Prescription Opioids Trainer Guide

Transcription

Prescription Opioids:
What HIV Clinicians Need to Know
Trainer Guide
Table of Contents
Background Information ..................................................................................................................... 3 What Does the Training Package Contain? ....................................................................................... 4 What Does This Trainer’s Manual Contain? ...................................................................................... 4 How is This Trainer’s Guide Organized? ........................................................................................... 4 General Information about Conducting the Training........................................................................ 4 Materials Needed to Conduct the Training ........................................................................................ 5 Overall Trainer Notes ........................................................................................................................... 5 Slide-By-Slide Trainer Notes ............................................................................................................... 6 Title Slide and Training Collaborators (Slides 1-2) .................................................................. 6-7
Pre-Test Questions and Educational Objectives (Slides 3-11) ..............................................7-9
Introduction to Psychoactive Drugs (Slides 12-15) .............................................................10-12
What is a Substance Use Disorder? (Slides 16-21) ............................................................13-14
A Quick Overview of Prescription Drug Misuse: What’s the Problem? (Slides 22-29) ........ 15-22
A More In-Depth Look at Prescription Opioids (Slides 30-42).............................................23-30
The Epidemiology of Prescription Opioids (Slides 43-57) ...................................................30-39
Pain Management: Issues for HIV Clinicians and Other Health Care Providers
(Slides 58-70) ......................................................................................................................39-49
Effective Behavioral Treatment Interventions for Rx Opioid Misuse (Slides 71-78) ............49-55
Effective Medical Treatment Interventions for Rx Opioid Misuse (Slides 79-104) .............. 55-73
Importance of Coordinated Care (Slides 105-112) .............................................................74-76
Post-Test Questions, Take Home Points, and Key Resources (Slides 113-122) ...............76-81
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Background Information
The purpose of The Prescription Opioids Training Package is to provide HIV clinicians
(including, but not limited to physicians, dentists, nurses, and other allied medical staff,
therapists and social workers, and counselors, specialists, and case mangers) with a
detailed overview of prescription opioid misuse and behavioral and medical approaches
for treating opioid-dependent individuals. The package was developed for the Pacific
AIDS Education and Training Center, based at Charles R. Drew University of Medicine
and Science. Principle authorship was by Beth Rutkowski, M.P.H., Associate Director
of Training of UCLA ISAP, and Thomas Freese, Ph.D., Director of Training of UCLA
ISAP and Principal Investigator/Director of the Pacific Southwest ATTC. We wish to
acknowledge Phil Meyer, LCSW, Elissa Bradley, MPH, and Tom Donohoe, MBA from
the PAETC.
The introductory training includes a 122-slide PowerPoint presentation, this Trainer’s
Guide, and a companion 2-page fact sheet.
The duration of the training is
approximately 90-120 minutes, depending on whether the trainer chooses to present all
of the slides, or a selection of slides.
Slides 12-21 have been included for audiences who have little or no familiarity with
psychoactive drugs and substance use disorder-related terminology. If you are
presenting to an audience that is knowledgeable about SUD, you may decide to hide
these slides when presenting the information.
Pre- and post-test questions have been inserted at the beginning and end of the
presentation to assess a change in the audience’s level knowledge after the information
has been presented. An answer key is provided in the Trainer’s notes in slides 4-8 and
slides 114-118.
Audience Response System (ARS) can be utilized, if available, when facilitating the preand post-test question sessions, as well as the questions contained on slides 80-83.
In addition, a series of case studies have been inserted throughout the presentation to
encourage dialogue among the training participants, and to illustrate how the
information contained within the presentation can be used clinically.
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What Does the Training Package Contain?
 PowerPoint Training Slides (with notes)
 Trainer’s Guide with detailed instructions for how to convey the information and
conduct the interactive exercises
 Two-page fact sheet entitled, “Tips for HIV Clinicians Working with Prescription
Opioid Users”
What Does This Trainer’s Manual Contain?
 Slide-by-slide notes designed to help the trainer effectively convey the content of the
slides themselves
 Supplemental information for select material to enhance the quality of instruction
 Suggestions for facilitating the pre- and post-test questions and case studies
How is This Trainer’s Guide Organized?
For this manual, text that is shown in bold italics is a “Note to the Trainer.” Text that is
shown in normal font relates to the “Trainer’s Script” for the slide.
It is important to note that some slides in the PowerPoint presentation contain
animation. Animations are used to call attention to particular aspects of the information
or to present the information in a stepwise fashion to facilitate both the presentation of
information and participant understanding. Getting acquainted with the slides, and
practicing delivering the content of the presentation are essential steps for ensuring a
successful, live training experience. In addition, slide 35 contains a video. Please refer
to the instructions that accompany slide 35 for additional information regarding this
video.
General Information about Conducting the Training
The training is designed to be conducted in small- to medium-sized groups (10-25
people). It is possible to use these materials with larger groups, but the trainer may
have to adapt the small group exercises (case studies) to ensure that there is adequate
time to cover all of the material.
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Materials Needed to Conduct the Training
 Computer with PowerPoint software installed (2003 or higher version) and LCD
projector to project the PowerPoint training slides.
 Flip chart paper and easel/white board, and markers/pens to write down relevant
information, including key case study discussion points.
Overall Trainer Notes
It is critical that prior to conducting the actual training, the trainer practice using this
guide while showing the slide presentation in Slideshow Mode in order to be prepared to
use the slides in the most effective manner.
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Slide-By-Slide Trainer Notes
The notes below contain information that can be presented with each slide. This
information is designed as a guidepost and can be adapted to meet the needs of the
local training situation. Information can be added or deleted at the discretion of the
trainer(s).
Slide 1: Title Slide
The purpose of this introductory training is to provide HIV clinicians
(including, but not limited to physicians, dentists, nurses, and other
allied medical staff, therapists and social workers, and counselors,
specialists, and case managers) with a detailed overview of
prescription opioid misuse and behavioral and medical approaches for
treating opioid-dependent individuals. The duration of the training is
approximately 90-120 minutes (1 ½-2 hours), depending on whether the
trainer chooses to present all of the slides, or a selection of slides.
Slides 12-21 have been included for audiences who have little or no
familiarity with psychoactive drugs and substance use disorder-related
terminology. If you are presenting to an audience that is
knowledgeable about SUD, you may decide to hide these slides when
presenting the information.
Pre- and post-test questions have been inserted at the beginning and
end of the presentation to assess a change in the audience’s level
knowledge after the information has been presented. An answer key is
provided in the Trainer’s notes in slides 3-8 and slides 113-118.
Audience Response System can be utilized, if available, when
facilitating the pre- and post-test question sessions.
In addition, a series of case studies have been inserted throughout the
presentation to encourage dialogue among the training participants,
and to illustrate how the information presented can be used clinically.
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Slide 2: Training Collaborators
This PowerPoint presentation, Trainer Guide, and companion fact sheet
were developed by Beth Rutkowski, M.P.H. (Associate Director of Training of
UCLA ISAP) and Thomas Freese, Ph.D. (Director of Training of UCLA ISAP
and Principal Investigator/Director of the Pacific Southwest ATTC) through
supplemental funding provided by the Pacific AIDS Education and Training
Center, based at Charles R. Drew University of Medicine and Science. We
wish to acknowledge Phil Meyer, LCSW, Elissa Bradley, MPH, and Tom
Donohoe, MBA, from the PAETC.
Slide 3: [Transition Slide] Pre-Test Questions
The purpose of the following five pre-test questions is to test the
current level of prescription opioid knowledge amongst training
participants. The five questions are formatted as either multiple choice
or true/false questions.
INSTRUCTIONS
Read each question and the possible responses aloud, and give
training participants adequate time to jot down their response before
moving on to the next question.
Do not reveal the answers to the questions until the end of the training
session (when you administer the post-test).
Slide 4: Pre-Test Question #1
Answer Key:
Correct response: D (A friend or relative)
**Audience Response System (ARS)-compatible slide
Answer Key:
Correct response: B (False)
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Answer Key:
Correct response: D (All of the above)
Answer Key:
Correct response: D (A and C)
Answer Key:
Correct response: C (Mix them with an undesirable substance)
Slide 9: Introductions
INSTRUCTIONS
In an effort to break the ice and encourage group interaction, take a few
minutes to ask training participants to briefly share the answers to
these four questions. You can ask for several volunteers to share their
responses, if the size of your audience prevents all participants from
sharing.
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Slide 10: Educational Objectives
INSTRUCTIONS
Briefly review each of the educational objectives with the audience.
Slide 11: Educational Objectives, continued
INSTRUCTIONS
Continue by briefly reviewing the remaining two educational objectives
with the audience.
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Slide 12: [Transition Slide] Introduction to Psychoactive Drugs
The first topic of the presentation is a brief introduction to psychoactive drugs
and key terminology. Several of the slides in this section have been adapted
from the “Drugs 101” presentation developed for the United Nations Office of
Drugs and Crime’s Treatnet international training program.
More Information on Treatnet
Treatnet is a network of drug dependence treatment and rehabilitation
centres covering all regions of the world. An initiative of United Nations
Office on Drugs and Crime (UNODC), Treatnet aims to provide
diversified, effective and quality drug dependence treatment and
rehabilitation services, including HIV/AIDS prevention and care. Its
main strategy is to promote dialogue and the sharing of experience
amongst its members and with its partners.
Twenty selected resource centres, together with a capacity-building
consortium and UNODC constitute Treatnet, also known as the
"International network of drug dependence treatment and rehabilitation
resource centres". Participating centres are located in Australia, Brazil,
Canada, China, Colombia, Egypt, Germany, India Indonesia, Iran,
Kazakhstan, Kenya, Mexico, Nigeria, Russia, Spain, Sweden, United
Kingdom and United States. Treatnet collaborates with a variety of
partners including other drug dependence treatment centres
(Associated Treatment Providers) and international organizations.
During its first two years, the network focused on two main goals:
identifying and sharing good practices for drug dependence treatment
and rehabilitation, and improving the capacity to deliver quality
services.
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Slide 13: What are Psychoactive Drugs?
INSTRUCTIONS
Explain that psychoactive drugs achieve their effects by interacting
with the central nervous system (CNS).
Provide some examples from the following:
•
Examples of affected mental processes and behavior:
memory, attention, the way people talk, increased
impulsiveness or aggressiveness.
•
Examples of altered perceptions of reality. For instance,
psychoactive drugs change alertness, response time, and
perception of the world. For example, they can slow down
reaction time while driving. Some can cause
visual/auditory hallucinations.
Additional Information for the Trainer
When absorbed into the body, drugs interact with and modify cells,
organs, and bodily systems by:
•
Altering the way the body normally functions (increasing,
slowing, or enhancing bodily processes, or level or
quality of functioning)
•
Altering the operation of tissues, organs, and systems
•
Affecting hormones and enzymes
•
Impacting processes such as digestion, respiration,
circulation, and mental functioning
Slide 14: Why Do People Initiate Drug Use?
1. While there are many reasons for the initiation into and continued use of
both licit and illicit drugs, key motivators pivot around the main factors
included in the slide.
2. These motivators are not mutually exclusive. They may co-occur for
many people. A person may take drugs for any or all of the reasons
shown.
3. A person may not be aware that these are the underpinning drivers of
drug use. For example, a young woman who finally gets into treatment,
after being referred by her general practitioner, may realize during
treatment that traumatic events that happened to her in childhood
(childhood sexual abuse is very common among women in AOD
treatment) are integrally linked to her problematic drug use.
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Slide 15: [No Title]
1. Drug addiction is considered a brain disease because drugs change the
structure of the brain and how it works.
2. As a result of scientific research, we also know that addiction is a disease
that affects behavior.
3. These brain changes can be long lasting, and can lead to the harmful
behaviors seen in people who abuse drugs.
4. We have identified many of the biological and environmental factors and
are beginning to search for the genetic variations that contribute to the
development and progression of the disease.
5. Scientists use this knowledge to develop effective prevention and
treatment approaches that reduce the toll drug abuse takes on
individuals, families, and communities.
6. Despite these advances, many people today do not understand why
individuals become addicted to drugs or how drugs change the brain to
foster compulsive drug abuse.
At first, people may perceive what seem to be positive effects with drug
use. They also may believe that they can control their use; however,
drugs can quickly take over their lives. Over time, if drug use
continues, pleasurable activities become less pleasurable, and drug
abuse becomes necessary for abusers to simply feel "normal." Drug
abusers reach a point where they seek and take drugs, despite the
tremendous problems caused for themselves and their loved ones.
Some individuals may start to feel the need to take higher or more
frequent doses, even in the early stages of their drug use.
The initial decision to take drugs is mostly voluntary. However, when
drug abuse takes over, a person's ability to exert self control can
become seriously impaired. Brain imaging studies from drug-addicted
individuals show physical changes in areas of the brain that are critical
to judgment, decision making, learning and memory, and behavior
control. Scientists believe that these changes alter the way the brain
works, and may help explain the compulsive and destructive behaviors
of addiction.
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Slide 16: Substance Use Disorder (SUD)
1. This slide provides several examples of terms that are used to describe
the act of ingesting alcohol and other drugs, and terms to describe the
individual who is ingesting these substances.
