Substance Abuse Counselors Research Articles

The need for Hispanic cultural competency in drug abuse treatment training programs: An empirical and ethical evaluation of US universities

Ethical clinical practice requires cultural competency. In the United States, Hispanics report stronger attitudinal barriers to drug abuse treatment than any other racial/ethnic group. Hispanics report feeling that drug abuse treatment providers do not understand their unique cultural needs and are unfamiliar with their experiences of discrimination and immigration. Using this case study to explore broader ethical and policy issues, this study investigates the extent to which US universities train counselors to address the culturally specific needs of Hispanic patients and how this is reflected in practice in Los Angeles County. Based on a content analysis of the required courses, syllabi, and course descriptions at 30 universities related to culture/race/racism/ethnicity/diversity at the undergraduate and graduate levels on the addiction therapist track, and thematic analysis of eight in-depth interviews with counselors working in outpatient rehabilitation centers in Los Angeles, I argue that cultural competency education for drug abuse counselors is too surface level and infrequent to adequately prepare students for a career in addiction counseling for Hispanic clients. Significant changes must be made to how cultural diversity is valued and prioritized in the field of psychology to provide better care for Hispanic people with a substance use disorder and fulfill the moral obligation to eliminate this health disparity. Although this study focuses on counselors in Los Angeles, these findings are relevant for professionals and healthcare systems across the United States and beyond who seek to provide equitable and effective care for Hispanic patients.

Trends in the Incidence and Risk Factors of Pregnancy-Associated Stroke.

Pregnancy is a female-specific risk factor for stroke. Although pregnancy-associated stroke (PAS) is a rare event, PAS leads to considerable maternal mortality and morbidity. It is estimated that 7.7–15% of all maternal deaths worldwide are caused by stroke and 30–50% of surviving women are left with persistent neurological deficits. During last decade, several studies have reported an increasing incidence of PAS. The objective of this review is to summarize studies on time trends of PAS in relation to trends in the prevalence of stroke risk factors in pregnant women. Seven retrospective national healthcare register-based cohort studies from the US, Canada, UK, Sweden, and Finland were identified. Five studies from the US, Canada, and Finland reported an increasing trend of PAS. Potential biases include more sensitive diagnostics and improved stroke awareness among pregnant women and professionals toward the end of the study period. However, the concurrent increase in the prevalence of several stroke risk factors among pregnant women, particularly advanced age, hypertensive disorders of pregnancy, diabetes, and obesity, indicate that the findings are likely robust and should be considered seriously. To reduce stroke in pregnancy, increased awareness among all medical specialties and pregnant women on the importance of risk-factor management during pregnancy and stroke symptoms is necessary. Important preventive measures include counseling for smoking cessation and substance abuse, treatment of hypertensive disorders of pregnancy, use of aspirin in women at high risk for developing preeclampsia, and antithrombotic medication and pregnancy surveillance for women with high-risk conditions. Epidemiological data from countries with a high risk-factor burden are largely missing. National and international registries and prospective studies are needed to increase knowledge on the mechanisms, risk factors, management, and future implications for the health of women who experience this rare but devastating complication of pregnancy.

Opioid Use Disorder Increases Readmissions After Cardiac Surgery: A Call to Action

BackgroundOwing to the opioid epidemic, more cardiac surgery patients present with opioid use disorder (OUD). A better understanding of national readmissions among these patients is necessary to improve outcomes and optimize resource utilization. We sought to examine the effect of OUD on readmission after cardiac surgery. MethodsOf 555 394 cardiac surgery patients from 2016 to 2017 in the Nationwide Readmissions Database, 6082 (1.1%) presented with OUD. These patients were assessed at 30, 90, and 180 days after discharge. The OUD patients and non-OUD patients were propensity score matched for patient- and procedure-level characteristics. Kaplan-Meier curves were compared using the log rank test. ResultsFirst-time readmissions were significantly higher among patients with OUD (30 days 19.7% vs 15.7%, P = .04; 90 days 31.8% vs 24.2%, P < .0001; and 180 days 42.3% vs 30.6%, P < .0001). There was a trend toward higher reoperation by 180 days, with 90% of those being isolated valve surgery. By 180 days, significantly more OUD patients had three or more readmissions (7.8% vs 4.5%) compared with non-OUD patients. Yet, only 2.4% of OUD patients received any counseling or treatment for substance abuse during the index admission. The most common readmitting diagnosis was infection (55% vs 41%, P < .0001) including endocarditis, prosthetic infections, and skin or subcutaneous infections. Respiratory failure, opioid overdose, and acute pain were also more common among patients with OUD. ConclusionsCardiac surgery patients with OUD have multiple readmissions but are rarely provided adequate addiction management during their index admission. Greater emphasis on multidisciplinary management is necessary to limit costs and morbidity associated with readmission or reoperation.

