1. Management of Alcohol Use Disorders Education Rounds for ED and Hospital Counsellors, Crisis Workers and Withdrawal Management Staff

2. About META:PHI Mentoring, Education, and Clinical Tools for Addiction: Primary Care–Hospital Integration Goals: – Promote evidence-based addiction medicine treatment – Implement care pathways between the ED, hospital, WMS, primary care, and rapid access addiction medicine clinics Seven sites in Ontario are currently involved, with plans to expand the spread of the project in the future Funding and support provided by the Adopting Research to Improve Care (ARTIC) program (Council of Academic Hospitals of Ontario & Health Quality Ontario) https://www.porticonetwork.ca/web/meta-phi META:PHI 2015

3. The baseline survey is anonymous and entirely optional. You may skip any question that you do not wish to answer. We will not ask you for any personal information Please tear off and keep the front page with contact information, should you have any questions about the survey or the META:PHI project. Baseline Survey Please return the completed or incomplete survey face down to the facilitator when you leave the presentation. META:PHI 2015

4. ROLE OF THE COUNSELLOR IN MANAGING AUDS META:PHI 2015

5. Role of the Counsellor in Patients with an AUD In managing alcohol use disorders in the ED, hospital, or WMS, counsellors play a key role: – Counsellors spend more time with patients than physicians – Patients are more likely to confide in counsellors than in medical staff – Counsellors are more likely to provide discharge advice – Counsellors can send patients to the RAAM clinic without a formal MD referral META:PHI 2015

6. Beyond Clinical Knowledge Counsellors play a significant role in a patient’s early recovery – Counsellor attitude toward a patient with AUD during their first treatment encounter can influence their future participation in treatment Showing compassion is essential as often patients seek help with their substance use after it has gotten them into some sort of crisis (e.g. partner threatening to leave, children taken by CAS, DUI, job loss etc.) These individuals may be at increased risk for self harm – A counsellor’s compassion, knowledge and brief counselling offers patient immediate support and the hope that things will improve if they continue working on their recovery META:PHI 2015

7. Counsellor Goals for AUD Patients in the ED, hospital, WMS 1.Explain to client what an Alcohol Use Disorder diagnosis means 2.Provide advice on avoiding alcohol-related harms. 3.Address patient concerns. 4.Provide referral to rapid access addiction medicine clinic for long term medication-assisted treatment META:PHI 2015

8. COUNSELLING YOUR CLIENT ON THEIR AUD DIAGNOSIS META:PHI 2015

9. The Addicted Brain Humans have a reward centre in the brain and when an essential activity for survival is performed (e.g. eating), dopamine is released – Dopamine makes us feel good, so we are motivated to repeat the activity Drinking and using drugs also cause a release of dopamine, more powerful even than with survival activities This is what reinforces people’s substance use, even when rationally they know it is harmful to them META:PHI 2015

10. What is an AUD? People with AUDs often have the following four traits: (1) They cannot control their drinking (2) They continue to drink despite knowing it is harmful (3) They spend a lot of time drinking (4) They have powerful urges or cravings to drink AUDs have nothing to do with character, will power, or morals – Many good and strong people have an alcohol or drug problem People with AUDs find that once they start drinking, it is no longer about choice META:PHI 2015

11. Concurrent Disorders People with substance use disorders often suffer from other mental health issues – These may have contributed to their initial and ongoing misuse of drugs or alcohol Common concurrent disorders include: – PTSD – Anxiety – Depression These issues must be addressed through counselling, in addition to working on issue of substance misuse META:PHI 2015

12. AVOIDING ALCOHOL-RELATED HARMS META:PHI 2015

13. Standard Drink Size META:PHI 2015 Image from Canadian Centre on Substance Abuse

14. Low-Risk Drinking Canada’s low-risk drinking guidelines suggest that: – Women not exceed 10 drinks a week no more than 2 drinks a day most days – Men not exceed 15 drinks a week no more than 3 drinks a day most days Both men and women should plan non-drinking days every week to avoid developing a habit Special occasions: – It is expected that people may drink more on special occasions, but to minimize risk: Women should not exceed 3 drinks on any single occasion Men should not exceed 4 drinks on any single occasion META:PHI 2015

15. Harm Reduction Advice If client drinks in excess of the low-risk guidelines, you can provide the following advice: – Consume no more than one drink per hour (or two drinks every three hours) – Sip rather than gulp – Switch to non-favourite drink – Avoid unmeasured drinks – Alternate alcoholic drinks with non-alcoholic drinks – Eat before and while drinking – Set limits for yourself and stick to them META:PHI 2015

