Learn about the non-pharmacologic components of recovery. When developing individualized treatment plans, what factors are considered? The Medical Director and the Director of Quality and Compliance for Washburn House, a new treatment facility in Worcester, Massachusetts, will share their stories of starting a new treatment facility, and the challenges of putting evidence-based practices into practical use.
Learning Objectives: Individualized Treatment and Understanding the non-pharmacologic Components that are Part of Recovery   Understand the rationale and treatment options for managed withdrawal of a patient with opioid use disorder Understand the rationale and treatment options for Medication Assisted Treatment in a patient with opioid use disorder Understand the non-pharmacologic components that are part of recover

Gonzalez, Gerardo

Halpin, Susan

Silva, Lindsey

English

eScholarship@UMMS

University of Massachusetts Medical School eScholarship@UMMS National Network of Libraries of Medicine New England Region (NNLM NER) Repository National Network of Libraries of Medicine New England Region 2018-01-26 Individualized Treatment and Understanding the Non-Pharmacologic Components that are Part of Recovery Gerardo Gonzalez MD University of Massachusetts Medical School Et al. Let us know how access to this document benefits you. Follow this and additional works at: https://escholarship.umassmed.edu/ner  Part of the Community Health Commons, Counseling Commons, Library and Information Science Commons, Psychiatric and Mental Health Commons, Psychiatric and Mental Health Nursing Commons, Psychiatry and Psychology Commons, Public Health Commons, Public Health and Community Nursing Commons, Social Work Commons, and the Substance Abuse and Addiction Commons Repository Citation Gonzalez G, Silva L, Halpin S. (2018). Individualized Treatment and Understanding the Non-Pharmacologic Components that are Part of Recovery. National Network of Libraries of Medicine New England Region (NNLM NER) Repository. https://doi.org/10.13028/7ewy-y159. Retrieved from https://escholarship.umassmed.edu/ner/53 This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in National Network of Libraries of Medicine New England Region (NNLM NER) Repository by an authorized administrator of eScholarship@UMMS. For more information, please contact Lisa.Palmer@umassmed.edu. Welcome to the Webinar Individualized Treatment and the Non-Pharmacologic Components of Recovery How To Connect to Webinar AudioTo receive a call back, provide your phone number when you join the event, or call the number below and enter the access code 624 494 571Call-in toll number (US/Canada) 1-650-479-3208. This Webinar is being recorded. To view the captions for this event click on the URL below.http://livewrite-ncc.appspot.com/attend?event=citwebexDo any of these myths strike a cord with you? While we are waiting to begin….If you feel comfortable, share your thoughts about these myths in the chat box. 5 Common Myths About Substance Use DisorderSusan Halpinsusan.halpin@umassmed.eduNational Network of Libraries of Medicine (NNLM), New England Region (NER) Education & Outreach CoordinatorUniversity of Massachusetts Medical School Worcester, MassachusettsYour Webinar HostWebinar Learning Objectives• Become familiar with the National Library of Medicine (NLM) and its free, digital resources• Understand the how the NLM provides outreach by the National Network of Libraries of Medicine (NNLM) through comprehensive online resources, training classes and grant funding opportunities.• Understand the rationale and treatment options for managed withdrawal of a patient with opioid use disorder.• Understand the rationale and treatment options for Medication Assisted Treatment in a patient with opioid use disorder.• Understand the non-pharmacologic components that are part of recovery.NLMs mission Advance the progress of medicine and improve public health by making biomedical information accessible to everyone.The NLM physical library is Bethesda, MD on the NIH campus. NLM is the largest biomedical library in the worldNLM is one of the federal government’s largest providers of digital contentThe library is open to everyone. All of its resources are FREE.