Screening, Identification, Counseling, and Treatment of Opioid Use Disorder

Screening, Identification, Counseling, and Treatment of Opioid Use Disorder Joji Suzuki, MD Assistant Professor of Psychiatry, Harvard Medical School Director, Division of Addiction Psychiatry, Brigham and Women s Hospital *Images used for educational purposes only. All copyrights belong to image owners*

Outline 1. What are screening/identification, motivational counseling, and referral to treatment? 2. Screening and identification of unhealthy opioid use 3. Counseling to increase motivation 4. Planning for treatment

Why screen for and identify opioid use disorders? The vast majority of individuals with OUD who could benefit from treatment are not receiving it in any given year. Stein 1999; McLellan et al 2000; SAMHSA 2015

Why screen for and identify opioid use disorders? Untreated, opioid use disorders can lead to significant negative consequences, including overdose and death. Stein 1999; McLellan et al 2000; SAMHSA 2015

Why screen for and identify opioid use disorders? Your brief intervention can help increase motivation to reduce risky use and initiate evidence-based treatments. Stein 1999; McLellan et al 2000; SAMHSA 2015

Why screen for and identify opioid use disorders? Universal and opportunistic screenings are well suited for general medical settings like primary care and hospitals. Stein 1999; McLellan et al 2000; SAMHSA 2015

97.5 million people (36.4% of total pop 12+) SAMHSA NSDUH 2015 OUD Misuse Unhealthy Opioid Use No Misuse

Screening/ Identification Brief Intervention/ Counseling Treatment

Evidence to Support Screening, Identification, Counseling, and Treatment in Primary Care Screening Identification Brief Intervention Counseling Treatment Alcohol Tobacco Illicit drugs X SAMHSA 2011, Thomas et al Psychiatric Services 2014

istock Photo Case: Jane (1) Jane is a 26-year-old female with a history of asthma, depression, and prior history of marijuana use who presents for her annual physical exam. She is employed as a chef. Her PCP had prescribed antidepressants in the past, but Jane has not been to the clinic for the past few years.

Case: Jane (2) In recent years, the clinic has instituted universal screening for substance use at annual visits, and Jane is given a pre-visit form to complete. Jane fills out the pre-visit form, which includes the screening question about drug use. Jane indicates she has used prescription medications recreationally several times in the past 12 months.

istock Photo Case: Jane (3) Upon seeing the positive screen, the medical assistant hands Jane an additional form to complete, the TAPS Tool.

Tools for Screening and Identification 1)Tobacco, Alcohol, Prescription Medication, and Other Substance Use Tool (TAPS) 2) NIDA quick screen and modified- ASSIST 3) Drug Abuse Screening Test (DAST- 10)

Tobacco, Alcohol, Prescription Medication, and Substance Use Tool (TAPS) TAPS-1 Brief Screen In the past 12 months, how often have you used any prescription medications just for the feeling, more than prescribed, or that were not prescribed for you? https://www.ncbi.nlm.nih.gov/pubmed/27595276

Tobacco, Alcohol, Prescription Medication, and Substance Use Tool (TAPS) TAPS-2 Brief Assessment In the past 3 months did you use a prescription opiate pain reliever not as prescribed or that was not prescribed for you? (no=0, yes=1) https://www.ncbi.nlm.nih.gov/pubmed/27595276

Tobacco, Alcohol, Prescription Medication, and Substance Use Tool (TAPS) TAPS-2 Brief Assessment (Cont.) In the past past 3 months have you tried and failed to control, cut down or stop using an opiate pain reliever? (no=0, yes=1) In the past 3 months has anyone expressed concern about your use of an opiate pain reliever? (no=0, yes=1) https://www.ncbi.nlm.nih.gov/pubmed/27595276

Tobacco, Alcohol, Prescription Medication, and Substance Use Tool (TAPS) Scoring A score of 1 more may indicate risky use with possible SUD and may warrant further evaluation and/or counseling. https://www.ncbi.nlm.nih.gov/pubmed/27595276

Single-Question Screener (NIDA Quick Screen) Asks about drugs, prescription medications, alcohol, and tobacco Example Question: How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons? * Any answer other than zero is a positive screen Smith et. al 2010

Smith et. al 2010 NIDA-Modified ASSIST (1) 1. In your lifetime, which of the following substances have you ever used? 2. In the past three months, how often have you used the substances you mentioned? 3. In the past three months, how often have you had a strong desire or urge to use? 4. During the past three months, how often has your use of the drug led to health, social, legal, or financial problems?