OVERVIEW OF THE IMPACT OF SUBSTANCE USE DISORDER ON TRAFFIC CRASHES: A CASE OF BOTSWANA

Addictions to drug and alcohol, which stem from substance abuse (SA), are universal public health problems and cause a significant burden to individuals and societies resulting in a multitude of physical, social, economic and legal problems including transport crashes. In spite of epidemic levels of substance abuse in society, many individuals do not receive treatment at all let alone adequate treatment. This continues to make substance use disorder a major cause of transport crashes (with the attendant menace) in developing countries. Research suggests that counsellors (and other helping professionals) are disinterested in SA counselling, and have SA training, attitude, and skill deficits. There is a dearth of empirical research particularly in developing countries that addresses counsellors’ (or trainee counsellors’) knowledge and attitudes in relation to substance use and substance users. This paper therefore reviewed the effect of substance abuse, the overall burden of which could have been reduced, had there been adequate and appropriate exposure to treatment, on highway traffic crashes.

Primary healthcare approach to substance abuse management.

Substance abuse is common amongst patients attending primary healthcare settings. Despite the substantial impact on one’s health, substance abuse is often underdiagnosed by primary care providers owing to a lack of training and time for screening. Self-reported screening tools are easy to administer and efficient to make a substance abuse diagnosis in primary care settings. Comorbid mental illness and intimate partner violence are common amongst patients presenting with substance abuse in primary care. An early diagnosis and a brief behavioural change counselling are effective in managing substance abuse before it develops into dependency. A brief motivational communication rather than a confrontation during substance abuse screening, counselling and treatment is important to achieve optimum patient outcomes.

Virtualization of mental health care in the midst of chaos: is telepsychiatry a silver lining

Telephonebased mental health services have become available in Turkey in recent decades, including a suicide crisis intervention hotline administered by the Bakirkoy Prof. Mazhar Osman Training and Research Hospital for Psychiatry, Neurology, and Neurosurgery, and remote substance abuse counseling services provided by the Ministry of Health and the Turkish Green Crescent Society (8,9). (32) identified 6 areas of ethical challenges for the delivery of remote mental healthcare: data security, privacy, and confidentiality;clinical safety of telepsychiatry recipients;competency and readiness of telepsychiatric practitioners;legal, regulatory, and financial concerns;informed consent for services;and social justice concerns. [...]we suggest that formal mental health care programs should include telepsychiatry training that includes competency in technical requirements, clinical assessment, communication strategies, the therapeutic relationship, consultation, liaison with other disciplines, ethical and legal aspects, and evaluation of the sociocultural characteristics of patients (36,37). Growth and success in telehealth has emerged as an unexpected silver lining of the COVID-19 pandemic and reminds us that it is critical to develop more effective mental health service delivery systems that can enhance treatment access and quality.

KOMUNIKASI TERAPEUTIK DALAM KONSELING ANTARA KONSELOR DAN PASIEN PENYALAHGUNAAN NARKOBADI KLINIK BADAN NARKOTIKA NASIONAL PROVINSI JAWA BARAT

The purpose of this study was to determine Therapeutic Communication in Counseling between Counselors and Drug Abuse Patients. To answer the research objectives, the four focus of the researcher, namely the pre-interaction phase, the orientation phase, the working phase, and the termination phase of Counselor Therapeutic Communication in Rehabilitating Drug Abuse Patients at the National Narcotics Agency Clinic of West Java Province.This study uses qualitative research methods with descriptive studies. The number of informants in this study were four people, consisting of three key informants and one supporting informant. Data collection techniques used in this study are literature study, internet searching, indepth interviews, non-participant observation and documentation.The results of research conducted by the Clinical Counselor of the National Narcotics Board of West Java Province are the pre-interaction phase where the counselor studies patient data. The orientation phase in which the counselor performs the Screening approach and builds trusting relationships with the patient and the Assessment of the counselor ensures patient safety as well as establishes a counseling service plan, and a termination phase where a drug abuse counseling service has been completed and will be referred to post-rehabilitation

The Relationship Between Housing Status and Substance Use and Sexual Risk Behaviors Among People Currently Seeking or Receiving Services in Substance Use Disorder Treatment Programs.

