Evidence-Based Practice Scholar Program Initiative 2013-2014

Identifying Readiness to Change in Veterans

with Opioid Dependence

L. Mann MSN, RNDepartment of Veterans AffairsVeterans Health Care System of the OzarksHarding UniversityMental Health ClinicFayetteville, AR

Topic of InterestOpioid Dependence and Readiness to Change

Cause for concern:Over 7 million people are addicted or physically dependent to some form of opiate or prescription pain killer in the United States. Depressive, anxiety and drug abuse disorders are associated with increased use of regular opioids in the general population.

Death and Dollars:Retail sales of prescription drugs jumped 250 percent from $72 billion to $250 billion, while the average price of prescriptions has more than doubled from $30 to $68.

Topic integrated with EBP Purpose

VA scholar will implement an initiative through the Evidenced Based Practice program for Veterans that utilize the outpatient Mental Health Clinic in Fayetteville, Arkansas.

PICO Question: In an outpatient VA mental health clinic, is there

sufficient evidence to suggest that augmenting the nursing intake process of Veterans with opiate dependence through the use of a Socratic self-assessment tool can improve treatment alliance, and provide subjective data critical in identifying Veterans’ levels of readiness for change?

PICO Question:Breaking it down:

Population: Veterans in an outpatient clinic with opioid dependence as listed in the problem section of outpatient’s electronic chart

Intervention: Mental health nurses will present to identified Veteran the self assessment SOCRATES Form 8D during intake

Comparison: To those Veterans with opioid dependence who do not have option to complete self-assessment tool during intake

Outcomes: identify specific stage for Veteran, and facilitate recovery for treatment success, increase in treatment completion data, and appropriate resource referrals

Evidenced Based Practice: Defined at VA level

6. VISION All Veterans with PTSD, depression, and other mental and

behavioral health conditions must have access to specific EBPs being nationally disseminated and implemented in VHA when treatments are clinically appropriate.

EBPs must be fully available to Veterans when clinically indicated, and that there must be sufficient staff capacity to provide these therapies, as they were designed and shown to be effective, in a timely fashion.

VHA is beginning to disseminate and implement EBP’s for additional mental and behavioral health conditions, including substance use disorders…These efforts will continue to be an important focus within VHA and EVOLVE OVER TIME. (Section 11, VHA Handbook 2012).

Current Practice No self assessment tool was being used by RN

specific for opioid abuse assessment AUDC screen for ETOH done by RN Depression screen PHQ9 or BDI done by RN

Veterans admitted for substance abuse detoxReferred to substance abuse treatment-

may or may not be ready for change Assessments for substance abuse done by social workers Possible integration of cognitive based therapy or other

individualized therapy can be offered Groups/Classes offeredProcess could be enhanced with SOCRATES and nursing dialogue

and facilitation

Understanding Change

Behavior for change is rarely a discrete single event A patient moves from being uninterested or unaware to…

considering options, and then…. preparing to make a change. Relapses become part of process of working toward lifelong

integration of change Actual Stages of Change model has 5 stages

1. Precomtemplation stage 2. Contemplation stage 3. Preparation stage 4. Action stage 5. Maintenance and Relapse Prevention stage

Methods of Literature Review Multiple online searches of literature were completed Use of EBSCHO, Medline, and PsychINFO Used key words:

Opioid dependence Opiate use Readiness to change SOCRATES assessment Substance abuse Mental health self assessment tools

Some articles eliminated if not directly related to topic i.e. Suboxone therapy PTSD/MST

Overall Evidence SummationA total of 12 different

studies and reviews were utilized

Level I: Experimental studies-1 Level II: Quasi experimental-0 Level III: Non-experimental,

qualitative-2 Level IV: Opinion of experts

based on research-8 Level V: Opinion of experts

based on non-research-1

Details of Evidence Summation Level 1: One experimental study from Journal of Addiction (1992) was

reviewed. One research report by Rollnick, Heather et al. used a questionnaire based on

Prochaska and DiClemente’s stages of change model using 141 alcohol consumers recruited through a disguised screening method and psychometric analysis of a 20 item scale. This questionnaire provides a short, convienient measure of readiness to change which may be used with interventions in excessive drinkers.

