Transcription for
EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF SUBSTANCE USE DISORDERS
DR. DANIEL KIVLAHAN
Continuing Education Programs APA
MARCH 2017
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March 21, 2017
DR. DANIEL KIVLAHAN
EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF SUBSTANCE USE DISORDERS
2:01 length
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DR. LIESE: All right, let's get started.Great to see all of you.It's good to see the familiar faces.
I'm Dr. Bruce Liese, a professor at the University of Kansas and I'm also the course director for this series of five webcasts.We are in our fourth of five, and in a moment I will introduce Dr. Dan Kivlahan to you with great pleasure.
First, I want to cover some housekeeping details.We will be going for two hours, as we have in the past.The last half hour will be my favorite, because it's a very, very pleasant conversation about anything you'd like to know following the presentation.
I would ask everybody who is also watching us online to please submit your questions.You can do so by pressing on the little tab on the left-hand side of your screen.We'll be asking for questions from people up here and also from people who receive the webcast.
We have gotten so many questions that we haven't been able to answer them all.So, last week we had dozens and didn't have enough time.So please keep sending the questions to us, and please do so by 2:30, and that's for the people who are at home.
And also please keep the introductions to your questions as short as possible.Sometimes they're so long, I'm not sure which is a statement and which is a question.
So, we appreciate all, even though we won't be...I hope we can get to them all.So, again that's 30 minutes there.I want to make sure I don't leave anything out.
Oh, and the materials...Dr. Kivlahan has been very generous and provided us with approximately a dozen terrific handouts.So you have them as PDFs here, and if you are at home, you will find them at the second tab of the two tabs.
So, CE certificates for those of you onsite, we will provide them to you afterwards.Those of you who are not onsite, those of you who are at home, also, please be sure to keep an eye on the number of the characters on the screen because that's how we know you watched.So we're going to have you write down the characters on the screen as we go through it.You'll get a few that'll flash up there, they'll stay up there for a while, you write them down at the end, and that's our attendance method.
Okay, what else do I want to do?I certainly...Oh, and it's a two credit scores, two hours for each one, and ten hours for the entire series.We are grateful to a bunch of people who made this possible.We are certainly grateful to NIDA and NIAAA, for funding this.That's what's making it possible for all of you to do this at no charge.So, thank you,NIDA and NIAA.
I first heard that this was going to be possible from Dr. Geoff Mumford and the Science Directorate.And so his getting us started was vital to the whole process taking place.
I also want to thank the Center for Learning and Career Development and the Office of Continuing Education in Psychology.Both have contributed substantially to the implementation of these webcasts.
And no thanks would be complete without thanking Janice, thank you.Janice Pitt has done tremendous things for us, made a lot of this possible.Marcia Segura and Greg Neimeyer, who I'm pretending to be in introducing us today.And Jason, in the back, who [LAUGH] is always helpful in technology.
So, before I introduce our guest, I also want to thank my own division.I'm President elect of Division 50, the division on addictions of APA.They have been vital in the development and implementation of this entire program.So, to my friends and colleagues in Division 50--and here's the plug, if you aren't a member of Division 50, we certainly encourage you to become one.
The presenters do not get paid a dime--none of us, not me, not any of our presenters get paid for this.We're doing it because we're passionate about it and because we believe strongly that everyone should know about the psychology of addictions.
So...And we have some regulars here...Thank you all for coming again.I think that'll do the trick for introducing the program.
Now I have the good pleasure of introducing my new friend.We've been on the phone so much, that we're like old friends.
Dr. Daniel Kivlahan is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington.
Are you still that, now that you're retired?
DR. KIVLAHAN: Still am.
DR. LIESE: Still am.His doctorate was from the University of Missouri at Columbia.His postdoctoral fellowship was at the Addictive Behaviors Research Center in the Department of Psychology at the University of Washington, a terrific program for addictions research and training.He was the Director at the Center of Excellence and Substance Abuse Treatment and Education at the VA Puget Sound, Seattle.
And one of the things we really appreciate in programs like this, is a researcher who also practices, and Dr. Kivlahan has done both.He has been the clinical coordinator of the VA Substance Use Disorder Quality Enhancement Research Initiative.And he's been involved in implementing evidence-based practices, which is what this will be about today.
