<p> Motivational Interviewing (MI) Regarding Substance Use in the Medical Setting</p><p>Lecture outline</p><p>John M. Wryobeck, Ph.D. University of Toledo (Slide 1)</p><p>I. Introduction</p><p>A. Importance of substance use disorders (SUD) intervention in medical setting (Slide 2)</p><p>1. SUD in the Emergency Department (ED)</p><p> a. ~ 30% ED patients (pts) have alcohol use disorders (AUD)1</p><p> b. 50% Severe trauma pts under drug influence2</p><p> c. Trauma includes falls, violence, accidents </p><p>2. SUD in hospitalizations</p><p> a. 24% hospital admissions have AUD3</p><p> b. 33% Of non-trauma admissions related to AUD4</p><p>3. SUD in primary care (Slide 3) </p><p> a. ~ 20% medical clinic pts have AUD5</p><p> b. SUD among top 3 diseases worldwide6 </p><p> c. SUD related to 60+ types of injury/diseases5 </p><p>B. Current approaches to changing drinking behavior (Slide 4) 7</p><p>1. Through external motivation – have limitations, not effective for all</p><p> a. Education - information motivates change</p><p> b. Persuasion - logic motivates change</p><p>2. Elicit internal motivation</p><p> a. Explore pts knowledge and thoughts about change </p><p>1 b. Allow pt to argue for change</p><p>C. This lecture reviews (Slide 5) </p><p>1. Definition & Principles of MI </p><p>2. Basic Skills of MI – communication techniques used</p><p>3. Basic Steps of MI – strategies for use in medical setting</p><p>4. Research supporting MI – empirical evidence in the medical setting</p><p>II. Definition and Principles of MI (Slide 6) 7</p><p>A. Directing - Dr takes charge, leads, manages (is appropriate style for many medical </p><p> situations) versus:</p><p>1. Guiding style - helping one find their way (two active participants)</p><p>2. Not typically taught in medical schools</p><p>3. Prescribing behavior change requires interpersonal approach (asking one to </p><p> change lifestyle is different from fixing bone, excising tumor)</p><p>4. Guiding - input from both pt & Dr; Dr elicits, encourages, supports </p><p>B. Explores & resolves ambivalence – feeling two ways about change (Slide 7) 8</p><p>1. Acknowledge & respect pt’s right to choose course of action</p><p> a. Ambivalence seen as “normal” part of change (ambivalence about </p><p>“change” not necessarily about use)</p><p> b. Persuasion & confrontation avoided (if clinician argues for change, pt </p><p> likely to argue for status quo if ambivalent)</p><p>2. Elicits from pt what they need/want at this time</p><p> a. Skills used to elicit/reinforce pt motivation/readiness for change</p><p> b. Facilitate discussion on how changes related to pt’s desires</p><p>2 C. Principles Empathy (Slide 8) 8</p><p>1. First principle of MI is Express empathy – acceptance of pt’s experience </p><p>& ambivalence 9 </p><p> a.  Understanding and honesty; nonjudgmental attitude of Dr fosters </p><p> environment where pt is comfortable expressing self</p><p> b. Communicates acceptance, support</p><p>1) Non verbal expression of empathy</p><p> i) Facing pt, eye contact</p><p> ii) Avoiding office/clinic distractions (phone, staff, etc.)</p><p>2) “Reflective” empathy</p><p> i) State the “emotion” underlying pt statement</p><p> ii) Paraphrase pt statement to show understanding</p><p> c. Example: (Slide 9) </p><p>1) Pt: “I always say I am going to quit drinking, but I never do.” </p><p>Dr. “It is frustrating not being able to accomplish something </p><p> you want so much.”</p><p>2) Pt: “I realize that drinking is ruining my health but I don’t think</p><p>I can change.”</p><p>Dr. [Ask audience for possible empathetic responses to above.</p><p>Be supportive and affirming in acknowledging their responses.]</p><p>2. Second principle of MI: Roll with resistance (Slide 10) </p><p> a.Resistance ↑ when pt feels unheard and/or lectured to</p><p>3 1) Respect pt’s right to make decisions (good/bad) for themselves</p><p>2) Ambivalence often mistaken for resistance</p><p> b.  Resistance through reflective listening (stating back to pt the essence</p><p> of or specific aspect of pt statement)</p><p>1) Easier to ask questions – reflection requires full attention to </p><p> understanding patient</p><p>2) Invite pt to view situation from different </p><p> perspective</p><p>3) Active process - core element of the MI “guiding”</p><p> style</p><p> c. Example: (Slide 11)</p><p>1) Pt: “What do you know about drinking? You </p><p> probably don’t even drink.” </p><p>Dr: “It’s hard to imagine how I could possibly understand.”</p><p>2) Pt: “My drinking really isn’t that bad.”</p><p>Dr. [Ask audience for possible reflective responses to above </p><p> that would minimize resistance. Be supportive and affirming </p><p> in acknowledging their responses.]