1. Recovery from Opioid Dependence Building Trust, Building Bridges

2. Presentation Outline Recovery from Opioid Dependence
OST Information Sessions
OST Support Group
Building Trust, Building Bridges
Our Program Framework
OST Clinic Collaborations
OST
Opioid Substitution Therapy
Methadone and Buprenorphine/Naloxone
that this is one model that evolved because of
the particular configuration of resources and potential partners in our community
and the choice of our LHIN to designate funds to specifically address the unique issues of the prescription opioid user (you may have that covered – in other words)  
Not every community had this opportunity – and as you know some others choose not to dedicate their funds in this way (Grey Bruce example)

3. A Health System Strategy
The estimated social, economic and health costs for Ontario resulting from untreated opioid misuse exceeds $1B
The ministry provides over $3M annually to community methadone treatment services across the province
Treatment for prescription opioids is the fastest growing problem seen in addiction services in Ontario. In recent years, liberal prescribing practices and the high availability of OxyContin have meant that prescription opioids have become the substance of choice for a broader range of people who may have begun using opioids for pain
Research also suggests that up to 70% of first-time users access opioids from friends or relatives, whether experimenting with opioids from a parents’ medicine cabinet or accepting leftover medication from a friend to manage pain, demonstrating the accessibility and changing face of opioid addiction.
Since 2004, the number of oxycodone-related deaths has nearly doubled.
From 2004 to 2008, admissions to publicly funded treatment and addiction services doubled for narcotics misuse
Source: Program Framework: Community Opioid Treatment Programs Ministry of Health and Long-Term Care Page 1 September 17, 2012
Program Framework: Community Opioid Treatment Programs
Health System Strategy and Policy Division
Ministry of Health and Long-Term Care

4. Principles of COAP Program Overview
Improve health and social outcomes and quality of life for people living with opioid addictions
Priority populations include:
People living with HIV/AIDS and/or Hepatitis C
Women who are pregnant and/or parenting
Youth (12+)
Increase access to opioid addiction treatment and primary health care
Improve linkages between community programs
Reduce involvement with criminal justice system

5. Community Opioid Addiction Program (COAP)
Direct Client Services
Screening, assessment, treatment planning, counselling, and case management
Ability to meet in the community (e.g. health care centres, Methadone and Suboxone clinics, hospitals, shelters)
Community Education Services
Increase knowledge and awareness about opioid addiction and Opioid Substitution Therapies (OST)
Presentations, educational events, consultation services
5 Addiction/Mental Health Counsellors
10 Points of Access:
London: ADSTV, Maison Louise Arbor, London Intercommunity Health Centre, Dr. Lee’s Suboxone Clinic
Middlesex County: Strathroy- Thomas Street Treatment Clinic
Elgin County: St. Thomas, Aylmer, West Elgin Community Health Centre (West Lorne)
Oxford County: Woodstock and Area Community Health Centre, Ingersoll Nurse Practitioner Led Clinic
Service numbers- 151 open clients as of April 30/15

6. Recovery from Opioid Dependence

7. Client Engagement Focus Groups
Purpose
To gather first-hand knowledge in order to better understand the following:
The lived experience of individuals using opioids or on Opioid Substitution Therapy (OST) across Thames Valley Region (London, Middlesex, Elgin and Oxford Counties);
The ways in which individuals learn about, understand and access OST;
The barriers related to accessing treatment or support for opioid addiction;
How and if individuals are accessing other supportive community services;
The current gaps in service for opioid users and/or those on OST
The focus groups and interviews were conducted between September 16th and October 8th 2013 in London, St. Thomas and Woodstock. A total of 15 individuals participated in the interview or group discussion formats. The majority of these participants (12) were existing ADSTV clients.

8. Client Engagement Focus Groups
Key Findings
Lack of knowledge about Methadone and Suboxone
Counselling support is integral to helping understand the substitution therapy process and be successful
Making the decision to taper should be a personal choice
People abusing opioids often want help, but want help to come to them
Lack of options when you don’t want Opioid Substitution Therapy

9. Individual Counselling: Common Themes
First exposure to opioids often obtained through legal prescription from physician
Prescription discontinued due to misuse
Opioid use for pain management purposes
Continued use to manage and/or avoid withdrawal symptoms
Prescribed OST but supplementing with illegal opioids to avoid an increase in dosage
Readiness to taper off OST
Not fully aware of all treatment options and potential impacts and/or side effects of OST

10. Unique Needs of the Population
Stigma of OST
What is abstaining?
Is OST treatment considered an addiction?
Chronic Pain
Narcotics Anonymous
Side effects and how to manage
Advocacy with doctors and pharmacists
Women Specific Services
Not enough research for women’s issues (e.g. OST effects on women, estrogen levels)

11. Two Groups: To Meet the Needs
OST Information Session
Address the lack of knowledge about Methadone/ Suboxone
Provide treatment alternatives
Empower individuals to make informed decisions
OST Support Group
Evidenced-based practice that OST combined with counselling is important for a successful recovery
Group members in various stages of change
Shared experiences and common themes

12. OST Information Session
Educational group for people contemplating OST and/or on OST, family members, and service providers
The 5 W’s
Who: people contemplating OST, family members and friends who want to learn more, service providers.
What: educational and information session that will discuss OST – methadone and Suboxone, as well as other treatment options for opioid dependency.
Where: ADSTV, main office, thinking about taking it on the road to community partners to gain more attendance.
When: second Tuesday evening of every month, started December 2014.
Why: COAP mandate to provide education, also a concern that people have a lack of awareness about OST and their options, and that people on OST do not fully understand the medication and the process of treatment.

