Methadone MaintenanceMethadone Maintenance

Opioid Addiction AssessmentOpioid Addiction Assessment

• Assess yourself and your team firstAssess yourself and your team first

You and Your ClinicYou and Your Clinic

• High Threshold vs Low ThresholdHigh Threshold vs Low Threshold

• High threshold says IV opioids for High threshold says IV opioids for yearsyears

• Low threshold says opioids affecting Low threshold says opioids affecting life function – accepts codeinelife function – accepts codeine

High Tolerance vs Low High Tolerance vs Low ToleranceTolerance

• High tolerance accepts many behaviour High tolerance accepts many behaviour problems and ongoing drug use, if some problems and ongoing drug use, if some stability is occurringstability is occurring

• Low tolerance has strict rules – may take Low tolerance has strict rules – may take you off for missed appointments, ongoing you off for missed appointments, ongoing marijuana or cocaine use, etcmarijuana or cocaine use, etc

• Carry policy and Urine Drug Screen PolicyCarry policy and Urine Drug Screen Policy

ComplexityComplexity

• SocialSocial

• MedicalMedical

• PsychiatricPsychiatric

• AdolescentAdolescent

• PregnantPregnant

• HIV and Hep CHIV and Hep C

• The unpleasant patientThe unpleasant patient

• Chronic painChronic pain

Clinic ComprehensivenessClinic Comprehensiveness

• Methadone onlyMethadone only

• Methadone and primary care (Accept Methadone and primary care (Accept stable patients after start elsewhere)stable patients after start elsewhere)

• Methadone, Contingency, Methadone, Contingency, CounsellingCounselling

• High level combined care – HIV, Hep High level combined care – HIV, Hep C, street outreach, pregnancy………C, street outreach, pregnancy………

MoneyMoney

• Clinics with government supportClinics with government support

• Clinics with fee for service – it doesn’t Clinics with fee for service – it doesn’t pay enough for the associated work pay enough for the associated work loadload

• Can you link with addiction programs?Can you link with addiction programs?

Goals of AssessmentGoals of Assessment

1. 1. Is the patient addicted to opioids?Is the patient addicted to opioids?

2.2. If so, is the patient a candidate for methadone?If so, is the patient a candidate for methadone?

3. 3. If so, does the patient want methadone?If so, does the patient want methadone?

4.4. If so, do you want this patient?If so, do you want this patient?

5.5. Identify other potential problems (housing, financial, Identify other potential problems (housing, financial, legal, family, travel)legal, family, travel)

6.6. Any special health risks?Any special health risks?

The Invisible AssessmentThe Invisible Assessment

• Therapeutic Alliance begins here.Therapeutic Alliance begins here.

• You evaluate the patient for honesty, humor, You evaluate the patient for honesty, humor, intelligence, perseverance…..dishonesty, intelligence, perseverance…..dishonesty, anger, criminalityanger, criminality

• The patient evaluates you - frankness, The patient evaluates you - frankness, kindness, trust, confidentiality, do you know kindness, trust, confidentiality, do you know addiction?addiction?

Setting the Stage for Setting the Stage for SuccessSuccess• Honesty and franknessHonesty and frankness

• Accepting of where they’re at – with hope Accepting of where they’re at – with hope for change – environment of supportfor change – environment of support

• Safety talkSafety talk

• Early limit settingEarly limit setting

AssessmentAssessment

• Social – who are they as a person? Social – who are they as a person? Who are their supports? Housing? Who are their supports? Housing? Other family members or close friends Other family members or close friends on opioids or unstable? Legal? on opioids or unstable? Legal? Financial? Kids?Financial? Kids?

• Income? Dealing, stealing, peeling?Income? Dealing, stealing, peeling?

• Behavioural addictions?Behavioural addictions?

• Goals in lifeGoals in life

Substance UseSubstance Use

• Identify past or present significant Identify past or present significant problems – do any need to be part of problems – do any need to be part of a care plan?a care plan?

