoeducation component:
- Provides information about dual disorders

• Teaches communication skills and builds problem solving skills in family members, including the client
• Helps family develop relapse prevention strategies –> increase support; reduce burden; decrease conflict

Question 26

What is integrated therapy?

Answer 26

• Typically starts with MI (pre-contemplation > contemplation)
• Moves on to CBT (action; development of behavioural action / change plan) and relapse prevention
• Moves back and forth between approaches
• Includes psychoeducation and can involve family intervention

Question 27

What is contingency management?

Answer 27

Behaviour Modification:

• Contingency management (CM) – incentivises and reinforces abstinence with the aid of vouchers, privileges, prizes or financial incentives (clear urine screen = reward) can also used in interventions to reduce substance use
• Recommended by NICE for substance use interventions but evidence currently lacking for dual diagnosis
• Circle Trial (Johnson et al, 2019) recruited 500+ cannabis users with psychosis. No difference in outcome between those receiving CM and control

Question 28

What is the evidence summary for MI-CBT?

Answer 28

positive results in small trials but not replicated in larger ones – MI-CBT may reduce amount of substance used, but this doesn’t translate to improved symptoms and functioning

Question 29

What is the evidence summary for family intervention?

Answer 29

very promising, but needs more evidence in dually-diagnosed samples

Question 30

What is the evidence summary for contingency management?

Answer 30

good evidence in SUD more generally, but not in dual diagnosis

Question 31

Is there currently any evidence that supports only one line of treatment for substance misuse?

Answer 31

no

Cochrane Review 2019 (Hunt et al) concluded:

“There is currently no high‐quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse…”