Recovery from

Opioid Dependence

Building Trust,

Building Bridges

Presentation Outline

Recovery from Opioid Dependence• OST Information Sessions• OST Support Group

Building Trust, Building Bridges• Our Program Framework• OST Clinic Collaborations

OSTOpioid Substitution TherapyMethadone and Buprenorphine/Naloxone

A Health System Strategy

The estimated social, economic and health costs for Ontario resulting from untreated opioid misuse exceeds $1B

Principles of COAP

Program Overview• Improve health and social outcomes and quality of life for

people living with opioid addictions• Priority populations include:

• People living with HIV/AIDS and/or Hepatitis C• Women who are pregnant and/or parenting• Youth (12+)

• Increase access to opioid addiction treatment and primary health care

• Improve linkages between community programs• Reduce involvement with criminal justice system

Community Opioid Addiction Program (COAP)

Direct Client Services• Screening, assessment, treatment planning, counselling,

and case management• Ability to meet in the community (e.g. health care centres,

Methadone and Suboxone clinics, hospitals, shelters)

Community Education Services• Increase knowledge and awareness about opioid addiction

and Opioid Substitution Therapies (OST)• Presentations, educational events, consultation services

Recovery from

Opioid Dependence

Client Engagement Focus Groups

Purpose• To gather first-hand knowledge in order to better

understand the following:• The lived experience of individuals using opioids or on Opioid

Substitution Therapy (OST) across Thames Valley Region (London, Middlesex, Elgin and Oxford Counties);

• The ways in which individuals learn about, understand and access OST;

• The barriers related to accessing treatment or support for opioid addiction;

• How and if individuals are accessing other supportive community services;

• The current gaps in service for opioid users and/or those on OST

Client Engagement Focus Groups

Key Findings• Lack of knowledge about Methadone and Suboxone• Counselling support is integral to helping understand the

substitution therapy process and be successful• Making the decision to taper should be a personal choice• People abusing opioids often want help, but want help to

come to them• Lack of options when you don’t want Opioid Substitution

Therapy

Individual Counselling: Common Themes

• First exposure to opioids often obtained through legal prescription from physician

• Prescription discontinued due to misuse • Opioid use for pain management purposes• Continued use to manage and/or avoid withdrawal

symptoms• Prescribed OST but supplementing with illegal opioids to

avoid an increase in dosage• Readiness to taper off OST• Not fully aware of all treatment options and potential

impacts and/or side effects of OST

Unique Needs of the Population

• Stigma of OST• What is abstaining? • Is OST treatment considered an addiction?

• Chronic Pain• Narcotics Anonymous• Side effects and how to manage• Advocacy with doctors and pharmacists • Women Specific Services

• Not enough research for women’s issues (e.g. OST effects on women, estrogen levels)

Two Groups: To Meet the Needs

OST Information Session• Address the lack of knowledge about Methadone/

Suboxone• Provide treatment alternatives• Empower individuals to make informed decisions

OST Support Group• Evidenced-based practice that OST combined with

counselling is important for a successful recovery • Group members in various stages of change• Shared experiences and common themes

OST Information Session

Educational group for people contemplating OST and/or on OST, family members, and service providers

OST Information Session

Outline of the group:• Information about Opioids• What is Opioid Substitution Therapy? • Benefits and Drawbacks• Things to Consider with OST• Mixing OST with Other Substances• Overdose• Resources

What is Opioid Substitution Therapy?

Other Full Agonists include:MethadoneFentanylPercocetDilaudid

Buprenorphine + Naloxone = Suboxone

OST: Methadone and Suboxone

Opioid Substitution Therapy: Benefits

• Manages withdrawal symptoms and cravings• Stabilize mood (clear thinking)• Improved access to health care• Reduce use of illegal opioids and other substances• Reduce injecting• Harm reduction• Not “chasing the high” all day• Pain reliever• More energy, better sleep and health• Improved family relations and/or parenting ability• Overall increase in quality of life

Opioid Substitution Therapy: Drawbacks

• Impact on Daily Routine• Daily visits to a clinic• Eligibility criteria• Still opioid dependent• Stigma• Increased risk of overdose

(methadone)**• Travel can be more difficult• Frequent urine testing• Physical Side Effects:

• Nausea and Vomiting• Drowsiness• Diarrhea or Constipation• Excessive Sweating

• Decrease in Sex Drive and Hormonal Impact for Men and Women

• Oral Health Concerns

OST Info Session: Successes

• Creating a safe space to address questions and concerns about OST

• Un-biased presentation• Allows individuals to make informed treatment

choice/decision• Building capacity of service providers• Providing well-researched information from the MMT

guidelines and CPSO• Resolve ambivalence

OST Info Session: Challenges

• Lots of information to cover in a short period of time

• Attendance issues – not reaching the populations who would benefit from this material • Taking it “on the road”!

