Quality Improvement: Shared Decision Making for Methamphetamine Recovery

Jalyn A. Stinardo

Department of Nursing, Idaho State University

Dr. Susan Tavernier

March 13, 2023

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Table of Contents

I. Introduction

Problem Statement

Purpose of Project

Clinical Question (PICOT)

Review of the Literature

II. Implementation/ Methodology

Participants

Setting

Intervention

Data Collection

Data Analysis

III. Results

IV. Discussion

V. Implications for Practice

VI. Conclusion

References

Appendix

Decision Aid

IRB

Letter from Agency

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Quality Improvement: Shared Decision Making for Methamphetamine Recovery

Introduction

Addiction medicine has advanced over the past few years, with focus on the opioid epidemic.

Empathy can be extended as more people fall to addiction: a mother, friend, brother, cousin, or

nephew. Those with addiction can be difficult to care for as the behaviors, symptoms, and

presentation associated with it force providers to see a person driven by compulsions that can be

difficult to understand. For these reasons, this population is largely on the fringe of healthcare

and the community.

At this time, there is no Federal Drug Administration (FDA) approved treatment for

methamphetamine addiction and withdrawal. Due to the intensity and enveloping nature of

methamphetamine use and addiction individualization of treatment patient centered care is

crucial. Methamphetamine/ amphetamines are highly addictive and patients require support not

only from their personal relationships, but also from the relationship they forge with their

providers. Patient education about their treatment options offers patients empowerment through

involvement in their care plan. Without clear guidelines, it can be difficult for providers to offer

education to their patients. A literature review was conducted to develop a standardized, written

education tool to provide to patients admitted for methamphetamine detox protocol for the

Allumbaugh House, a 16 bed inpatient detox facility.

Background

Methamphetamine, a white bitter powder or pill, can be smoked, ingested, snorted, and/or

injected via IV when dissolved into water and/or alcohol (National Institute on Drug Abuse

[NIDA], 2019). While non medically directed opiates are dangerous,

methamphetamines/amphetamines are equally as dangerous with the possibility of mental health

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disorders/psychosis, high rates of infectious disease transmissions, cardiovascular dysfunction,

renal dysfunction, and overdose and death (Centers for Disease Control and Prevention [CDC],

2020). In 2020, 2.5 million Americans reported methamphetamine use, and up to 53% met

criteria for a methamphetamine use disorder as defined by the Diagnostic and Statistical Manual

of Mental Disorders-V (CDC, 2021). For females with methamphetamine dependence, the death

rate is expected to be 26 times greater than the general population and six times greater in males.

Additionally, when age, sex, and socioeconomic status are accounted for, rates of self reported

suicide attempts are higher with methamphetamine use (Paulus, 2022). Throughout the rest of

this paper, methamphetamine/amphetamines will be referred to as MA.

Allumbaugh House opened May 3, 2010 as a regional facility offering sobering,

detoxification, and crisis mental health services to all qualified residents. Allumbaugh House is

open for detoxification and crisis mental health services 24 hours a day, seven days a week. It

serves Region IV (Ada, Boise, Elmore, and Valley Counties) residents. Admission to

Allumbaugh House is voluntary and based on capacity, which is up to 16 patients. A referral

must be made by designated clinicians for admission to Allumbaugh House using the approved

screening and assessment.

Terry Reilly Health Services operates Allumbaugh House but contracts with Sage Health

Care for psychiatric and medical care. Life’s Kitchen provides lunch and dinner service and

Terry Reilly Health Services partners with other community entities for operations and

continuity of client services. The facility itself is owned and maintained by Boise City/Ada

County Housing Authority.

The Allumbaugh House is the only inpatient facility in Idaho that accepts withdrawal

from methamphetamines/amphetamines/stimulants. From April 2021 to March 2022

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Allumbaugh House admitted 702 patients for detox, 314 of those admissions for stimulants,

approximately 23 admission a month. If a patient is admitted for stimulants, there is no protocol

or scheduled medications. Patients are able to have the routine as needed medications available:

ibuprofen 400 mg, acetaminophen 650 mg, milk of magnesia 30 mL, imodium 4 mg, and

mylanta 30 mL and other medications as needed at the discretion of the medical staff.

Project Purpose

The purpose of this project is to analyze what informed decisions/ shared decision

patients with MA use choose after being provided with education regarding their treatment

options with a provider.