• Nationwide network of health sciences libraries, public libraries & information centers • Each region has a partnership with a regional medical library• Outreach provided through Free access to online health & medical  resourcesFree Training & Professional DevelopmentGrant funding opportunitiesNLM Implements Outreach Through the National Network of Libraries of Medicine (NNLM)NNLM has about 6800 Network Members.Members are • Librarians, • Healthcare providers, • Public health professionals• K-12 Educators and students• ConsumersAnyone can join the network, it’s FREEJoining the network provides you access to training classes and grant funding opportunitiesTo Join the NNLM Network :https://nnlm.gov/members/join-networkhttps://nnlm.gov/National Network of Libraries of Medicine (NNLM)Dr. Gerardo Gonzalez, MDMedical Director, Washburn House, Worcester, MA Director of the Division of Addiction Psychiatry& Associate Professor of Psychiatry, University of Massachusetts Medical School IntroducingYour  Webinar PresentersLindsey Silva, RN, MSN Director of Quality and Compliance, Washburn House, Worcester, MA Gerardo Gonzalez, MDLindsey Silva, MSN, RN Individualized Treatment and Understanding the Non-Pharmacologic Components that are Part of  Recovery PresentersGerardo Gonzalez, MD Director of the Division of Addiction Psychiatry and Associate Professor of Psychiatry, University of Massachusetts Medical School Medical Director, Washburn House, Worcester, MALindsey Silva, RN, MSNDirector of Quality and Compliance, Washburn House, Worcester, MA Disclosures• We have no financial conflicts to disclose• We will review evidence based off-label use of medications OutlineOutline• Epidemiology• Longitudinal outcomes• Preventive efforts• Treatment• Conclusions• Recovery elementsEpidemiologyNSDUH, 2014Drug overdose deaths involving opioids by type of opioidUnited States, 2000–2014CDC, 2016Prescription Opioids and Heroin use during the Previous YearUnited States, 2000–2014.Comptom, 2016Prescription Opioids and Heroin Drug Poisoning United States, 2000–2014.Comptom, 2016Main medical diagnosis UMMC Worcester MA: 2008-2012Ross et al, unpublishedRoss et al, unpublishedLast treating services UMMC Worcester MA: 2008-2012Source Where Pain Killers Were ObtainedAge 12 or Older: 2010-2011 Substance use disorders (DSM-5)• Neuroadaptation:ToleranceWithdrawal• Cognitive distortion:Importance of  substance useSubjective awareness of decrease controlCraving or a strong desire or urge to use • Behavioral dyscontrol:Obtaining, using and recoveringUse despite knowledge of problemsUsing more and longer than intendedSubstance use disorders (DSM-5)• Neuroadaptation:ToleranceWithdrawal• Cognitive distortion:Importance of  substance useSubjective awareness of decrease controlCraving or a strong desire or urge to use • Behavioral dyscontrol:Obtaining, using and recoveringUse despite knowledge of problemsUsing more and longer than intendedPreventive effortsPreventive efforts• Education of medical and nursing students on universal precautions with controlled substances• Prescription guidelines for practicing physicians and dentists on safe pain management• Prescription monitoring program (PMP)• Safe storage of opioid analgesics (locked box)• Appropriate disposal of unused opioid analgesics• Naloxone rescue kits available (standing orders) Treatment• The proportion of all clients receiving methadone was 22 to 25 percent between 2006 and 2010.• The proportion of clients receiving buprenorphine was 1 percent or less from 2006 to 2008, but increased to 2 percent in 2009 and 2010.Patients in Treatment, by type of  care received: 2006-2010Substance use disorder treatment services1. Detoxification / stabilization units (ATS)2. Inpatient acute hospitalization 3. Nonhospital residential rehabilitation (CSS)4. Partial hospital day Program (PHP)Intensive outpatient program (IOP) 5.   Outpatient treatment / office-basedSubstance use disorder treatment services1. Detoxification / stabilization units (ATS)2. Inpatient acute hospitalization 3. Nonhospital residential rehabilitation (CSS)4. Partial hospital day Program (PHP)Intensive outpatient program (IOP)5.  Outpatient treatment / office-basedPsychosocial treatments  1. Drug Counseling2. Motivational Enhancement Therapy3. Relapse prevention4. Cognitive Behavioral Therapy5. Mindfulness base treatment6. Contingency Management7. Twelve Steps facilitation8. Self-help groupsLet’s expand our view.Use of MedicationsManaged withdrawal (ATS)• In-patient stabilization units• Reduce opioid withdrawal symptoms• Transition off daily opioid use• Evaluate and treat comorbid medical and psychiatric problems• Usually 4-5 days  needs follow-up• Reduction of the intensity of opioid withdrawal• 1 or 2 attempts are reasonable• Should be considered initial step in recovery• Efficacy alone is very low ( less 20%) • Efficacy improves with IOP or PHP• ATS is not necessary to start MATManaged withdrawal (ATS)• Clonidine protocol  Naltrexone (IM)• Buprenorphine protocol  • Methadone protocolManaged withdrawal (ATS)• Joint selection of protocol is helpful for engagement• Motivation enhancement for treatment is needed• Challenges include wide variation of motivation for treatment and risk of use while on the unit.Medication assisted treatment (MAT)• Outpatient settings• Suppress opioid withdrawal symptoms• Suppress craving for opioids• Stop opioid use and relapse• Adjust daily dose to avoid sedationMedication assisted treatment (MAT)• Naltrexone (PO and IM)• Buprenorphine + Naloxone• MethadoneNaltrexone• Indications: Severe opioid use disorder• Mechanism: Opiate receptor antagonist• Efficacy: Oral is good in high motivated.