Although HIV risk behaviors such as substance use and condomless sex are prevalent among people currently seeking or receiving services at substance use disorder (SUD) treatment programs, associations with housing status in this population have not been well studied. We examined the associations between housing status, substance use and HIV-related sexualriskbehaviors among 1281 participants from 12 US community-based SUD programs. In addition, substance use was examined as a potential mediator of the relationship between housing status and sexual risk behaviors. We conducted Chi-square, univariate and multivariate logistic regression models on data from the National Drug Abuse Treatment Clinical Trials Network HIV Rapid Testing and Counseling study. Path analysis was used to test the mediation and indirect effects. Unstable housing was significantly associated with having multiple concurrent condomless sex partners, condomless sex with non-primary partners, and partners of unknown HIV serostatus. Homelessness was significantly associated with condomless vaginal sex and condomless sex with any substance use. The path between unstable housing and sexual risk behaviors was mediated by problematic drug use, particularly by cocaine, opioids, and marijuana use. Because housing status impacts HIV risk behaviors for individuals in SUD treatment programs, both housing status and substance use behaviors should be assessed upon program entry in order to identify and mitigate risk behaviors.

E-cigarette or vaping product use-associated lung injury (EVALI) features and recognition in the emergency department.

Since August 2019, the pulmonary disease termed e‐cigarette or vaping product‐use associated lung injury (EVALI), has resulted in 2758 hospitalizations and 64 deaths in the United States. EVALI is considered in patients who have vaped or dabbed within 90 days of symptom onset, and have abnormal lung imaging in the absence of any pulmonary infection. The majority of EVALI patients are otherwise healthy adolescents and young adults. The leading etiology of EVALI is contamination of delta‐9‐tetrahydrocannabinoid (THC) e‐liquids with vitamin E acetate. Although the exact pathophysiology of vitamin E acetate‐induced lung injury is unknown, vitamin E acetate may lead to pulmonary lipid accumulation and/or interfere with surfactant functioning. EVALI symptoms are vague but consist of a constellation of constitutional, pulmonary, and gastrointestinal symptoms. Patients often present multiple times to healthcare facilities as their clinical condition worsens with a considerable mortality risk. The diagnosis of EVALI hinges on obtaining history leading to the recognition of vaping/dabbing. Physicians need to be persistent, but nonjudgmental, in obtaining vaping histories, especially in THC‐prohibited states. Radiographical findings of nonspecific bilateral ground‐glass infiltrates are best detected on computed tomography. Management for EVALI requires a multidisciplinary approach focused on supportive respiratory care and ruling‐out infectious causes. Corticosteroids may be of benefit. Most patients who are hypoxic, have comorbidities, or lack appropriate follow‐up within 24–48 hours should be admitted for monitoring. Patients may benefit from substance abuse counseling and should be instructed to avoid vaping. As the outbreak continues, cases should be reported to local health departments and poison control centers.

Pharmacy students’ personal health practices and perceptions on lifestyle medicine

ABSTRACT Pharmacists are accessible and positioned to facilitate health behavior change among patients with chronic diseases. The readiness of pharmacy students to practice lifestyle medicine is unclear. Doctor of Pharmacy students were surveyed on personal characteristics, health behaviors, and opinions on lifestyle counselling in September 2016. Ninety-three out of 359 (26%) students participated. A greater percentage of students with body mass index less than 25 kg/m2 responded that substance abuse counselling was highly relevant to their intended practices as compared to students classified as overweight or obese (p <.05). Over two-thirds of students without health care-related work experience indicated that weight management (p < .05) and alcohol abuse counselling (p < .05) were highly relevant to their intended practices. Student-specific factors are associated with perceptions on whether particular lifestyle medicine topics are relevant to their intended practices. Pharmacy programs can use study results to identify curricular areas where lifestyle medicine should be further emphasized.