Smith et. al 2010 NIDA-Modified ASSIST (2) 5. During the past three months, how often have you failed to do what was normally expected of you because of your use of drugs? 6. Has a friend, relative, or anyone else ever expressed concern about your use of drugs? 7. Have you ever tried and failed to control, cut down, or stop using the drug? 8. Have you ever used any drug by injection?

https://www.drugabuse.gov/publications/resource-guide-screeningdrug-use-in-general-medical-settings/nida-quick-screen NIDA-Modified ASSIST: Results (1) Level of risk Lower Risk Score 0-3 Moderate Risk Score 4-26 Action required Reinforce abstinence Offer continued support Provide feedback on the screening results Provide counseling Offer or refer to further treatment if clinically indicated Offer continuing support and accountability

https://www.drugabuse.gov/publications/resource-guide-screeningdrug-use-in-general-medical-settings/nida-quick-screen NIDA-Modified ASSIST: Results (2) Level of risk Action required High Risk Score 27 Provide feedback on the screening results Provide counseling Offer or refer to further treatment Offer continuing support and accountability

https://archives.drugabuse.gov/diagnosis-treatment/dast10.html Drug Abuse Screening Test (DAST-10) In the past 12 months Circle 1 Have you used drugs other than those required for medical Yes No reasons? 2 Do you abuse more than one drug at a time? Yes No 3 Are you unable to stop abusing drugs when you want to? Yes No 4 Have you ever had blackouts or flashbacks as a result of drug Yes No use? 5 Do you ever feel bad or guilty about your drug use? Yes No 6 Does your spouse (or parents) ever complain about your Yes No involvement with drugs? 7 Have you neglected your family because of your use of drugs? Yes No 8 Have you engaged in illegal activities in order to obtain drugs? Yes No 9 Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 10 Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding)? Scoring: Score 1 point for each question answered Yes, except for question 3, which receives 1 point for No. Yes No Yes No Score:

Drug Abuse Screening Test (DAST-10): Results (1) Level of Risk 0 No problems reported 1-2 Low level (Risky use) Suggested Action Reinforce abstinence Offer continued support Provide feedback on the screening results Monitor and re-assess at a later date Provide counseling Offer continuing support and accountability

https://archives.drugabuse.gov/diagnosis-treatment/dast10.html Drug Abuse Screening Test (DAST-10): Results (2) 3-5 High moderate level (Possible SUD) 6+ Severe level (Likely SUD) Provide feedback on the screening results Investigate further Provide counseling Offer or refer to further treatment if clinically indicated Offer continuing support and accountability Investigate further Provide counseling Offer or refer to further treatment if clinically indicated Offer continuing support and accountability

Case Continued: Jane During the visit with the PCP, Jane is noted to have 2 mm pupils and is mildly somnolent. Reviewing the form, Jane scored a 23 for prescription opioids, primarily oxycodone, but not heroin, and does not inject. She uses almost daily (6), has cravings daily (6), experiences weekly financial problems (6), and misses work every month (5). She denies using other drugs.

istock Photo Then, the PCP asks: Jane, you noted on our screening questions that you have been using prescription pain medications on a daily basis. I appreciate you honestly answering these questions. Would it be ok if we spend a few minutes talking about it?