2. There is a movement within the alcohol and other drug treatment field to
use the term “substance use disorder,” as opposed to substance misuse
or addiction.
Slide 17: What is a Substance Use Disorder?
1. The term “drug addiction” has been replaced with “substance use
disorder” in the definition provided.
2. A substance use disorder is a state in which an individual engages in a
compulsive behavior, even when faced with negative consequences.
This behavior is reinforcing, or rewarding. A major feature of a
substance use disorder is the loss of control in limiting intake of the
addictive substance.
3. The most recent research indicates that the reward pathway may be
even more important in the craving associated with addiction, compared
to the reward itself. Scientists have learned a great deal about the
biochemical, cellular and molecular bases of addiction; it is clear that
substance use disorders are a disease of the brain.
Slide 18: Some Additional Important Terminology
1. This slide reviews three important concepts related to substance use
disorders.
2. Each concept will be reviewed in more detail in the subsequent slides.
Slide 19: Psychological Craving
INSTRUCTIONS
Review the definition of psychological craving.
Provide some examples. For instance, a woman who quit smoking
years ago, but who still feels cravings when exposed to certain
situations (friends who smoke, parties, coffee time).
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Slide 20: Tolerance
INSTRUCTIONS
Review the definition of tolerance.
Provide some examples. For instance, a man who has been drinking
heavily for a while who is able to drink more than other people and not
feel the effects of alcohol because he has developed a tolerance for the
drug.
Ask your audience to provide some examples, as well.
“The most common change produced by prior experience with a drug
is a decrease in responsiveness to its effects. When an organism
becomes less sensitive to the actions of a drug by virtue of past
experience with the drug, we refer to this change as acquired
tolerance.”
Slide 21: Withdrawal
INSTRUCTIONS
Review the list of possible withdrawal symptoms.
Ask participants to provide examples of withdrawal symptoms from
their experience with clients.
1. You can think of the effects of withdrawal as the opposite of those seen
with intoxication.
“The essential feature of Substance Withdrawal is the development of a
substance-specific maladaptive behavioural change, with physiological
and cognitive concomitants, that is due to the cessation, or reduction
in, heavy and prolonged substance use (Criterion A). The substancespecific syndrome causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning
(Criterion B). The symptoms are not due to a general medical condition
and are not better accounted for by another mental disorder (Criterion
C)” (APA, 1995, p. 184-185).
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Slide 22: [Transition Slide] A Quick Overview of Prescription Drug
Misuse: What’s the Problem?
It is almost time to move into the portion of the presentation that describes, in
detail, prescription opioid misuse. Before we get into the specifics of
prescription opioids, we will quickly review prescription drug misuse in
general.
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Slide 23: What is Considered Misuse?
1. Virtually any prescription or over-the-counter medication can be misused.
2. Katz and colleagues define prescription drug misuse as “use of a
medication (for a medical purpose) other than as directed or as indicated,
whether willful or unintentional, and whether harm results or not."
Prescription drug abuse is "any use of an illegal drug; the intentional selfadministration of a medication for a nonmedical purpose such as altering
one’s state of consciousness, e.g., getting high." (SOURCE: Katz NP,
Adams EH, Chilcoat H, Colucci RD, Comer SD, Goliber P, et al. (2007).
Challenges in the Development of Prescription Opioid Abuse-deterrent
Formulations. Clinical Journal of Pain, 23 (8), 648-660).
3. There is no universally accepted terminology for the different aspects of
prescription drug misuse. The following are a few commonly used terms,
and the rationale for their use:
4. Prescription drug misuse – This term can serve as an umbrella term.
Misuse refers to the use of a drug not consistent with medical or legal
guidelines. It can include any of the following: non-medical use,
substance abuse or dependence, addiction, or diversion. But it does not
include physical dependence unless it is part of a pattern of symptoms as
defined under the criteria below:
5. Non-medical use – Defined as the use of prescription medication
without a prescription or the use of a prescription medication for
purposes other than those for which it is prescribed (e.g., for the feelings
it produces or to get high).
6. Substance Abuse/Prescription Drug Abuse – Defined as a pattern of
non-medical use of prescription drugs that causes one or more of the
following adverse consequences related to the repeated use of
substances: (1) failure to fulfill major obligations; (2) use even when it is
physically hazardous to do so; (3) recurrent legal problems; (4) recurrent
social or interpersonal problems.
7. Substance Dependence – A cluster of cognitive, behavioral, and
physiological symptoms indicating that the individual continues use of the
substance despite significant substance-related problems. There is a
pattern of repeated self-administration that can result in tolerance,
withdrawal, and compulsive drug-taking behavior. A problem with this
definition is that patients with chronic pain who take opioids may appear
to have a substance abuse disorder.
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[Notes continue for Slide
23]
Slide 23: What is Considered Misuse?
8. “Addiction” as a term is often replaced by “substance dependence,” etc.
However, many physicians feel that the term ADDICTION more clearly
distinguishes compulsive drug use from physical dependence due to
prolonged medical use. This definition was developed by the American
Society of Addiction Medicine, the American Academy of Pain Medicine,
and the American Pain Society. Addiction is defined as chronic relapsing
brain disease, a primary, chronic, neurobiologic disease with genetic,
psychosocial, and environmental factors influencing its development and
manifestations. It is characterized by behaviors that include one or more
of the following: impaired control over drug use, compulsive use,
continued use despite harm, and craving.
9. Diversion – Defined as diverting opioids from therapeutic channels to
share or sell them for recreational use, treatment of untreated pain in
others, or for financial gain.
**Physical dependence is a biological phenomenon, an adaptive
physiological state that can occur with regular drug use and results in a drug
class-specific withdrawal syndrome with abrupt cessation, rapid dose
reduction, decreasing blood level of the drug, and/or administration of an
antagonist. Most patients who are on chronic opioids or chronic
benzodiazepines, or beta blockers, or clonidine will become physically
dependent. During the first visit(s), it will be difficult to determine which
chronic-pain patients have true addictions. However, with good monitoring in
place, one will start to see aberrant medication-taking behaviors possibly
suggestive of addiction.
SOURCE: NIDA Centers of Excellence for Physician Information.
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Slide 24: Prescription Drugs are Easy to Obtain
1. Review the list of possible sources of prescription medications.
2. Ask participants to provide examples of other places people might
access prescription medications.
3. Psychotherapeutic drugs now make up a larger part of the overall U.S.
drug problem than was true 10–15 years ago, in part because use
increased for many such drugs over that period, and in part because use
of a number of street drugs has declined substantially since the mid1990s. It seems likely that young people are less concerned about the
dangers of using these drugs outside of medical regimen, likely because
they are widely used for legitimate purposes. Also, prescription
psychotherapeutic drugs are now being advertised directly to the
consumer, which implies both that they are used widely and are safe to
use (Monitoring the Future Survey, 2010).
Slide 25: Methods of Prescription Diversion: Four Major Pathways
1. Friends share or trade prescription drugs with other friends (often for
free).
2. Family members may leave medicine in easily accessible places, such
as medicine cabinets and bedroom dressers.
3. Doctor shopping is a method where individuals see several doctors in an
attempt to obtain multiple prescriptions without revealing what they are
doing.
Slide 26: The Prescription Drug Epidemic is Unique in Some Ways
1. Unlike illicit drugs like heroin, cocaine, and methamphetamine,
prescription medications are not illegal or inherently harmful.
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Slide 27: Factors Fueling the Epidemic
1. The increase in prescriptions written for controlled drugs is 12 times
higher than the rate of increase in the general population and almost
three times higher than the increase in prescriptions written for all other
medications.
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Slide 28: Federal Drug Schedules
1. In 1970, the Controlled Substances Act (CSA), Title II of the
Comprehensive Drug Abuse Prevention and Control Act, was signed into
law, thereby providing legal foundation for government prevention of
abuse of drugs and other substances. It consolidates many laws
regulating the manufacture and distribution of narcotics, stimulants,
depressants, hallucinogens, anabolic steroids, as well as chemicals used
in production of controlled substances.
2. Most prescription opioids are classified either as Schedule II or III.
3. Penalties for possession and trafficking differ, depending on the
Schedule of the substance. Refer to
http://nationalsubstanceabuseindex.org/act1970.htm for more information
regarding various penalties.
Schedule I
(a) The drug or other substance has a high potential for abuse.
(b) The drug or other substance has no currently accepted medical use
in treatment in the United States.
(c) There is a lack of accepted safety for use of the drug or other
substance under medical supervision.
Schedule II
(a) The drug or other substance has a high potential for abuse.
(b) The drug or other substance has a currently accepted medical use
in treatment in the United States or a currently accepted medical use
with severe restrictions.
(c) Abuse of the drug or other substances may lead to severe
psychological or physical dependence.
Schedule III
(a) The drug or other substance has a potential for abuse less than the
drugs or other substances in schedules I and II.
(c) Abuse of the drug or other substance may lead to moderate or low
physical dependence or high psychological dependence.
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28]
Slide 28: Federal Drug Schedules
Schedule IV
(a) The drug or other substance has a low potential for abuse relative to
the drugs or other substances in schedule III.
(c) Abuse of the drug or other substance may lead to limited physical
dependence or psychological dependence relative to the drugs or other
substances in schedule III.
Schedule V
(a) The drug or other substance has a low potential for abuse relative to
the drugs or other substances in schedule IV.
(c) Abuse of the drug or other substance may lead to limited physical
dependence or psychological dependence relative to the drugs or other
substances in schedule IV.
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Slide 29: Commonly Misused Rx Drugs
1. The categories of prescription drugs most widely used as illicit intoxicants
and broadly recorded in many of the pertinent databases are: opiates,
sedatives/ tranquilizers, and stimulants.
2. Opioids are primarily used to treat pain – some examples include
Vicodin, Tylenol with codeine, OxyContin, and Percocet.
3. CNS Depressants are used to treat sleep disorders and anxiety
disorders – some examples include: barbiturates, benzodiazepines, and
brands such as Klonopin, Nembutal, Soma, Valium, and Xanax.
4. Stimulants are mainly prescribed to treat ADHD – some examples
include amphetamines, methylphenidate, and brands such as Adderall,
Concerta, Dexedrine, and Ritalin. People also use prescription stimulants
such as Dexedrine and Fastin for weight.
Prescription drug users have developed their own modern, subcultured slang words for prescription pills.
The most common form of slang is for the brand or manufacturer name
to be shortened to one syllable. For example, Vicodin or Percocet
would be called a "Vic" or "Perc."
OxyContin is associated with many individual slang terms. These
include "Oxy," "OC," "Roxy," and "Ocean.”
Many of the euphoria-inducing prescription medications have a
common chemical base of either hydrocodone or oxycondone, so
these slang terms include "Hydros" and "Dones.“
Another way to decipher slang terms for prescriptions medications is
to know the pill's weight or dosage size.
Pharm parties and trail mix refer to parties where several types of pills
are placed in a bowl and attendees grab a handful and ingest some or
all of the pills.
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Slide 30: [Transition Slide] A More In-Depth Look at Prescription
Opioids
The next section of the presentation describes, in detail, prescription opioids.
As was previously mentioned, prescription drug misuse and abuse involves
taking a prescription medication that is not prescribed to you, or taking it for
reasons or in dosages other than as prescribed. Misuse and abuse of
prescription medications can produce serious health effects, including
addiction. Commonly abused classes of prescription medications include
opioids (for pain), central nervous system depressants (for anxiety and sleep
disorders), and stimulants (for ADHD and narcolepsy). Specific opioids
include hydrocodone (Vicodin®), oxycodone (OxyContin®), propoxyphene
(Darvon®), hydromorphone (Dilaudid®), meperidine (Demerol®), and
diphenoxylate (Lomotil®).
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Slide 31: Opioids
INSTRUCTIONS
Introduce opioids by pointing to the different pictures showing various
forms of opioids, including several types of prescription opioid
medications.
Additional information for the Trainer
Opioids are analgesic, or pain-relieving, medications. Studies have
shown that properly managed medical use (taken exactly as
prescribed) of opioid analgesics is safe, can manage pain effectively,
and rarely causes addiction.
Among the compounds that fall within this class are hydrocodone (e.g.,
Vicodin), oxycodone (e.g., OxyContin—an oral, controlled-release form
of the drug), morphine, fentanyl, codeine, and related medications.
Morphine and fentanyl are often used to alleviate severe pain, while
codeine is used for milder pain. Other examples of opioids prescribed
to relieve pain include propoxyphene (Darvon); hydromorphone
(Dilaudid); and meperidine (Demerol), which is used less often because
of its side effects. In addition to their effective pain-relieving properties,
some of these medications can be used to relieve severe diarrhea (for
example, Lomotil, also known as diphenoxylate) or severe coughs
(codeine).
Opioids can be taken orally, or the pills may be crushed and the
powder snorted or injected. A number of overdose deaths have
resulted from the latter routes of administration, particularly with the
drug OxyContin, which was designed to be a slow-release formulation.
Snorting or injecting opioids results in the rapid release of the drug
into the bloodstream, exposing the person to high doses and causing
many of the reported overdose reactions.
