#19 Return to Use Prevention Counseling with Dr. Eve Lasswell, PsyD

August 24, 2023 | By Carolyn Chan

Audio

Video

Jumpstart your knowledge on how to counsel patients in primary care to help decrease their risk of returning to substance use! Learn how to help patients identify triggers, develop plans on how to navigate high-risk situations & so much more! We are joined by psychologist Dr. Eve Lasswell PsyD at the University of California San Diego!

Claim free CME for this episode at curbsiders.vcuhealth.org!

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.

Production Partner: ACAAM

The Curbsiders Addiction Medicine are proud to partner with  The American College of Addiction Medicine (ACAAM) to bring you this mini-series.  ACAAM is the proud home for academic addiction medicine faculty and trainees and is dedicated to training and supporting the next generation of academic addiction medicine leaders. Visit their website at acaam.org to learn more about their organization.

Show Segments

• Intro, disclaimer, guest bio 00:00
• Guest one-liner  5:30
• Case from Kashlak  8:25
• Preparing for a visit 9:22
• Pre – Planning At Risk Scenarios 17:25
• Marlatt’s Framework 18:50
• People, places, and things 22:55
• Pearls and Pitfalls 27:30
• Virtual Visits 31:50
• Time Limited Visits 35:20
• Mutual Support Groups  38:35
• Sustained Remission 45:50
• Substance Specific Tips 47:15
• Take Home Points 49:20
• Outro  53:30

Return to Use Prevention Counseling Pearls

1. Returning to substance use is common. It’s vital to normalize these conversations and approach them in an open, compassionate, and nonjudgmental manner.
2. Pre-plan with patients how they may respond in different risky situations where they may be pressured or offered to use substances.
3. Try to find out what the person’s relationship is to the behavior – How are you feeling about what happened?  
4. Use the framework of people, places, and things to explore possible substance use triggers.
5. Try to acknowledge that people use substances for a reason. Eve reminds us to try to determine the function of the substance use, asking, what are you trying to feel, get, or not feel?
6. Remember that change does not have to happen all at once. Build in grace so people can continue to live their lives, but at a pace that does not overwhelm them.
7. In a time-limited visit, consider exploring an individual’s personal support systems and pre-plan for what may be coming up in the near future.
8. Mutual support groups can be helpful for patients, and there are a variety of different styles and types of groups such as Alcoholics Anonymous, SMART recovery (secular), and Moderation Management.

Return to Use Prevention Counseling – Notes 

Preparing for a Visit

Be sure to review prior interactions, how individuals frame their substance use, and prior medication trials. Having an understanding of local mental health resources as well as how insurance coverage may play a role in the resources available to an individual. Be aware of local mutual support groups and their different characteristics (e.g. spiritual or non-secular, secular, specific populations-focused like for women, LGBTQ+, etc).

Framing Substance Use:  Some individuals may frame or view their substance use through a “12-step framework” borrowed from mutual support groups, through a chronic disease model, a harm reduction approach, an abstinent vs non-abstinent approach, or a controlled use vs chaotic use framework. 

Terminology

There can be many different terms a patient uses to refer to a period where an individual returned to substance use. The term return to use is often preferred over relapse. Eve often reflects the language the patient is using, such as a slip or that the patient says they slipped up, lapsed, “messed up”, or framing like they switched from controlled use to chaotic use. 

Discussing episodes of return to use

Eve reminds us that return to use is common, and it’s important to normalize the experience. When this occurs, be as nonjudgmental and open-minded as possible. She recommends being curious, and trying to understand how did this start, and what was going on?  Try to learn from an individual’s prior successes as well and draw from a strength-based approach when having these conversations.

In addition, try to find out what the person’s relationship is to the behavior.

• How are you feeling about what happened?  – Some individuals may have viewed it as a helpful learning experience, while others may have a sense of shame around it. Exploring that emotional response or the emotion underneath it is vital
• Mirror the affect of the patient and take cues from them if space is needed

Frameworks to Discuss Return to Use Prevention

Pre-planning for At-Risk Scenarios

Discuss the situations or environments that represent at-risk situations where an individual will be pressured or offered to use substances. Discuss the skills a patient may use in these situations. You can consider role-playing in the office by asking the following questions.

• “How would you refuse X substance at a party?”
• “Who would you call during or after a certain at-risk situation?”

Marlatt’s Framework

Marlatt’s relapse prevention model is a framework for understanding episodes of return to use (Hendershot, 2011). This involves a high-risk situation occurring, the individual not coping effectively, and then resulting in a period of use. The first use represents an “abstinence violation”,  meaning that “1 is too many, and a million is not enough;”then an individual may be at risk of continued use. Eve recommends reminding a patient that if a one-time substance use does happen, it does not have to mean continued use.

In applying this framework, Eve recommends asking, what was the last situation you were in that was risky and you felt tempted to use a substance?  Ask how it felt after that last drink (or substance use), whether it was harder to continue or to not drink, and get an example from a patient’s own life to illustrate some of these points. 

Tip: If a patient has no idea what happened and what led to a return-to-use situation, put your detective hat on. Ask what was going on the week before – were there any stressors? What was on their mind the week before, and did any of those connect to someone’s desire to relieve stress, or avoid thinking about certain topics?   Eve recommends trying to slow the timeline down, to try to sort out what occurred. 

People, Places, and Things

Consider reviewing people, places, and things as possible return-to-use triggers. This can hit on the supports, and risks to someone’s path forward. Sometimes, the people closest to the patient can be the biggest triggers. Eve recommends discussing that this does not necessarily mean a person needs to completely cut ties with this individual. Instead, in order for an individual to live their life aligned with their values, this relationship may need to undergo some changes. She recommends that there has to be a plan that works for the context of a patient’s life, as it may not be feasible to completely avoid all persons, places, and situations that pose a risk. 

