The Role of Motivational Interviewing in SUD

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Introduction

History can provide many examples of using different substances to change an individual’s psychological state, mood, cognitive processes, or behavior. However, although substance use can be viewed as a part of human life typical of different national, social, and cultural contexts, this practice can potentially result in abusing drugs and cause significant psychological and physical harm, destroying interpersonal relations. Even though some drugs can be used safely, most people using substances face health and social problems (Lal 2005).

It is possible to refer to drug addiction as a specific substance use disorder. This illness can be defined as mostly a chronic condition, for which the continuous and repeated seeking, use, and misuse of drugs are typical despite experienced harmful consequences. This specific psychological and mental illness has a relapsing nature, and it provokes critical changes in the brain, being the most severe form of a substance use disorder (National Institute on Drug Abuse n.d.).

The National Institute on Drug Abuse (NIDA) refers to the term “addiction” when discussing such specific behavior as obsessive drug-seeking. Nevertheless, in The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), “addiction” is not mentioned as a separate condition or diagnosis, and it is regarded under the category of “substance use disorder.” This disorder can be specified as mild, moderate, or severe (National Institute on Drug Abuse n.d.).

The condition is characterized by a variety of symptoms: social impairment, decreased control, the risky use of drugs, and pharmacological criteria. Ten diagnostic criteria are used to determine a problematic pattern of using drugs according to DSM-5. These criteria help to distinguish between different degrees of the disorder. Thus, a mild disorder is characterized by 2-3 criteria, a moderate disorder – by 4-5 criteria, and a severe disorder – by 6-10 criteria (National Institute on Drug Abuse n.d.).

Referring to this classification, researchers agree that, despite the degree of disorder, the key influential factor is the client’s commitment to realizing change in the pattern of using substances (Lal 2005). Behavior change models in this case are frameworks that can explain what stages and steps individuals overcome on their paths to change their behavioral patterns. There are several models of behavior change, the two-stage model by Tuchfeld and the trans-theoretical model by Prochaska and Di Clemente are most remarkable.

According to Prochaska and Di Clemente’s model, the key stages of change are pre-contemplation, contemplation, preparation, action, maintenance, and possible recurrence (Lal 2005). Interventions to treat a substance abuse disorder apply these change models. Behavioral counseling, the use of medications, cognitive behavioral therapy, and motivational interviewing are actively used to treat drug addiction.

Motivational interviewing (MI) was developed by William Miller in the 1980s to affect clients’ motivation to change their drinking behavior as the motivation to change is a critical element in the behavior change process (Lal 2005). MI provides patients with opportunities to determine how they can change their conduct and condition for the better. Discussing the model of change appropriate for this intervention, Miller focused on the contemplation stage, when MI can work most effectively (Smedslund et al. 2011). Still, the use of this intervention at all stages of change is suitable, concerning positive results regularly observed at the preparation and maintenance stages.

Despite the presence of many studies on using different types of interventions, including motivational interviewing, on people’s abuse of drugs and possible changes in behavior, the systematic approach to analyzing the effectiveness of this intervention is required. In their study “Motivational Interviewing for Substance Abuse,” Smedslund et al. (2011) concentrated on examining MI in comparison to other interventions and treatment or the absence of any.

The objective of the study was to evaluate the effectiveness of MI for changing the behavior associated with drug use along with supporting retention in treatment and predicting repeat convictions. This paper will present the analysis of the available literature on the topic of using MI for substance abusers with a focus on the discussion of the main study’s results, strengths and weaknesses, and implications for practice.

Rationale for the subject and its importance in the field of addiction and healthcare

In the United States, the use of alcohol, tobacco, and different types of illicit drugs cost the government about $750 billion per year related to cover healthcare and workplace expenses. Thus, in 2016, “drug overdoses killed over 63,000 people in America, while 88,000 died from excessive alcohol use” (National Institute on Drug Abuse n.d., para. 2). Currently, various psychological treatments of drug addiction among other types of substance abuse are supported by the American Psychological Association, and the application of motivational interviewing is among them (Madson et al. 2016). Health care professionals actively use behavior change interventions like cognitive behavioral therapy and motivational interviewing because they are reported to be effective in assisting in changing individuals’ behaviors (Lal 2005).

