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CHAPTER OUTLINE
Many professionals who prescribe medicines for addictions or other medications, such as psychotropics, as part of addiction treatment are faced with the question of what sort of evidence base exists for the “talking part” of what they do, as well as how best to do this. Independent of the impact of pharmacotherapies, several types of brief psychosocial intervention have been established as effective in treatment of drug use disorders, with meta-analyses demonstrating low-moderate to high-moderate effect sizes depending on the specific substance disorder or treatment type (1,2). For busy physicians who treat addicted patients, this may present somewhat of a quandary, especially if that clinician is in a solo practice, is not trained to deliver psychotherapy, or does not typically provide those services in the course of daily clinical practice. For physicians who work with or in addiction treatment programs, given current cost constraints, effective interdisciplinary teamwork that can coordinate psychosocial treatments with medical care often makes the difference between a first-rate program and an average one.
One of the great strengths of the addiction field has been its evolution of a multidisciplinary approach and teamwork. Today, with the movement in primary care to patient-centered medical homes that encompass multiple clinical disciplines and care coordination, the decades of team approaches to addiction care appear prescient. Though a physician who works in a program with multiple components is an essential part of the health care team, clinicians who offer psychosocial interventions also play a major role. Thus, there are various combinations of individually administered and collaborative psychosocial approaches that physicians may use in addressing the treatment of substance use disorders (SUDs), with or without psychiatric comorbidity.
This chapter is in two sections. The first section provides an overview of the issues and approach for the addiction medicine physician regarding the integration of brief psychosocial interventions with medication treatment for addiction. Then begins a discussion of a basic psychosocial intervention that clinicians can and should be implementing with all patients. The term “brief” in this context most usually refers to the total number of sessions but in this chapter may also refer to the relatively “brief” amount of time that a prescribing clinician has in the context of a 15-to 30-minute medication management session. Such sessions are often of short duration due to limits on insurance or other benefit coverage, or that patients may be getting most of their psychosocial treatment through a structured addiction program or 12-step groups. Section One further explicates the evidence base for the various psychotherapeutic interventions for SUD (many of which are found more fully discussed in this volume) and presents principles for integrating brief but more differentiated behavioral interventions into medication management sessions.
The second section focuses on the clinician who is engaged in coordinating addiction and psychosocial treatment services on behalf of patients with substance use as well as with co-occurring psychiatric disorders. It addresses key elements affecting how physicians in office-based practice, through teamwork and coordination, become adept at integrating services that are not provided at the office site. Finally, good supervision or collaboration is time consuming and requires strong facilitation skills at the leadership level. When treatment providers are in conflict, patients suffer. This section also describes a variety of common situations and dilemmas and offers practical options for handling them.
OVERVIEW OF ISSUES AND APPROACHES
Clinical Skills Any Clinician Should Use
Engagement
Since the outcome of addiction treatment has been related to the time spent in treatment (3,4), techniques that maximize treatment engagement and retention are likely to promote better outcomes. The underlying clinical approaches to treating patients with co-occurring SUD and other mental disorders are also active for those with SUD alone. Clinicians can use these basic techniques, which use clinical skills to achieve a specific outcome, manage intoxication, develop a therapeutic alliance, and facilitate patients’ engagement in or adherence to psychosocial or medical treatment. In order to facilitate the accomplishment of these goals, clinicians can learn specific techniques such as motivational interviewing (MI), cognitive–behavioral relapse prevention, 12-step facilitation, supportive psychotherapy, and contingency management (CM) (5).
One technique likely to sustain engagement and retention in treatment is to facilitate the therapeutic alliance through psychological support. Observational studies suggest that psychological support is among the most prominent and necessary components of management of addicted patients, especially those with more severe dependence (6). As such, clinicians, even very busy ones, should focus special attention, supporting the development of a therapeutic alliance with the patient. Alliance building is one of the core tactical techniques of supportive therapy and uses several straightforward approaches accessible to clinicians who may not have had any formal psychotherapy training: expression of interest, expression of empathy, expression of understanding, and repairing a misalliance (7). For example, interest is expressed by the clinician’s bringing in his or her knowledge of the patient into the conversation. In assessing primary care quality, more whole-person knowledge (medical history, home/work/school responsibilities, health concerns, values, and beliefs) of the patient by the clinician predicts lower drug and alcohol addiction severity scores on the addiction severity index and lower odds of subsequent substance use in recently detoxified primary care patients (8). It is also important that the clinician is aware that asking too many questions of some patients, especially “why?” questions, can be experienced as intrusive or even an attack, which is off-putting to patients and reduces the likelihood of engagement. Information is best garnered by what, when, where, and how questions, but monitoring patient comfort in this process, since if the patient does not return, such “interrogation” information is not doing the patient or clinician much good.