OST Info Session: Feedback

• From clients:• Information presented has been useful in helping them make a

decision to start OST• Information has helped them feel confident in their decision to

choose OST as a treatment option• From family members:

• More likely to suggest OST to someone• Consider OST if unable to go “cold turkey” from opioids

• From service providers:• Information presented will help them better support their clients on

OST• Feel better informed about OST and where clients can access

these treatments

OST Support Group

10 week psycho-educational & support group for people on OST

OST Support Group

Topics1. OST and Me

2. Strength Through Stigma

3. Personalizing Your Treatment

4. Lifestyle and OST

5. OST Side Effects

6. Pain Management and Types of Pain

7. Safe Coping Skills

8. Working with Worries

9. Healthy Relationships

10. Beyond OST: Progressing Through Recovery

Sample : Week 1 OST and Me• Open group• Session length: 1 hour 45 minutes• Check In• Topics

• Introduction• Decisional Balancing Exercise• Life Inventory Scale• My Goals• What does Success Look Like on OST?

One thing I learned today…“Other people feel the same way I do about some things”

“How important it is to take care of yourself, body, mind, emotions, spiritual”.

“Search for other options to deal with pain besides prescription drugs”

OST Support Group: Benefits

• Unique: • No other similar groups• Specialized focus results in high affinity• Safe, non-judgemental, supportive environment

• Variety of participants on methadone and Suboxone and in various stages of change

• Share what works and what does not work about OST• Helps reduce stigma of OST• Group facilitators at the Suboxone clinic – wrap around

and client engagement

OST Support Group: Challenges

Challenges:• Group dynamics• Stigma conversations and over-generalizations • Remind participants it is not a race to get off OST – can

stall progression in treatment

Areas to Improve:• Increased referrals to OST information session• Offer more women-specific information, especially around

side effects• More visual aids (e.g. videos)• Promoting/informing patients at the clinics

OST Support Group: What Clients Say

One new thing I learned today is…

• “I walk away from today reminded that I should remain patient”

• “Being informed is key”• “That I am at a good place in my recovery”• “The power stigma can have on others”• “Compassion for self is the beginning of compassion for

others”• “To look for the positives in OST”

OST Support Group: What Clients Say

Because of today’s session I am going to do or try…

• “Don’t be afraid to try new things and do as much positive thinking as I can”

• “Inspire yourself, carry something positive”• “To keep on the right track so I don’t have pain”• “Set a goal based on positive things”• “To maintain an honest program with myself”• “To relax while remaining concerned and caring”• “I need to start asking my MMT doctor more questions”• “Apply the knowledge I learned in this group to my life”

Building Trust,

Building Bridges

COAP Clinic Collaborations

• Through service delivery partnership, increase capacity for : • client engagement and retention for both ADSTV and OST clinics

• ease of access to OST

• meeting individual client needs

• consultation between ADSTV and OST/health care providers in our community

• being responsive to the relapsing nature of opioid/substance use

COAP Clinic Collaborations

Thomas Street Treatment Clinic, Strathroy, ON• Located in rural SW Ontario• Serves Strathroy and surrounding area • Serves 60 patients• Must be a clinic patient to access counselling onsite• Two physicians, Two administrative staff

Dr. Lee Suboxone Clinic, London, ON• Located at CMHA and operates out of same location as medical clinic• Serves London population• Serves 24 patients and increasing• Must be a clinic patient to access counsellors onsite• One physician, one admin staff

COAP Clinic Collaborations: Our Doctors

• Dr. Ken Lee: • Suboxone Clinic, London ON

• Dr. Janel Gracey: • Thomas Street Treatment Clinic, Strathroy

• Dr. Tom McDonagh: • Thomas Street Treatment Clinic, Strathroy

COAP Clinic Collaborations: Service Profile

Thomas Street Treatment Clinic, Strathroy, ON• One counsellor, onsite twice a week• Clients required to meet with COAP counsellor at least once• Full individual community treatment services onsite• COAP Staff does not perform clinic duties

Dr. Lee Suboxone Clinic, London, ON• 2 counsellors, onsite once a week• Clients required to meet with COAP counsellor at least once• Limited individual community treatment onsite, depending on

availability• COAP staff perform clinic duties: intake, screening and urine drug

screening (UDS)

COAP Clinic Collaborations: Client Engagement• Strong referral paradigm

• Rate of referral: 100% for both clinics• Normative: in-house pairing• Immediacy and Primacy

