Running head: EXERCISE PROGRAM AND DIETARYSTRATEGIES
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Exercise Program and Dietary Strategies to Manage Weight
PMHNP-BC
Mental Health of Essex County, Prospect House, East Orange, NJ
Liberty University
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Abstract
In the local area and clinical setting, heroin abuse is on the rise and treatment is often not
effective. Relapse is an important issue to address when considering decreasing the number of
fatal overdoses due to heroin use, treatment adherence, and the recovery process. Retention in
addiction treatment programs needs to be addressed to reduce: the number of actively addicted
individuals, the serious consequences of addictions, and the high cost to the individual, family
and society. The findings across all systematic reviews show that while motivational
interviewing (MI) is a recommended approach for behavior change, it is mostly supported in the
areas of alcohol and drug use. The project coordinator utilized a MI intervention involving 10
young adult participants with a history of heroin use in a private outpatient facility located in an
eastern state. Outcomes were measured by the Addiction Severity Index Tool (ASI-5) for
functional status at the initiation into treatment for heroin addiction, and again after receiving
two sessions of MI. Also attendance and drop-out rates were collected. Relapse rates were
monitored by weekly urine drug screen results. Composite scores for both pre and post ASI-5
tests were calculated and assessed for percent change. Attendance rates and drop-out rates were
compared to one month prior. Results included a >20% increase in functional status, < 20%
improvement in attendance, and relapse rates were reduced > 20%. MI demonstrated that it was
an effective intervention to engage and retain young adults in a heroin addiction treatment
program. It will be proposed facility-wide as a standard of care to improve treatment
effectiveness.
Key words: heroin abuse; drug counseling; treatment retention; motivational interviewing; drop-
out; addiction; treatment recovery
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Introduction
According to the World Drug Report of 2010, more than 15 million people worldwide
use opiates (United Nations Office on Drugs and Crime (UNODC), 2014). Among these opiates,
heroin is the most used. Heroin originates from opium poppy and is produced in Afghanistan
(80%), Myanmar, Mexico, and Columbia. Heroin, the most lucrative of the illicit opiates, has a
market value of $55 billion in United States (US) currency. In general, the global illicit opium
production has been increasing, as the supply is in demand (UNODC, 2014).
According to the National Institute on Drug Abuse (NIDA) 2014 report, 4.2 million
Americans aged 12 years or older have experimented with heroin more than twice in their lives.
In comparison, a United States Department of Health and Human Services 1997 report identified
2.4 million Americans who have experimented with it (Downey, Helmus, & Schuster, 2000). An
additional 23% of heroin users will become addicted to heroin (NIDA, 2014). With the national
statistics regarding heroin abuse on the rise, the clinical problem will focus on the increase in
young adult heroin users within the local area clinic who have difficulty remaining in treatment
to begin their recovery process.
Background/Significance of the Problem
The definition of recovery is the process of returning to normal state, whether in health,
mind or strength. It could also mean giving back something that was lost (Merriam Webster
Online, 2015, para. 1). In healthcare literature, recovery is defined collectively as a process that
includes the following characteristics: the discovery and purpose of meaning in life along with
introspection, accomplishment and self-respect, the ability to act or behave without any
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constraints, the ability to make decisions, adaptation that is goal-directed, emancipation,
resilience, and progressive advances (Brennaman & Lobo, 2011).
Furst, Curtis, and Balletto (2011) reported that the geographical location of heroin use
was only found in medium sized cities prior to 1970s. During the 1990s, it had spread to small-
sized towns. It is no longer the trend to find heroin abuse in urban centers. Currently heroin use
is now in non-metropolitan (NMAs) and suburban areas. The attraction of New York City,
experimentation, and subsequent dependence all play a part in the geographical diffusion from
urban centers to NMAs and suburban areas (Furst, Curtis, & Balletto, 2011). Locally, there has
been a noted increase in young adult heroin users within a suburban treatment program who were
struggling to recover and avoid the negative consequences of addiction. The rate of relapse with
substance use was stated to be as high as 50 to 70% within the first year after addiction treatment
(Leach & Kranzler, 2013).