16. Alcohol and Trauma Risk of trauma dramatically increases with each drink Refer patients to rapid access addiction clinic even if you think they are just young and reckless rather than addicted – Young, weekend heavy binge drinkers are at high risk of trauma and need treatment even if not daily drinkers, don’t have withdrawal etc. META:PHI 2015

17. Ways to Avoid Trauma if 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 META:PHI 2015

18. Abstinence If the patient has a serious AUD (e.g. recurrent visits to ED for intoxication/ withdrawal), harm reduction advice is unlikely to work – Patient needs to remain abstinent – This goal can be reached through the use of counselling and appropriate medication – Counsellors play an important role in emphasizing that medication works, and is safe META:PHI 2015

19. Coping with Cravings – Advice for Patients in Early Recovery (1) Keep busy: Scheduling and keeping a routine can be a helpful way to avoid using – Attend self-help groups like NA or SOS, which provide structure, social support and accountability through sponsors – Exercise, take daily walks – Keep Regular sleeping and eating routines – Spend as much time as possible with supportive family and friends who do not use drugs – Keep appointments with addiction counsellors and doctors META:PHI 2015

20. Coping with Cravings – Advice for Patients in Early Recovery (2) Keep focused: Staying sober requires paying close attention to how you're feeling, and keeping sobriety as the main priority – Take medication prescribed to you by your doctor – Avoid HALT states: Hungry, Angry, Lonely, Tired – When feeling the urge to use opioids, pause and call a support first – Don't focus on other issues - they can be dealt with later as long as you remain sober – Know your triggers and do your best to avoid them (e.g. certain people or places, or emotions like stress) – Don't give up - sub-acute withdrawal can last for several weeks or months, and the anxiety, insomnia, fatigue, and cravings that you may be experiencing are all temporary META:PHI 2015

21. Patient Concern: Coping with Anxiety and Low Mood “I feel too anxious and depressed when I'm not drinking.” Mood disorders and AUDs often go together. – If you have problems with your mood as well as with drinking, it is important that you seek treatment for both issues. – Treating one often helps with the other: if you stop or reduce your drinking, your mood will almost certainly improve, and if you receive treatment for anxiety or depression, you are also less likely to drink META:PHI 2015

22. Coping with Anxiety and Low Mood (2) Patients can employ different strategies to get through cravings brought on by moods: – Focus on mindful breathing. – Remind yourself that cravings only last ~20 minutes. “This will pass, it's only temporary.” "I've gotten through this before, so I know I can do it now." – Drink a large glass of water or juice and pause. – Call a friend or sponsor and visit them if possible. – Ground yourself in the moment. Look around at what you see, hear, smell, sense. – Engage in a hobby. What have you enjoyed in the past? What have you always wanted to try? – Write down your thoughts and feelings. This helps to get them out of your head. – Pamper yourself! Do something you really enjoy or do something relaxing. – Find an affirmation that you can repeat to yourself when you need encouragement (even if you don't believe it at first!). – Visualize a drink-free positive future, seeing yourself doing the things you want to be doing. – If you have a setback, don't beat yourself up. Be aware of what triggered it so that you can avoid being triggered again. – Just take it one step at a time. Don't plan too far ahead or focus on worries that are not related to your recovery. META:PHI 2015

23. TREATMENT OPTIONS FOR YOUR CLIENT WITH AN AUD META:PHI 2015

24. Patient Concern: Attending Treatment “Do I really need treatment? Shouldn't I be able to stop using on my own?” Successful recovery from an AUD requires treatment Like other illnesses such as diabetes and depression, AUD is caused by biological, psychological, and social factors, and just like these other illnesses, it is very hard for patients to manage on their own – However, effective treatment is available Chances of recovery are greatly improved if the patient has: – had long periods of sobriety in the past – social supports, such as family and friends – only one substance of misuse META:PHI 2015

25. Treatment Programs and Support Counsellors can advise patients of different treatment and support options available: – Medication-Assisted Inpatient Programs: inpatient programs that last up to six months, and incorporate anti-craving medications into recovery plan May be publicly or privately funded – Abstinence Based Inpatient Programs: inpatient programs that last up to six months, and do not permit anti-craving medications to be taken May be publicly or privately funded – Outpatient Programs: day programs usually lasting a few weeks, where patient returns home at night May be run through community organizations, withdrawal management centres, hospitals, or as after-care at organizations that offer inpatient programs May be publicly or privately funded META:PHI 2015

