Opioid Addiction – Opioid Addiction – Pathways to RecoveryPathways to Recovery
ObjectivesObjectives
• What does recovery from addiction entail?
• What is “treatment”?
• How can doctors access treatment for patients? How can doctors help patients?
Conflict of InterestConflict of Interest
• Work in a methadone practice, under AFM
• Have had honoraria for speaking about addiction, methadone use, and suboxone use
My work…………..My work…………..
• 20+ years emergency medicine – lots of addiction
• 2003 – moved to Addiction Unit (detox unit) and visited many treatment providers
• 2005 – involved with prescription opioid addiction, aware of deaths and destroyed lives
QuestionsQuestions
• What is recovery?
• What is treatment?
• How can I interact with patients to move along a path of improvement?
RecoveryRecovery
• Recover from addiction
• Recover from a damaged life
Problems – before addictionProblems – before addiction
• Broken families, foster care, loss
• Trauma and abuse secrets
• School problems, bullied
• Identity – racial, sexual
• ADD, depression, anxiety
Problems – after addictionProblems – after addiction
• Family estranged
• Kids in custody, unplanned pregnancy
• Legal charges
• Health challenges, suicidality
• Debt, lost job, failing school
• Housing
• Unhealthy friends and partners
Coping SkillsCoping Skills
• Family modelling
• Feeling safe and supported as you try new things – recovering from failure
• Teen years – Using drugs blocks feeling emotions, learning to cope
Coping Skills of an AddictCoping Skills of an Addict
• Alcohol• Marijuana• Pills• Cocaine
• Excitement – risks, sex, crime• Anger & violence, blame• Lies and Secrets
Good AssessmentGood Assessment
• Alcohol
• Cocaine/crack
• Opioids
• THC
• Behaviours – gambling, eating disorders, sex or porn
A Good HistoryA Good History
• It’s not about the drugs –
• It’s about the person…..strengths, supports, goals, problems, medical and psych diagnoses, children, legal issues…..
RecoveryRecovery
• At first, they want a “chemical fix” or detox
• Often want to regain control of drug use, can’t imagine stopping forever – also want to get work, $, school right away – can’t believe it takes time
• Blind or resistant to the idea of emotional and spiritual growth needs
RecoveryRecovery
Build skills, don’t use pills!!!!!!
RecoveryRecovery
• Stage 1 – chaos & survival
• Stage 2 – gaining stability
• Stage 3 – living the meaningful and examined life, giving back
RecoveryRecovery
• Stage 1 – chaos and survival
• - housing, food
• - trustworthy people
• - income
• - facing consequences – physical illness, debt, legal issues, loss of family, loss of work
• JUST TRYING TO STAY SOBER
RecoveryRecovery
• Stage 2 - Gaining stability
• -work, housing, money
• -emotional skills
• -parenting, family contacts, healthy friends
RecoveryRecovery
• Stage 3 – meaning in life – honesty, responsibility, gratitude, persistence, service, spirituality, facing pain and shame, finding joy, grace & balance
• Maintenance!!!!
TreatmentTreatment
• A variety of supports that address body, mind, spirit
• Medication and/or emotional skills
• Outpatient or residential – or internet
• Professional or self-help
• Religion based or “humanistic”
• Addiction care or psychiatric care
DETOX IS NOT TREATMENTDETOX IS NOT TREATMENT
• The family and addict think detox or taper will be the quick invisible cure
• Opioid addicts feel more misery and craving every day of detox – may have protracted withdrawal for months
• Risk of death
Treatment starts with detox…forTreatment starts with detox…for alcohol, cocaine, crystal meth….alcohol, cocaine, crystal meth….
BUT – treatment for opioid addiction starts with assessment, and then consideration of different treatment options
-attempt at abstinence
-attempt at controlled prescribing
-refer for methadone or suboxone
Treatment ChoicesTreatment Choices• Methadone/suboxone – for those medically ill,
pregnant, really out of control – reasonable choice for most
• Abstinence – for those who insist – for those who still have some supports & stability
• Controlled dispensing/or taper – for select patients – or for those on waitlist for methadone
Treatment is “longterm”Treatment is “longterm”
• Methadone – at least 1-2 years – may be lifelong
• Abstinence – at least a year of intense work to stay clean, change life - must keep up recovery connections, especially with stress
Narcotics Anonymous &Narcotics Anonymous & Alcoholics Anonymous Alcoholics Anonymous
• Very valuable
• Available to most – free – welcoming
• Sober social activity
• Active guidance towards sobriety
• Sponsor, work the steps
• Relieve shame, self-acceptance
• Create hope - stories
NA & AANA & AA
• Can guide towards honesty, spirituality, atonement and responsibility, helping others
• It’s free!
