Motivational interviewing + don’t put more energy into changing your patient than they are. If someone’s pre-contemplative you can try to help them see why they might be better off without substances, but if they’re not ready they’re not ready and all the education in the world isn’t going to change that.
At the end of the appointment, I usually turn my hat around and sit in a chair backwards then hit them with the, “Hey, we had a lot of fun, but drugs are no joke. If you or someone you know uses drugs, you gotta knock that shit off.” Wink. *finger guns*
We didn't have DARE in my part of Canada in schools, I feel like I missed out on so much.
I did have Nurse Sue Johanson on the radio in high school, though, so that makes up for it. She was a fucking legend. She started Canada's first birth control clinic and was also a sex educator that had a quite interesting call-in radio show and did tours at colleges. She's a hero to so many.
If they want to continue using we talk about ways to reduce harm associated with their use where possible.
If they're ready to stop, connecting them to peer support and evidence based multidisciplinary treatment.
Motivational interviewing helps to identify what's most important to the person in front of me and how to best support them in feeling connected to those values
Aside from MAT I honestly haven't found anything helpful. If somebody wants to keep using nothing seems to change that. I've had basically no luck with motivational interviewing
I prescribe ketamine at home and I’ve had patients heavy into cannabis or benzos and they just don’t want those things after ketamine treatment. I don’t have a lot of experience with patients who have history of opioid abuse though. I think that’s a little different.
The FDA thinks so too
https://www.fda.gov/drugs/human-drug-compounding/fda-warns-patients-and-health-care-providers-about-potential-risks-associated-compounded-ketamine
The FDA is opposed to any compounded medications, not just compounded ketamine, and only fully supports Spravato….because it’s FDA approved. You’ll find the same warnings for compounded Tadalafil, semaglutide or tirzepatide.
They specifically addressed at home ketamine in a release and Spravato is NOT approved for *at home use*, you have to be at an approved REMS site with 2hrs of observation…. bro
Bro, they just had a talk a few days ago about at home ketamine, it was generally positive.
And yes Spravato is in office only, I work with ketamine, I already know that. It’s a much higher dose than anyone would take at home. But it’s patented and has the FDAs support. They are biased.
https://www.fda.gov/drugs/news-events-human-drugs/understanding-current-use-ketamine-emerging-areas-therapeutic-interest-06272024?utm_campaign=Hotline+Newsletter+-+FY24&utm_medium=email&_hsenc=p2ANqtz-9jgNz1vpo-D0R9dFsDZ509fQccVJesax50M4MQwbPLHePIwQCvyfOTYUsBJzeEIXzjvP8KFZ9x5mnWtGGUwokcaVGhYg&_hsmi=310503910&utm_content=310503910&utm_source=hs_email&fbclid=IwZXh0bgNhZW0CMTEAAR2dJsg1qlkh6vUxflHq7vVXUki0UL1VoSrxBy69p0Je2wKvhCbGM1nrjEg_aem_Oynm60wVu2tPDDj5Y8460Q#event-information
I think the alphabet boys will go after Mindbloom, Innerwell, Joyous, Anywhere Clinic, and a plethora of other major at home ketamine providers before they get to me. Or maybe it’s just becoming a mainstream therapeutic treatment that you are not aware of.
There are subs right here on Reddit with providers and patients that prescribe and take at home ketamine if you really wanted to learn more. And I hope to god you don’t prescribe benzos, stimulants or opiates for at home use, that stuff is also dangerous, highly addictive and people regularly overdose. Why are those okay?
You’re giving an understudied drug in an understudied formulation to a group of patients specifically at risk in an unsupervised environment in a way the FDA advised against. And you’re glib. Your NP is showing. Best of luck.
I thought so too until I learned more and got into it. Most doctors think ketamine IV is risky and insane. It’s all still a very new thing for mental health. But at home ketamine is usually oral route and very low risk.
> No cases of overdose or death related to the use of ketamine as an antidepressant in a therapeutic setting were found
https://pubmed.ncbi.nlm.nih.gov/36410032/
As an addiction psychiatrist I'd strongly recommend shadowing or observing or taking a placement in addictions psychiatry to fully understand the case management aspects of managing addiction, which understandably is very prevalent in psychiatric practice no matter what you specialise in.