Clinical Question

For patients 18 years or older who use MA or MA with another substance, what treatment

decision do they make after reviewing treatment options through a decision aid with a provider

during a one on one evaluation?

Search Strategy

A literature review was performed using CINAHL, PubMed, Google Scholar, and

Medline Complete. Articles published between 2016-2022 were included in the review. Articles

were excluded if they researched methamphetamines in relation to sexual preferences,

methamphetamine induced psychosis, and/or examined risky decision making while under the

influence of methamphetamine. Search terms were used and key terms included

“methamphetamine” AND “amphetamine” “withdrawal” AND “detox” “naltrexone” OR

“vivitrol” OR “treatment” “education” AND “informed decision” AND “shared decision

making” OR “shared decision-making” OR “sdm” AND “patient centered care.” One article was

found outside the literature search. Duplicates were removed from the 26 results. This left 20
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articles which were then analyzed. Articles were removed if they reviewed shared decision

making in regards to specific populations such only females specific diseases such as diabetes or

end of life care. 20 full text articles were reviewed. 17 articles were included in this literature

review.
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Review of Literature

Lack of Methamphetamine Treatment

Despite rising use and dependence of methamphetamines, there is no current standard of

care regarding pharmacological treatment for withdrawal or prevention of relapse (American

Psychological Association, 2021). Due to the nature of the drug, it is often used in a binging

pattern and users will forgo sleep, food, and physiological necessities while using. Short term

effects include decreased appetite, increased rate of breathing and wakefulness, irregular/rapid

heartbeat and increased blood pressure and body temperature. Long term effects with prolonged

use include weight loss, dental problems, skin sores from itching, anxiety, brain

structure/function changes, confusion/memory loss, sleep dysfunction, paranoia, and

hallucinations (NIDA, 2019). Despite this evidence that MA use can result in serious health

implications and possible death, without lack of standardized care it could suggest that MA use is

not regarded as seriously as other substances.

In conjunction with misperceptions regarding MA use, lack of provider knowledge lends

to lack of treatment (Dunn et al., 2022). Studies are limited regarding provider experience with

treating MA. One study by Dunn et al. identified that providers struggle with problem

identification and clinically managing methamphetamine use disorders (2022). Specifically, it is

difficult for primary care providers to properly screen, identify, and diagnose. Even with a

diagnosis, providers have a hard time deciding on treatment plans without an identified protocol

or medication (Dunn et al., 2022). Additionally, with lack of visibility of those who use MA,

stigma can decrease treatment implementation despite availability of care (Ward et al., 2021).

Current Treatment Modalities

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Addiction medicine treatment is most successful when implementation combines not only

pharmacotherapies, but also biopsychosocial aspects of care (NIDA, 2019). When compared to

no interventions at all for most stimulant use disorders, either cognitive behavioral therapy,

motivational interviewing, interpersonal therapy, and/ or psychodynamic therapy decreased

treatment dropout rates, increased continuous abstinence after treatment, and increased the

longest period of abstinence (Minozzi et al., 2016). However, it may not significantly increase

continuous abstinence from the longest follow up (Minozzi et al., 2016). According to UptoDate,

mild, moderate, and severe stimulant use disorders first line treatment is intensive outpatient

therapy (IOT). If IOT is not successful, it is then recommended to follow with behavioral therapy

for 8-12 weeks (UptoDate, 2022).

As previously mentioned, there is no current FDA approved pharmacotherapy for

methamphetamine or amphetamine use disorder. A systematic review and meta analysis by Chan

et al. found that there was low strength evidence for methylphenidate reducing MA use, resulting

in approximately 4% reduction of positive urine drug screenings (2019). The meta analysis also

reported a non stimulant, atomoxetine, had no differences in use, retention or abstinence.

Conversely, antidepressants as a class showed no statistical significance on abstinence or

retention. Atypical antipsychotics, such as aripiprazole, had no difference in abstinence, use, or

retention as compared to placebo. Anticonvulsants and muscle relaxants (topiramate, baclofen,

and gabapentin) exhibited no difference in abstinence and retention rates but rates of use were

significantly lower with topiramate vs. placebo (Chan et al., 2019).

