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