Different addiction treatments have been and are being developed to decrease the global
challenge related to addiction use disorders and recovery. Addiction treatment is geared toward
decreasing substance use or achieving abstinence and preventing the frequency or severity of
relapse; therefore, improving adaptive functioning (Arnevik et al. ,2013). Treatment completion
is the most reliable factor related to positive outcomes in addiction treatment centers. Patients
who drop-out of treatment programs have unfavorable outcomes compared to those who
complete programs. Certain factors that result from dropping out include increased risk of
relapse, legal and financial difficulties, poor health, and readmission. Criminal behaviors,
spreading of Human Immunodeficiency Virus (HIV), and the effects of loved ones all contribute
to the high cost in society as it relates to treatment drop-out rates (Arnevik et al. ,2013).
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Arnevik et al. (2013) conducted a systematic review to assess the available research
regarding predictors of drop-out from addiction treatment. The studies show that poor treatment
program attendees were about seven times more likely to drop out early than those maintaining
attendance in the programs. In this review, several factors were looked at and discussed as it
related to treatment drop-out. Out of the factors studied, younger age, cognitive deficits, anti-
social and histrionic personality disorders, and treatment alliance were consistently reported to
show associations with treatment drop-out rates across varying study designs, samples, and
methods (Arnevik et al., 2013).
Retention in addiction treatment programs needs to be a primary focus to reduce: the
number of actively addicted individuals, the serious consequences of addictions, and the high
costs to the individual, family and society. The number of Americans using heroin has been
growing at exponential rates. Increasing the retention rates to promote recovery is vital for
control of this current substance epidemic.
Literature Summary
Constructing evidence from research to come up with the best practice is the foundation
of literature review. A comprehensive review was conducted to determine the best practice to
support recovery rates and program retention for young adult heroin users. In order to address
research findings pertaining to the problem of treatment and recovery, the question of how young
adults suffering from heroin addiction can improve their recovery and program retention rates.
The literature provided Motivational Interviewing (MI) as the treatment method to enhance
recovery rates and program retention rates of heroin addicts (Melnyk & Fineout-Overholt, 2011).
Several articles looked at the intervention, motivational interviewing (MI) and its use in
treatment adherence, its effectiveness when combined with cognitive behavioral therapy (CBT),
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and one that looked at its effects on change in patient attitudes toward substance abuse. Articles
that included other addictions, such as alcohol that used motivational interviewing were also
reviewed. The articles demonstrated that MI was a treatment option that successfully increased
both treatment retention and recovery rates for not only heroin users but also substance abusers
in general.
Magill, Stout, and Apodaca (2013) examined two core therapeutic principles of MI with
alcohol and other substances use disorders. Three therapeutic interventions were implemented:
Cognitive Behavioral Therapy (CBT), Twelve-Step Facilitation Therapy, and the Motivational
Enhancement Therapy (MET). Results showed that when therapists elicited MI in individual
sessions in order to bring out a client’s commitment to positively change their alcohol
consumption, an increase in abstinence rates of both AC and OP clients were evident.
D’Amico et al. (2015) assessed 129 group session audio recordings from a randomized
control trial of adolescents receiving MI within group modality. In this study MI was presented
as a promised intervention that would help adolescent Americans to decrease polysubstance use
of illicit drugs. This study described the process of group MI and the effects of group-level
change talk on each individual’s marijuana or drug use. Change talk was defined as speech
derived from an individual, while employing MI, which allowed for behavior assessment and a
move toward positive change.
Youths involved in the Teen Court (TC) system in Santa Barbara, California were picked
based on their level of substance use, alcohol and other drugs (AOD). Youths who committed a
first time offense of AOD were to attend six alcohol and drug awareness groups, in addition to
other legal requirements. The teens were randomized into a group using MI and a usual care
control group. The delivery of content was supported through the use of MI in each session.
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Behavior change tools were also utilized to help teens bring out their confidence and willingness
to change. The average group size was five adolescents (M= 4.54, SD= 1.96), and lasted 55
minutes (D’Amico et.al., 2015). Group change talk was related with lessened intention to use,
alcohol use, and heavy drinking three months following the intervention. Group sustain talk
(normal intervention) was related to a decreased motivation to change, greater objectives to use
marijuana, and a higher positive alcohol and marijuana expectation (D’Amico et. al., 2015).