Single Case Evaluation of a Mindfulness-Based Mobile Application with a Substance Abuse Counselor

We implemented an exploratory A-B single case research design with a phenomenological lens to analyze journal entries to assess the effectiveness of a 12-week mindfulness-based mobile intervention to reduce burnout and increase mindfulness and self-compassion. Our participant was one 55-year-old White woman employed as a substance abuse counselor at a medium sized treatment facility in a midwestern state. We collected three weeks of baseline data followed by a 12-week intervention using the Calm © app and collected self-reported scores on the Copenhagen Burnout Inventory, Freiburg Mindfulness Inventory, and the Self-Compassion Scale across baseline and intervention phases. Data analyses using the Percentage of Data Exceeding the Median provide preliminary evidence that using the Calm © app across 12 weeks may decrease levels of burnout and increase levels of mindfulness but provided no evidence for increased self-compassion. We provide suggestions for substance abuse counselors and discuss the limitations and future research recommendations.

Mental health, substance use and HIV risk behaviors among HIV-positive adults who experienced homelessness in the United States – Medical Monitoring Project, 2009–2015

ABSTRACTHomelessness is a challenge to retention in HIV care and adherence to antiretroviral therapy. We describe the sociodemographic and behavioral characteristics of HIV-positive adults who reported recent homelessness. The Medical Monitoring Project is a complex sample survey of HIV-positive adults receiving medical care in the United States. We used weighted interview and medical record data collected from June 2009 to May 2015 to estimate the prevalence of depression, substance use, and HIV risk behaviors among adults experiencing recent homelessness. From 2009 to 2015, 8.3% of HIV-positive adults experienced recent homelessness. Homeless adults were more likely than housed adults to have major depression, to binge drink, use non-injection drugs, use injection drugs, and smoke. Over 60% of homeless adults were sexually active during the past year, with homeless adults reporting more condomless sex with an HIV-negative or unknown status sex partner than housed adults. Programs attempting to improve the health outcomes of HIV-positive homeless persons and reduce ongoing HIV transmission can focus on providing basic needs, such as housing, and ancillary services, such as mental health counseling or substance abuse treatment and counseling.

Mindfulness Training for Social Service Providers in Hawaii: Context and Considerations

Few studies exploring outcomes for mindfulness training have specifically focused on social service providers such as case managers, juvenile justice (probation/parole) officers, family court liaisons, substance abuse and mental health counselors, and school behavioral health specialists, among others. This study examined whether social service professionals across various agencies in the state of Hawai‘i would be accepting of mindfulness-based training and practices, and explored their personal practice experiences. Participants (N = 97) received mindfulness skills training including mindful breathing, mindful walking, and the body scan. Through post-evaluation surveys, practice logs of homework practices, and reflections, they were then asked to reflect on their experiences with the practice and identify potential changes that they would attribute to mindfulness. Interpretative phenomenological and content analyses revealed that participants generally reported a high level of acceptance of the mindfulness training and practices but progress, continuity, and sustainability were slow. Findings provided some indications of mindfulness resulting in salutary effects for social service professionals, but the training structure was problematic. Future research needs to examine how institutional, cultural milieu facilitate or hinder opportunities for social service professionals to embody and embed mindfulness in daily life; this would require multimodal and qualitative methodologies that seek to highlight and understand the live experiences of social service providers.

Pharmacist utilization of prescription opioid misuse interventions: Acceptability among pharmacists and patients.

This study evaluates pharmacist and patient acceptance of pharmacy-based opioid interventions, and identifies interventions both groups find acceptable. Using two surveys simultaneously administered to Ohio Pharmacists and patients in treatment for substance use disorders, this study compares pharmacist and patient acceptance of five (5) pharmacy-based opioid misuse interventions through the use of Cohen's Kappa using the Altman Benchmark Scale. Through this analysis, we found that both pharmacists and patients view the use of patient counseling and Prescription Drug Monitoring Program-based validation of prescriptions as acceptable prescription misuse interventions. While patients expressed interest in Naloxone-based interventions, many pharmacists were opposed to Naloxone-based interventions. Both pharmacists and patients appear to be far more comfortable with the use of counseling and Prescription Drug Monitoring Program-based validation of prescriptions compared to interventions that involve referral to treatment resources or distribution of Naloxone.