Naltrexone for Methamphetamine Use

Methamphetamine is a psychomotor stimulant and rapidly elevates dopamine levels

through the release of dopamine from vesicles and reversal of dopamine transporters (Wise &
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Robbie, 2020). With long term use, methamphetamine will decrease expression of Dopamine

Receptor D₂, receptor, known as D2R, ultimately leading to reduced sensitivity to non-habitual

rewards (Wise & Robbie, 2020). Endogenous opioid peptides/receptors located within the

mesolimbic system, which regulates dopineragic release, have been associated with the addiction

process (Horner et al., 2017). Naltrexone, an opiate receptor antagonist, has had success in

attenuating cravings through disruption of reward related memory. Primitive studies with mice

have shown that naltrexone reduced methamphetamine hyperlocomotion and decreased

locomotor sensitization (Wang et al., 2021). This suggests a decrease in reward learning related

to methamphetamine.

Studies performed with brain imaging have shown changes with Naltrexone

administration for M/A addiction. The striato-limbic system, associated with cravings and drug

reinforcement learning, is affected by Naltrexone through modulation of the striatal dopamine

system (Kohno et al., 2018). Brain imaging results showed that Naltrexone reduces the

striatolimbic resting state functional connectivity (RSFC), with a significant association between

reduced RSFC and reduced M/A use (Kohno et al., 2018). However, when controlling for

baseline response to methamphetamine, severity of use, and methamphetamine related functional

problems, executive functioning, as defined by various neurocognitive assessments, has effects

on “desire to access the drug” and “want more of the drug” (Lim et al., 2020). Low executive

functioning with Naltrexone administration was found to have a greater decrease in craving and

desire of the drug as compared to those with higher executive functioning (Lim et al., 2020).

In regards to cravings, Naltrexone for MA use is associated with decreased cravings but

studies vary if this difference is statistically significant or not. One study found that while there

were decreases in mean craving scores, they were not statistically significant. This study
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attributed lack of significance to the fact that the dopamine changes related to Naltrexone alone

do not reduce cravings unless paired with drug cues which were not exhibited in a laboratory

setting (Kohno et al., 2018). However, cue induced cravings are positively associated with a

larger effect with M/A use. When given Naltrexone vs. placebo, results showed that it attenuated

the relationship between the cue induced cravings and the positive effects (Roche, 2017). This

illustrates that Naltrexone can reduce cue induced cravings through moderation of reinforcement

pathways.

A systematic review showed mixed results regarding amphetamine vs methamphetamine

use. For amphetamines alone, the abstinence rate through use of naltrexone was increased

significantly (p < 0.05). Only one study produced significant results for methamphetamines

showing decreases in cravings and subjective effects (p < 0.05). Both studies illustrated that

naltrexone was well tolerated with few adverse effects (Lam et al., 2019). While these results are

mixed, it does show that naltrexone produced better results than placebo although they may not

be statistically significant.

Overall, studies have shown that Naltrexone has reduced days of MA use. One meta

analysis reported that in a study of 52 randomized participants, 37 self reported reduction in use

of MA. In Sweden, when given Naltrexone MA positive urine drug screenings were reduced as

compared with placebo. In regards to the Naltrexone injectable, Vivitrol, it was found that those

that received treatment vs placebo also had reduced positive urine drug screenings (Siefried,

Acheson, Lintzeris & Ezard, 2020).With use of Extended Release Naltrexone (Vivitrol), self-

reported days of M/A use decreased from 5.06 to 1.56 (Kohno et al., 2018). Over 12 weeks for

those who received extended release naltrexone and oral extended release bupropion, participants

had a lower rate of methamphetamine positive urine drug screenings (although not statistically
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significant) than those that received placebo (Trivedi et al., 2020). Additionally, a 2 stage open

label pilot study confirmed that Vivitrol, in combination with extended release bupropion yielded

significant results with 6 out of 8 urine drug screenings resulting negative (Mooney et al., 2016).

Informed/Shared Decision Making

Shared decision making is defined as when both the patient and provider have active

roles while deciding a treatment plan. The provider reports all available information and

treatment recommendations to the patient so that the patient can use their judgment to decide

their preference based on their needs, concerns and circumstance. (Driever, Stigglebout, &

Brand, 2020). Shared decision making involves a dialogue between the patient and provider

about the patient’s presenting problem, explanation of available options, discussion of the

associated risks and benefits, and discussing the patient’s preferences and motivations (Hughes

et al., 2018). Through shared decision making, a patient is able to make an informed decision

regarding their care creating a patient centered care plan (Driever, Stigglebout, & Brand, 2020).

