Integrate motivational interviewing into your busy practice, and learn the basic principles of cognitive behavioral therapy. This episode highlights common psychosocial interventions for individuals with substance use disorders. After this episode, you will feel empowered to connect patients to these evidence-based resources. We’re joined by Dr. Carla Marienfeld, MD from UCSD, @DrMarienfled who gives us practical ways to counsel patients on these interventions, as well as bring them into the busy clinic setting.
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By listening to this episode and completing CME, this can be used to count towards the new DEA 8-hr requirement on substance use disorders education.
Motivational interviewing (MI) is an evidence-based approach that uses a facilitated conversation to move people towards positive behavior change (Miller, 2012). It is best understood as a communication style for addressing and resolving ambivalence about change (SAMHSA, 2019). MI aims to evoke a person’s own values, motivations, and reasons for change as the foundation for promoting healthier behaviors. It has been shown to improve outcomes for a range of physiological and psychological conditions (Rubak, 2005), especially substance use disorders (Smedslund, 2011; Lindson-Hawley, 2015), and can be applied to other behaviors including medication adherence (Palacio, 2016).
The spirit that one should bring to MI can be captured by the mnemonic PACE: (Haque, 2019)
P – Partnership (“my job is to do what I can to help you be successful”)
A – Acceptance (non-judgment, meeting the person where they’re at)
C – Compassion (do no harm, wanting the best for the person)
E – Evocation (evoke/elicit what is important to a person and changes they want to make)
Key micro-skills that form the core of MI conversations can be summarized with the mnemonic OARS: (Haque, 2019)
O – Open-ended questions: to ensure the patient is doing most of the talking
A – Affirmations: offer positive observations of patient strengths, acknowledge their efforts
R – Reflections: the “bread and butter” of MI – use a simple or complex reflection to demonstrate empathy, interest, and understanding of a patient’s perspective.
S – Summaries: “mega-reflection” – summarize the “change talk” you’ve heard and the steps the patient is taking towards behavior change, and move towards planning the next steps
When it’s time for a clinician to advise or share information with a patient, they can use the “Ask-Tell-Ask” approach to ensure information is offered in a way patients can hear and use it.
Ask: assess patient’s knowledge about options (“what do you know about ___________?”)
Tell: use their answer to choose key bullet points you want to share with them
Ask: get feedback on what you shared, or use teach-back to ensure they’ve understood
Cognitive Behavioral Therapy (CBT) is a therapy modality initially used to treat depression and anxiety, then expanded for the treatment of substance use disorders with a focus on relapse prevention (Larimer et al, 1999). CBT is focused on the connection between thought and behavior. While individuals may not be able to directly change how they feel about something, they do have the ability to change their thinking patterns, which can influence their feelings and ultimately their behavior. With respect to substance use disorder, CBT helps patients recognize triggers and cues for substance use and strategize ways to anticipate, avoid, and cope with them. CBT also focuses on the development of coping skills to manage cravings, emotions, and anxiety in a healthy way.
While CBT can be delivered in a structured, manualized approach by a trained health professional, it can also be applied in a busy primary care office with just a few techniques. For example, clinicians can help patients identify triggers and explore coping skills that have worked for them in the past. Another tool to review with patients is “Catch it, check it, change it,” wherein an unhelpful or triggering thought or craving is identified (“catch it”), challenged (“check it”), and re-evaluated (“change it”). This framework helps patients recognize when they are at risk, take a pause, and then respond (rather than react) to the situation.
Additional Psychosocial Interventions
In addition to CBT, individual therapy, couples therapy, and group therapy there are other options available to patients.
Contingency Management (CM): CM is based on operant conditioning where immediate rewards are provided to reinforce and promote positive behavior change. Rewards are determined based on goals identified collaboratively with patients, such as stopping or reducing substance use, addressing related health conditions, or showing up to medical appointments. CM is considered the gold standard for treating stimulant use disorders (Crescenzo, 2018). It can be practiced individually, in groups, and in both outpatient and inpatient settings.
Acceptance and Commitment Therapy (ACT): ACT combines components of mindfulness and cognitive behavioral therapy to help patients learn to accept rather than avoid challenging situations in their lives. ACT has six core processes: acceptance, cognitive defusion, being present, self as context, values, and committed action. It has been shown to be an effective treatment for individuals with substance use disorders (Osaji, 2020).
Community Programs: Also known as mutual help or mutual support groups, these programs are free and peer-run groups such as Alcoholics Anonymous (AA), SMART Recovery, and Refuge Recovery. The ease and flexibility of participation, group dynamics, and introduction to a peer cohort can support behavior change in patients with SUD. Programs have diverse ideologies and approaches; for example, 12-step programs such as AA are more strictly oriented towards abstinence, and SMART Recovery has a CBT approach. Most programs have online meeting options. You can use this list to learn more about options and find out which are accessible to your patients.
Community Reinforcement Approach and Family Therapy (CRAFT): CRAFT is a program based on the premise that substance use is a learned behavior, and that the loved ones of individuals with substance use disorder can be trained to use reinforcement techniques to make treatment engagement and abstinence more rewarding, and to diminish positive reinforcements of substance use (Archer, 2020).
Many patients, families, and community members assume addiction treatment to mean brief and intensive residential treatment (“rehab”). However, this level of treatment may not be necessary or effective for a given patient, and like all chronic illnesses, SUD often requires sustained treatment.
The American Society of Addiction Medicine (ASAM) criteria involve six dimensions to assess a patient’s substance use severity and biopsychosocial needs to determine the appropriate level of care (ASAM’s six dimensions):
One universal hurdle faced by clinicians is knowing what resources exist in their area. In addition to the sponsorship model of addiction recovery, in which individuals in sustained recovery support peers, drug and alcohol counselors often offer services in the community. Licensed marriage and family counselors, social workers, and clinical psychologists can offer more structured assessment and therapy services. Psychology Today can be a useful tool to identify local providers based on geography, insurance, and preferred treatment focus (e.g. addiction) or modality (e.g. CBT).
Review: What can you do in five minutes as a busy PCP?
Need more time? Turn to your outpatient options and specialists who can discuss care options further with patients and help get them connected.
Take Home Points
Listeners will describe common psychosocial interventions used to treat individuals with substance use disorders.
After listening to this episode, listeners will…
Dr. Carla Marienfeld reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Danesvhar H, Marienfeld C, Morford K, Stahl N, Williams P, Chan, CA. “10 The ABCs of CBT: Psychosocial Interventions 101”. The Curbsiders Addiction Medicine Podcast. http://thecurbsiders.com/episode-list September 8th, 2022.
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