The Goals of Counseling: Demonstrate respect for patient autonomy Demonstrate empathy using reflective listening Evoke and strengthen patient s own reasons for change (i.e., change talk) Probe the patient s readiness and willingness to engage in treatment

istock Photo However, there should be no expectation that a brief encounter alone is sufficient to successfully engage all patients into treatment.

istock Photos Once identified, multiple encounters over a period of weeks or months may be needed before the patient is willing to try further treatment. Therefore, it is important to meet patients at their degree of readiness.

Spirit of Motivational Interviewing Acceptance Compassion Partnership Evocation

istock Photo Spirit of MI Must Be Demonstrated (1) Avoiding the impulse to immediately offer solutions and fixes Asking permission before giving advice or information Demonstrating accurate empathy Miller and Rollnick 2015

Spirit of MI Must Be Demonstrated (2) Respecting patient s decisions, even if you disagree Reinforcing personal choice and responsibility Affirming positive qualities and efforts to change Respecting autonomy does not mean agreeing with their decisions Miller and Rollnick 2015

Some Strategies for Starting the Conversation about Behavior Change Would it be ok if we spent a few minutes talking about the results of the questionnaire? Tell me a little bit about how your heroin use fits into your life? What do you like about heroin? What are some of the drawbacks?

Using Reflective Listening to Demonstrate Accurate Empathy What the patient is trying to communicate What the patient said Reflection What you heard Your interpretation of what the patient was trying to say

Simple reflections stay close to what the patient said I need to stop using heroin. You need to stop using heroin.

Simple reflections stay close to what the patient said I need to stop using heroin. You want to cut back on how much heroin you use.

Complex reflections go deeper and add substantial meaning I need to stop using heroin. You ve decided to get professional help.

Complex reflections go deeper and add substantial meaning I need to stop using heroin. The overdose was a real wake-up call.

Double-sided reflections reflect ambivalence I need to stop using heroin. On one hand, heroin has helped with your pain, and on the other hand, it s led to a lot of physical and social problems.

Case Continued: Jane (1) Jane s PCP asks permission to talk with her about her pain medication use, and she responds: Okay Her PCP responds: Tell me how the use of these pain medications fit into your life. istock Photo

Case Continued: Jane (2) Instead of drinking and smoking weed like I used to, I choose to take some pills here and there. It s not like I use them all the time. Last year, I even had an entire month I didn t used any just to prove I could do it. I don t think it s a big deal. All my friends use them - it s not like I m injecting heroin, so I m not that concerned.

Case Continued: Jane (3) Taking these pills is something you enjoy, and many of your friends do it as well. You ve cut back at times - it hasn t gotten to the point of injecting heroin, so right now you re not too concerned about it. Tell me what you like about these pills?

Change Talk (DARN-CAT) D : Desire I want to, I wish, I d like to A : Ability I could, I know I can, I could try R : Reason I want to change because N : Need I should, I need to, I must C : Commitment I will, I promise to.., I guarantee A : Activating I am ready to, I am willing to T : Steps Taken I ve tried https://www.porticonetwork.ca/treatments/treatmentmethods/motivational-interviewing/mi-change-talk

The vast majority of patients are ambivalent to some extent about their drug use I want to change. I don t want to change. This side of the ambivalence is called Change Talk This side of the ambivalence is called Sustain Talk

The vast majority of patients are ambivalent to some extent about their drug use I want to change. I don t want to change. Clinicians often argue for change, which often pushes patients to the other side of the ambivalence.

The vast majority of patients are ambivalent to some extent about their drug use I want to change. I don t want to change. Clinicians typically focus more on addressing the excuses and barriers to change.

The vast majority of patients are ambivalent to some extent about their drug use I want to change. I don t want to change. The goal of MI is for the patient The to argue goal for of MI change, is for the not patient the clinician. to argue The for clinician this, not should the work clinician. to evoke The and clinician strengthen should work to change evoke and talk. strengthen change talk.

Examples of Questions to Evoke Change Talk (1) If you were to stop using pills, how would you be successful? What are the most important reasons for you to cut back on using pills? On a scale of 1-10, 10 being completely ready, and 1 being not at all ready, how ready are you to stop using pills? - Follow-up: Why did you pick that number, and not a lower number?