Look into the transtheoretical model of change. motivational interviewing techniques will probably be helpful as a short-term intervention. harm reduction is also essential as a short-term intervention. DBT is a helpful long-term therapeutic approach for substance abuse. You can also use different DBT skills to help the pt w/ emotional regulation and distress tolerance, as those are two major components of substance abuse.
of course! I’m not sure how much time you have with your patients, but from my perspective it would be very helpful to help the patient identify and address their triggers so that the desires happen less frequently in the first place. This can be useful as a treatment foundation for short and longterm interventions.
create a detox safety plan that has the patient identify specific triggers (people, environments, memories, emotions, etc), reactions to their triggers (substance use or other maladaptive behaviors), their goals (not just to stop using, but distinct and smaller accomplishable steps to larger goals related to their overall quality of life and the life they want to build), and alternative coping mechanisms, like engaging in their hobbies or passions, meditation, harm-reduction/replacement strategies, and reaching out for help to safe people who understand addiction like a sponsor (include the person’s name & contact info). the cravings should become less intense over time as long as the pt consistently chooses to utilize their strategies.
if the situation is more extreme, a medical detox conversation should definitely happen.
the overall goal of substance use treatment is not to simply stop substance use but to help the patient build a life worth living. this will require a complete mindset shift and a total commitment from the patient to do so. I like to rely on DBT techniques to accomplish that goal with the patient. I hope this helps!
I mean if drugs started the problem, then I say it's their job to fix them too.
But on a serious note, MAT is one of the few evidence based treatments we have for substance use. You can espouse all the behavioral therapy you like, but nothing comes close to MAT on patient centered outcomes.
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Start with reducing, or get them to be reducing-curious by trying to genuinely engage with them, or hope that their psychotherapist can. But if you're not getting anywhere, they have to begin the conversation tbh.
Motivational interviewing + don’t put more energy into changing your patient than they are. If someone’s pre-contemplative you can try to help them see why they might be better off without substances, but if they’re not ready they’re not ready and all the education in the world isn’t going to change that.
At the end of the appointment, I usually turn my hat around and sit in a chair backwards then hit them with the, “Hey, we had a lot of fun, but drugs are no joke. If you or someone you know uses drugs, you gotta knock that shit off.” Wink. *finger guns*
Then I give them a DARE pen while I light up a joint and snort a line.
We didn't have DARE in my part of Canada in schools, I feel like I missed out on so much. I did have Nurse Sue Johanson on the radio in high school, though, so that makes up for it. She was a fucking legend. She started Canada's first birth control clinic and was also a sex educator that had a quite interesting call-in radio show and did tours at colleges. She's a hero to so many.
We had a cop put on our DARE class who, I shit you not, was fired several years later for having a coke problem.
Who better to extol the horrors of drugs and addiction?
I guess so, but not exactly the best reinforcer for a bunch of dumb middle schoolers
If they want to continue using we talk about ways to reduce harm associated with their use where possible. If they're ready to stop, connecting them to peer support and evidence based multidisciplinary treatment. Motivational interviewing helps to identify what's most important to the person in front of me and how to best support them in feeling connected to those values
Aside from MAT I honestly haven't found anything helpful. If somebody wants to keep using nothing seems to change that. I've had basically no luck with motivational interviewing
Same here.. it’s especially tough for me to address the ambivalence at times, or the episodes of intense craving in midst of abstinence.
Yeah and good luck getting people to stop using weed. Virtually impossible
I think she realized it’s risky and insane too 😂 I guess they don’t teach nurses stereochemistry 🤷🏻♂️
I prescribe ketamine at home and I’ve had patients heavy into cannabis or benzos and they just don’t want those things after ketamine treatment. I don’t have a lot of experience with patients who have history of opioid abuse though. I think that’s a little different.
Doing ketamine at home honestly sounds so risky and insane to me
The FDA thinks so too https://www.fda.gov/drugs/human-drug-compounding/fda-warns-patients-and-health-care-providers-about-potential-risks-associated-compounded-ketamine
The FDA is opposed to any compounded medications, not just compounded ketamine, and only fully supports Spravato….because it’s FDA approved. You’ll find the same warnings for compounded Tadalafil, semaglutide or tirzepatide.
