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Management of Opioid Use Disorders Education Rounds for ED and Hospital Counsellors, Crisis Workers and Withdrawal Management Staff About META:PHI Mentoring, Education, and Clinical Tools for Addiction: Primary Care–Hospital Integration • Goals: – Promote evidence-based addiction medicine treatment – Implement care pathways between the ED, hospital, WMS, primary care, and rapid access addiction medicine clinics • Seven sites in Ontario are currently involved, with plans to expand the spread of the project in the future • Funding and support provided by the Adopting Research to Improve Care (ARTIC) program (Council of Academic Hospitals of Ontario & Health Quality Ontario) https://www.porticonetwork.ca/web/meta-phi META:PHI 2015 Baseline Survey The baseline survey is anonymous and entirely optional. You may skip any question that you do not wish to answer. We will not ask you for any personal information Please tear off and keep the front page with contact information, should you have any questions about the survey or the META:PHI project. Please return the completed or incomplete survey face down to the facilitator when you leave the presentation. META:PHI 2015 ROLE OF THE COUNSELLOR IN MANAGING OUDS META:PHI 2015 Role of the Counsellor in Patients with an OUD • Counsellors play a key role in the management of OUDs in the hospital/ED/WMS: – Counsellors spend more time with patients than physicians – Patients are more likely to confide in counsellors than in medical staff – Counsellors are more likely to provide discharge advice – Counsellors can send patients to the RAAM clinic without a formal MD referral META:PHI 2015 Beyond Clinical Knowledge • Counsellors play a significant role in a patient’s early recovery – Counsellor attitude toward a patient with an OUD during their first treatment encounter can influence their future participation in treatment • Showing compassion is essential as often patients seek help with their substance use after it has gotten them into some sort of crisis (e.g. children taken by CAS, DUI, job loss etc.) • These individuals may be at increased risk for self harm – A counsellor’s compassion, knowledge and brief counselling skills offer patients immediate support and the hope that things will improve if they continue working on their recovery META:PHI 2015 Counsellor Goals for OUD Patients in the ED, hospital, WMS 1. Explain to client what an Opioid Use Disorder diagnosis means 2. Provide advice on avoiding opioid-related harms 3. Address patient concerns 4. Provide referral to rapid access addiction medicine clinic for long term medication-assisted treatment META:PHI 2015 WHAT ARE OPIOIDS AND WHAT DO THEY DO? META:PHI 2015 Prescription Opioids • Commonly prescribed opioids can often be misused: – Hydromorphone – Oxycodone – Codeine – Fentanyl – Morphine • These may be taken orally, crushed and snorted, injected, or inhaled META:PHI 2015 Illicit Opioids • Heroin is the most common non-prescription opioids META:PHI 2015 The Addicted Brain • Humans have a reward centre in the brain and when an essential activity for survival is performed (e.g. eating), dopamine is released – Dopamine makes us feel good, so we are motivated to repeat the activity • Drinking and using drugs also cause a release of dopamine, more powerful even than with survival activities • This is what reinforces people’s substance use, even when rationally they know it is harmful to them META:PHI 2015 COUNSELLING YOUR CLIENT ON THEIR OUD DIAGNOSIS META:PHI 2015 What is an OUD? • People with OUDs often have the following four traits: (1) They cannot control their opioid use. (2) They continue to use opioids despite knowing it is harmful. (3) They spend a lot of time obtaining opioids, using opioids, and recovering from opioid use. (4) They have powerful urges or cravings to use opioids. • OUDs have nothing to do with character, will power, or morals. Many good and strong people have a drug or alcohol problem. • People with OUDs find that once they have started using an opioid, it is no longer about choice. META:PHI 2015 What it Means to have an OUD Diagnosis • Explain to your client that: – They have been diagnosed with this disorder because they have repeatedly tried but have been unable to cut down or stop their opioid use. – People with OUDs have lost control over their illicit and/or prescription opioid use, and take more opioids than they intend to, or are prescribed, despite knowing that it's harmful to them. – This happens to certain people because of biological, social, and psychological reasons META:PHI 2015 Concurrent Disorders • People with substance use disorders often suffer from other mental health issues, which may have contributed to their initial and ongoing misuse of drugs or alcohol • Common concurrent