C2 Mod 7 Evidence-Based Practices

8/11/2019 C2 Mod 7 Evidence-Based Practices

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MODULE 7EVIDENCE-BASED

PRACTICES FOR TREATMENT

INTERVENTION

Treatment for Substance Use

DisordersThe Continuum of Care

for Addiction Professionals

The Colombo Plan Asian Centre for Certification and Education of Addiction Professionals Training Series

Curriculum 2


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7.2

Module 7 Learning Objectives

Define evidence-based practice (EBP)

Describe why it is important to know about

EBPs

Identify key components of six specific EBPs

Discuss the applicability of these EBPs to your

work


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7.3

Creating Small Groups

A range of experience is needed in each group

Line up left to right, based on length of time

worked as an SUD counselor

Part-time and full-time work, internships, and

volunteer work counts

Count off from one to four, starting on the left

Move to new group tables and introduceyourselves


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7.4

Prior Module Topics

Recovery, recovery management, recovery

capital

Factors that may affect treatment outcomes

Process and stages of change

Basic principles of treatment

Components of treatment


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7.5

What is an evidence-based

practice?


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7.6

Evidence-based Practices (EBP): Definition

Practices for which the evidence is strongest

and most acceptedand that are most likely

to have significant impact on improving care

Source: U.S. National Quality Forum. (2007). National voluntary consensus standards for the

treatment of substance use conditions: Evidence-based treatment practices (abridged version).

Washington, DC: Author.


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7.7

EBP Definition: Improving Care

Substandard SUD treatment was common

Substandard was defined as treatment that

was not:

Safe

Effective

Patient-centered

TimelyEfficient

Equitable (fair)

Source: McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A. et al.

(2003). The quality of health care delivered to adults in the United States. New England Journal ofMedicine 348.


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7.8

EBP Definition: Improved Care

Only 10 percent of people with alcohol use

disorders received recommended care,

resulting in increased mortality and morbidity

Source: McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A. et al.

(2003). The quality of health care delivered to adults in the United States. New England Journal of

Medicine 348.


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7.9

EBP Definition: Practices

Practices are sets of techniques and

approaches that may include elements from

more than one counseling theory


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7.10

Evidence-Based Practice

EBP

Clinicalexpertise

Science

Clinical &financialfeasibility


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7.11

Evidence-based: Science

Empirically validated evidence, meaning

evidence that is based on information gained

through:

Direct observationExperience

Experiments


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7.12

Evidence-based: Clinical and Financial

Feasibility

In a real-life treatment setting, not just in a

research setting, implementing the practice is:

Reasonable

Achievable

Economically possible


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7.13

Evidence-based: Clinical Expertise

Counselors implementing a practice have

basic counseling skills, can connect with

clients, and have been trained in the use of the

specific practice

Photo credit: Family Health International, Hanoi,Vietnam


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7.14

Why Evidence-Based Practices?

Question:

Why do we need to know and care about EBPs?


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7.15

EBPs Improve Outcomes

EBPs have been shown to improve treatment

outcomes

Source: World Health Organization (WHO) and UNODC. (2008). Principles of drug

dependence treatment: Discussion paper.

(http://www.unodc.org/documents/eastasiaandpacific//china/UNODC-WHO-Principles-of-Drug-Dependence-Treatment.pdf)


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7.16

WHO and United Nations Office on

Drugs and Crime

Evidence-based good practice and

accumulated scientific knowledge on the

nature of drug dependence should guide

interventions and investments in drugdependency treatment. The high quality of

standards required for approval of

pharmacological or psychosocial interventions

in all the other medical disciplines should beapplied to the field of drug dependence.

Source: World Health Organization and UNODC (2008). Principles of drug dependence treatment: Discussion paper.

