Facilitating Behavior Change in Plastic Surgery Patients Who Inject Drugs Through Motivational Interviewing

Abstract

Background: Plastic surgeons treat a large volume of patients with upper limb morbidity resulting from intravenous drug use. The use of motivational interviewing by health care providers has demonstrated effectiveness in eliciting behavioral change, leading to improved health outcomes. This paper aims to explore the concept and process of motivational interviewing and its role in facilitating behavior change in the plastic surgery setting. Methods: The authors reviewed the literature on motivational interviewing in various health care settings. Results: Motivational interviewing, first developed in the field of psychology, has demonstrated effectiveness in facilitating behavior change in various clinical contexts, including brief clinical encounters. Using motivational interviewing guides the patient as they move through the stages of readiness for change in dealing with unhealthy behaviors. The authors demonstrate these techniques in a supplemental instructional video. Conclusions: Motivational interviewing is an evidence-based method for facilitating behavior change. All plastic surgeons should be prepared to use this person-centred counselling method in clinical practice.

Introduction

Intravenous drug use and other forms of substance abuse fall under the umbrella of addiction. The American Psychiatry Association (APA) characterizes addiction as “a brain disease that is manifested by compulsive substance use despite harmful consequences”. ¹ Mental health disorders are a leading cause of disease burden, costing the American health care system a notable $89 billion in 2013. ² As the most common sites for infection are the antecubital fossa and hand, plastic surgeons, the experts of hand, wrist, and soft tissue, are often consulted to perform surgical debridement and incision and drainage. ³ Over the past ten years, hospitalization secondary to intravenous drug use (IVDU)-related complications has increased, from 4 to 9 per 100 000 people between 1993 and 2010. ⁴ The upper extremities are the most common site for injection, making people who inject drugs more susceptible to soft tissue abscesses, osteomyelitis, and septic arthritis, all of which may lead to pain and disability.^5,6 Mortality rates among intravenous drug users are also a cause for concern. Canadian epidemiological data suggested that people who inject drugs were at 13 and 54 times greater risk of premature mortality than the general population. ⁷ Individuals are highly likely to relapse, with relapse rates ranging from 40% to 60%, primarily driven by compulsive cravings for the substance. ⁸

A potentially important tool for plastic surgeons to use when addressing this specific patient population is the practice of motivational interviewing. Motivational interviewing (MI) is an evidence-based practice that has proven effective for supporting various behavioral changes, including those with substance use disorders. ⁹ Using traditional methods, physicians may encourage patients to stop injecting, but their advice may be met by resistance or noncompliance. ⁹ There is a large body of literature to suggest that MI may be useful in overcoming this resistance. Although a surgeon may be “time poor”, evidence suggests that brief interventions utilizing MI techniques are clinically and cost-effective in fostering behavior change in individuals with substance use disorders.^10-12 This article explores the concept and process of MI and its potential role in facilitating behavior change by plastic surgeons in patients using intravenous drugs.

Definition of Motivational Interviewing

Motivational interviewing was defined by founders William Miller and Stephen Rollnick as “a person-centered counseing method for addressing the common problem of ambivalence about change”. ¹³ MI is an alternative to the traditional, paternalistic conversation model between the physician and patient. The goal of MI is to strengthen the patient's motivation toward achieving a change in behavior, leading to better health outcomes.

MI utilizes a conversational interviewing style to address ambivalence and perceived barriers that patients face when tasked with the need to change their behavior. ¹³ Rather than asserting a need for change and confronting the patient, a physician applying MI will seek to develop a collaborative partnership with their patients and co-develop achievable goals for change.

Evidence

Motivational interviewing has demonstrated effectiveness in facilitating behavior change when used by formally trained therapists. ¹⁴ A two-arm parallel randomized control trial comparing MI to a brief educational intervention among people who inject drugs demonstrated that at six months follow-up, participants in the MI group were at 50% fewer odds of reporting any risky injection behavior (odds ratio [OR] = .50; 95% CI = .13–.87). ¹⁵ A review of four meta-analyses suggested that MI may have a small to moderate effect in the context of substance use and dependence compared to no treatment (Cohen's d = .19 to .43). ¹⁶ Another systematic review with a median 12-month follow-up (range two months to 4 years) demonstrated that MI could be effective in brief encounters of only 15 min. ¹⁷ Short motivational interviews have also proven to be cost-effective compared to standard care.^11,12 Additionally, there is a growing body of evidence suggesting health care professionals do not have to be formally trained therapists to practice MI effectively. Previous studies have supported the use of MI by obstetricians, ¹⁸ pediatricians, ¹⁹ general practice physicians, ²⁰ dental professionals, ²¹ nurses, and dietitians. ²² However, there is no evidence evaluating the use of motivational interviewing by plastic surgeons to our knowledge.

