Brief Motivational Intervention is effective in reducing opiate abuse in many populations, especially with patients with co-occurring conditions (co-morbidity) (Barrowclough et al., 2010). Opiate abuse and addiction is a growing problem in the United States and in the top 3 most abused categories of both illegal and prescription drugs worldwide. A great percent of the prison population in the United States are incarcerated directly or indirectly due to addiction and opiate addiction is one of the leading addiction problems within the prison population. BMI has been found very effective in working with inmates and ex-convicts and helping them overcome addiction and avoid re-incarceration (Forsberg et al., 2011). BMI’s can be used effectively to move someone through the stages of change and in the early stages of recovery, even while detoxing (Berman et al., 2010).
Opiate Abuse a Growing Problem
Opiate abuse is a significant and growing problem with both (Illegal) street drug and (Prescription) drug users. Opiate dependence is a huge economic burden as it raises healthcare cost, work absenteeism, social/welfare costs, crime, incarceration & death rates, and lowers productivity and quality of life (Doran, 2008). The United Nations in a recent report estimated that nearly 80 million people abuse Opium, Heroine, or opiate based substances worldwide (Doran, 2008). The World Health Organization (WHO) estimates the harm from opiate use at 11,200,000 disability-adjusted life-years (DALYs). Death rates due to HIV, overdose, and suicide are greatly increased by opiate use disorders (Doran, 2008).
It is estimated that 60% of all prison inmates are incarcerated for drug related crimes. This population of abusers are more resistant to change and yet their success in being rehabilitated and not returning to jail or prison may be directly correlated to their recovery from addiction. Opiate use disorder is one of the leading causes of drug related crime (Forsberg et al., 2011).
Brief Motivational Intervention (BMI)
Brief Motivational Intervention (BMI) is an evidence-based practice for treating Opiate use disorders. Motivational Interviewing or intervention is a interviewing or conversational style defined as a person-centered, humanistic, and collaborative method of guiding an opiate user to elicit and strengthen their motivation to change (Miller & Rollnick, 2009). Although many behavioral and pharmacological interventions have a high efficacy they come at a high economic cost and still involve lost opportunities or a decreased quality of life. BMI’s have similar effectiveness without such a high cost since they can be part of normal health and behavioral care and can motivate change to a level far deeper and better than most other intervention options (Doran, 2008).
In a recent study conducted in an urgent care clinic that regularly treated opiate and other addictions. They separated treated patients into groups that in group 1) Received Motivational Interviewing (a client-centered approach to counseling that helps clients overcome their ambivalence or lack of resolve for behavioral change through brief intervention sessions), and group 2) Those that received Motivational Enhancement Therapy (MET) that incorporated structured assessments and follow-up sessions for personal feedback regarding assessment findings. Both were done in a collaborative and supportive setting, where trained counselors elicited motivation to change from the client rather than through direction or persuasion. The heroin abusers using both methods of MI had results of 40.2% abstinence compared to 30.6% found in the more formal drug intervention programs that patients were being referred to before the study. The conclusion was that BMI may help patients achieve abstinence from heroin effectively at the point of medical service (Bernstein et al., 2009).
Early studies on using BMI back in the 90’s were inconclusive but did see marked increases in self-efficacy and increased motivation. Later studies begin to find marked higher effectiveness in specific population’s responses to MI and opiate use disorder with co-occurring conditions is one of those populations (Saunders et al., 1995).
Specific BMI Effectiveness
BMI works with various populations of addicts, helps support motivation while in detox and is very effective for patients with Dual Diagnosis/Co-occurring Conditions. In a study that explored using BMI during detox it was found to be a good fit where patients were not yet ready for other counseling models due to impaired cognition and lack of commitment to recovery. BMI’s not only fit into the short time periods the providers had face to face with patients but showed great effectiveness in moving patients through the stages of change and preparing and motivating them to seek out continued recovery resources (Berman et al., 2010).
In co-morbid situations where addiction was co-occurring with behavioral health issues, using Cognitive Behavioral Therapy (CBT) with BMI was found to be much more effective than CBT alone (Barrowclough et al., 2010). The efficacy of HARM reduction with dual-diagnosis cases, or addiction with co-occurring depression, anxiety, bi-polar disorder, and other disorders was greatly enhanced for addicts and their families using BMI (Laker, 2007).