• Know how to get patients to try it……
VernaVerna
• 24 year old health professional
• Early life – parents divorced, rarely saw dad
• Mom alcoholic
• Good student – episode of depression @ 19
• Loved health care work – married, pregnant – profound depression
• Found stealing morphine at work
• Immediate losses & intense shame• -job and reputation, licence• -financial stability• -marriage threatened• -all friends were colleagues• -future• -?custody
OutcomeOutcome
• Starts methadone in hospital – premature baby delivered, 4 weeks in hospital
• C&FS want to apprehend
• Close follow-up thru methadone clinic – worry is depression, not addiction
• Never used opioids since Day 1
• Loving mother
OutcomeOutcome
• Year 1 – coping with motherhood, marriage, depression, isolation
• Year 2 – struggles with College, does 12 months DBT emotional resilience work
• Year 3 – gets licence with undertaking – first attempts at work unsuccessful – then finds work
• Year 4 – second baby, marriage strong, no depression for 3 years, weans down MMT
Verna used….Verna used….
• Methadone, encouragement and supervision at clinic – for years
• DBT = Dialectical Behaviour Therapy – emotional skills training, cognitive skills, communication skills
• Work
• Being a mother
Ada -grandmother with painAda -grandmother with pain
• 64 – loved work, friends, garden – chronic hip arthritis, on high dose dilaudid for 2 years, finally had hip replacement
• Off work for 2 years – marriage unexpectedly ended – withdrew from friends – couldn’t garden or tend to house
• After surgery – could not wean off pain meds – became panicky and distraught
AdaAda
• Great shame at thought of “addiction” , also feels her useful life is over
• Comes to addiction unit for assessment for help with taper
• Plan – ward admission for 10 day taper
• - must attend addiction groups as many of the recovery and emotional issues are the same
AdaAda
• Struggles but persists – down to zero – warned she will have several weeks of protracted withdrawal with some pain, sleep problems, lethargy
• Got family involved and reconnected
• One year later – Happy, working PT, active grandma, tramadol for pain “I never want to be addicted again”
Ada used…Ada used…
• Helpful family doctor
• Support with detox
• Some information about addiction
• A rebuilt social life with meaning
ShawnShawn
• Terrible violent early life – father murdered mother, siblings sent to orphanages
• Joined army – substitute family life
• Tours of Bosnia and Somalia – PTSD - progressive alcoholism and codeine addiction – two admissions to army hospital for abstinence fail
• Now employed but in trouble
ShawnShawn
• Empty, alone, shamed, devastated, hopeless
• In alcohol and opioid withdrawal
• After discussion, wants methadone – started in hospital setting to treat withdrawal, get psych opinion, start groups
• Very needy and emotional
ShawnShawn
• Manages to keep job
• Year 1 & 2 – continually distraught – joins AA
• Does 12 months DBT – some emotional peace
• Reconnects with his adult children and ex-wife
• Forced to stop marijuana
ShawnShawn
• Year 5 – weans off methadone
• The future????
Shawn used…..Shawn used…..
• Army abstinence programs (failed)• Ward admission to manage severe alcohol
withdrawal and to start methadone• Support of methadone clinic for years• DBT 1 year• Work – strong contract• Army – PTSD program• Family reconnection
MarthaMartha
• Comes from “nice part of town” – dad had cocaine problem for several years, now very active in recovery groups
• Bright and beautiful, but drifts, drops out of school, travels to BC with boyfriend, on and off heroin
• Back in Winnipeg – on IV fentanyl – sees boyfriend die from accidental OD – distraught, suicide risk
MartinaMartina
• Parents very concerned, involved, scared
• Admitted to hospital – starts methadone – goes to residential treatment, minimal participation – sees addiction psychiatrist
• Year 1 – erratic
• Year 2-5 – heavy involvement in N A, cleans up, slowly rebuilds trust from family, slowly finds work
MartinaMartina
• Slow wean off methadone
• 12 months later - back – tried dilaudid at a party, habit “took off” – came back quickly to treatment – on suboxone – will wean off in next few months
Martina used….Martina used….