13. OST Information Session
Outline of the group:
Information about Opioids
What is Opioid Substitution Therapy?
Benefits and Drawbacks
Things to Consider with OST
Mixing OST with Other Substances
Overdose
Resources
Purpose? Topics?
OST info session
What is it? Who attends? Length? How often?
People’s responses to materials
Can be in group or 1:1
Attendance: people who don’t know a lot about it and want more information, service providers, people already on OST who don’t have all the information (more likely 1:1), family members can attend to increase their ability to be understanding or supportive and to help family members support their loved ones better
Can use this information to help make an informed decision/choice to start or get a better sense of/increase understanding the medication they are taking
Outline of what we cover, choose the most relevant slides or pieces that may be good to show

14. What is Opioid Substitution Therapy?
Other Full Agonists include:
Methadone
Fentanyl
Percocet
Dilaudid
Buprenorphine + Naloxone = Suboxone
Full Agonist vs. Partial Agonist
Buprenorphine is a partial agonist; methadone, like heroin, is a full agonist. It is by their actions on opioid receptors that opioids achieve their analgesic (pain-killing) as well as their addictive effects.
Methadone is a full agonist which means it fits snugly into the opioid receptor –disallowing other opioids to activate the receptor.
Buprenorphine, as a partial agonist, does not activate receptors to the same extent as methadone. Its effects increase until they reach a plateau. At that level, patients can discontinue opioid use without experiencing withdrawal. Buprenorphine reaches its ceiling effect at a moderate dose, which means that its effects do not increase after that point, even with increases in dosage. Buprenorphine is a key ingredient of Suboxone and is a partial agonist.
Like all opioids, buprenorphine can cause respiratory depression and euphoria, but its maximal effects are less than those of full agonists. The benefits of this from an overdose perspective constitute the safety profile of buprenorphine—a lower risk of abuse, addiction, and side effects than with full agonists.
Precipitated Withdrawal: Because Buprenorphine is a partial agonist it has partial antagonist properties. This means that if someone who has already taken a dose of Suboxone, then takes another opioid- the partial antagonist properties of buprenorphine will act to remove the opioids from the receptors resulting in precipitated withdrawal symptoms for the individual.
Naloxone: Naloxone is the second ingredient in Suboxone. Naloxone is a full antagonist. This means that it clears the opioid receptors of all opioids and temporarily blocks opioids from reattaching to these receptors- resulting in immediate onset of opioid withdrawal. Naloxone taken by mouth does not have any active antagonist properties. Suboxone taken intravenously allows Naloxone to directly enter the blood stream allowing for the full antagonist effect of the drug.
For people who are not addicted to or dependent on opioids, the effects of partial (buprenorphine) and full (methadone) agonists are indistinguishable. However, at a certain point, the increasing effects of partial agonists reach maximum levels. For this reason, people who are dependent on high doses of opioids are better suited to treatment with a full agonist, such as methadone.

15. OST: Methadone and Suboxone
Methadose is a liquid, taken as a drink, one time per day
Suboxone is a tablet, taken under the tongue, one time per day

16. Opioid Substitution Therapy: Benefits
Manages withdrawal symptoms and cravings
Stabilize mood (clear thinking)
Improved access to health care
Reduce use of illegal opioids and other substances
Reduce injecting
Harm reduction
Not “chasing the high” all day
Pain reliever
More energy, better sleep and health
Improved family relations and/or parenting ability
Overall increase in quality of life
The Benefits of OST
Effects of methadone can last hours
Dose is taken orally; safer than injecting, snorting, or smoking
OST will not get you high, but will help keep away any physical drug cravings or the feeling that you need to get high
OST is legal when prescribed by a doctor and dispensed by a pharmacist; no fear of arrest and the source is reliable
OST is made using strict manufacturing guidelines and never cut with unknown substances
Cost of OST varies between methadose and Suboxone, $4-$40 a day and can be covered under your Ontario Drug Benefit Card, prescription drug plan through work, or Trillium Drug Plan
(Centre for Addiction and Mental Health (2008) Methadone Maintenance Treatment: Client Handbook. Centre for Addiction and Mental Health: Toronto, Ontario.)