The effectiveness of using BMI for the inmate population has been extensively tested in Sweden. The inmate population is very similar to that in the U.S. as far as percent of addiction related convictions, substance use in jail, and return to use after release from jail. The opiate use disorder problem is also almost identical percentage-wise. The study concluded that prison staff could be effectively and consistently trained to use BMI skills, that the use of BMI made a difference with improved trust and relations in between workers and inmates, and that BMI lowered opiate abuse in prison, after release, and lowered recidivism (Forsberg et al., 2011).
Strategies for Using BMI for Opiate Use Disorders
The most effective use of BMI with opiate use disorders is consistent use across the stages of readiness and using specific strategies for each population of opiate addiction,
BMI is most effective if used regularly by trained staff (Doran, 2008, Forsberg et al., 2011). Use by frontline staff during medical checkups, social services & behavioral health contacts, during detox, and even with controlled populations like prison inmates can greatly motivate opiate use disorder patients to be motivated to change (Doran, 2008, Forsberg et al., 2011, Bernstein, 2009, Berman et al., 2010).
Brief Motivational Intervention can be very effective in reducing opiate abuse in many populations. BMI’s is effective moving addicts through the stages of change, it helps while detoxing patients, in the early stages of recovery, with co-occurring conditions (co-morbidity), and even in working with inmates and ex-convicts and helping them overcome addiction and avoid re-incarceration (Barrowclough et al., 2010, Forsberg et al., 2011, Berman et al., 2010).
There is certainly enough evidence based findings to increase the use of BMI on its own in the medical and social service industry. It also appears that adding BMI and the person centered principles of MI would work together with and greatly enhance the effectiveness of all other forms of intervention, treatment, and counseling (Doran, 2008).
Barrowclough, C., Haddock, G., Wykes, T., Beardmore, R., Conrod, P., Craig, T., Tarrier, N. (2010). Integrated motivational interviewing and cognitive behavioral therapy for people with psychosis and comorbid substance misuse: randomized controlled trial. British Medical Journal, 341(7784), 1-12. doi:10.1136/bmj.c6325
Bernstein, J., Bernstein, E., Tassiopoulos, K., Heeren, T., Levenson, S., & Hingson, R. (2005). Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol Dependence, 77(1), 49-59.
Berman, A. H., Forsberg, L., Durbeej, N., Källmén, H., & Hermansson, U. (2010). Single-session motivational interviewing for drug detoxification inpatients: Effects on self-efficacy, stages of change and substance use. Substance Use & Misuse, 45, 384-402. doi:10.3109/10826080903452488
Doran, C. M. (2008). Economic evaluation of interventions to treat opiate dependence: A review of the evidence. Pharmacoeconomics, 26(5), 371-393. doi:10.2165/00019053-200826050-00003
Forsberg, L. G., Ernst, D., Sundqvist, K., & Farbring, C. A. (2011). Motivational interviewing delivered by existing prison staff: A randomized controlled study of effectiveness on substance use after release. Substance Use & Misuse, 46, 1477-1485. doi:10.3109/10826084.2011.591880
Laker, C. J. (2007). How reliable is the current evidence looking at the efficacy of harm reduction and motivational interviewing interventions in the treatment of patients with a dual diagnosis? Journal of Psychiatric and Mental Health Nursing, 14, 720-726. doi:10.1111/j.1365-2850.2007.01159.x
Saunders, B., Wilkinson, C., & Phillips, M. (1995). The impact of a brief motivational intervention with opiate users attending a methadone programme. Addiction, 90, 415-424. doi:10.1111/j.1360-0443.1995.tb03788.x
I believe Many practitioners and counselors in addiction treatment see pharmacotherapies as the answer alone for addiction treatment because it fits into the medical model in the U.S. of prescribe to take care of symptoms. It also takes less time & effort, and is does not need to be as specific to the needs of the individual in a person centered treatment plan. (It can be more standardized) Obviously for detox and ambulatory or out-patient medical treatment for addictions the new medications are helping address the problems far better than ever before.
There are also those involved in addiction treatment like myself that although realizing there are benefits in many cases to use pharmacotherapy as part of the treatment plan (especially with co-occuring conditions), have come to believe that to get at the heart of the underlying causes not just the symptoms a combination of medication, behavioral, and even other complimentary treatments will get not only the best results short term, but will address healing the chronic and progressive nature of addiction long term. Hopefully customizing the treatment plan to the individual and allowing them to be more proactive in their treatment choices will lower re-lapse rates and bring about deeper and more persistent change.