He cochaired work groups that completed revision of the VA and Department of Defense Clinical Practice Guidelines.And he'll be talking about those.And he's been active in the development and validation of quality indicators based on guidelines recommendations.
So he's really been immersed in this stuff and we're fortunate to have him here.
Couple of last things...
In 2010, Dr. Kivlahan was appointed as Associate National Mental Health Program Director for Addictive Disorders, Mental Health Services Veterans Health Administration.And he retired there...makes me envious, retired in 2015.
He has more than 150 peer-reviewed papers, and many of them are on the validation of the Audit-C to screen for substance use, alcohol misuse across care settings.
So, with that said, it is my complete pleasure to introduce Dr. Daniel Kivlahan.Thank you for being here.
Why don't we welcome Dr. Kivlahan?
[APPLAUSE]
DR. KIVLAHAN: Thank you, Bruce, and thank you all very much.It's a pleasure to have the opportunity to work with Bruce and the other presenters on this series.
And I'll try and give you multiple reasons why it's important for all psychologists to have awareness of some of these issues, and how Division 50 really provides a unique community, both of practice, of research, and of policy, to help promote some of these ideas.
Here's my disclosure statement.I have an investment in clinical practice guidelines, that I'm actively involved in the advisory steering committee for the APA's effort and the effort that just came to fruition with the public announcement this week that they released the clinical practice guideline for treatment of post-traumatic distress disorder.
As Bruce mentioned, I've also been involved over the years with the VA and Department of Defense efforts to really evolve the clinical practice guidelines, and I'll be talking about the most recent iteration of that.I have had previous funding from VA's Health Services Research and Development Program.
And the Quality Enhancement Research Initiative, which is intended to be one of those important bridges between research and practice, as well as from NIAAA and NIDA.
I'm an experienced, currently inactive clinician.I really want to acknowledge the many colleagues I've worked with and learned from over the years who continue to do this important and challenging work.
Just so many dedicated colleagues who are promoted to successful recovery...
I'd like to start out by previewing concluding comments, where I hope to help you get in our time together.You've heard from previous presenters there are multiple pathways into addiction.
There are also multiple pathways to recovery.Many of those are via treatments, that's not the only way.You have heard some mention already of people who find different pathways to recovery that don't involve treatment.
But we are in a profession of being able to address those who are seeking help and trying to make sure that they find their particular pathway.Ideally, that involves access to a choice of recommended interventions.That's the nature of patient-centered care.
We realize, and I think Dr. Pierce will elaborate next week on, the reality that that's often not the case in many settings of care.And we have a lot of work to do to try and broaden that continuum of services to be closer to that ideal.
I want to emphasize that the recommended options differ across the four major substance use disorders that are reviewed.We often talk in more generic terms about SUDs.There are differences depending upon whether you focused on alcohol, opioid, cannabis, or stimulant use disorders.
The evidence gaps differ across those.Make no mistake, there are evidence gaps.Our evidence base could be a lot stronger.And I'm hoping that we'll, through some of these educational efforts, persuade some of our earlier career colleagues to take on that mission and help to build that base.
But where we stand today is that there's a very limited basis for even experienced professionals being able to counsel somebody about which option will work best for them.We don't have a consensus treatment of choice.
As a result, our current responsibility, I would say, is to emphasize a shared decision making process.This means people have to have choices if there's going to be some sharing of that decision.And that measurement-based care, as I'll elaborate about, is a fundamental method for trying to promote that effort.And in case that concept of measurement-based care is unfamiliar to some, I really want to emphasize it now and I'll return to it later.
But this is an example that resonated with me.It came out of the depression literature, but I think you'll see that it can generalize to a range of conditions.So here's a provider, summing up after an initial evaluation with somebody that they have just seen...
"We have several good treatment options to choose from.On average, they have about the same chance of success.You are not an average, you're an individual.At this time, there is no scientific way to predict which treatment will work best for you.Together we'll look at your options and decide which treatment to start with, but it's important to remember that there are other options.If the first treatment we pick does not work out for you, some other treatment might work well."
Always a plan B...
And here's the emphasis, the measurement-based care part of it...
"Regular follow-up over the next several weeks will tell us whether to stay with our first choice or to try something else."
So it's intended to really convey that message of hopefulness, of not "do it my way or hit the highway..." Which, unfortunately, has been all too often one of the messages in especially addiction treatment in some settings.
So now we'll return to my closing comments, after you've got that sense of what measurement-based care is about.