For patients who seek psychotherapy without recognizing that their alcohol or drug use is problematic, motivational enhancement strategies (described below) have proved beneficial (9–12). The therapist identifies where the patient is on the continuum of readiness to change and makes reflective statements matched to his or her current stage in order elicit intrinsic motivation from the patient (13).
Expression of accurate empathy has a long history as an important psychotherapeutic technique and corresponds to the concept “reflective listening” used in MI (14), as well as the “E” for empathy in the BRENDA therapy for the Penn clinical trials of SUD pharmacotherapies (15). Empathy, which is more than simple care or concern, is expressed by the clinician relating his or her own internal emotional experience to corroborate that of the patient; for example, “It must’ve felt terrible to come back after your last binge and find out your drunken behavior was so scary that she’d changed the locks.” The clinician can express his or her understanding by simply stating that he or she “gets” what the patient is communicating and sometimes paraphrasing what the patient has said. This demonstrates his or her alignment with the patient in a cognitive way, which helps the patient to feel “in sync” with the clinician.
Misalliances occur in all human relationships, and addiction treatment is certainly no exception. However, when patients in substance abuse treatment get frustrated or resentful about the treatment, they frequently drop out of treatment, relapse, or both, either of which typically has a negative impact on outcome. Part of the draw of Alcoholics Anonymous (AA) and other mutual help groups is that they can offer a context where an addict can experience not being judged for his or her feelings and actions related to addiction, since there is no cross talk in the groups, and further it is likely that they will hear others tell similar stories to their own. The willingness of the clinician to entertain a patient’s grievances, whether factually based or the result of misconstrual, is a powerful interpersonal reinforcer for patients who may have relatively little experience of a nonjudgmental person willing to listen. Trust (including the experience of the clinician as the patient’s agent) is also a factor associated with a lower risk of substance use in detoxified SUD patients in primary care (8). In dealing with the patient’s negative sentiments or concerns, it is a useful strategy to first start with practical issues related to the current situation, and if the misalliance is not resolved with careful evaluation and response to the actual facts and the patient’s experience of them, the clinician can only then tactfully move to discussion of possible problems in the relationship between the patient and the clinician (7). The clinician can clarify the facts or address incorrect assumptions to help support the patient having more accurate perceptions and assumptions.
Example:
Clinician: “Hi, how have you been doing since last visit?”
Patient: “Well, it seems that the main thing you want is that I keep taking my meds so it will help the pharmacy budget. Do you get kickbacks or something?”
Clinician: “Wow, it sounds like you are frustrated with something. We’ve discussed this before—medications are only a part of what addiction treatment and recovery are all about. First, the simple answer to your question is no, I don’t get any kickbacks. That would actually be illegal. (Patient frowns.) But I get a sense that there’s more to this. Can you tell me what this frustration is all about? Did something happen?
Patient: “Um, uh, I threw my naltrexone away 2 weeks ago because my friend told me that it was bad stuff and addicting, and then I relapsed briefly last week. So, I guess you doctors might be right… Anyway, you guys have it so easy.”
Clinician: “So you listened to your friend, threw the medications away, and relapsed. Is that accurate?”
Patient: “Yeah.”
Clinician: “OK. I wanted to be clear that I understood you. Now, I don’t understand what you mean when you say ‘you guys have it so easy’?”
Patient: “I don’t know, look, I’m just, I don’t know… (annoyed)…I know I screwed up, but I guess I’m waiting for the other shoe to drop, and you kick me out of treatment” (looks away).
