Multimodal Pain Managementfor

Persons with Opioid Use Disorder

Steamboat Springs, COMay 19, 2018

Steven Wright, MD Mountain Medical CareFamily Medicine 1982

Addiction Medicine 1987Medical Pain Management 2003

Disclosures: Steven Wright MD

• Cordant Health Solutions Drug testing

• Daiichi Sankyo Movantik, Morphabond

• Depomed CDC opioid guidelines

• Halyard Pain management

• Indivior Opioid addiction, Suboxone, Sublocade

This presentation is not supported by industry

Objectives

• Outline the rationale for good pain management for persons with Opioid Use Disorder (OUD)

• Discuss the non-pharmacologic pain management approaches for those with OUD

• Discuss the pharmacologic pain management approaches for those with OUD

• Discuss the importance of communication, coordination, and integration of pain management in OUD

Pain and OUD

• Persons with pain often have OUD: 8-41% of those on opioids 1-5

• Persons with OUD often have pain

• Good pain management best practice: Multimodal approach 6-8

• Good OUD management best practice: Multimodal approach 9-11

1 Boscarino. OUD in LT opioid therapy. Subst Abuse Rehabil. 2015;6:83-91 2 Noble. LT opioids for chronic noncancer pain. Coch Rev. 2010;20:CD006605 3 Vowels. Rates of opioid misuse, abuse, addiction in chronic pain:. Pain. 2015;156(4):569-76 4 Højsted. Addiction to opioids in chronic pain. Eur J Pain. 2007;11(5):490-518 5 Salsitz. Chronic pain, chronic opioid addiction. J Med Tox. 2016;12(1):54-76 Dale. Multimodal treatment of chronic pain. Med Clin North Am. 2016;100(1):55-64

7 DeBar. 1º interdisciplinary team approach to chronic pain. Transl Behav Med. 2012; 2(4):523-308 Giordano. Integrative, multi-disciplinary pain medicine. Pain Phys. 2008;11(6):775-849 Alford. Collaborative OUD care in 1º care using buprenorphine. Arch Int Med. 2011;171(5):425-3110 Amato. Psychosocial + pharmacological Rx v pharmacological Rx for opioid detox. Cochrane Rev. 2011;(9):CD00503111 Watkins. Collaborative care for OUD, AUD in 1º care. JAMA Int Med. 2017;177(10):1480-8

Multimodal OUD Treatment

• Mutual Help Programs

• Addiction Therapy

• Medication Management

Opioid Use Disorder Treatment

Patient Oriented Not

Program Oriented

• Mutual Help Programs

• Addiction Therapy *

• Medication Management *

Opioid Use Disorder Treatment

Patient Oriented Not

Program Oriented

* Addiction treatment services: Provided professionally 1

1 ASAM: Alcohol, other drug addiction public policy. 2010. Accessed 7/16/16

Mutual Help Programs

• Not self - help — Mutual help • 12-step or other formats • Peer Recovery Coaching 1

• Narcotics Anonymous • Pills Anonymous or Prescriptions Anonymous • Alcoholics Anonymous

• Effective 2-13 Dose: weekly 9,11 • Accessible • Inexpensive

1 SAMHSA - BRSS TACS: Addiction recovery peer service roles. 2010. Accessed 7/19/16 2 Gossop. NA, AA meeting attendance and outcomes. Addiction. 2008;103(1):119-25 3 Humphreys. Encouraging posttreatment self-help. Alc Clin Exp Res. 2007;31(1):64-8 4 Kelly. Youth Rx outcomes, 12-step attendance. Drug Alc Dep. 2013;129(1-2):151-7 5 Kelly. 12-step strengthens adolescent addiction Rx. Drug Alc Dep. 2010;110(1-2):117-25 6 Vederhus. High effectiveness of self-help. BMC Psych. 2006;6:35