17. Opioid Substitution Therapy: Drawbacks
Impact on Daily Routine
Daily visits to a clinic
Eligibility criteria
Still opioid dependent
Stigma
Increased risk of overdose (methadone)**
Travel can be more difficult
Frequent urine testing
Physical Side Effects:
Decrease in Sex Drive and Hormonal Impact for Men and Women
Nausea and Vomiting
Drowsiness
Diarrhea or Constipation
Oral Health Concerns
Excessive Sweating
The Drawbacks of OST
OST impacts daily routine- may impact your employment, etc.; having to make daily clinic visits  
OST does not cure opioid dependence, and does not address the reasons “under the iceberg” that lead to drug use in the first place
OST replaces opioids with another opioid, methadose & buprenorphine. You are still opioid dependent and if you miss more than one dose you will experience flu-like withdrawal symptoms
Individuals on OST may be branded as “still addicted” by those in the community who do not understand methadose treatment. This can include some treatment programs who are abstinent-based, some doctors and pharmacists, and potential employers
OST maintenance is a long-term treatment and you can expect to be on it for as long as a year or two. Some stay on for even longer depending on how long they have been using opioids **The increased risk of overdose is most significant in the first 2 weeks due to breakthrough pain while establishing proper dose
(Centre for Addiction and Mental Health (2008) Methadone Maintenance Treatment: Client Handbook. Centre for Addiction and Mental Health: Toronto, Ontario.)
Oral Health Concerns- can cause problems, people need to ensure they are taking good care of their oral health as OST can cause dryness of the mouth
Being on Opioids or substitution therapy in the long-term is likely to result in Hormonal Impacts for both men and women which can include:
Loss of libido, infertility, fatigue, depression, anxiety, loss of muscle strength and mass, alteration of gender role, osteoporosis and compression fractures, impotence in men, and menstrual irregularities in women (glactorrhea which is producing milk from the nipples when not lactating, amenorrhea absence of a period, and infertility.
All of these effects have to do with the complication of opioid use on the endocrine system which according to the Mayo Clinic is defined as “…including the pituitary gland, thyroid gland, parathyroid glands, adrenal glands, pancreas, ovaries (in females) and testicles (in men).” (
Feedback from OST Support Group: There is a lot of information about side effects that are being missed when a client is started on OST.  Many clients were not aware of hormonal impact of opioids or OST.

18. OST Info Session: Successes
Creating a safe space to address questions and concerns about OST
Un-biased presentation
Allows individuals to make informed treatment choice/decision
Building capacity of service providers
Providing well-researched information from the MMT guidelines and CPSO
Resolve ambivalence

19. OST Info Session: Challenges
Lots of information to cover in a short period of time
Attendance issues – not reaching the populations who would benefit from this material
Taking it “on the road”!

20. OST Info Session: Feedback
From clients:
Information presented has been useful in helping them make a decision to start OST
Information has helped them feel confident in their decision to choose OST as a treatment option
From family members:
More likely to suggest OST to someone
Consider OST if unable to go “cold turkey” from opioids
From service providers:
Information presented will help them better support their clients on OST
Feel better informed about OST and where clients can access these treatments

21. OST Support Group
10 week psycho-educational & support group for people on OST
The Five W’s
Who: clients must be on OST – methadone or Suboxone, can be at any stage of change, can be using substances other than opioids but no discussion in group permitted about other substance use. HOW MANY PEOPLE ARE ATTENDING? RATIO OF MMT TO SUBOXONE
What: a 10-week psycho-educational and support group for people on OST – methadone or Suboxone.
When: weekly, Monday nights.
Where: ADSTV, main office, two group facilitators also work at Suboxone clinic, easy to refer clients.
Why: best practice is counselling with OST, this format allows for clients to share experiences with other people on OST and receive support from people with similar lived experiences. This group works because we have created 10 weeks of topics that are important to the needs of this population, using their feedback from CTs and the focus groups.

22. OST Support Group Topics OST and Me Strength Through Stigma
Personalizing Your Treatment
Lifestyle and OST
OST Side Effects
Pain Management and Types of Pain
Safe Coping Skills
Working with Worries
Healthy Relationships
Beyond OST: Progressing Through Recovery
How are the topics? Do they fit well with everyone or only people at certain stages of change within OST treatment? The topics work well and we seem to reference various topics during each session.  We have rich conversation during group and find that topics naturally progress through the material well. I think this is a good group for those who are in action, maintenance and maybe even preparation.  We have people in group who have been on OST for 7 yrs as well as folks who just started and it provides for a good balance. 