Clinician: “So to me, it sounds like you’re upset with your relapse, and angry at yourself that your stopping medications may have been part of that. Perhaps it’s more comfortable for you to be angry at me and at the treatment? Did you maybe think I was going to get mad at you and retaliate in some way?
Patient: (shrugs) “Been there, done that.”
Clinician: “I hear that you have felt mistreated in the past, in past treatment? Is that right?
Patient: “Right.”
Clinician: “But, have I done anything specific in our work together that made you feel this way? I want to address it if I have.”
Patient: “hmmm….well, no, not yet.”
Clinician: “So, going forward I need to be mindful of your concern that I’ll be unhelpful to you, as others may have done.”
Patient: “Huh….well, yes.” (turns and gives clinician full eye contact)
Clinician: “What can I do to help get things back on track? I’ll help in any reasonable way I can …do you want to restart the naltrexone?”
Patient: “You mean I could try it again even though I threw the last bottle away?”
Clinician: “Sure, we can restart it. This stuff can happen as part of recovery. But, can we also take a look at what else happened with your relapse, and how you are dealing with it in your groups and 12-step meetings?”
Clinical attention to patient treatment satisfaction is associated with better attendance at outpatient visits for SUD (16).
Motivational Interviewing
Motivational interviewing is detailed in Chapter 55 of this book but, in short, is a very well-researched and evidence-based technique for interacting with patients in such a way as to enhance better communication, engagement, and motivation to change. Compared to a traditional paternalistic and prescriptive approach to the patient’s maladaptive choices around substance sue, MI encourages internally driven change through a collaborative effort that elicits, through the use of clinical feedback, the patient’s own recovery-oriented thoughts and feelings (intrinsic motivation), thus promoting and supporting the patient’s sense of autonomy. It is strongly suggested that clinicians read the chapter in this ASAM text, and for more detailed information, read the online version of the Center for Substance Abuse Treatment Improvement Protocols TIP 35 (17), which is focused on the MI overview and application, and TIP 42 Chapter 5 (18), which addresses using MI with patients who have co-occurring mental disorders addition to SUD. In addition to the standard supportive stance with the patient, the motivational interviewer further explores the patient’s feelings and comments and more specifically “rolls with the resistance.” This would be in the service of tipping the patient’s “decisional balance” toward higher motivation toward treatment engagement and reducing substance use. The clinician would have continued to explore and clarify exactly what the patient was feeling, what the patient wanted to call that feeling, and why they were having it, by restating the patients concerns, supplying statements of empathy, and asking for clarification:
Clinician: “You sound angry—do I have that right?”
Patient: “No, I don’t get angry, but I am frustrated.”
Clinician: “Tell me about this frustration.”
Patient: “Well, it just seems that nothing I do works, and I relapsed last week.”
Clinician: “Relapse is usually frustrating. I am sorry that happened.”
Patient: “I thought you would be angry at me.”
Clinician: “No, I am not angry with you, but tell me more about your frustration: what happened? How can I help?”
Behavioral Therapies in the Context of Detoxification
It is well described that the rates of relapse to drug dependence after detoxification are quite high (19). Only about 20% to 50% of patients receive post–detoxification treatment for substance dependence, yet engagement in followup treatment increases the time to a second admission for detoxification (20). Systematic review has demonstrated that over and above pharmacologic detoxification for opioid dependence, psychosocial treatments such as CM or drug counseling offered in addition demonstrate beneficial effects in terms of completion of treatment (relative risk [RR] 1.68), use of opiate (RR 0.82), follow-up abstinence (RR 2.43), and compliance with clinic visits (RR 0.48) (21). During outpatient opioid detoxification, relapse to opioid use is not uncommon (21,23), but CM improves treatment retention and reduces symptom complaints (24).
It is important to remind clinicians that detoxification is not a treatment for SUDs per se, but rather is medical stabilization and an opportunity to engage patients in the work of recovery. Thus, it appears sensible to provide some form of effective psychosocial intervention in addition to pharmacotherapy of substance withdrawal, and clearly, this obtains with opioid dependence. Given that the exposure to treatment during inpatient detoxification is relatively brief and that the most important outcome for those in detoxification programs is continued engagement in treatment, IM is probably the modality of therapy that best matches the needs of the patient during the interval of treatment (25). With outpatient detoxification, given the generally longer interval of treatment, MI with boosters to support continued motivation for treatment engagement, plus some form of CM, is a sensible approach to treatment.