7 Kaskutas. AA effectiveness: faith meets science. J Addict Dis. 2009;28(2):145-57 8 Krentzman. How AA, NA) work. Alcohol Treat Q. 2010;29(1):75-84 9 Hoffman. Effective Rx for alcohol, drug disorders. Psych Clin North Am. 1993;16(1):127-40 10 Witbrodt. 12-step attendance, abstinence over 9y J Sub Abuse Treat. 2012;43(1):30-43 11 Humphreys. Self-help for alcohol and drugs. J SubAbuse Treat. 2004;26(3):151-8 12 Cloud. Dose, underutilization of 12-step. Recent Dev Alc. 2008;18:283-301 13 Monterosso. Behavioral economics of will in addiction recovery. Drug Alc Dep. 2007;90 Suppl 1:S100-11

Professional Role: 12-step

Facilitation

Addiction Therapy• Motivational Enhancement Therapy (MET)

• Cognitive Behavioral Therapy (CBT)

• Supportive- Expressive Therapy

• Contingency Management

• Trigger Management

• Network Therapy

• Peer Coaching

• Social Support

• Drug Court

1 McAuliffe. Recovery training + self help for opioid addicts. J Psychoact Drugs. 1990;22:197-209 2 Bickel. Adding behavioral Rx to opioid detox. J Consult Clin Psych 1997;65:803-10 3 Azrin. Behavior therapy: drug abuse controlled Rx outcome study. Behav Res Ther. 1994;32(8):857-66 4 Windsor. CBT meta-analysis: race, substance use. Cultur Divers Ethnic Minor Psych. 2015;21(2):300-13 5 Waldron. CBT: adolescent substance abuse. Addiction. 2004;99 Suppl 2:93-105 6 Magill. CBT with adult alcohol, illicit drug users: meta-analysis. J Stud Alc Drugs. 2009;70(4):516-27

• Opioid addiction: 2 RCTs - beneficial results 1,2

• “Substance” or “Drug” abuse: Beneficial 3-10

• Effect size varies by meta-analysis: • Very strong 4 • Meaningful 5 • Small 6,7

• Benefit tends to ↓ over time 5 • Moderators of benefit uncertain 7

• Guideline support with reservation 11-12

Effective

7 Blodgett. SUD continuing care effectivenss: meta-analysis. J Sub Abuse Treat. 2014;46(2):87-97 8 Schumacher. Cost, effectiveness: substance abuse Rx for homeless. J MH Policy Econ. 2002;5(1):33-42 9 Woody. Psychotherapy for opiate addicts. Arch Gen Psych. 1983;40(6):639-45 10 Kaminer. Adolescent substance abuse evidence-based practice. Curr Psych Rep. 2002;4(5):397-401 11 NICE: Drug misuse psychosocial intervention guidelines. 2008. Accessed 7/16/16 12 VA / DoD: SUD management guideline. 2015. Limited recommendation. Accessed 7/16/16

Medication Management

• Withdrawal meds: Preparation for treatment

• Adjunctive symptom meds: Post-acute withdrawal

• Anti-Craving meds: Primary medication management

• Methadone Full mu opioid agonist 1-6

•Buprenorphine Partial mu opioid agonist 3-9

•Naltrexone Mu opioid antagonist 10-15

FDA Approved MedicationsOUD Treatment

1 Fullerton. Med-assisted Rx with methadone review. Psych Serv. 2014;65(2):146-572 Mattick. Methadone v no opioid replacement for OUD. Cochrane Rev. 2009 Jul 8;(3)3 Mattick. Buprenorphine v placebo, methadone in OUD. Cochrane Rev. 2014 Feb 6;24 Potter. Buprenorphine-naloxone, methadone for Rx opioid, heroin. J Stud Alc Drug. 2013;74(4):605-135 Nielsen. Opioid agonist Rx for Rx for OUD. Cochrane Rev. 2016;(5)6 Nosyk. QOL improvement in opioid agonist Rx. Drug Alc Dep. 2015;157:121-87 Colson. Office-based OUD Rx. Pain Phys. 2012;15(3 Suppl):ES231-68 Thomas. Med-assisted Rx with buprenorphine. Psych Serv. 2014;65(2):158-70