Mitigating Risk, Managing Cancer Related Pain in the Setting of Substance Misuse

1)Identify the challenges of managing cancer pain in a patient with substance misuse.2)Recognize the benefit of providing a comprehensive management strategy.3)Understand the clinical role of the interdisciplinary team and specialist mental health services. Concern regarding opioid safety in the chronic non-malignant pain population is ubiquitous; however, patients with cancer are not included in current management guidelines of professional and state organizations. The pain experienced by patients with cancer may be exacerbated by disease progression but also by other factors such as existential distress, or a history of substance misuse. A step-wise approach has been developed to identify patients at risk, but management of high-risk oncology patients may be especially complex. Prescribers may find themselves in a precarious situation of managing malignant pain with high dose opioids in the context of substance misuse. BW is a 63 year old male with history of poly-substance misuse and metastatic prostate cancer with extensive osseous metastatic disease causing pain. He presented for ongoing management of neoplastic related pain rated 10/10 on Edmonton System Assessment Scale (ESAS). Review of the Prescription Monitoring Program (PMP) identified multiple prescriptions from outside physicians and a urine drug screen (UDS) positive for cocaine. He cited several reasons for his relapse including inadequate pain control and fear of death. Care expectations were set, specifically: short intervals between clinic visits; evaluation and brief motivational interviewing by the palliative care team (physician, nurse, and psychologist) at each visit; enrollment in substance abuse counseling; and frequent UDS. He was started on methadone 10 mg TID. After 4 months, he was titrated to methadone 30 mg TID, and pain score was 6/10 on ESAS. All UDS and PMP results were normal. However, due to disease progression, he was enrolled in home hospice and died at home 5 months later. Our case demonstrates that a comprehensive management approach can effectively manage cancer pain, in patients with substance misuse and advanced disease, with improved quality of life.

Abstracts from the NIH Office of Research on Women's Health 2018 Annual BIRCWH Meeting – Building Interdisciplinary Research Careers in Women's Health November 28, 2018

Abstracts from the NIH Office of Research on Women's Health 2018 Annual BIRCWH Meeting – Building Interdisciplinary Research Careers in Women's Health November 28, 2018

Solution Focused Counseling with a Substance Abusing Client

Substance abuse counseling is typically offered from a cognitive-behavioral or 12-step based approach. Solutionfocused theory can offer counselors with an alternative perspective for working with clients with drug abuse issues. In this article, a case report is presented in which the author utilized a solution-focused approach with a client experiencing co-occurring anxiety and severe alcohol use. Solution-focused theory is briefly described and techniques for use with the model are detailed. The effective use of exception and coping questions are described in the case report and outcomes of these interventions are presented. The article concludes with a discussion on the need for further research and suggests specific areas for additional investigation.

Prevailing knowledge about Male and Female lifestyle habits and In Vitro Fertilization in the 21st century

At least one million infants have been born in the United States with the help of in-vitro fertilization (IVF) or other assisted reproductive technologies. Lifestyle factors including smoking, alcohol, recreational drugs, stress, lack of physical activity, and obesity in men and women, which may profoundly influence IVF success rates. Nevertheless, many women and men about to undergo fertility treatment make poor lifestyle choices that may possibly affect their chances of becoming pregnant. A follow-up systematic review was conducted in PubMED (MEDLINE) from 2005-2017 to evaluate the effects of male and female lifestyle habits on success rates of IVF. There was strong evidence that smoking affects almost every endpoint of IVF. There is also mounting evidence that obesity profoundly affects pregnancy, live birth rates, and is also associated with cancelled cycles. The literature on stress and IVF continues to be contradictory. The results were almost equally divided between four studies that found a negative effect of stress on number of oocytes, embryo transfer, and pregnancy, and three studies that reported no effect on IVF outcomes. The evidence for an association for exercise, alcohol, caffeine, and recreational drugs and IVF is inadequate based on a paucity of studies. In order to resolve this dilemma, national or international databases could be used to effectively and accurately capture lifestyle habits over time on thousands of couples undergoing IVF. This information could eventually help create guidelines for primary care physicians, specialists, and infertile patients. From a medical standpoint, it is probably advisable for men and women contemplating IVF to be encouraged to engage in healthy lifestyles. At this time, a structured educational program, ongoing wellness support, and therapeutic interventions (e.g., smoking cessation, relaxation techniques, substance abuse counseling) could be part of the comprehensive care received at fertility clinics in order to promote healthy lifestyle changes.

