Transcript Presentation on opioid use disorders for crisis

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