What Is Motivational Interviewing? Principles and Practice

The objective of using motivational interviewing is to guide the patient as they move through the stages of readiness for change (concerning the targeted behavior)^23,24 (Table 1). The objective is to enable the patient to move from the precontemplation stage to the maintenance or relapse stage.^14,15

Table 1.

Stages of Readiness for Change.

Client stages	Explanation and examples
Precontemplation	The patient does not believe that a problem exists (“I use, but I don't have a drug problem”)
Contemplation	The patient recognizes that a problem exists and starts to contemplate a change in behavior or treatment. (“Maybe I do have a drug problem, and I should seek treatment, or find ways to reduce my drug use”)
Preparation-action	The patient begins the change in behavior (“I’ve had enough. I want to enter rehab and kick this bad habit”)
Maintenance	The patient incorporates new behavior into their daily life (“I’ll avoid a situation that have triggered my drug use in the past”)
Relapse	The patient returns to the unhealthy behavior (“I went back to injecting, it helps me cope with the loss of my sibling”)

The overall spirit of MI is centered on empathy. ²⁵ Empathy manifests in the relationship between the physician and patient in four ways: partnership, acceptance, compassion, and evocation (Table 2). ²⁶ The founders of MI have commented that implementing MI strategies in the absence of the spirit of MI is ineffective. ²³

Table 2.

Spirit of Motivational Interviewing.

Partnership	The plastic surgeon collaborates with the client to work together on specific change goals
Acceptance	The plastic surgeon accepts the client for who they are, respects the client's autonomy and understands the need for the client to make his or her own decisions
Compassion	The plastic surgeon understands that the client's well-being is of utmost importance. Definition of well-being is determined from the patient's perspective
Evocation	The plastic surgeon seeks to evoke from the client what his or her goals are and how they would like to be helped. The surgeon avoids viewing the client as an individual in need of instruction and direction

Motivational Interviewing in Practice

The skills required for MI may appear simple, but the process takes practice, feedback, and commitment. ²⁶ The plastic surgeon has three critical tasks:

reflective listening,

eliciting “change talk,”

offering information, feedback, and advice using MI principles.

Reflective listening assists in building rapport and establishes the therapeutic relationship consistent with the spirit of MI. Reflective listening utilizes four skills represented by the acronym OARS (Open ended questions; Affirmations; Reflections; Summarizing) (Table 3). ²⁵

Table 3.

OARS: The Four Skills Used to Listen Reflectively.

Asking Open-ended questions	The surgeon allows the patient to do most of the talking Providing the surgeon with an opportunity to learn more about the patient's values and beliefs “I heard you have some concerns about your drug use, would you like to share those concerns with me?”
Make Affirmations	The surgeon makes compliments or statements of appreciation and understanding Building rapport between the surgeon and client “I appreciate the courage that is required for you to discuss your drug use with me today. I imagine this is not easy for you”
Use Reflections	Involves the plastic surgeon rephrasing a statement in an effort to capture the implicit meaning and the feelings accompanying a client's statements Use of reflections can strengthen the empathic connection between the two parties “It sounds you don't necessarily want to use. I am getting the impression using helps you cope with your day to day and you hate the feeling of withdrawal.”
Use Summarizing	The surgeon uses active listening to find key points in what the client says and offers it back to the client for confirmation and revision Ensure mutual understanding between both parties Allows the surgeon to purposefully and accurately guide the conversations from one topic to another in a way the client feels understood “Let me make sure I understand everything we have spoken about. You have been experiencing […]. How am I doing?”

Change talk is a conversation with the patient that favors healthy behavior change. ²⁶ Multiple strategies are available for eliciting change talk, but the simplest way is by asking a series of questions based on four categories ²³ (see Table 4):

disadvantages of the status quo;

advantages of change;

optimism for change; and

intention to change.

Table 4.

Questions to Elicit “Change Talk” and Examples of Change Talk.

Change talk	Questions and response example
Disadvantage of the status quo	What worries you about your drug habit? “I’m afraid I’m going to OD one of these days”
Advantages of change	What would be different in your life if you stop using drugs? “If I stopped injecting, I think I’ll be able to live a better life…who knows, maybe my wife and kids will accept me in their lives”
Optimism for change	When have you made a significant change to your life? How did you do it? “I had stopped injecting a few years back, and it definitely helped. I had entered rehab and was determined to get my life back together”
Intention to change	Let's ignore the process for now, if you could change anything, what would it be? “I would like to go back to my family, wife, and kids. I want to go back to being healthy and responsible. I never thought it would get this bad. I only used drugs recreationally in the beginning, mostly because they made me feel good … and now it's completely taken over my life”

Application of Motivational Interviewing in Brief Interactions

The time required for the implementation of a comprehensive MI intervention can be a challenge. A solution is to simplify the practice of MI for healthcare settings through four guiding principles. ²³ The acronym RULE represents the following principles:

resisting the righting reflex;

understanding your patient's motivations;

listening with empathy; and

empowering your patient.