disorders include: – PTSD – Anxiety – Depression • These issues must be addressed through counselling, in addition to working on issue of substance misuse META:PHI 2015 AVOIDING OPIOID-RELATED HARMS META:PHI 2015 Tolerance and Withdrawal • When opioids are taken frequently for an extended period of time the brain reacts and changes – Specifically, the opioid user develops tolerance, and in the case of sudden abstinence, they will experience withdrawal • Tolerance is when the person requires an increasing amount of the substance to experience the same effects as before • Withdrawal refers to the physical and psychological distress experienced when the regular opioid dose is missed (e.g. agitation, insomnia, craving, muscle aches, diarrhea) META:PHI 2015 The Brain in Withdrawal • Opioids activate opioid receptors in the brain – As a result, patients feel less pain and less stress • When opioids start to leave receptors suddenly, patient may start to experience withdrawal – Methadone and buprenorphine/naloxone (bup/nx) are medications that can relieve this withdrawal by attaching themselves to the brain’s opioid receptors, where the opioid of dependence had previously been META:PHI 2015 Image from NAABT, Inc Harm Reduction • If a patient has gone through withdrawal and been abstinent, they may be at particularly high risk for overdose if they use because they have lost tolerance • Advise the patient that if they do use opioids they should: – Use much less than before going through withdrawal – Not use intravenously – Not use benzodiazepines, alcohol, or other sedating drugs while using opioids – Never use opioids alone - a friend should always be with them – Call 911 if a friend has taken opioids and is nodding off – Never let someone who is nodding off fall asleep – Carry naloxone META:PHI 2015 Naloxone • Naloxone is a medication that prevents opioid overdose by knocking the opioid causing the overdose off opioid receptors in the central nervous system and taking their place – This buys the consumer 20-30 extra minutes to get to a hospital for overdose treatment • Naloxone is not a drug of abuse and cannot harm someone Images from Toward the Heart, B.C. META:PHI 2015 Take-Home Naloxone • One or two vials of naloxone can be given to patients in the ED to take home in case of a future overdose – As long as they don’t use alone, someone else can inject them with naloxone if they show signs of overdose • • • • slow and shallow breathing slow heartbeat/pulse loss of consciousness/unresponsive blue or purple skin/lips – Even if the consumer is not overdosing, they will not be harmed by naloxone injection if administered unnecessarily META:PHI 2015 Distribute Take-Home Naloxone to Patients at High Risk of Overdose • Not on methadone or bup/nx, on these medications but started in the past two weeks, or on these medications but continuing to use substances • On high dose opioids for chronic pain • Treated for overdose (or reports a past overdose) • Injects, crushes, smokes or snorts potent opioids (fentanyl, morphine, hydromorphone, oxycodone) • Buys methadone or other opioids from the street • Recently discharged from an abstinence-based treatment program, WMS, hospital, or prison • Uses opioids with benzos and/or alcohol META:PHI 2015 Naloxone Kit • Naloxone kits are provided by Public Health, and sometimes in the ED, hospital pharmacy, and/or RAAM clinic • Kit contains: – 1-2 vials of naloxone – Syringes – Patient ID card stating what patient is carrying (naloxone) – Educational info Image from Ontario Harm Reduction Distribution Program META:PHI 2015 Administering Naloxone Instruct patient on naloxone use: - Shake the overdose victim, call their name - If they cannot be fully woken up, call 911 - Inject a full naloxone vial into an arm or leg muscle - Start chest compressions - Inject another vial if they don’t wake up in 3-4 minutes META:PHI 2015 Coping with Cravings – Advice for Patients in Early Recovery (1) • Keep busy: Scheduling and keeping a routine can be a helpful way to avoid using: – Attend self-help groups like NA or SOS, which provide structure, social support and accountability through sponsors – Exercise, take daily walks – Keep Regular sleeping and eating routines – Spend as much time as possible with supportive family and friends who do not use drugs – Keep appointments with addiction counsellors and doctors META:PHI 2015 Coping with Cravings – Advice for Patients in Early Recovery (2) • Keep focused: Staying sober requires paying close attention to how you're feeling, and keeping sobriety as the main priority: – Take medication prescribed to you by your doctor – Avoid HALT states: Hungry, Angry, Lonely, Tired – When feeling the urge to use opioids, pause and call a support first – Don't focus on other issues - they can be dealt with later as long