Slide 32: Opiate vs. Opioid – Is there a Difference?
1. The term “opiate” refers only to drugs or medications that are derived
directly from the opium poppy. Examples include heroin, morphine, and
codeine.
2.
The term “opioid” is a broader term referring to opiates and other
synthetically-derived drugs or medications that operate on the opioid
receptor system and produce effects similar to morphine. Examples
include buprenorphine and methadone.
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Slide 33: Opioid Receptors
1. Differences in mu receptor interactions are related to clinical use and
abuse liability.
2. Opioids act by attaching to specific proteins called opioid receptors,
which are found in the brain, spinal cord, and gastrointestinal tract. When
these compounds attach to certain opioid receptors in the brain and
spinal cord, they can effectively change the way a person experiences
pain.
3. In addition, opioid medications can affect regions of the brain that
mediate what one perceives as pleasure, resulting in the initial euphoria
or sense of well-being that many opioids produce. Repeated abuse of
opioids can lead to addiction—a chronic, relapsing disease characterized
by compulsive drug seeking and abuse despite its known harmful
consequences.
Slide 34: What is Dopamine?
1. Dopamine is important to normal functioning including mood, decision
making, and memory.
2. L-DOPA is a precursor of dopamine, the medicine which revolutionized
treatment of Parkinson’s Disease; people who suffer from abnormal
dopamine functioning are receiving medication to help regulate it!
3. Using medication to treat abnormal dopamine functioning is standard (i.e.
we have an opportunity to revolutionize treatment of addiction by
extending medications which correct abnormal dopamine functioning to
those suffering from addiction).
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Slide 35: Let’s Take a Look at Normal Dopamine Functioning
INSTRUCTIONS
In order to understand the impact of crack/cocaine on the brain, you
first need to understand the way that the brain works normally (in the
absence of these substances). It is then possible to see how
stimulants like crack change this functioning. A movie will play here
depicting the normal dopamine transmission process.
1. [This slide contains a movie clip that will play when the trainer
clicks on the happy face. In order for this to work, the connection
between the PowerPoint presentation and the video file must be
maintained. When moving the PowerPoint file to another location
on your computer or to another computer, make sure to always
move the video file along with it. If the link becomes broken, the
video will need to be reinserted. Delete the black box that appears
behind the happy face. From the insert menu in PowerPoint, select
“movie.” Select the video file that was included for this training.
When asked, indicate that the movie should play automatically. It
will appear as a black box on the screen. Move the black box
behind the happy face and it should play when the slide show is
being viewed when the trainer clicks on the happy face].
Slide 36: Now let’s take a look at Opioid Addiction
1. When opioids bind to the opioid receptor, they:
- Block the pain signal
- Indirectly cause a release of dopamine
2. This release of dopamine is what leads to much of the pleasurable
sensation from opioids.
- 26 -
Slide 37: Abnormal Dopamine Functioning
1. Alcohol and other drugs change the way that dopamine works in the
brain. At first, they cause a spike in dopamine (resulting in the
euphoric feelings associated with intoxication).
2. In these graphs, the red line indicates the level of dopamine present
in a rat’s brain at baseline and then following the ingestion of
amphetamine, cocaine, alcohol, and opioids.
3. Amphetamine/methamphetamine results in the highest spike,
resulting in intense feelings of euphoria for an extended period of
time.
4. Cocaine also causes a significant spike, although the duration is
much shorter than seen with amphetamine/methamphetamine.
5. Alcohol works on many systems of the brain, but you can see that
some of the effect comes from a small spike in dopamine.
6. With Opioids (e.g., morphine, hydrocodone, oxycodone, heroin), even
though they primarily work on another system in the brain, like
alcohol, they do cause at small spike in dopamine levels.
Slide 38: Opioids: Acute Effects
1. Review the slide to the audience.
2. Opioids can produce drowsiness, constipation and, depending on
amount taken, can depress breathing.
3. A “rush” is generally reported with administration by injection or smoking.
It is not commonly associated with oral administration.
4. Drowsiness is commonly referred to as “nodding out.”
Slide 39: Acute Effects of Opioids, continued
1. The first four (4) effects need to be present to meet the DSM-IV criteria
for opioid intoxication.
2. Other acute effects include itchiness and myoclonus (a brief, involuntary
twitching of a muscle or a group of muscles).
3. Prescription opioids are only safe to use with other substances under a
physician’s supervision. Typically, they should not be used with alcohol,
antihistamines, barbiturates, or benzodiazepines. Because these other
substances slow breathing, their effects in combination with opioids could
lead to life-threatening respiratory depression.
- 27 -
Slide 40: Long-Term Effects of Opioids
1. Read the long-term effects of stimulant use to the audience.
2. Point to the areas of the body that are affected by the use of these drugs.
3. Long-term use of opioids or central nervous system depressants can
lead to physical dependence and addiction.
Chronic users of opioids may develop collapsed veins, infection of the
heart lining and valves, abscesses, cellulitis, and liver disease.
Pulmonary complications, including various types of pneumonia, may
result from the poor health condition of the abuser, as well as from
heroin’s depressing effects on respiration.
Opioid abuse during pregnancy and its many associated environmental
factors (e.g., lack of prenatal care) have been associated with adverse
consequences including low birth weight, an important risk factor for
later developmental delay. In addition to the effects of the drug itself,
street heroin may have additives that do not readily dissolve and result
in clogging of the blood vessels that lead to the lungs, liver, kidneys, or
brain. This can cause infection or even death of small patches of cells
in vital organs. (SOURCE: NIDA InfoFacts.)
There are also consequences from behaviors that may be associated
with opioid abuse, such as infections resulting from unprotected
sexual behaviors, malnutrition, etc. Many of the consequences refer
specifically to injection drug use:
Collapsed veins resulting from repeated injections.
Ask trainees: What do people do if their veins collapse? (Answer: find
another place).
Ask trainees: Where besides the bend in the arm might people inject?
(Answer: other possible places include between toes/fingers, in the
neck, in the thigh, under the tongue, in the groin or genital area).
Viral Infections such as HIV or Hepatitis C, resulting from sharing
injection equipment with people.
Bacterial infections may be caused by not cleaning the injection site
properly or by using needles that have been exposed to bacteria. This
can introduce bacteria to the blood stream.
An abscess is a subcutaneous infection. If untreated, an abscess can
rupture and lead to sepsis or even death.
- 28 -
40]
Slide 40: Long-Term Effects of Opioids
Blood infections can be contracted from bacteria transferred into the
bloodstream via dirty needles/ syringes. The bacteria settles in the
heart, causing an infection of the heart lining (endocarditis) or a
breakdown of the heart’s valves (which causes them to become less
effective at bringing blood to and from the heart).
Arthritis and other rheumatologic problems may develop as a result of
chronic infections and muscle/tissue inflammation.
Slide 41: Symptoms of Opioid Withdrawal
1. Once the body becomes accustomed to an opioid being on board, it may
react if the opioid is removed. The intensity of the withdrawal symptoms
will depend on the level of use (dose and type of opioid) and the
frequency and duration of use (chronicity).
2. Withdrawal symptoms are basically a rebound effect; those functions that
have been depressed or altered by the opioid suddenly emerge again.
Withdrawal symptoms are often the opposite of symptoms seen when
actively using the opioid (e.g., people get constipated when taking
opioids and have diarrhea when withdrawing).
3. First signs of withdrawal occur shortly after the next scheduled dose.
4. The length of withdrawal depends upon the half-life. Opioids with short
half-lives (e.g., heroin) have acute withdrawal symptoms that peak at 3-4
days and then subside by days 3-7. Opioids with longer half-lives have
longer acute withdrawal periods.
5. Regardless of the length of the acute withdrawal, there are protracted
withdrawal symptoms (e.g., aches and pains, general malaise) that
persist for weeks or months after use ceases.
6. Acute withdrawal symptoms are the opposite of acute intoxication
symptoms.
7. Protracted withdrawal symptoms are less severe than the acute
symptoms, but are still experienced as extremely disruptive and
uncomfortable.
8. Anorgasmia = inability to have an orgasm.
9. Anhedonia = inability to feel pleasure in anything (everything seems
“gray”).
- 29 -
Slide 42: A Note Regarding Poly Drug Use
1. Poly drug use often carries with it more risk than use of a single drug,
due to an increase in side effects and drug synergy. The potentiating
effect of one drug on another is sometimes considerable and licit drugs
and medicines – such as alcohol, nicotine, and prescription
medications/HIV antiretrovirals – have to be considered in conjunction
with controlled psychoactive substances.
2. The risk level will depend on the dosage level of the ingested
substances. Concerns exist about a number of pharmacological pairings:
alcohol and cocaine can increase cardiovascular toxicity; alcohol or
depressant drugs, when taken with opioids, lead to an increased risk of
overdose; and opioids or cocaine taken with ecstasy or amphetamines
also result in additional acute toxicity.
“A very dangerous activity among youth and young adults is the
indiscriminate mixing and sharing of prescription drugs, often in
combination with alcohol or other drugs. The effects of these
combinations of substances can be fatal. Combined drug intoxication
(CDI) is an unnatural cause of death due to the simultaneous use of
multiple drugs. Although once uncommon, a medical study recently
showed that over two decades from 1983 to 2004, CDI deaths have
risen 360.5 percent. It has also become a prevalent risk for older
patients.”
SOURCE:
http://www.prescriptiondrugmisuse.org/index.php?page=consequence
s_combination_effect)
Slide 43: [Transition Slide] The Epidemiology of Prescription Opioids
The next portion of the presentation will provide training participants with a
detailed overview of patterns and trends in prescription opioid misuse in the
United States. No single drug abuse indicator can tell the full story of the
extent or impact of prescription opioids. Therefore, data from several
available indicators are presented in an attempt to paint a comprehensive
picture of who uses prescription opioids, and the populations in which use is
most prevalent.
- 30 -
Slide 44: Prevalence of Use
1. Recent concern has focused on opioid use among adolescents and
young adults. Rates of heroin use are on the downturn among youth,
however, the rates of non-medical use of opioids have been steadily
increasing.
2. The annual prevalence of heroin use among youth rose in the mid- and
late 1990s, reaching peak levels in 1996 among 8th graders (1.6%), in
1997 among 10th graders (1.4%), and in 2000 among 12th graders
(1.5%). Since those peak levels, heroin use has declined among
students in all three grade levels to 0.7-.09% (Johnston, O’Malley,
Bachman, and Schulenberg, 2009).
3. However, for the general population over 12 years of age, recent data
show that 13.4% of individuals who reported new use of heroin in the
past 13 to 24 months meet criteria for substance dependence (SAMHSA,
OAS, 2008).
In a first-of-its-kind report, the Centers for Disease Control and
Prevention (CDC) broke down data on health disparities by race,
ethnicity, income, and education, The New York Times reported Jan. 13.
The report included data on the impact of alcohol and drug use on
different segments of the United States population. For example, more
Americans now die from prescription drug overdoses than from illicit
drugs. In particular, White, non-Hispanic deaths from prescription drug
overdoses outnumber those of African-Americans.
The Times said that the "trend switched in 2002, after doctors began
prescribing more powerful painkillers, antidepressants and
antipsychotics - more easily obtained by people with health insurance.“
The full report, CDC Health Disparities and Inequalities Report - United
States, 2011 (PDF), was published Jan. 14, 2011 in the Morbidity and
Mortality Weekly Report, Supplement /Volume 60.
- 31 -
Slide 45: Lifetime Non-Medical Use of Pain Relievers among Young
Adults
1. In 2007, Vicodin/Lortab, Darvocet/Darvon, and Percocet/Percodan were
the most frequently reported prescription pain relievers among young
adults aged 18-25.
2. The rates of lifetime non-medical use of pain relievers are even more
alarming when you compare the 2007 rates with those from just five short
years ago.
3. The largest increases were seen for Vicodin/Lortab, Hydrocodone, and
OxyContin.
Nearly 14% of U.S. residents--an estimated 35 million people ages 12
and older—reported using prescription pain relievers non-medically at
least once in their lifetime, according to data from the 2009 National
Survey on Drug Use and Health (NSDUH). Hydrocodone products (such
as Vicodin® and Lortab®), codeine or propoxyphene products (such as
Darvocet® and Darvon®), and oxycodone products (such as
OxyContin®, Percocet®, and Percodan®) were the most commonly
reported pain relievers, used by 67%, 60%, and 44%, respectively, of
persons who had used a prescription pain reliever non-medically in
their lifetime. Other pain relievers used non-medically included
morphine, Demerol®, tramadol products, methadone, and Dilaudid®.
- 32 -
Slide 46: Past Month Illicit Drug Use among Persons Aged 12 or Older:
U.S., 2009
1. In 2009, 21.8 million individuals aged 12 or older reported past month
use of any illicit drug.
2. Prescription medications (psychotherapeutics) were the second most
prevalent drug, following marijuana. Approximately 7 million individuals
misused a prescription medication at least once in the past month.
3.
Alcohol is not included on this graph. As a point of reference, in 2009,
there were a reported 59.6 million past month alcohol users in the U.S.