The benefits of shared decision making such as patient centered care, increased patient

and provider attention to concerns and goals, and strengthened therapeutic alliance is seen across

different study designs, patient populations, treatment settings, and outcome measures (Fisher et

al., 2021). The importance of shared decision making, especially in chronic conditions such as

mental health diagnoses and substance use disorders can be attributed to the fact that chronic

conditions require ongoing decisions in which factors such as the therapeutic alliance and patient

centeredness “might be more important than in the context of more acute conditions involving a

discrete treatment choice” (Fisher et al., 2021).

Decision aids, tools to present patients different treatment options make informed

decisions, have been studied in regards to behavior change and substance use. Decision aids
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focus on shared decision making by discussing unbiased information and encouraging informed

decisions with increased reasoning (Gültzow et al., 2021). With the use of decision aids through

shared decision making, providers felt they gained more insight and knowledge about the patient,

expanded treatment options, and reported greater satisfaction with face to face time with the

patient (Friedrichs, Spies, Haerter, & Buchholz, 2016). Results suggest that decision aids had a

positive effect for smoking cessation, smoking aid cessation uptake, and alcohol consumption

but ultimately did not effectively test the decision effect outcomes (Gültzow et al., 2022).

Most commonly reported as an outcome of shared decision making was the formation of

a therapeutic alliance between the patient and provider. Additionally, the therapeutic alliance was

associated as a predictor of substance use treatment engagement (Marchand et al., 2019). When

shared decision making is not utilized, it is associated with poor patient reported outcomes,

quality of care, and increased utilization of healthcare such as ER visits (Hughes et al., 2018). In

regards to substance use, it has been shown that the practice of shared decision making increased

the patient’s sense of trust and they felt respected by the physician (Marchand et al., 2019). This

is important as stigma and shame are cited as barriers to treatment for those with substance use

disorders (Friedrichs, Spies, Haerter, & Buchholz, 2016). When patients were treated with their

preferred/ chosen treatment, those using illicit drugs showed better outcomes through decreased

use over 90 days (Friedrichs, Spies, Haerter, & Buchholz, 2016).

Theoretical Framework

The Social Learning Theory, developed by Albert Bandura, was used as a framework for

this project. The goal of this project is to create a tool used by providers that can be used to

increase informed decision making for those who use methamphetamines/amphetamines. The

Social Learning Theory proposes that behavior is influenced by relationships created through
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observational learning of the external environment, including other people. This model helps to

identify how the social environment can influence behavior through observation and that

mediational processes can determine whether or not a behavior is enacted.

New behavior initiation is determined by four mediational processes: attention, retention,

reproduction, or motivation. Attention is defined as how much the behavior engages someone

while retention is how well the behavior is remembered. Reproduction is the ability to produce

the behavior and motivation is the will to enact the behavior and is often influenced by

consequences perceived by the learner. Additionally, positive and negative reinforcement are

important in determining behavior, as the learner must decide if the reward is greater than the

cost.

As someone with a methamphetamine use disorder starts to use more, it affects their

relationships with family, friends, and the community as a whole. Their social and physical

environments include less people without use disorders. The observational learning models poor

coping skills and continued use as the person's social circle is focused on the drug. As proposed

by the Social Learning Theory, it is important for those with methamphetamine use disorder to

have access to healthy environments and people. To engage in a new behavior, they must be

attentive and motivated. Through informed decisions, a person is more likely to be intrinsically

motivated to engage.

Methodology/Implementation

Participants

Participants were those admitted to the Allumbaugh House for voluntary detox from

Methamphetamines/Amphetamines. Patients, per admission guidelines set by Allumbaugh

House, were 18 years or older, had no insurance or Medicaid only, and required medically
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assisted detox. All participants had a documented diagnosis of methamphetamine use disorder

which may or may not have been in conjunction with another substance use disorder

(polysubstance). Participants verbally consented to participate.

Setting

This was conducted at the Allumbaugh House, a non-profit 16 bed hospital that accepts patients

for voluntary, acute detox for various drugs and alcohol. Allumbaugh House is located in Boise,

Idaho. It was selected due to being the only facility in Boise that offers inpatient detox for

methamphetamines.

Intervention

After at least 48 hours from admission, patients that are admitted to Allumbaugh House for

methamphetamine or methamphetamines in conjunction with another drug were educated during

a one on one assessment by the same provider using the decision aid created about treatment

options available to them. Participants could choose no treatment options or multiple options.

The decision aid was reviewed by several staff of the Allumbaugh House including social

workers, nursing staff, and the program director to offer comprehensive treatment options.