In a pilot study by Secades-Villa, Fernande-Hermida, and Arnaez-Montoraz (2004) the
effects of MI in an outpatient heroin addictions treatment program was evaluated. A group
receiving MI was shown to have a 50% increase in program retention compared to a group of
heroin addicts who did not receive MI. The usual dropout rate was stated to be 20% during the
initial treatment program. However because of the effects of MI as noted in the study program
retention had increased significantly resulting in increased recovery rates (Secades-Villa,
Fernande-Hermida, & Arnaez-Montoraz, 2004).
There were three main contributions of MI to pharmacotherapy noted. First, there is a
strong effort on improving a patient’s motivation to overcome their depression with
antidepressant therapy, therefore boosting confidence and defeating treatment barriers. The
second one is the use of MI with pharmacotherapy stresses the use of counseling skills during
pharmacotherapy encounter. This allows the clinician to focus care on understanding the
patient’s treatment journey and responding appropriately. Lastly, motivational pharmacotherapy
changes the patient-clinician relationship as one of equal specialists, who together explore what
course to follow. The use of MI and pharmacotherapy proves how MI can possibly be integrated
into psycho-pharmacotherapy in order to address hesitancy about medication adherence.
Purpose of Project
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The purpose of this EBP change project is to increase retention rates and prevent relapse
of heroin dug users among the young adult population in drug treatment programs. With the
practice change project, MI will be implemented for the purpose of program engagement in
treatment and treatment retention, along with relapse prevention.
Plan for IRB approval
The plan for IRB approval included using the Chatham University IRB approval process.
The proposal was submitted on August 12th, 2015 for approval. This EBP change project
potentially places the participant at a minimal level of discomfort due to the nature of completing
the Addictions Survey Index 5th edition (ASI-5) pre and post intervention and MI sessions. To
minimize discomfort, the participants will be reminded their participation is completely
voluntary, they may withdraw from the project at any time for any reason, and they may refuse
to answer any questions that they do not feel comfortable answering. The approval letter was
received on August 31st, 2015.
Project Description
With the practice change project, motivational interviewing (MI) will be implemented for
purpose of program engagement in treatment and treatment retention, along with relapse
prevention. The ASI-5 would evaluate the functional status of an individual before and after MI
implementation, further determining the level of recovery and rate of relapse prevention.L In this
practice change project, the (ASI-5) was used to evaluate treatment recovery of heroin users
within an Intensive Outpatient Program (IOP).L The focus of treatment would be to evaluate
various aspects of the individual’s life to avoid drug use and promote recovery (Kessler et. al.,
2012). The idea is to have heroin users lengthen their treatment stay with the implementation of
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motivational interviewing while assessing specific areas of needs. Also, treatment retention were
measured by assessing the attendance and drop-out rates of participants.
For the project change a sample population for recruitment included young adults ages 18 thru
35, both men and women alike who struggled with heroin addiction. Participants were enrolled
in the three-day intensive outpatient program. These individuals used heroin via inhalation or IV
as their primary route for drug of choice and were seeking sobriety.
Recruitment was conducted by way of flyer handouts to substance abuse (SA) group
members during community group meetings and also during SA groups within the IOP program
therapists employed by the facility made group announcements at the beginning of each group in
order to recruit members, also flyers will be posted throughout the facility. Once SA group
members showed interest, a number was provided for interested participants to call for details of
the project change. Selection occurred when inclusive criteria for change project was met.
Participants
Total participant count for the entire Evidence Based Project (EBP) was ten. A total of
eight males and two females participated. Out of the two females both of them used heroin via
intravenous (IV) verses four males using via inhalation. A total of four males used heroin via
IV. Just two participants were married verses eight who were single. All participants were
enrolled in the intensive outpatient program (IOP) which entailed a three day a week treatment
structure. Most of the participants were enrolled from previous referrals from their outpatient
private providers. Only two clients were referred from the facility’s detox program prior to
being enrolled in the full day partial hospitalization program. Other clients enrolled had come
from other treatment centers, specifically local rehab centers.