Medication Adherence
Medications do not work unless one takes them. It is estimated that the overall adherence to medication regimens for general medical disorders such as hypertension, diabetes, and asthma is between 40% and 60%, with factors such as low socioeconomic status, lack of family and social supports, or significant psychiatric comorbidity associated with the lowest percentages (26). It would be surprising if adherence rates for unsupervised addiction medications were higher, and they are not. In a 12-week randomized, controlled trial (RCT) of naltrexone versus placebo for alcohol dependence in a clinic setting with 98 subjects, the medication showed only modest effects in reducing alcohol drinking, but the subjects who were highly compliant with taking medication had high naltrexone treatment efficacy on a range of measures (27). Similarly, in the VA Cooperative Study, a randomized placebo-controlled trial of disulfiram for alcohol dependence in 605 subjects showed no difference in the intention-to-treat sample in abstinence rates from placebo, or from an inactive dose of disulfiram. Yet, in a subgroup with high adherence to medication, there were clear improvements in abstinence rates (28).
Thus, improved medication adherence could improve the efficacy of pharmacologic interventions for SUD, and it makes sense to propose behavioral interventions that might foster improved medication adherence (29).
Various factors have been identified that adversely affect patients’ adherence to a medication regimen. Some of these factors, both intrinsic to patients and external to them, are co-occurring mental disorders, medication side effects, long waiting times, and inadequate understanding of the proposed treatment (30). For short-term pharmacotherapeutic interventions, counseling, written materials, and personal phone support may be helpful (31). In general, interventions that are effective in increasing long-term medication adherence, albeit modestly, include providing information, counseling, reminders, self-monitoring, reinforcement, family therapy, additional supervision or attention, and higher convenience of care (32).
Reid et al. (33) conducted a randomized controlled trial with forty subjects with alcohol dependence of four to six individual sessions of usual medical care versus a compliance therapy for acamprosate consisting of exploration of the patient’s beliefs and ambivalence about alcohol dependence and the nature of medication and psychosocial treatment; addressing the patient’s concerns, symptoms, and side effects; supporting patient’s evaluation of benefits and consequences of sobriety versus a return to drinking; and support for self-efficacy and continued treatment engagement. Post hoc analyses of the group that attended at least 50% of the compliance groups demonstrated significantly more days on acamprosate and more days to an extended relapse (3 or more days of more than five drinks) than the usual care group. Therefore, psychosocial interventions specifically aimed at supporting medication adherence appear to have clinical impact; however, a common concern in both the acamprosate and the disulfiram studies is that better results may not be caused by better adherence, but rather a common other trait results in both better adherence and better addiction treatment outcome.
Network therapy has as one of its main foci to enlist the aid of the patient’s supportive others to assist in optimizing patient adherence with medications. An 18-week randomized controlled trial of Network Therapy or medication management in opioid-dependent patients receiving daily suboxone (16 mg) demonstrated higher abstinence rates in the Network Therapy group (34).
Sometimes, strategies designed to promote medication adherence do not demonstrate the magnitude of effects due to patient characteristics or due to loss of impact over time. Naltrexone would seem to be a tailor-made medication for opioid-dependent patients; however, adherence rates with oral preparations are very poor. Preston et al. (35) conducted a 3-month randomized clinical trial in detoxified patients with opioid dependence (n = 58) using CM voucher incentives for adherence to naltrexone versus random vouchers independent of adherence versus giving no vouchers. Those getting the contingent vouchers had better treatment retention and a higher number of naltrexone doses taken than either control group. Behavioral naltrexone therapy (BNT) was a therapy specifically developed to improve retention on oral naltrexone by adding elements of CM as above, MI and CBT, and a significant other for monitoring medication adherence similar to Network Therapy (36). However, in a 6-month, randomized, controlled trial (RCT) in heroin-dependent patients, BNT (n = 36) improved retention in treatment compared to standard medical management (MM), but overall treatment dropout was very high (>75%), and there was no between-group difference in the subjects who were very adherent (i.e., >70% of doses) with the medications (37).
