Transcript Relapse Prevention and Monitoring in Pharmacists and

Relapse or Relapse Prevention:
A Choice
CAPTASA 2016
Brian Fingerson, B.S. Pharm., R.Ph., FAPhA
President, Kentucky Professionals Recovery Network, Louisville, KY
Disclosures
Brian Fingerson, R.Ph. declares no conflicts of interest,
real or apparent, and no financial interests in any
company, product, or service mentioned in this
program, including grants, employment, gifts, stock
holdings, and honoraria.
Learning Objectives
1. Describe the six most common reasons for relapse in
health care professionals.
2. Define psychiatric factors that can increase the
potential for relapse.
3. Describe back-to-work issues, that when addressed,
can promote success in maintaining sobriety.
4. Define individual characteristics that statistically
increase potential for relapse.
Relapse Prevention and Monitoring
• You’ve been to treatment (or not) and then
what? How do we help them continue the
process……of what?
• Abstinence?
• Recovery?
• Sobriety?
Recovery
• Recovery commonly refers to a process of
initiating abstinence from illicit drug and/or
alcohol use, along with necessary life changes
to help maintain sobriety over time
• It’s a life long progression – and there may be
obstacles and setbacks along the journey
What do you think?
• Recovering
• Recovered
• In remission
Relapse – yes or no?
• Substance Use Disorder said to be a relapsing
disease so…is relapse inevitable?
Simple definition of relapse
• Relapse involves much more than just
returning to drug or alcohol use – it is the
progressive process of a once stable recovery
program becoming so dysfunctional that
returning to use has become a viable option.
• ASAM = relapse is defined as the recurrence
of behavioral or other substantive indicators
of active disease after a period of remission
in a healthcare or other licensed professional.
So….
• How can relapse happen to an intelligent,
high-functioning individual who is trying to
stay sober?
Six common reasons for relapse
• 1. The patient doesn’t buy into the idea (?)
or fact (?) that it is a chronic disease.
– After a period of time they feel they’ve
gotten better
Six common reasons for relapse
• 2. The patient doesn’t sincerely invest in
AA/NA and/or quit going to meetings.
– Many reasons to be addressed later
– “Meeting makers make it”
Six common reasons for relapse
• 3. The patient has minimal acceptance of
their disease.
– Feel they are not as bad as others and therefore
do not have to do as much.
– “Yets”
Six common reasons for relapse
• 4. The patient has a mistreated or
undiagnosed co-morbid psychiatric disorder
(dual diagnosis).
– Example = bipolar disorder = compromised
judgment especially around use
Six common reasons for relapse
• 5. The patient has an uneducated family or
other support system.
– Questions like – “Do you have to go to a meeting
tonight? You went to one yesterday.” Or…”Can’t
you have a glass of wine with me? Your problem
was with pills.”
Six common reasons for relapse
• 6. The patient doesn’t buy into the concept
that they cannot safely use any moodaltering/addicting drug.
– They actually have the glass of wine or don’t
consult on an Rx or OTC medication e.g. talk with
sponsor first or their PHP monitor.
Relapse – yes or no?
The window of greatest vulnerability for
relapse after treatment is the first 30-90 days
following discharge
It has been said
• Yale University researchers concluded that it
takes at least three months of abstinence for
the brain’s pre-frontal cortex to be able to
process the kinds of information related to
decision making and analytical functions
Lapse
• Sometimes called a “slip”
– “Sobriety Losing Its Priority”
– “Something Lousy I Planned”
– Could be defined as an initial episode of
drug or alcohol use after a period of
abstinence.
Preventing a lapse (slip) from
becoming a relapse
• Stop consuming the illicit substance(s) as soon as
possible.
• Stopping sooner means far less physical and
mental anguish due to renewed substance
dependence and craving.
• Use the slip as a learning experience.
• Tell their sponsor/home group/significant
other/monitor
Relapse
• It is commonly viewed as a breakdown
in the recovery process i.e. a major
digression in the individual’s attempt to
escape the bonds of addiction.
More prevention:
• Examine the sequence of events leading up
to the slip; what could have been done
differently to avoid it?
• Do not make excuses but, at the same time,
do not beat yourself up.
• Get immediately back into the program of
recovery
More prevention:
• Take pride in renewed efforts to stay “clean”;
rather than punishing yourself for past events
leading up to the slip.
• (adapted from: Volpicelli and Szalavitz 2000)
Issues that increase the potential for
relapse in healthcare professionals
• A family history – the genetics = inherited
physiology
• Isolation
• Inadequate monitoring contract – continuing
care plan
• Lack of a spiritual program – failure to
maintain it
Issues that increase the potential for
relapse in healthcare professionals
• Lack of tailored treatment of professionals
• Lack of effective coping skills re: stress
• Use of an injectable controlled substance esp.