Treatment options included Intensive Outpatient (IOP), Partial Hospitalization (PHP),

Residential, counseling services, pharmacological options, and community supports such as AA,

NA, Dharma Recovery, Peer Wellness Center, SMART Recovery, and Phoenix Gym.

Data Collection

This project obtained IRB approval as exempt from Idaho State University. Data collection

began November 1st, 2022 and was completed January 6th, 2023 resulting in 42 participants.

Data points included which treatment option(s) the patient chose after the one on one assessment

and brief explanation as to why.

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Data Analysis

Descriptive analysis was performed to determine the nominal points of data collected.

Percentages, averages, and totals were analyzed as a complete data set, methamphetamines only,

methamphetamines and opiates, methamphetamines and bath salts, and methamphetamines and

kratom.

Results

Participant Characteristics

There were a total of 42 participants. As seen in Table 1, more than half of the sample was

admitted for a polysubstance detox. Half admitted for meth and opiate detox while

approximately 40% admitted for meth detox only. There was a small amount for meth and

kratom and meth and bath salts. Less than twenty percent of admissions were on probation or

parole. Nine admissions had never had inpatient or formal treatment previously besides AA or

NA while eleven had been admitted previously at Allumbaugh House. Approximately 20% had

mental health providers in the community already established.

Table 1: Demographics

Diagnosis N %
Meth/Opiates 21 50
Meth 17 40.48
Meth/ Bath Salts 3 7.14
Meth/ Kratom 1 2.38

Findings

After the one on one assessment, only one participant declined any treatment options/ discharge

planning. Table 2 illustrates that the majority of participants chose at least two to four treatment
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options. The highest number of treatments chosen was five treatments, and one participant

admitted for meth and kratom chose five treatments. All the treatment options were chosen at

least once.

Table 2: Number of Treatments Chosen

# of Participants # of Treatments Chosen %

19 2 45.24
9 3 21.43
6 4 14.29
6 1 14.29
1 5 2.38
1 0 2.38

Table 3: Treatments Chosen for all Patients

Type of Treatment- All # of times chosen

Anti- depressants 18
IOP 17
Naltrexone 15
Residential 14
Anti- anxiety 14
NA 12
ADD/ ADHD 10
Counseling 8
AA 6
Peer Wellness Center 5
Dharma Recovery 5
PHP 3
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SMART Recovery 2
Phoenix Gym 1
*IOP: Intensive Outpatient Program, PHP: Partial Hospitalization Program

While collectively antidepressants were the most requested across the entire data set,

there were differences across admission diagnoses for treatment options chosen. Among those

admitted for meth/opiates, the highest treatment option was naltrexone with 11 participants.

Meth only admissions were even with 7 respondents in each medication category:

antidepressants, anti-anxiety, and ADD/ADHD. Among meth/ bath salts, residential and

antidepressants were the most chosen options. Phoenix Gym received the least amount of

participants with one response by a participant admitted for meth and opiates. As for community

supports, the most commonly chosen was NA across meth and meth/opiates and AA was the

second most commonly chosen.

Table 4: Treatment Choices of Those with Meth and Opiate Diagnosis

Type of Treatment- Meth/ Opiates # of times chosen

Naltrexone 11
IOP 10
Anti- depressants 8
Residential 6
Anti- anxiety 6
NA 6
Counseling 5
AA 3
Peer Wellness Center 3
Dharma Recovery 3
ADD/ ADHD 2
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SMART Recovery 1
Phoenix 1
PHP 0
*IOP: Intensive Outpatient Program, PHP: Partial Hospitalization Program

Table 5: Meth Admit Choices

Type of Treatment - Meth # of times chosen

Anti- depressants 7
Anti- anxiety 7
ADD/ ADHD 7
IOP 6
Residential 6
NA 5
Naltrexone 3
PHP 2
Counseling 2
AA 2
Dharma Recovery 2
Peer Wellness Center 1
SMART Recovery 1
Phoenix Gym 0
*IOP: Intensive Outpatient Program, PHP: Partial Hospitalization Program

Table 6: Meth and Bath Salt Admit Choices

Type of Treatment - Meth/ Bath Salts # of times chosen

Residential 2
Anti- depressants 2
IOP 1
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Naltrexone 1
AA 1
NA 1
PHP 0
Counseling 0
Anti- anxiety 0
ADD/ ADHD 0
Peer Well Center 0
Dharma Recovery 0
SMART Recovery 0
Phoenix Gym 0
*IOP: Intensive Outpatient Program, PHP: Partial Hospitalization Program

