1. Methadone Maintenance Opioid Addiction Assessment

2. Assess yourself and your team first Assess yourself and your team first

3. You and Your Clinic High Threshold vs Low Threshold High Threshold vs Low Threshold High threshold says IV opioids for years High threshold says IV opioids for years Low threshold says opioids affecting life function – accepts codeine Low threshold says opioids affecting life function – accepts codeine

4. High Tolerance vs Low Tolerance High tolerance accepts many behaviour problems and ongoing drug use, if some stability is occurring High tolerance accepts many behaviour problems and ongoing drug use, if some stability is occurring Low tolerance has strict rules – may take you off for missed appointments, ongoing marijuana or cocaine use, etc Low tolerance has strict rules – may take you off for missed appointments, ongoing marijuana or cocaine use, etc Carry policy and Urine Drug Screen Policy Carry policy and Urine Drug Screen Policy

5. Complexity Social Social Medical Medical Psychiatric Psychiatric Adolescent Adolescent Pregnant Pregnant HIV and Hep C HIV and Hep C The unpleasant patient The unpleasant patient Chronic pain Chronic pain

6. Clinic Comprehensiveness Methadone only Methadone only Methadone and primary care (Accept stable patients after start elsewhere) Methadone and primary care (Accept stable patients after start elsewhere) Methadone, Contingency, Counselling Methadone, Contingency, Counselling High level combined care – HIV, Hep C, street outreach, pregnancy……… High level combined care – HIV, Hep C, street outreach, pregnancy………

7. Money Clinics with government support Clinics with government support Clinics with fee for service – it doesn’t pay enough for the associated work load Clinics with fee for service – it doesn’t pay enough for the associated work load Can you link with addiction programs? Can you link with addiction programs?

8. Goals of Assessment 1. Is the patient addicted to opioids? 2.If so, is the patient a candidate for methadone? 3. If so, does the patient want methadone? 4.If so, do you want this patient? 5.Identify other potential problems (housing, financial, legal, family, travel) 6. Any special health risks?

9. The Invisible Assessment Therapeutic Alliance begins here. Therapeutic Alliance begins here. You evaluate the patient for honesty, humor, intelligence, perseverance…..dishonesty, anger, criminality You evaluate the patient for honesty, humor, intelligence, perseverance…..dishonesty, anger, criminality The patient evaluates you - frankness, kindness, trust, confidentiality, do you know addiction? The patient evaluates you - frankness, kindness, trust, confidentiality, do you know addiction?

10. Setting the Stage for Success Honesty and frankness Honesty and frankness Accepting of where they’re at – with hope for change – environment of support Accepting of where they’re at – with hope for change – environment of support Safety talk Safety talk Early limit setting Early limit setting

11. Assessment Social – who are they as a person? Who are their supports? Housing? Other family members or close friends on opioids or unstable? Legal? Financial? Kids? Social – who are they as a person? Who are their supports? Housing? Other family members or close friends on opioids or unstable? Legal? Financial? Kids? Income? Dealing, stealing, peeling? Income? Dealing, stealing, peeling? Behavioural addictions? Behavioural addictions? Goals in life Goals in life

12. Substance Use Identify past or present significant problems – do any need to be part of a care plan? Identify past or present significant problems – do any need to be part of a care plan? Crack, Cocaine. Crystal meth, OTC’s, Alcohol, Benzo’s Crack, Cocaine. Crystal meth, OTC’s, Alcohol, Benzo’s Is cocaine the major drug and opioids a side issue? Is cocaine the major drug and opioids a side issue?

13. Opioids How and when did it begin? What effect did they feel? How long have they had daily or near-daily use? What happens when they try to quit? What’s their drug of choice and what’s their dose range? Any high risk use of other opioids? (Tyl 1’s. IV use, fentanyl, street methadone) How and when did it begin? What effect did they feel? How long have they had daily or near-daily use? What happens when they try to quit? What’s their drug of choice and what’s their dose range? Any high risk use of other opioids? (Tyl 1’s. IV use, fentanyl, street methadone) Evaluating addiction vs abuse Evaluating addiction vs abuse Evaluating addiction vs pain Evaluating addiction vs pain Street or Prescription? Who’s the doctor? Street or Prescription? Who’s the doctor?

