Let me thank you for taking time out of your busy life to explore psychosocial treatments in substance use. This presentation is presented by the American Osteopathic Academy of Addiction Medicine as part of our Essentials of Addiction Medicine in our Learning Management System. My name is Dr. Gregory Landy, and again, thank you. And let's get started. At this point, the narrator has no disclosures to make, but would like to note that this slide set was created by Dr. Anthony Decker and is being narrated once again by Dr. Gregory Landy. And so with those two things in mind, let's move on to the content of this presentation. Let's begin our discussion of the psychosocial treatment of substance use disorders in the next few slides by reviewing some of the principles of effective treatment that we're all familiar with. It goes without saying that when contemplating the individualized treatment plans for an individual with a substance use disorder, no single treatment is effective for everyone. As a consequence, treatment needs to be readily available, and we need to have a wide range of options so that we can tailor treatments for our individuals. Extending that comment, effective treatment attends to the multiple needs of the individual, which of course is predicated on the comprehensive biopsychosocial assessment that was conducted as a part of the treatment planning. Treatment plans must be assessed and modified on an ongoing basis to meet the changing needs of our patients as their environmental circumstances may also be changing as they go through treatment. And one of the most important components of any effective treatment for substance use disorders rests on the critical notion that remaining in treatment for an adequate period of time is critical for sustained treatment effectiveness. A comprehensive biopsychosocial treatment plan integrates both the medical, social, and psychological treatment considerations when you're building your individualized treatment plan for your patients. Coexisting and other behavioral therapies are, of course, critical components when you're designing a treatment plan. At the same time, medication-assisted therapy, of course, is also an important component to consider. Coexisting disorders should be treated in an integrated way that includes both medical and psychiatric disorders. And it should be noted that medical detoxification is only the first stage of what becomes a comprehensive treatment plan. And it may be counterintuitive, but treatment does not need to be voluntary to be effective. When it comes to principles of effective treatment, the old phrase, trust but verify, comes to mind. It must be kept in the central focus of your treatment that possible substance use during treatment may occur and must be monitored continuously. This includes both talking with your patient and discussing these issues, but should also include the use of routine laboratory testing. Once again, trust but verify. The principles of effective treatment should also assess for such conditions as HIV-AIDS, the presence of hepatitis, tuberculosis, STIs, and other infectious diseases, and in the process, help your patients modify at-risk behaviors. And it goes without saying, although saying it to your patient clearly is indicated, but recovery can be a long-term process. And it frequently requires multiple episodes of treatment as the individual's recovery waxes and wanes on their path to sobriety, if that is the ultimate goal. Clinicians considering psychosocial interventions as part of a comprehensive treatment plan should keep in mind that there are evidence-based practices that involve these activities for alcohol treatment, and several are listed on this slide. Brief intervention is an evidence-based practice and is covered in more detail in another presentation from the American Osteopathic Academy of Addiction Medicine, and I invite you to explore that topic also. But basically, what brief intervention envisions is that the clinician, relying on sound diagnostic principles, can convey to a patient the significance of their alcohol misuse. And with a discussion of the risks, that brief intervention, which can be as little as five minutes, can have a significant impact in motivating the individual to reconsider their use of alcohol. Social skills training is another evidence-based practice. And like the brief intervention topic, the American Osteopathic Academy of Addiction Medicine has a presentation on motivational enhancement, otherwise known as motivational interviewing, which is also an evidence-based practice that can be incorporated for your patients as part of their recovery from alcohol use disorders. Motivational interviewing is a type of psychotherapy, and it's premised on a number of factors, such as building a solid rapport with the individual, while at the same time, challenging the individual to consider and reconsider their use of alcohol in terms of how it's affected their life, both from any advantages they have seen and also disadvantages. Community reinforcement and behavioral contracting are two other evidence-based practices for alcohol use disorder treatment. This slide covers other scientifically-based approaches to addiction treatment. Cognitive behavioral interventions, which usually require a good deal of training, but can be very effective in helping individuals cope with their substance use disorders. Community reinforcement is another option. As I just mentioned, motivational enhancement therapy or motivational interviewing is an evidence-based practice that can be used in a number of substance use disorders, and is covered in more detail in another of the American Osteopathic Academy of Addiction Medicine's presentations. Twelve-step facilitation or twelve-step programming is another psychosocial intervention. Perhaps the most famous in this regard would be