Table 7: Meth and Kratom Admit Choices

Type of Treatment - Meth/ # of times chosen

Kratom
PHP 1
Peer Wellness Center 1
Counseling 1
Anti- depressants 1
Anti- anxiety 1
ADD/ ADHD 1
SMART Recovery 0
Residential 0
Phoenix Gym 0
Naltrexone 0
NA 0
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IOP 0
Dharma Recovery 0
AA 0
*IOP: Intensive Outpatient Program, PHP: Partial Hospitalization Program

Discussion

As data was collected regarding which treatment options were chosen, several themes appeared

regarding why patients choose certain treatments over others. The most prominent and regarded

reason was time commitments. As previously mentioned, there were patients currently on parole

or probation with legal obligations to their parole officer (PO) and/ or the court. Options such as

PHP or residential were not feasible, as many were required to hold a job, mandated an amount

of AA or NA meetings, and/or curfews that limited their schedules. Some patients felt that it was

overwhelming to try to fit in another treatment. The relationship between a patient and their

parole officer differed from person to person and this affected continuity of care. Some patients

did not want their PO to know they had relapsed/ admitted and as a result they felt weary about

introducing new therapies and signing releases of information. Those in parole or probation most

often cited time/ prior commitments as their top factor in decision making.

Discussions with patients about time availability for treatments allowed for deeper

holistic assessments: do they have kids, do they have a job, what kind of social support do they

have, do they have transportation, etc. This aspect of the shared decision was important, as

collectively choosing a treatment that a patient could not physically commit is

counterproductive. For example, one patient had been in PHP before but stated “it set me up to

fail” because he couldn’t manage the time commitment. He did choose IOP after discussing his

options with the eventual plan to graduate to AA since he had done NA previously. Another
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patient had court ordered NA and IOP and didn’t want to add anything because he also was

trying to find a job, as ordered by the court.

Secondly, religion was another factor in treatment decision making. Religiously based

treatment programs, like AA and certain IOPs, were either deterrents or the reason why a patient

specifically chose that treatment. It is important to discuss this with the patient in order to

accurately ascertain their preferences in treatment and help make the appropriate treatment

decision. This also meant that the provider had to be educated about different program’s core

values. Some patients had discontinued treatment as they didn’t resonate with the message or

core values of that treatment program. Setting clear expectations about treatments and what was

important to each program was appreciated by patients as they could make an informed decision.

While NA and AA are similar, it is important to note that patients experience these

programs differently and this is mostly due to the fact that AA stresses religion through a higher

power more than NA does. Additionally, some patients that didn’t use alcohol preferred AA over

NA because they felt that they were less likely to run into people they knew from using, that NA

was “too triggering”, and that they were more likely to meet someone that was going to sell

drugs to them in NA vs AA.

Patients that had been previously admitted at Allumbaugh House or in another treatment

program were more likely to choose at least two treatment options. These patients cited their

previous experience as a learning opportunity, displayed better insight in regards to their

discharge plan, and acknowledged the importance of a multimodal approach for their recovery.

“I keep telling myself that I've got this and I'm smarter than the system but I just end up doing

the same thing which is abusing drugs. I know how to do it right.” Many of those with prior

admissions also chose pharmacological treatments. “The zoloft helped with the anxiety and I
 21

need to get back with someone to restart it. That's usually my triggers because I haven't taken

care of my problems.” Another patient stated, “My anxiety is why I use.” Substance use

disorders and major depressive disorder are highly comorbid and patients choosing anti-

depressants and anti- anxiety medications suggests that recognition of their mood/ initial triggers

is important to effectively begin to address their addiction (Hunt et al., 2020).

