understanding the journey into and out of addiction · addiction and stages as individuals move...
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Understanding the Journey into
and out of Addiction
Carlo C. DiClemente, Ph.D.
University of Maryland Baltimore County
Center for Community Collaboration
(http://communitycollaboration.umbc.edu/)
(www.umbc.edu/psyc/habits)
Shake Your Family Tree
Most families can identify family members with a substance use or gambling disorder
On a piece of paper write first names of extended family members who have of have had one (make sure you include alcohol, marijuana, nicotine, etc.)
Most of us know addiction personally
We need to keep in mind that we are talking about loved ones not “Addicts” “Homeless Drug Abusers” “Substance Abusers”
What are Addictions?
Habitual patterns of intentional, appetitive behaviors
Become excessive, problematic and produce serious consequences
Stability of these problematic behavior patterns over time
Interrelated physiological, psychological and social components
Addicted individuals have difficulty modifying and stopping these patterns of behavior (smoking, alcohol, marijuana, heroin or process addictions like gambling, sex, etc.)
Definition of a DMS 5 Severe Use Disorder
Addiction and Change
Both acquisition of and recovery from an
addiction require a personal journey
Through an intentional change process marked
by personal decisions and choices
Each journey is influenced at various points by
many biological, psychological, and social factors
Defining Addiction Severity should describe the
problematic nature of the pattern of
involvement with the addictive behavior
Addiction and Stages
As individuals move through stages of initiation they
◦ move from thinking about doing it,
◦ to experimenting,
◦ to developing a pattern of behavior (social drinker, binge drinker,
daily drinker, non drinker) that becomes habitual or consistent
over time.
Many patterns are normative and socially acceptable, do
not create problems or get judged excessive
Addiction, however, is best represented as a well
maintained, problematic pattern of engagement best
equated with a severe use disorder or dependence
Once an individual has created such a maintained, rather
stable pattern of this nature, interventions move from
prevention of initiation to recovery from addiction
Stage of Change Labels and Tasks
Precontemplation
◦ Not interested
Contemplation
◦ Considering
Preparation
◦ Preparing
Action
◦ Initial change
Maintenance
◦ Sustained
change
Interested, concerned and willing to consider
Risk-reward analysis and decision making
Commitment and creating a plan that is effective/acceptable
Implementing plan and revising as needed
Consolidating change into lifestyle
DiClemente. Addiction and Change: How Addictions Develop and Addicted People Recover. NY: Guilford Press; 2003.
DiClemente. J Addictions Nursing. 2005;16:5.
* THE STAGES OF CHANGE FOR ADDICTION AND RECOVERY
ADDICTION
RECOVERYSustained
Change
Dependence
PROCESSES, CONTEXT AND MARKERS
OF CHANGE
Dependence
PC C PA A M
PC C PA A M
Stages of Change are Pattern Neutral
Many of us have moved through stages of initiation to achieve
a regular pattern of consuming alcohol, smoking, gambling
Critical to be able to distinguish among engagement patterns:
◦ Use, Misuse, Abuse, Dependence, or
◦ DSM 5 - Mild, Moderate, Severe Use Disorders
Trajectories of engagement can
◦ change over time (social use or medical use to misuse to
dependence) and
◦ depend on developmental and contextual factors and influences
(e.g., time limited heavy binge drinking pattern in college; money
spent gambling)
Motivation focuses on how individuals move into and out of
these different patterns of behavior;
Addiction focuses on the end state: a well maintained
pattern of behavior
Patient Safety and Addiction
Obviously the safest way to avoid Addiction and its consequences is to never engage in an addictive behavior
Second best is to interfere with initiation so never becomes moderate or severe use disorder
Third if addicted, get them to stop the behavior
Fourth, keep them safe from harm until we can get them to make a more significant behavior change
Understanding the Challenges
Why do we need options:
Addictions are chronic conditions that
involve multiple risk and protective
factors that we can influence but not
always control
Addicted individuals are often trapped in
a vicious cycle where biology, behavior
and social influences create a pattern that
is hard to break
Mechanisms of Addiction Severity There seem to be a small set of mechanisms that
characterize the end state of addiction that could be used
to indicate severity and help understand the Opioid Crisis
My candidates are the following:
◦ Neurobiological Adaptation – brain and biological
adaptations to frequent exposure to addictive
behavior/substance (a brain disease)
◦ Reduced/Impaired Self-Regulation – The sense of
loss of control and compromised self-regulation despite
consequences that are the hallmark of addictions (a
behavioral control disease)
◦ Salience and Narrowing of Behavioral Repertoire
– The addictive behavior becoming so valued a reinforcer
that the behavior becomes more ubiquitous and potent
in the life of the individual
In a vulnerable brain….