• Crack, Cocaine. Crystal meth, OTC’s, Crack, Cocaine. Crystal meth, OTC’s, Alcohol, Benzo’sAlcohol, Benzo’s

• Is cocaine the major drug and opioids Is cocaine the major drug and opioids a side issue?a side issue?

OpioidsOpioids

• How and when did it begin? What effect How and when did it begin? What effect did they feel? How long have they had did they feel? How long have they had daily or near-daily use? What happens daily or near-daily use? What happens when they try to quit? What’s their drug when they try to quit? What’s their drug of choice and what’s their dose range? Any of choice and what’s their dose range? Any high risk use of other opioids? (Tyl 1’s. IV high risk use of other opioids? (Tyl 1’s. IV use, fentanyl, street methadone)use, fentanyl, street methadone)

• Evaluating addiction vs abuseEvaluating addiction vs abuse• Evaluating addiction vs painEvaluating addiction vs pain• Street or Prescription? Who’s the doctor?Street or Prescription? Who’s the doctor?

• If it’s opioid addiction, continueIf it’s opioid addiction, continue

• If it’s not, follow another trackIf it’s not, follow another track

GusGus

• Alcoholic, sober for 15 years and Alcoholic, sober for 15 years and very active in AAvery active in AA

• At 48, suffers relationship break-up At 48, suffers relationship break-up and failure of business – rapid and failure of business – rapid decline into IV cocaine and IV opioidsdecline into IV cocaine and IV opioids

• After assessment, the cocaine After assessment, the cocaine appears to be the main driver, and appears to be the main driver, and the opioids are a “smoothing” or the opioids are a “smoothing” or “crash rescue” use“crash rescue” use

Significant Chronic PainSignificant Chronic Pain

• Avoid these complex patients until Avoid these complex patients until you are experiencedyou are experienced

• And then you’ll still have trouble! And then you’ll still have trouble!

Other BasicsOther Basics

• Medical history, risk of HIV & Hep C, Medical history, risk of HIV & Hep C, pregnancypregnancy

• Psychiatric history – suicide risk, past Psychiatric history – suicide risk, past trauma, Bipolar, ADD, eating trauma, Bipolar, ADD, eating disorderdisorder

• SmokingSmoking

DPINDPIN

• Check it – look for non-compliance, Check it – look for non-compliance, consistency with history, early refills consistency with history, early refills (which indicate physician behaviour (which indicate physician behaviour as well as patient behaviour)as well as patient behaviour)

• Notify physiciansNotify physicians

• Explore taking over benzo Explore taking over benzo prescribingprescribing

Physical ExamPhysical Exam

• BasicsBasics

• Infected injection sitesInfected injection sites

• Pregnancy, need for birth controlPregnancy, need for birth control

Urine Drug ScreenUrine Drug Screen

• Is it consistent with history?Is it consistent with history?

• A non-addicted patient can take some A non-addicted patient can take some percs or T 3’s to have a positive screenpercs or T 3’s to have a positive screen

• Synthetics (oxycodone, fentanyl) may Synthetics (oxycodone, fentanyl) may not show – know your screennot show – know your screen

• Some patients have negative drug Some patients have negative drug screens but are addicted and need screens but are addicted and need treatmenttreatment

CollateralCollateral

• Very useful in difficult casesVery useful in difficult cases

Are These a Problem?Are These a Problem?

• TransportationTransportation

• Lives out of townLives out of town

• Paying for medicationPaying for medication

• Driving and sedationDriving and sedation

• Unsafe housing (no Sat or Sun carries)Unsafe housing (no Sat or Sun carries)

• Clinic hours vs work and schoolClinic hours vs work and school

• Addicted family membersAddicted family members

Assessment Is DoneAssessment Is Done

• Is the patient addicted to opioids?Is the patient addicted to opioids?• ASAM – loss of control, craving, ASAM – loss of control, craving,

compulsion, consequences and compulsion, consequences and can’t stopcan’t stop

• DSM 4 – tolerance, withdrawal, time DSM 4 – tolerance, withdrawal, time spent obtaining, loss of other spent obtaining, loss of other interests, consequences, interests, consequences, preoccupation and planningpreoccupation and planning

Yes, He’s AddictedYes, He’s Addicted

• Is he appropriate for methadone?Is he appropriate for methadone?