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Implementation Steps
The implementation process commenced on August 31, 2015. Flyers were posted around
the facility, two in the hallways, and one in each group room. Participants were expected to call
the project coordinator’s number provided on the flyer. Commitment of approximately three and
half hours was required for this project through. A consent was signed by each individual, a
thorough explanation of the project, including risks, anonymity, and time requirement was also
discussed with each participant. A total of 10 participants were included within the project, both
male and female all within ages of 18 to 35.
After consent is obtained, the individual will be scheduled a 90 minute time period to
complete the ASI-5 survey. The individual will complete the ASI-5 survey with the PC in a
private, clinical office space at the IOP facility during the IOP program time. Demographic
information within the ASI-5 survey that will call for identifiable information will not be asked
or disclosed.
After the ASI-5 survey is completed, the individual will be scheduled for two (20) minute
motivational interviewing (MI) session. The sessions will take place once a week for two weeks.
The second follow up session occurred within one or two weeks from the first and lasted for 20
minutes. Participating in the MI sessions resulted in the individual missing 30 minutes of one
group session that was associated with the standard care for IOP clients. Each group session
lasted one and a half hours. The sessions took place within the facility with the primary project
coordinator (PC), a psychiatric advanced practice nurse (APN). The APN was available one day
during the week and also made some adjustments based on scheduling conflict with an individual
participant. There were two standard days available during one week where MI sessions will be
conducted. The PC had completed a 16-hour intense training in MI prior to project
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implementation. During the MI sessions the individual/participant completed MI activities
(change talk, relapse planning prevention) and had been given opportunities for questions or
concerns after completion of the sessions.
After the individual completed the last scheduled MI, he/she was then scheduled to
participate in a 90 minute session to complete the post intervention ASI-5 survey. The individual
will completed the ASI-5 survey in a private, clinical office space at the IOP facility during the
IOP program time. This office space was also used to hold MI sessions. Urine drug screens
were collected at least once a week as included within the IOP program. Also included within
the IOP were weekly individual sessions with primary therapist, groups sessions, and medication
management by each individual’s prescriber. Once all MI sessions had been conducted, data
analysis was completed and included days of attendance, urine drug screen results, and recovery
rates as computed by ASI-5.
Setting and Evaluation
To improve the outcome of recovery, literature reported that program retention was
essential. The highest rate of drop out is in the first two to three weeks of treatment. Program
attendance will also be collected to see if participants who were retained in the program had
better attendance than those who dropped out. The number of participants who stayed in the
program would represent retention in the program. Those participants who dropped out during
the first two weeks of treatment would not be included. Attendance numbers would be
documented based on the three day a week IOP schedule.
Retention would be reported as a percentage of the total number of participants enrolled
in the project. This percentage would be compared to the program retention percentage prior to
the implementation of the motivational interviewing intervention. Program attendance would
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also be collected and reported as a percentage of the total number of treatment days in the three-
week time frame. The anticipated outcome was an increase in retention with high program
attendance.
The functional status of the participant would be assessed in the following areas of life:
medical, employment, legal aspects, family/social, psychiatric, alcohol use, and other drug use
(specifically heroin). This functional status relates to the recovery process of the individual. The
functional status would then be computed into a composite score which is given to determine
severity of status within a specific life area. The use of motivational interviewing will assist the
participant and counselor in identifying ways to improve function in those areas of life the
participant is interested in changing.
The (ASI-5) evaluation tool was chosen to evaluate treatment recovery of opiate users
within this program. This tool would evaluate the functional status of an individual before and
after treatment to determine the level of recovery. The main reason to include this measurement
tool is for its comprehensive evaluation of multiple aspects of the individual’s life.
To evaluate the outcome of recovery, the pre test and the post test scores of the ASI-5
were compared using the t-test. Descriptive statistics was run to find the mean and standard
deviation pre and post intervention. When comparing the two time points, a benchmark score of
a 20% increase was set. This would be described as the intervention group experiencing a 20%
increase post after motivational interviewing. Excel program from Microsoft Office was utilized
to compute composite scores for each individual.
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