So, the next talk, we're going to focus on psychosocial supports for patients, and especially kind of the more non-traditional ways to access psychosocial supports, because we know that there's a huge shortage nationwide of behavioral health professionals, and the ones that are there are already overworked and overbooked, and also that patients themselves have a lot of, you know, reasons why they are not willing or able to access traditional kind of one-to-one therapy. So, we're going to talk a little bit about what some other supports, evidence-based supports that can be considered to be utilized to help provide support for people who are using substances. So, there's, you know, a broad range of supports, so the ones, you know, we typically think of, you know, individual counseling and residential treatment, intensive outpatient care, but there are community supports, and there are virtual supports, and other sorts of supports that can be helpful when those, or in addition to those supports, or when those supports aren't available for patients. So, first of all, as we mentioned kind of earlier today, that the lack of access or participation in substance use disorder counseling should not be a barrier to medication access, and there are a number of, there really isn't any data that supports requiring behavioral health support in order to get medication for opioid use disorder. When we look at the kind of the three most important quality indicators for care for opioid use disorder, which would be being able to stop using abstinence, retention in treatment, and reduction of mortality, we know that medications like buprenorphine and methadone are very good at doing all of those things. However, the addition of counseling services to medication treatment isn't actually shown to improve the outcomes for those most important components, so it can help to address underlying comorbid conditions, it can help to improve patients' quality of life, to reduce symptoms especially of other comorbid mental health issues that are going on, so it can provide benefits to patients, especially addressing those underlying conditions, but it is not necessary at all in order to get the most important benefits, the life-saving benefits of the medication, do not require the addition of counseling for that to occur. So, it's valuable, but it should not be required. So, again, here, this is kind of looking at review, despite, you know, there's really mixed results from the addition of psychosocial treatment that, you know, especially when people, you know, aren't meeting their goals or have, you know, a lot of other comorbid issues that there are, you know, aspects of their quality of life that can be improved by offering psychosocial support, and the majority of our patients are going to have comorbid mental health diagnoses with their substance use. That is normal. Not everyone, but most people do, and that intersection of many people are using the substances to self-medicate those underlying mental health diagnoses, and if those comorbid diagnoses continue to be not addressed, then they can continue to be triggers for return to use. So, it's really important to, at the same time that we're treating the substance use disorder, to ideally, at the same time and the same place, to treat the other mental health disorders, and also medical conditions that can be causing symptoms that are triggering for people to want to use, and so, and really focusing on, you know, non-narcotic medications to treat those other comorbid conditions and other psychosocial support to treat those comorbid conditions. Again, even in recovery, you know, over two-thirds of people in recovery report that they have ongoing mental health issues. You know, some people, when they stop substances, their mental health dramatically improves. You know, the mental health problems they were dealing with were really being caused by that substance, but for many people, there is an underlying comorbid condition. It's not going to go away even after they stop their substance use, and when we look, you know, particularly at amphetamine use, we know that that comorbid use can really increase the, you know, when people are not, when they're using, they can experience psychosis, and when they're not using, they can have very prolonged severe symptoms of depression, anxiety, sleep disorders that can go on for a long time that are huge triggers for people to return to use, so addressing those underlying conditions can help people be more successful in trying to stop stimulant use. So, for patients who are dealing with anxiety and depression, we definitely want to avoid the use of benzodiazepines if they're not already on them. People are on them. You know, we don't want to taper them rapidly. A study just came out this week showing increased mortality with discontinuation of benzodiazepines, but we want to offer people, you know, some non-narcotic options to help manage their anxiety and depression, and oftentimes to people, you know, if we can get the substance use under control, we're going to be more successful in, you know, in treating some of these underlying issues. A lot of folks, you know, really haven't had an adequate trial, you know, of all the good evidence-based treatments of this while they were also, you know, in treatment and controlling their substance use, so they can have improved responses to medication than they may have had in the past when they were maybe continuing to use substances. And also, you know, with sleep, the most effective treatment for sleep disorders, specifically insomnia, is cognitive behavioral therapy for sure, and that it can be really difficult to, but it helps to, you know, to reframe a patient's perception of insomnia of, you know, it really being an anxiety disorder about people being anxious about their quality of their sleep, and so getting to the root of that is the most effective way to relieve those