Try to acknowledge that people use substances for a reason. She reminds us to try to determine the function of the substance use, what are you trying to feel, get, or not feel?

Pearls and Pitfalls To Return to Use Prevention Counseling

Be sure to be open, nonjudgmental, and manage your own reactions. We are there to support our patients, and even if an individual is using self-shaming language, you do not need to reflect that language. 

It can also be really overwhelming to think about how life may look different without substances. It’s ok to slow the conversation down and use ask-tell-ask approach to help pace the conversation. Ask what they are thinking about, give information, and ask what they think about that information.

Avoid imposing the expectation that change has to happen all at once. Integrate grace into the process, allowing people to continue living their lives at a pace where this discussion and potential for change does not overwhelm them. These techniques do not have to align with abstinence but can be used with a harm reduction lens. 

Type of Visits

Virtual Visit Tips

There have been a lot of pros and cons with telehealth visits. Eve recommends using video telehealth visits to explore the environment the patient is in. For example, for a patient motivated for vaping cessation, consider “walking” through an individual’s house and if they are ready, be present when they get rid of the vapes in their house. She recommends reflecting on what you can do “in vivo” in the environment. 

Time Limited Visits

Eve recommends asking about a person’s support systems. Ask who has your back, and who will you talk about this visit with.  Ask, how what will define success on leaving this visit, what your strategy is for staying safe in at-risk situations, who you will call if things don’t go well, and does life need to look a little bit different today so that it can get back to a place that feels more normal in the future (e.g. decline an invitation to a family member’s birthday party, because an individuals’ family drinks a lot and it could be challenging). Focus on what is coming up in the near future that could potentially jeopardize a person’s ability to achieve their goals. 

Non-abstinent goals

Many of the approaches will still be similar. Continue to help a patient look for a social support system to help decrease substance use, consider medications, and pre-plan for at-risk scenarios.

Mutual Support Groups

Mutual aid groups can be helpful for patients, and they should be aware of the options available to them. Many patients have tried a mutual support group, with a variety of experiences. For those who have attended one meeting and did not find it meeting their needs, Eve recommends reminding a patient that “if you’ve tried one meeting, then you’ve only tried one meeting. There are a lot of different types of meetings, formats, different people at each meeting (some for women, LGBTQ+, etc)”.

 She would recommend encouraging individuals to try a few more meetings, on different topics, different days of the week, etc, to get a better feel of the types of meetings out there. Some different types of mutual support groups are listed below. 

• Alcoholics Anonymous (AA): 12-step group, often spiritual; individuals share their experiences, strengths, and hopes, to help individuals remain abstinent. They are widely available, and it’s often easy to find meetings. Often involves a sponsor. 
• Narcotics Anonymous – same framework as above, but often individuals present who identify with using drugs.
• SMART Recovery: similar to cognitive behavioral therapy, and often has a trained facilitator who will guide a topic. Support individuals who want recovery without the spiritual element. Individuals will then share their experiences on that topic, but there is no sponsorship.  There can be meetings focused on “tools”, or meetings focused on sharing experiences.
• Moderation Management: The focus is on moderating use rather than stopping use. Individuals discuss their goals and how they can support each other in achieving it
• Life Ring Secular Organizations for Sobriety 

12-step facilitation: a manualized protocol, where individuals work the first few steps of AA in individual or group therapy. The goal is to set people up for success by continuing a 12-step group in the community with a sponsor.  It may be more challenging to find access to a trained therapist who offers this approach.

12-step groups: groups where people come together in the community, and the goal is to connect with a sponsor to work the 12 steps. 

Sustained Remission from SUDS

Eve would be curious to check in with patients in sustained remission from substance use if any current behaviors have sparked an individual’s desire to return to prior substance use. When an individual has had a lot of success in abstaining, you can mine that history to draw it into the present if an individual is having challenges with new substance use.

Do strategies change around specific substances?

In general, there is a lot of overlap in return-to-use prevention counseling for all types of substance use. Try to determine the emotion that someone is trying to avoid by using substances.  Is that emotion life-threatening? How can we help you to feel that emotion without relying on substances to dampen the emotion? Through this process, can we find alternative ways to cope?

One scenario that may be unique that Eve points out is that methamphetamine use can be highly associated with sex. So an individual may not want to abstain from sex, but does want to abstain from methamphetamine use. For this goal, the discussion could involve a lot of relearning around sex and intimacy. 

Take Home Points

• Conversations around substance use are vital for helping our patients live the lives they want to live. Normalize that these conversations can be difficult to have AND are necessary to pre-plan given the ups and downs of life occur. 
• Offer compassion, and support, and be nonjudgmental in your conversation around return to use. 

Links

1. Vanderpump Rules
2. SAMHSA Library
3. Trauma Informed Care

Goal

Listeners will develop return-to-use prevention counseling strategies to help care for individuals with substance use disorder. 

Learning objectives

After listening to this episode listeners will…  

1. Describe possible causes of return to substance use, as well as their effects
2. Recognize components of Marlatt’s cognitive-behavioral theory of relapse prevention.
3. Describe counseling strategies to reduce the return-to-use risk. 
4. Describe practical counseling aids a primary care physician can use for return-to-use prevention in their office.

Disclosures

Dr. Eve Lasswell, PsyD reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Kryzhanovskaya E, Lasswell E, Sonoda K, Chan CA “#19: Return to Use Prevention Counseling with Eve Lasswell PsyD”. The Curbsiders Addiction Medicine Podcast. https://thecurbsiders.com/addiction August 24th, 2023