• Methadone clinic and support, counselling
• Extensive use NA – travelled, spoke in public
• Her own strengths – intelligence, warmth, humor, work ethic, persistence, self-examination
• Strong family support
Relapse is the normRelapse is the norm
• Their brain will always “love opioids”
• Relapse is a learning opportunity
• Good connections with clinic and NA usually mean quickly regain stability
Is Methadone Forever?Is Methadone Forever?
• Past history – most patients had 10-20 years of heroin addiction, medical illness, had lost friends and family, crime to survive – most were not successful at coming off methadone and being clean
• Young prescription opioid addicts with good supports – 46% clean, 2 years after weaning off – Ontario study
MannyManny
• Using opioids and crystal meth IV for 15 years – schizophrenic, refuses psych meds – on and off various methadone programs – no interest in AA
• Sticks with our program for 4 years• Year 1 – no major change• Year 2 – no major change• Year 3 – cleans up for 2 weeks to go to
wedding
MannyManny
• Year 4 – gets Hep C, arranges own followup and treatment – cuts back on crystal meth, rarely misses methadone doses, grooming better
• Year 5 – moves back to parents – only using opioids about once a month, doing social activities, looks normal, has holiday to BC
• Future????
Manny used….Manny used….
• Tried several clinics til he found one he felt he could work with
• “harm reduction” approach
• Social chance – a wedding
• Family reconnection
• Longterm program
• Program didn’t give up
Carly and BobbyCarly and Bobby
• Both ran away from severely abusive home, poor education, survived with street skills – two children
• Abuse of benzo’s, crack, alcohol – then tried oxycontin, severe addiction, no money, lost housing, gave kids to friends, sought treatment – no spots – kids in C&FS care
Carly and BobbyCarly and Bobby
• Finally on methadone
• Year 1 – stopped all crack, benzo’s, opioids – both did residential treatment as C&FS required it
• Year 2 – Bobby in drug court – started high school course, good marks
• Year 3 – have baby with disability – with supervision, allowed to take her home
Carly and BobbyCarly and Bobby
• Bobby finished Grade 12 – both help look after daughter
• Both wean down from methadone 160 mg to 80 mg. Only drug use is THC
• In prolonged battle to get other kids back with no end in sight
They used….They used….
• Methadone program, longterm support
• Month of residential treatment
• Drug court
• Schooling opportunities, “not a dummy”
• Their desire to be a family & regain children..persistence and hope
• Counselling for past trauma
Residential treatment Residential treatment
• If your patient goes to AFM, the option can be discussed if appropriate
• Sometimes doctors are in trouble themselves, or need help for spouse or kids
• Where? What happens? Cost?
Residential TreatmentResidential Treatment
• A month to “clear your head”, structure
• Education about addiction
• Groups plus individual sessions
• Heavy exposure to AA
• Possibly – cognitive and emotional skills, life balance, trauma recovery, psych assessment, help with housing & transition
Residential ProgramsResidential Programs
• Public or subsidized low cost
• Addiction Foundation - 4 weeks
• Behavioural Health Foundation – 6-12 months
• Anchorage @Salv’n Army – 2 months
Residential ProgramsResidential Programs
• Private – often $20-30,000 a month – addiction medical staff, psych assessments, yoga, exercise, meditation, family week
• Homewood, Donwood, Bellwood, Top of the World Ranch, The Orchard, Whispering Pines
Who goes to residential?....Who goes to residential?....
• Court mandated
• C&FS mandated
• Family mandated
• Work mandated
• Many of the sickest
• People often have to attend 2 or more times, and often do better on the second or third attempt
VanessaVanessa
• Dad died when she was 13
• Stormy teenager – became dancer – very punk and tough and tattooed
• Used IV cocaine and morphine – on and off methadone
• Saw me to give methadone 3rd try “I’ll be off in 3-6 months”
VanessaVanessa
• Severe cellulitis several times, in and out of hospital – Hep C – mood swings, desperation – every time she tries to wean off methadone she reverts to IV cocaine and morphine abuse & gets sick
• Tries AFM residential, “hates it”
VanessaVanessa
• $15,000 inheritance - blows half on blow – then “to save my life” searches internet and goes to small private program in rural Saskatchewan – “more intense than AFM”. “really trusted the people”, strong AA
• Episodes of sobriety for 3 months, then 6 months, then 2 years
• Married with baby in small town Manitoba
What Vanessa Used….What Vanessa Used….