9 Orman. Buprenorphine-naloxone in OUD review. Drugs. 2009;69(5):577-60710 Tanum. IM ER NTX v bup-nxo for opioid dependence. JAMA Psych. 2017 Oct 18. [Epub]11 Comer. Injectable, SR NTX for opioid dependence RCT. Arch Gen Psych. 2006; 63(2):210-812 Krupitsky. Injectable ER NTX for opioid dependence RCT. Lancet. 2011; 377(9776):1506-1313 Krupitsky. Injectable ER NTX for opioid dependence LT. Addiction. 2013;108(9):1628-3714 Syed. ER IM NTX in opioid dependence review. CNS Drugs. 2013;27(10):851-61 15 Lobmaier. SR NTX for opioid dependence. Cochrane Rev. 2008; (2):CD006140

Opioid Addiction Treatment Combinations

• Adding Mutual Help to Addiction Therapy: No data • Adding Mutual Help to Medication Management: No data

• Adding Addiction Therapy to Medication Detox: Beneficial 1,2

• Adding Addiction Therapy to Medication Management: Studies mixed 3-15 Reviews mixed 16,17 Meta-analysis - no benefit 18

• Adding psychiatric treatment for psychiatric problems: Beneficial 19,20

Evidence-based data does not necessarily address individualized needs

1 Amato. Psychosoc + med v med for opioid detox. Coch Database Syst Rev. 2011;(9) 2 Bickel. Adding behavioral Rx to buprenorphine in detox. J Consult Clin Psych. 1997;65(5):803-10 3 Montoya. Psychotherapy attendance, buprenorphine Rx. J Subs Abuse Treat. 2005;28(3):247-54 4 Stein. Buprenorphine retention in 1º care. J Gen Int Med. 2005;20(11):1038-41 5 Weiss. Buprenorphine-naloxone, counseling. Drug Alc Dep. 2014;140:118-22 6 Weiss. Counseling in buprenorphine-naloxone Rx. Arch Gen Psych. 2011;68(12):1238-46 7 Woody. Psychotherapy for opiate addicts. Arch Gen Psych. 1983;40(6):639-45 8 McLellan. Psychosocial in substance abuse Rx. JAMA. 1993;269(15):1953-9 9 Rothenberg. Behavioral naltrexone Rx in opiate dependence. J Sub Abuse Treat. 2002; 23(4):351-60 10 Carroll. Behavioral Rx, naltrexone in opioid dependence. Arch Gen Psych. 2001;58(8):755-61

11 Subramaniam. Abstinence predict: buprenorphine-Rx. J Am Acad Child Adol Psych. 2011;50(11):1120-8 12 Nunes. Behavioral Rx, po naltrexone for opioid dependence. Am J Drug Alc Abuse. 2006;32(4):503-17 13 Fiellin. CBT in 1º care-based buprenorphine RCT. Am J Med. 2013;126(1):74.e11-7 14 Ling. Behavioral Rx in buprenorphine maintenance RCT. Addiction. 2013;108(10):1788-98 15 Galanter. Network therapy & buprenorphine maintenance. J Sub Abuse Treat. 2004;26(4):313-8 16 Copenhaver. Counseling, buprenorphine, opioid dependence. Am J Drug Alc Abuse. 2007;33(5):643-54 17 Orman. Buprenorphine-naloxone use in opioid dependence review. Drugs. 2009;69(5):577-607 18 Amato. Psychosocial + agonist v agonist in opioid dependence. Coch Database Syst Rev. 2011;(10) 19 Beaulieu. Managing comorbid mood, SUD. Ann Clin Psych. 2012;24(1):38-55 20 Baigent. Managing patients with dual Dx. Curr Opin Psych 2012;25(3):201-5

Doctors are like sadists

who like to play Godand watch lesser people

scream in pain. - Juno

• Anti-inflammatories 1-4

• Mono-amine reuptake inhibitors: TCA, SSRI, SNRI, Atypical 5,6

• Calcium channel modulators: Gabapentin, Pregabalin 7

• Sodium channel agents: Lidocaine, some anti-seizure meds 8,9

• NMDA receptor antagonists: Ketamine, Memantine, Methadone 10

• Skeletal muscle relaxants: Cyclobenzaprine, Metaxalone 11

• Cannabinoids (evidence limited) 12,13

• Opioids 14

• Medical foods: Diet, Glucosamine, a-lipoic acid, Theramine, Unsaponafiables 15-21