With regards to long-term trends among persons aged 12 or older, the
prevalence of past month psychotherapeutic misuse was 2.7% in 20022003, 2.5% in 2004, 2.7% in 2005, 2.9% in 2006 (peak year), 2.8% in 2007,
2.5% in 2008, and 2.8% in 2009. The difference between the 2008 and
2009 estimates were statistically significant, meaning that a
significantly greater number of individuals reported past month
psychotherapeutic misuse in 2009 than in 2008.
Slide 47: Percentage of US Population with Past Month Use of
Pharmaceuticals, by Type
1. The number and percentage of current nonmedical users of
psychotherapeutic drugs in 2009 (7.0 million or 2.8 percent) were higher
than in 2008 (6.2 million or 2.5 percent).
2. Pain relievers are the most prevalent class of pharmaceuticals used by
survey respondents, and are driving the drastic increases in prescription
medication misuse nationwide.
3. Small but statistically significant increases in the percentage using
stimulants (from 0.4 percent in 2008 to 0.5 percent in 2009) and
sedatives (from 0.09 to 0.15 percent) contributed to this increase, along
with a small increase for pain relievers (from 1.9 to 2.1 percent) that was
not statistically significant.
4. Though higher than in 2008, the 2009 rates for any psychotherapeutic
drug use were similar to those in 2007 (6.9 million or 2.8 percent).
- 33 -
Slide 48: Past Month Non-Medical Use of Prescription Medications, by
Age
1. According to the 2008 National Survey on Drug Use and Health, the
percent of U.S. household population aged 12 and older reporting past
month non-medical use of various psychotherapeutic medications is
shown in the table.
2. Opioid drugs show the highest prevalence in this classification with the
highest rates of use among young adults aged 18-25
3. Pain relievers were the most abused prescription drugs overall.
Slide 49: New Non-Medical Users of Prescription Pain Relievers
1. Data from the 2008 NSDUH show that 2.2 million people aged 12 or
older, initiated non-medical use of prescription pain relievers within the
past year.
2. This averages to approximately 6,000 initiates (new users) per day.
3. Young females (aged 12 to 17) are more likely than their 12-17 year-old
male counterparts to have used pain relievers non-medically in the past
year.
4. On the other hand, young adult males aged 18 to 25 (and adult males
aged 26 to 34) had higher rates than their female counterparts.
- 34 -
Slide 50: Treatment Admissions for Primary Prescription Drug Abuse:
U.S., 2007
1. The proportion of all substance abuse treatment admissions aged 12 or
older that reported primary other opiate abuse increased more than fivefold between 1997 and 2007, from less than 1 percent to 5.5 percent.
2. Increases in percentages of admissions reporting non-heroin opiate
abuse cut across age, gender, race/ethnicity, education, employment,
and region.
3. Just over half (53 percent) of primary non-heroin opiate admissions were
male.
4. Most primary non-heroin opiate admissions (89 percent) were nonHispanic White.
5. For primary non-heroin opiate admissions, the average age at admission
was 32 years.
6. One in five (20 percent) non-heroin opiate abusers had a treatment plan
that included medication-assisted opioid therapy.
7. Nearly two-thirds (63 percent) reported secondary drug use (22 percent
reported secondary alcohol use; 22 percent reported secondary
marijuana use; and 18 percent reported secondary cocaine/crack use).
Slide 51: Treatment Admissions for Less Prevalent Primary
Substances: LA County, 2006-2009
1. Primary other opiates treatment admissions accounted for 1.6% of all
admissions in Los Angeles County in the first half of 2009 (JanuaryJune).
2. Further, primary OxyContin treatment admissions specifically accounted
for 0.7% of all admissions in the first half of 2009.
- 35 -
Slide 52: Primary OxyContin and Other Opiate Treatment Admissions,
by LA County SPA
1. In FY 2009-10, a total of 318 treatment admissions in LA County were
attributed to primary OxyContin abuse and a total of 784 were attributed
to primary other opiate/synthetic abuse.
2. If you break down these admissions by Service Planning Area (SPA),
3.5% of all primary OxyContin treatment admissions and 8.9% of all
primary other opiate/synthetic treatment admissions were reported in
SPA 6 (South LA).
3. Primary OxyContin and other opiate/synthetic treatment admissions were
most concentrated in SPA 2 (San Fernando Valley) SPA 3 (San Gabriel
Valley), and SPA 8 (South Bay).
- 36 -
Slide 53: Estimated Number of Drug-Related Emergency Dept. Visits
Related to the Misuse or Abuse of Pharmaceuticals & Illicit Drugs:
2004-2009
1. The estimated number of emergency department (ED) visits involving the
misuse or abuse of pharmaceuticals increased significantly from 2004 to
2009. Nearly 630,000 ED visits in 2004 were related to the misuse or
abuse of pharmaceuticals, compared to more than 1.2 million in 2009.
2. In 2009, approximately one-half (48%) of these pharmaceutical misuse or
abuse visits involved pain relievers, and more than one-third (35%)
involved drugs to treat insomnia and anxiety.
3. Hydrocodone/combinations, oxycodone/combinations, and methadone
are the most frequently mentioned opiates/opioid analgesics.
4. In contrast, the number of ED visits involving illicit drug use was relatively
stable over the same time period. There were 973,591 ED visits related
to the misuse or abuse or illicit drugs in 2009, primarily for cocaine (43%)
and marijuana (39%).
5. These DAWN findings highlight the “importance of heightening
emergency room medical staff’s awareness of nonmedical use of
pharmaceuticals, because these personnel might be the first responders
to people in need of intervention and treatment.”
In 2008, there were an estimated 256,097 emergency department visits
by adults ages 50 or older involving the misuse and abuse of
pharmaceutical drugs—more than double the estimated 115,803 visits
in 2004. According to data from the Drug Abuse Warning Network
(DAWN), pain relievers were the type of pharmaceutical most
commonly involved in such visits (43.5%), followed by anxiety or
insomnia drugs (31.8%). In addition, one-fifth of the ED visits related to
pharmaceutical misuse or abuse also involved alcohol. The authors
suggest that “education for caregivers about the abuse potential of
certain medications and the early warning signs of abuse may be
needed” and that “prevention messages that target older adults could
warn against the dangerous combination of alcohol and
pharmaceuticals.”
SOURCE: Adapted by CESAR from Substance Abuse and Mental
Health Services Administration (SAMHSA), “Drug-Related Emergency
Department Visits Involving Pharmaceutical Misuse and Abuse by
Older Adults,” The DAWN Report, November 25, 2010. Available online
at https://dawninfo.samhsa.gov/pubs/shortreports/default.asp.
- 37 -
Slide 54: OxyContin and Vicodin Use among Secondary School
Students: 2010
1. The misuse of psychotherapeutic prescription drugs (amphetamines,
sedatives, tranquilizers, and narcotics other than heroin) has become a
more important part of the nation’s drug problem in recent years, in part
because the use of most of these classes of drugs continued to increase
beyond the point at which most illegal drugs ended their rise in the late
1990s, and in part because use of most of those same illegal drugs has
declined appreciably since then.
2. The proportion of 12th graders in 2010 reporting use of any of these
prescription drugs without medical supervision in the prior year was
15.0%, up slightly from 14.4% in 2009 but a bit lower than in 2005, when
it was 17.1%.
3. Lifetime prevalence for the use of any of these drugs without medical
supervision in 2010 was 21.6%.
Slide 55: Substance Abuse Challenge: Prescription Drug Sources
1. The majority of people who use prescription drugs non-medically, for
unintended purposes, obtain the drugs from friends and family.
- 38 -
Slide 56: Rx Drug Abuse among Older Adults
1. Older adults have different risk factors than younger adults, due to
differences in metabolism and age-related physiological changes.
2. Older adults use a disproportionate amount of legitimately prescribed
medications.
3. Rates of prescription drug abuse among older adults are high, both
nationally and locally.
Prescription drug abuse among older adults may begin with misuse
due to inappropriate prescribing or lack of compliance. Other factors
may include:
o
Age-related physiological changes (metabolism and
response).
o
Greater likelihood of undiagnosed psychiatric and
medical co-morbidities.
o
Difficulties with complying with complex drug regimens.
o
Drug interactions.
Slide 57: Gender Difference in Prescription Opioid Misuse
1. Jamison and colleagues recommended that women who are taking
opioids to treat non-cancer chronic pain and show signs of "significant
affective stress" should receive treatment for the mood disorder and
counseling on the dangers of relying on opioids to reduce stress and
improve sleep.
2. For male patients taking opioids for non-cancer chronic pain, doctors
should closely monitor known or suspected behavioral problems, conduct
frequent urine screenings, pill counts and compliance monitoring.
- 39 -
Slide 58: [Transition Slide] Pain Management: Issues for HIV Clinicians
and Other Health Care Providers
The next segment of the presentation corresponds to pain management.
More than half of adults in the United States experienced chronic or recurrent
pain in 2003 (Peter D. Hart Research Associates, 2003). Effective
management of pain not only reduces suffering, but also improves sleep,
reduces affective stress, and increases levels of daily functioning (Roper
Public Affairs & Media, 2004); Schneider, 2005). The information contained
in this section of slides will assist health care providers in understanding that
opioid medications can effectively manage pain, distinguishing between
physical and psychological dependence, and reducing patients’ risk of
psychological dependence on opioids during pain management.
In 2010, Jeff Baxter, M.D. (University of Massachusetts Medical School),
wrote a training curriculum entitled, “Minimizing the Misuse of Prescription
Opioids in Patients with Chronic Nonmalignant Pain.” This educational
module was designed as an introduction for health professions students and
primary care residents to a standardized approach to the management of
patients with chronic nonmalignant pain that integrates techniques for the
prevention and detection of misuse of prescription opioids. It is the hope that
increasing provider knowledge and skills early in the educational process will
improve patient safety and the quality of pain treatment while also
decreasing the misuse and diversion of prescription opioids. These
curriculum resources from the NIDA Centers of Excellence for Physician
Information have been posted on the NIDA Web site as a service to
academic medical centers seeking scientifically accurate instructional
information on substance abuse. Questions about curriculum specifics can
be sent to the Centers of Excellence directly: http://www.drugabuse.gov/coe
- 40 -
Slide 59: [No Title]
1. Pain can be thought of as the fifth vital sign (in addition to temperature,
blood pressure, heart rate, and respiration.
2. In 2000, the Joint Commission of Accreditation of Healthcare
Organizations (JCAHO, now known as The Joint Commission) mandated
pain assessment and treatment (with nurse and physician education
required).
3. When opioids are prescribed properly for pain, addiction is rare in
patients without underlying risk factors, and the vulnerabilities are the
same as they are for other addictions: genetic, peer and social
influences, trauma and abuse history
4. It is critical to adequately assess a patient’s pain symptoms before
prescribing a medication (opioid or otherwise).
Slide 60: The Dilemma
1. It is critical to accurately assess and diagnose acute and chronic pain,
and provide the necessary and effective analgesia, if needed.
Slide 61: Non-Opioid Pain Management
1. Adjuvant medications may include antidepressants, anticonvulsants,
steroids, anxiolytics, and muscle relaxants.
2. Many medications with proven efficacy in pain management have also
established potential for abuse and possible progression to psychological
dependence.
3. This potential for abuse requires some caution in their short- and longterm use that initially may increase a clinician’s reluctance to
appropriately prescribe a medication that might be required to alleviate
pain.
4.
Cognitive-behavioral techniques include: (a) relaxation training; (b)
biofeedback; (c) stress management; and (d) self-hypnosis. These
techniques have been shown to increase pain thresholds, thus reducing
the necessity for pharmacological treatments.
- 41 -
Slide 62: Pain Control and Addiction
1. Pseudoaddiction is a phenomenon that is commonly misconstrued as a
form of drug-seeking behavior with the primary aim of abuse.
2. It involves patient behaviors that may occur when pain is under-treated
(e.g., increased focus on obtaining medications or “drug seeking,” “clock
watching,” use of illicit drugs, or deception) and that can be mistaken for
true addiction.
3. You may also see “hyperalgesia,” which is increased pain with increasing
opioid doses.
Slide 63: Diagnosing Addiction in Opioid-Maintained Pain Patients
1. Because pain is subjective the level and kinds of treatment. For this
reason, there are no specific diagnostic criteria to determine when
someone has become addicted.
2. The clinician must consider several factors to determine if use become
problematic including: (1) their ability to control the medication and take it
only as prescribed; (2) use has become compulsive; (3) use continues
despite physical or psychological harm; and/or (4) the presence of
craving.
3. Information about overall risk for problematic or dependent level of use
should come from multiple sources including: (1) a thorough history; (2)
standardized screening instruments; (3) behavioral checklist and
observations; and (4) information gained through therapeutic interactions.
With regards to early intervention for prescription drug abuse, health
care providers should: (1) screen patients w/ abuse symptoms; (2) be
aware of increases in medication amount needed; and (3) frequent,
unscheduled refill requests.
Pharmacists should: (1) provide clear information about proper
medication use, effects and danger of drug interactions; and (2)
prevent prescription fraud by looking for false prescription forms.
