Transcription for
TREATMENT OF SUBSTANCE USE DISORDERS IN THE REAL WORLD
DR. JESSICA PEIRCE
Continuing Education Programs APA
MARCH 2017
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March 29, 2017
DR. JESSICA PEIRCE
TREATMENT OF SUBSTANCE USE DISORDERS IN THE REAL WORLD
2:17
DR. NEIMEYER: Why don't we go ahead and get started?
I'm Dr. Greg Neimeyer, the Director of the Office of CE in Psychology at the American Psychological Association and the Center for Learning and Career Development. So on behalf of the Center, on behalf of the Office of CE in Psychology, on behalf of APA, I'd like to welcome you to today's webcast.
This is the fifth in a series of five webcasts that are dedicated to the topic of substance use disorders. And I want to be sure to mention to you that within about four weeks of today's date, they will be also available online free of charge on a complimentary basis. So just be aware that they will have self life, they will be out there, you can access them, you can direct your colleagues to them as well.
We're delighted to have you here on board today. A couple of housekeeping things before we get going... We are going to reserve plenty of time for Q and A. And if you're live in the room, you can feel free to ask questions. We're going to designate 30 minutes at the end of today exclusively and expressly for questions and answers with Dr. Peirce. So I'm looking forward to that piece.
If you're joining us live online, though, you can also participate, not a problem. You'll see a little tab in the lower left-hand side of your screen, marked Questions. Just click on that and email us any questions you have at any time throughout the webcast, and we'll go ahead and get them to the presenter for her to be able to address.
I just want to underscore for you that if you are asking questions and if you are participating, all of which we encourage, be aware that we are also recording the program for archive purposes. So you too will be recorded and your contributions will be registered in perpetuity, okay? So I appreciate your contributions in advance.
Let me just also express appreciation... Any of these kind of things have a lot more going on underneath the water line in order to launch them and be able to implement them than you can see visibly above the water line.
And I want to just make a notable appreciation particularly to the Science Directorate at APA and Geoff Mumford, who were instrumental in sort of inaugurating the series. We could not do this series without the generous underwriting support of NIDA and NIAAA as well. Thanks to both organizations for their ongoing support of the important work in the area substance. That extends as well to Division 50 of the American Psychological Association, the Society of Addiction Psychology, also instrumental. And, of course, to all the presenters involved in the webcast series...
No one has been more central to this series, however, than our Curriculum Director and that's Dr. Bruce Liese, who has played a critical role in helping to sculpt all of the content, to recruit the presenters, and to develop the kind of implementation that has allowed us to have such a successful five-part series.
So without further ado, let me just ask you to join me in welcoming Dr. Bruce Liese.
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DR. LIESE: Thank you. Actually, I'll put this one here, I have my own mic.
It is bittersweet to be here for the last of the series. Bitter, because it's been really a joy and I really don't want to stop, I mean, it's been wonderful. And sweet because we now have a package of really, really vital material for any member of APA to watch for free. And eventually, it's going to be continuing education material for credit.
So I am glad to be here, though. I want to reiterate there have been five of these, and the five have been, I think, terrific and the first one... I just want to name them.
The first one is an overview by Dr. Kenny Sher, and he kicked it off for us.
The second one was Dr. Carlo DiClemente, and he did the one on SBIRT, the presentation on SBIRT.
Dr. Jennifer Reed did the third presentation on understanding people with addictions.
The fourth, Dr. Dan Kivlahan on clinical guidelines for treating people with addictive behaviors.
And now we have Dr. Jessica Peirce, who is going to be presenting what I think is the catchiest title of all: Treatment in the Real World.
To reiterate on the structure, we go for five minutes now just kind of introducing, and we do about 85 to 90 minutes talking, having Dr. Peirce's presentation. And then finally, 30 minutes at the end where we have conversation, questions, and your input.
Please, if you are watching this from afar, please send your questions in as early as possible so I have them nice and early on that tab that Dr. Neimeyer mentioned.
And I want to also thank people before we get started. I really want to thank the committee that got this off the ground.
Dr. Peirce has been with us from the very beginning, as have been Dr. Sher and Dr. DiClemente. We recruited Drs. Reed and Kivlahan onto the project.
Everyone who has been involved has done it voluntarily, so there's been no pay, no stipend, no honorarium. It's just all out of the passion we feel for this topic area.
I want to thank my division. I'm president-elect of Division 50. That's as Dr. Neimeyer says, the division on addictions. I hope you will become a member. I think we do vital things and this is probably among the best of examples.
I cannot ever do my thanks without thanking the Continuing Education in Psychology Office. Janice Pitt has been terrific in keeping us organized and moving forward, as has been Marcia Segura, so thank you to her. And again, thank you, Dr. Greg Neimeyer, and Geoff Mumford in the Science Directorate, who also is involved in getting us started.
So, now I'd like to introduce our speaker. Dr. Jessica Peirce is a licensed clinical psychologist and an associate professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine. She is Associate Director for Addiction Treatment Services, that's an outpatient methadone clinic as I understand. And she provides direct patient care and supervises the psychological treatment of 400 patients with opioid and other substance use disorders.
Dr. Peirce's research and clinical interests center on improving outcomes for urban substance use disorder patients, and in and out of treatment, with specific focus on the relationship between new traumatic events and episodes of PTSD and substance use.
So it is a pleasure to introduce Dr. Peirce to you, who will talk to us about treatment in the real world. Thank you so much.