• Support of methadone program over time – finally agreed to bipolar meds
• SELF-ENGAGED – found program, used her money, used psychologist
• Sask program was life-saving to her – went back, could phone
• Strong NA++++ - women’s group
• Took cautious time to fall in love
Family DoctorsFamily Doctors
• Longterm support to someone in difficulty
• Know the system for psych and addiction referrals
• Don’t be a prescription push-over
Benzo’s and OpioidsBenzo’s and Opioids
• NOT “patient centered care”!
• Physician-led care!
• Use with restraint, only after assessment. Consider other options. Be able to say NO.
Structured Opioid Therapy -Structured Opioid Therapy - yes or no? yes or no?
• Impulsive, difficult, intelligent 19 year old girl comes to ward to try to detox from opioids – difficult behaviour – walks away from treatment
• Finds GP who offers her morphine 400 mg/day and wean down – continues to inject – tries 4 times, always starts street purchase at 200 mg – still injecting
Two years in…Two years in…
• GP phones for advice “how can I make the next attempt at taper more likely to be successful?”
• “She is a special girl and not suitable for methadone”
Opioid Rx, awaiting methadoneOpioid Rx, awaiting methadone
• Long wait list in city for methadone spots – many doctors supporting patients with daily dispensing moderate dose opioid rx til spot opens
• Davinder sees GP, shows him note he has seen addiction doctor and is on waitlist – requests oxycontin 320 mg /day
• Receives it, daily dispensed – sells half
Awaiting treatment…Awaiting treatment…
• Faces legal charges, goes to jail on no meds – when out goes back to pharmacy & they resume rx, no questions asked – sells ¾ of it
• Goes to treatment, off opioids, for 2 months – when he gets out, rx is still available!!!
• I find out thru a friend and inform GP
If you do structured rx for If you do structured rx for addict…….addict…….
• Consider addiction consult or assessment at methadone clinic or AFM
• Have a contract
• Time limited!
• See the patient regularly, urine screens
• Have clear arrangement with pharmacist
Use your leverageUse your leverage
• Insist no cocaine or street opioids or Rx stops
• Insist on some form of addiction care – AFM or narcotics anonymous
• Expect manipulation – check with methadone clinic if “wait list” problematic
Trying a taper with an addict….Trying a taper with an addict….
• OK to try – also OK to refuse
• Expect failure and watch for problems
• Don’t do it repeatedly
• Don’t do it for “snorters” and injectors
• Insist on some form of treatment
• Send them to a methadone clinic to be more knowledgeable about options
What dose?What dose?
• Ask them the least and most they use in a day – go low with Rx
• Consider a challenge dose in the office – they pick up a “lowish” dose, take it in front of you, wait 2 hours & see how they look
My son…My son…
• “Mom, a few of my friends have found they can make lots of money going to the doctor with a pain story and then selling the pills….”
• Know and practice the Opioid Guidelines
ResourcesResources
• Google “methadone clinics in Manitoba”
• 1. AFM mine clinic – counselling, programs, but wait list
• 2. CARI – some counselling - 2 locations
• 3. OATS clinics – 3 locations
• 4. mbatc – telehealth – some counselling
Patient access to methadone and Patient access to methadone and suboxonesuboxone
• Patient can self –refer to any of the clinics – some have same-week intake, some have wait list
• AFM clinic –we enjoy complex patients - rapid access for pregnant patients, or significant medical illness – will assess patients under 18
Patient access to abstinence Patient access to abstinence treatmenttreatment
• AFM assessment – will help with arranging detox if necessary – can get addiction physician opinion – can help patient change to methadone program if abstinence too difficult
• Patient just phones the AFM intake line
Complex Patient, what to do?Complex Patient, what to do?
• Opiate Assessment Clinic, Addiction Unit, Health Sciences Centre – outpatient assessment, 2 month wait to be seen – can help arrange further treatment
• Patients with addiction, psych illness, medical illness, chronic pain – referral must come from physician
• Fax referral to Talia Weisz 204-787-3996
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