Patients should: (1) provide complete medical history; (2) describe
reason for the visit to ensure proper medication; (3) avoid increasing or
decreasing doses or abruptly discontinuing prescription use without
permission from a physician.
- 42 -
Slide 64: Opioid Risk Tool (ORT)
1. Several screening tools are available for the detection of risky opioid use
(see SAMHSA TIP #40 and #43). One that is both brief and easy to use
is the Opioid Risk Tool (ORT). Administration involves simply checking
boxes in the appropriate column for males or females if a symptom is
present.
2. Once completed, add the numbers next to each checked item to obtain
the total score.
3. Scores of 8 or more are indicative of a risk related to opioids and further
assessment should be conducted.
- 43 -
Slide 65: HIV-Related Pain
1. The first step in managing HIV related pain is identifying the type, and if
possible, the cause of pain.
2. Some common types of pain include the following:
a. Peripheral Neuropathy – Pain due to nerve damage, mostly
in the feet and hands. It may be described as numbness,
tingling, or burning. Nerve damage can be caused by HIV
drugs or other medical conditions such as diabetes. The older
HIV drugs that caused the most peripheral neuropathy are not
commonly used today
b. Abdominal Pain – There are many possible causes of
abdominal pain: (1) a side effect of some HIV drugs (for
example cramps); (2) infections caused by bacteria or
parasites; (3) problems of the intestinal tract such as irritable
bowels; (4) inflammation of the pancreas (pancreatitis) caused
by some HIV drugs or by drinking alcohol; (5) bladder or
urinary tract infections (especially in women) ; (6) menstrual
cramps or conditions of the uterus, cervix, or ovaries.
c. Headache – Head pain can be mild to severe, and may be
described as pressure, throbbing, or a dull ache. The most
common causes of mild headaches include muscle tension,
flu-like illness, and HIV drug side effects. Moderate or severe
headaches can be caused by sinus pressure, tooth infections,
brain infections, brain tumors, bleeding in the brain, migraines,
or strokes. Sometimes the cause cannot be determined.
d. Joint, Muscle and Bone Pain – This pain can also be mild to
severe. It may be related to conditions such as arthritis, bone
disease, injury, or just aging. It can also be a side effect of
some HIV drugs and medications for other conditions like
hepatitis or high cholesterol.
e. Herpes Pain – Herpes is a family of viruses common in HIV+
people. Herpes viruses stay in the body for life, going into
hiding and flaring up later. The varicella-zoster herpes virus
first causes chickenpox and later can cause shingles, a
painful rash along nerve pathways. Herpes simplex virus
types 1 and 2 cause painful blisters around the mouth (“cold
sores”) or genital area. Even after a herpes sore heals, a
person may still have persistent pain.
- 44 -
65]
f.
Other Types of Pain: (1) painful skin rashes due to infections
or HIV drug side effects; (2) chest pain caused by lung
infections such as TB, bacterial pneumonia or PCP
pneumonia (Pneumocystis pneumonia); (3) mouth pain
caused by ulcers (“canker sores”) or fungal infections like
thrush; (4) fibromyalgia or related chronic pain conditions; (5)
pain due to cancer anywhere in the body.
In Winter 2010, the NY/NJ AETC released a guide entitled, “Opioid Pain
and Addiction Management Medications: Drug Interactions with HIV
Antiretrovirals.” It is a drug interaction guide for clinicians. The data in
the guide are intended for use by clinicians and other health care
providers as guidance to minimize drug interactions and toxicities
among patients being treated with pain management / addiction
management medications in conjunction with antiretrovirals. For more
information or to order a copy, please visit: www.nynjaetc.org.
With regards to the management of HIV-related pain, several options
exist:
Non-medicinal Therapies (pain relief without medications) include: (a)
massage; (b) relaxation techniques; (c) physical therapy; (d)
acupuncture; (e) heat and cold therapy; (f) hypnosis; and (g) mental
imagery or visualization. While these may be enough to relieve pain,
they are often used along with pain medications.
Non-opioid Medications (pain-relief medications that do not contain
narcotics [opiates]) include those that are available over-the-counter or
by prescription. These medications relieve mild to moderate pain
related to inflammation or swelling. Some people with a history of drug
addiction prefer non-opioid pain medicines such as: (a) Tylenol
(acetaminophen); (b) non-steroidal anti-inflammatory drugs (NSAIDs)
such as aspirin or ibuprofen (for example Advil); (c) COX-2 inhibitor, a
type of NSAID that is less likely to cause stomach problems, for
example Celebrex (celecoxib); and (d) steroids, natural or
manufactured hormones that reduce inflammation. Examples include
prednisone and hydrocortisone. Non-opioid pain medicines can cause
side effects including liver damage (Tylenol), easy bleeding (aspirin),
stomach pain or damage (aspirin and other NSAIDs), and heart
problems (COX-2 inhibitors).
- 45 -
65]
Additional Information for the Trainer, continued
Opioids/Narcotics are usually the strongest pain relievers, and are
available only by prescription. They are used to treat moderate to
severe pain.
Opioids are classified by how fast and how long they work: (a)
immediate release opioids – act rapidly but pain relief lasts for a
shorter period of time; (b) sustained-released opioids – take longer to
start working but pain relief lasts longer.
Opioids are also classified by their strength: (a) mild to moderate pain
relievers (they are often mixed with non-opioid medicines to improve
their action) – hydrocodone; Vicodin (hydrocodone plus
acetaminophen); codeine; Tylenol with codeine (acetaminophen plus
codeine); Ultram (tramadol) ; (b) severe pain relievers – morphine ;
fentanyl; OxyContin (oxycodone); methadone or buprenorphine (not
commonly prescribed in first-line pain reliever treatment).
Opioids can cause side effects including drowsiness, nausea, and
constipation. Overdoses can slow down breathing and cause death.
Opiates can lead to dependence or addiction and may be a problem for
people with a history of substance use.
Topical or Local Therapies are medications that are injected or applied
to the skin around a painful area. Examples include the local anesthetic
Xylocaine (lidocaine) and capsaicin, which comes from chili peppers.
Other Therapies are medicines prescribed for other purposes that also
have pain-relieving properties: (a) anti-depressants – relieve
neuropathic pain such as peripheral neuropathy. An example is
Cymbalta (dulozetine); (b) anti-convulsants – usually used to treat
seizures, some of these drugs work for peripheral neuropathy. An
example is Neurontin (gabapentin).
- 46 -
Slide 66: Reciprocal Nature: Depression-Pain Relationship
1. A significant connection exists between depression and pain.
2. In one study, 2/3 of patients with depression also experienced pain. In
fact, the more physical symptoms that an individual experienced, the
more likely they were to meet criteria for depression.
3. Among pain patients, there was great variability (5-85%) among those
who also experienced depression. Pain patients with depression, had
more pain with greater intensity and longer duration. Depressed patients
were also more likely to have difficulty getting their pain under control.
With regards to grief and pain, a 2008 study by Kowalski & Bondmass
investigated pain and grief correlation in widows. Self-reported
physical symptoms included: pain, gastro-intestinal problems,
medical/surgical conditions, sleep disturbances, and
neurological/circulatory issues. Psychological symptoms included:
depression, anxiety, and loneliness. Of the 173 women in the sample,
about two-thirds the sample reported at least one physical complaint
following spousal loss.
Slide 67: Possible Signs of Inappropriate Opioid Use by Patients
1. Patients taking opioids appropriately for pain management and those
who pain is inadequately relieved may occasionally display behaviors
listed on this slide.
2. The possibility of psychological dependence, however, should be
considered when a pattern of one or more of these signs is observed in
patients.
- 47 -
Slide 68: Reducing the Risk of Psychological Dependence on Opioids
1. Physical dependence is often a natural part of the long-term use of
opioids prescribed for pain and can be managed effectively with
appropriate identification and treatment.
2. Distinguishing between physical and psychological dependence on
opioids is critical for the well-being of the patient.
3. Physical dependence is a physiological adaptation to a substance,
defined by a growing tolerance for its effects and/or withdrawal
symptoms when use is reduced or ends.
4. Psychological dependence is a primary, chronic, neurobiological disease,
with genetic, psychosocial, and environmental factors influencing its
development and manifestations. It may occur with or without physical
dependence.
5. Determining a diagnosis of psychological dependence requires careful
evaluation.
6. The slide contains strategies health care providers can use to reduce the
risk of psychological dependence.
Slide 69: What to do if Opioid Abuse or Dependence is Suspected
1. This slide presents multiple steps health care providers can take when
they suspect that a patient is dependent upon or abusing prescription
opioids.
2. It is important to be nonjudgmental – patients are more likely to be
forthcoming if they are not put on the defensive.
3. Start with sweeping questions, such as “how helpful have your
medications been for you,” rather than beginning with questions about
medication misuse.
4. Ask questions about warning signs.
5. Listen to what patients say about how and why they take their
medications.
6. Inquire about their willingness to try alternative, non-opioid forms of pain
therapy.
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Slide 70: Case Study #1: Pain Management Options for Prescription
Opioid Users
INSTRUCTIONS
Read the case study aloud.
Ask participants to break into pairs or small groups (depending on the
size of the audience), and spend 5-10 minutes discussing the two
questions.
De-brief as a full group for 5-10 minutes. Ask for volunteers to briefly
share responses to the two questions.
Slide 71: [Transition Slide] Effective Behavioral Treatment Interventions
for Prescription Opioid Misuse
The following section pertains to effective behavioral treatment interventions
for prescription opioid misuse. Behavioral treatments help engage people in
drug abuse treatment, modifying their attitudes and behaviors related to drug
abuse and increasing their life skills to handle stressful circumstances and
environmental cues that may trigger intense craving for drugs and prompt
another cycle of compulsive abuse. Moreover, behavioral therapies can help
people remain in treatment longer. Behavioral interventions—particularly,
cognitive-behavioral therapy—have been shown to be effective for
decreasing drug use and preventing relapse. Length of time in treatment is
the #1 predictor of a successful treatment experience. The longer you can
keep a person engaged in treatment, the more likely he/she is to be
successful. Treatment must be tailored to the individual patient’s needs in
order to optimize outcomes—this often involves a combination of treatment,
social supports, and other services. Early engagement techniques should be
utilized to ensure that the client comes back for his/her group and individual
sessions.
Slide 72: What Treatments are Effective for Prescription Opioid
Abusers?
1. Currently, several behavioral treatment approaches have been shown to
be effective for treating prescription opioids.
2. Since several medications have been found to be effective in treating
opioid dependence, it is important to combine use of a medication with a
comprehensive behavioral therapy program. Research shows that this
combination of pharmacological and behavioral interventions is the most
effective method to reduce drug use in the long term.
- 49 -
Slide 73: Behavioral Approach #1: Contingency Management (CM)
1. Contingency management is a tool to enhance treatment and facilitate
recovery, and is used as an adjunct to other therapeutic clinical methods.
2. CM targets specific behaviors that are part of a patient treatment plan.
3. CM helps to celebrate the success of behavioral changes chosen by
therapist and patient.
4. Can be used to help motivate patients through stages of change to
achieve an identified goal.
Slide 74: Behavioral Approach #2: Cognitive Behavioral Therapy (CBT)
1. CBT seeks to help patients recognize, avoid, and cope with the situations
in which they are most likely to abuse drugs.
2. Thoughts cause feelings and behaviors, not external things, like people,
situations,
and events.
3. You can change the way we think to feel / act better even if the situation
does not change.
Slide 75: Behavioral Approach #3: Therapeutic Communities (TCs)
1. Peer influence is used to help individuals learn and assimilate social
norms and develop more effective social skills.
2. Treatment staff and those in recovery are key agents of change.
3. The second fundamental TC principle is "self-help," which implies that
the individuals in treatment are the main contributors to the change
process.
- 50 -
Slide 76: Behavioral Approach #4: Motivational Interviewing (MI)
1. Compared with non-directive counseling, motivational interviewing is
more focused and goal-directed.
2. The examination and resolution of ambivalence is its central purpose,
and the counselor is intentionally directive in pursuing this goal.
Additional Information for the Trainer regarding the “MI Spirit”
The spirit of MI can be characterized in a few key points. The following
information was excerpted directly from
www.motivationalinterview.org:
Motivation to change is elicited from the client, and not imposed from
without. Other motivational approaches have emphasized coercion,
persuasion, constructive confrontation, and the use of external
contingencies (e.g., the threatened loss of job or family). Such
strategies may have their place in evoking change, but they are quite
different in spirit from motivational interviewing which relies upon
identifying and mobilizing the client's intrinsic values and goals to
stimulate behavior change.
It is the client's task, not the counselor's, to articulate and resolve his
or her ambivalence. Ambivalence takes the form of a conflict between
two courses of action (e.g., indulgence versus restraint), each of which
has perceived benefits and costs associated with it. Many clients have
never had the opportunity of expressing the often confusing,
contradictory and uniquely personal elements of this conflict, for
example, "If I stop smoking I will feel better about myself, but I may
also put on weight, which will make me feel unhappy and unattractive."
