________________________________ Substance Use Disorders and Pain Management: MATE Act Training
The Tobacco, Alcohol, Prescription medication, and other Substance Use (TAPS) Tool is validated for use with adults to generate a risk level for each substance class. It can be self-administered or conducted via clinician interview and combines screening and brief assessment of past 90-day problematic use into one tool [14]. The TAPS Tool has two components. The first component (TAPS-1) is a four-item screen for tobacco, alcohol, illicit drugs, and non-medical use of prescription drugs. If an individual screens positive on TAPS-1 (i.e., reports other than “never”), the tool will automatically begin the second component (TAPS-2), which consists of brief substance-specific assessment questions to arrive at a risk level for that substance. Clinicians are encouraged to provide posi- tive feedback to patients who screen negative and support their choice to abstain from substances. The tool can be accessed online at https://nida.nih.gov/taps2/#/. DIAGNOSIS As noted, the DSM-5-TR defines substance use disorder as a problematic pattern of substance use, leading to clinically significant impairment or distress. While criteria are outlined for specific substances in the DSM-5-TR, the components are generally the same regardless of substance used. The diagnosis of substance use disorder is made by meeting two or more criteria in a one-year period [1]: • Substance taken in larger amounts or over a longer period than was intended • A persistent desire or unsuccessful efforts to cut down or control use • Excessive time spent to obtain, use, or recover from using the substance • Craving, an intense urge to use • Substance use interferes with obligations • Continued use despite life disruption • Reduction or elimination of important activities due to use • Recurrent use in physically hazardous situations • Continued use despite physical or psychologic problems • Tolerance ‒ Need for increased doses of the substance for the desired effect ‒ A markedly diminished effect with continued use of the same amount • Withdrawal In the case of opioid use disorder, the criteria for tolerance and withdrawal are not considered to be met for those taking opioids solely under appropriate medical supervision.
SUBSTANCE USE DISORDER TREATMENT
All substance use disorder treatment plans should reflect the patient’s most important goals and establish measurable and achievable steps toward achieving those goals. As such, all treat- ment plans will be individualized and created in collaboration with the patient. This recovery roadmap also requires that clinicians communicate with clear, nonstigmatizing language regarding the patient’s condition and options.
TREATMENT PLANNING Assessing Readiness to Change
Readiness to Change is Dimension 4 of the American Society of Addiction Medicine’s (ASAM’s) Six Dimensions of Multi- dimensional Assessment (also known as the ASAM Criteria) that is the standard for placement, continued stay, transfer, or discharge of patients with substance use disorder and co- occurring conditions [15]. Several factors influence a person’s readiness and ability to change behaviors. It is useful to help patients to weigh the risks of continued substance use and benefits of decreasing or eliminating substance use. Healthcare professionals can help motivate the patient to become ready for treatment if the patient appears ready to change. Is the patient ready to change? The role of motivation is an important part of changing behavior. Motivational Interviewing Motivational interviewing is a method of counseling designed to enhance patients’ motivation to change by helping them explore and resolve their ambivalence about making the change [16]. It is a collaborative, non-confrontational, “guiding” approach. In substance use disorder, motivational interview- ing utilizes active listening to understand how the patient feels about his or her substance use in an effort to uncover any ambivalence [17]. The healthcare provider elicits the patient’s own views regarding consequences of continuing to use and benefits of quitting and asks permission to share additional information on risks when necessary. Goals are developed collaboratively, based on the patient’s current readiness to change. Originally developed as an intervention for alcohol use disorder, it has shown promise as a successful strategy for other substances as well. PSYCHOSOCIAL THERAPY Treatment of substance use and dependence with psychoso- cial or behavioral therapy is based on the assumption that addictive behavior is developed and maintained by specific mechanisms [18]: • Expectancies and modeling
• Reinforcing properties of the drug • Secondary social reinforcement
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