(http://www.unodc.org/documents/eastasiaandpacific//china/UNODC-WHO-Principles-of-Drug-Dependence-Treatment.pdf)


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7.17

Recommended EBPs

Pharmacotherapy (use of medications to treat

SUDs)

Cognitive-behavioral therapies

Motivational enhancement therapy

Contingency management

12-step facilitation therapy

Marital and family therapies

Source: U.S. National Quality Forum. (2007). National voluntary consensusstandards for the treatment of substance use conditions: Evidence-based treatment

practices: A consensus report. Washington, DC: Author.


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7.18

Practices NotRecommended

Acupuncture, relaxation therapy, education,

drug testing, detoxification as stand-alone

treatments

Individual psychodynamic therapyUnstructured group therapy

Confrontation as the mainapproach to

treatmentDischarge from treatment in response to relapse

Source: U.S. National Quality Forum. (2004). Evidence-based treatment practices for substance use

disorders: Workshop proceedings. Washington, DC: Author.


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7.19

Important to Know

An empathic, supportive approach may be just

as important as the specific practices used

A counselors ability to engage and develop a

helping relationship with a client is critical


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7.20

EBPs Well Cover

Cognitive-behavioral therapy

Motivational approaches

Certain family approaches

Therapeutic community

Contingency management

Pharmacotherapy for opioid dependence


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7.21

Cognitive-Behavioral Therapy

A combination of:

Cognitive therapy, which was originally

developed by Aaron Beck to treat depression

Behavioral therapy, which was originallydeveloped and conceptualized by Ivan Pavlov

and modified by B. F. Skinner and Albert

Bandura


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7.22

Cognitive Therapy

Thoughts and interpretations cause feelings

and behaviors

Feelings and behaviors are not caused by

external thingsPeople can change the way they think (and

feel and act), even if the situation does not

change


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Instead of This

EventFeelings

andbehavior


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7.24

This

EventThoughts

andInterpretations

Feelingsand

behavior


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7.25

Behavioral Therapy Focus

Emotional and behavioral disorders are

learned responses that can be replaced by

healthy ones with appropriate training


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Focus on identifying factors that initiate and

maintain behavior

Focus on the adaptive and maladaptive

behaviors that lead to client discomfort andproblems

Focus on observableand measurable

behaviors

Behavioral Approaches


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Behavioral Approaches

Do notfocus on concepts like self-esteem,

thoughts, values, the unconscious, or defense

mechanisms


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7.28

CBT: Central Questions

The how question relates to building skills.

How does he change?

The what question addresses the things that

reinforce patterns of thought, affect, and

behavior.

What keeps a person doing what hes doing?


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CBT Approach to Treating SUDs

Teaching clients skills that help them

recognize and learn strategies to:

Reduce risks of relapse

Maintain abstinenceSolve problems

Enhance self-efficacy


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7.30

CBT Techniques

Asking questionsand teaching clients to ask

themselves questionsto explore the

relationship of their thinking to their emotional

responses to events. For example:How do I really know those people are laughing at

me?

Are there any other possible explanations?

Could they be laughing about something else?


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CBT TechniquesPart II

Explore positive and negative consequences

Teach self-monitoring

Help clients develop strategies for avoiding or

coping with high-risk situations

Help clients develop effective coping strategies

for general life challenges

Teach problem-solving skills


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CBT TechniquesPart III

Homework:

Reading assignments

Keeping track of certain behavior and thoughts

Practicing new skills (behavioral rehearsal)

C C S


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Cognitive-Behavioral Coping Skills

Therapy

A structured CBT approach

Each session includes:

Discussion of the rationale

Specific skill guidelines

Behavioral rehearsal (skill role-plays)

Practice exercises for a particular topic area

U.S. National Institute on Alcohol Abuse and Alcoholism. (1995). Cognitive-behavioral coping skills therapy manual: A

clinical research guide for therapists treating individuals with alcohol abuse and dependence. Project MATCH

Monograph Series, Volume 3. Bethesda, MD: Author.


