OPIOID USE DISORDER (OUD) TREATMENT IN A PATIENT CENTERED HEALTH CENTER

Transcription

1 OPIOID USE DISORDER (OUD) TREATMENT IN A PATIENT CENTERED HEALTH CENTER Ed Johnson M.Ed., MAC, LPC, CCS Associate Director, Training & Technical Assistance Southeast Addiction Technology Transfer Center (Southeast ATTC) edjohnson@msm.edu

2 LEARNING OBJECTIVES Increase understanding of Substance Use Disorders (SUD) as a chronic medical condition. Become familiar with the stigma of SUD and the concurrent discrimination people with Opioid Use Disorder (OUD) experience. Discuss how our language reflects our concepts of SUD Treatment and Recovery and impacts Stigma

3 We Can t Fight This Epidemic Without Removing Stigma President Barack Obama Charleston, West Virginia October 21, 215

4 STIGMA Stigma A mark of disgrace or infamy associated with a particular circumstance, quality or person.

5 CELEBRITY ADDICTION When the actor Phillip Seymour Hoffman died the description was found half naked on the bathroom floor with a needle hanging out of his arm. If that had been a heart attack would they have said half naked on the bathroom floor with a BigMac in his hand and French fries scattered across the floor? 5

6 LEVELS OF STIGMA Legal vs. Illicit Type of illicit substance used Method of Use

7 SHAME A painful feeling of humiliation or distress caused by the consciousness of wrong or foolish behavior. It is differentiated from guilt in that guilt involves a behavior, shame involves the intrinsic sense of one s self. Guilt- I behaved badly; Shame I am bad.

8 THE POWER OF WORDS TO HURT OR HEAL Stigmatizing Words Addict, Abuser, Junkie, User Relapse Substance Abuse / Prescription Drug Abuse Alternative Terminology Person in active addiction, person with a substance use disorder, person experiencing an alcohol/drug problem, patient /client, person served Recurrence / return to use Substance Use Disorder, Prescription Drug Misuse Clean, Dirty Replacement or Substitution Therapy Negative, positive/ Drug free, Free from illicit and nonprescribed medication Treatment, medication-assisted treatment, medication The Rhetoric of Recovery Advocacy: An Essay On the Power of Language W.L.White; E.A Salsitz, MD., Addiction Medicine vocabulary; Substance Use Disorders: A Guide to the Use of Language Prepared by TASC, Inc. Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), part of the U.S. Department of Health and Human Services (DHHS), rev

9 OTHER WORDS OR CONCEPTS WE SHOULD THINK ABOUT Drug of Choice Denial Clean and Sober Victims

10 THOSE PEOPLE Alcoholic Addict Drunk Old Wino Crack Head Junkie Needle Freak Benzo Queen Garbage Head Burn Out Pot Head Borderline Nut Job Crazy And then there is Chronic Relapser

11 THE LANGUAGE THAT WE USE They re not ready They don t want it bad enough They haven t hurt/lost enough They re too resistant They are in denial

12 WHAT IS ADDICTION?

13 Is it willful misconduct or Is it a Medical Condition?

14 We know from the research that has been conducted by some of the worlds leading neuroscientists that drug addiction is not a moral failing on the part of the individual, it s a chronic disease of the brain and it can be treated. This isn t my opinion and is not a political statement and it really isn t open for debate because the evidence is clear and it s unequivocal. It s a fact born out by decades of study and research and it s a fact that neither the government nor the public can ignore. Gil Kerlikowske, Director of National Drug Control Policy Betty Ford Center June 12, 212

15 AMPHETAMINE DA DOPAC HVA Time After Amphetamine % of Basal Release Accumbens Time After Nicotine 3 hr COCAINE DA DOPAC HVA hr NICOTINE Accumbens Caudate Accumbens 4 % of Basal Release % of Basal Release % of Basal Release Effects of Drugs on Dopamine Release Accumbens 2 3 Time After Cocaine 4 5 hr MORPHINE Dose (mg/kg) Time After Morphine 4 Source: Di Chiara and Imperato (as adapted for National Institute on Drug Abuse Presentation) 5hr

16 Natural Rewards Elevate Dopamine Levels % of Basal DA Output Empty Box Feeding 6 FOOD 12 Time (min) NAc shell 18 DA Concentration (% Baseline) Scr Scr Bas Female 1 Present SEX Sample Number Scr Mounts Intromissions Ejaculations Scr Female 2 Present Copulation Frequency Source: Di Chiara et al. Source: Fiorino and Phillips

17 ADDICTION IS A dysregulation of the midbrain dopamine (salience/ reward) system due to unmanaged stress resulting in symptoms of decreased functioning. Specifically: 1. Loss of control 2. Craving 3. Persistent drug use despite negative consequences