• Depends on your provincial guidelines and Depends on your provincial guidelines and your clinic guidelines….in Manitoba, your clinic guidelines….in Manitoba, addicted for one year with significant life addicted for one year with significant life consequencesconsequences

• Pregnant patients and medically ill patients Pregnant patients and medically ill patients do not need the “one year” requirementdo not need the “one year” requirement

What Does the Patient Want, What Does the Patient Want, How Does He Perceive the How Does He Perceive the Problem?Problem?• Does he think he ‘s addicted? Does he think he ‘s addicted? • Does he think it’s a serious problem that Does he think it’s a serious problem that

needs organized help and real work?needs organized help and real work?• Does he want to keep it a secret from all?Does he want to keep it a secret from all?• Is he totally focused on only one kind of Is he totally focused on only one kind of

treatment – “I only need detox” or “It has treatment – “I only need detox” or “It has to be methadone”to be methadone”

• Has he learned from friends’ experience?Has he learned from friends’ experience?

Choices in Opioid AddictionChoices in Opioid Addiction

• 1. Continue using1. Continue using

• 2. Abstinence (detox plus treatment)2. Abstinence (detox plus treatment)

• 3. Methadone with goal of taper3. Methadone with goal of taper

• 4. Methadone as long term medication4. Methadone as long term medication

• 5. Suboxone5. Suboxone

• 6. Chronic pain - perhaps tightly 6. Chronic pain - perhaps tightly controlled opioid dispensing or methadonecontrolled opioid dispensing or methadone

SuboxoneSuboxone

• Many advantages – safer, better side effect Many advantages – safer, better side effect profile, easier to wean off, better with HIV profile, easier to wean off, better with HIV medsmeds

• Expensive ($500 a month) – might get it Expensive ($500 a month) – might get it coveredcovered

• Once you have your methadone exemption, do Once you have your methadone exemption, do the internet course and apply to the College the internet course and apply to the College (www.suboxonecme.ca)(www.suboxonecme.ca)

ChoicesChoices

• 1. continue using1. continue using

• 2. abstinence2. abstinence

• 3. methadone/suboxone3. methadone/suboxone

You Think His Choice is You Think His Choice is Crazy!Crazy!• Who decides? Will you help him into Who decides? Will you help him into

abstinence based treatment even though abstinence based treatment even though you’re sure he needs the long term you’re sure he needs the long term stability of methadone?stability of methadone?

• What about the nice guy who looks What about the nice guy who looks normal, is working, has money – you think normal, is working, has money – you think he should try abstinence, he wants MMT?he should try abstinence, he wants MMT?

• Or the guy who knows detox alone will Or the guy who knows detox alone will cure him?cure him?

Try Abstinence First?Try Abstinence First?

• Old thinking – yesOld thinking – yes

• New thinking – MMT is reasonable New thinking – MMT is reasonable first option in patient with significant first option in patient with significant addiction who wants this option – but addiction who wants this option – but know your provincial guidelinesknow your provincial guidelines

• MMT is option of choice in patients MMT is option of choice in patients with major life instabilitywith major life instability

Consider AbstinenceConsider Abstinence

• Relative Stability Relative Stability

• healthy, psychiatric stabilityhealthy, psychiatric stability

• supports with sober family and friends supports with sober family and friends and finances and finances

• not addicted very longnot addicted very long

• interested in “recovery” work and AA, NAinterested in “recovery” work and AA, NA