14. If it’s opioid addiction, continue If it’s opioid addiction, continue If it’s not, follow another track If it’s not, follow another track

15. Gus Alcoholic, sober for 15 years and very active in AA Alcoholic, sober for 15 years and very active in AA At 48, suffers relationship break-up and failure of business – rapid decline into IV cocaine and IV opioids At 48, suffers relationship break-up and failure of business – rapid decline into IV cocaine and IV opioids After assessment, the cocaine appears to be the main driver, and the opioids are a “smoothing” or “crash rescue” use After assessment, the cocaine appears to be the main driver, and the opioids are a “smoothing” or “crash rescue” use

16. Significant Chronic Pain Avoid these complex patients until you are experienced Avoid these complex patients until you are experienced And then you’ll still have trouble! And then you’ll still have trouble!

17. Other Basics Medical history, risk of HIV & Hep C, pregnancy Medical history, risk of HIV & Hep C, pregnancy Psychiatric history – suicide risk, past trauma, Bipolar, ADD, eating disorder Psychiatric history – suicide risk, past trauma, Bipolar, ADD, eating disorder Smoking Smoking

18. DPIN Check it – look for non-compliance, consistency with history, early refills (which indicate physician behaviour as well as patient behaviour) Check it – look for non-compliance, consistency with history, early refills (which indicate physician behaviour as well as patient behaviour) Notify physicians Notify physicians Explore taking over benzo prescribing Explore taking over benzo prescribing

19. Physical Exam Basics Basics Infected injection sites Infected injection sites Pregnancy, need for birth control Pregnancy, need for birth control

20. Urine Drug Screen Is it consistent with history? Is it consistent with history? A non-addicted patient can take some percs or T 3’s to have a positive screen A non-addicted patient can take some percs or T 3’s to have a positive screen Synthetics (oxycodone, fentanyl) may not show – know your screen Synthetics (oxycodone, fentanyl) may not show – know your screen Some patients have negative drug screens but are addicted and need treatment Some patients have negative drug screens but are addicted and need treatment

21. Collateral Very useful in difficult cases Very useful in difficult cases

22. Are These a Problem? Transportation Transportation Lives out of town Lives out of town Paying for medication Paying for medication Driving and sedation Driving and sedation Unsafe housing (no Sat or Sun carries) Unsafe housing (no Sat or Sun carries) Clinic hours vs work and school Clinic hours vs work and school Addicted family members Addicted family members

23. Assessment Is Done Is the patient addicted to opioids? Is the patient addicted to opioids? ASAM – loss of control, craving, compulsion, consequences and can’t stop ASAM – loss of control, craving, compulsion, consequences and can’t stop DSM 4 – tolerance, withdrawal, time spent obtaining, loss of other interests, consequences, preoccupation and planning DSM 4 – tolerance, withdrawal, time spent obtaining, loss of other interests, consequences, preoccupation and planning

24. Yes, He’s Addicted Is he appropriate for methadone? Is he appropriate for methadone? Depends on your provincial guidelines and your clinic guidelines….in Manitoba, addicted for one year with significant life consequences Depends on your provincial guidelines and your clinic guidelines….in Manitoba, addicted for one year with significant life consequences Pregnant patients and medically ill patients do not need the “one year” requirement Pregnant patients and medically ill patients do not need the “one year” requirement

25. What Does the Patient Want, How Does He Perceive the Problem? Does he think he ‘s addicted? Does he think he ‘s addicted? Does he think it’s a serious problem that needs organized help and real work? Does he think it’s a serious problem that needs organized help and real work? Does he want to keep it a secret from all? Does he want to keep it a secret from all? Is he totally focused on only one kind of treatment – “I only need detox” or “It has to be methadone” Is he totally focused on only one kind of treatment – “I only need detox” or “It has to be methadone” Has he learned from friends’ experience? Has he learned from friends’ experience?