Nevertheless, little research is available regarding the population and types of drug addiction in which motivational interviewing can be used most effectively. Although MI as a therapeutic intervention is applied widely to treat a substance abuse disorder, it is still significant to determine in which cases it helps, it is beneficial, or it can harm patients and be rather ineffective.

Thus, the reason for conducting this review of the literature on the application of MI to address a substance abuse disorder is that more evidence is required to conclude about the effectiveness of the MI in different contexts. It is important to refer to the assessment of the wide synthesized review of the literature on the topic to find out how MI can affect changes in the behavior of adult individuals suffering from drug addiction as numerous systematic reviews and meta-analyses have been published on the issue (Madson et al. 2016).

Still, the available literature is rather limited to cover different national contexts, and much research is provided on the situation only in the United States and European countries. This paper will focus on examining how MI can be applied to reduce the use of drugs in patients concerning the study by Smedslund et al. (2011) to determine how MI is effective in treating the addiction and what strengths and weaknesses of the study can be identified. The implications of the study for practice, health care, and theory will also be provided at the end of this report.

The question that will be addressed concerning this review of the literature is what is the quality of the existing evidence on the application of motivational interviewing in cases when patients’ behavior needs to be changed to help them reduce drug addiction. The results of the review will be used to guide health care professionals, therapists, counselors, and researchers regarding their application of the most effective interventions for the particular purpose of treating a substance abuse disorder.

Structured critical review of the recent relevant literature

Neurobiology

Neurobiological processes associated with the activities of drugs are complex, and researchers pay much attention to examining them in detail. Substances can directly influence how neurons usually receive, send, and analyze signals with the help of neurotransmitters. Such drugs as marijuana and heroin have a specific chemical structure that can mimic neurotransmitters’ activities and activate neurons (National Institute on Drug Abuse 2018).

Still, the similarity with the brain’s chemicals does not mean that drugs influence neurons in the same way as neurotransmitters, resulting in exchanging atypical messages. The effect of such drugs as cocaine and amphetamine on the brain and neurons’ network is that these substances make neurons release extremely large numbers of neurotransmitters, such as dopamine, serotonin, and endorphin among others, and interfere with transporters (National Institute on Drug Abuse 2018). As a result, the healthy communication between neurons becomes affected.

Thus, drugs change brain areas required for life-sustaining functions and, as a result, provoke the compulsive drug use associated with addiction. Related neurobiological processes are usually observed in such parts of the brain as the extended amygdala, basal ganglia, and prefrontal cortex among others. For instance, opioids have an impact on such a part as the brain stem that controls different such basic body functions as heart rate and breathing (National Institute on Drug Abuse 2018).

As a result, the heart rate and the frequency of breathing controlled by the brain stem become affected when individuals use opioids, and overdoses can lead to problems with breathing and even death. However, despite the obvious connection between the use of drugs, their impact on the brain, and the associated development of drug addiction, researchers have not found out why some individuals are more predisposed to addiction than others. Researchers also share the view that compulsive drug use develops as a result of various factors, including biological, psychological, and environmental ones (National Institute on Drug Abuse 2018).

Epidemiology

The epidemiological evidence available for the recent years allows for focusing on the connection between the number of drug abusers in the United States and worldwide and increased morbidity and mortality rates. According to the data collected by the Substance Abuse and Mental Health Services Administration (SAMHSA), about 22.5 million people living in the United States and aged 12 and older years were reported to have drug and alcohol problems requiring treatment in 2014 (National Institute on Drug Abuse 2019). This number comprises 8.5 percent of the overall population of the country.

