A View From the Front Lines Motivating Patients and Providers What Makes a Difference

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A View From the Front LinesMotivating
Patients (and Providers) - What Makes a
Difference?

• Ken Saffier, MD
• Contra Costa Regional Medical Center
• California Academy of Family Physicians
• Primary Care and the Chemically Dependent Patient
• April 14, 2005

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Learning Objectives

• By the end of this presentation, participants
  will be able to
• List at least 3 ways a positive provider attitude
  improves outcomes.
• Appreciate how motivational interviewing
  facilitates referrals to treatment.
• List at least 5 tools that primary care providers
  can use to promote increased diagnosis and
  treatment of addictive disease.

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Outline of Presentation

• 4 Brief Case Presentations
• Reflections by patients about being referred to
  treatment (video)
• Reflections and comments from providers about
  supporting patients motivation to change (panel
  and audience discussion)

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Patients for this afternoon
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As a PCP seeing these next 4 patients, consider
the following

• What stage(s) of change do you think might
  describe each patient?
• What treatment needs might he/she have?
• What interview approaches would you take?
• What motivational strategies would you consider?
• (Refer to CSAT Treatment Improvement Protocol
  Summary)

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Steve

• 21 years old
• Lacerated nose during todays college football
  game
• Sew it up w/o local, its OK, I just want to be
  with my team
• After 10 sutures, went to party.

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Steve 21 years old

• As a star athlete, he drank daily, smoked
  marijuana, and before the big game, snorted
  cocaine.
• He didnt smoke cigarettes.
• Although he was not asked about his use of drugs
  or alcohol in the ER, he denied he had a problem
  during college.

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Steve 26 years old

• Began having problems with recurrent bronchitis.
• Tried to stop smoking marijuana unsuccessfully.
• Began seeing physicians for his pulmonary sxs,
  ultimately given dx. of sarcoidosis several years
  later.
• Began using heroin, intermittently, then daily.
• Due to trouble at work when he was really loaded,
  he entered treatment via his EAP.

9
Becky 33 years old

• Married, mother of 9 y.o. son and 11 y.o.
  daughter.
• No FHx of etohism
• Husband drank excessively
• She began drinking more after 3 yrs. of marriage
• Routine HCM - wnl

10
Becky 35 years old

• At her family MDs, she was shaking and anxious.
  I couldnt sign a check.
• Its caused by my marriage falling apart.
• Rx Diazepam 5 mg., which she flushed down the
  toilet.
• No screening if he asked, I would have
  minimized my sxs./signs of w/d.

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Becky 36 years old

• CC bloated stomach
• W/u included lab, ugi series
• Drinking continued heavier.
• . Months later
• Couldnt walk, was admitted to hospital
• Dx peripheral neuropathy, alcoholic hepatitis,
  DTs
• Entered treatment program

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Bruce 40 years old

• Psychiatrist
• Married
• Active practice in E. SF Bay area
• Drinks etoh, smokes MJ, experimented with others

13
Bruce 40 years old

• For 8 years, has seen internist and for the last
  5 years gets check up q 1-2 yrs.
• Hes a good doc if youre really sick.
• LFTs SGOT (AST) 173, SGPT (ALT) 82.
• Dx. Enlarged liver.
• Was advised that alcohol isnt the best for
  you.

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Bruce 55 years old

• Emotionally labile for 5 years
• Mood swings were noted by colleagues and patients
  I was in denial.
• Office secretary, good friend, helped him
  function with work responsibilities.
• Marriage fell apart 6 years earlier.
• For 5 years 12-15 drinks per day smoothed over
  the activation of smoking MJ daily.

15
Bruce 56 years old

• One evening, while under the influence, phoned a
  patient, not remembering exactly what he said.
• Soon after, a SWAT team visited him at home.
• He was arrested, went to jail.
• Entered CMB Diversion Program to save his
  license.

16
Lori 20 years old

• Left home at 16 yo
• Began smoking 8 yo
• Etoh 12 yo
• Cocaine, meth 18
• 16 yo to present domestic violence
• Fam Hx drugs and etoh

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Lori 20 years old

• Frequent ER visits, 4/year, for fever, throat
  pain, couldnt swallow, talk.
• Often was so sick before I went for care.
• If she were to have been asked about drug use,
  she would have strongly denied use and/or
  problems.
• I felt stuck, using crank daily.

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Lori 26 years old

• Pregnant
• Went to 2 prenatal visits before delivery.
• Scared that baby would be taken away.
• I didnt know what to do.
• Still was in abusive relationship.
• Hx prior surgery for nasal septal perforation.