The counselor's task is to facilitate expression of both sides of the
ambivalence impasse, and guide the client toward an acceptable
resolution that triggers change.
Direct persuasion is not an effective method for resolving ambivalence.
It is tempting to try to be "helpful" by persuading the client of the
urgency of the problem about the benefits of change. It is fairly clear,
however, that these tactics generally increase client resistance and
diminish the probability of change (Miller, Benefield and Tonigan, 1993,
Miller and Rollnick, 1991).
- 51 -
76]
Slide 76: Behavioral Approach #4: Motivational Interviewing (MI)
The counseling style is generally a quiet and eliciting one. Direct
persuasion, aggressive confrontation, and argumentation are the
conceptual opposite of motivational interviewing and are explicitly
proscribed in this approach. To a counselor accustomed to confronting
and giving advice, motivational interviewing can appear to be a
hopelessly slow and passive process. The proof is in the outcome.
More aggressive strategies, sometimes guided by a desire to "confront
client denial," easily slip into pushing clients to make changes for
which they are not ready.
The counselor is directive in helping the client to examine and resolve
ambivalence. Motivational interviewing involves no training of clients in
behavioral coping skills, although the two approaches not
incompatible. The operational assumption in motivational interviewing
is that ambivalence or lack of resolve is the principal obstacle to be
overcome in triggering change. Once that has been accomplished,
there may or may not be a need for further intervention such as skill
training. The specific strategies of motivational interviewing are
designed to elicit, clarify, and resolve ambivalence in a client-centered
and respectful counseling atmosphere.
Readiness to change is not a client trait, but a fluctuating product of
interpersonal interaction. The therapist is therefore highly attentive and
responsive to the client's motivational signs. Resistance and "denial"
are seen not as client traits, but as feedback regarding therapist
behavior. Client resistance is often a signal that the counselor is
assuming greater readiness to change than is the case, and it is a cue
that the therapist needs to modify motivational strategies.
The therapeutic relationship is more like a partnership or
companionship than expert/recipient roles. The therapist respects the
client's autonomy and freedom of choice (and consequences)
regarding his or her own behavior.
- 52 -
Slide 77: MI: Basic Principles and Micro-Skills
1. The strategic goals of MI are to: (a) resolve ambivalence; (b) avoid
eliciting or strengthening resistance; (c) elicit “Change Talk” from the
client; (d) enhance motivation and commitment for change; and (e) help
the client move through the Stages of Change.
2. A series of MI micro-skills (which will be described on the next slide) can
be used to move a patient/client through the Stages of Change to elicit
and reinforce self-motivational statements (a.k.a., Change Talk).
3. Empathy may be the most crucial principle. It creates an environment
conducive to change, instills a sense of safety and a sense of being
understood and accepted, and reduces defensiveness. Empathy sets the
tone within which the entire communication occurs. Without it, other
components may sound like mechanical techniques.
4. By developing discrepancy, the clinician can help the client to become
more aware of the discrepancy between their addictive behaviors and
their more deeply-held values and goals. Part of this is helping client to
recognize and articulate negative consequences of use. It is more
effective if the client does this, not the clinician.
5. With regards to rolling with resistance, in general, it is not helpful to argue
with clients. Confrontation elicits defensiveness, which predicts a lack of
change. It is particularly counter-therapeutic for a clinician to argue that
there is a problem while the client argues that there isn’t one. The client
does not need to accept a diagnostic label (e.g. “addict” or “alcoholic”) for
change to occur.
6. Supporting self-efficacy can be conceptualized as a specific form of
optimism, that is, a “can-do” belief in one’s ability to accomplish a
particular task or change. This principle is crucial to help the client see
and experience his/her own ability to make positive changes. Part of this
is the clinician believing in the client’s ability to change.
7. Open-ended questions: (a) solicits information in a neutral way; (b) helps
the person elaborate his/her own view of the problem and brainstorm
possible solutions; (c) helps the therapist avoid prejudgments; (d) keeps
communication moving forward; (e) allows the client to do most of the
talking.
- 53 -
77]
Slide 77: MI: Basic Principles and Micro-Skills
8. Affirmations should be focused on achievements of the individual, and
are intended to: (a) support the individual’s persistence; (b) encourage
continued efforts; (c) assist the individual in seeing the positive in the
situation; and (d) support the individual’s proven strengths.
9. With reflective listening, one should: (a) listen to both what the person
says and to what the person means; (b) check out assumptions; (c)
create an environment of empathy (nonjudgmental); and (d) be aware of
intonation (statement, not question). The clinician does not have to agree
with the client.
10. Summaries capture both sides of the ambivalence (You say that
___________ but you also mentioned that ________________.) They
demonstrate the clinician has been listening carefully. Summaries also
prompt clarification and further elaboration from the person. Lastly,
summaries prepare clients to move forward.
- 54 -
Slide 78: Behavioral Approach #5: 12-Step Facilitation Therapy
1. Acceptance includes the realization that drug addiction is a chronic,
progressive disease over which one has no control, that life has become
unmanageable because of drugs, that willpower alone is insufficient to
overcome the problem, and that abstinence is the only alternative.
2. Surrender involves giving oneself over to a higher power, accepting the
fellowship and support structure of other recovering addicted individuals,
and following the recovery activities laid out by the 12-step program.
3. While the efficacy of 12-step programs (and 12-step facilitation) in
treating alcohol dependence has been established, the research on other
abused drugs is more preliminary but promising for helping drug abusers
sustain recovery.
4. 12-Step meeting dates, times, and locations can be found by visiting:
http://www.aa.org (Alcoholics Anonymous); www.ca.org (Cocaine
Anonymous); www.na.org (Narcotics Anonymous).
Further Reading:
Carroll, K.M.; Nich, C.; Ball, S.A.; McCance, E.; Frankforter, T.L.; and
Rounsaville, B.J. (2000). One-year follow-up of disulfiram and
psychotherapy for cocaine and alcohol users: Sustained effects of
treatment. Addiction, 95(9): 1335-1349.
Donovan D.M., and Wells E.A. (2007). "Tweaking 12-step": The potential
role of 12-Step self-help group involvement in methamphetamine
recovery. Addiction, 102(Suppl. 1): 121-129.
Project MATCH Research Group. (1997). Matching alcoholism
treatments to client heterogeneity: Project MATCH posttreatment
drinking outcomes. Journal of Studies on Alcohol, 58(1): 7-29.
Slide 79: [Transition Slide] Effective Medical Treatment Interventions
for Prescription Opioid Misuse
The following section pertains to effective medical treatment interventions for
prescription opioid misuse. Medication assisted treatment (MAT) is any
opioid addiction treatment that includes an FDA-approved medication for the
detoxification or maintenance treatment of opioid addiction (i.e., methadone,
buprenorphine, buprenorphine-naloxone, naltrexone). MAT may be provided
in an OTP, a medication unit affiliated with an OTP, a physician’s office, or
another health care setting. It includes comprehensive maintenance, medical
maintenance, interim maintenance, detoxification, and medically supervised
withdrawal. MAT increases the likelihood for cessation of illicit opioid use or
of prescription opioid abuse (TIP 42 Quick Guide, SAMHSA, 2005).
- 55 -
Slide 80: MAT: What do you think? – Medication is not a part of
treatment
1. Medication can be an effective part of treatment.
2. The idea that medications cannot be a part of addiction treatment is held
by some programs.
3. Medication is used in the treatment of many diseases, including
addiction.
4. Medical decisions must be made by trained and certified medical
providers.
5. Decisions about using medications are based on an objective
assessment of the individual client’s needs.
Additional information for the trainer
The pharmacotherapies that are FDA-approved for treatment of
addiction should be used in conjunction with psycho-socialeducational-spiritual therapy. Therefore, medications can be used
as a part of treatment, but only one part.
It is important to emphasize key point #4. It is beyond the scope
of practice for most substance use disorders treatment providers
to make specific recommendations about medications. All
medical decisions should be made by a medical provider who
has received specific training for the treatment of these
conditions.
- 56 -
Slide 81: MAT: What do you think? – Medications are drugs, and you
cannot be “clean” if you are taking anything
1. The field needs to change terminology to reflect current trends. “Drugs”
are illicit psychoactive substances that are used to achieve a “high.”
“Medications” are available by prescription and are used to treat an
illness, disorder, or disease.
2. Millions of Americans use medications (e.g., Zyban, nicotine patches) to
quit smoking, and this practice is widely encouraged by addiction
professionals.
3. Physical dependence and addiction are not the same thing.
4. The goal of addiction treatment is to assist a client in stopping his or her
compulsive use of drugs or alcohol and live a normal, functional life.
5. If appropriately administered, medication-assisted treatment for addiction
will not produce euphoric effects.
6. Pharmacotherapies are effective. Clinical data suggest that clients
perform better in treatment when psycho-social-educational-spiritual
therapy is combined with appropriate pharmacotherapies.
7. This myth relates to the previous myth and is one of the reasons that
people believe that medications should not be a part of treatment.
8. It is important to emphasize that there is a difference between physical
dependence on a substance and addiction. Anyone who takes certain
kinds of medications (opioids, certain blood pressure meds, etc.) for an
extended period of time will become physically dependent on it. This
means that they will have withdrawal symptoms if they suddenly stop
taking it. This does not mean that they are addicted. Addiction is defined
as a collection of symptoms that may include physical dependence, but
requires other behavioral symptoms indicating loss of control over use,
exacerbation of problems because of use and continued use despite
negative consequences.
- 57 -
Slide 82: MAT: What do you think? – Alcoholics Anonymous (AA) &
Narcotics Anonymous (NA) do not support the use of medications
1. AA/NA literature and founding members did not speak or write against
using medications. In fact, AA/NA endorses participants to use medicines
as prescribed for the treatment of medical conditions.
2. In Chapter 9 of the Big Book, it says: “But this does not mean that we
disregard human health measures. God has abundantly supplied this
world with fine doctors, psychologists, and practitioners of various kinds.
Do not hesitate to take your health problems to such persons. Most of
them give freely of themselves, that their fellows may enjoy sound minds
and bodies. Try to remember that though God has wrought miracles
among us, we should never belittle a good doctor or psychiatrist. Their
services are often indispensable in treating a newcomer and in following
his case afterward.” [Chapter 9, p. 133].
3. http://www.na.org/?ID=bulletins-bull29 - This is the 1996 NA bulletin
about methadone. It seems to indicate that people who attend NA
meetings on methadone treatment should not speak and cannot lead
meetings. Some NA groups are hostile to methadone treatment.
- 58 -
Slide 83: MAT: What do you think? – MAT is not effective
1. MAT is believed to be less effective than the research suggests, partly
because our experience is based on the cases we’ve seen. The classic
Clinician’s Illusion results from seeing "prevalence" sample – those
currently with disease. The probability that a case will appear in a
prevalence sample is proportional to its duration, thus clinicians thus
biased toward cases of long duration and therefore greater intractability.
In correctional settings we tend to be exposed most to severe cases and
relapsers who return often (“frequent flyers”). Patients who get better
generally do not return to these settings. This situation produces a
cognitive bias (availability bias) in which our pessimism is formed by
remembering severe cases who relapse and return. (SOURCE:
http://www.nida.nih.gov/Infofacts/TreatMeth.html)
2. Formal clinical trials research has demonstrated the efficacy of each of
the medications that have been FDA approved for addiction treatment.
Some of this data will be reviewed during the remainder of this training.
3. We tend to have a biased perception that patients who improve, leave
the program and are forgotten, while those patients who do not improve
return frequently and are remembered. This perception leads us to think
that most patients do not improve…contrary to scientific data.
Slide 84: How do Medications for Opioid Addiction Work?
1. For opioids, medications work in three different ways.
2. Agonists produce opioid effects.
3. Partial Agonists produce moderate opioid effects.
4. Antagonists reverse opioid effects.
- 59 -
Slide 85: How do Medications for Opioid Addiction Work?
1. This slide depicts a graphic representation of how opioids work in the
user’s body.
2. Full Agonists (salmon/pink line) bind to the receptors and activate them.
The more of a full agonist you use, the more effect you get. This makes
these medications dangerous if the dose is too high or if they are used in
combination with other drugs.
A useful metaphor: A full agonist is like having the right key to the
door. If you put the key in the door, the lock will turn and you can
open the door all of the way.
3. Antagonists (green line). These medications block the effects of opioids.
They bind strongly to the receptor prevent other opioids from binding to
the receptor. It is important to note, that antagonists will replace other
opioids (agonists) at the receptor site and therefore will cause withdrawal
for someone who is addicted to opioids.
A useful metaphor: An antagonist is like having the wrong key to
the door. If you put the key in the door, the lock will not turn, the
door will not open, and no other key can be put in until the key is
removed.
4. Partial Agonists produce moderate opioid effects. At higher doses, there
is a ceiling effect. This means that after a certain point, taking more of
the medicines will not produce any greater effect. This ceiling effect is
particularly true for the euphoric effects and the respiratory suppression.
A useful metaphor: A partial agonist is like having the right key to
the door, but the chain is on the door. If you put the key in the door,
the lock will turn, the door will open. However, the chain will stop
the door after it is only partially open.
