Initiating Conversations to Reduce Harm Across Care Settings: Healthcare Opportunities

Transcription

1 Harm Reduction in an Opioid Era: Initiating Conversations to Reduce Harm Across Care Settings: Healthcare Opportunities Presented by: Kerry Nolte, PhD, FNP-C January 18, 2018

2 Harm Reduction: It s Not Just for SSPs Harm Reduction = Engagement Communicates Caring Discuss 1-2 opportunities to reduce risk Learn more about substance use patterns in your community

3 Source

4 Less About What You Say More About Your Approach

5 Reframing the Starting Point: Engagement in Care Acceptance Provider Humility Curiosity to Learn About SUD Supportive and Pragmatic Conversation

6 Engage in Goal Setting to Reduce Harm Goal: provide support and resources for client s self defined goals PWID are interested and capable of making changes to improve health and safety Safety messages shared could be rapidly spread through a social network Recognize and support readiness to change, whether safer injecting or recovery

7 SBIRT Screening Brief Intervention Referral to Treatment Consider questions about injecting or injury Have you ever used a drug by injecting it? Can you tell me more about this wound because I think we can treat and prevent this? Were you using drugs when this injury occurred because we could talk about ways to prevent another injury?

8 BNI: Brief Negotiated Interview Discussion based on pt report: 0-3: expresses concern, asks if pt wants more info, then offers support and makes f/u plan about future visits (drops it in respect of pt s choice) 4-7, ask Why did you choose and not (a lower number)?, What would need to happen for you to go from (a given number) to a (a higher number)? Stimulates change talk. After reflecting/summarizing, negotiate a plan with pt to cut back or quit; help pt identify resources. 8 or higher, help pt develop action plan. Assist pt with identifying resources to help cut back/quit. Instill hope!!!

9 BNI: Brief Negotiated Interview Referral to Treatment: 0-3: Know I (or agency) am here as a resource if you are interested in support in decreasing or stopping substance use. Could we discuss some things that could help to keep you safe? **HARM REDUCTION MOST IMPORTANT** 4-7: make the referral and ask patient what he or she thinks might happen with it 8 or higher: work with pt to make an appointment with an appropriate treatment provider ( active referral )

10 Harm Reduction: It s Not Just for SSPs Harm Reduction = Engagement Communicates Caring Discuss 1-2 opportunities to reduce risk Learn more about substance use patterns in your community

11 SBIRT Screening Brief Intervention Referral to Treatment Consider questions about injecting or injury Have you ever used a drug by injecting it? Can you tell me more about this wound because I think we can treat and prevent this? Were you using drugs when this injury occurred because we could talk about ways to prevent another injury?

12 BNI: Brief Negotiated Interview Discussion based on pt report: 0-3: interviewer expresses concern, asks if pt wants more info about substance effects on health, then offers support and makes f/u plan about future visits (drops it in respect of pt s choice) 4-7, ask Why did you choose and not (a lower number)?, What would need to happen for you to go from (a given number) to a (a higher number)? Stimulates change talk. After reflecting/summarizing, negotiate a plan with pt to cut back or quit; help pt identify resources. 8 or higher, help pt develop action plan. Assist pt with identifying resources to help cut back/quit. Instill hope!!!

13 BNI: Brief Negotiated Interview Referral to Treatment (for those who screen as dependent use): 0-3: Although referring you to treatment is what I recommend, I understand you are not ready to do this today. If you change your mind please let me know and can I bring it up again at our next visit? **HARM REDUCTION CARE CAN STILL OCCUR ** 4-7: make the referral and ask patient what he or she thinks might happen with it 8 or higher: work with pt to make an appointment with an appropriate treatment provider ( active referral ) Example of Brief Intervention with a Heroin User (Credit Boston Univ. School of Public Health BNI-ART Institute):

14 Safer Supplies Ask: Are you able to get clean supplies (needles, cookers, cottons)? If needles have to be reused, HCV can be reduced and HIV eliminated with bleach. 7 Risk dramatically reduced with rinsing 3 times with water Advise using clean, single use works Cottons, cookers, and clean water (sterile)

15 Safer Use Ask: What steps do you take to keep yourself safe when using? Advise to not use alone and only with trusted people who can provide care if needed Caution with all drug supplies and new sources Avoiding taking all the drug at once and avoid rushing Starting with a test shot may help prevent overdose as drug cannot be taken back once injected. 6 Problem solve around a safer environment and/or opportunities to decrease frequency.