26. Choices in Opioid Addiction 1. Continue using 1. Continue using 2. Abstinence (detox plus treatment) 2. Abstinence (detox plus treatment) 3. Methadone with goal of taper 3. Methadone with goal of taper 4. Methadone as long term medication 4. Methadone as long term medication 5. Suboxone 5. Suboxone 6. Chronic pain - perhaps tightly controlled opioid dispensing or methadone 6. Chronic pain - perhaps tightly controlled opioid dispensing or methadone

27. Suboxone Many advantages – safer, better side effect profile, easier to wean off, better with HIV meds Many advantages – safer, better side effect profile, easier to wean off, better with HIV meds Expensive ($500 a month) – might get it covered Expensive ($500 a month) – might get it covered Once you have your methadone exemption, do the internet course and apply to the College (www.suboxonecme.ca) Once you have your methadone exemption, do the internet course and apply to the College (www.suboxonecme.ca)

28. Choices 1. continue using 1. continue using 2. abstinence 2. abstinence 3. methadone/suboxone 3. methadone/suboxone

29. You Think His Choice is Crazy! Who decides? Will you help him into abstinence based treatment even though you’re sure he needs the long term stability of methadone? Who decides? Will you help him into abstinence based treatment even though you’re sure he needs the long term stability of methadone? What about the nice guy who looks normal, is working, has money – you think he should try abstinence, he wants MMT? What about the nice guy who looks normal, is working, has money – you think he should try abstinence, he wants MMT? Or the guy who knows detox alone will cure him? Or the guy who knows detox alone will cure him?

30. Try Abstinence First? Old thinking – yes Old thinking – yes New thinking – MMT is reasonable first option in patient with significant addiction who wants this option – but know your provincial guidelines New thinking – MMT is reasonable first option in patient with significant addiction who wants this option – but know your provincial guidelines MMT is option of choice in patients with major life instability MMT is option of choice in patients with major life instability

31. Consider Abstinence Relative Stability Relative Stability healthy, psychiatric stability healthy, psychiatric stability supports with sober family and friends and finances supports with sober family and friends and finances not addicted very long not addicted very long interested in “recovery” work and AA, NA interested in “recovery” work and AA, NA no polysubstance abuse or alcoholism no polysubstance abuse or alcoholism honesty honesty

32. Abstinence Choices Know your resources Know your resources Detox alone is not a good option – follow it with treatment unless patient refuses Detox alone is not a good option – follow it with treatment unless patient refuses Plan for real support - rarely successful on the first try Plan for real support - rarely successful on the first try Family and patient may be very demoralized by failure Family and patient may be very demoralized by failure Risk of death higher in abstinence Risk of death higher in abstinence

33. Methadone in the “nice patient”? Fairly stable, healthy, appears “together”. Using 1-2 years Fairly stable, healthy, appears “together”. Using 1-2 years Financial strain and can’t stop Financial strain and can’t stop ?reasonable for methadone ?reasonable for methadone Discuss all options fully, time to think Discuss all options fully, time to think

34. Consider Methadone 1. Psychiatric instability 2. Physical health consequences, HIV 3. Pregnancy 4. Chronic pain 5. Unstable family, addicted relatives 6. Polysubstance abuse 7. Social and legal and financial stressors 8. Failed abstinence attempts 9. Addicted for significant length of time (18 months) 10. Injection Use

35. Does the Patient Want MMT? Discuss Discuss Reading material Reading material Time to decide Time to decide Informed consent Informed consent Knowledge of tight program rules Knowledge of tight program rules Knowledge of long-term program, may not be able to ever stop using opioids Knowledge of long-term program, may not be able to ever stop using opioids

36. Family “I get sick to my stomach just hearing the word methadone” “I get sick to my stomach just hearing the word methadone” “His uncle is a doctor who says methadone is totally inappropriate`` “His uncle is a doctor who says methadone is totally inappropriate`` ``We want him to …….`` ``We want him to …….`` The patient has the right to decide but it’s hard without family back up. The patient has the right to decide but it’s hard without family back up.

37. Yes, he wants it…. Clinic rules and treatment agreement Clinic rules and treatment agreement Safety considerations Safety considerations Notify prescribers and pharmacy Notify prescribers and pharmacy Go! Go!