When a client is ambivalent towards treatment options, especially when medications are involved the time needs to be invested to educate them to the objectives and benefits of the medications, allowing the client/patient to personally choose pharmacotherapy as part of their treatment plan and truly “buy in” to the plan, so they will remain compliant with the use of the medication and achieve the progress and recovery they desire. If they are not using the medications properly they can become part of the addiction cycle and may reinforce the addicts thinking that they always need to reach for something to feel better. The best strategy long term is for the client to develop inner coping methods to work through their pain, only then will they develop self regulation and coping skills.
The subject of addiction brings up many opinions and beliefs. These views on addiction can greatly affect ideas on what is addiction, if it’s possible to stop or recover from addiction, and what are the best ways to treat or overcome addiction if it is possible (Sellman, 2009). An addict, loved one of an addict, or a professional treating addiction has to wonder at times is addiction a lack of will power, a psychological or emotional issue, a chronic illness, a progressive disease, or a combination of all of the above?
Addiction comes in many forms but the process of becoming addicted and the progression of the disease has many commonalities that are better understood today than ever before. Whether the addiction is to a substance, a pleasurable activity, or a process the transition from a genetic vulnerability to a disease that changes the structure and function of the brain is similar in various ways (HMHL, 2011). First the desired subject/object/action stimulates Dopamine and other neurotransmitter activity and interaction in the brain, bringing about pleasure or reward. The speed and consistency of the result determines the strength of the connection made in between stimulus and pleasure (HMHL, 2011). As this hedonic drive moves from desire to need the motivation to seek the pleasure is increased. Eventually this pleasure seeking mechanism becomes more of a compulsive unconscious obsession as the limbic system goes on auto pilot with the amygdala whispering heavily emotional lies about how great the pleasure really was. Even though tolerance has eroded the majority of the pleasure, many parts of the experience have become directly linked to the past pleasurable results that it triggers the frontal cortex to shut down and the limbic system to take over when triggered (HMHL, 2011).
Once one is in the trenches of addiction how can this all-encompassing subconscious automatic behavior become interrupted to the point of causing a shift in awareness or an epiphany that the strategy that once worked in finding pleasure now just brings them pain and sorrow (Sellman, 2009). When in the grip of addiction it is difficult to stop without motivators. This is not due to a lack of desire or will; it’s simply due to the fact that the majority of the pattern has become an autonomic reaction in the brain far from consciousness (HMHL, 2011). You need to have awareness before ownership and transformation can take place. Because addiction is full of stealthy memories in the brain that have such strong emotional content that can be triggered at any minute by recalled data throughout the visual and sensory cortex, recovery will take time (HMHL, 2011). Addicts need to move through the stages of change at their own pace based upon their own intentions and development (Sellman, 2009). New strategies and skills for self-regulation and behavioral & lifestyle modification will be the most important parts of that development.
All forms of therapy get results (Sellman, 2009). Like the law of inertia the addict will need to put apposing energy, time, and work into moving in a new direction. Energy equal to what they put into obsessing about, seeking, and using that which they were addicted too. There is not one answer for all alcoholics and addicts (Sellman, 2009). A person needs to on one hand find what will work for them, while on the other hand be open and teachable. Programs need to take a person centered, humanistic approach; tailoring treatment plans to address the individual uniquely and holistically to get best results (Sellman, 2009). Both physical and behavioral co-occurring conditions that acerbate the addiction need to be addressed, (since such a high percentage of addicts have psychiatric and other comorbidity factors) and the continuum of care needs to support recovery for as lengthy a time as possible (Sellman, 2009). Relapses although not excusable are part of the disease and should be expected as part of recovery. Learning from relapses may be as important as relapse prevention in supporting one on the journey of healing and recovery (Sellman, 2009). Only when physical, emotional, mental, and spiritual needs are being met in healthier ways can an addict fully recover from addiction.
The time has come to combine the best evidence based traditional and complimentary medical treatments with therapeutic approaches that reach and support an addict in recovery, meeting them where they are at and helping them make the steps needed to overcome that which enslaves them (HMHL, 2011). This will only occur as old beliefs and opinions are discarded for the current view on addiction prevention, intervention, treatment and recovery. More providers, caregivers, therapist, social workers, and school counselors etc., that end up being the first point of contact so often for addicts, need to be more aware of intervention skills and open to helping their clients/patients find the resources for help earlier in the addiction cycle (Sellman, 2009).
How addiction hijacks the brain. (2011). Harvard Mental Health Letter, 28(1), 1-3. Retrieved from http://www.health.harvard.edu
Sellman, D. (2009). The 10 most important things known about addiction. Addiction,105, 6-13. doi:10.1111/j.1360-0443.2009.02673.x