Opioid
• Under-treated coexisting psychiatric disorder
• Previous history of relapse
• Lack of 12-Step involvement
• Lack of effective advocacy/monitoring
Other relapse factors
• Drug-related “reminder” cues e.g. sights,
sounds, smells, drug thoughts or drugdrinking dreams that are linked to the
preferred drug(s)
• “Play people, play places, play things”
A relapse factor
• Negative mood states or stress – want to feel
better
• Positive mood states or celebrations – more
wanting to feel better
Other relapse factors
• Sampling the drug itself, even in very small
amounts
• I must add that it doesn’t have to begin with
the use of the “drug of choice”
Other relapse factors - overconfidence
• No longer need to form healthy habits
• Can simply resist on my own
• Can revert to old patterns of behavior
Other relapse factors - overconfidence
• Notion that my craving was a phase – over it
now
• If I can just learn enough about it I’ll be OK
• Naïve perception of immunity
• Hubris = false pride
JAMA. 2005;293:1453-1460
• Domino et al did a study on “Risk Factors for
Relapse In Health Care Professionals With
Substance Use Disorders.”
• And what they found was – and yes…this is
some repetition….however….
The risk of relapse with substance use
was increased in HCP who:
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Used a major opioid
Or had a coexisting psychiatric illness
Or a family history of substance use disorder
And……
And….
• The presence of more than one (1) of these
risk factors and previous relapse further
increased the likelihood of relapse.
• And these observations should be considered
in monitoring the recovery of HCP (and for
how long?)
Co-morbid diagnoses that decrease
stability in a recovery program
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Depression
Bipolar disorder
Generalized anxiety disorder
Cognitive impairment
Eating disorders
Sexual/gambling or other process addictions
Severe chronic pain
Co-morbid diagnoses that decrease
stability in a recovery program
• Personality disorders
– Avoidant personality disorder
– Narcissistic personality disorder
– Borderline personality disorder
– Antisocial personality disorder
Impact of personality disorders on
relapse potential
• Cause significant dysfunction in personal life,
social life, and work life and especially in
interpersonal relationships making it far
more difficult to connect with 12-Step
programs in a meaningful way and to interact
in group therapy.
– Inflexible
– Ingrained
– Pervasive
Impact of post-acute withdrawal on
relapse potential (PAW)
• Has the capacity to make an individual
believe they felt much better when they
were using. Can significantly limit an
individual’s enthusiasm for recovery.
PAW Symptoms
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Mood swings – irritability
Insomnia / tiredness
Inability to think clearly / memory problems
Low motivation / enthusiasm
Anxiety
Anhedonia (strong stimulants)
Depression (strong stimulants)
PAW helpful approaches
• Encourage the person to talk about it in
group and at meetings
• Meditation
• Yoga
• Exercise
• Pharmacotherapy – questionable – need a
knowledgeable clinician
Back to work – environment
• Practice stressors – patients, staff, third-party
issues
• Normal life stressors – finances, home and
family issues
• Culture of self-medication/treatment
• Pharmaceutical invincibility
• Ease of access
Should you recommend or require?
• 90 meetings (12-Step recovery meetings) in
90 days and then….in our case typically 12
meetings per month with a minimum of 2 in
any one week period.
Factors that inhibit AA/NA (12-Step)
involvement
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Shame
The religious language
Shy – social phobia
Lack of support from family
Availability of meetings
Other “more important” priorities
Could they provide a medication List:
Are the meds OK to use?
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Yes
No
Maybe
What precautions e.g. MAR, witnesses
“Safe medication booklets”
Non-drug alternatives
How to enhance the odds for
recovery
by William L. White
• Don’t use – no matter what
• Choose a treatment program that offers a
rich menu of continuing care services and
actively use these supports
How to enhance the odds for
recovery
by William L. White
• Find a recovery support group and stay
actively involved. Make meetings a priority,
get a sponsor, build a sober social network,
and apply recovery program principles to
the problems of daily living
How to enhance the odds for
recovery
by William L. White
• If you do not have a living environment
supportive of recovery, investigate the
growing network of recovery homes
• Involve your family members in recovery
support groups and activities
• Become an expert on your own recovery
and take responsibility for it
So….
• Fellowship and the support of those in a
network of recovering HCP can help minimize
the risk of relapse in our HCP clients
• It works – we’ve shown that it does
A required prescription
“The alcoholic is like a tornado roaring
through the lives of others.” page 82
Page 82 also says: “Hearts are broken.” Our
goal is: Recovery
Recovery:
by
Mike Vye
We would like to return to this:
• Successful practice and to “LIFE”
And not this:
Questions?
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Brian Fingerson, BS Pharm, RPh, FAPhA
Brian Fingerson, Inc. dba KYPRN
202 Bellemeade Road
Louisville, KY 40222-4502
502-749-8385
[email protected]