• Implementation: 50-100 mg/per day; LFT’s• Side effects : nausea, headache, anxiety, OD• Compliance: Improved with naltrexone depot (IM) (Comer, 2006; Krupitsky, 2011)Naltrexone DepotKrupitsky, 2011Methadone• Indications: Severe opiate use disorder• Mechanism: Full opiate receptor agonist.• Efficacy: 70-80 % retention in OTP.• Implementation: Start at 25-30mg and built-up dose until opiate free urines. • Side effects : sedation• Interactions: benzodiazepine – alcohol.Methadone• Age >18 or 2 documented failures of detox.• One year history of severe opiate use disorder• Exceptions:PregnancyRelease from prisonHistory of previous treatment.Strain, 1999Methadone dose: illicit opioid useBuprenorphine• Partial opiate receptor agonist• Combination tablet /film (Bup/naloxone)• Sublingual administration• High affinity and slow dissociation• Office based opiate use treatment• Death associated with IV use and with benzodiazepinesMAT – Buprenorphine - NaloxoneRomero-Gonzalez et al, 2017Treatment of  opioid dependent youthWoody, 2008Buprenorphine and Memantine for young adultsGonzalez, 2015Long-term outcomesLong-term outcomes• Reduction of mortality compared to untreated controls (Gronbladh, 1990)• Decrease IVDU from 81% to 29% vs 82% at 1 year of those who left treatment (Ball and Ross, 1991)• HIV seroconversion: methadone 3.5% vs active IVDU 22% Prevalence of  past month heroin use, heroin dependence and other drug use across the 11-year follow-up periodTeesson, 2015Comorbid disorders impactMajor Depression * 1.96 (1.50 – 2.55)Antisocial Personality 1.02 (0.70 – 1.32)Borderline Personality 1.16 (0.91 – 1.48)PTSD 0.81 (0.63 – 1.05)Teesson, 2015Teesson, 2015Treatment  effectMAT 1.11 (0.90 – 1.38)Detoxification * 1.52 (1.20 – 1.92)Residential Rehab * 0.59 (0.46 – 0.76)Teesson, 2015Teesson, 2015NON-PHARMACOLGIC COMPONENTS OF RECOVERYASAM criteria: • Dimension 1: Acute intoxication/withdrawal potential• Dimension 2: Biomedical complications• Dimension 3: Emotional, behavioral or cognitive complications; co-occurring disorders • Dimension 4: Readiness to change • Dimension 5: Relapse, Continued use potential• Dimension 6: Recovery environment COMPONENTS OF RECOVERY• EBP recognizes that treatment should be individualized based on a comprehensive assessment• Offering a continuum of care allows for more time to address major life problems requiring continued work from the individual, such as:– Homelessness– Legal issues– Family and interpersonal struggles– Education and vocational training– Life skills • Case Management services are critical  • Current opioid use epidemic is responsibility of all to help reduce.• Education and change in prescription practices are key elements in prevention.• Reduction of diversion and appropriate disposal is important.• Stabilization treatment alone is not effective• Medication - assisted treatments are effective.• There is still need to develop effective short-term treatments.ConclusionOpiate Addiction & Treatment Portal https://sis.nlm.nih.gov/enviro/addiction.html#a7Handy NLM Tool To Identify a Pillhttps://pillbox.nlm.nih.gov/pillimage/search.phphttps://medlineplus.gov/NLM Resources Related to Mental and Behavioral Healthhttps://mentalhealth.gov/https://www.nlm.nih.govOffering programming on addiction and recovery? Consider borrowing one of our Graphic Medicine Book Club Kits featuring Sobriety: A Graphic Novel! From the publisher… “Through rich illustration and narrative, Sobriety: A Graphic Novel offers an inside look into recovery from the perspectives of five Twelve Step group members, each with a unique set of addictions, philosophies, struggles, and successes while working the Steps.”To Request a Kit: www.nnlm.gov/ner/kitsFor Questions or Further Information, Contact Matthew Noe at Matthew.Noe@umassmed.eduPromotional Items & Printable Handoutshttps://sis.nlm.nih.gov/outreach/promotional_materials.htmlThank you all for attending this webinar!Thank you Dr. Gonzalez and Lindsey for sharing your experience and  knowledge!Please complete the webinar evaluation to receive MLA credithttp://www.surveygizmo.com/s3/3529624/62b1b6a48e79 For more information about how you can benefit from NNLM NER outreach contact Susan Halpin, Education & Outreach Coordinatorsusan.halpin@umassmed.eduI am planning the next series of webinars about Substance Use Disorder. Is there a topic you would like to learn about? Let me know.

Individualized Treatment and Understanding the Non-Pharmacologic Components that are Part of Recovery

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Individualized Treatment and Understanding the Non-Pharmacologic Components that are Part of Recovery

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