Slide 86: Medications for Opioid Addiction
1. Currently, there are three medications that have been FDA approved for
the treatment of opioid addiction – methadone, buprenorphine, and
naltrexone.
- 60 -
Slide 87: Methadone
1. Methadone is used to alleviate withdrawal symptoms and help the
individual to feel normal. It is used both for withdrawal from opioids and
for ongoing maintenance.
2. It has been available since 1964 for the treatment of opioid dependence
and is covered by most third-party payers.
3. Methadone is the most frequently used medication for opioid addiction
treatment in Opioid Treatment Programs (OTPs).
4. Methadone suppresses pain for 4-6 hours and suppresses withdrawal
and drug craving for 24-36 hours in most patients who are opioid
dependent.
5. Methadone is administered daily for opioid addiction treatment and may
be given in split doses.
6. Methadone has an excellent safety profile when taken as directed. In
addition, the medication has been shown to be safe and effective when
used with appropriate safeguards and psychosocial services.
Any changes to a patient’s methadone regimen or HIV medications
should be reported to both providers to ensure potential interactions
are identified (NY/NJ AETC).
Several HIV antiretroviral medications decrease methadone AUC (area
under the concentration time curve); so use of methadone and certain
HIV medications requires an increase in methadone dose.
Certain medications that are used to treat HIV (and some psychiatric
conditions) may inhibit or induce the activity of the cytochrome P34A
enzyme system and can cause clinically significant increases or
decreases in serum and tissue levels of opioid medications.
Refer to the NY/NJ AETC’s product entitled, “Recreational Drugs and
HIV Antiretrovirals: A Guide to Interactions for Clinicians, 2009” for a
full listing of HIV medications that may interact with methadone. You
may also refer to: Drug Interactions Associated With HAART: Focus on
Treatments for Addiction and Recreational Drugs. AIDS Reader
13(9):433-450, 2003. Available at:
www.medscape.com/viewarticle/461892_4
- 61 -
Slide 88: How Does Methadone Work? - Full Agonist
1. Methadone is a full opioid agonist. This means that the more you take,
the more effect you get. This makes it very effective for people who have
a very high level of tolerance with opioids (i.e., they are taking very large
doses).
2. Increasing the dose of a full agonist produces increasing effects until the
receptor is fully activated and a maximum effect is reached.
3. Patients should be instructed, however, about the dangers of mixing
methadone with other opioids or with CNS depressants (e.g., alcohol),
because they will have a cumulative effect. This increases the possibility
of overdose.
Slide 89: What Does the Research Say?
1. Methadone has been studied in a large number of research trials and the
benefits of this medication have been very well demonstrated.
Methadone has been show to improve a number of factors associated
with addiction including:
•
Death rates
•
Opioid use
•
Involvement in criminal behavior
•
Social and occupational functioning
•
Health
•
Continuation in treatment
References
Dole, V. P., & Nyswander, M. (1965). A medical yreatment for
diacetylmorphine (heroin) addiction: A clinical trial With methadone
hydrochloride. Journal of the American Medical Association, 193(8), 646650.
Bickel, W. K., Stitzer, M. L., Bigelow, G. E., Liebson, I. A., Jasinski, D. R., &
Johnson, R. E. (1988). A clinical trial of buprenorphine: Comparison with
methadone in the detoxification of heroin addicts. Clinical Pharmacology and
Therapeutics, 43, 72–78.
Ball, J. C., Lange, W. R., Myers, C. P., & Friedman, S. R. (1988). Reducing
the risk of AIDS through methadone maintenance treatment. Journal of
Health and Social Behavior, 29(3), 214-226.
- 62 -
Slide 90: High Rate of Relapse to IV Drug Use after Drop-Out from
Methadone Treatment
1. This study demonstrates the return to substance use following cessation
of methadone treatment. The far left of the slide demonstrates rates of
injection drug use among patients while in treatment. The longer that the
person has been out of treatment, the greater the percentage of people
who have used drug by injection. After being out of treatment for 8 to 10
months more than 8 in 10 people have returned to injection drug use.
2. This study also demonstrates the effectiveness of methadone treatment
for reducing criminal behavior (data not shown). In 6 different programs,
dramatic reductions were seen in the number of crimes committed per
year prior to and during treatment with methadone. This, in turn, would
indicate lower incarceration rates among methadone treated individuals.
(Adapted from Ball & Ross - The Effectiveness of Methadone
Maintenance Treatment, 1991).
Many providers hold negative impressions about methadone. Some
concerns are listed below along with possible ways of addressing
them. Diversion: There have been a number of high profile cases of
methadone overdose recently. This is likely to occur for one of two
reasons. (1) People are supplementing with other opioids or are taking
other CNS depressants. Careful monitoring and patient education can
help to address this. (2) Methadone prescribed for addiction must be
administered in liquid form, available only in specially licensed clinics.
Take-home doses are limited. However, methadone can also be
prescribed for pain (in pill form). Most of the overdoses have been
attributed to diversion of this form of the medication. Physician
education and careful prescription control are techniques used to
address this. Worse than heroin: Many patients and providers hold this
perspective. However, methadone has been shown in clinical trials to
be safe and effective. However, because the medication is very long
acting, withdrawal from the medication generally lasts longer than from
shorter acting opioids. Careful medical monitoring, management of
withdrawal symptoms, and a slow taper schedule can make the
withdrawal process more comfortable if it is indicated. Nodding out:
When dosed and used appropriately, methadone should make the
person feel normal. If the person is nodding, it is an indication of too
much effect from the medication. This likely means that (1) the dose is
too high or (2) they are supplementing with other opioids or CNS
depressants. In either case, this kind of sedation symptoms should be
referred back to the prescriber for evaluation.
- 63 -
Slide 91: Buprenorphine
1. Buprenorphine is marketed as Suboxone and Subutex by ReckittBenckiser [pronounced reck-it ben-key-ser]. It is available by prescription
from specially trained and certified physicians in office based settings,
not just in specialty programs like methadone.
2. Buprenorphine was approved in 2002 for use in physicians’ offices and
other medical and health care settings and in 2003 for use in opioid
treatment programs (OTPs).
3. Physicians must obtain a waiver from SAMHSA; OTPs must receive
SAMHSA certification to provide buprenorphine.
4. Additional Information for the Trainer
5. In August 2005, the AETC National Resource Center released a threepage flyer entitled, “Buprenorphine in the Context of HIV.” The flyer was
developed by the NY/NJ AETC. The flyer is available at www.aidsetc.org.
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Slide 92: Buprenorphine/Naloxone “the Combo Tablet”
1. Buprenorphine may be used for both medical maintenance
pharmacotherapy and for medically supervised withdrawal from an opioid
addiction treatment medication.
2. Buprenorphine/naloxone (marketed as Suboxone) is the formulation of
the medication being emphasized in the US. Buprenorphine/naloxone
combines buprenorphine with a powerful opioid antagonist (naloxone).
3. The difference in the way the medication is absorbed into the body is the
key to how it works. The tablet formulations of buprenorphine must be
administered by placing the tablet under the tongue and allowing them to
absorb (sublingually). Naloxone does not absorb in this way. So, when
the combo tablet is administered sublingually, the clinical effect is
identical to taking pure buprenorphine.
4. However, if the tablet is crush and injected, naloxone, a powerful opioid
antagonist is most clinically effective. When used by injection, the
antagonist properties of naloxone will cause the opioid addicted
individual to experience full opioid withdrawal.
5. This unpleasant clinical effect reduces the likelihood of diversion and use
by injection, increasing the overall safety profile of the medication.
6. This combined with the ceiling effect allowed the FDA to determine that
this medication was appropriate for use by prescription like other
medications prescribed by a physician.
7. Buprenorphine/naloxone has a ratio of 4 parts buprenorphine to 1 part
naloxone.
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Slide 93: How Does Buprenorphine Work? - Partial Agonist
1. Buprenorphine is a partial agonist. This means that it works very much
like a full agonist at lower doses, but a ceiling effect is seen at higher
doses, especially for the respiratory suppression and euphoric effects
seen with full agonists. This gives that medication a very good safety
profile.
2. The partial agonist effects of buprenorphine make it much safer at higher
doses than full agonists. This is due primarily to the ceiling effect
preventing the respiratory suppression seen at higher doses of agonists.
3. Partial Agonists share some characteristics of full agonists. At low doses,
full and partial agonists produce effects that are essentially
indistinguishable. However, increasing the dose of a partial agonist
DOES NOT produce as great an effect as occurs with a full agonist.
There is a CEILING to the agonist (intoxicating/euphoric/respiratory
depression) effects.
4. In individuals who are not physically dependent on opioids,
buprenorphine produces typical opioid agonist effects, such as analgesia,
sedation, nausea, and dizziness, but these reach a “ceiling” in most
individuals with sublingual doses of 24 to 32 mg.
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Slide 94: How Does Buprenorphine Work?
1. Buprenorphine binds strongly to the opioid receptor and helps the
individual to feel normal without experience either cravings or withdrawal
symptoms.
2. Because of the strength of the bond, buprenorphine will also block the
effects of other opioids, helping the patient to maintain treatment goals.
3. Because of the ceiling effect, overdose is unlikely.
Patients should be educated about the importance of carrying an
information card that indicates that they are on buprenorphine.
In case of a medical emergency, the way the pain medications are
administered will need to be changed because of the presence of
buprenorphine in the system.
Patients should be cautioned against the use of benzodiazepines
without the supervision of a physician due to an increased risk of
overdose due to the combined effects of these medications.
Patients should be educated that the use of other opioids will
likely have no effect due the presence of buprenorphine and may
actually make the person experience withdrawal like symptoms
due to the interactions between the medications.
According to the AETC-developed flyer “Buprenorphine in the
Context of HIV,” data are limited on interactions between
buprenorphine and antiretroviral drugs. Studies have found no
interaction with zidovudine. Efavirenz has been found to lower
buprenorphine levels but with no clinical impact. Protease
inhibitors may increase buprenorphine levels via CYP 3A4
inhibition; providers should be alert to the possible need for dose
adjustment.
Slide 95: Some Advantages of Buprenorphine
1. Several advantages exist to using buprenorphine for the treatment of
opioid addiction. [Review contents of slide]
2. Unlike methadone, buprenorphine has a fairly short half-life. However, it
still has a very long duration of action. In this case, the duration of action
results from high receptor affinity.
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Slide 96: Some Disadvantages of Buprenorphine
1. For someone on 16mg of buprenorphine per day (an average dose) it
costs approximately $300 per month for the medication.
2. Monitoring of medication compliance also requires a specific urine test.
This too can increase costs associated with the medication.
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1. In order to be approved by the FDA, medications must be proven to be
effective in rigorous clinical trials research.
2. With buprenorphine, over 5,000 patients participated in these studies
over 25 years. These studies demonstrated that buprenorphine is both
safe and effective for the treatment of opioid dependence.
3. These studies demonstrated that buprenorphine is about as effective as
moderate doses of methadone. Because of the ceiling effect, individuals
with a very high level of tolerance may not be sufficiently maintained on
buprenorphine and may experience withdrawal symptoms. For such
individuals, methadone may be a better treatment option.
4. Retention in treatment is known to improve long-term treatment
outcomes. In one study comparing counseling plus either buprenorphine
to placebo, 75% of those treated with buprenorphine were retained in
treatment at one year, compared to 0% of the placebo group.
References
Fischer, G., Gombas, W., Eder, H., Jagsch, R., Peternell, A.,
Stuhlinger, G., Kasper, S. (1999). Buprenorphine versus methadone
maintenance for the treatment of opioid dependence. Addiction, 94(9),
1337-1347.
Johnson, R. E., Jaffe, J. H., & Fudala, P. J. (1992). A controlled trial of
buprenorphine treatment for opioid dependence. Journal of the
American Medical Association, 267, 2750–2755.
Johnson, R. E., Eissenberg, T., Stitzer, M. L., Strain, E. C., Liebson, I.
A., & Bigelow, G. E. (1995) A placebo controlled clinical trial of
buprenorphine as a treatment for opioid dependence. Drug and
Alcohol Dependence, 40(1), 17-25.
Kakko, J., Svanborg, K., Kreek, M., & Heilig, M. (2003). 1-year
retention and social function after buprenorphine-assisted relapse
prevention treatment for heroin dependence in Sweden: A
randomised, placebo-controlled trial. The Lancet, 361(9358), 662-668.
Ling, W., Charuvastra, C., Collins, J. F., Batki, S., Brown, L. S., Jr.,
Kintaudi, P., et al. (1998). Buprenorphine maintenance treatment of
opiate dependence: A multicenter, randomized clinical trial. Addiction,
93, 475–486.
- 69 -
97]
Schottenfeld, R. S., Pakes, J. R., Oliveto, A., Ziedonis, D., & Kosten T.
R. (1997). Buprenorphine vs methadone maintenance treatment for
concurrent opioid dependence and cocaine abuse. Archives of
General Psychiatry, 54, 713–720.
Strain, E. C., Stitzer, M. L., Liebson, I. A., & Bigelow, G. E. (1994).