16 Microscope View of Needle After Use

17 Safer Use Ask: Do you have naloxone (Narcan) available in the case of an overdose?

18 Naloxone Administration

19 Safer Use Ask: How do you prevent injury to your veins and infections? Wash hands or use hand sanitizer/ alcohol 8 Tourniquet improves vein access (fewer needle sticks, less risk for infection) 6 Removing tourniquet before injecting Do not inject if bright red blood fills syringe Bevel up to avoid going through the vein Recognize valves in veins and inject above Recognize infections and when to seek care for wound/ illness/ infection Offer the Harm Reduction Coalition s manual Getting Off Right for more tips. 6

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21 Normal Vein Valves Injured Valves Image source

22 Safer Disposal Ask: Are you able to safely get rid of supplies like syringes and needles? Syringe service programs can dispose of needles Some health, fire departments, and transfer stations provide safe places to dispose of syringes Consider if your care setting can help in safe disposal If unavailable, needles should be placed in a hard plastic bottle (e.g. detergent bottle). Once ¾ full, tape the lid with duct tape, label DO NOT RECYCLE, and place in the regular trash. 6

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24 Health Promotion Offer Preventative Care: Screening, Testing, and Education HIV testing is recommended at least annually for PWID. Include HIV 1/2 antibody and HIV 1 p24 antigen testing (positive 21 days after infection). 9 Consider discussing PreExposure Prophylaxis (PrEP) for HIV prevention. (CDC, 2017) Hepatitis C antibody testing is recommended periodically for PWID. 10 If exposure may have occurred with 6 months consider HCV RNA testing. 11 Check Tdap, HPV, Hepatitis A and B vaccination status and immunize as needed. 12 Discuss safe sexual practices and provide condoms. 12 Review pregnancy prevention options. 12

25 Refer and Collaborate with SSPs

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29 Questions? Contact Info: Kerry Nolte

30 References Bartlett, R., Brown, L., Shattell, M., Wright, T., & Lewallen, L. (2013). Harm reduction: compassionate care of persons with addictions. MedSurg Nursing, (6) Botticelli, M. P., & Koh, H. K. (2016). Changing the Language of Addiction. Jama, 316(13), doi: /jama Case, A., & Deaton, A. (2017). Mortality and morbidity in the 21st century. Brookings Papers On Economic Activity, 397. Centers for Disease Control and Prevention (2016). Reducing harms from injection drug use and opiod use disorder with syringe service programs. Retrieved from Connery, H. S. (2015). Medication-Assisted Treatment of Opioid Use Disorder: Review of the Evidence and Future Directions. Harvard Review Of Psychiatry (Lippincott Williams & Wilkins), 23(2), doi: /hrp Drew, D.J. and St. Marie, B.J. (2011). Pain in Critically Ill Patients with Substance use Disorder or Long-term Opioid Use for Chronic Pain. AACN Advanced Critical Care. 22(3), pp D'Onofrio, G., O'Connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S., Owens, P. H., &... Fiellin, D. A. (2015). Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence. JAMA, The Journal Of The American Medical Association, (16), Foundation for Healthy Communities (2017). Language is powerful. Retrieved fromhttps://healthynh.com/index.php/fhcinitiatives/oud-access-to-treatment.html Katz, J. (Sept 26, 2017) The First Count of Fentanyl Deaths in 2016: Up 540% in Three Years. New York Times. Retrieved at: Kelly, J. F., & Westerhoff, C. M. (2010). Research paper: Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. International Journal Of Drug Policy, doi: /j.drugpo Kelly, J. F., Dow, S. J., & Westerhoff, C. (2010). Does our choice of substance-related terms influence perceptions of treatment need? An empirical investigation with two commonly used terms. Journal Of Drug Issues, (4), 805. Kelly, J.F. Saitz, R.and Wakeman, S.(2016) Language, Substance Use Disorders, and Policy: The Need to Reach Consensus on an Addiction-ary, Alcoholism Treatment Quarterly, 34:1, , DOI: /

31 References Harm Reduction Coalition (n.d.) Principles of harm reduction. Retrieved from Noska, A., Mohan, A., Wakeman, S., Rich, J., & Boutwell, A. (2015). Managing Opioid Use Disorder During and After Acute Hospitalization: A Case-Based Review Clarifying Methadone Regulation for Acute Care Settings. Journal Of Addictive Behaviors, Therapy & Rehabilitation, 4(2) Rollnick, S., Miller, W. R., & Butler, C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York: Guilford Press. Smedslund G, Berg RC, Hammerstrøm KT, Steiro A, Leiknes KA, Dahl HM, Karlsen K.(2011). Motivational interviewing for substance abuse. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD DOI: / CD pub2. Summers, P. (May 16, 2017), Harm Reduction International Conference presentation. Strang J, Groshkova T, Uchtenhagen A, van den Brink W, Haasen C, Schechter M, et al. Heroin on trial: systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction. Br J Psychiatry 2015; 207: 5 14 Svalavitz,M. (2017). The Social Life of Opioids. Scientific American. Retrieved at: White, W. (June 10, 2016). Peer Recovery Coaching: Recent Evidence Reviews. Retrieved at: See conversations handout for additional numbered resources