as you remain sober – Know your triggers and do your best to avoid them (e.g. certain people or places, or emotions like stress) – Don't give up - sub-acute withdrawal can last for several weeks or months, and the anxiety, insomnia, fatigue, and cravings that you may be experiencing are all temporary META:PHI 2015 Patient Concern: Stopping Opioids in the Presence of Chronic Pain “If I stop taking opioids, won't my pain get much worse?” • No; in fact, OUDs often make pain worse for two reasons: 1) Patients with OUDs typically experience withdrawal every day as the opioid wears off. Withdrawal greatly magnifies perception of pain. 2) People with OUDs are often depressed and anxious because their addiction is making their life very difficult. Depression, like withdrawal, magnifies people's sense of pain. By treating the OUD, the patient will experience a decrease in chronic pain as well as an improvement in daily functioning. META:PHI 2015 TREATMENT AND REFERRALS META:PHI 2015 Patient Concern: Attending Treatment “Do I really need treatment? Shouldn't I be able to stop using on my own?” • Successful recovery from an OUD requires treatment • Like other illnesses such as diabetes and depression, OUD is caused by biological, psychological, and social factors, and just like these other illnesses, it is very hard for patients to manage on their own – However, effective treatment is available • Chances of recovery are greatly improved if the patient has: – had long periods of sobriety in the past – social supports, such as family and friends – only one substance of misuse META:PHI 2015 RAAM Clinic • Patients from the ED, WMS and community can access the Rapid Access Addiction Medicine clinic without medical referral – Clinic is staffed by addiction physicians – Here they will receive medication if indicated and ongoing treatment until more stable – Patients do not need to be in withdrawal to benefit from seeing the RAAM physician • Clinic is held at least one half day / week – Patients can walk in during clinic hours • Counsellors will be a critical referral source • ED counsellors can refer using RAAM referral card META:PHI 2015 Opioid Replacement Therapy • Opioid Use Disorders are often treated with methadone or buprenorphine/naloxone (bup/nx) – Both of these medications can be prescribed through the RAAM clinic – Medications start to reduce cravings in just a few days – Bup/nx can also be prescribed in the ED to manage withdrawal symptoms • Bup/nx must be initiated while patient is in withdrawal, or else it will trigger it META:PHI 2015 Opioid Replacement Therapy (2) • Methadone and bup/nx are dispensed under the observation of a pharmacist daily • After several weeks the patient is given takehome doses if they have stopped illicit drug use, as demonstrated by regular urine drug screens • This ‘contingency management approach’ is effective at reducing drug use, and ensures patient safety META:PHI 2015 Methadone Vs. Bup/Nx Methadone Bup/Nx Classification Full opioid – effects opioid receptors until all are fully activated Partial opioid – opioid receptors are not activated to the same extent as with methadone Method Taken once daily, mixed in fruit juice Usually taken once daily, in sublingual tablet Side Effects More side effects More likely to cause overdose Fewer side effects Less likely to cause overdose Withdrawal and Cravings More effective at relieving withdrawal and cravings Potentially less effective at relieving withdrawal and cravings META:PHI 2015 Patient Concern: Isn’t Medication ‘Cheating’? “Don't these medications simply substitute one addiction for another?” • • • • Methadone and bup/nx are very different from other opioids When taken in the right dose, neither one causes euphoria or intoxication Neither will cause withdrawal symptoms when taken as prescribed The other benefit for patients is that they will not have to spend time and money trying to acquire these medications; all they need is a doctor's prescription and access to a pharmacy With medication-assisted treatment, patients’ lives will become far less chaotic, and daily functioning will improve, compared to when they were misusing opioids. META:PHI 2015 Patient Concern: Is Medication for Life? “How long do I need to stay on this medication for?” • How long the patient stays on opioid replacement therapy is up to them – However, they are much less likely to relapse if they are tapered off of these medications gradually once life becomes more stable • Abstinence from non-prescribed opioids for at least six months might be an indicator that they are ready to start tapering • The longer the patient has been addicted to opioids, the longer they should stay on methadone or bup/nx META:PHI 2015 Treatment Programs and Support • Counsellors can advise patients of different treatment and support options