Comparison of buprenorphine and methadone in the treatment of
opioid dependence. American Journal of Psychiatry, 151, 1025–1030.
Slide 98: Naltrexone
1. Naltrexone is available in an oral formulation and in a long acting
injectable formulation.
2. Trade names are indicated. The oral formulation is also available as a
generic medication
3. Naltrexone is a full mu opioid antagonist.
4. It blocks the effects of heroin, morphine, and methadone.
5. It can block opioid effects for up to 72 hours.
6. Naltrexone is known to have poor patient compliance.
Slide 99: Naltrexone
1. Naltrexone can precipitate opioid withdrawal but causes no withdrawal
symptoms of its own when a patient stops using it. It has no street value.
2. Naltrexone effectively prevents relapse in most patients when used as
directed.
3. Naltrexone is generally safe when used as recommended by the
manufacturer.
4. The oral medications average about $3.70 per day and are covered by
most third-party payers.
5. The injectable formulation costs about $27 per day. It is covered by most
insurers but is not on many formularies for public funding. Cost is
therefore an issue that must be addressed for patients for whom it is
recommended.
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Slide 100: How Does Naltrexone Work? - Antagonist
1. Naltrexone is an opioid antagonist.
2. It binds strongly to the receptor site, blocking the effect of other opioids.
Therefore, if someone uses illicit opioids they will not experience the
effect.
3. Patients taking naltrexone do not get high on opioids. In other words,
using opioids on naltrexone is a waste of money.
4. Patients have to decide whether to stop using opioids or stop their
naltrexone. The opioids often win, leading patients to stop taking their
medication.
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Slide 101: How Does Naltrexone Work?
1. As discussed before, opioid use stimulates the opioid system. This in
turn, causes a release of dopamine, leading to the euphoric effects of
opioids. By blocking the opioid system, the pleasurable effects of opioids
will be reduced or eliminated.
Additional Notes for the Trainer
Patients should be educated that use of illicit opioids will probably not
have any noticeable effect. However, if they try to use more, it may be
medically dangerous. If they use enough to overcome the effects of the
naltrexone, they are likely to overdose, leading to respiratory
suppression and possible death. Ongoing monitoring is essential to
ensure that the medications being used appropriately.
Patients who receive naltrexone should also carry a patient-information
card indicating that they are taking this medication. In the event of an
emergency that requires opioids for pain, the dosages will need to be
adjusted and additional medical intervention needed.
When the individual is exposed to stimuli previously associated with
opioid consumption (e.g., drug dealer’s house, being offered pills, a
party environment) the conditioned stimulus results in excess
glutamate release within the brain reward circuits and limbic structures
(emotion), which can generate feelings of depression, anxiety and
dysphoria as well as the anticipation of opioids. These feelings may
precipitate relapse in a patient who is trying to maintain abstinence.
Because conditioning is a very long-lasting phenomenon in the brain,
these cue-induced, or opioid-related conditioned behaviors can occur
weeks, months, or even years after physical withdrawal has dissipated
completely.
SOURCE: Littleton J. (1998). Neurochemical mechanisms underlying
alcohol withdrawal. Alcohol Health Research World, 22, 13-24.
- 72 -
1. Studies of naltrexone have demonstrated that use of naltrexone reduces
the risk of returning to opioid use and lowers the risk of re-imprisonment.
2. Compliance is often an issue for patients, however. Providers should
work with patients receiving the medication to develop strategies to
increase medication compliance.
3. By using the injectable form of the medication, compliance issues are
reduced, due to the fact that once the injection is given, it continues to be
clinically effective for a month.
1. The primary side effect from the use of naltrexone is nausea (especially
for the injectable form). However, tolerance usually develops quickly for
this side effect. Generally, patients tolerated the medication well and
people on active medication had lower rates of opioid use that those
receiving placebo.
2. Additional improvements in the treated group include lower use of CNS
depressants, improved legal status, and lowered psychiatric symptoms.
Slide 104: Case Study #2: Referring for Services
INSTRUCTIONS
Read the case study aloud.
Ask participants to break into pairs or small groups (depending on the
size of the audience), and spend 5-10 minutes discussing the
questions.
De-brief as a full group for 5-10 minutes. Ask for volunteers to briefly
share responses to the two questions.
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Slide 105: [Transition Slide] Importance of Coordinated Care
The patient who enrolls in medication-assisted treatment is facing more than
a medical issue. The disease of addiction can affect all aspects of a patient’s
life, and the consequences of addiction must be addressed if substance
abuse treatment is to be effective. Since a variety of different professionals
from several agencies may participate in some aspect of treatment or patient
care, it is important to examine how that care can be delivered in a
consistent, coordinated, and patient-friendly manner. All involved systems
and their key players have a role in care coordination. Often, agency
personnel develop informal means of collaboration, as one staff member
becomes familiar with the programs and service providers in another agency.
These staff members, and sometimes their agencies, may work very closely
to meet the needs of mutual patients because of such voluntary efforts.
Effective coordination combines the strengths of various systems and
professions. The roles of addiction counselors and community support
providers may vary by state, depending upon the identified scope of practice
for each profession. While previous opioid treatment occurred only in the
context of federally regulated programs, buprenorphine treatment extends
the treatment arena to the physician’s office. Developing a coordinated
system of care is the only means that the physician has of ensuring that
his/her patient is benefiting from the drug he/she has prescribed. Treatment
is most successful when there are comprehensive and continuing services.
This collaborative approach can best be achieved through care coordination.
This section of the training will explore the issue of effective coordination of
care.
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Slide 106: Attributes of Successful Care Coordination
1. Familiarization with the roles, procedures, and organization of the other
participants’ agencies/offices allows participants to anticipate the effect of
their actions on the other team members.
2. Maintain ongoing communication: Groups involved in collaborative
efforts need to plan for effective communication. This may involve
specifying mechanisms for communication, such as periodic meetings,
reports, memoranda, and both formal and informal communication
channels. Feedback is vital in communication loops.
3. Personal contact is important; people are more likely to talk and listen to
people they know.
4. Permanence must be ensured by vesting responsibility for ongoing
communication in an office or institution. Intermediaries can help foster
communication when certain individuals feel they lack authority to
communicate.
5. Furthermore, it is important to work within the scope of current practices
and have linkages to other professionals. There is no wrong door for
treatment.
6. On the flip side, barriers to successful care coordination may include: (a)
Misunderstanding respective roles; (b) conflicting goals for treatment; (c)
confidentiality restrictions; (d) control issues; and (e) misconception of
other professional perspectives.
Slide 107: What is the Role of a Prescription Drug Monitoring Program?
INSTRUCTIONS
Review the information on the slide with the audience.
Slide 108: CURES: CA’s Prescription Drug Monitoring Program
1. CURES is committed to assisting in the reduction of pharmaceutical drug
diversion without affecting legitimate medical practice or patient care.
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Slide 109: Real-Time Statewide Prescription Drug Monitoring Program
1. A Prescription Drug Monitoring Program (PDMP) system allows preregistered users, including licensed healthcare prescribers eligible to
prescribe controlled substances, pharmacists authorized to dispense
controlled substances, law enforcement, and regulatory boards to access
real-time patient controlled substance history information.
2. The role of the PDMP entrusts that well informed prescribers and
pharmacists can and will use their professional expertise to evaluate their
patients care and assist those patients who may be abusing controlled
substances.
3. The contents of the database record include: drug name; date filled;
quantity, strength, and number of refills; pharmacy name and license
number; doctor’s name and DEA number; and prescription number.
Slide 110: Safe Disposal of Prescription Drugs, Part 1
1. If a drug take back or collection program is not available, there are
several steps you can take to safely dispose of unused prescription
drugs.
2. Be sure to conceal or remove any personal information, including Rx
number, on the empty containers by covering it with black permanent
marker or duct tape, or by scratching it off.
Slide 111: Safe Disposal of Prescription Drugs, Part 2
1. Do not flush prescription drugs down the toilet or drain unless the label or
accompanying patient information specifically instructs you to do so.
2. To dispose of prescription drugs not labeled to be flushed, you may be
able to take advantage of community drug take‐back programs or other
programs, such as household hazardous waste collection events, that
collect drugs at a central location for proper disposal. Call your city or
county government’s household trash and recycling service and ask if a
drug take‐back program is available in your community.
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Slide 112: Concluding Thoughts
1. Prescription opioids are becoming a major drug of abuse in the United
States, and impact individuals of all ages and racial/ethnic backgrounds.
2. Opioids are the most prevalent type of prescription medications being
misused.
3. Behavioral and pharmacological treatments are available to treat
prescription opioid abuse and dependence.
Slide 113: [Transition Slide] Post-Test Questions
The purpose of the following five post-test questions is to test the
change in prescription opioid knowledge amongst training participants.
The five questions are identical to the pre-test questions.
INSTRUCTIONS
Read each question and the possible responses aloud, and give
training participants adequate time to jot down their response before
moving on to the next question.
Reveal the answers to each question once participants have had a
chance to indicate their responses to each question.
Slide 114: Post-Test Question #1
Answer Key:
Correct response: D (A friend or relative)
Answer Key:
Correct response: B (False)
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Answer Key:
Correct response: D (All of the above)
Answer Key:
Correct response: D (A and C)
Answer Key:
Correct response: C (Mix them with an undesirable substance)
Slide 119: Take Home Points for Clinicians
1. It is important to be familiar with local resources, including substance use
disorders treatment facilities, 12-step meetings, and mental health
resources.
2. Prescription opioid abuse impacts the user’s brain and body, but can be
treated.
3. Continue to dialogue with patients about their prescription opioid misuse
use and the importance of appropriate pain management and HIV care.
- 78 -
Slide 120: Key Resources
1. Several important resource documents have been produced that focus
on substance use disorders in general, and on prescription medications.
All of the featured resources are available for free from NIDA, SAMHSA,
or the NY/NJ AETC.
On April 19, 2011, Today, Gil Kerlikowske, Director of National Drug
Control Policy; Howard Koh, Assistant Secretary for Health and Human
Services; Margaret A. Hamburg, M.D., Food and Drug Administration
Commissioner; and Michele Leonhart, DEA Administrator, will release
the Obama Administration’s comprehensive action plan to address the
national prescription drug abuse epidemic.
The Administration’s Prescription Drug Abuse Prevention Plan,
entitled, “Epidemic: Responding to America’s Prescription Drug Abuse
Crisis,” provides a national framework for reducing prescription drug
diversion and abuse by supporting the expansion of state-based
prescription drug monitoring programs; recommending secure, more
convenient, and environmentally responsible disposal methods to
remove expired, unused, or unneeded medications from the home;
supporting education for patients and healthcare providers; and
reducing the prevalence of pill mills and doctor shopping through
enforcement efforts. Additional information is available at:
http://www.whitehousedrugpolicy.gov/prescriptiondrugs/.
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Slide 121: URLs for Key Resources
1. This slide includes links to the resources featured on the previous slide.
The links were verified as being active, as of January 21, 2011.
Additional Resources (not pictured on previous slide)
Talking with Your Adult Patients about Alcohol, Drugs, and/or Mental
Health Problems: A Discussion Guide for Primary Health Care
Providers (created to accompany SAMHSA’s TIP 42, Substance Abuse
Treatment for Persons with Co-Occurring Disorders, PDF available at:
http://kap.samhsa.gov/products/brochures/pdfs/Talking_with_Your_Pat
ients.pdf
Pain Management without Psychological Dependence: A Guide for
Healthcare Providers – Substance Abuse in Brief Fact Sheet, PDF
available at:
http://www.kap.samhsa.gov/products/brochures/pdfs/saib_0401.pdf
Medication-Assisted Treatment for Opioid Addiction: Facts for Families
and Friends, PDF available at:
http://www.kap.samhsa.gov/products/brochures/pdfs/med_assisted_tx
_facts.pdf
Getting Started with Medication-Assisted Treatment: With Lessons
Learned from Advancing Recovery, PDF available at:
http://www.niatx.net/PDF/NIATx-MAT-Toolkit.pdf
TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid
Treatment Programs – Quick Guide for Clinicians, PDF available at:
http://www.ncchc.org/education/otp/pdfs/QGC_43.pdf
Psychotherapeutic Medications 2008: What Every Counselor Should
Know was originally developed as a companion piece to the MidAmerica ATTC systems change curriculum, A Collaborative Response:
Addressing the Needs of Consumers with Co-Occurring Substance Use
and Mental Health Disorders. This booklet is an excellent reference
document for clinicians, containing information on generic and brand
names, the purpose of each medication, usual dose & frequency,
emergency conditions and cautions. The Mid-American ATTC is in the
process of developing an online, searchable psychotherapeutic
medications database. The booklet is available for download, at
http://www.attcnetwork.org/regcenters/index_midamerica.asp.
Additional information on this database will be forthcoming on this
same website.
- 80 -
Slide 122: Thank you for your time!
This concludes the presentation. Thank the participants for their time
and address any last-minute questions about the content. Encourage
participants to reach out to the Pacific Southwest ATTC or Pacific
AETC, should they have questions or concerns following the training
session.
- 81 -

Prescription Opioids Trainer Guide

Transcription

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