symptoms. There are some apps. There's a free app from the VA that gives some support for that. If we are going to prescribe, you know, there's very little evidence that medications are really helpful for quality of sleep, especially in the long term, but if we are going to prescribe those, which in the short term, especially early in recovery when people are really struggling with sleep, can be a major trigger for them, so choosing, you know, non-narcotic medications to try to help, at least in the short term with their sleep, can help people kind of get over that struggle in early recovery, and it's important to remember that psychosocial support becomes in many forms. It's not just in one-to-one counseling. There are a number of evidence-based approaches to providing psychosocial support, and it really is, you know, what is accessible and available to the patient. So, and utilizing things like peer support can be very helpful, even, you know, texting with a peer support person. It's, you know, it's a little thing, but that can make a difference in people's lives. Doing motivational interviewing during their appointment while they're there, you know, it's just a little bit, but doing, when you do that every time you see them, that can really add up, and it absolutely can result in people getting motivated to make significant changes in their life. When we think of the roles that, you know, a behavioral health aid or peer support person can play in a person's life, they, you know, they can really kind of help fill that role that we can't traditionally fill, like, in the medical or the traditional behavioral health model of, you know, being that person that they can be connected to outside of the medical appointments, they can text with them, and, you know, can help them to maybe help them to attend a support group, maybe go with them, help them to, you know, maybe go for a walk and just, you know, get out and get away from their situation, helping people to navigate the system, to get those other resources they need, to get housing, to get, you know, other support, to get connected with legal advice, and all those sorts of things that can help to improve their quality of life and their stability in their day-to-day lives, and also kind of being that touch point for warm handoffs and navigating the system for the patients. And making those connections with other social service organizations in your community is really important that they, you know, that once you're, you know, offering treatment and accepting new patients, that you make sure that, you know, that those social service offices know that patients can get treatment there so that they can refer people if they need to. But then also you or your peer support person or case manager or behavioral health aid has an understanding of what services are offered at the other social services agencies so that they can connect patients to those social services that they need to improve their quality of life. And some communities will have community coalitions or task force where people, you know, from the medical field, from behavioral health, from these different social support services will all come together, you know, maybe once a quarter and sit around and all talk about what they're doing. So everyone understands what everyone else is doing and we can kind of create a community in which patients can kind of flow seamlessly between these different agencies and rather than having these silos that are difficult for patients to navigate to get all the services that they need. Scheduling barriers, wanted to specifically talk a little bit more about the idea of group visits here. So group, integrated care group visits, the idea behind this is that patients who are kind of at a similar stage in their treatment journey and have similar diagnoses are grouped together and then all seen at one appointment, both to get some behavioral health support and to get the medical check in. So that might be a group of between four maybe to eight people who maybe they come in at the same time every week, every other week, once a month, you know, depending on where they're at in their journey and they can, you know, while they're there, they can do things, you know, some of the logistical things that need to be done as far as, you know, maybe they need to give a sample for a drug screen or have their medications counted. Maybe they need their vital signs checked, you know, when they're coming in and then they can, you know, sit down with this other group of people and have, you know, a group that's facilitated by, it really could be facilitated by anyone. I mean, it could certainly be facilitated by a licensed behavioral health professional, but it also could be kind of more maybe like mutual support group focused where it's led by a person with lived experience, you know, maybe a behavioral health aid, a peer support person, you know, there's lots of different ways that they can be facilitated ways that these groups can be structured from the standpoint of, you know, the discussion or the kind of the therapeutic support that's happening within that group of people. And then sometimes the provider will sit in on those visits. Sometimes there'll be a separate visit where a patient either right before, right after, or even during the group just comes out for five to 10 minutes and chats with the provider about like, you know, are you taking your medications? How are you doing? Are you using? Here's your refill for the next two weeks. very, very brief visit. And sometimes that even becomes part of the group where people kind of go around and talk about like, how are you doing with taking your medication? You know, how are you doing with your mood? And, and this is actually can be, you know, is a billable service. And it can be depending on how you operate, it can be billed, sometimes by behavioral health and by medical at the same time. And it can