23. Sample : Week 1 OST and Me Introduction Decisional Balancing Exercise
Open group
Session length: 1 hour 45 minutes
Check In
Topics
Introduction
Decisional Balancing Exercise
Life Inventory Scale
My Goals
What does Success Look Like on OST?
Open group – clients added ongoing basis, assists with managing the waitlist and providing faster service
Introduction:
We will be looking at the good things and the not so good things about substitution therapy, as well as starting to identify ways to change some of the not so good things.
We will be discussing the changes that you have noticed since being on OST.
We will be reviewing your OST goals and how COAP can help you achieve your goals.
We will discuss common contributors to ‘getting stuck’ and first steps for getting unstuck.
Decisional Balance
Life Inventory Scale
Self Reflection Exercise - to take a look at where we came from, what brought us to this point in our lives, the mistakes we made, the
lessons we learned, our progress, and our hopes for the future .
 Encourage participants to recognize any changes (positive, negative, unforeseen) that they have experienced while on OST.
My Goals
Encourages discussion and reflection on individual reasons for taking OST, there is not “one size fits all” when it comes to treatment.
Also, encourages discussion and reflection on personal goals, progression of goals and adding or changing goals based on stage of recovery.
What does Success Look Like on OST
For many, OST must continue indefinitely for ongoing recovery. OST may be necessary for more helpful and productive lives.
Patients who discontinue OST before they are ready, or those not pursuing an ongoing program of recovery after leaving, usually
return to substance abuse and addiction.
Focus on engaging reflection and discussion on how to make OST experience most successful, necessary lifestyle changes, understanding clinic contract rules, attending and participating in counselling, resist any temptation to leave OST prematurely for example.

24. OST support group
Action: Need to discuss with Megan VB and Nicole A regarding feedback from client’s, perhaps use anonymous quotes from feedback forms
Similar to OST info session – outline, who attends, etc.

25. One thing I learned today… “Other people feel the same way I do about some things” “How important it is to take care of yourself, body, mind, emotions, spiritual” “Search for other options to deal with pain besides prescription drugs”
OST support group
Action: Need to discuss with Nicole A and Megan VB regarding feedback from client’s, perhaps use anonymous quotes from feedback forms
Similar to OST info session – outline, who attends, etc.

26. OST Support Group: Benefits
Unique:
No other similar groups
Specialized focus results in high affinity
Safe, non-judgemental, supportive environment
Variety of participants on methadone and Suboxone and in various stages of change
Share what works and what does not work about OST
Helps reduce stigma of OST
Group facilitators at the Suboxone clinic – wrap around and client engagement
What is going well with the OST support group?
No other similar groups- that specialize in OST
Client feedback: client’s report that the experience of being in a group, specialized to their unique experience of OST, increases the value of their group experience resulting from a high affinity to the materials and their peers.
We hear that there is nothing like it in the community so people like to have a space where they can come and share their experiences.  We have a good group at this time who work well together (lots of sharing and support offered).  The time works well b/c it supports those who are working during the day. It’s great to see a variety or participants on buprenorphine and methadone in various stages of change. 
What are the benefits of having the group? How are the participants progressing? The benefits to having the group are putting people in common circumstances in the same place to share what is work and what isn’t work.  It’s been a good forum to discuss change and stigma attached to OST as well.  Many participants have voiced that coming in helps them to feel less stigmatised.  Progression varies among the group.  A few more shy members have begun to open up more and ask questions.  Some participants feel more confident to share more openly about their experiences.  A lot of work has to be done to remind participants that it isn’t about the race to be off of ost but rather how to cope with being on it.  Sometimes folks will want to dwell on “how long til I get to 10mg” or “how long until I can be off of this”.  This can sometimes stall progression. 

27. OST Support Group: Challenges
Group dynamics
Stigma conversations and over-generalizations
Remind participants it is not a race to get off OST – can stall progression in treatment
Areas to Improve:
Increased referrals to OST information session
Offer more women-specific information, especially around side effects
More visual aids (e.g. videos)
Promoting/informing patients at the clinics
What are the challenges of the group? Any particular group dynamics?
There are a couple of stronger voices that can tend to carry the group and do most of the talking.  We have to be sure to include everyone during open discussions. Clients believing the stigma that is put on them and perpetuating this belief to the group.  “You really are still substituting this drug for another”.  “We do try to manipulate to get what we need”.  We have to be careful not to allow for generalizations.
Progression varies among the group.  A few more shy members have begun to open up more and ask questions.  Some participants feel more confident to share more openly about their experiences.  A lot of work has to be done to remind participants that it isn’t about the race to be off of ost but rather how to cope with being on it.  Sometimes folks will want to dwell on “how long til I get to 10mg” or “how long until I can be off of this”.  This can sometimes stall progression. 
-peoples views of OST and being stuck in how they think about OST, perpetuating stigma
-when to taper, what’s the best time?
What would you change or alter about the materials? Offering more women-specific information specifically around side effects (although I know this information isn’t easy to find).  I would not make it continuous enrollment, or if we did continuous enrollment maybe limit it to the first 2-3 weeks.  Having more visuals to use – videos/web clips to break up the group focus. Maybe doing a week on what is buprenorphine and what is methadone?  Maybe a week on the history of opiates?

28. OST Support Group: What Clients Say
One new thing I learned today is…
“I walk away from today reminded that I should remain patient”
“Being informed is key”
“That I am at a good place in my recovery”
“The power stigma can have on others”
“Compassion for self is the beginning of compassion for others”
“To look for the positives in OST”
Overall feedback from the participants? Not enough women-specific information.  Participants enjoy open discussion, sharing experiences and overall atmosphere of the group. This is a unique group of its kind and it would be good to have more advertising at all methadone/buprenorphine clinics in town.  Seeking more information about how to cope with money struggles due to going into debt during addiction.

