Zufall Center Worshop Harm Reduction and Other Evidence-Based - PDF document

Zufall Center Worshop Harm Reduction and Other Evidence-Based November 12, 2019 Treatments for Addiction Download Slides, Handouts, Forms Harm Reduction and Other Evidence-Based Written for office-based practitioners Treatments for Substance Use Disorders TheWashtonGroup.com/resources Arnold M. Washton, Ph.D. Arnold M. Washton, Ph.D. Joan E. Zweben, Ph.D. New York: Guilford Publications www.guilford.com www.thewashtongroup.com www.thewashtongroup.com Today’s Topics Harm Reduction- A Paradigm Shift n Harm reduction is creating a major paradigm shift in 1. Harm reduction paradigm how SUDS are conceptualized and treated 2. Pharmacology of opioids and other n Alternative to disease model of SUDs and “one size psychoactive substances fits all” abstinence-only treatment approaches 3. Evidence-based pharmacotherapies n Recognizes a continuum of substance use problems 4. Alcohol moderation and other evidence- and a continuum of substance-related consequences based behavioral interventions n Emphasis on therapeutic relationship and meeting 5. Abstinence and relapse prevention strategies patients “where they are” What is Harm Reduction? What is Harm Reduction Therapy? What is Harm Reduction Therapy? n A philosophy, clinical stance, and style of n A set of therapeutic principles and practices u Abstinence is always the safest course! working with substance users aimed at reducing adverse consequences u But better to engage clients in a process of incremental (harms) associated with substance use and other change than turn them away until they “ hit bottom ” or n Not a set of protocols and procedures cause more harm to self and others risky behaviors and promoting positive change n Umbrella for integrating many different types of u Those who encounter difficulty with moderation often without requiring abstinence as a starting point therapeutic interventions become more self-motivated to abstain and/or endpoint of treatment Arnold M. Washton, Ph.D. thewashtongroup.com 1

Zufall Center Worshop Harm Reduction and Other Evidence-Based November 12, 2019 Treatments for Addiction What is Harm Reduction? What is Harm Reduction Therapy? What is Harm Reduction Therapy? n It provides a framework for helping problematic n Incremental change in the direction of reduced Views any steps taken to reduce the risks and harmfulness of substance use is accepted and alcohol/drug users who cannot or will not stop consequences of substance use and other risky supported whether or not abstinence is the goal completely (the majority of them) reduce the behaviors as worthwhile steps in the right n Recognizes that a trusting empowering therapeutic harmful consequences of their substance use alliance may need time to develop and that issues direction , whether or not abstinence is the other than substance use may need to be addressed n Acknowledges that abstinence is the safest and ultimate goal before harm reduction goals are fully achieved often the best outcome, but does not define it n Harm reduction therapy begins and continues while as the only acceptable goal or criterion of clients are still engaging in risky/addictive behaviors success What is Harm Reduction Therapy? What is Harm Reduction Therapy? What is Harm Reduction Therapy? n Recognizes that there is a continuum of substance n Respects that treatment goals are client-driven, not n Based primarily on principles and practices of use, substance-related consequences, and substance pre-determined or imposed, that change is client-centered psychotherapy incremental not all or nothing, and that any and all use goals. attempts to reduce harm are worthwhile n Therapeutic relationship is key n Unlike traditional “all or nothing” approaches, HR n Attractive to a diverse client population as it recognizes a spectrum of substance use issues n “Compassionate pragmatism” (Marlatt) advocates an individualized approach that respects ranging from problematic use to severe dependence; individual differences including cultural n Accepts clients “where they are” in terms of and, substance use goals ranging from less risky/less considerations and the rights of clients to choose goals and readiness for change, etc. harmful use to complete abstinence. their own goals and path to achieve those goals What is Harm Reduction Therapy? What is Harm Reduction Therapy? What is Harm Reduction? n Contrasts sharply with traditional disease model of n Empathetic, empowering, non-judgmental, non- n Harm reduction does not try to transform alcoholics or addiction coercive collaborative relationship others with severe addiction problems into controlled n Not everyone with a significant substance use users n Supports clients in discovering the truth about their problem is an addict/alcoholic attachment to alcohol/drugs, its functional n It provides an attractive, lower-threshold starting point for n Abstinence is not the only acceptable goal and significance, how it impacts their life, and what treatment that can help substance users accept the need indicator of success goals/approaches might work best for them for abstinence n One size does not fit all n Treatment goals are client-driven, not dictated or n Accepting clients “where they are” is empowering n Treatment is more likely to succeed when patients imposed by the clinician not enabling choose and are personally invested in the treatment goals and the methods used to achieve those goals Arnold M. Washton, Ph.D. thewashtongroup.com 2