Medical Management
MM is a manualized intervention that is a composite of several different psychosocial interventions focusing upon medication compliance and psychosocial treatment engagement and adherence, all of which were integrated for use in the Project COMBINE study (38). The MM intervention is semistructured and brief in both duration (about nine sessions), and for each session (about 20 minutes after the initial 40 minute session) suitable for delivery in a primary care environment by a medical professional and, with some adaptation, could focus upon medications other than that used in COMBINE and on SUD other than alcohol dependence (39). The manual is available for hard copy order or online (http://pubs.niaaa.nih.gov/publications/combine/) and is highly recommended as probably the most clinically useful, evidence-based practice manual available to the addiction clinician who combines medications and psychosocial interventions in typical office visits. The initial intervention has several components, each of which has evidence supporting its use—using targeted feedback of medical information and individualized advice, the intervention motivates the patient toward medication adherence and reduction in harmful substance use, educates the patient about the need for medication, and offers referral to support groups, such as AA. Brief interventions have a substantial evidence base, and brief motivational interviewing–type interventions have been demonstrated as more effective than traditional advice giving in the treatment of alcohol and other drug dependence, with small to moderate effect sizes (40–42). Giving the patient self-help materials and supporting involvement in mutual self-help groups, each has support in the research literature (43–45). In Project COMBINE, the most expensive multisite trial that NIAAA has performed to date, which evaluated the effect of both psychosocial therapy and medications (acamprosate and naltrexone), this relatively brief but well-rounded biopsychosocial therapy alone accounted for the bulk of positive treatment outcome whether the patients took active or placebo medications. Thus, MM is a model that the busy clinician can use, whether using medications as part of treatment or not. Further, as mentioned above, though not yet tested, it is likely that the MM strategy and structure of sessions would also allow apply for better adherence to both psychosocial and psychiatric medication interventions, and thus outcomes, for those with addiction and co-occurring psychiatric disorders.
The intrinsic themes of MM are educating the patient about the disorder and its specific personal impact; advising the patient about the nature of the treatment, the specific rationale for the medication, and the importance of medication adherence; and recovery support in the form of discussion and advice for implementing medication adherence and alcohol or drug abstinence strategies (46). The initial MM visit takes place after comprehensive clinical evaluation and lasts 40 to 60 minutes. In many cases in clinical practice, this may be shortly after the initial evaluation, but it is optimal to have an interval within which the clinician can compile the relevant medical information necessary for the initial feedback to the patient. In the case of alcohol problems, these data will typically include blood pressure, liver enzymes, other significant lab findings (e.g., urine or blood), findings on physical exam, recent alcohol intake (days, amount/day), self-reported alcohol problems, and description of specific alcohol dependence or abuse symptoms (47). The MM manual offers a Clinician Report (form A-1) that offers a concise format in which to record the salient data. The clinician reviews the results of the evaluation with the patient, first focusing on the medical data and then moving to a review of the symptoms of alcohol dependence that the patient endorsed. Any medical concerns of the patient are addressed. The intent is to link the patient’s use of alcohol in this case, to each biopsychosocial consequence that has been identified. Having done so and answering his or her questions, the patient is then given information about alcohol dependence in a clear, nonthreatening, and supportive manner and advised to stop drinking.
Framing the problem as a routine medical one and offering a friendly “can-do” attitude about treatment and recovery supports the patient in not feeling impugned by the clinician, since patients with SUD are frequently full of shame or hopelessness about their drinking. Communicating a judgmental attitude is likely to engender more resistance to treatment engagement. The clinician advises the patient about the rationale and use of pharmacotherapy as an important medical strategy in assisting recovery. The patient is then instructed about how to take the medicine, and potential side effects are discussed in advance so as to minimize their contribution to nonadherence (46). The clinician also discusses the rationale of checking the patient’s adherence with medication at each subsequent session. The patient’s past patterns of medication adherence are evaluated and discussed, so that the patient and clinician together can elaborate a specific plan to assist the patient in remaining adherent with the regimen. The MM manual appendix has a Medication Compliance Plan (form A-13) that can assist the clinician in formalizing the plan with a patient. Finally, the patient is given education and encouragement for attendance at support groups such as AA and is given brochures and other written materials that have source information on medications, alcohol dependence, and recovery groups. Time is given to the patient to raise questions about the diagnosis or treatment plan (47).
