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: Improve care for patients with addictions Improve care provider experience Improve population health Reduce service use Provide sustainable care

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

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)

Explaining a substance use disorder diagnosis

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

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 are 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

What is a substance use disorder? People with a substance use disorder usually have the following four traits: They cannot control their substance use They continue to use substances despite knowing it is harmful They spend a lot of time using substances 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

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

Explaining treatment options

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!

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

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 are 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

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

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

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

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

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

Providing harm reduction advice

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

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

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

Wrap-up: Key Messages

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 co-occurring 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

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 meldon.kahan@wchospital.ca Manager: Kate Hardy kate.hardy@wchospital.ca Knowledge broker: Sarah Clarke sarah.clarke@wchospital.ca