Alcoholics Anonymous and Narcotics Anonymous. Twelve-step programs rely on fellowship, where individuals meet in a group setting that's nonjudgmental and reinforcing. And as they work the program or the twelve steps, they increasingly gain confidence in learning how to manage their addictive disorder. Contingency management is another scientifically-based approach. And of course, one of the major foundations of modern treatment of substance use disorders involves the pharmacologic therapies. And there are a number of these beyond the scope of this presentation. But certainly, pharmacologic strategies form a core part of any biopsychosocial management of a substance use disorder and should be considered. And finally, we have systems treatment. So, let's take a short pause at this point and take a look at what we've learned so far. Psychosocial treatments for substance use disorders offer you, as a clinician, the opportunity to improve the treatment that you provide your patients. As we've noted so far, these are effective and they are cost-efficient treatments that are available. Certainly, when it comes to treatments such as motivational interviewing or brief interventions, these are easily learned principles that can be adopted into your clinical practice. They take little time. They're effective. And your patients can greatly benefit from these psychosocial treatments. So, let's now turn our attention to ASAM's patient placement criteria, which offer clinicians standardized guidance in managing their patients with substance use disorders. The patient placement criteria are used for initial evaluation, clinical placement, continued stay, transfer, and discharge planning, and are very helpful in understanding best practices in treating our patients. The ASAM patient placement criteria make their suggestions on managing individuals with substance use disorders based on specific life dimensions. Patient placement criteria take into account your patient's level of intoxication and withdrawal potential. The patient placement criteria also look at biomedical criteria, emotional, behavioral, and cognitive factors. And not to be forgotten, the patient placement criteria take into account your patient's readiness for change. Where are they at in the stages of change? In other words, what is their motivation to change? The patient placement criteria also take into account relapse, continued use, and continued problems, and certainly take cognizance of your patient's recovery environment and the degree to which that facilitates or harms the potential for recovery. Based on your assessment and the aforementioned criteria, the ASAM patient placement criteria envision five levels of care that your patient would most likely benefit from. Point five involves prevention and early intervention, and of course would be the lowest level of care. Next would be the provision of outpatient services, followed by the next step of intensive outpatient services. For patients that need much more care, we have residential treatment. And finally, the highest level of care that ASAM's patient placement criteria envision would include inpatient hospitalization. The ASAM criteria provide treatment criteria for substance-related, addictive, and co-occurring conditions. The manual is user-friendly, and most importantly, is fully compliant with DSM-5. Like DSM-5, the ASAM criteria also deal with tobacco use disorder, gambling disorder, and also include treatment criteria for specific populations, such as those in the criminal justice system, older adults, and even looks at prospective parents. There are certain key elements of the ASAM criteria which we can briefly review. The first is the notion of multidimensional assessments. The ASAM criteria clearly recognize the importance of a comprehensive biopsychosocial assessment of your patients. The ASAM criteria are outcomes-driven, focused on treatment outcomes. There's also consideration of variable lengths of service. The ASAM criteria are broad and flexible in their consideration of the continuum of care. And again, in a specific subgroup, the ASAM criteria look at the specific needs of adolescents. And once again, the criteria clarify the goals of medication management. The ASAM criteria have certain advances that are recognized as best practices in the management of substance use disorders. And perhaps first and foremost is stop using treatment failure as a prerequisite for admission. The ASAM criteria enshrine the interdisciplinary team approach to the management of the complexities of substance use disorders, and in doing so, clarifies the role of the physician. Once again, the ASAM criteria focus on treatment outcomes, measurement-based care. Informed consent is an important concept since all voluntary treatment revolves around this. The ASAM criteria clarify medical necessity and the definition of addiction. Individuals have varying degrees of motivation to change any behavior. And that's certainly true of individuals who are at risk of a substance use disorder or already have a substance use disorder. The stages of change help us understand where a particular individual is in terms of their motivational aspirations. And it's an important area that clinicians should consider when developing their initial treatment planning. And so the stages of change are listed on this slide. For most individuals contemplating any change, and certainly those contemplating addressing a substance use disorder, most are going to be at the pre-contemplation level. Contemplation is that stage of change where the individual does not see a problem and really has no interest in making any changes. The next phase, contemplation, is when the very first inklings of a problem with their substance use are beginning to seep into their consciousness, but it's not until the preparation phase that an individual begins