META PHI in Primary Care Implementing Best Practices
META: PHI in Primary Care: Implementing Best Practices for Addictions Brief Counselling for Patients with Substance Use Disorders
What is META: PHI? • Mentoring, Education, and Clinical Tools for Addiction: Primary Care–Hospital Integration • Collaborative project to implement integrated care pathways for addiction throughout Ontario • Partnership between hospitals, withdrawal management services, FHTs, CHCs, and community agencies • Goals: 1. Improve care for patients with addictions 2. Improve care provider experience 3. Improve population health 4. Reduce service use 5. Provide sustainable care 2
How it works • Patients presenting with addiction-related concerns receive evidence-based interventions and are referred to rapid access addiction medicine (RAAM) clinics for treatment • RAAM clinics offer substance use disorder treatment on walk -in basis; no formal referral/appointment needed • Patients stabilized at RAAM clinic referred back to primary care for long-term addiction treatment (with ongoing support from RAAM clinic as required) • Key components: • Integration of care at hospital, RAAM clinic, primary care • Training, support, and mentorship from addictions specialists • Capacity-building 3
Role of PCPs With support from META: PHI team: • Follow best practices for prescribing opioids • Screen and diagnose patients for substance use disorders • Refer patients to treatment at RAAM clinic when necessary • Assume long-term addiction care for patients from RAAM clinic (with ongoing support from RAAM clinic doctor) 4
EXPLAINING A SUBSTANCE USE DISORDER DIAGNOSIS 5
Substance use and the brain (1) • When an essential activity for survival is performed (e. g. , eating, sex), dopamine is released from the reward centre of the brain • Dopamine makes us feel good, so we are motivated to repeat the activity • Alcohol and drugs also cause a dopamine release, even stronger than the one associated with survival activities • This is what reinforces people’s substance use 6
Substance use and the brain (2) • Almost everyone has this reaction to drugs/alcohol to some degree, but some people are more affected by it than others • There a few different reasons for this: • Some people with a strong family history of addiction react to alcohol/drugs differently: They get more pleasure out of it, have increased tolerance, and experience fewer deterrents (e. g. , hangovers) • People may start using alcohol or drugs as a way to cope with traumatic things that happened to them in childhood • People with a mood disorder (like anxiety or depression) may use alcohol/drugs to temporarily help them feel better 7
What is a substance use disorder? • People with a substance use disorder usually have the following four traits: 1. They cannot control their substance use 2. They continue to use substances despite knowing it is harmful 3. They spend a lot of time using substances 4. They have powerful urges or cravings to use • Substance use disorders have nothing to do with character, will power, or morals • It is a chronic condition that affects a person’s brain, body, and life 8
Fault vs. responsibility • Important to emphasize that it is not the patient’s fault that they have a substance use disorder • However, it is their responsibility to get treatment 9
EXPLAINING TREATMENT OPTIONS 10
Patient concern: Treatment “Shouldn’t I be able to stop using on my own? ” • Successful recovery from a substance use disorder requires treatment • Substance use disorders are no different from other chronic illnesses like diabetes and depression: they are very hard for patients to manage on their own • Effective treatment is available! 11
Treatment options • Treatment for a substance use disorder can involve many different elements • Pharmacotherapy • Psychosocial treatment • Peer support • Self-help • A treatment plan can be made up of any or all of these elements 12
Pharmacotherapy • There are medications that help relieve physical need to use • For opioid use disorders: buprenorphine/naloxone, methadone • For alcohol use disorders: naltrexone, acamprosate, gabapentin • There also aversive medications • Disulfiram helps people stop drinking by causing a toxic reaction to alcohol • This kind of medication is best for people with a supportive partner who can make sure they take it every day 13
Patient concern: Pharmacotherapy (1) “Isn’t pharmacotherapy cheating? ” • Absolutely not! • Cravings are partly biological, with physical symptoms • They can be torturous for people who are trying to recover • These medications can ease those cravings and relieve physical distress, allowing people to focus on their recovery 14
Patient concern: Pharmacotherapy (2) “Doesn’t this just substitute one addiction for another? ” • No! • While patients can be on these medications as long as they need to, most do not need to be on them for life • Medications for alcohol use disorders are non-addictive; they can be stopped when the patient wishes • Buprenorphine/naloxone and methadone work differently from other opioids • Last for 24 hours • In the right dose, they do not cause sedation or euphoria 15
Psychosocial treatment • Many patients with substance use disorders benefit from a psychosocial treatment program • Programs staffed with counsellors, case managers, other care providers with experience in addiction management • Many different options: inpatient vs. outpatient, religious vs. secular, more intensive vs. less intensive, group vs. individual, public vs. private, etc. • Choice of program depends on what works best for the individual’s life 16
Peer support • Many patients benefit from peer support groups: • Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Secular Organization for Sobriety (SOS), SMART Recovery, Women for Sobriety (WFS) • Peer support groups allow connections and sharing between people in different stages of recovery • Meetings provide structure and substance-free socializing • Sponsorship can be very valuable for accountability 17
Self-help • Patients can make lifestyle changes that promote recovery: • Keep a regular schedule for eating and sleeping • Exercise • Spend time with supportive family and friends • Keep medical/counselling appointments • Engage with hobbies • Patients can use techniques to deal with cravings/triggers: • Relaxation and breathing exercises • Meditation or prayer • Mindfulness, grounding • Journaling • Affirmations 18
PROVIDING HARM REDUCTION ADVICE 19
Reduced drinking tips • Consume no more than one drink per hour (or two drinks every three hours) • Sip rather than gulp • Avoid unmeasured drinks • Alternate alcoholic drinks with non-alcoholic drinks • Eat before and while drinking • Set limits for yourself and stick to them 20
Avoiding trauma when drinking • Do not drive a car or boat after drinking • Do not get in a car or boat with people who have been drinking • Do not engage in arguments with intoxicated people • Leave a party when strangers arrive, or if it gets chaotic • Have a non-drinking friend accompany you and take you home 21
Reducing risk of opioid overdose • Do not inject • If you are using opioids after even a brief period of abstinence, take a much smaller opioid dose than usual • Start with a test dose • Do not mix opioids with alcohol/benzodiazepines • Always have a friend with you while you’re using • Always carry naloxone • If your friend appears drowsy, has slurred speech, or is nodding off after taking opioids: • Shake/talk to them to keep them awake • Call 911 and start chest compressions • Administer naloxone 22
WRAP-UP: KEY MESSAGES 23
Our responsibility • Managing substance use disorders is our responsibility as health care providers • Addiction is the same as any other chronic illness: patients need specialist referrals, medication, treatment of cooccurring conditions, and regular follow-up • Effective addiction interventions are simple, safe, and satisfying • Purpose of META: PHI project is to facilitate adoption of best practices and support clinicians 24
Resources • META: PHI website: www. metaphi. ca • META: PHI mailing list for clinical questions and discussion (e -mail sarah. clarke@wchospital. ca to join) • META: PHI contacts: Medical lead: Dr. Meldon Kahan Manager: Kate Hardy Knowledge broker: Sarah Clarke meldon. kahan@wchospital. ca kate. hardy@wchospital. ca sarah. clarke@wchospital. ca 25
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