29. OST Support Group: What Clients Say
Because of today’s session I am going to do or try…
“Don’t be afraid to try new things and do as much positive thinking as I can”
“Inspire yourself, carry something positive”
“To keep on the right track so I don’t have pain”
“Set a goal based on positive things”
“To maintain an honest program with myself”
“To relax while remaining concerned and caring”
“I need to start asking my MMT doctor more questions”
“Apply the knowledge I learned in this group to my life”
Overall feedback from the participants? Not enough women-specific information.  Participants enjoy open discussion, sharing experiences and overall atmosphere of the group. This is a unique group of its kind and it would be good to have more advertising at all methadone/buprenorphine clinics in town.  Seeking more information about how to cope with money struggles due to going into debt during addiction.

30. Building Trust, Building Bridges

31. COAP Clinic Collaborations
Through service delivery partnership, increase capacity for :
client engagement and retention for both ADSTV and OST clinics
ease of access to OST
meeting individual client needs
consultation between ADSTV and OST/health care providers in our community
being responsive to the relapsing nature of opioid/substance use
Through service delivery partnership, increase capacity for :
client engagement and retention for both ADSTV and OST clinics
ease of access to OST for both service providers
meeting individual client needs- example Dennis S- TBI, cognitive disability, ADHD, PTSD- consistency and reliability of care, bridging services, increasing therapeutic reliance to service delivery sites as well as clinician and physician
consultation with OST providers in our community
being responsive to the relapsing nature of opioid/substance use

32. COAP Clinic Collaborations
Thomas Street Treatment Clinic, Strathroy, ON
Located in rural SW Ontario
Serves Strathroy and surrounding area
Serves 60 patients
Must be a clinic patient to access counselling onsite
Two physicians, Two administrative staff
Dr. Lee Suboxone Clinic, London, ON
Located at CMHA and operates out of same location as medical clinic
Serves London population
Serves 24 patients and increasing
Must be a clinic patient to access counsellors onsite
One physician, one admin staff
Through service delivery partnership, increase capacity for :
client engagement and retention for both ADSTV and OST clinics
ease of access to OST for both service providers
meeting individual client needs- example Dennis S- TBI, cognitive disability, ADHD, PTSD- consistency and reliability of care, bridging services, increasing therapeutic reliance to service delivery sites as well as clinician and physician
consultation with OST providers in our community
being responsive to the relapsing nature of opioid/substance use

33. COAP Clinic Collaborations: Our Doctors
Dr. Ken Lee:
Suboxone Clinic, London ON
Dr. Janel Gracey:
Thomas Street Treatment Clinic, Strathroy
Dr. Tom McDonagh:
Dr. Ken Lee
over 20 years’ experience working in addictions, both in community Methadone/Suboxone clinics and at an in-patient Psychiatric Hospital Addiction Unit. 
Past experience includes medical coverage of detention facilities, detox units, homeless shelter clinics and transitional housing.  
Dr. Lee currently runs a medical clinic for CMHA London and is on staff at SJHC & LHSC (UH).  
With ADSTV, he provides consultation to the London Drug Treatment Court Program and runs a Suboxone Clinic with the COAP team.
Dr. Janel Gracey
family physician in London
strong interest in chronic pain and addiction medicine.
After getting her methadone for pain exemption, Dr. Gracey also received her methadone for addiction exemption in 2010 and began working part-time in addictions in London, St. Thomas, and Woodstock methadone clinics.
In 2013, she became certified by the International and Canadian Society of Addiction Medicine. She changed her scope to interventional pain management in November 2014 and recently became certified by the American Academy of Pain Management in September.
She opened her own addiction treatment centre in Strathroy in November 2012. 
She works one day a week at Regional Mental Health London as a hospitalist.
She is also a consultant for ADSTV and the London Drug Treatment Court Program.
Lastly, she is a medical examiner for the Medical Council of Canada and an adjunct professor at Schulich School of Medicine at the University of Western Ontario.
Dr. Tom McDonagh

34. COAP Clinic Collaborations: Service Profile
Thomas Street Treatment Clinic, Strathroy, ON
One counsellor, onsite twice a week
Clients required to meet with COAP counsellor at least once
Full individual community treatment services onsite
COAP Staff does not perform clinic duties
Dr. Lee Suboxone Clinic, London, ON
2 counsellors, onsite once a week
Limited individual community treatment onsite, depending on availability
COAP staff perform clinic duties: intake, screening and urine drug screening (UDS)
TSTC: Individual Community Treatment services: program inquiry, drop in, screening, assessment, treatment planning, individual counselling, case-management and referral
Dr. Lee Clinic: community treatment: program inquiry, drop in, screening and referral
Also provided clinic services including intake form completion, file updates, UDS
Provide orientation to clinic process and induction process
Describe the step by step process for each clinic
1 describe intake/ orientation
2. describe weekly visit