looking around and seeking opportunities to address their substance use disorder, and it's here that the clinician can, in earnest, begin partnering with an individual in discussing the various treatment options. Of course, the action phase is the brass ring. It's here that the individual firmly takes hold of their treatment options and is engaged in the pursuit of the best treatment outcome. As the name suggests, the maintenance phase is a sort of plateau. It's here where the individual has adopted certain activities and behaviors, and these have been beneficial, and the individual is maintaining these, but relapse can occur. In terms of stages of change and the clinician's response to it, it's important to recognize that relapse is seen as one of the stages of change. Almost expected, not inevitable, but when it does occur, it's an opportunity to discuss with the patient what it means and help the individual get back on the path of action as they return to a beneficial treatment plan. As I mentioned previously, the American Osteopathic Academy of Addiction Medicine has a more comprehensive presentation on motivational interviewing, and to avoid redundancy, and hopefully to encourage you to take advantage of that particular presentation, I'm just going to cover the highlights and some of the terms involved with motivational interviewing. Again, let me point out that motivational interviewing, although its name may not suggest it, is actually a specific type of psychotherapy that involves managing extrinsic and intrinsic motivations in your patient. It encourages enlightened self-interest. It helps develop discrepancy, helping the individual look at the advantages and disadvantages of their substance use. Dealing with resistance is part of the management of the relationship with the patient. Of course, individuals will be resistant at various points in their treatment, but motivational interviewing encourages an empathic relationship with your patient, gently interpreting their behavior to them. Decisional balance, once again, is looking at the pros and cons of substance use. And finally, developing a change plan worksheet, which sets down in fairly concrete terms how the individual proposes to achieve the goals that they've set for themselves. Here we have a brief definition of the matrix model. The basic elements of a matrix model are group sessions, individual sessions, along with encouragement to participate in 12-step programming, all of which is delivered over a 16-week intensive treatment period. So as you can see, the matrix model integrates treatment elements from a number of different strategies, including relapse prevention, the previously discussed motivational interviewing, the use of psychoeducation, encouragement of family participation, and again, 12-step programming. The matrix model, through this comprehensive and integrative approach, combines a number of evidence-based treatments, including motivational interviewing, cognitive behavioral therapy and classic conditioning, drug and alcohol education, basic brain chemistry, and once again, helping educate our patients about the stages of recovery and what they can expect. Dialectical behavior therapy can be a useful intervention for some patients with substance use disorders, but it does require specific skill training. Otherwise known as DBT, your patients will learn and practice skills in the areas of mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness. And some of the ways that they can achieve this are through the use of diary cards, chain analysis. So the ultimate goal of DBT is to help the individual build a life worth living. Once again, 12-step facilitation is discussed in greater detail in another presentation from the American Osteopathic Academy of Addiction Medicine. So this particular slide is either an overview or a review, depending on where you're at in your training. So 12-step facilitation encourages acceptance of the addiction, commitment to a life of abstinence, and the willingness to participate actively. And that's a key word in 12-step facilitation, is actively or action. And 12-step fellowships as a means of establishing their individual path to recovery. 12-step facilitation evaluates the substance use problems and advocates abstinence. 12-step facilitation is an area where you can explain to your patient what are the basic 12 steps and its concepts. And through your understanding and possible participation in open meetings, you can encourage your patient to engage in 12-step meetings with a confidence and understanding that will convey your acceptance of such as a treatment paradigm. As part of your interactions with your patients, you want to facilitate their ongoing participation in 12-step meetings. And so naturally, we want to include this support system as one element in a comprehensive individualized treatment program. You can also utilize a 12-step network when your patient is in crisis. And that is the particular benefit they gain from having a home group and a sponsor. 