Examples of Questions to Evoke Change Talk (2) Why did you decide to stop using completely last year? How were you successful in not using for an entire month last year?

istock Photo Case Continued: Jane Jane & her PCP continue the conversation: I like them because it helps me to relax, and I m not as anxious. I know I go overboard sometimes, but I think it s better than drinking. It helps you to relax, and also you re not as anxious. I can see why the pills might be attractive - we all need a way to unwind and relax. However, sometimes it gets out of control. Tell me more about that.

They are addictive, and it s easy to just keeping taking more and more. Then when you try to stop, the withdrawals are horrible, so you just want that feeling to go away. You can t focus on anything else. It s pretty bad. It s easy to get hooked on these, especially because the withdrawals are terrible. So how were you able to stop for an entire month?

I stopped cold turkey, but I don t think I could do that again. If you were to cut back or stop how many pills you use, what would be the most important reasons to do so?

I guess I don t want this to get worse and start using heroin. I never imagined I d ever want to try, but I ve thought about it. That scares me. Plus, I ve missed work too many times because of this, and I can t afford to lose my job. You feel like you could end up using heroin, and that s not a line you want to cross. Not to mention it s affecting your work. If you were to decide to stop again, how would you be successful?

istock Photo I ve tried slowly, taking less each day, but that really hasn t worked. I d probably need some help with the withdrawals and cravings. I don t want to go to any hospital or rehab - I ve got a job and too much to do.

Change Talk Bouquet and the Key Question Change talk bouquet Key question PCP: The pills help you to relax, but sometimes you go overboard. The withdrawals are terrible, and you re worried you might start using heroin and it s already affecting your job. You ve tried stopping in the past, and now you think you could do it if you had some help. So, where do we go from here?

istock Photo Case Continued: Jane A friend of mine stopped taking pills completely by taking a medication from a doctor. She said it worked really well, it took away the cravings and all. I m not sure if I want to take medications, but it sounds like a reasonable option. You ve decided you want to stop, and you feel like you need help to do it. You re wondering if medications could support you through this. What do you already know about medications to help stop using pain medications?

I think it s a pill that you put under your tongue, and it s supposed to keep you from going into withdrawal. Plus, if I m taking it, I can t get high from the pills. I think I need something like that You re right, the medication is called buprenorphine, and it will take away the withdrawal and reduce cravings, as well as help prevent relapse. You think something like this would help you stop taking the pills. istock Photo

SAMHSA 2011 Engaging OUD Patients in Further Treatment Patient s Willingness Patient is willing to engage in treatment Intervention Explore appropriate treatment options Affirm and recognize efforts to seek treatment Offer treatment on-site or refer to off-site programs Provide resources Offer information on naloxone rescue

SAMHSA 2011 Engaging OUD Patients in Further Treatment Patient s Willingness Patient is not yet willing to engage in treatment Intervention Continue to engage patient to increase motivation Continue to explore ambivalence Demonstrate empathy Avoid coercive strategies Agree to provide ongoing support and accountability Offer information on naloxone rescue

Referral to Further Treatment For patients willing to consider treatment for OUD and other substances, the following are options to consider in addition to medications: 1) Outpatient treatment 2) Intensive outpatient, partial hospital programs, residential programs 3) Acute treatment services (medical withdrawal or detoxification) 4) Peer-support programs (AA, NA, SMART Recovery)** **Used supplemental to other treatment options

Screening/ Identification Motivational Counseling Treatment

Unit Resources: Physician/Patient Communication Skills Videos Reports and Detailed Tables From the 2015 National Survey on Drug Use and Health (NSDUH) Instrument: TAPS Tool Instrument: The NIDA Quick Screen Instrument: NIDA Modified ASSIST (pdf) Instrument: Drug Abuse Screening Test (DAST-10) Portico, Canada s Mental Health & Addiction Network - MI: Change Talk