available: – Medication-Assisted Inpatient Programs: inpatient programs that last up to six months, and incorporate anti-craving medications into recovery plan • May be publicly or privately funded – Abstinence Based Inpatient Programs: inpatient programs that last up to six months, and do not permit anti-craving medications to be taken • May be publicly or privately funded – Outpatient Programs: day programs usually lasting a few weeks, where patient returns home at night • May be run through community organizations, withdrawal management centres, hospitals, or as after-care at organizations that offer inpatient programs • May be publicly or privately funded META:PHI 2015 Other Supports – Self-help groups can provide valuable emotional support and information about programs and services • Examples: Narcotics Anonymous (NA) Secular Organizations for Sobriety (SOS) – Family and friends can offer patients key social supports which can reduce feelings of loneliness, and provide activities away from using opioids META:PHI 2015 Primary Care • Family doctors can play a central role in patient recovery – They can prescribe bup/nx and some can prescribe methadone – They are able to treat withdrawal, monitor and intervene with mental and physical health during recovery, and provide ongoing support during and after treatment – They can also refer the patient back to treatment if they relapse • Counsellors can assist the patient in finding a family doctor: – Health Care Connect (1-800-445-1822) will connect patient to family doctors and nurse practitioners accepting new patients: • http://www.health.gov.on.ca/en/ms/healthcareconnect/public/ – Community Health Centres (CHCs) sometimes have openings for patients within their region – Locate local CHCs: • http://www.health.gov.on.ca/english/public/contact/chc/chcloc mn.html META:PHI 2015 WRAP UP – KEY TAKEAWAYS META:PHI 2015 Key Messages for Patients • “You have been diagnosed with an OUD” – This means that you have been unable to stop using opioids, even though it has become harmful to you • “Treatment exists and is incredibly effective” – Explain options for medication-assisted treatment – Explain options for psychosocial treatment • “There are things you can do to help cope with cravings” • “Once you start treatment, other aspects of your life will improve tremendously” – E.g. mood, pain, relationships, daily functioning, finances META:PHI 2015 Discharge • Depending on where you see the patient, there are different referral options – RAAM Referral • If you are in the ED, hand patient RAAM referral card • Non-ED counsellors can also refer the patient, by simply letting them know clinic hours and location • RAAM is located close to or inside the hospital and patient can be seen in 1-6 days • Patients do not need to be in withdrawal to be referred – WMS Referral if warranted: • If patient is in crisis • If patient needs safe place to stay until RAAM appt • If patient is keen to start treatment right away – Medication-Assisted inpatient treatment programs – Medication-Assisted outpatient treatment programs META:PHI 2015 Discharge (2) • Always ensure patient has access to naloxone kit through ED physician or nurse, pharmacy or RAAM in your area - If possible review instructions for use META:PHI 2015 Pamphlet courtesy of The Works, Toronto Case Scenario - Karen Karen is a 30 year old woman who was brought by her friends to the ED after an accidental overdose after injecting fentanyl purchased from a ‘friend’. Her overdose symptoms have resolved and she was started on bup/nx. She is now ready to go home. META:PHI 2015 Question • What discharge advice and information would you provide to Karen? META:PHI 2015 Discharge Advice for Karen • • • • • • • Emphasize to Karen that she must take her bup/nx daily as prescribed to relieve withdrawal symptoms and cravings Reinforce to Karen that she must attend the RAAM clinic before her bup/nx prescription runs out – Let her know that she can bring a support person with her to her first RAAM clinic appointment Encourage Karen to connect with her primary care doctor if she has one Karen should carry the take-home naloxone kit with her at all times, and know how to administer the medication Ensure that Karen understands that being on bup/nx does not necessarily protect her from an overdose, especially on fentanyl – If she must use, she must use the smallest amount possible to relieve any withdrawal symptoms – She must not mix opioids with benzos or alcohol, and must never use alone Let Karen know that treatment is incredibly effective, and that if she stays on her treatment plan, her mood and function will improve dramatically Until Karen gets involved in the RAAM clinic, Karen must do her best to avoid people who use drugs, and instead spend time with people who are supportive META:PHI 2015