Zufall Center Worshop Harm Reduction and Other Evidence-Based November 12, 2019 Treatments for Addiction What is Harm Reduction? Why Harm Reduction? Harm Reduction expands treatment options n Opens the door to office-based treatment for SUDs as n Harm reduction has been applied to treating n Many users do no want to stop alternative to traditional treatment programs problems with all types of substances n Abstinence is seen as undesirable, unthinkable, and/or anxiety- n Attracts patients with earlier stage and less severe problems provoking n Today’s presentation will focus on harm n Fosters better integration, retention and outcomes in n Alcohol and/or other drug use has become an integral part of reduction as a general framework for treatment therapy for co-occurring behavioral health problems their lives and they can’t imagine life without it and more specifically for alcohol and opioid use n Provides greater opportunities to collaborate with n Diverse population requires individualized treatments to meet physicians providing evidence-based pharmacological n Moderate drinking strategies treatments for SUDs (e.g., Suboxone, Naltrexone, diverse needs Antabuse) n Provides valuable opportunity for early intervention n Opioid substitution therapy (Buprenorphine) Prefatory Statement Prefatory Statement Moderate Drinking Controversy n Dangerous enabling? n None of the strategies discussed today profess to transform u Abstinence is always the safest course! n Holds out false hopes, controlled drinking has been alcoholics into moderate drinkers u But better to engage clients in a process of incremental proven to be dangerous and ineffective n Nonetheless, only the clients themselves can choose their change than turn them away until they “ hit bottom ” or n Gives permission to engage in very risky, potentially drinking goals, no matter what we think is best for them cause more harm to self and others fatal behaviors n There is much to be said for an INCREMENTAL approach that u Those who encounter great difficulty with moderation n Denies that addiction is an incurable disease often become more self-motivated to stop drinking at “starts where the patient is” and then coaxes them stepwise characterized by progression and permanent loss of least temporarily control away from harmful drinking toward less risky drinking, moderate drinking, or no drinking at all Prefatory Statement Case Vignettes Case Vignettes n Roberto (22 yo graduate student). “I’m not sure what to do. I know n A professionally-guided attempt at moderation is often the n Walter (68 yo retired attorney). “Before retiring several years that sometimes I drink way too much, although most of the time best way for clients to learn through their own experience ago, I never drank the way I do now that I have so much I’m able to limit my drinking and it’s not a problem. I don’t want to whether moderation is a realistic goal or if abstinence is a leisure time. Work was my whole life and I never developed stop drinking completely. I’d like to just cut out the heavy drinking better choice and stop the problems it’s causing with my girlfriend.” other interests. Now, I sit home alone and pass the time by sipping wine until my wife gets home from work. When my n Moderation (Harm Reduction) is one of the most effective n Jessica (31 yo accountant, newlywed). “Now that I’m married, I doctor told me that my liver enzymes are elevated, he guess I need to get a handle on my drinking. I get pretty buzzed engagement strategies for all types of alcohol problems when I go out with my co-workers a couple of times a week. We all suggested that I come see you. My wife agrees. How long will n Often a stepping-stone toward abstinence have a great time. My husband says that he doesn’t want to start a it take for my liver enzymes to return to normal, if I cut back family until I get my drinking under control. I’m not quite ready to on my drinking without stopping completely.?” give up the good times and live a sober life.” Arnold M. Washton, Ph.D. thewashtongroup.com 3