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Motivational Interviewing

• Nonjudgmental
• Respects individual differences
• Tolerance for disagreement/ambivalence
• Patience with incremental changes
• Caring and interest in patients served, express
  empathy

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Motivational Interviewing Basic Principles

• A process that works
• DARES
• Develop discrepancy
• Avoid argumentation
• Roll with resistance
• Express empathy
• Support self-efficacy

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Motivational Interviewing Basic Principles - 1

• Develop Discrepancy
• The patient, not the PCP, presents the
  arguments for change.
• Change is motivated by a perceived discrepancy
  between present behavior and important personal
  goals or values.
• Miller, W.R., Rollnick, S. (2002) Motivational
  interviewing, Preparing people to change. New
  York Guilford Press (2nd edition)

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Motivational Interviewing Basic Principles - 2

• Roll with Resistance
• Avoid arguing for change.
• Resistance is not directly opposed.
• New perspectives are invited but not imposed.
• Resistance is a signal to respond differently.
• Patient is a primary resource in finding answers
  and solutions.
• Miller, W.R., Rollnick, S. (2002) Motivational
  interviewing, Preparing people to change. New
  York Guilford Press (2nd edition)

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Motivational Interviewing Basic Principles - 3

• Express Empathy
• Acceptance facilitates change.
• Skillful reflective listening is fundamental.
• Ambivalence is normal.
• Miller, W.R., Rollnick, S. (2002) Motivational
  interviewing, Preparing people to change. New
  York Guilford Press (2nd edition)

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Motivational Interviewing Basic Principles - 4

• Support Self-efficacy
• The patients belief in the possibility of change
  is an important motivator.
• The patient, not the PCP, is responsible for
  choosing and carrying out change.
• The PCPs own belief in the persons ability to
  change becomes a self-fulfilling prophecy.
• Miller, W.R., Rollnick, S. (2002) Motivational
  interviewing, Preparing people to change. New
  York Guilford Press (2nd edition)

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An Introduction to Motivational Interviewing

• Tools for building motivation OARS
• Open ended questions
• Affirming, supporting patients involvement
• Reflective listening, be empathic
• Summarizing

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What really makes a difference?

• A Positive Provider Attitude
• A Significant Predictor of Positive Outcome

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Positive AttitudesImplications for Patient Care

• Increased screening
• Increased diagnoses
• Increased access and referrals to tx
• Improved outcome
• Increased hope for patients, families, staff
• Chappell, JN, Schnoll, S Physician attitudes,
  effect on the treatment of chemically dependent
  patients. JAMA 212318-19, 1977

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Grant me the serenity to accept the things I
cannot change, the courage to change the things
I can and the wisdom to know the difference.
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Components of a Brief Intervention

• Ask about use
• CAGE, Two Question screen, AUDIT
• Suspect more than one cause or drug
• Asses use abuse, or dependence ?
• readiness to change?
• Advise about consequences nonjudgmental
  education May I share with you some facts
  about ______?
• Assist with a plan to stop
• Arrange for follow-up or referral

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Addiction Medicine Tools for Primary Care
Providers

• Screen all patients for SUDs.
• Motivational Interviewing
• Brief office or ward interventions
• Medical management of withdrawal
• Pharmacological tools (e.g., methadone,
  buprenorphine, disulfiram)
• Urine tox screens
• Your positive provider attitude

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Selected References

• Chappel, JN, Schnoll, SH. Physician attitudes
  effect on the treatment of chemically dependent
  patients. JAMA 19772372318-2319
• Miller, W.R., Rollnick, S. (2002). Motivational
  interviewing, Preparing people to change. New
  York Guilford Press (2nd edition)
• An excellent, comprehensive text by the
  masters, refined after 10 additional years of
  experience and further research.

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Selected References

• Prochaska, J.O. and DiClemente, C.C.,
  Transtheoretical therapy toward a more
  integrative model of change. Psychotherapy
  Theory, Research, and Practice 1982, 19276-288
• Rollnick, S, Mason, P., Butler, C. (1999). Health
  Behavior Change, London Churchill Livingstone

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Selected References

• Substance Abuse and Mental Health Administration
• Center for Substance Abuse Treatment
• Treatment Improvement Protocol (TIP) Series
• Enhancing Motivation for Change in Substance
  Abuse Treatment 35
• Detoxification From Alcohol and Other Drugs 19
• A Guide to Substance Abuse Services for Primary
  Care Services 24
• Brief Interventions and Brief Therapies for
  Substance Abuse 34
• National Clearinghouse for Alcohol and Drug
  Information
• (800) 729 6686 or (301) 468 2600
• www.health.org

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Selected Web Sites

• www.motivationalinterview.org
• www.niaaa.nih.gov National Institute for
  Alcoholism and Alcohol Abuse
• www.nida.nih.gov National Institute for
  Drug Abuse
• www.health.org National Clearinghouse for
  Alcohol and Drug Information

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Special Thanks To

• Steve
• Beckie
• Bruce
• Lorrie
• And all of the thousands of patients, in and
  progressing toward recovery, who are our
  inspirational teachers.

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Additional Thanks To

• Fera Byrd, Byrd Productions
• Chris Verdugo, Contra Costa TV
• Adrian Cooley, IS Director, HELP Desk