From the provider’s point of view, there was as much education from provider to patient

as there was patient to provider. Listening to patient experiences with each treatment allowed for

the provider to make better suggestions for other patients. As mentioned previously, the

therapeutic alliance was strengthened through shared decision making, and the patient was

empowered to make their own treatment plan. Ultimately, this allowed the provider to make

better treatment suggestions throughout their visit as they were individualized. Normalization of

patient experiences also became easier and as a result, the provider felt it came naturally to

relate/ extend empathy to the patients. The provider also had to check their own assumptions

about patients because even though a patient may have been previously admitted, it did not mean

that they were aware of all treatments available to them/ what each meant. Most surprising to this

provider was how few patients had previously been offered Naltrexone. If they had, it was also

shocking that within Region IV Idaho, many patients had difficulty getting a prescription for

Naltrexone due to a provider’s lack of education. More than one patient had stated that they

weren’t able to get Naltrexone from their primary care provider because they had believed it was

a controlled substance. For methamphetamine admits, Naltrexone is not FDA approved for

methamphetamine detox and therefore was not covered by insurance. Despite this, patients felt it

was needed for their recovery. “What is twelve dollars if I can help my cravings?” As predicted,
 22

Naltrexone was chosen more often when patients were educated about it and offered as a

treatment option as it was the third most chosen treatment across the sample.

Despite different treatment options available for methamphetamine detox/ recovery,

people who use MA have difficulty receiving proper treatment recommendations. As a result,

these patients are often left without informed/ shared consent and may become stuck in the cycle

of addiction. While healthcare providers may be uncomfortable or unsure about what is available

to these patients, it is clear that this relationship between provider and patient can make a

profound difference in their recovery. Shared decision making not only increases the patient's

knowledge, but also allows the provider to know their patient better through increased treatment

needs assessments. Anecdotally, this writer also felt that because they were more involved in the

patient care, they were better able/ more comfortable in using motivational interviewing to

prevent precipitous discharges. It felt as though patients were more likely to take into

consideration this provider’s suggestions, as the suggestions were personalized and made more

relevant to the patient situation based on the prior one on one assessments.

It was also important to note that because not all treatment recommendations were

pharmacological, interprofessional and interdisciplinary communication was increased. The

provider was better able to discuss treatment options with the social work team and other staff

members to provide holistic care.

Implications for Practice

Since medications are limited for methamphetamine recovery/ detox, the advanced practice RN

must be educated about all options available for their patients. The use of shared decision making

within substance use disorders allows for the provider to establish a therapeutic alliance with

their patients which can make a difference in how much information a patient shares with their
 23

provider which ultimately can change treatment decisions and or outcomes. The decision aid

reviewed through shared decision making also allows for preliminary conversations about

treatment without employing a paternalistic approach, increasing a patient’s trust in the provider.

Wrap around services are important for recovery and this often begins with establishment of

providers. When a patient feels that only is their provider is not only educated about treatment

options available for them but can offer those options through a patient centered approach,

patients can feel more confident in their plan. The APRN is poised for holistic care and with the

use of shared decision making with substance use disorders, they can ensure that patients receive

individualized, comprehensive information which can increase the patient’s likelihood to return

and follow up. This provider felt that patients were more likely to voluntarily offer updates about

them and their discharge plan during their admission which could translate to better follow up

compliance in an outpatient setting.

In summary, this project’s implications for practice can help providers feel more

comfortable prescribing and treating patients with methamphetamine use disorders in a

respectful and meaningful way through patient involvement in their own healthcare. This, in

turn, has the potential to mean increased abstinence and better patient outcomes.

Limitations

This project has potential limitations. The small sample size makes the results of this study less

generalizable. Further, data collection was limited by the disease process of methamphetamine

detoxification, as patients were typically too fatigued to meaningfully engage in assessment

while the provider was present. As a result, some patients were unable to participate during their

admission. Studying a larger sample size and with more providers could offer more generalizable

data and potentiate more themes outside the inpatient setting. There is lack of prior data and
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research available regarding substance abuse and decision aids specifically, therefore there was

little data to compare against the results of this project.

Conclusion

There is no FDA approved medication for MA recovery or withdrawal symptoms. For this

reason, providers must familiarize themselves with other treatment options outside of

pharmacology. While medications can be helpful as part of their recovery process, the complete

wrap around care service can help a patient maintain sobriety. Patients need strong provider

support in conjunction with their therapies as this increases their access to care. The purpose of

this project was to create a standardized decision aid to help providers provide patients with their

treatment options to allow for patient centered care through shared decision making. When a

patient is empowered in their decision regarding their care, not only does it improve patient

outcomes but also increases the therapeutic relationship between patient and provider. This

therapeutic relationship is crucial and begins with providing patients with all options in an

unbiased, non-judgmental manner so they feel supported and heard. With the associated risk of

methamphetamine use, the healthcare community cannot afford to not explore all treatment

modalities.

Acknowledgments

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Appendix A
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Appendix B
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Appendix C