18 TYPES OF CHRONIC DISEASES Hypertension Asthma Diabetes Addiction

19 Chronic Disease Treatment FOR EACH OF THE CHRONIC DISEASES LISTED, ANSWER THE FOLLOWING QUESTIONS: - WHAT IS THE TREATMENT - WHAT IS THE GOAL OF TREATMENT - WHAT HAPPENS IF THE PATIENT IS NONCOMPLIANT WITH TREATMENT -WHEN IS THE PATIENT DISCHARGED FROM TREATMENT

20 HARM REDUCTION Harm Reduction refers to a range of services that lessen the adverse consequences of drug use and protect public health. Unlike approaches that insist people stop using drugs, harm reduction acknowledges that many people are not able or are not willing to abstain from illicit drug use and that abstinence should not be a precondition for help.

21 ADDICTION CAREER Number of abstinent periods one month or longer followed by return to drug use prior to current abstinence* 5% reported 4 or more abstinent periods followed by a return to active addiction *Outside of controlled environment, among those who report one or more such periods: 71% N=248 Laudet & White 24

22 Recurrence Rates Are Similar for Addiction and Other Chronic Illnesses Percent of Patients Who Relapse to 5% 5 to 7% 5 to 7% Drug Dependence Type II Diabetes Hypertension Asthma Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2.

23 Health Care Providers: Myths and Misperceptions

24 OPIOID ADDICTION First step is liking the drug or at least finding it eases emotional problems Endorphins and enkephalins relieve stress by making you feel warm, safe, fed and loved If you are a trauma survivor these drugs are especially appealing reinforcing the connection between the drug and life s fundamental comforts

25 Treatment For Opioid Use Disorders

26 MEDICATION ASSISTED RECOVERY The use of medication as prescribed and overseen by a physician knowledgeable about addiction care to support recovery from Substance Use Disorders (SUD).

27 TERMINOLOGY Dependence versus Substance Use Disorder (SUD) An SUD may occur with or without the presence of physical dependence. Physical dependence results from the body s adaptation to a drug or medication and is defined by the presence of Tolerance and/or Withdrawal

28 TREATMENT OPTIONS FOR INDIVIDUALS WITH OPIOID USE DISORDER Behavioral treatments educate patients about the conditioning process and teach recovery management strategies. Medications such as methadone and suboxone operate on the opioid receptors to relieve craving. Medications such as naltrexone block opioid receptor sites Combining the two types of treatment enables patients to stop using opioids and return to more stable and productive lives.

29 PURPOSE BEHIND USING MEDICATION WITH OPIOID USE DISORDER: Manage physical withdrawal symptoms Reduce risk of drug overdose Block any euphoric effect Facilitate therapeutic engagement Achieve long-term changes and prevent return to use

30 AGONIST A chemical that binds to a receptor site and triggers a response by the cell. They mimic the action of naturally occurring substances.

31 PARTIAL AGONISTS A chemical that binds and activates to a given receptor site but has only partial efficacy at the site relative to a full agonist. Buprenorphine Buprenex, Suboxone, Zubsolv, Subutex, Sublocade Probuphine Bunavail

32 OPIOID ANTAGONISTS Antagonist: Type of receptor ligand that does not provoke a biological response upon binding to a receptor but blocks agonist response. Naloxone Narcan Naltrexone ReVia, Vivitrol, Trexan

33 FULL AGONIST VS PARTIAL AGONIST

34 REVIEW OF DO S AND DON TS HANDOUT

35 EVIDENCE SUPPORTING METHADONE / BUPRENORPHINE MAINTENANCE

36 Heroin Abuse Frequency Vs. Methadone Dose % I.V. Drug Use Daily Dose In MGS. V.P. Dole, JAMA, VOL. 282, 1989, p. 1881

37 REDUCTION OF HEROIN USE BY LENGTH OF STAY IN METHADONE MAINTENANCE TREATMENT (BALL AND ROSS, 1991) N = 617

38 CRIME AMONG 491 PATIENTS BEFORE AND DURING MMT AT 6 PROGRAMS Crime Days Per Year Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991

39 RETURN TO IV DRUG USE AFTER TERMINATION OF METHADONE MAINTENANCE TREATMENT Percentage In Tx Months Since Drop Out Ball, JC & Ross A The Effectiveness of Methadone Maintenace Treatment, Springer-Verlag, New York, 1991

40 MORTALITY RATES IN TREATMENT AND 12 MONTHS AFTER DISCHARGE ZANIS AND WOODY, 1998 % Died 1.% 9.% 8.% 7.% 6.% 5.% 4.% 3.% 2.% 1.%.% 1.% 8.2% In Treatment (n=397) Discharged (n=11) 4

41 I ve learned that people Will forget what you said, people will forget what you did but people will never forget how you made them feel. Maya Angelou