Those of you with training in principles of psychology already have some of the fundamental perspective necessary to help people with substance use disorders.These involve relational factors, promoting engagement, other things that will be very familiar to you.It's not a separate part of healthcare, there's a continuum.
And we need to help people generalize the skills they've already developed with one set of conditions for a particular population and recognize that these are overlapping populations and the principles generalize as well.But to my knowledge, there are very few individuals who have expertise in all the different interventions I'll talk about today.
So our responsibility is to try and pursue effective training in areas where we can still take on new skills, those that are unfamiliar.But it's equally important to be able to identify other professionals who have the expertise that might be needed.
In part, for that reason, I'll be talking with you a considerable amount about pharmacotherapy for substance use disorders.Even though at this stage relatively few of you are likely to be providing that directly...
My final point is that all psychologists can be advocates as the respected healthcare professionals you are, thought leaders in the community.People in the family turn to you often for consultation about some of these ubiquitous issues.
In whatever setting you work with, you want to inevitably be working with individuals who either have substance use disorders or are no more than one or two steps removed from suffering with substance use disorders.These issues come up if you're sensitive to them.And there are multiple opportunities to try and nudge people toward the help that they can benefit from.
So these are intended to have you thinking both about individuals with substance use disorders that you will inevitably care for, as well as people that you care about.
I would like to emphasize that the guideline I'll be talking about was developed by an interprofessional working group.I particularly want to call out one of our Division 50 colleagues, Jim McKay, who's at University of Pennsylvania and the Philadelphia VA, made major contributions to the guideline.
Many of the other names are unlikely to be familiar to you, so I've highlighted their degrees and want to emphasize the range of other providers that were involved.So in alphabetical order--addiction medicine specialist, chaplain, dietician, nursing, pharmacist, primary care physicians, social work.
Quite a range of input and perspectives for this kind of an undertaking...But what perspective is missing?Anybody tell me what jumps to mind as a key stakeholder who's not included in that list?
AUDIENCE MEMBER: Nursing...
DR. KIVLAHAN: I'm sorry?
AUDIENCE MEMBER: Nursing.
DR. KIVLAHAN: Nursing is there.Dr. Bubka...
AUDIENCE MEMBER 2: Patients.
DR. KIVLAHAN: Thank you, Dr. Bubka.The patient perspective...
But even though we all enter these sorts of efforts, anticipating that we can be the advocate for the patient, there is nothing like having the patient in the room, or somebody who is a designated patient advocate.That's an area where the APA guidelines have made concerted efforts to assure that level of involvement that's notably absent here.
There are all sorts of ways that these guidelines can be improved, but that's one I want to alert you to.It's also a reminder that clinical practice guidelines are not intended to be developed exclusively by the discipline for which they're intended.
These are human disorders that we're dealing with, not just professional turf.And so guidelines really need to have that perspective of other providers.
What is an evidence-based clinical practice guideline?Several years ago, the Institute of Medicine launched their effort to try and set standards, unprecedented standards, for what they referred to as: guidelines we can trust.
And let it be known that there are guidelines out there that have clear proprietary interests that you would be wise to have some skepticism about, about who they best serve.
So, according to the Institute of Medicine standards, "Clinical practice guidelines are statements that include recommendations intended to optimize patient care.They are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options."
In a nutshell, that's what they are.
If you want the full, elaborate story on it, there's not only the Institute of Medicine report, but also a paper in the Review of Clinical Psychology that Dr. Steve Holland was first author on, along with a number of us on the advisory steering committee for the APA guidelines.And I have included that in the key references if you want to be able to pursue that further.
There are a lot of misconceptions about clinical practice guidelines.
They're not performance measures, although they can sometimes be informing performance measures.
They are not considered legal standards of care.
They won't teach you how to provide evidence-based practice.They're not treatment manuals or treatment protocols.Those always rely on local resources and procedures.
They're not, by any means, the sole determinants of treatment plans.There are a range of other considerations that have to be made.
They are not intended to be dictating coverage policies.
And most important, they're not a substitute for clinical judgment, they're a complement to clinical judgment.
So what's left for them to do?What do they aspire to be?
Well, they aspire to be evidence-based and clinically informed educational tools that can address needs both of practitioners but also patients in support of others.These are places that you can direct somebody who's trying to find more about the options that may help them.