Chronic Intractable Pain TreatmentPharmacologic

1 Leppert. Corticosteroids in cancer pain. Curr Pain HA Rep. 2012;16(4):307-13 2 van der Goes. Glucocorticoid co-therapy for rheumatic diseases. Arth Res Ther. 2014;16 Suppl 2:S23 Reginster. European OA guide. OA Cartilage. 2015;23(12):2086-93 4 Bertolini. Acetaminophen. CNS Drug Rev. 2006;12(3-4):250-75 5 Dharmshaktu. Antidepressants as analgesics review. J Clin Pharmacol. 2012;52(1):6-17 6 Mika. Basis of antidepressants in chronic pain. Pharm Rep. 2013;65(6):1611-21 7 NICE: Neuropathic pain pharmacologic management guideline. 2013. Accessed 9/12/16

8 Casale. Topical Rx for localized neuropathic pain. Curr Pain HA Rep. 2017;21(3):159 Levinson. Na channels in chronic pain. Muscle Nerve. 2012;46(2):155-6510 Strong. NMDA receptor modulator patents. Expert Opin Ther Pat. 2014;24(12):1349-66 11 See. Choosing a skeletal muscle relaxant. Am Fam Phys. 2008;78(3):365-70 12 Whiting. Medical cannabinoids. JAMA. 2015;313(24):2456-7313 Metts. Medical MJ: Rx worth trying? J Fam Pract 2016;65(3):178-85 14 Kalso. Opioids in chronic nonCA pain. Pain. 2004;112(3):372-80

15 Castrogiovanni. Nutraceuticals in OA. Int J Mol Sci. 2016;17(12)16 Isasi. FM & non-celiac gluten sensitivity: remission. Rheum Int. 2014;34(11):1607-1217 Kapala. Pain reduction by diet in advanced cancer. Ann Agric Env Med. 2013;Spec no.1:18-2218 Henrotin. Chondroitin, glucosamine for OA Maturitas. 2014;78(3):184-7 19 Shell. Pain, inflammation reduction in chronic LBP with theramine. Am J Ther. 2016;23(6):e1353-e136229 Christiansen. Avocado/soybean unsaponifiables for OA. Cartilage. 2015;6(1):30-44 21 Mostacci. Nutraceuticals for neuropathy. Curr Drug Metab. 2017 Oct 31. [Epub]

Not Benzodiazepines

Chronic Intractable Pain TreatmentNon – Pharmacologic: Modalities

Self-directed after Training

• Sleep hygiene

• Weight management

• Physical activity / Exercise

• Traction / Splinting / Bracing

• Hydrotherapy / Thermal therapy

• Meditation Movement

• Biofeedback

• Meditation

• TENS

Professionally Directed

• Education

• Massage

• Ultrasound

• Physical therapy

• Osteomanipulation

• Mind - Body Therapy

• Pain Behavioral Therapy

• Transcranial Magnetic Stimulation

• Transcranial Electrical Stimulation

Chronic Intractable Pain TreatmentNon – Pharmacologic: Procedures

• Acupuncture

• Prolotherapy

• Low-level laser therapy

• Injections: Nerve blocks

• Injections: Trigger points

• Injections: Platelet Rich Plasma

• Injections: Joints (peripheral, facet)

• Injections: Epidural spine

• Radiofrequency ablation

• Radiotherapy (cancer)