26. Other Supports – Self-help groups can provide valuable emotional support and information about programs and services. Examples: Alcoholics Anonymous (AAA) Secular Organizations for Sobriety (SOS) – Family and friends can offer patients key social supports which can reduce feelings of loneliness, and provide activities away from using alcohol META:PHI 2015

27. Primary Care Family doctors can play a central role in patient recovery – They can prescribe naltrexone, acamprosate, etc. – They are able to treat withdrawal, monitor and intervene with mental and physical health during recovery, and provide ongoing support during and after treatment – They can also refer the patient back to treatment if they relapse Counsellors can assist the patient in finding a family doctor: – Health Care Connect (1-800-445-1822) will connect patient to family doctors and nurse practitioners accepting new patients: http://www.health.gov.on.ca/en/ms/healthcareconnect/public/ – Community Health Centres (CHCs) sometimes have openings for patients within their region – Locate local CHCs: http://www.health.gov.on.ca/english/public/contact/chc/chcloc mn.html META:PHI 2015

28. Anti-Craving Medications The ED physician or RAAM physician may start the patient on a medication that helps reduce their alcohol cravings and binges Counsellors play an important role in emphasizing that these medications are safe and effective Common anti-craving medications to be aware of are: – naltrexone – acamprosate – topiramate – gabapentin – baclofen – disulfiram META:PHI 2015

29. MedicationWhat it DoesIs it Addictive? Does it cause nausea if you drink? Naltrexone *Frontline treatment Reduces alcohol cravings Reduces rewarding effects of alcohol No Acamprosate *Frontline treatment Reduces alcohol cravingsNo TopiramateReduces alcohol cravings Reduces rewarding effects of alcohol No GabapentinReduces alcohol cravings Improves mood Improves sleep No BaclofenReduces alcohol cravings Reduces rewarding effects of alcohol No DisulfiramMakes you sick if you drink Most effective if dispensed daily by spouse or friend NoYes META:PHI 2015

30. Patient Concern: Medication Safety “Is anti-craving medication safe?” All medications prescribed to help with alcohol addiction are safer for your liver than alcohol is You will not need to take these medications for the rest of your life – Most are taken for the first six months of treatment, as that is often how long it takes to establish an abstinent lifestyle These medications are non-addictive and can be stopped if you find them ineffective or if they give you side effects You and your doctor will go over each medication to determine the appropriate one for you META:PHI 2015

31. WRAP UP – KEY TAKEAWAYS META:PHI 2015

32. Key Messages for Patients “You have been diagnosed with an AUD” – This means that you have been unable to stop drinking alcohol, even though it has become harmful to you “Treatment exists and is incredibly effective” – Explain options for medication-assisted treatment – Explain options for psychosocial treatment “There are things you can do to help cope with cravings” “Once you start treatment, other aspects of your life will improve tremendously” – E.g. mood, pain, relationships, daily functioning, finances META:PHI 2015

33. Discharge Depending on where you see the patient, there are different referral options – RAAM Referral If you are in the ED, hand patient RAAM referral card Non-ED counsellors can also refer the patient, by simply letting them know clinic hours and location RAAM is located close to hospital and patient can be seen in 1-6 days Patients do not need to be in withdrawal to be referred – WMS Referral if warranted If patient is in crisis If patient needs safe place to stay until RAAM appt If patient is keen to start treatment right away – Medication-Assisted inpatient treatment programs – Medication-Assisted outpatient treatment programs META:PHI 2015

34. Case Scenario - Gary Gary is a 46-year-old street-involved man with a short but severe history of alcohol use. Gary frequently presents to the ED, usually intoxicated, occasionally in withdrawal. Gary arrived at the ED last night severely intoxicated and was kept overnight. His withdrawal has resolved and he is ready for discharge. META:PHI 2015

35. Question What discharge advice and information would you provide to Gary? META:PHI 2015

36. Management Plan for Gary Recommend immediate treatment at WMS (if there is space) and through support programs like AA Advise patient to seek longer term treatment, possibly in a residential setting – Let him know that WMS staff can assist in facilitating this Refer patient to the RAAM clinic which offers anti-craving medication Advise patient to connect with his family doctor if he has one (RAAM clinic can help him connect with one if he is unattached) Provide Gary with a message of hope that treatment does work, and that he will feel much better once he stops drinking Work with him to establish plan to keep busy, now that drinking will not be in his life META:PHI 2015