..the brain’s frontal (STOP!)
circuitry is not modulating
downstream (GO!) systems –
the “brain brakes” may be
bad – or the connection
between the brakes and the
other regions may be
“broken”.
Result: poor decision-making…poor
impulse control…greater risk-taking…poor
inhibition…an “over-reacting” brain
Anna Rose Childress UPENN
Neurobiological Adaptation
Ability to use more/tolerance
Emotional/stress regulation tied to use
State dependent learning
Compulsive use
Altered thresholds of stress & pleasure
Increased strength and scope of cues
Negative emotional states when use is blocked
Possible withdrawal & other rebound effects
FMRI indicators
Mild Severe
Insula
VTA
IncentiveSalience
Binge-Intoxication
Withdrawal-Negative affect
Preoccupation-Anticipation
NegativeEmotionality
ExecutiveFunction
Cue Reactivity
Task
Facial Emotion
Matching Task
Delay
Discounting
Stages of the Addiction Cycle: Associations with Neurocircuits & Addictions Neurochemical
Assessment
mPFC(AC)
Hippo
OFC
DS GP
Thal
VSVTA
Adapted from George Koob . Curr Top Behav Neurosci. 2011 Jul 10.
VS
Modified from: Kwako LE et al. (2015)
Reduced Self-Regulation
Use becomes more automatic
Difficulty controlling or cutting back
Using to cope and self-regulate
Continued use despite consequences
Impulsivity increases
Upset if use is interfered with
Underestimating consequences
Both ECF and Affect Regulation effects
Mild Severe
Increased Salience and Narrowing of
Behavioral Repertoire
More highly valued & meaningful; Alcohol/Drug
Expectancies
Integrated into lifestyle (related to life domains)
Meets more basic needs
Difficult to imagine life without it
Feel conflicted when incongruent with other values
Decreases in other important activities
More time using; arranging for use
Social interactions and networks narrowed to similar users
Mild Severe
Opioid Crisis: the Search for Long
Term Solutions
Many overdoses are among individuals with severe use disorders.
◦ Brains compromised by neuroadaptation
◦ Severely impaired self-regulation
◦ Lives completely dominated by addiction
Recovery not simply Resuscitation
Medication and Motivation
Intensity not simply brief Interventions
Short and Long Term Perspectives
Solution not simply Crisis Resolution
Breaking News
In a large study researchers at National Cancer Institute in the US have discovered that watching television more than 1 to 2 hours a week causes brain cancer.
How many of you would stop watching TV immediately?
How Do People Change?
People change voluntarily only when
◦ They become interested and concerned about the
need for change
◦ They become convinced the change is in their best
interest or will benefit them more than cost them
◦ They organize a plan of action that they are
committed to implementing
◦ They take the actions necessary to make the change
and sustain the change
Clear Difference Between Pre Action
and Action Stages
The Key Link
Pre Action
Stages
Action
Stages
What do individuals/organizations have to do in Pre
Action Stages to be successful in Action Stages? What do
they have to do in the Action stages to sustain success?
WHY DON’T PEOPLE CHANGE?
NOT CONVINCED OF THE
PROBLEM OR THE NEED FOR
CHANGE – UNMOTIVATED
NOT COMMITTED TO MAKING A
CHANGE – UNWILLING
DO NOT BELIEVE THAT THEY
CAN MAKE A CHANGE - UNABLE
Theoretical and Practical Considerations
Related to Movement Through the Stages of
Change
Motivation
Precontemplation Contemplation Preparation Action Maintenance
Personal
Concerns
What would help or hinder completion of the tasks of each of the stages
and deplete the self-control strength needed to engage in the processes of
change needed to complete the tasks?