• Stimulators

• Pain pumps

• Stem cells

• Surgeries

• History including prior medical records

• Physical examination

• Studies

• Diagnosis Might evolve

• Plan Does continuously evolve

Initial EvaluationPain and OUD

Goals↑ Function 30%

↓ Pain 30% ↓ Substance use

• History including prior medical records

• Physical examination

• Studies

• Diagnosis Might evolve

• Plan Does continuously evolve

Initial EvaluationPain and OUD

Skill development goals

Goals↑ Function 30%

↓ Pain 30% Abstinence or Harm reduction

Comprehensive: Biomedical, psychosocial, complementary health, spiritual care

Person-centered

Focuses on maximizing function and wellness

Care plans: Shared decision-making model Based on evidence regarding optimal clinical practice Based on person’s goals and values

1 Academy of Integrative Pain Management. Integrative Pain Care Policy Congress. 20172 Saitz. Chronic disease management for addiction. J Addict Med. 2008;2(2):55–653 Manchikanti. EBM, Part I: intro, general considerations. Pain Phys. 2008;11(2):161-864 MacAuley. Integration of EBM & personal care. Ir J Med Sci. 1996;165(4):289-915 Upshur. Meaning and measurement: model of health care evidence. J Eval Clin Pract. 2001;7(2):91-66 Hudson. Navigating evidence-based practice maze. J Nurs Manag. 2008;16(4):409-16 7 Nolan. Evidence-based practice implications, concerns. J Nurs Manag. 2008;16(4):388-93 8 Tonelli. The limits of evidence-based medicine. Respir Care. 2001;46(12):1435-409 Stamatakis. Undue industry influences in healthcare research, practice. Eur J Clin Invest. 2013;43(5):469-7510 Egnew. Suffering, meaning, healing: challenges of contemporary medicine. Ann Fam Med. 2009;7(2):170-511 Bell. Nonlinear dynamical models for complementary, alternative med. Forsch Komplementmed. 2012;19 Suppl 1:15-21

Integrated Care: Definition 1,2

Evidence Based Medicine 3-7

Personalized Medicine 8-11

Comprehensive: Biomedical, psychosocial, complementary health, spiritual care

Person-centered

Focuses on maximizing function and wellness

Care plans: Shared decision-making model Based on evidence regarding optimal clinical practice Based on person’s goals and values

1 Academy of Integrative Pain Management. Integrative Pain Care Policy Congress. 20172 Saitz. Chronic disease management for addiction. J Addict Med. 2008;2(2):55–653 Manchikanti. EBM, Part I: intro, general considerations. Pain Phys. 2008;11(2):161-864 MacAuley. Integration of EBM & personal care. Ir J Med Sci. 1996;165(4):289-915 Upshur. Meaning and measurement: model of health care evidence. J Eval Clin Pract. 2001;7(2):91-66 Hudson. Navigating evidence-based practice maze. J Nurs Manag. 2008;16(4):409-16 7 Nolan. Evidence-based practice implications, concerns. J Nurs Manag. 2008;16(4):388-93 8 Tonelli. The limits of evidence-based medicine. Respir Care. 2001;46(12):1435-409 Stamatakis. Undue industry influences in healthcare research, practice. Eur J Clin Invest. 2013;43(5):469-7510 Egnew. Suffering, meaning, healing: challenges of contemporary medicine. Ann Fam Med. 2009;7(2):170-511 Bell. Nonlinear dynamical models for complementary, alternative med. Forsch Komplementmed. 2012;19 Suppl 1:15-21

Integrated Care: Definition 1,2

Insuffic

ientEvidence Based Medicine 3-7

Personalized Medicine 8-11

• Overlapping care* 1

• Only referrals 2

• Only communication 2

• Only co-location 2

• Linear 1

• Quick 1

Integrated Care is Not …

1 Brian Standley. Personal communication2 Waxmonsky. Integrated Practice Assessment Tool. https://www.integration.samhsa.gov/operations-administration/IPAT_v_2.0_FINAL.pdf Accessed 1/3/18 3 Watkins. Collaborative care for OUD, AUD. JAMA Int Med. 2017;177(10):1480-8 4 Weisner. Integrating 1º medical care with addiction Rx. JAMA. 2001;286(14):1715-235 Willenbring. Integrated outpatient Rx for medically ill alcoholic men. Arch Int Med. 1999;159:1946-526 Samet. Benefits of linking 1º medical care and substance abuse services. Arch Int Med. 2001;161:85-91 7 Parthasarathy. Utilization, cost impact: integrating substance abuse Rx and 1º care. Med Care. 2003;41(3):357-67

