Opioid Addiction Pathways to Recovery

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1 Opioid Addiction Pathways to Recovery

2 Objectives What does recovery from addiction entail? What is treatment? How can doctors access treatment for patients? How can doctors help patients?

3 Conflict of Interest Work in a methadone practice, under AFM Have had honoraria for speaking about addiction, methadone use, and suboxone use

4 My work 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

5 Questions What is recovery? What is treatment? How can I interact with patients to move along a path of improvement?

6 Recovery Recover from addiction Recover from a damaged life

7 Problems before addiction Broken families, foster care, loss Trauma and abuse secrets School problems, bullied Identity racial, sexual ADD, depression, anxiety

8 Problems after addiction Family estranged Kids in custody, unplanned pregnancy Legal charges Health challenges, suicidality Debt, lost job, failing school Housing Unhealthy friends and partners

9 Coping 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

10 Coping Skills of an Addict Alcohol Marijuana Pills Cocaine Excitement risks, sex, crime Anger & violence, blame Lies and Secrets

11 Good Assessment Alcohol Cocaine/crack Opioids THC Behaviours gambling, eating disorders, sex or porn

12 A Good History It s not about the drugs It s about the person..strengths, supports, goals, problems, medical and psych diagnoses, children, legal issues..

13 Recovery 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

14 Recovery Build skills, don t use pills!!!!!!

15 Recovery Stage 1 chaos & survival Stage 2 gaining stability Stage 3 living the meaningful and examined life, giving back

16 Recovery 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

17 Recovery Stage 2 - Gaining stability -work, housing, money -emotional skills -parenting, family contacts, healthy friends

18 Recovery Stage 3 meaning in life honesty, responsibility, gratitude, persistence, service, spirituality, facing pain and shame, finding joy, grace & balance Maintenance!!!!

19 Treatment 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

20 DETOX 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

21 Treatment starts with detox for 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

22 Treatment 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

23 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

24 Narcotics 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

25 NA & AA Can guide towards honesty, spirituality, atonement and responsibility, helping others It s free! Know how to get patients to try it

26 Verna 24 year old health professional Early life parents divorced, rarely saw dad Mom alcoholic Good student episode of 19 Loved health care work married, pregnant profound depression

27 Found stealing morphine at work Immediate losses & intense shame -job and reputation, licence -financial stability -marriage threatened -all friends were colleagues -future -?custody

28 Outcome 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

29 Outcome 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

30 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

31 Ada -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

32 Ada 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

33 Ada 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

34 Ada used Helpful family doctor Support with detox Some information about addiction A rebuilt social life with meaning

35 Shawn 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

36 Shawn 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

37 Shawn Manages to keep job Year 1 & 2 continually distraught joins AA Does 12 months DBT some emotional peace Reconnects with his adult children and exwife Forced to stop marijuana

38 Shawn Year 5 weans off methadone The future????

39 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

40 Martha 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

41 Martina 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

42 Martina 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

43 Martina used. Methadone clinic and support, counselling Extensive use NA travelled, spoke in public Her own strengths intelligence, warmth, humor, work ethic, persistence, selfexamination Strong family support

44 Relapse 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

45 Is Methadone Forever? Past history most patients had 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

46 Manny 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

47 Manny 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????

48 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

49 Carly 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

50 Carly 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

51 Carly 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

52 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

53 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?

54 Residential 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

55 Residential Programs Public or subsidized low cost Addiction Foundation - 4 weeks Behavioural Health Foundation 6-12 months n Army 2 months

56 Residential 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

57 Who goes to residential?... Court mandated C&FS mandated Family mandated Work mandated Many of the sickest

58 People often have to attend 2 or more times, and often do better on the second or third attempt

59 Vanessa 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 3 rd try I ll be off in 3-6 months

60 Vanessa 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

61 Vanessa $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

62 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

63 Family Doctors Longterm support to someone in difficulty Know the system for psych and addiction referrals Don t be a prescription push-over

64 Benzo s and Opioids NOT patient centered care! Physician-led care! Use with restraint, only after assessment. Consider other options. Be able to say NO.

65 Structured Opioid Therapy - 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

66 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

67 Opioid 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

68 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

69 If you do structured rx for 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

70 Use 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

71 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

72 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

73 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

74 Resources 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

75 Patient access to methadone and suboxone 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

76 Patient access to abstinence treatment 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

77 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

opiates alcohol 27 opiates and alcohol 30 April 2016 drug addiction signs 42 Ranked #1 123 Drug Rehab Centers in New Jersey 100 Top 10 380

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