Decision Making Self-efficacy
Relapse
Environmental
Pressure
Decisional
BalanceCognitive
Experiential
Processes
Behavioral
Processes
Recycling
Regression, Relapse and Recycling
through the Stages
Regression represents movement backward
through the stages
Slips are brief returns to the prior behavior that
represent a some problems in the action plan
Relapse is a return or re-engaging to a significant
degree in the previous behavior after some initial
change
After returning to the prior behavior, individuals
most often Recycle back into pre-action stages
Relapse is Not a Substance Abuse
Problem
Relapse is probable with any health
behavior change
Often at same rates as addictive behaviors
A problem of starting and sustaining
behavior change
A problem of adequately completing the
critical tasks of the stages of change
Precontemplation
Increase awareness of need to change
Contemplation
Motivate and increase confidence
in ability to change
Action
Reaffirm commitment
and follow-up
Termination
Stages of Change Model
Relapse
Assist in Coping
Maintenance
Encourage active
problem-solving
Preparation
Negotiate a plan
Cyclical Model
for Intervention Most addicted individuals will recycle through multiple
quit attempts and multiple interventions
To accomplish each stage task well enough to support recovery
However successful recovery occurs for a large number of addicted individuals over time (if they live long enough)
Keys to successful recycling◦ Persistent efforts
◦ Repeated attempts
◦ Helping individuals take the next step
◦ Enhance motivation and support self-efficacy
◦ Support for impaired self-regulation (scaffolding)
◦ Match strategy to stage of change
How does Severity interact with
Motivation
Recovery represents a series of tasks that are
critical to moving through the stages to sustained
change
Motivation is behavior and goal specific so pattern
of use and severity are critical to goal setting
Severity impairs self-regulation and self-control
which are critical to coping needed to manage
addictive behavior and reduce use
Severity interacts with ambivalence, decision making,
commitment, support, planning, and implementation of
action plan as well as relapse and recycling
Motivation Challenges
Intrinsic and Extrinsic Motives
◦ External forces (stop not necessarily change)
◦ Internal values and reasons
◦ Incentives
◦ Imposed versus Intentional (Chosen) Change
Motivated to do What?
◦ Take medications
◦ Enter treatment
◦ Abstinence
◦ Harm Reduction
◦ Continue doing what I am doing
Helping Change Happen
Focus on where person is in stages◦ For what change (cutting down, sharing needles,
getting methadone, quitting opiates)
◦ Readiness ruler ( On a scale of 1 to 10)
Create conversations about change (when sober or least impaired)
Help person with current stage tasks
Focus on important personal values and possibility of change
Offer support to scaffold severity mechanisms (impaired brain, loss of self-control, loss of pleasure and functional lifestyle
Families and Friends
Experience disappointment, burnout, betrayal,
and despair about change when facing addiction
Often offering help, getting frustrated and angry,
threatening, confronting, and supporting
Families cannot be motivated for the individual
suffering from an addiction BUT
Can make a difference
◦ with caring concern, setting limits/boundaries,
promising only what they are willing to do, doing
everything they promise, helping consequences teach,
and support for completing tasks of the stages of
change and making positive steps toward recovery
Some Solution Focused
Suggestions
Use a model that focus on patient needs and
desires, motivation, and self-regulation
Create systems of care not treatment
programs
Build Integrated Care training capacity not
just learning about what other specialists do
Create a system of communication among
professionals that focuses on client and is
used to coordinate interventions and
treatment
Harm Reduction
Getting the change you can while promoting
the change you want.
Myths of Harm Reduction
◦ Promotes Heroin Use (Promotes concern about
HIV; promotes interest and concern for change
◦ Interferes with Recovery and Abstinence (opens a
door to recovery)
We promote harm reduction all the time
(prom promise, uber when drinking, screening
and brief interventions, pill returns)
The Role of Harm Reduction in Combating the Opioid Epidemic
Kip Castner, MPS, ChiefCenter for HIV/STI Integration and Capacity
Infectious Disease Prevention and Health Services BureauPrevention and Health Promotion Administration
CURRENT LANDSCAPE FOR PWID
36PWID = People Who Inject Drugs
Public Health:
PreventionPublic Health:
Treatment
Law Enforcement:
Arrest
Incarceration
MEETING PEOPLE WHERE THEY ARE
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Stages of Change