*Providers each providingMedical care

On own

But …It is Effective 3-10

8 Oslin. Integrated care v enhanced specialty referral in at-risk alcohol use. Psych Servs. 2006;57(7):954-8 9 Donovan. Kaiser integrated pain management program. Permanente J. 2002;6(2):24-34 10 Flor. Efficacy of multidisciplinary pain Rx centers. Pain. 1992;49(2):221-30

• Does not exclude Overlapping Care

• Comprehensive + Continuity

• Communication which is Interactive

• Co-located with Equal Involvement of all providers

• Coordination and Collaboration

Integrated Care Features

1 Brian Standley. Personal communication2 Waxmonsky. Integrated Practice Assessment Tool. https://www.integration.samhsa.gov/operations-administration/IPAT_v_2.0_FINAL.pdf Accessed 1/3/18 3 Heath. Framework for levels of integrated healthcare. SAMSHA-HRSA Center for Integrated Health Solutions. 2013 4 Working Party Group. Integrating behavioral health into patient-centered medical home. Ann Fam Med. 2014;12(2):183-5

• Addiction medicine

• Pain management

• Medical pain management

• Pain intervention

• Surgery

• Psychiatry

OUD-Pain Integration Primary Disciplines

• Functional medicine

• Sleep medicine

• Addiction therapy

• Pain behavior therapy

• Mind-body practitioners

• Physical modalities

• Common diagnosis

• Common treatment goals

• Common treatment plan

• Common monitoring process

• Shared medical record with team-based notes

• Balanced resource allocation

Integrated Care FeaturesDirect Patient Care

1 Waxmonsky. Integrated Practice Assessment Tool. https://www.integration.samhsa.gov/operations-administration/IPAT_v_2.0_FINAL.pdf Accessed 1/3/18 2 Heath. Framework for levels of integrated healthcare. SAMSHA-HRSA Center for Integrated Health Solutions. 2013 3 Working Party Group. Integrating behavioral health into patient-centered medical home. Ann Fam Med. 2014;12(2):183-5

• Recovery Oriented

• Person Centered

• Trauma Informed

• Privacy Protected

• Destigmatized

Integrated Care Principles

1SAMHSA. Recovery Oriented Systems of Care. 2010. https://www.samhsa.gov/sites/default/files/rosc_resource_guide_book.pdf Accessed 1/3/18

2White. Definition of Recovery Oriented Systems of Care. http://www.williamwhitepapers.com/pr/CSAT%20ROSC%20Definition.pdf Accessed 1/3/18

3CDC. Adverse Childhood Experiences. https://www.cdc.gov/violenceprevention/acestudy/ Accessed 1/3/18

4SAMHSA. Trauma Informed Care in Behavioral Health Services.TIP-57. https://store.samhsa.gov/product/TIP-57-Trauma-Informed-Care-in-Behavioral-Health-Services/SMA14-4816 Accessed 1/3/18

5Dept Health & Human Services. HIPAA Privacy Rules. https://www.hhs.gov/hipaa/for-professionals/privacy/index.html Accessed 1/3/18

6Heath. Framework for levels of integrated healthcare. SAMSHA-HRSA Center for Integrated Health Solutions. 2013

7Working Party Group. Integrating behavioral health into patient-centered medical home. Ann Fam Med. 2014;12(2):183-5

• Strength-based self efficacy

• Community-based

• Significant-other participation

• Peer-involved

• Outcomes-based

Not your FaultIs your Responsibility

• Care Manager / Peer Recovery Coach

• Behavioral Health

• Prescribers

• Physical modality providers

• Trainees

Integrated Care FeaturesTeam Members

Equally Involved

1 Waxmonsky. Integrated Practice Assessment Tool. https://www.integration.samhsa.gov/operations-administration/IPAT_v_2.0_FINAL.pdf Accessed 1/3/18 2 Working Party Group. Integrating behavioral health into patient-centered medical home. Ann Fam Med. 2014;12(2):183-5