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Topic Areas

Topic areas:

Managing thoughts about using substances

Solving problems

Developing substance refusal skillsPlanning for emergencies and coping with a lapse

Dealing with seemingly irrelevant decisions


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Seemingly Irrelevant Decisions


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Coping Skills Training

Helps clients look at eachlink in a chain of

events that led to relapse

Helps clients learn to recognize decisions that

can be the start of a process of relapse


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CBT Effectiveness

Documented effectiveness for SUDs involving:

Alcohol

Marijuana

CocaineMethamphetamine

Nicotine

Clients maintain skills and gains for a yearafter treatment

Source: U.S. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment:

A research-based guide,2nd Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.


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7.38

Small-Group Exercise: CBT

Small-group topic assignments:

Group 1: Overview of characteristics

Group 2: Primary techniques/applications

Group 3: StrengthsGroup 4: Challenges


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7.39


Summarize your assigned topic:

On newsprintfor group presentation

On whitepaper for posting on CBT wall graphic

Use resources:Your manuals and notes

What you already know about this EBP

Resource Page 7.2 (especially helpful forstrengths and challenges)


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Lunch60 minutes


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7.42

Motivational Approaches

Motivational interviewing (MI)

Motivational enhancement therapy (MET)


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7.43


Change occurs in stages

Motivation for change varies over time

Motivation can be enhanced

Pre-contemplation

Contemplation

PreparationAction

Maintenance


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7.44


Are client-centered and nondirective

Acknowledge that substances have rewarding

properties that can disguise hazards and

negative long-term effectsHelp clients resolve ambivalence about

treatment and stopping substance use


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Motivational ApproachesPart 2

Use the internal motivation of clients to evoke

and sustain rapid change

Include problem-solving or solution-focused

strategies that build on clients past successes


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The Counselor

Acts as a coach or consultant rather than as

an authority figure

Helps client discover,

understand, and build on

past successes

P i T h i f M ti ti l


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7.47

Primary Techniques of Motivational

Approaches

FRAMES approach

Decisional balance exercises

Identifying discrepancies

Pacing

Personal contact with clients not in treatment


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7.48

FRAMES

Feedback

Responsibility

Advice

Menus

Empathy

Self-efficacy


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FRAMES: Feedback

After assessment of substance use patterns,

associated problems, and recovery capital, the

counselor provides feedbackto the client

regarding personal risk or impairment


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FRAMES: Responsibility

Responsibilityfor change is placed squarely

and explicitly on the client, with respect for the

clients right to make choices for herself or

himself


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FRAMES: Advice

Adviceabout changingreducing or

stoppingsubstance use is clearly given to

the client by the counselor in a nonjudgmental

manner


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FRAMES: Menus

Menusof self-directed change options and

treatment alternatives are offered to the client


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FRAMES: Empathy

Empathiccounseling is emphasized

Counselor shows:

Warmth

Respect

Understanding


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FRAMES: Self-Efficacy

The client:

Develops self-efficacy

Is encouraged to change

The counselor:Helps client explore strengths and past

successes

Identifies skills and abilities to make changes

Promotes idea that change and recovery are

possible


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Decisional Balance Technique

Decisional balanceis the concept of exploring

the pros and consor benefits and

disadvantagesof change


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Decisional Balance Exercise

Client weighs pros and cons of changing or

not changing substance-using behavior

Counselor assists by asking the client to:

Talk about both the good and less good aspectsof using substances

Write them down in two columns on a sheet of

paper


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Decisional Balancing Purpose

The purpose of exploring the pros and cons of

a substance use problem is to tip the scales

toward a decision for positive change


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Identifying Discrepancies

Help clients recognize discrepancy or gap

between future goals and current behavior:

How does your cocaine use fit in with having a

happy family and a stable job?When clients see present actions conflicting

with important personal goals, change is more

likely to occur


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7.59

Pacing

Each client moves through stages of change at

his or her own pace

Counselor meets client at the stage in which

he or she isPushing a client at a faster pace than he or

she is ready to take may cause the

relationship between counselor and client to

break down

Personal Contact With Clients Not in


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7.60

Personal Contact With Clients Not in

Treatment

Research shows simple motivation-enhancing

interventions like letters and telephone calls

encourage clients to:

Return for another clinical consultationReturn to treatment following a missed

appointment

Stay involved in treatment

Increase treatment adherence


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Motivational Interviewing Definition

Counseling technique or style focusing on

creating a favorable climate for change in a

person-centered setting

Essence is collaborative nature:Communicating in a partner-like relationship

Interviewer creates a positive interpersonal

atmosphere


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MI Principles

Five primary principles or concepts to enhance

the client-counselor relationship are

summarized by the acronym READS:

Roll with resistanceExpress empathy

Avoid arguments

Develop discrepancy

Support self-efficacy


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MI Therapeutic Skills

Counselor uses four basic therapeutic skills or

methods:

Listening reflectively or responding to a clients

statement by stating back either the essence or aspecific aspect of what was said

Asking open-ended questions

Affirming

Summarizing


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MI Goal

Responsibility for change is left to client in

that:

The goal is to increase intrinsic motivation to

make the change the client determines to beimportant

Change is never imposed


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MI and SUD Treatment

First used to improve adherence

Can be assessment strategy and therapeutic

intervention to:

Determine readiness to engage in target behaviorExplore and resolve ambivalence and resistance

Apply specific skills and strategies to create a

climate for change, based on the level of

readiness

Motivational Enhancement Therapy


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Motivational Enhancement Therapy

(MET)

MET seeks to:

Help clients create their own motivation for

change

Consolidate clients decision and plan for changeApproach is client centered, but counseling

sessions are planned and directed by the counselor


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7.67

MET and Goal-Setting

Counselors impose no absolute goal

Counselors may advise about specific goals, such

as complete abstinence

A broader range of life goals may be explored aswell


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MET Concept of SUD Problems

SUD problems viewed as behaviors at least

partially under voluntary control of the client

Normal principles of behavior change apply


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MET Summary

Based on principles of cognitive and social

psychology, where the counselor:

Assumes that internal motivation is a necessary

and often the only factor needed to create changeHelps clients perceive discrepancies between

current behavior and personal goals

Emphasizes clients self-motivational statements

of both desire for and commitment to change

ff


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7.70

MET Effectiveness

Researchers have found MET to be effective

for addressing the following addictions:

Alcohol

MarijuanaNicotine

Source: U.S. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-based guide,

2nd Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.

Small-Group Exercise: Motivational


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7.71

p

Approaches

Small-group topic assignments include:


Group 2: Challenges

Group 3: Overview of characteristicsGroup 4: Strengths



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p

Approaches








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7.73

Break15 minutes



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p

Approaches

Presentations

F il I l t


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Family Involvement

Family involvementis not a model, but it canenhance outcomes

Most programs offer some family services

F il S i


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Family Services

Family services frequently include:

Family education

Family support groups

Family counseling

F il I l t


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Family Involvement

Why do you think family involvement isimportant in SUD treatment?

F ili f Cli t With SUD


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Families of Clients With SUDs

Inconsistent behaviors

Few or rigid rules

Emotional distress

Isolated or rigid roles

Medical issues in response to stress

Families Can Enhance Reco er


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Families Can Enhance Recovery

Family members were involved with the clientbeforetreatment

The will be involved with the client after

treatmentChanges in family functioning can be a positive

influence on recovery

Family Involvement Goals


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Family Involvement Goals

Learning about SUD as a chronic diseasehelps family members understand:

How SUD is intertwined with family problems

SUD causes and effects from a family perspectiveFamily relationship patterns working against

recovery

Prepare for early recovery challenges

Relapse warning signs

Family Involvement Goals Part II


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Family Involvement GoalsPart II

Help family members:

Discover and build on family strengths

Find long-term support for themselves

Families Can Be Roadblocks


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Families Can Be Roadblocks

Family members may need treatmentthemselves before they can be a resource

Many clients are from families that:

Are particularly chaotic and dysfunctionalHave multi-generational SUDs, mental disorders,

and other problems

Family Approach EBPs


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Family Approach EBPs

Behavioral couples therapy (BCT)

Multisystemic therapy (MST) (adolescents)

Multidimensional family therapy (MDFT)

(adolescents)Brief strategic family therapy (BSFT)

(adolescents)

Behavioral Couples Therapy (BCT)


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Behavioral Couples Therapy (BCT)

Assumptions:

Intimate partners can reinforce abstinence

Reducing relationship stress reduces chances

for relapse

BCT Program Components


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BCT Program Components

Recovery or abstinence contract

Activities and assignments to enhance

relationship

Relapse prevention planning

BCT Program Techniques


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BCT Program Techniques

Between 15- and 20-hour-long sessions over 5to 6 months to:

Assess use since last session

Discuss compliance with recovery contractDiscuss homework assignments

Discuss relationship problems

Present new material

Assign new homework, and then discuss it

BCT Effectiveness


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BCT Effectiveness

BCT is effective for:

Men with alcohol use disorders and their spouses

Men and women with drug use disorders and

their significant others

Source: U.S. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-based guide,

2nd Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.

BCT Effectiveness Part II


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BCT EffectivenessPart II

Compared to individual treatment at one-yearfollow-up, BCT produces higher:

Treatment attendance

Naltrexone adherence for opioid users Rates of abstinence

BCT also produced fewer drug-related, legal,

and family problems

Multisystemic Therapy (MST)


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Multisystemic Therapy (MST)

Intensive in-home and in-community approach

Focuses on changing thinking and behavior of:

Adolescents with SUDs

Their parentsUses cognitive-behavioral and social-

development strategies

Concentrates on family strengths

MST Interventions


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MST Interventions

Occur in-home to overcome high drop-outrates and focus on:

Promoting responsible behavior

Decreasing irresponsible actions by familymembers

Addressing what is currently occurring in the

adolescents life

Taking immediate actions targeting specificproblems

MST InterventionsPart II


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MST InterventionsPart II

MST focuses on:

Assessing patterns of behavior within and between

elements in adolescents life that sustain problems

family, teachers, friends, home, school, and

community

Building adolescents peer relationships

Acquiring academic and vocational skills


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MST Effectiveness


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MST Effectiveness

MST found to:Significantly reduce adolescent drug use during

and for at least six months aftertreatment

Reduce the number of incarcerations and out-of-home juvenile placements

Source: U.S. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A

research-based guide, 2nd Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.

Multidimensional Family Therapy (MDFT) for


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Adolescents

Adolescent substance use viewed in terms ofa network of influences:

Individual

FamilyPeer

Community

MDFT TreatmentWith Adolescents


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MDFT Treatment With Adolescents

Individual and family sessions are held inhomes, schools, courts, or the community

The counselor and adolescent work on:

Developmental tasks, such as decision-making,negotiation, and problem-solving skills

Vocational skills

Skills in communicating thoughts and feelings

MDFT TreatmentWith Parents


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MDFT Treatment With Parents

Parallel sessions with parents to:Examine parenting styles, learning to distinguish

influence from control

Develop a positive and developmentallyappropriate influence on their children

MDFT Effectiveness


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MDFT Effectiveness

Researchers have found MDFT to be effectivefor reducing the severity of:

Cannabis and alcohol use

Substance abuse-related problems

Source: U.S. National Registry of Evidence-based Practices and Programs. (2011). Multidimentional Family Therapy.