Pre-Contemplation
Contemplation Preparation Action Maintenance
OVERDOSE
REVERSAL
WITH
NALOXONE
SYRINGE SERVICES
PROGRAMS
OVERDOSE REVERSAL
WITH NALOXONE
TREATMENT
ENTRY: MAT, DETOX, INTENSIVE
OUTPATIENT, OP
MAT, RECOVERY
SUPPORTS, AA, NA, OTHER
GROUPS
P E E R S
REIMAGINED LANDSCAPE FOR PWID
38
Public Health:
PreventionPublic Health:
Treatment
Law Enforcement:
Arrest
Incarceration
Public Health: Harm Reduction
HARM REDUCTION
Harm Reduction is a public health philosophy
operationalized as a set of interventions designed to
reduce the harms associated with drug use, such as:
Infectious Disease education, testing, and linkage to
prevention and care (e.g., HIV PrEP, HCV treatment)
Wound care and education on safe injection
practices
Naloxone, condom use, and syringe distribution
Linkage to substance abuse treatment and other
needed services
39
SCOTT COUNTY, INDIANA
190 people were diagnosed with HIV in Scott
County, Indiana, in 2015 after HIV was introduced
into a network of Injection Drug Users (IDU)
THAT
That sign was acute Hepatitis C, a virus
whose national incidence--driven by
injection drug use--has risen sharply in
recent years
The cluster of cases of HCV pointed to
widespread injection drug use
VULNERABILITY INDEX
CDC followed up to the Scott County,
Indiana outbreak by studying the variables
(e.g., overdose deaths, poverty,
unemployment) that made the county so
vulnerable to an HIV outbreak
CDC analyzed and scored all the counties in
the U.S. on these variables
CDC estimates that 50% of the counties in
West Virginia are at highest risk of an HIV
outbreak
HCV PREVALENCE & VULNERABILITY
Co-infection rate of HCV and HIV in Scott County Indiana, was upwards of 90%
Rising overdose deaths and inadequate surveillance infrastructure suggested a silent epidemic of HCV among Persons Who Inject Drugs (PWID) in Maryland
Better capture of HCV prevalence can be a predictor of HIV outbreak vulnerability
SYRINGE SERVICES PROGRAMS
(SSP) ARE LEGAL
As part of his response to the heroin epidemic, Governor Hogan signed SB97 into law on May 10 ,
2016.
REQUIRED SSP COMPONENTS
Collection and safe disposal of used syringes
Distribution of sterile injection equipment
HIV/HCV education
Naloxone education
Condom distribution
Linkage to needed services, e.g. treatment for substance use disorders
OPTIONAL SSP COMPONENTS
HIV, HCV, STI testing
Wound care
Naloxone training
Reproductive health services
Substance use disorder treatment planning
HIV Pre-Exposure Prophylaxis (PrEP)
SSP SAVE LIVES
SSP SAVE $$
The lifetime cost of treating HIV is
approximately $600,000
The cost of curing Hepatitis C (once)
ranges from $54,600 to $94,500
The cost of a liver transplant ranges
from $100,000 to $575,000
A sterile syringe costs about 10 cents
SSP BRIDGE USERS TO HELP
“When properly structured, syringe exchange
programs provide a unique opportunity for
communities to reach out to the active drug
injecting population and provide for the
referral and retention of individuals in local
substance abuse treatment and counseling
programs and other important health
services.“ -- Surgeon General’s Review of
SSP Effectiveness
In Seattle, SSP users were 5 times more likely
to enter treatment than PWID who didn’t
use the SSP
PROGRESS
Baltimore County approved for
implementation in August, has completed
hiring, slated to launch
Washington County in final draft stage
Anne Arundel, Cecil, Frederick, Howard and
St. Mary’s (Tri-County w/ Charles and
Calvert) County Health Departments are
developing applications; Family Medical and
Counseling Services developing application
in Prince George’s County
First Training Cohort completed
Calvert
Somerset
Caroline
Queen
Anne's
Kent
Anne
Arundel
Harford
WashingtonAllegany
Garrett
Baltimore
Carroll Cecil
Charles Dorchester
Frederick
Howard
Montgomery
Prince
George's
St. Mary's
Talbot
Wicomico
Worcester
Syringe Service Programs Being Developed
Baltimore
City
The Baltimore City Health Department has operated an SSP since 1994. The Baltimore County Health Department’s application to implement SSP was approved this summer. They will go live in 2018. Lighter-shaded jurisdictions are developing their applications to operate SSP. (St. Mary’s for Southern)
MARYLAND / WEST VIRGINIA
BORDER
YOU CAN HELP
53
Share these key messages:
Maryland is at risk for a new outbreak
of HIV due to injection drug use
SSP establish trust between users and
public health, making it easier for
users to seek help when they’re ready
SSP reduce the costs and harms
related to using keeping patients safe
CONTACT INFORMATION
Kip Castner, Chief
Andrew Bell, SSP Coordinator
HIV/STI Center for Integration and Capacity
Infectious Disease Prevention and Health Services Bureau
Maryland Department of Health