35. COAP Clinic Collaborations: Client Engagement
Strong referral paradigm
Rate of referral: 100% for both clinics
Normative: in-house pairing
Immediacy and Primacy
Warm Referrals
Timely
Promotes Therapeutic Rapport
Ease of Access
Low Attrition Rates ?
Point of access for addressing Concurrent Disorders and Comorbidity
Best Practice
Through service delivery partnership, increase capacity for : Client engagement and retention for both ADSTV and OST clinics/ease of access to OST for both service providers
Strong referral relationship-improves access to service and client engagement
Rate of Referral: Increase likelihood and rate that clinics will make a counselling referral- 100% referral rate for both clinics (differentiate between referral and client uptake- which is not 100%)
Normative: The in house referral mechanisms communicate that the pairing of OST and counselling is what is considered to be the normal or standard way of OST.
Immediacy and Primacy of connection- counsellor on site- increase access to direct client engagement at time of optimal motivation to make change
Relationship with clinics have allowed direct referrals and follow-up, follow client more closely
Warm Referrals:
More support for the client, meet COAP worker at ADSTV intake, then meet at clinic (and vice versa), piece of mind for client care, familiarity
Timely:
reduced amount of time between point of first contact and starting services (clinic/ ADSTV)
Referrals are fluid, it is quick to get into the clinics with the collaboration relationship COAP-Dr. Lee collaboration/ TSTC
Promotes Therapeutic Rapport
Weekly interactions with counsellors while at clinic introduces element of consistency, reliability and familiarity
Consistency: Follow-up can happen at ADSTV after the clinic, more alert and informed about client issues now because of client engagement and rapport building at clinic
Weekly interactions allow for immediate access to support when needed- ease of access
Ease of Access/ Service Flexibility:
By physically residing in the same space - Reaching a population that would not be reached by ADSTV
Contemplative clients- provides ongoing tangible opportunity for engagement- versus one referral based encouragement
Able to respond to crisis in the moment
Play jeopardy- client engagement, rapport builidng, knowledge building
“Yes, we are typically able to provide an appointment within a week of referral from ADSTV/COAP.  Patient education has been provided by COAP prior to the initial appointment, so that Suboxone induction can usually be done on day 1”- Dr. Lee
Low Attrition Rates: “The attrition rate so far has been low, but it's still early to make any conclusions”- Dr. Lee
This is anecdotal feedback by one doctor at one clinic who is comparing attrition rates from a Suboxone clinic with clinics that prescribe both methadone and Suboxone.
Other factors that affect the attrition rates could also include the differences in the induction and stabilization paths between methadone and Suboxone.
And the nature and size differences in clinics being compared.
Best Practice:
We know that best outcomes are long term OST with counselling
Models that house counselling and OST services together, promote uptake for combined treatment. Thereby increasing probability of long term engagement. Other clinics without counsellors on site- don’t necessarily refer/ or encourage counselling as part of OST treatment model . Less formal/medical, not just an assembly line, take time with each client
Value Added: Linkages to OST support group – invite them to participate if appropriate

36. COAP Clinic Collaborations: Meeting Client Need
Flexibility for meeting special needs
Able to respond to crisis in the moment
Ease of Access/ Service Flexibility
Counselling with specialized knowledge of OST
Client engagement at earlier stage of change, rapport building, knowledge building
Responsive to individual goals/poly substance use/Mental Health
Increased client knowledge/access to all community resources
In what ways do these service collaborations increase ADSTV capacity to meet individual needs?
Flexibility to meeting special needs requests:
meeting at local women’s shelter,
DM-dog Benji
Counesllor selection: example Dennis S- TBI, cognitive disability, ADHD, PTSD- consistency and reliability of care, bridging services, increasing therapeutic reliance to service delivery sites as well as clinician and physician – during COAP info.
“We try to accommodate patients who can't attend the Tues morning clinic during other times the CMHA clinic is running”- Dr. Lee
Available and Accessible for crisis-
Example: JS- Naloxone program education and referral
Example: RM- active psychosis/risk of imminent harm to self/others- crisis planning and stabilization implementation
Ease of Access/ Service Flexibility: By physically residing in the same space Contemplative clients- provides ongoing tangible opportunity for engagement- versus one referral based encouragement
Able to respond to crisis in the moment
Client engagement at “Pre-contemplation” stage
Play jeopardy- client engagement, rapport building, knowledge building
Benefits are not all clients are ready for formal counselling, this gives an informal way to check-in and promote services if they do decide to engage
See clients at clinic at regular basis for 15 minute check-in but not necessarily counselling
Breaking down the barriers throughout this process
Responsive to Individual Goals:
Diversify message of substance use goals to clinic patients
Client’s who previously addressing opioid use with OST – now addressing other substances of use simultaneously
Screen for presence and severity level for mental health concerns/ trauma and incorporate into treatment planning
Provides support and information for harm reduction- needle exchange programs- review risk of overdose- create safety plans- some people will express a goal to stay on low doses of methadone- not necessarily interested in goal of abstinence
Meeting individual client needs
Positives of being able to check-in with a worker every clinic day
Maintaining a resource/referral rich environment in clinics