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DR. PEIRCE: Okay, so thanks to everybody for coming out. I know five two-hour sessions can get to be a bit long, but I think it's a good survey. You're not going to walk out of here being able to treat patients with complete confidence, but it's a good survey of the area.
So these are my objectives. We are going to talk about substance use disorder treatment modalities. We're going to give you some information so you can make realistic and informed treatment referral decisions. Then we're going to talk about addiction-related behaviors that can crop up in treatment of patients, and how to handle those.
So, my two major take home points... You are already treating patients who have substance use disorders, I guarantee it. Second point, you know more than you think you know about how to treat those patients. So...I'll explain that as we go.
So, just a moment about definitions... When I talk about drug use or drugs, I'm referring globally to alcohol, illicit drugs, prescription medications misuse... I'm not really differentiating between different drugs.
I will not be referring to tobacco. Although tobacco, tobacco dependence has the highest morbidity and mortality of any substance, we don't typically send people to treatment centers, specialized treatment centers for tobacco. There are such things, but we don't do so much of that. And the structure's a little bit different.
Also, I work on a hospital campus. I refer to the people who come to me to help as patients. I'm not making any kind of philosophical statement about what we call the people we work with, whether they're clients or consumers, or just... I will refer to them as patients. If you feel differently, don't take offense, please.
Okay. Starting with that you are already treating patients who have substance use disorders... So in this, I'm hoping I have a... Nope.
This is a graph from the National Survey of Drug Use and Health from 2014. And it represents the percent of the population who have a mental illness, who also in the past year had a substance use disorder, for different age groups. So if you work with patients in the 26 to 49, sort of, adult range, one in five of your patients have a substance use disorder. And that's higher than the general population. So the comorbidity that you heard about from Dr. Sher and Dr. Reed that presents in your population. If you work with late adolescence, young adults, it's even higher. It's one in three. Even if you work with seniors, it's still one in ten.
So, it's still a significant portion of your population, whether or not you know that they have substance use disorder.
And, this is also from the NSDUH... And this is really to show you that the vast majority of the people who have a substance use disorder and who need treatment, who objectively are assessed as needing treatment for that disorder, do not receive specialty treatment. So 88% do not receive any specialty care for their substance use disorder, although they needed treatment. So, that's, what, seven out of eight.
So, you're seeing patients who have a substance use disorder and they're generally not likely to have had treatment for it. Why haven't they gotten treatment? For the most part, because they don't believe they need it. So, again, these were objectively assessed people who clearly need a treatment for their substance use disorder. But 96% of them did not believe that they need treatment.
So you're seeing patients who have a disorder, who may not even realize they have a disorder, and who need treatment for it and may not speak about that to you.
So a moment about the history of substance use disorder treatment in the real world... The substance use disorder treatment developed in parallel to other psychiatric and psychological treatments.
The initial treatments, and we'll come back around to this idea, the initial treatments were offered by NIDA at the Lexington Farm, which was a prison community. So, it was seen as a criminal behavior, and so treatment was criminal behavior-related.
For that reason, and there has been a historic divide, and this is part of what sparked this conversation about needing some kind of survey course about treatment of addiction for psychologists, because even now we find that not very many psychologists receive instructions on how to treat patients with substance use disorder.
So in the real world, treatment is largely group-based and offered by paraprofessionals.
In the state of Maryland, for example, you can have as little as a high school diploma and some continuing education courses, and you can be credentialed as a substance use disorder provider. And the standards for training can vary widely across the country.
Evidence-based treatment is not uniformly offered. Dr Kivlahan did a great job of describing the highest standard of care. Although it was developed for the VA-DoD, it really was the best, it is the standard of care... But, frankly, as we all know, even in psychology, people aren't always getting the most evidence-based treatment. So, in fact, in some places, it's unlikely that they're going to get evidence-based treatment.
And because the standards for training and the expectations aren't necessarily at the highest standards, conceptualization of the disorder and treatment for it do not always meet the highest standards.
All right, so we're going to start with talking about treatment modalities. This is really sort of didactic. I'm going to start with...
So each of these is a category, I'm going to start with adjunctive care. I want to make this point--this care is not treatment. It should not be a stand-alone treatment, this is care that can support treatment.
And then we'll talk about inpatient treatment, outpatient treatment, and medication-assisted treatment.
The first level of adjunctive care is detoxification or detox. That is essentially a medically supervised withdrawal from a substance. It typically runs about three days in the hospital. And it tends to be reserved only for those substances that can be dangerous during withdrawal.
And that really is limited to benzodiazepines and alcohol, which can in withdrawal produce seizures. And as is the case with any seizure disorder, the potential for a status epilepticus or death is possible. So, in fact, in my hospital, they don't even accept people who don't have benzodiazepine or alcohol dependence for detox.
So again it's not treatment, it's a way to get the drug out of the body safely.
Another level of adjunctive care is 12-step programs, fellowships, Alcoholics Anonymous, Narcotics Anonymous, and the CBT-based SMART recovery are examples. They typically have regular meeting times, which are presented in a book like this where you can look up across days and times to find a meeting that you might want to go to.
The format of those meetings varies. From...usually, they'll have a speaker talk about their own recovery experience. And then they have a discussion group. But there is no leader, by definition, and there's no expectation of any particular training or experience for these support group participants. The purpose of 12-step or other fellowships is to offer social support for recovery. And for some people, this is a really, really important part.