Hall et al ²⁷ described the “importance ruler,” “confidence ruler” and change plan as quick employable strategies to elicit change talk in brief interactions. The following script has been adapted from their commentary.

The “importance ruler” highlights discrepancies between a patient's current and ideal situations. For example:

Plastic surgeon: Think of a scale from zero to 10 of how important it is for you to stop injecting. On this scale, zero is not important at all, and 10 is extremely important. Where would you be on this scale?

Patient: 4

Plastic surgeon: Why are you at four and not zero? What would it take for you to go from a 4 to a 7? ²⁷

The “confidence ruler” focuses on the patient's strengths, thereby building their confidence in their ability to change. ²⁷ For example:

Plastic surgeon: “On a scale from zero to 10—where zero is not confident at all and 10 is extremely confident in your ability to stay away from Fentanyl—where would you be on this scale?”

Patient: 6

Plastic surgeon: Why are you at 6 and not zero? What would it take to take you to go from 6 to a higher number?

Lastly, it is crucial to work collaboratively on a change plan. Utilizing the principles of MI, surgeons should not immediately advise their patients, as is characteristic of the paternalistic approach. ²⁷ They should remind patients that they are their own experts. Using empowering language such as, “You are the expert on you, so I’m not sure I am the best person to judge what will work for you. But I can give you an idea of what the evidence shows us and what other people have done in your situation” ²⁷ may prove helpful in facilitating behavior change. Other useful phrases include the following: ²⁷

“It sounds like things can't stay the same as they are. What do you think you might do?”

“What changes were you thinking about making?”

“Where do we go from here?”

“What do you want to do at this point?”

“After reviewing all of this, what's the next step for you?”

Discussion

Considerable barriers prohibit the implementation of MI, which may include time pressures, patient complexity, lack of training, and the culture of the “medical expert”. ²⁷ Medical education at both the undergraduate and postgraduate levels has not traditionally included the principles of motivational interviewing in their curriculum. A training course in MI can be as brief as three days and still improve interactions between patients and healthcare professionals. ²⁸ Moving away from the “specialty silo” approach in medical education and inviting experts from different fields for grand rounds and other interdisciplinary medical education activities are suitable approaches to facilitating the use of MI by plastic surgeons. ²⁴

While it may not be feasible to implement MI in all patient interactions, using motivational interviewing where possible will serve plastic surgeons and their patients more effectively. During the minor procedure of evacuating a forearm abscess, there is an approximately 20–30 minute window where the patient is awake and may consider a lifestyle change under current circumstances. This opportunity to engage in productive conversations is often underutilized. Unfortunately, these vulnerable patients who receive medical attention are often met with stigmatizing attitudes, leading to an avoidance of the health care system. ²⁹

The field of plastic surgery would benefit from the formal investigation of the effectiveness of motivational interviewing in facilitating behavioral change in patients who inject drugs. The study methodology could emulate previous randomized controlled trials. Such research would be useful in encouraging the utilization of MI by plastic surgeons. Although patients who inject drugs are the subject of this paper, MI can help other plastic surgery patients. A recent pilot randomized controlled trial on bariatric surgery patients demonstrated that MI was a feasible and effective intervention to improve dietary adherence, binge eating symptoms, and confidence for change. ³⁰ Similarly, a 2016 systematic review ³¹ demonstrated improved outcomes related to smoking cessation, pain management, fatigue, and healthy eating habits following MI in cancer patients and survivors. Considering the many potential applications of MI by plastic surgeons, MI should be researched further in the context of plastic surgery. Programs with trained and dedicated MI counselors could be cost-effective and lead to better patient outcomes. There is also evidence to suggest that MI may also be especially beneficial for those who have experienced substance use relapse. ³² These findings strengthen the argument that MI can lower health system costs and better health outcomes for patients.

Conclusion

The complexity of a patient's medical and social comorbidities is highlighted when their addiction brings them into the tertiary care setting for a plastic surgeon's treatment. Using the principles of motivational interviewing ensures patients have positive encounters with the healthcare system when they are most vulnerable. Enhancing rapport may make patients more receptive to multidisciplinary care, involving addiction medicine and social workers who can offer continuing treatment. Importantly, research has demonstrated that early intervention is the most effective way to prevent someone with a substance use problem from becoming worse. ³³