12-step programming also helps your patient conduct a moral inventory and make amends as they learn more about themselves and the ravages that the substance use disorder has created in their life and those around them. Best outcomes for individuals with a substance use disorder takes into account a multidimensional approach to care. This involves regular conversations within a treatment program and collaborative treatment planning, which would include ancillary providers, psychologists, social workers, the individual's primary care provider, and even perhaps a dentist. And of course, there should be some effort to maintain continuity with community support meetings. The American Osteopathic Academy of Addiction Medicine, through this presentation and the others in the learning management system, recognize that there are challenges in the treatment of substance use disorders that we need to collectively overcome. There's uncertainty about what is the most appropriate care. Few practitioners apply scientific findings about the best care. Little information is available about standard practices. And of course, technology and costs change rapidly. Again, education is the key to unlocking these challenges. And the AOAAM, through these presentations, hopes to help overcome these challenges. There are other challenges in the treatment of individuals with substance use disorders that we need to take into account. Some of the treatment approaches that we've talked about even in this presentation can be difficult to implement. Some require specialized training and supervision, such as I briefly mentioned with dialectical behavior therapy, which although it can be effective for some patients, it does require specialized training. There can be issues with the organization of care. There can be inadequate access to certain medications that physicians would find necessary, as part of medication-assisted therapy. And we should never forget that there are financing hurdles that can compete with your interest and your patient's interest in developing your comprehensive treatment approach. There are some, and this may apply perhaps more so to psychotherapy interventions that are not reimbursed. And there may also be agency values that have to be taken into account when you manage a patient with a substance use disorder. So I've used the term comprehensive assessment and comprehensive treatment many times throughout this presentation. And this slide, it's a busy slide, shows what are the core components of comprehensive services. And you can see there are many to consider. So let's take a few moments and examine it in some detail. The core treatment of your patients, of course, starts with a comprehensive intake assessment and the development of an individualized treatment plan. That treatment plan can consist of group or individual counseling. It can be or not be abstinence-based. It may or may not include pharmacotherapy. And it may include self-help programs, such as Alcoholics Anonymous or Narcotics Anonymous. Your core treatment program may also need to include urine monitoring, the trust but verify component. Case management and the social services are also important. And continuing care. Now aside from the core treatment, there are other factors that hover or orbit around that core treatment. You have medical issues, mental health, co-occurring disorders, the individual's job and how the core treatment impacts that, educational issues, what are the legal ramifications and how does that play into your treatment plan, AIDS, HIV risks, and the impact on the family. Should the family be involved? How has the family been affected? Is the family willing to be involved? And of course, child care can be an important impediment that must be considered in the construction of your treatment plan, as would housing and transportation also be similar impediments to care. And financial, always a consideration. Another term I've used repeatedly throughout this presentation is the biopsychosocial model. So let's take a closer look at that. Risks in substance use treatment can be increased by looking at the combination of the biological, psychological, and social factors leading to alcohol and drug misuse. Because many individuals experience problems stemming from substance use disorders, treatment programs must consider common difficulties associated with alcohol and drug misuse. But even the best crafted biopsychosocial model that leads to an individual treatment plan cannot be successful if the individual with a substance use disorder does not want to get treatment. Change and the desire to seek change is the most important variable in recovery from any addiction. With that in mind, let's take another look at the biopsychosocial system and the individual factors that are included in each. Now obviously this is not a comprehensive list, but it gives you an idea. The biological factors involved in substance use disorders include abnormal neurotransmitter functioning and genetic predisposition. There's a great deal of research looking at individuals' susceptibility to substance use disorders from a genetic standpoint. And as this area of research ripens, the hope is that it will lead to more focused treatments. Social factors, of course, include such things as a dysfunctional family system and community-based expectations. Psychological factors include expectancies towards abusive behavior, sensitivity to environmental cues for drug abuse. Poor self-esteem can be a significant factor. And of course, peer influences can never be subtracted as an important component contributing to substance use disorders. So in summary, psychosocial interventions are effective and cost efficient. Some require little training but yield big benefits in terms of patient impact. Other psychosocial interventions require specialized training. Motivation is perhaps the central component. An individual that's not motivated to seek treatment or to sustain treatment most likely will not achieve a good outcome. And finally, substance use disorders benefit from multidimensional treatment and the assessment and integration of biopsychosocial concepts. So as we come to the end of this presentation, let me again thank you for your time and attention. And my name is Dr. Gregory Landy, and on behalf of the American Osteopathic Academy of Addiction Medicine, I hope you found this overview helpful. And I invite you to look at our other presentations, which provide more detail on some of these subjects.

psychosocial treatments

substance use disorders

individualized treatment plans

medical, social, and psychological treatment

evidence-based practices

multidimensional assessments

biopsychosocial model