• Warm Referrals• Timely • Promotes Therapeutic Rapport• Ease of Access• Low Attrition Rates ? • Point of access for addressing Concurrent Disorders and

Comorbidity• Best Practice

COAP Clinic Collaborations: Meeting Client Need• Flexibility for meeting special needs• Able to respond to crisis in the moment• Ease of Access/ Service Flexibility • Counselling with specialized knowledge of OST• Client engagement at earlier stage of change, rapport

building, knowledge building• Responsive to individual goals/poly substance use/Mental

Health• Increased client knowledge/access to all community

resources

COAP Clinic Collaborations: Consultation

Consultation with Other Service Providers

• Increases capacity of COAP Addiction/Mental Health Counsellors

• Increases linkages with Pharmacies/hospital

• Potential to link COAP program to innovative projects

COAP Clinic Collaborations: Ability to be Responsive to Relapse• Client education

• Learning about lapses

• Overdose Education and Naloxone Training referrals

• Resolving ambivalence/increasing skills• Promoting OST retention

COAP Clinic Collaborations: Dr. LeeRationale for Collaboration:“For various reasons, patients have a tendency to not attend referrals for counselling.   With counsellors on site, it eases the anxiety of having to make contact with a new agency and then meet a new person.   The patients are very comfortable with the on-site staff and this facilitates their attendance at booked 1:1 sessions, or even group work.”

Benefits:

“There is a noticeable improvement in how quickly patients become abstinent from opiate use -versus at the other clinic that I work where it seems to take longer to achieve abstinence.”

COAP Clinic Collaborations: Dr. Gracey

Rationale for Collaboration:“The recovery process is more than just medication. Counselling helps to address the underlying issues and give alternatives to chemical coping.”

Benefits:“Timing is key. It’s better to have counselling in house. It’s more accessible, less intimidating and people are more likely to attend when it feels familiar. You have to get them while they are ready.”

Dr. Janel Gracey

COAP Clinic Collaborations: Dr. McDonagh

Rationale for Collaboration:“The treatment of addiction requires a multifaceted approach. Pharmacological treatment alone, doesn’t work”

Benefits:“Having counselling in house shows greater interest in the patient and reinforces the common goal of recovery. It encourages people to come back and slow down their service encounter. It’s a win, win, win situation.”

Dr. Tom McDonagh

Client Story• BB is a longstanding client of the agency with multiple physical and mental

health concerns

• BB experienced a recent relapse and sought Drop In support at ADSTV

• COAP staff met with BB, provided OST education and set up a referral to the Suboxone Clinic.

• BB attended the clinic for induction to Suboxone, but was hospitalized the next day due to an infection from injecting.

• Dr. Lee was able to see BB at the hospital, to check in on BB’s status and provide a Suboxone script.

• After discharge, BB returned to the clinic and received a physical health follow up.

• BB expressed overwhelming satisfaction with the process

• BB reported feeling supported and appreciated seeing the same people from place to place, having that warm transfer and personal follow up. 

COAP Clinic Collaborations: Challenges

• Adhering to routine, scheduled appointments• Balancing respect for self determination with engagement

strategies• Space and Time constraints

• limits service delivery• Confidentiality considerations between clients and clinic• Role of advocacy/redirecting triangulation • Stigma

COAP Clinic Collaborations: Challenges

Urine Drug Screening & The Therapeutic Alliance• No clear negative impacts• Possible benefit:

• Full disclosure of substance use with counsellor• Allows for counsellor to deliver more comprehensive service

• Clinical Considerations• Normalize and separate UDS and counselling• Provide client with full disclosure of dual role at time of intake• Invite questions and provide reassurances of confidentiality and

self determination• Establish clear consent to discuss UDS results in counselling

and/or in front of clinic doctor

COAP Clinic Collaborations: Challenges

Readiness• Readiness for OST

does not automatically indicate readiness for counselling

10% Addiction

90% Underlying

Issues

ExcitementTrauma (past/present)

Mental HealthChronic Pain

LossGrief

HomelessnessPovertyShameGuilt

StressLonelinessBoredom…

The behaviour of

using

COAP Clinic Collaborations: Insights

• Time to stopping opiate use seems to be faster than traditional Methadone/Suboxone clinic settings.

• Mandatory initial consult good practice• Stigma is pervasive- address at individual and systemic

level• Clear communication about confidentiality is key• Complaints of chronic pain common- challenging to

address substance use problem and chronic pain • Robust communication between counselor and clinic

benefits the counselor, clinic and client

Questions/Comments/Discussion