In each of the subsequent visits, which typically range from 15 to 25 minutes, the clinician checks the patient in terms of medical status, appropriate laboratory data, vital signs, and weight and evaluates the blood alcohol concentration. Then, the drinking status is asked about, focusing upon how the patient coped: with difficulty or ease, the strength of the desire to drink, or, in the case of continued drinking, what was the context of use. If the patient is abstinent, other problems, such as an increase in other drug use, are evaluated.
Since patients often stop medications when they feel better, it is important that the patient is instructed that even if he or she is doing well in treatment and is abstinent, that is not the time to stop the medication. The patient should be given positive feedback for medication adherence, and the positive health and lifestyle impact of abstinence are reiterated.
If the desire to drink has reduced but the patient is still drinking, that reduction is reinforced as a first step toward change. A nonjudgmental attitude is key in supporting that change may occur slowly, that there may be ups and downs along the way, and that continuing attempts are associated with success. Any positive step, however small, in reduction in use or craving is given positive feedback, and consistent with supportive therapy, the clinician looks for opportunities to provide appropriate, data-based praise (7). If it is earlier in treatment and the patient is continuing to drink but adherent to the medication, it is important that the patient is told that the medication has not yet had sufficient time to work completely. In addition, the patient is encouraged to attend mutual-support groups. In determining the patient’s context of use, the patient can be advised to avoid “people, places, and things” associated with use or to substitute a different healthy pleasure at the time when use usually occurs.
Clinician: “So, how have you been doing over the past week?”
Patient: “I’m taking the naltrexone, but it makes me a little jittery and queasy after I take it.”
Clinician: “We discussed that it might do that. Is it severe enough to make you want to stop?”
Patient: “No, It’s not too bad. I just distract myself, and it gets better as the day goes on. I’m using the plan we talked about!”
Clinician: “Well, it’s really good that you are able to continue on it, and usually, those side effects tend to go away over time. Any effects on your desire to drink?”
Patient: “I think so, maybe a little. I hadn’t really thought about it. I still get pretty strong urges at times, but I think maybe they’re less frequent.”
Clinician: “Changes in your desire to drink may be an early sign of a change for you. How well were you able to keep from drinking?”
Patient: “I’m still drinking, but I think it’s less twice this week—Wednesday and yesterday, I started and basically had had enough after two drinks. That’s not regular for me. Actually, I didn’t even finish the second one yesterday. Funny, I don’t know why, I just lost interest!”
Clinician: “Well, you’ve only been on the medication for a week, and we know it takes time to fully kick in. What’s happening with going to AA?”
Patient: “I went to a meeting on the day after I saw you, then I started drinking again and sort of figured “what the hey?”
Clinician: “You know that “what the hey” attitude frequently comes with the experience of relapse almost automatically. One of the benefits of going to meetings is that it offers social support for abstinence. Listening to all those stories and folks succeeding in their recovery can really help motivate and support you in your own recovery.”
Patient: “I know, I think I need to plan it out in advance, so I know where I’m supposed to go. That way, it’ll be easier to get to the meetings.”
Clinician: “That’s an excellent way to anticipate problems in getting support for yourself by planning properly. Can we review? In spite of it giving you some uncomfortable feelings, you are sticking with the medications and coping with unpleasant effects according to your plan, which demonstrates your commitment. And though you briefly relapsed, your alcohol intake has diminished somewhat… All in all, I’d say that was progress. You are making better plans to get to AA meetings—in fact, let’s talk about what specific meeting you are going to go to next, where it is, and what you will say when you get there.”
The patient who is abstinent but not taking medications as prescribed is given positive feedback for not drinking, and the general benefits of abstinence are reinforced. The reasons for the nonadherence (e.g., side effects, forgetting, misinformation) are explored with the patient, and the clinician presents the patient with the information that over time the risks of relapse are reduced on the medication. The compliance plan is amended with strategies addressing the reasons for nonadherence.
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