</p><p>3. Third principle of MI: Support pt’s confidence in ability to change (Slide 12) </p><p> a. Develop confidence 10, 11 </p><p>1) Pts unlikely to change until they believe they can</p><p>2) Emphasize pt’s ability to change </p><p> b. Support small changes</p><p>4 1) Any positive change seen as good, fosters confidence & </p><p> optimism in patient</p><p>2) Elicit change behaviors pt willing to make</p><p> c. Eliciting/Strengthening statements regarding confidence</p><p>1) Evocative questions (Slide 13)</p><p> i) What might be a good first step?</p><p> ii) What gives you confidence that you might do this?</p><p> iii) [Ask audience for another possible question.]</p><p>2) Review past successes</p><p> i) What change have you made successfully and what did </p><p> you learn in making that change?</p><p> ii) When you abstained for 3 months, what worked for </p><p> you?</p><p> iii) [Ask audience for another possible evocative question.]</p><p>D. Transition: We have reviewed definition & principles of MI covering major points: </p><p>(Slide 14)</p><p>1. MI is a guiding style</p><p>2. MI addresses ambivalence through</p><p> a. Empathy</p><p> b. Open Questions, reflections</p><p> c. Offering support</p><p>III. Basic Skills that reflect the principles of MI (Slide 15) 7</p><p>A. Asking</p><p>5 1. Open-ended questions – use to gain understanding</p><p> a. Avoid repeated closed ended questions (can be answered yes/no or </p><p> with one word) feels more like an interrogation vs. collaboration. </p><p>“How much do you drink? Do you want to stop drinking? Don’t you </p><p> think it is hurting you? Are others telling you to stop?”</p><p> b. Good open-ended questions get more info faster 12,13</p><p> c. Skillful asking is element of guiding style</p><p> d. What makes for good open-ended questions?</p><p>1) Simple</p><p>2) Focused</p><p>3) Tone neutral – not sarcastic</p><p> e. Examples of questions (asking) (Slide 16)</p><p>1) Learning questions ,asking the pt to recall any past success with</p><p> any behavior change, use following questions</p><p> i) What went well and why? </p><p> ii) What would you do differently now? </p><p> iii) How might the outcome be improved? </p><p> iv) [Elicit additional examples from audience]</p><p>2) Value questions (Slide 17)</p><p> i) What are your priorities at this time in your life? </p><p> ii) What matters to you? </p><p> iii) How does alcohol fit in your life?</p><p> iv) [Elicit additional examples from audience]</p><p>6 3) Skill questions (Slide 18)</p><p> i) What did you learn about your skills as you cut back on</p><p> your drinking?</p><p> ii) Were there any surprises? </p><p> iii) What are you doing when everything is going well?</p><p> iv) [Elicit additional examples from audience]</p><p>B. Second skill of MI: Listening - as a tool to guide pt (Slide 19)</p><p>1. Reflect resistance; don’t confront. Use pt’s statement to show you hear and </p><p> understand – not agree.</p><p>2. Reflect change-talk </p><p> a. Change talk predicts commitment which predicts change 14 </p><p> b. Change talk builds up, tips balance in favor of change</p><p> c. Identify change talk: desire, ability, reasons for change, eg: </p><p>Pt: I know I should stop drinking but I am not sure I really want to.</p><p>Dr: Why do you know you should stop drinking? Focus is on </p><p> change</p><p>C. Third skill of MI: Informing (Slide 20) </p><p>1. Information exchange vs information receptacle</p><p> a. Learn what pt knows, assume nothing</p><p> b. Inform based on what pt knows</p><p>2. Provide choice</p><p> a. Giving pt options keeps them in control</p><p>7 b. Your help in defining the options keeps you as guide</p><p>3. Skillful ways to inform</p><p> a. Avoid advice giving, provide options based on evidence</p><p> b. If asked, provide list of options that have worked for others</p><p>D. Transition: We have reviewed basic skills of MI covering major points: (Slide 21)</p><p>1. Asking</p><p>2. Listening</p><p>3. Informing</p><p>IV. Basic steps of MI (Slide 22) </p><p>A. Establish rapport</p><p>1. Ask permission, respect pt’s decision making capacity</p><p>2. Use non threatening language and be reassuring</p><p>3. Case example, preface this with it is known that the chart indicates that the </p><p> patient consumes alcohol (Slide 23)</p><p> a. I know from your chart that you drink. If it is alright with </p><p> you, I would like to spend a few minutes talking about how alcohol fits</p><p> into your life. Would that be ok?</p><p>B. 2nd step used in MI: Assess pt motivation (Slide 24)</p><p>1. Importance ruler, goes for understanding & elicits change talk</p><p> a. On 10-point scale (10= most important), how important is changing </p><p> drinking?</p><p> b. Point out that most of us want to ask “Why isn’t it a “10?”</p><p>8 c. When given #, ask why not less important (Why did you say a 3 and </p><p> not a 1?). This produces reasons for change. Asking “Why 3 and not </p><p> a 10” produces reasons against change</p><p>2. Confidence ruler, goes for understanding and elicits confidence talk</p><p> a. On 10-point scale (10= most confident), how confident are </p><p> you that you could make changes? </p><p> b. Point out that most of us want to ask “Why isn’t it a “10?”