Level 2: As of yet, no Level II studies examined. Level 3: There were two studies in this category.

The first report by Sklar & Turner from 1999 took place at an addiction facility in Ontario, Canada. The authors used a measure of coping self-efficacy in substance users and administered a tool at intake to treatment. It was determined the Socrates tool is useful for the assessment and monitoring of confidence levels during treatment and is a promising research tool for outcome evaluation.

The second Level 3 study was completed in England within 54 treatment agencies using a longitudinal prospective cohort design with structured interviews at intake and then 1 year follow up collecting data about illicit drug use.

Details of Evidence Summation Level 4: The majority of studies were assigned level IV A, B or C. A total of 6

unique studies/reviews were examined. Comprehensive review applying the Transtheoretical Model to substance abuse using

a Change Assessment scale and Socrates (Stages of Change Readiness and Treatment Eagerness scale) that offers a promising ambitious approach but leaving unanswered questions

Written by DiClemente himself, Schlundt & Gemmell a review examining current perspectives on readiness, criticisms and clinical applications for future use

Predictors of Initiation & Engagement in VA patients as a systematic review involving 270,877 veterans identified with substance abuse**main effects for gender were not significant and were removed from model: patient who are younger than 30, not married and have substance use disorder identified were more likely to engage

Article review by DiClemente distinguishing change vs. readiness for treatment and impact

A cognitive behavioral intervention and case report of its use with a cocaine dependent patient (component of Level 5)

One Clinical Practice Guideline on Management of Opioid Therapy for Chronic Pain which included addressing misuse and discontinuation of therapy

Level 5: One comparing buprenorphine and methadone by the National Institute on Drug Abuse that lists benefits and research highlights of use

About SOCRATES(The Stages of Change Readiness and Treatment Eagerness Scale)

An experimental instrument designed to assess readiness for change in a simplified three scale score:

1. Recognition (Re) (Range = 7-35)2. Ambivalence (Am) (Range = 4-20)3. Taking Steps (Ts) (Range = 8-40)

Different forms of the SOCRATES have been developedForm 8D is a 19 item drug/alcohol questionnaire for clients and the

one of interest for this EBP projectOthers are 32 item drug/alcohol questionnaires for significant

others and will not be used for this EBP project

Self Assessment Tools University of Rhode Island Change

Assessment This tool differs from SOCRATES in that it asks about “problems”

in a general manner and not as specific as SOCRATES about substance use

Brief Addiction Monitor (BAM) 17 item questionnaire currently used by substance abuse

counselors in mental health for only those patients enrolled in SAC program

A pilot study on BAM found that a 5 minute assessment can monitor progress in multiple areas

However- it is not done by nurses on all patients

Project Planning Literature Review

Created a 10 page outline from which to create an abstract on literature review and EBP

Submission for Approval Abstract, Request for EBP, and CITI training forms were

submitted to Little Rock IRB to proceed Development

Included mentors, substance abuse team and nurses Formed an initiative to educate on Socrates model and use of

self assessment tool in outpatient clinic Goals

To implement this model upon nursing intake in a mental health clinic

To identify the Veteran’s stage and readiness to change

Methods of Implementation

Education Nursing service and mental health staff Biweekly, monthly meetings & updates