Furthermore, only 4.2 million people received any appropriate treatment to treat their problem in the same year (National Institute on Drug Abuse 2019). Additionally, 2.6 million people participated in specialty treatment programs to get the required assistance. Today, there are about 35 million drug abusers in the country who require treatment (National Institute on Drug Abuse 2019). Thus, researchers conclude that millions of people in the United States need effective treatment to overcome their drug addiction, but only a limited number receive the necessary aid.

Research and ethical subjects: the study by Smedslund et al. (2011)

Smedslund et al. (2011) in their study were aimed at determining the effectiveness of motivational interviewing for affecting substance abusers in terms of their readiness to change, focus on treatment, and possible repeat convictions. The authors started their article with the background, describing the nature of motivational interviewing and its objectives. The researchers organized a study as a systematic review based on the application of meta-analysis.

The selected methodology for conducting the study and addressing the objective can be regarded as appropriate because the researchers received access to a high range of data to conclude about the outcomes of using motivational interviewing with abusers of substances. Thus, Smedslund et al. (2011) searched 18 web-based databases, websites, and mailing lists to retrieve randomized controlled trials with such participants as drug abusers, to whom motivational interviewing and motivational enhancement therapy were applied.

The authors of the research successfully organized the data collection and analysis processes concerning efficient inclusion and exclusion criteria. The researchers were unbiased when selecting articles to analyze, and 59 articles were finally retrieved for further examination and discussion. Smedslund et al. (2011) used an effective approach to categorizing the received findings into outcomes related to motivational interviewing versus no-treatment control, motivational interviewing versus usual treatment, motivational interviewing versus assessment, and motivational interviewing versus other treatment.

The researchers found out that MI had a significant effect on substance users when being compared to no treatment. Weaker effects were determined when comparing motivational interviewing with other treatment options. The authors concluded that MI should be selected as therapy in cases when no treatment is used, but in comparison to other types of treatment, interviewing can be not so effective (Smedslund et al. 2011).

The ethical aspect to pay attention to concerning the study by Smedslund et al. (2011) and other researchers is that motivational interviewing as a brief intervention can be ineffective in cases when stronger treatment options are required. Furthermore, the application of MI can be connected with certain ethical issues. Thus, the treatment of patients with a substance abuse disorder can be associated with many ethical dilemmas, such as the treatment of people against their will, the respect for patients’ choices, and the respect for their autonomy. Thus, before the application of MI, it is important to ensure that patient’s rights are addressed to avoid their involuntary participation in the interview session (Parmar, Patil & Sarkar 2017).

Additionally, according to Smedslund et al. (2011), motivational interviewing can be not as effective as cognitive behavior therapy when a behavior change is expected, and a healthy lifestyle choice should be done. Some studies tend to report positive outcomes for patients depending on the use of MI and suggest using the intervention to overcome different behavioral and health issues (Madson et al. 2016). On the contrary, other researchers do not completely support these views, concerning the findings by Smedslund et al. (2011) and (Lal 2005). Thus, before selecting a treatment program, a careful assessment of a client’s state is required to concentrate on the evolution of a person’s drug intake, their family history, degree of dependency, and other factors.

Strengths and weaknesses of the undertaken literature review

The key strength of the study by Smedslund et al. (2011) is that only credible and reliable sources were selected for further analysis. Thus, the researchers chose only studies based on examining video and sound recordings related to therapies to ensure that motivational interviewing was applied in all discussed cases. The selection of 59 appropriate studies allows for concluding that the researchers’ findings are reliable and valid.

Another important strength of the study is that it was supported by the Norwegian Knowledge Centre for the Health Services, Norway. The researchers’ activities and needs were supported and funded by the resources of the center to guarantee that all procedures were conducted efficiently, and the results can contribute to the research, theory, and practice in the field of applying MI when working with patients suffering from substance abuse and other drug-related conditions.

Still, the study’s design also has some weaknesses that should be taken into account when evaluating the quality of research. First, to select articles for reviewing in the context of their study, Smedslund et al. (2011) developed their evaluation and inclusion criteria. Second, the problem is that other reviewers can assess the quality of articles included in this research in a different way that can affect the findings. In addition, the received data are not enough to conclude about the impact of applying motivational interviewing on patients’ readiness to change, their repeat convictions, and possible retention in treatment. This aspect was also mentioned by the researchers as one of the limitations of their study.