• Clinical summary / progress presented by primary provider → Problem list

• Goal review → Decision-making

• Safety monitoring review → Decision-making

• Treatment array review → Decision-making

• Medication, non-medication dose review → Decision-making

• Team-note documentation

Integrated Care FeaturesTeam Process

Implemented only uponshared decision-making

with the patient *

* Dependent upon1) New information at patient encounter 2) Necessity due to safety considerations

• Network with • Overlapping providers• Stakeholders

• Outcomes driven• Tracking mechanisms• Continuous process improvement

Integrated Care FeaturesClinical Setting

• Funding• Adequate • Flexible • Balanced resource allocation

1 White. Definition of Recovery Oriented Systems of Care. http://www.williamwhitepapers.com/pr/CSAT%20ROSC%20Definition.pdf Accessed 1/3/18 2 Working Party Group. Integrating behavioral health into patient-centered medical home. Ann Fam Med. 2014;12(2):183-5

ED buprenorphine initiation

Peer Coaches

• Referral

• Communication

• Collaboration

• Co-location

• Integration

Integrated Care - Where are You ?

Waxmonsky et al. Integrated Practice Assessment Toolhttps://www.integration.samhsa.gov/operations-administration/IPAT_v_2.0_FINAL.pdfAvailable on SAMHSA website Accessed 1/3/18

• Abuse → Non-medical use • Denial → Ambivalence

• Dirty urine → Inconsistent Clean urine → Consistent

• Aftercare → Continuing care • Recovered → Recovering

LanguageDifferences that Make a Difference

1 Botticelli. Changing the language of addiction. JAMA. 2016;316(13):1361-22 Kelly. Referring to individuals with substance-related conditions? Int J Drug Pol. 2010;21(3):202-73 Kelly. Substance-related terms & perceptions of Rx need? J Drug Issues. 2010;40(4):805-184 Broyles. Stigma & pejorative language in addiction. Sub Abuse. 2014;35(3):217-21 5 Kelly. (2016). Language, SUD, policy. Alc Treat Quart. 2016;34(1):116-23

6 Saitz. Statement recommending against terminology that can stigmatize. J Addict Med. 2016;10(1): 1-2 7 Betty Ford Institute Consensus Panel. What is recovery? J sub Abuse Treat. 2007;33:221-8 8 Savage. Definitions related to medical use of opioids. J Pain Symp Manage. 2003;26:655-679 Smith. Classification / definition of misuse, abuse, related events.. Pain. 2013;154(11):2287-9610 Newell. Patient-centered communication in hospital. JBI Data Syst Rev Implement Rep. 2015;13(1):76-87

Recovery Implies

Always awareGoal-directed action

Treatment and support as neededNever complete

• Relapse → Return to use

• Drug of choice → Drug of use

• Drug addict → Person with addiction

• Relapse prevention → Recovery management

• Dependence → Addiction → Substance use disorder

• Medication assisted treatment → Medication management

LanguageDifferences that Make a Difference

1 Botticelli. Changing the language of addiction. JAMA. 2016;316(13):1361-22 Kelly. Referring to individuals with substance-related conditions? Int J Drug Pol. 2010;21(3):202-73 Kelly. Substance-related terms & perceptions of Rx need? J Drug Issues. 2010;40(4):805-184 Broyles. Stigma & pejorative language in addiction. Sub Abuse. 2014;35(3):217-21 5 Kelly. (2016). Language, SUD, policy. Alc Treat Quart. 2016;34(1):116-23

6 Saitz. Statement recommending against terminology that can stigmatize. J Addict Med. 2016;10(1): 1-2 7 Betty Ford Institute Consensus Panel. What is recovery? J sub Abuse Treat. 2007;33:221-8 8 Savage. Definitions related to medical use of opioids. J Pain Symp Manage. 2003;26:655-679 Smith. Classification / definition of misuse, abuse, related events.. Pain. 2013;154(11):2287-9610 Newell. Patient-centered communication in hospital. JBI Data Syst Rev Implement Rep. 2015;13(1):76-87