Rockville, Maryland: SAMHSA. (http://nrepp.samhsa.gov/ViewIntervention.aspx?id=16)

Brief Strategic Family Therapy

(BSFT)


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(BSFT)

Delivered in 12 to 16 sessions

Targets family interactions that sustain SUDs

and other co-occurring behaviors, such as:

Conduct problems at home and at schoolOppositional behavior

Illegal activities

Associating with antisocial peers

Aggressive and violent behaviors

Risky sexual behavior

BSFT Techniques


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BSFT Techniques

Family systems approach

Counselors role: To identify and change

patterns of family interaction that support

SUDsFlexible approach adapted to range of family

situations in various:

Settings

Treatment modalities

BSFT Manual


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BSFT Manual

BSFT is a manual-based, highly structuredprogram

Specific training is required to implement

BSFT

BSFT Effectiveness


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BSFT Effectiveness

Urban Hispanic families have been the primaryrecipients

Researchers found BSFT effective for:

Reducing marijuana and overall substance useReducing conduct problems

Increasing family functioning

U.S. National Registry of Evidence-based Practices and Programs. (2011) Multidimentional Family Therapy.Rockville,

Maryland: SAMHSA. (http://nrepp.samhsa.gov/ViewIntervention.aspx?id=151)

Exercise: Journal Writing


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Exercise: Journal Writing

What was the most important thing youlearned today?

What surprised you?

What would you like to learn more about?

Day 4 Wrap-Up and Evaluation


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y p p

Thank you for your participation today.

Does anyone have questions or thoughts

before we end the day?

Please complete a Daily Evaluation Form.

Day 5: Module 7


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ay 5 odu e

Welcome to

your last day

of training!

Small-Group Exercise: Family-based

Approaches


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Approaches

Small-group topics:Group 1: Challenges

Group 2: Strengths

Group 3: Primary techniques/applicationsGroup 4: Overview of characteristics

Small-Group Exercise: Family-based

Approaches


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7.106

Approaches

Summarize your assigned topic:On newsprintfor group presentation

On whitepaper for posting on family-based wall

graphicUse resources:

Your manuals and notes


Resource Page 7.4 (especially helpful for

strengths and weaknesses)

Therapeutic Community (TC)


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p y ( )

Intensive, long-term (up to one year)residential model

Community as methodThe community as a

whole is the therapeutic agent with its:Social organization

Staff and clients

Daily activities

TC Structure


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Structured day includes ordered activities to:Counter disordered lives of clients

Distract clients from negative thinking and

boredom

Group sessions and job functions to teach

specific behaviors and skills

Useful elements for clients with histories of

severe SUDs and criminal behavior

Key Therapeutic Factor


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y p

Researchers documented that:Restoring warm, interpersonal relationships

reverses the damaging changes produced on

brain formation, function, and structural damage

caused by childhood neglect and abuse

With the well-recognized TC role, each

participant is considered with love and respect

and as part of a new family, while fillingaffective gaps

Source: Personal communication: Gilberto Gerra, M.D., Chief, Drug Prevention and Health

Branch, UNODC

TC Model


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TC model used in countries around the world

13 countries with professional associations on

every continent (except Antarctica)

The Asian Federation of TherapeuticCommunities (http://www.asianfedtc.org)

TC Model Components


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p

A sense of community, as separation from thesubstance-using environment

Peers and staff members learn new roles and

become role models for othersWork as therapy and education

Peer encounter groups, awareness training,

and emotional growth training

TC Treatment Stages


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g

Introduction Treatment CommitmentTransition &

Aftercare

TC Introduction Stage


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g

Help clients accept responsibility for SUDbehaviors and consequences through:

Groups

Individual counseling sessionsEducational seminars

TC Treatment Stage


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Clients live and work in a supportivecommunity, helping one another develop

coping skills:

Social structure is hierarchical with varyingdegrees of responsibility

Activities focus on normal, daily work projects and

leisure interests

Includes a creative therapy programOutside support meetings are initiated

TC Commitment Stage


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Link between treatment and reintegrationEmphasis is on:

Career development

Social relationshipsPractical living skills

TC Commitment StagePart II


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Support is provided for community reentryfrom:

Voluntary work to full-time employment or school

From TC to transitional housing and to home incommunity or back with family

Weekly support groups and counseling

Additional support from peers who have

completed the TC programParticipation in 12-step groups

TC Transition/Aftercare Stage


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Requirements of:Full-time job or school

Place to live

Support networkFamily reconciliation

Coping skill development to maintain a drug-

free lifestyle, which can take many months

TC Effectiveness


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Conclusions from long-term U.S. Drug AbuseTreatment Outcome Studyfound those who

completed TC treatment had lower levels of:

Cocaine, heroin, and alcohol use

Criminal behavior

Unemployment

Indicators of depression

Source: National Institute on Drug Abuse (2002). Research report seriesTherapeutic community:

What is a therapeutic community. Bethesda, Maryland: Author.

(http://www.nida.nih.gov/PDF/RRTherapeutic.pdf)

TC EffectivenessPart II


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Modified TCs are also effective for treatingindividuals with special needs, including:

Adolescents

WomenHomeless individuals

People with severe mental disorders

Individuals in the criminal justice system

Source: National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-

based guide,2nd Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.

Small-Group: TC


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Small-group topics:Group 1: Strengths


Group 3: ChallengesGroup 4: Primary techniques/applications

Small-Group Exercise: TCs


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On whitepaper for posting on TC wall graphic




strengths and challenges)


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Break15 minutes

Contingency Management (CM)


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Based on the behavioral principle thatrewarding a behavior reinforces it, or makes it

more likely to be repeated

In SUD treatment, CM means that clients aregiven the chance to earn low-cost incentives,

or rewards, for desirable behavior

Behavioral Perspective of SUDs


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Substance use is maintained by:The positively reinforcing effects of the substance

itself

The negative reinforcement of reliving pain of

withdrawal

Pull of dependence and its immediate

rewards are very strong

Abstinence Rewards


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The process of becoming abstinent has itsown eventual rewards, including:

A healthier lifestyle

Employment and self-sufficiencyEducational opportunities

Maintaining positive relationships

Reward Motivation


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It takes a long time for internalrewards ofabstinence to be experienced by the client

attempting to make major behavioral changes

So, CM uses other rewards to motivate:Treatment adherence

Abstinence

Lifestyle changes

CM Motivation


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Motivates behavior change and abstinence by:Systematically rewarding desirable behaviors

Reinforcers are positive, pleasurable, and

rewarding events or objectsNegative reinforcers are also effective, such as

removing a fine or restriction

CM Guiding Principles


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Each has unique techniques, but all areguided by a set of guiding principles:

Identifying behavior that is observable and

measurable

Selecting desired behavior change that can meet

treatment goals

Rewarding small changes

More Guiding Principles


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Additional shared principles:Choose rewards important to clients by asking

them which would be the most desirable

Reward the targeted behavior immediately

Provide frequent reinforcers

Deliver all rewards as promised

Use escalating series of rewards to provide

greater incentive

CM Types


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Several CM types with a research base:Contingent access to privileges; for example,

through a system of levels with increasing

privileges

Onsite prize distribution

Refunds or rebates

Vouchers or other token economy systems

CM Challenge


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Identify a reward for a desired behavior that is:Practical

Available without too much cost or expenditure of

staff energy

Sufficiently powerful over time to replace or

substitute for potent, pleasurable, or pain-

reducing effects of the abused substance

Community Reinforcement (CR)


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Uses social, recreational, familial, andvocational reinforcers, rather than material

rewards or within-program privileges

Is based on the premise that environmentalresources can be effective in changing

substance use behavior

Has strong case management as an essential

component

CR Approach Plus Vouchers


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Documented as an EBP: Intensive 24-week outpatient therapy for

treatment of cocaine and alcohol addiction

Treatment goals:Maintain abstinence long enough to learn new life

skills to sustain abstinence

Reduce alcohol consumption for clients whose

drinking was associated with cocaine use

CR Approach with Vouchers Format


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Clients attended one or two individualcounseling sessions each week, focusing on:

Improving family relationships

Learning skills necessary for reducing drug and

alcohol use

Receiving vocational counseling

Developing new recreational activities and social

networks

Other Program Aspects


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Vouchers were usedVouchers could be exchanged for retail goods

consistent with cocaine-free lifestyle

Outcomes


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The CR approach was found to:Facilitate clients engagement in treatment

Facilitate increasing periods of cocaine

abstinence

Community Reinforcement: Effectiveness


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CR has been found to be effective: With a variety of adult and adolescent

populations

With a variety of ethnic backgrounds

In a variety of settings, such as outpatient and

residential programs, methadone maintenance

clinics, and specialized programs for adolescents

CM in General: Effectiveness


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CM has been documented as an effectiveintervention for SUDs involving:

Alcohol

Stimulants

Opioids

Marijuana

Nicotine

Source: National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-

based guide,2nd Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.

Small-Group Exercise: CM


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Small-group topic assignments:Group 1: Overview of characteristics


Group 3: StrengthsGroup 4: Challenges

Small-Group Exercise: ContingencyManagement


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On whitepaper for posting on CM wall graphic





Pharmacotherapy for Opioid

Dependence


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p

Pharmacotherapy is defined as the use ofmedically prescribed psychoactive substances

to treat psychiatric and behavioral conditions

Also called medication-assisted treatment(MAT)
http://1.bp.blogspot.com/_9DRouAPA7j0/S70goKUVO_I/AAAAAAAAAw0/j2IesEmYaik/s1600/methadone_powder_100g_bot_s.gif


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Pharmacotherapy Background


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Medications are available for alcohol, opioids,and nicotine

Opioid medication must be prescribed by a

medical practitioner

WHO calls for combining pharmacotherapy

with counseling (CBT and CM) and case

management

MAT for Opioid Use Disorders


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Uses one of the following three medications:Naltrexone

Buprenorphine

Methadone

Naltrexone


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Blocks all the effects of opioids, preventing aperson from getting high

To prevent immediate and severe opioid

withdrawal symptoms, a person must be

medically detoxified and opioid free for several

days before beginning naltrexone

Naltrexone


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Compliance is often a problem, so it is seldomused

A new, injectable form is available in the

United States

Buprenorphine (Subutex)


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Reduces or eliminates withdrawal symptomswithout producing euphoria and sedation

caused by heroin or other opioids

At high doses, can produce euphoria, so it is

often combined with another medication that

blocks these effects

Methadone Overview


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Widely usedMaintenance treatment in specialized settings

Stabilized clients may receive take-home doses

Methadone Function


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Methadone:Prevents opioid withdrawal

Blocks euphoric effects of illicit opioid use

Decreases opioid craving

Stabilized clients can:

Work

Take care of families

Avoid crime and violence

Reduce exposure to HIV

Small-Group Exercise: Pharmacotherapy


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Group 1: Primary techniques/applicationsGroup 2: Challenges


Group 4: Strengths

Small-Group Exercise: Pharmacotherapy


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Lunch60 minutes

Small-Groups: EBPs


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Form new small groups of four or five peoplewho work in the same area

Reseat yourself in those groups

Select a facilitator to be sure everyone has anopportunity to participate

Select a reporter

Small-Group Discussion: EBP

Questions


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Which EBPs are you using in your organizationand area?

Which EBPs would be most difficultto implement,

based on your organizational, regional, and

cultural perspectives? What are some of the

challenges?

Large-Group Discussion: EBPs


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What common threads did you hear in thesummaries?

What type of SUD counseling is used in your

region?

What models and practices might be most

promising to explore, given the populations

you serve?

Documents

C2 Mod 7 Evidence-Based Practices