allow you to consolidate, you know, multiple patient appointments into a shorter period of time. And, and also to provide kind of a regularly scheduled time that can create some routine for patients rather than having appointments, you know, moving all over the place on the schedule and having a hard time remembering when their when their appointment is. So so this is one, you know, one kind of approach that a number of practices have utilized that has helped them to, you know, both provide that, you know, both services at the same time, you know, providing that behavioral health support when it otherwise isn't available. And while also, you know, reducing the burden on the scheduling both for the for the behavioral health and for the medical provider can can really kind of simplify things in some ways. So it's definitely an alternative kind of scheduling approach to providing the integrated care with less resources. When we look at other evidence based research interventions, the again, so we talked a little bit, you know, cognitive behavioral therapy, you know, if we're going to look at a traditional therapy does have evidence that it improves, it can help people improve the quality of their life. And we're going to talk a little bit more about some of these other approaches here to treatment. So community reinforcement approach can be particularly helpful to help. And this can be part of part of that group, group therapy, or it can be one on one, where we're focusing not on a particular mental health diagnosis, but rather focusing on improving people's quality of life of helping people to have a more be able to get more joy out of life and have a more fulfilling life to help with their relationships to help them get a job, to help them find sober activities that are fun, things that bring them joy, ways to fill their time, those sorts of things as an approach to improving the quality of life. The other thing that can be dramatically helpful to get people into treatment and to keep them in treatment is is therapy, not for the patient, but for their family. So craft or community reinforcement and family training can be very helpful to by providing training to the family members about, you know, what's helping them understand the disease of addiction, helping them understand how treatment works, helping them understand how they can support their loved one to encourage them to engage in and to stay in treatment is very effective at increasing people's uptake of treatment. And so some studies have shown that up to two thirds of family members who, who got training and craft were then able to help their loved one to engage in treatment. So providing that the support to the family, in turn can help provide that support to the patient. And there are, there are online resources as well, groups as well as books and things that people can get information to get some of this training on craft, even if it's not available locally. And so these are some, some websites that are kind of groups that are based in the craft model that can help families to get some of the support they need to better support their loved ones who are dealing with substance use. Again, some more online resources. And this, this website here, helping families help also has lists of like all kinds of great books and just like a really lots of information about evidence behind craft. So it's a good, a good resource to check out. Contingency management. This is something that generally it's not widely available, but it's going to potentially become more widely available now that it's getting more opportunities for funding, as well as kind of more, more acceptance, and more clarity, clarity, that it is, you know, very effective intervention to treat all different kinds of substance use disorders. So in contingency management, we reward people for meeting objective goals. So those rewards typically are monetary, they don't have to be sometimes they're prizes, sometimes they're other affirmations. But typically, it's a monetary rewards that could be averaged like one to $200 per month, that reward people for meeting specific goals. So typically, the most two most common objective goals would be abstinence from a particular drug. Most commonly, this is utilized for stimulant use disorders. So abstinence from stimulants as demonstrated by a drug test, and attend engaging with treatment. So attending their behavioral health appointments, attending their groups, or it could also be for getting their staying on their medication. So getting their their monthly medication injections, rewarding that. And this is can be incredibly, incredibly effective at increasing abstinence rates, increasing engagement and treatment and increasing medication compliance. And the idea behind this is that we are trying to make again, making, making real life more rewarding for people early sobriety can be very difficult, it can be very uncomfortable, people are lonely, people are depressed, you know, it's a very hard time for people. So we want to make life rewarding. Again, for people, we want to make meeting their goals rewarding. And so that's the idea behind this is that to making abstinence, the perceived reward from abstinence or meeting their goals to outweigh the perceived reward associated with a drug use. And by far, the the it is the most effective psychosocial intervention for almost any kind of substance use, contingency management, but unfortunately, it's also some of the least utilized. And when we look at like some different ways in which it's used, it can be dramatically effective and things like even like helping adolescents stop smoking, increasing, increasing abstinence, it can be very helpful in helping people stay on their medication. Especially when we look at, you know, you know, a monthly medication, getting people to come in and get those injections. People, you know, studies that looked at that showed that people were