1. Changing the Culture
Rethinking the bio/psycho/social approach to treating opioid use disorders

2. The complexity of the opioid epidemic requires a multi-disciplinary Approach
Physician, Counselor, Social Worker
Family, Criminal Justice System, Social Service Agencies
Employers, Landlords, Faith Community
Treating opioid use disorder is everyone’s job, physician, counselor, social worker, family, criminal justice system, but also; employers, landlords, faith community, social/fraternal organizations etc. Those in recovery need jobs, housing, recreation, social and spiritual activities so everyone is a treatment provider. Medication is a critical part of treating opioid disorder however it is an intervention not complete treatment. Medications help an individual function more normally so that psychosocial services can be introduced and applied. We practice a medication first model but also realize that often the patient’s stage of readiness to change does not match what we believe is an ideal time for buprenorphine or a naltrexone product.

3. Samsha – definition of recovery
A process of change through which individuals improve their health and wellness, live a self- directed life, and strive to reach their full potential.
SEMO BH as an agency believes in and follows a medication first model, we must not confuse medication first with medication only, psychosocial support is critical to the definition of recovery. It is the integrated application of the medical and psychosocial services in a logical manner based on stage of change and priority.

4. Changing psychosocial services
Change item - We usually become aware of OUDs when it is in an acute phase but the disease is chronic and the ultimate goal must be to prevent the acute phases.
Change item - EBPs work, non-evidence based practices may work, or they may not. Use something proven, others might just be superstition
Change item - If you can’t measure it how do you know it is good?
Change item- Create No Barriers
The only constant is change. The biology part of the bio/psych/social model has based interventions on best practices for over a century, the psychosocial parts have been a lot slower. As behavioral and physical healthcare become integrated it is critical for those of us in behavioral health to catch up.

5. treatment must be coordinated
With the increase in integration and team treatment care coordination is more and more critical. If interventions are not in the proper order and well coordinated the end result may not be what you want. A trauma team would not talk about healthy lifestyles while a patient is bleeding profusely, so do not introduce someone to relapse prevention or vocational training when they are withdrawing. At the same time only treating the acute phases will usually just result in a cycle of hospitalizations, so plan for the future, just don’t execute until the time (stage of change) is right.
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6. Assess to determine & prioritize needs
Assessment is critical to prioritize services and assessment is ongoing to measure change.
Objective assessment tools:
Forensics – UDS, metabolic screening, liver functions, etc.
History - previous medical records, self-reported history
Withdrawal scales, CIWA
DLA-20
Stage of Change-URICA, Readiness Ruler, SOCRATISE
We think of assessment when starting treatment but it must be ongoing as the person’s situation changes. All of the above are familiar assessment tools to most of us

7. Triage – first things first
Public schools learned years ago that it is difficult to self-actualize when you are hungry, treatment providers must realize that you cannot expect anyone to discuss coping skills when they are in active opioid withdrawal, or cold, tired, hungry, afraid, or worried about your children.
Biological needs
Safety needs are a close second-
Love and belonging – people must feel more than just physically safe for effective treatment
Esteem needs-purpose and pride
Self-actualization
Assessment is critical to categorize needs. We are in a data driven world, so assessment tools must be objective which means measurable.

8. Readiness to change
Everyone is ready to change or they would not come see us
Sick and Tired of Being Sick and Tired
Change Ruler, URICA and SOCRATISE
Our culture has to change from one of knowing all the answers to one of discovering the problem, then working on the answers. The individuals we treat will prioritize change areas if we explore and guide.
This Photo by Unknown Author is licensed under CC BY-ND

9. dla-20, stages of change AND MASLOW for more effective treatment
Find the deficit area(s), with the appropriate desire to change by matching it to a strength area whenever possible. Start with the most basic need
The DLA-20 provides strength as well as deficit areas, our task is to work on those areas most important at the time to the individual, using a strength area to improve a deficit. A practical area would be a low score in # 1 & 8, on the DLA, medical and problem solving because your client does cannot remember to take medications as prescribed, and a high score in 9 family relationships, as she lives with her very supportive aunt. The solution in this oversimplified problem would be to involve the aunt in treatment educating her in the importance of medication compliance and her potential role in reminding and assisting in following the medication schedule.

10. Common life areas and change
Physical health
Housing
Legal
Vocational
Family and social connectedness
Mental health/Substance use disorder
How do the problems in the different life areas correspond to the individuals readiness to change and where do they fall for the individual within Maslow’s hierarchy?

11. Medical domain
Someone withdrawing from opioids work in the medical domain is likely going to be based on meeting a physiological need.
When withdrawal is completed the medical domain focus may change to safety, treating Hepatitis, practicing safe sex.
Self actualization in the medical domain would come when the individual is practicing preventive care, exercise and diet, regular A1C screens, annual wellness exams.
Assess well and don’t waste time addressing an area that is not a need, not everyone will have unmet safety, love and belongingness, esteem needs.
The hierarchy of needs can be used with any life area, housing for example; sleeping outside in the winter relates to physiological needs, living with an abusive person is a safety as well as, love/belonging, and esteem need. Your client starts to self actualize when they begin budgeting for future rent, repairs, or upgrades.

12. Questions?