To get started, I want you to decide if you agree with this statement, "Abstinence is the only acceptable goal of treatment for someone with a substance use disorder." Historically, the goal of addiction treatment has been uni-dimensional. The message has been either accept the goal of total abstinence, or you aren't really interested in treatment. So come to treatment when you change your goal. In fairness, abstinence is the gold standard because it's the healthiest and safest form of recovery. However, expecting abstinence from the outset can actually be a barrier to treatment. For example, a lot of people won't consider treatment at all because they think it will require abstinence, and therefore it's not for them. At other times, patients may want treatment, but they are excluded from a particular setting because a facility requires total abstinence to enter or to stay there. Another unfortunately common example is when a prescriber stops a medication. Let's say for alcohol use disorder because the patient continues to drink without realizing that the patient is actually drinking significantly less than previously. Or what about a person with opiate use disorder who isn't interested in treatment but is willing to accept a naloxone kit that might reverse an overdose? What's been missing in the treatment of substance use disorders is acknowledging the continuum of progress on the way to abstinence. In this lesson, you will learn how to clarify your patient's treatment goals and how to guide your patient through five stages of change using various motivational interviewing techniques. So let's start with treatment goals. Generally, there are four categories of goals that you will encounter with patients. The first group is what I'm calling "use with less harm". This group wants to continue using, but would like to be safer. For example, they would like to avoid an overdose or avoid contracting a transmitted disease. The second group I call the controlled use group. This group wants to continue using, but would like to reduce the amount they are using or use in a more controlled way. The third group is called conditional abstinence. This group is willing to try abstinence for a limited period of time, but not as a long-term goal. They give themselves the option to use every once in a while. The last group is the complete abstinence group. People in this group have a stated goal of long-term, typically, lifetime abstention. The first three treatment goals collectively fall under the umbrella term harm reduction. While we might want our patients to be 100 percent safe from any future harm and therefore might recommend abstinence, it's important to recognize that perfect, might indeed be the enemy of good enough. Let's use the example of a patient who is smoking. After learning of their smoking status, you politely provide the following advice. Quitting smoking is the single best thing you can do for your health and I can help you. Are you interested? If they say no, that's not a dead end. It just means that they are in the precontemplation stage of change in which they seem unaware or unwilling to change. This is the first of five stages of change. Even though the person has no treatment goal at this stage, there are things you can do. For example, instead of stopping at their no, you can ask them probing, typically open-ended follow-up questions to learn more. Consider these questions. Have you ever thought about quitting or tried to quit? Or what would make you interested in quitting, or lead you to consider that smoking might be a problem worth tackling? Generally, people have some ambivalence about smoking. In this visit, you might explore the option of non-combustible or electronic cigarette use as a means to reduce harm. Or if they have some anxiety about cancer risk, you might talk to them about screening and signs of potential cancer. You might conclude your visit with this patient by saying, remember, we are here to help if your smoking goal changes. There's a good chance that the guided self-exploration about smoking, along with some good old-fashioned reflective listening brings them closer to the contemplation stage of change. So in the contemplation stage, a patient is considering a change but has not yet made the commitment. In this stage, you want to capitalize on this growing ambivalence and use the motivational interviewing tactic of evoking change talk. Well, there are many techniques for evoking change talk, one of the simplest and one that I use all the time is the use of the change rulers. To illustrate this, you will ask on a scale from 0-10, how important is it to you to quit smoking? Where zero is not at all important and 10 is extremely important. The patient will give you a number. In this case, let's say the person says three. No matter what the number is, you will follow up by asking. A three? Why are you at a three and not a one? Note that you are deliberately choosing a lower number in order for them to answer why it's important at all. They might respond, "Well, I know it's bad for me and I'm scared of cancer. Also my partner doesn't like it." This is change talk. I find using the ruler a pretty sure way to get a person to talk about change. If this is all you do in one appointment, then I count that is a win. You got them thinking about quitting and that's progress. The next stage of change is the preparation phase, where the patient has decided to make a change, but has not yet taken action. This is where you're going to negotiate and clarify their treatment goal. For example, a person might want to first try cutting back the number of cigarettes they smoke in a day. This would put that person in the controlled use group. Or a person might want to try switching to an electronic cigarette, and this would put them in the use with less harm group. Or the person might want to quit altogether, and that's the complete abstinence group. No matter which goal the person chooses, you should utilize the motivational interviewing process of planning for change. When we help people plan for change, we generally focus on making an action plan, removing barriers to change, and engaging outside support. I like to brainstorm with the patient a shorter time-frame and discuss the coming week or two. For example, I might say, "We've talked about several things you could do to plan for this change. Please tell me which three things you will commit to over the next two weeks." Ask for specifics, problem-solve, and brainstorm with patients. This isn't particularly hard stuff, but it can be extremely powerful when delivered by a patient's healthcare provider. Now particularly for those not attempting complete abstinence, you will want to ask about what a failed trial might look like. For example, you've made a goal to reduce from 10 cigarettes a day to six cigarettes a day over the next two weeks. Now I'm going to assume that you'll be successful. But it's also really important to plan for all possible outcomes. So what might alert you that this plan isn't working? What might you do next if this is the case? Again, anticipating obstacles ahead of time will be super-helpful to your patient. Understanding progress or like their offer also guides feature encounters. So for example, if a patient mentions a failed trial you could say, "Last month you gave reducing your cigarette use a try, and it sounds like that was pretty hard. What are your thoughts about trying something different?" The fourth stage of change is the action stage. This is where the person is putting the plan into action. It's important to have regular contact during this phase and in order to adjust the treatment goal or the treatment plan, according to how easy or difficult the changes for your patient. Know if a patient has consistently been taking actions to change their substance use, and they've reached their personal goal, then they are in the maintenance phase of change. In this phase, the patient has developed a new way of being. But keep in mind there are going to be bad days. We all have triggers, whether it's the stress of everyday life, or something unexpected like getting laid off, or a death in the family. Explore with your patient what would happen if they returned to use. Often, a little pre-planning and expectation setting can help keep an isolated laps from spiraling into a sustained relapse. So those are the five stages of change. Precontemplation stage of change, where you as the healthcare provider guide the patient to reflect on their use and explore ambivalence. Contemplation stage of change, where you continue to explore ambivalence and work to evoke change talk, perhaps, utilizing the change rulers I mentioned. The preparation stage of change, where you negotiate a treatment goal with your patient, and together create a change action plan. The action stage of change where the patient is enacting change. Finally, the maintenance stage of change where you apply principles of relapse prevention and partner with your patient to continue in the direction of substance use change. To recap, we talked about four treatment goals, five stages of change, and recalled motivational interviewing tactics. There are many factors that play here that will help you individualize your treatment recommendations and cater to your patient. No matter what a patient's goal is, it's important to clarify that goal, and then help a patient move along the stages of change in order to implement that goal. Finally, to continually reflect and revise if that goal isn't working as your patient imagined. Remember, we want to avoid the trap of one-size-fits-all. Instead of expecting patients to make a huge leap into complete abstinence, we can build a bridge towards abstinence by encouraging small incremental changes.