much more likely to come in every month and get those injections if they got incentive for doing so. And when we combine contingency management along with that community reinforcement approach, you know, making those immediate giving patients those immediate rewards and then also helping them to get the skills and resources they need to make their life more rewarding. That is really by far the most effective treatment for stimulant use disorder. And it dramatically increases abstinent rates by like fourfold or higher, even having a persistent effect to some degree after the therapy is stopped. Motivational interviewing, I won't go into this too much, but there's lots of resources for motivational interviewing. Again, this is something that we can provide patients in just, you know, five minutes or less at every visit, even if they're not engaged in other formal mental health, to allow people to talk themselves into change based on their own values and interests. And it is efficacious for many different diseases and disorders, not just substance use. And, you know, people are really better persuaded by reasons that they have themselves rather than us being the authoritarian and telling them what to do. That internal, you know, fueling that internal motivation is what we want to do. And it really also helps to nurture that therapeutic relationship we have with a patient that we're giving them autonomy, we're working together with them, for them to be setting the goals and making the decisions about their lives. And there are a couple of resources that can help that are more culture specific for learning about motivational interviewing. So it's something anyone can learn about motivational interviewing. So it's absolutely something that, you know, that ancillary staff can learn, behavioral health and peer support people can learn about how to do motivational interviewing, and medical doctors who don't have other, you know, psychiatric training can learn about motivational interviewing. So it's a very low barrier, easy to offer, you know, intervention that anyone can get the training and be able to do whenever they interact with someone. And to not underestimate the support from the general community supports and cultural support. So familiarizing yourself, you know, with what is available for supports in your community, so that you or your peer support person or a behavioral health person can try to help, you know, connect patients with some of these other supports, you know, that might be helpful for them. And behavioral health aides, in particular, are a greatly underutilized resource. There are people, you know, there that are, you know, already part of that community and that culture that, you know, live there and are and can provide kind of be that bridge to help help people get some of the services they need, and fill in some of those gaps when we have, you know, this ongoing significant shortage and behavioral health professionals. And some, some tribes have culture camps, that can be really helpful in supporting people. So finding out if there might be opportunities locally there for culture based, you know, therapeutic retreats or other supports that can help people reconnect to their community and reconnect to their culture and get that really 360 mind, body and spirit support that isn't otherwise available in their in their day to day life. The Lakota seven direction model has some really nice information about about their program online, you know, about about kind of doing doing just that with a culture based therapy to really help support people all you know, all around in that way. And there are also some in different areas, you know, our meetings that are available online or by phone. And some of those are culture specific, and some of them are not. But now in this day and age of, you know, online access, there are so many more supports that are available if they're not available there locally. So this is just, you know, a short list of some of the virtual recovery meetings. So essentially, if people do have access online, which not all of them do, but if they do, you know, being able to like at any time at any place, you know, get that mutual support that they need, even if it's not available in their area. Now, it is important to and some of these have phone ins like the a lot of the AA and NA groups have phone lines, you can call in if you don't attend meetings if you don't have internet access, but it is very important before you refer a person, especially to a mutual support group, to find out if that mutual support group is supportive of patients taking their medication. Some AA groups and especially NA groups are not necessarily supportive or may even encourage patients to stop taking their medications, which is the last thing that we want. So and one, one that's always going to be supportive is, you know, a specific new group, this is online, medication assisted recovery anonymous. So this is a specifically a mutual support group that is for patients who are taking medications to treat their substance use disorder. So it's specifically designed to be supportive to that group of medications, that group of patients who are taking medications. And there are also a number of apps that can provide behavioral health support. And I have a list this isn't really I have a do have a list of those though that I can email you if that are things apps, I have a list of apps that are free apps where a patient can go to get to get some of that support that they need and those daily affirmations and reminders and track their sobriety and everything that they can do on you know, for free from their device if they have one. Okay, well that I'm that is the end of that and the end of our information for today. So I will stop there.

psychosocial support

medication access

comorbid mental health

evidence-based supports

non-narcotic treatments

integrated care group visits