Thus, more research can be required to test the conclusions made by the researchers in the context of this study to support or not findings regarding the role of MI in affecting behavior changes and outcomes in clients with substance abuse disorder. Furthermore, in complex cases, MI cannot be applied as an intervention because of its ineffectiveness to treat co-occurring illnesses. Additionally, not all therapists are skillful enough to apply effectively MI in their practice (American Addiction Centers 2019).

Possible practical or academic implications for the review

The main implication of this review to practice is that the researchers provided support to the idea that motivational interviewing has more effects on patients with drug problems when being compared to the absence of any therapy or intervention. In their practice, therapists can actively apply MI if there is a choice between using or not using this intervention in the context of therapy for a patient. Furthermore, the length of this intervention can also be discussed as advantageous in cases when therapists have a limited period to help their patients.

The contribution of this study to the academic field with a focus on research and theory is also significant as the researchers demonstrate that a simple examination of the effectiveness of MI in influencing patients’ outcomes is not important anymore.

The current research indicates that much evidence and literature are available on the role of MI in treating a substance abuse disorder. Thus, Smedslund et al. (2011) concluded that further research should be oriented toward investigating how and concerning what mechanisms MI can influence changes in patients’ behaviors. Additionally, in this field, more research is required to determine whether or not alternative modes of MI (other than face-to-face interviewing) can be used effectively to work with clients suffering from drug addiction (Jiang, Wu & Gao 2017). From this perspective, the traditional research interest in studying the effects of MI on patients’ outcomes should be shifted to new areas of academic research.

Summary and concluding remarks

Drug addiction can be treated as a result of applying different interventions, and many of them are oriented toward changing individuals’ behavior to help them overcome their disorder. Motivational interviewing is one of the short interventions actively used by therapists to assist clients in overcoming their drug addiction through working with their motivation. The research conducted by Smedslund et al. (2011) indicates that there are many high-quality studies in which the effects of using MI on readiness to change, retention in treatment, and patients’ repeat convictions were examined.

The strength of this study is based on analyzing 59 articles in the fact that the researchers found evidence to state that MI is more effective for patients than the absence of any therapy or intervention. However, the researchers were unable to support the positive role of MI in influencing individuals’ readiness to change, their retention in treatment, and their repeat convictions when comparing the results to other interventions. Still, this study has contributed to academic research and practice significantly as it indicated the appropriateness of using MI when other therapies are unavailable, but more research is required to find out what forms of MI are more preferable and how this technique works.

Reference List

American Addiction Centers 2019, Motivational interviewing in addiction treatment. Web.

Jiang, S, Wu, L & Gao, X 2017, ‘Beyond face-to-face individual counseling: a systematic review on alternative modes of motivational interviewing in substance abuse treatment and prevention, Addictive Behaviors, vol. 73, pp. 216-235.

Lal, R 2005, Substance use disorder: a manual for physicians. Web.

Madson, MB, Schumacher, JA, Baer, JS & Martino, S 2016, ‘Motivational interviewing for substance use: mapping out the next generation of research’, Journal of Substance Abuse Treatment, vol. 65, pp. 1-5.

National Institute on Drug Abuse 2018, Drugs and the brain. Web.

National Institute on Drug Abuse 2019, Treatment approaches for drug addiction. Web.

National Institute on Drug Abuse n.d., The science of drug use and addiction: the basics. Web.

Parmar, A, Patil, V & Sarkar, S 2017, ‘Ethical management of substance use disorders: the Indian scenario’, Indian Journal of Medical Ethics, vol. 2, no. 4, pp. 265-275.

Smedslund, G, Berg, RC, Hammerstrøm, KT, Steiro, A, Leiknes, Ka, Dahl, HM & Karlsen, K 2011, ‘Motivational interviewing for substance abuse’, Campbell Systematic Reviews, vol. 7, no. 1, pp. 1-126.

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