</p><p> c. When given #, ask why not less confident (Why did you </p><p> say a 3 and not a 1?). This produces why Pt feels some confidence. </p><p>Asking “Why 3 and not a 10” produces why Pt is not confident</p><p>3. Rulers allow one to focus intervention (Slide 25) </p><p> a. Low importance, low confidence e.g. “this is not important and I can’t </p><p> change”</p><p> b. High importance, low confidence e.g. “this is important but I can’t </p><p> change” (often we continue to educate on importance rather than </p><p> focus intervention on confidence)</p><p> c. Low importance, high confidence e.g. “this is not important but I can </p><p> change if I wanted to”</p><p> d. High importance, high confidence e.g. “this is important and I can do </p><p> it”</p><p>4. Case example (Slide 26)</p><p>Dr: How important is it that you make any changes to your drinking?</p><p>9 Dr: Now if you were to decide to make a change to your drinking, how </p><p> confident are you that you would be successful?</p><p>C. 3rd step used in MI: Elicit motivational statements (Slide 27)</p><p>1. Use basic skills discussed earlier</p><p> a. Examples of open-ended questions</p><p> b. Reflections of change talk</p><p>2. Case example (Slide 28)</p><p>Pt: I know I sometimes drink too much but I don’t think it is a real </p><p> problem.</p><p>Dr: Tell me what makes you think there are times you drink too much. </p><p>(Focus is on having patient expand upon potential reasons for change.)</p><p>Pt: There are times I don’t know when to quit and I get myself into </p><p> trouble.</p><p>Dr: You don’t feel you need to stop drinking but you are concerned that </p><p> drinking heavily, causes you problems, and you’d like to prevent that. </p><p>(Reflecting potential ambivalence; concerns with negative consequences; </p><p> and desire to change behavior.)</p><p>D. 4th step in MI: Resolving ambivalence (Slide 29)</p><p>1. Develop discrepancy</p><p> a. Discrepancy between values and behaviors</p><p> b. Discussion of pros and cons of change 15 </p><p>2. Identifying for what the pt is motivated</p><p>3. Case example (Slide 30)</p><p>10 Pt: I need to cut down on my drinking because of stomach problems, but </p><p> my job has me out entertaining clients.</p><p>Dr: The need of your clients takes precedence over your health.</p><p>Pt: No, no, my health is important to me. I shouldn’t have to make bad </p><p> health choices just to entertain clients.</p><p>Dr: You can entertain clients without having to drink and the reduction in </p><p> alcohol use will result in your being healthier.</p><p>E. Transition: We have reviewed basic steps of MI covering major points: (Slide 31) </p><p>1. Establish rapport</p><p>2. Importance & confidence ruler</p><p>3. Eliciting motivation</p><p>4. Pros & cons of change & ambivalence</p><p>V. Research supporting MI (Slide 32) </p><p>A. Meta-analysis of RCT’s: advice giving as control, MI as intervention and represented </p><p> by gold, rear row (N-72)16</p><p>1. Address addiction (vs advice giving) 75% had an effect,  = good</p><p>2. Rx diabetes, asthma & weight problems 77% had an effect</p><p>B. RCT interventions in medical & substance use settings (Slide 33) </p><p>1. Pts misusing pain medication N=126, after 3 </p><p> months 52%  drug use by 25% or more vs 30% in TAU 17</p><p>11 2. Pts in primary care setting (N=723) received two 15</p><p> minute MI interventions, after 12 months # of drinks per week by 82% in MI</p><p> group vs 60% in Treatment as Usual (TAU) group 18</p><p>3. Pts in substance use treatment setting (N=42) </p><p> received 2 sessions and at 12 months drinks per week were  by 76% in MI vs</p><p>35% in TAU 19</p><p>C. RCT ED interventions for harm reduction - % recurrence. In this slide MI is now </p><p> represented by gold in the front row (Slide 34) </p><p>1. Population = Motor vehicle accident & ↑ BAC or AUDIT N=126, </p><p> after 3 years 11% in MI reported DUI vs 22% in TAU 20</p><p>2. Teens (age 18 & 19) N=94 treated in ED with + screen followed 6 </p><p> months only 21% in MI reported alcohol related injury vs 50 in TAU 21</p><p>3. % Drinking excessively: 18% vs 47% at baseline MI; 32% vs 48% </p><p>TAU</p><p>VI. Summary (Slide 35)</p><p>A. Pt’s w/ AUD will be seen in medical setting</p><p>B. Guiding is alternative to directing style in behavior change</p><p>C. Goal is to understand/explore Pt’s ambivalence</p><p>D. Use MI principles/skills/steps to:</p><p>1. Support the Pt. & reduce resistance</p><p>2. Elicit change-talk & internal motivation</p><p>E. Research supports use of MI in medical & mental health settings</p><p>12 13 References</p><p>1. Bernstein E, Tracy A, Bernstein J, Williams C. Emergency department detection and referral rates for patients with problem drinking. Subst Abuse. 1996; 17:69-76. 2. Rivara FP, Jurkovich GJ, Gurney JG, et al. The magnitude of acute and chronic alcohol abuse in trauma patients. Arch Surg. 1993:128:907-12 3. 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