Questionnaire/self assessment Use of Socrates tool, a self-assessment for

Veterans with history of opioid abuse/dependence

Done by Veterans at nursing intake

Results o Received approval for project on: September

23, 2013

o Nurses and staff were then educated at Mental Health Staff meetings and nursing meetings

o Nursing service initiated SOCRATES assessments: 10/15/13

o Stop date 3/17/2014

o Total of 33 unique assessments were collected from RN’s in Mental Health

Barrierso Incomplete forms

o Due to Veteran not filling out back of Form 8D

o Incorrect informationo Not having opioid dependence listed in

Diagnoses (i.e. ETOH)

o Family memberso Veteran attempted to fill out and

deferred to wife to answer questions

o Nursing barriers: o RN misplacing the original form, but

could not be evaluated by Initiative Leader

Improving Outcomes Potential for future research project

Evaluation of treatment success and resources used or not used after 3 - 6 months

Feedback from SAC team if referred Feedback from psychotherapist if referred

What could be measured in future Treatment success Best use of resources

Success for this project defined Completion of Form 8D by Veteran and discuss with nurses Documentation in chart Provider acknowledgement and appropriate referrals

Resource options for Veterans Replacement therapy-Suboxone Outpatient follow up Groups/Individual therapy

ReferencesDiclemente, C. (1999.) Motivation for Change: Implications for Substance Abuse Treatment.

Psychological Sciences. Vol. 10 No. 3. 209-213.

DiClemente, C. C., Schlundt, D., & Gemmell, L. (2004). Readiness and stages of change in addiction treatment. The American journal on addictions/American Academy of

Psychiatrists in Alcoholism and Addictions, 13(2), 103.

Gossop, M., Stewart, D. and Marsden, J. (2007), Readiness for change and drug use outcomes after treatment. Addiction, 102: 301–308. doi: 10.1111/j.1360-0443.2006.01681.x

Harris, Alex H. S.; Bowe, Tom. (2008). Predictors of initiation and engagement in VA substance use disorder (SUD) treatment. Psychological Services, Vol 5(3), 228- 238. doi: 10.1037/1541-1559.5.3.228

Jakupcak, M., Hoerster, K., Blais, R., Malte, Hunt, Seal. (2013). Readiness for Change Predicts VA Mental Healthcare Utilization Among Iraq and Afghanistan War Veterans VA

Puget Sound Health Care System, Journal of Traumatic Stress. 26, 165–168.

References pg. 2Migneault, J., Adams, T., & Read, J.(2005). Application of the Transtheoretical Model to substance abuse: historical development and future directions. Drug and Alcohol Review, 24(5), 437-448.

Mitchell & Angelone, 2006 Military Medicine, 171. 9:900, 2006 Assessing the Validity of the Stages of Change Readiness and Treatment Eagerness Scale with Treatment- Seeking Behaviors

Morasco BJ, Duckart JP, Carr TP, Deyo RA, Dobscha SK. Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-

cancer pain. Pain. 2010; 151(3):625-632.

Okie, S. (2010). A Flood of Opioids, a Rising Tide of Deaths. New England Journal of Medicine 363:1981-1985 November 18, 2010 DOI: 10.1056/NEJMp1011512\

Rollnick, S., Heather, N., Gold, R. and Hall, W. (1992), Development of a short ‘readiness to change’ questionnaire for use in brief, opportunistic

interventions among excessive drinkers. British Journal of Addiction, 87: 743–754. doi: 10.1111/j.1360-0443.1992.tb02720.x

References pg.3Seal KH, Shi Y, Cohen G, et al. (2012). Association of Mental Health Disorders with

Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan. JAMA. 307(9):940-947. doi:10.1001/jama.2012.234.

Sklar, S. M. and Turner, N. E. (1999), A brief measure for the assessment of coping self- efficacy among alcohol and other drug users. Addiction, 94: 723–729. doi: 10.1046/j.1360-0443.1999.94572310.x

Veterans Affairs/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. (2010). Guideline Summary. Prepared by The

Management of Opioid Therapy for Chronic Pain Working Group. Version 2.0. 2-73.

Zimmerman GL, Olsen CG, Bosworth MF (2000) A 'stages of change' approach to helping patients change behavior. American Family Physician 61: 1409–1416. [PubMed]