• no polysubstance abuse or alcoholismno polysubstance abuse or alcoholism

• honestyhonesty

Abstinence ChoicesAbstinence Choices

• Know your resourcesKnow your resources• Detox alone is not a good option – Detox alone is not a good option –

follow it with treatment unless patient follow it with treatment unless patient refusesrefuses

• Plan for real support - rarely Plan for real support - rarely successful on the first trysuccessful on the first try

• Family and patient may be very Family and patient may be very demoralized by failuredemoralized by failure

• Risk of death higher in abstinenceRisk of death higher in abstinence

Methadone in the “nice Methadone in the “nice patient”?patient”?

• Fairly stable, healthy, appears Fairly stable, healthy, appears “together”. Using 1-2 years“together”. Using 1-2 years

• Financial strain and can’t stopFinancial strain and can’t stop

• ?reasonable for methadone ?reasonable for methadone

• Discuss all options fully, time to thinkDiscuss all options fully, time to think

Consider MethadoneConsider Methadone

1.1. Psychiatric instabilityPsychiatric instability2.2. Physical health consequencesPhysical health consequences, HIV, HIV3.3. PregnancyPregnancy4.4. Chronic painChronic pain5.5. Unstable family, addicted relativesUnstable family, addicted relatives6.6. Polysubstance abusePolysubstance abuse7.7. Social and legal and financial stressorsSocial and legal and financial stressors8.8. Failed abstinence attemptsFailed abstinence attempts9.9. Addicted for significant length of time (18 Addicted for significant length of time (18

months)months)10.10.Injection UseInjection Use

Does the Patient Want Does the Patient Want MMT?MMT?• DiscussDiscuss

• Reading materialReading material

• Time to decideTime to decide

• Informed consentInformed consent

• Knowledge of tight program rulesKnowledge of tight program rules

• Knowledge of long-term program, may Knowledge of long-term program, may not be able to ever stop using opioidsnot be able to ever stop using opioids

FamilyFamily

• ““I get sick to my stomach just I get sick to my stomach just hearing the word methadone”hearing the word methadone”

• ““His uncle is a doctor who says His uncle is a doctor who says methadone is totally inappropriate``methadone is totally inappropriate``

• ``We want him to …….````We want him to …….``

• The patient has the right to decide The patient has the right to decide but it’s hard without family back up.but it’s hard without family back up.

Yes, he wants it….Yes, he wants it….

• Clinic rules and treatment agreementClinic rules and treatment agreement

• Safety considerationsSafety considerations

• Notify prescribers and pharmacyNotify prescribers and pharmacy

• Go!Go!

Rules to Live ByRules to Live By

• Be able to care and to say noBe able to care and to say no• Safety always trumps other considerationsSafety always trumps other considerations• Trust is earned, not givenTrust is earned, not given• The patient who lies sounds just like the The patient who lies sounds just like the

patient who is telling the truthpatient who is telling the truth• An ongoing relationship becomes the most An ongoing relationship becomes the most

important therapeutic toolimportant therapeutic tool• Remember how disordered some families Remember how disordered some families

may bemay be

Methadone TaperMethadone Taper

• Placed the patient on methadone Placed the patient on methadone with goal of stabilization and taper with goal of stabilization and taper over few weeks or months – where over few weeks or months – where will the emotional growth and will the emotional growth and recovery treatment occur?recovery treatment occur?

• Can treat relapse as a learning Can treat relapse as a learning experience and try again with more experience and try again with more supportssupports

PracticalitiesPracticalities

• How many people here are How many people here are considering working in a setting considering working in a setting providing methadone services………..providing methadone services………..