• Thought self-regulation CBT, coping skills

• Emotion self-regulation Mindfulness meditation, coping skills

• Behavioral self-regulation Trigger management, social contexts

Strength - Based Language

“Come to Believe”

Return to UseNot a failure

when skill-buildingcontinues

Recovery – Related Terms

• Abstinence: No addiction-prone substance

• Sobriety: + Actively addressing problematic behaviors

• Recovery: + Developing a life with meaning, hope, and purpose

• Recovery Oriented Care: The complement of services intended to treat and support recovery

• Harm Reduction: Services intended to limit harm while active use continues

• Continuous Bias Adjustment• Be receptive to the team as a mirror• Incorporate reflected adjustments • Carry back to the patient encounter: New plan New skills

• Team does better than its parts• New / Forgotten approaches • Observing / Interpreting behavior • Observing / Responding to unintended consequences• Managing asymmetric disclosures• Managing splitting • Course correction

Collaborative Team – Management Skills

MaybeYou’reRight

Assessment: The 6 A’s 1,2

• Activity level (function)

• Abstinence

• Analgesia

• A ffect

• Adverse events

• Aberrancies

Follow – Up Patient Encounters

1 After Passik. Tool to assess, document pain outcomes in chronic pain patients receiving opioids. Clin Ther. 2004;26(4):552-61 2 Kirsch. 4 A's for ongoing monitoring. Medscape Neurol. 2005 Accessed 4/14/16

Follow – Up Patient Encounters

The Plan • Team-based plan adjusted by current circumstances • Pain plan• Addiction plan • Safety plan - Aberrancy management

• Shared decision-making

• Plan evolution • Adjusted for function, pain, aberrancies, craving• As goals met & disease intensity ↓

Primary TreatmentOften 1 year

Continuing CareIndefinite

Pain is realwhen you get other people

to believe in it

If no one believes in itpain is Madness

or HysteriaNaomi Wolfe

The Beauty Myth, 1990

sleighwright@gmail.com

SupplementalSlides

• HIPAA 42 C.F.R Part 2

• Center for Personalized Education for Physicians: courses

• Screening Brief Intervention Referral to Treatment (SBIRT): Health Teamworks Colorado

• Buprenorphine Treatment Practitioner Locator

• Opioid Treatment Program (methadone) Directory

• Depot Naltrexone Medical Provider Locator

• Narcotics Anonymous Alcoholics Anonymous Pills Anonymous

• SAMHSA: Knowledge Application Program (KAP)

• SAMHSA: Bringing Recovery Supports to Scale Technical Assistance Center Strategy (BRSS TACS)

• Providers Clinical Support System for Opioids (PCSS-O)

• Providers Clinical Support System for Medication Assisted Treatment (PCSS-MAT)

• Denver Harm Reduction Action Center

• Extension for Community Healthcare Outcomes (ECHO) Colorado: Chronic Pain Disease Management Program

• Extension for Community Healthcare Outcomes (ECHO) Colorado: Buprenorphine

Resources: Google Search

• Colorado SIM (State Innovation Model) HYBRID: Half online Half in-personhttp://www.practiceinnovationco.org/itmatttrs2/providers/

• Online Training • MDs, DOs, Residents 8 hours

• American Society of Addiction Medicine (ASAM) FREE https://elearning.asam.org/products/treatment-of-opioid-use-disorder-waiver-qualifying-it-matttrs

• American Academy of Addiction Psychiatry (AAAP) $196 non-members / $124 members https://www.aaap.org/education-training/buprenorphine/

• Providers' Clinical Support System for Medication Assisted Treatment (PCSS-MAT) FREEhttp://pcssmat.org/education-training/mat-waiver-training/

• PAs, NPs 24 hours• PCSS-MAT FREE http://pcssmat.org/education-training/mat-waiver-training/• ASAM FREE https://elearning.asam.org/products/nppa-24-hour-waiver-training-aapa

Resource: Buprenorphine Training