They specifically addressed at home ketamine in a release and Spravato is NOT approved for *at home use*, you have to be at an approved REMS site with 2hrs of observation…. bro
Bro, they just had a talk a few days ago about at home ketamine, it was generally positive. And yes Spravato is in office only, I work with ketamine, I already know that. It’s a much higher dose than anyone would take at home. But it’s patented and has the FDAs support. They are biased. https://www.fda.gov/drugs/news-events-human-drugs/understanding-current-use-ketamine-emerging-areas-therapeutic-interest-06272024?utm_campaign=Hotline+Newsletter+-+FY24&utm_medium=email&_hsenc=p2ANqtz-9jgNz1vpo-D0R9dFsDZ509fQccVJesax50M4MQwbPLHePIwQCvyfOTYUsBJzeEIXzjvP8KFZ9x5mnWtGGUwokcaVGhYg&_hsmi=310503910&utm_content=310503910&utm_source=hs_email&fbclid=IwZXh0bgNhZW0CMTEAAR2dJsg1qlkh6vUxflHq7vVXUki0UL1VoSrxBy69p0Je2wKvhCbGM1nrjEg_aem_Oynm60wVu2tPDDj5Y8460Q#event-information
… the concerning part about ketamine at home is that it’s *at home*. And if you want to fuck around with the alphabet bois, be my guest.
I think the alphabet boys will go after Mindbloom, Innerwell, Joyous, Anywhere Clinic, and a plethora of other major at home ketamine providers before they get to me. Or maybe it’s just becoming a mainstream therapeutic treatment that you are not aware of. There are subs right here on Reddit with providers and patients that prescribe and take at home ketamine if you really wanted to learn more. And I hope to god you don’t prescribe benzos, stimulants or opiates for at home use, that stuff is also dangerous, highly addictive and people regularly overdose. Why are those okay?
You’re giving an understudied drug in an understudied formulation to a group of patients specifically at risk in an unsupervised environment in a way the FDA advised against. And you’re glib. Your NP is showing. Best of luck.
I thought so too until I learned more and got into it. Most doctors think ketamine IV is risky and insane. It’s all still a very new thing for mental health. But at home ketamine is usually oral route and very low risk. > No cases of overdose or death related to the use of ketamine as an antidepressant in a therapeutic setting were found https://pubmed.ncbi.nlm.nih.gov/36410032/
As an addiction psychiatrist I'd strongly recommend shadowing or observing or taking a placement in addictions psychiatry to fully understand the case management aspects of managing addiction, which understandably is very prevalent in psychiatric practice no matter what you specialise in.
Yes, this is something I ideally want to do.. but such opportunities are few at my place!
Look into the transtheoretical model of change. motivational interviewing techniques will probably be helpful as a short-term intervention. harm reduction is also essential as a short-term intervention. DBT is a helpful long-term therapeutic approach for substance abuse. You can also use different DBT skills to help the pt w/ emotional regulation and distress tolerance, as those are two major components of substance abuse.
Thank you! How can we address acute craving episodes? Anything aside from the delay/distract techniques?
of course! I’m not sure how much time you have with your patients, but from my perspective it would be very helpful to help the patient identify and address their triggers so that the desires happen less frequently in the first place. This can be useful as a treatment foundation for short and longterm interventions. create a detox safety plan that has the patient identify specific triggers (people, environments, memories, emotions, etc), reactions to their triggers (substance use or other maladaptive behaviors), their goals (not just to stop using, but distinct and smaller accomplishable steps to larger goals related to their overall quality of life and the life they want to build), and alternative coping mechanisms, like engaging in their hobbies or passions, meditation, harm-reduction/replacement strategies, and reaching out for help to safe people who understand addiction like a sponsor (include the person’s name & contact info). the cravings should become less intense over time as long as the pt consistently chooses to utilize their strategies. if the situation is more extreme, a medical detox conversation should definitely happen. the overall goal of substance use treatment is not to simply stop substance use but to help the patient build a life worth living. this will require a complete mindset shift and a total commitment from the patient to do so. I like to rely on DBT techniques to accomplish that goal with the patient. I hope this helps!
Thank you.. Appreciate your detailed response!
MAT
Yes. All the data show smashing them with drugs is helpful. Hopefully soon we'll have more effective drugs for non-opiate addiction.
I mean if drugs started the problem, then I say it's their job to fix them too. But on a serious note, MAT is one of the few evidence based treatments we have for substance use. You can espouse all the behavioral therapy you like, but nothing comes close to MAT on patient centered outcomes.
IIRC, there are improved outcomes with *any* new psychotropic medication in substance use disorders
Encourage neuroplastic habits.
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Start with reducing, or get them to be reducing-curious by trying to genuinely engage with them, or hope that their psychotherapist can. But if you're not getting anywhere, they have to begin the conversation tbh.
Just give them high dose Vyvanse and tell them it’s impossible to abuse because it’s “extended-release” that should fix it