37. COAP Clinic Collaborations: Consultation
Consultation with Other Service Providers
Increases capacity of COAP Addiction/Mental Health Counsellors
Increases linkages with Pharmacies/hospital
Potential to link COAP program to innovative projects
Increases capacity of addiction counsellors
direct, immediate and accessible access for counsellors to addictions physicians and pain specialists
Resulting in increase in knowledge
Consultation with Health Care Providers/ OST providers in our community
We have an arrangement with London Centre PharmaChoice pharmacy to do our Suboxone inductions, even if the patients end up using another pharmacy in the city.  Also, Dr. Lee works one day a week at University Hospital on Wednesdays and can visit patients admitted to the hospital on this day
Potential to link COAP program to innovative projects
Dr. Lee now approved for Arctic grant,- potential for more referrals from the hospital
Dynamics of knowing about the Arctic Grant, relationship with Jolene, what this has done for our program, the Symposium – everything is connected .

38. COAP Clinic Collaborations: Ability to be Responsive to Relapse
Client education
Learning about lapses
Overdose Education and Naloxone Training referrals
Resolving ambivalence/increasing skills
Promoting OST retention
Client education: Support/assist client’s to understand /clarify treatment goals/ process relapse. Gives a different perspective than what they might get with clinic doctor i.e. use of stages of change, substance use goals,
Being responsive to the relapsing nature of opioid/substance use
not all clients are ready for formal counselling, this gives an informal way to check-in and promote services if they do decide to engage
Overdose Education:
Review risks related to stabilization period starting methadone
Review risks related to poly substance use, especially CNS (alcohol, benzo’s and other opioids)
promote information and provide referrals for Naloxone program.
Resolving ambivalence/ increasing skills- promoting retention
Assisting with safety plans and care plans for safe moderate use during induction/stabilization phases for methadone/suboxone
Example: TedV- Oxy 40’s/for 4 days- 24 abstinence/ comfort kit info/ provide family education to increase understanding and support

39. COAP Clinic Collaborations: Dr. Lee
Rationale for Collaboration:
“For various reasons, patients have a tendency to not attend referrals for counselling.   With counsellors on site, it eases the anxiety of having to make contact with a new agency and then meet a new person.   The patients are very comfortable with the on-site staff and this facilitates their attendance at booked 1:1 sessions, or even group work.”
Benefits:
“There is a noticeable improvement in how quickly patients become abstinent from opiate use -versus at the other clinic that I work where it seems to take longer to achieve abstinence.”
What we have observed
Some existing clients that were there when COAP started are not necessarily interested in counselling
For people well-established at the clinic who are fairly stable on OST, content with where things are at, not accessing services at this time
However, significant uptake for new people coming into the clinic, majority coming via ADSTV
There is a difference between people who started at the clinic before COAP vs. people who have started since COAP has been at the clinic
Benefits:
There is a noticeable improvement in how quickly patients become abstinent from opiate use (versus the other clinic that I work where it seems to take longer to achieve abstinence).   With on-site counsellors, patients will receive input and support from several different sources.   Although the patients might spend more time in the clinic, there is less time spent waiting - more time is spent engaged with a counsellor or physician.

40. COAP Clinic Collaborations: Dr. Gracey
Rationale for Collaboration:
“The recovery process is more than just medication. Counselling helps to address the underlying issues and give alternatives to chemical coping.”
Benefits:
“Timing is key. It’s better to have counselling in house. It’s more accessible, less intimidating and people are more likely to attend when it feels familiar. You have to get them while they are ready.”
Dr. Janel Gracey

41. COAP Clinic Collaborations: Dr. McDonagh
Rationale for Collaboration:
“The treatment of addiction requires a multifaceted approach. Pharmacological treatment alone, doesn’t work”
Benefits:
“Having counselling in house shows greater interest in the patient and reinforces the common goal of recovery. It encourages people to come back and slow down their service encounter. It’s a win, win, win situation.”
Dr. Tom McDonagh

42. Client Story
BB is a longstanding client of the agency with multiple physical and mental health concerns
BB experienced a recent relapse and sought Drop In support at ADSTV
COAP staff met with BB, provided OST education and set up a referral to the Suboxone Clinic.
BB attended the clinic for induction to Suboxone, but was hospitalized the next day due to an infection from injecting.
Dr. Lee was able to see BB at the hospital, to check in on BB’s status and provide a Suboxone script.
After discharge, BB returned to the clinic and received a physical health follow up.
BB expressed overwhelming satisfaction with the process
BB reported feeling supported and appreciated seeing the same people from place to place, having that warm transfer and personal follow up. 