Implementation of a Standardized Protocol for Hospitalized Patients Who Inject Drugs and Require Long-Term Antibiotics Reduces Length of Stay Without Increasing 30-Day Readmissions

BackgroundInjection drug use (IDU) is a growing epidemic, and persons who inject drugs (PWID) are at high risk for infection. IDU is a barrier to outpatient parenteral antimicrobial therapy (OPAT) and provider experience and knowledge may lead to variation in patient care. Recognizing this problem, a multi-disciplinary team implemented a protocol for management of PWID requiring IV antibiotics. The main goals were to standardize the evaluation and risk assessment of PWID with infections and to provide substance abuse counseling and treatment in order to decrease length of stay (LOS).MethodsA protocol was developed outlining the evaluation, diagnosis, risk-assessment, treatment, maintenance, and follow up of PWID requiring prolonged IV antibiotics (Figure 1). Patients meeting inclusion criteria were identified and the multidisciplinary team assessed the patient. ID confirmed the diagnosis and outlined the treatment plan, and addiction medicine performed a 9-point risk assessment. Low-risk patients were discharged to complete OPAT. Medium risk and high-risk patients remained hospitalized and were offered group therapy, opioid replacement therapy if applicable, and were reassessed weekly for discharge. These patients were compared with previously identified PWID requiring antibiotics prior to the protocol implementation.Results37 patients pre-protocol were compared with 34 patients following implementation. Demographics were similar except 56% of the post-implementation group were diagnosed with a concomitant psychiatric disorder vs. 27% in the pre-implementation group (P = 0.01). There was no statistical difference between the number of patients who left AMA in either group (13.5 % pre; 23.5% post; p 0.28) or the number of readmissions (51.4% pre; 32.4% post; P = 0.10). However, the median LOS was significantly reduced in the post implementation group (18. days vs. 42 days; P <0.001). There have been 418 hospital days saved post implementation.ConclusionImplementation of a standardized protocol with a multidisciplinary team and risk stratification to determine appropriate patients for discharge has led to improvement in LOS as well as improved addiction care for hospitalized PWID requiring long-term antibiotics.Figure 1Flow Diagram For PWID Requiring IV AntibioticsDisclosures All authors: No reported disclosures.

A Diagnostic Approach to Stroke in Young Adults.

Optimal diagnosis and management of stroke in young adults benefit from a multidisciplinary team, including a vascular neurology specialist. In addition to the "standard" vascular risk factors including smoking, hypertension, diabetes, and hyperlipidemia, one needs to consider alternative etiologies including substance abuse, carotid/vertebral artery dissections, and rare genetic conditions among others. Once a young patient is determined to have had a stroke, the next question a clinician should ask is why did this patient have a stroke? A "heart to head" diagnostic approach is recommended. A thorough history is performed, including a detailed family history with specific annotations on each family member. A thorough physical examination is necessary including a careful evaluation of the patient's general appearance, noting any joint laxity, and/or abnormalities of the skin, eyes, and heart. Findings across multiple organ systems in the patient and/or their family may indicate a genetic etiology. After an initial head CT rules out hemorrhagic stroke, additional testing should include a brain MRI, neck and cerebral vascular imaging (e.g., CTA for head and neck), transthoracic echocardiogram with a bubble study, telemetry monitoring, basic risk factor blood work (e.g., lipid panel, hemoglobin A1c, TSH, ESR, CRP, RPR, HIV, and toxicology screen), and, when appropriate, sickle screen and pregnancy test. There should be a low threshold to obtain blood cultures or a lumbar puncture. The acute treatment of ischemic stroke in young adult patients does not differ from treatment of older adults, using intravenous alteplase within 4.5h, assuming no contraindications. In suspected proximal large artery occlusive disease, interventional clot extraction procedures should be employed in patients deemed eligible. Long-term secondary prevention strategies aimed to reduce recurrent stroke risk by targeting and modifying vascular risk factors should be instituted. The mainstay of preventative therapy is aspirin for most etiologies; however, for atrial fibrillation, anticoagulation is recommended. Statin therapy is another pharmacologic intervention recommended in most stroke patients. Other measures employed are blood pressure reduction, smoking cessation, optimal glucose control in diabetic patients, the initiation of a healthy diet and regular exercise, and lastly, substance abuse counseling in appropriate patients.