38. Rules to Live By Be able to care and to say no Be able to care and to say no Safety always trumps other considerations Safety always trumps other considerations Trust is earned, not given Trust is earned, not given The patient who lies sounds just like the patient who is telling the truth The patient who lies sounds just like the patient who is telling the truth An ongoing relationship becomes the most important therapeutic tool An ongoing relationship becomes the most important therapeutic tool Remember how disordered some families may be Remember how disordered some families may be

39. Methadone Taper Placed the patient on methadone with goal of stabilization and taper over few weeks or months – where will the emotional growth and recovery treatment occur? Placed the patient on methadone with goal of stabilization and taper over few weeks or months – where will the emotional growth and recovery treatment occur? Can treat relapse as a learning experience and try again with more supports Can treat relapse as a learning experience and try again with more supports

40. Practicalities How many people here are considering working in a setting providing methadone services……….. How many people here are considering working in a setting providing methadone services……….. ?doctors ?doctors ?pharmacists ?pharmacists ?nurses and social workers and counsellors ?nurses and social workers and counsellors

41. How to Get an Exemption for MMT Methadone for pain – separate process Methadone for pain – separate process Methadone for addiction Methadone for addiction - addiction experience - addiction experience - knowledge of methadone & safety - knowledge of methadone & safety - book learning - book learning -practical learning at clinic – assessments and follow-ups -practical learning at clinic – assessments and follow-ups -find a mentor -find a mentor

42. A Methadone Exemption Ask College advice re your suitability Ask College advice re your suitability Take a course – 1 day in Winnipeg June 2010 Take a course – 1 day in Winnipeg June 2010 Clinical experience Clinical experience Submit documentation to the College Submit documentation to the College 1-4 months later, Health Canada provides exemption and you can start MMT prescribing 1-4 months later, Health Canada provides exemption and you can start MMT prescribing Enjoy working – minimal wage – major stress – major patient change! Enjoy working – minimal wage – major stress – major patient change!

43. Clinical Experience Minimum of 4 half day clinics, with experienced supervising physician who assesses you for appropriate knowledge, attitudes, skills Minimum of 4 half day clinics, with experienced supervising physician who assesses you for appropriate knowledge, attitudes, skills More experience if you want to open a new clinic or operate solo More experience if you want to open a new clinic or operate solo

44. Styles of Practice Full clinic - assessments, link with other addiction care, treat and follow, manage more complex problems Full clinic - assessments, link with other addiction care, treat and follow, manage more complex problems Family practice – follow 10-20 relatively stable patients who started treatment in a full clinic Family practice – follow 10-20 relatively stable patients who started treatment in a full clinic

45. Methadone Safety 1-3 per thousand patients die, usually during induction 1-3 per thousand patients die, usually during induction Family and friends may be unstable and have access to the methadone Family and friends may be unstable and have access to the methadone Diversion occurs - to people in withdrawal and to people who want to experiment Diversion occurs - to people in withdrawal and to people who want to experiment It has strange pharmacology It has strange pharmacology

46. Build in review and mentoring Your team – doctor, nurse, counsellor, pharmacist – are protocols needed? Your team – doctor, nurse, counsellor, pharmacist – are protocols needed? Your back up - questions, chart reviews, ongoing education Your back up - questions, chart reviews, ongoing education Review bad outcomes and learn from them Review bad outcomes and learn from them Remember long term addiction needs a lot of time to change behavioural characteristics – deception and manipulation and distrust have been survival traits Remember long term addiction needs a lot of time to change behavioural characteristics – deception and manipulation and distrust have been survival traits

47. Be Prepared for Change and Surprises

48. Financial and CME support CME can make this a self learning experience for significant CME credits – contact Dr Francois CME can make this a self learning experience for significant CME credits – contact Dr Francois Manitoba government will support some clinical training time if your RHA or Clinic not compensating you. Contact Dr. Lee Manitoba government will support some clinical training time if your RHA or Clinic not compensating you. Contact Dr. Lee

49. Books Client guide to methadone maintenance Client guide to methadone maintenance AFM recommended practices in MMT AFM recommended practices in MMT Ontario guidelines – for doctors Ontario guidelines – for doctors - for counsellors - for counsellors

50. A Side Issue - Safe Prescribing…

51. Opioids and Chronic Pain Toolkit Summary of the new guidelines Summary of the new guidelines The opioid manager The opioid manager Tool sheets –Opioid taper Tool sheets –Opioid taper -Benzo taper -Benzo taper -Opioid equivalence chart -Opioid equivalence chart -Opioid Risk Tool -Opioid Risk Tool -Urine drug screening -Urine drug screening -Treatment Agreement -Treatment Agreement