• ?doctors?doctors

• ?pharmacists?pharmacists

• ?nurses and social workers and ?nurses and social workers and counsellorscounsellors

How to Get an Exemption for How to Get an Exemption for MMTMMT• Methadone for pain – separate processMethadone for pain – separate process

• Methadone for addictionMethadone for addiction• - addiction experience- addiction experience• - knowledge of methadone & - knowledge of methadone & safetysafety• - book learning- book learning• -practical learning at clinic – assessments -practical learning at clinic – assessments

and follow-upsand follow-ups• -find a mentor-find a mentor

A Methadone ExemptionA Methadone Exemption

• Ask College advice re your suitabilityAsk College advice re your suitability

• Take a course – 1 day in Winnipeg June 2010Take a course – 1 day in Winnipeg June 2010

• Clinical experienceClinical experience

• Submit documentation to the CollegeSubmit documentation to the College

• 1-4 months later, Health Canada provides 1-4 months later, Health Canada provides exemption and you can start MMT prescribingexemption and you can start MMT prescribing

• Enjoy working – minimal wage – major stress – Enjoy working – minimal wage – major stress – major patient change!major patient change!

Clinical ExperienceClinical Experience

• Minimum of 4 half day clinics, with Minimum of 4 half day clinics, with experienced supervising physician experienced supervising physician who assesses you for appropriate who assesses you for appropriate knowledge, attitudes, skillsknowledge, attitudes, skills

• More experience if you want to open More experience if you want to open a new clinic or operate soloa new clinic or operate solo

Styles of PracticeStyles of Practice

• Full clinic - assessments, link with Full clinic - assessments, link with other addiction care, treat and other addiction care, treat and follow, manage more complex follow, manage more complex problemsproblems

• Family practice – follow 10-20 Family practice – follow 10-20 relatively stable patients who started relatively stable patients who started treatment in a full clinictreatment in a full clinic

Methadone SafetyMethadone Safety

• 1-3 per thousand patients die, 1-3 per thousand patients die, usually during inductionusually during induction

• Family and friends may be unstable Family and friends may be unstable and have access to the methadoneand have access to the methadone

• Diversion occurs - to people in Diversion occurs - to people in withdrawal and to people who want withdrawal and to people who want to experimentto experiment

• It has strange pharmacologyIt has strange pharmacology

Build in review and Build in review and mentoringmentoring• Your team – doctor, nurse, counsellor, Your team – doctor, nurse, counsellor,

pharmacist – are protocols needed?pharmacist – are protocols needed?

• Your back up - questions, chart reviews, Your back up - questions, chart reviews, ongoing educationongoing education

• Review bad outcomes and learn from themReview bad outcomes and learn from them

• Remember long term addiction needs a lot Remember long term addiction needs a lot of time to change behavioural of time to change behavioural characteristics – deception and manipulation characteristics – deception and manipulation and distrust have been survival traitsand distrust have been survival traits

Be Prepared for Change and Be Prepared for Change and SurprisesSurprises

Financial and CME supportFinancial and CME support

• CME can make this a self learning CME can make this a self learning experience for significant CME experience for significant CME credits – contact Dr Francoiscredits – contact Dr Francois

• Manitoba government will support Manitoba government will support some clinical training time if your some clinical training time if your RHA or Clinic not compensating you. RHA or Clinic not compensating you. Contact Dr. LeeContact Dr. Lee

BooksBooks

• Client guide to methadone Client guide to methadone maintenancemaintenance

• AFM recommended practices in MMTAFM recommended practices in MMT

• Ontario guidelines – for doctorsOntario guidelines – for doctors

- for counsellors- for counsellors

A Side Issue - Safe A Side Issue - Safe Prescribing…Prescribing…

Opioids and Chronic Pain Opioids and Chronic Pain ToolkitToolkit• Summary of the new guidelinesSummary of the new guidelines

• The opioid managerThe opioid manager

• Tool sheets –Opioid taperTool sheets –Opioid taper

• -Benzo taper-Benzo taper

• -Opioid equivalence chart-Opioid equivalence chart

• -Opioid Risk Tool-Opioid Risk Tool

• -Urine drug screening-Urine drug screening

• -Treatment Agreement-Treatment Agreement