43. COAP Clinic Collaborations: Challenges
Adhering to routine, scheduled appointments
Balancing respect for self determination with engagement strategies
Space and Time constraints
limits service delivery
Confidentiality considerations between clients and clinic
Role of advocacy/redirecting triangulation
Stigma
Adhering to routine, scheduled appointments
Space and Time constraints- limits service delivery
Confidentiality considerations between clients
Impossible to keep confidential who is attending counselling at TSTC due to shared waiting room and office hours with clinic
Considerations about confidentiality for clients- if /when groups are run- small pool of people all from same clinic/ same rural region- cross talk outside of group with other clinic patients
Confidentiality considerations regarding clinic: preserving the therapeutic rapport when client knows there is shared reporting of UDS information with clinic doctor. Client concerns about how much control they retain over the limits of what is shared between the two parties.
Role of advocacy/ Triangulation: fulfilling the role of advocate and promoting client self efficacy while maintaining respectful, professional relationship/ protecting partnership relationship with clinic- when client concern/ treatment goal revolves around relationship with clinic physician.- requires redirecting attempts at triangulation.
Stigma: responding to stigmatizing attitudes and beliefs expressed by clinic staff
=just an FYI, but most of the clients have expressed feeling less stigma at the COAP clinic than the others, as they do not have to sit in the methadone clinic- what is known as the methadone clinic.  (we also have a client who shared about the lack of stigma seeing his GP; the location is key for sure)
What we have observed
Some existing clients that were there when COAP started are not necessarily interested in counselling
For people well-established at the clinic who are fairly stable on OST, content with where things are at, not accessing services at this time
However, significant uptake for new people coming into the clinic, majority coming via ADSTV
There is a difference between people who started at the clinic before COAP vs. people who have started since COAP has been at the clinic
New model of care

44. COAP Clinic Collaborations: Challenges
Urine Drug Screening & The Therapeutic Alliance
No clear negative impacts
Possible benefit:
Full disclosure of substance use with counsellor
Allows for counsellor to deliver more comprehensive service
Clinical Considerations
Normalize and separate UDS and counselling
Provide client with full disclosure of dual role at time of intake
Invite questions and provide reassurances of confidentiality and self determination
Establish clear consent to discuss UDS results in counselling and/or in front of clinic doctor
We contemplated any benefits and consequences to the therapeutic rapport, from the dual role of performing UDS and counseling
Counsellors reflected that they have not observed negative consequences or received complaints/concerns about the dual role
Can be difficult to manage as a worker, unpleasant smell/process/blood in urine, how but does not negatively impact the client relationship
Traditionally counsellors would not perform UDSs.
But we were faced with the choice of to do this or not provide the counselling service at the clinic.
So counsellors developed ways to keep the relationship with the clients as transparent as possible.
It's common sense really but the "scope" issue can be a barrier that prevents service. Others may have to make other decisions. 
Possible Benefits:
Client’s are honest in session, unsure if this is due to UDS and knowing their test results will be discussed
UDS supposed to be helpful as well and allow COAP to provide support and education in non-judgmental way
If client does intake with COAP at the clinic, they do inform about administering the UDS and providing them all the information
Clinical Considerations:
Normalize and separate UDS and counselling
Two separate things, UDS is something people have to do, requirement, in order to maintain their Suboxone
Invite questions and provide reassurances of confidentiality and self determination
Explain that UDS results are not automatically shared with their COAP counsellor- noting the exception of the two counsellors at the clinic who are preforming the UDS
COAP worker would not use the UDS results during the session without client’s permission
The client is given the opportunity to not talk about the results of their UDS, not outing them
Establishing clear consent from the beginning
If find out using a substance that was not disclosed, COAP worker will ask for permission to sit in with Dr. Lee during the appointment
No concerns with client’s information being shared with Dr. Lee
Some people may challenge the UDS role with the counsellor role – again, you will have to articulate that
the need/desire to address the need created a need to modify traditional roles – and articulate the (as you have) the clarity that is established from transparent conversations with clients upfront.
Flexibility, with clinical integrity have guided the development of the clinic supports.

45. COAP Clinic Collaborations: Challenges
Readiness
Readiness for OST does not automatically indicate readiness for counselling
10% Addiction
90% Underlying Issues
Excitement
Trauma (past/present)
Mental Health
Chronic Pain
Loss
Grief
Homelessness
Poverty
Shame
Guilt
Stress
Loneliness
Boredom…
The behaviour of using
Managing clinical expectation:
Not everyone who starts substitution therapy will be ready for counselling. We must be careful not to equate readiness to make changes to the observable behaviours related to substance use i.e. getting substances, using substances, recovering from the use of substances and getting more substances with readiness to address the underlying issues of substance use.
Some people, after a period of stability on substitution therapy, may move toward counselling. For others, the stability gained from OST is enough and will never seek to address their underlying issues through formal counselling.

46. COAP Clinic Collaborations: Insights
Time to stopping opiate use seems to be faster than traditional Methadone/Suboxone clinic settings.
Mandatory initial consult good practice
Stigma is pervasive- address at individual and systemic level
Clear communication about confidentiality is key
Complaints of chronic pain common- challenging to address substance use problem and chronic pain
Robust communication between counselor and clinic benefits the counselor, clinic and client
“Time to stopping opiate use seems to be faster than traditional Methadone/Suboxone clinic settings.” Dr. Lee

47. Questions/Comments/Discussion