21Collaboration of Care Implementation Guideline Presented by: Sara Remaley, MSPC, CAADC, Clinical Supervisor WPIC NATP Valerie Gualazzi, MS, CADC, Program Director WPIC NATP Western Psychiatric Institute and Clinic
22WPIC currently treats approximately 420 patients on a regular basis. Western Psychiatric Institute and Clinic Narcotic Addiction Treatment Program (NATP) -Addiction Medicine ServicesWPIC NATP is a clinic specializing in opioid dependency in addition to psychiatric comorbidity.WPIC offers methadone maintenance treamtent, suboxone treatment, psychiatric care and medication management, mental health, and addiction therapy.WPIC currently treats approximately 420 patients on a regular basis.
23RationaleNATP recognized a need to address the misuse and abuse of prescription benzodiazepines by patients enrolled in medication assisted treatment.High rates of patients were enrolling in treatment and concurrently becoming addicted to and abusing benzodiazepines, posing health risks, adverse effects, and ultimately untimely discharge from treatment.
24Collaboration of Care2012- WPIC NATP redesigned the program’s philosophy and position regarding concurrent use and abuse of prescription benzodiazepines and opiates while taking methadone.Contraindications and potential for adverse effects helped NATP move in the direction of ‘therapeutic no tolerance’.The “Collaboration of Care” Procedure : indicating NATP’s willingness to work with patients currently on prescription benzodiazepines to taper off and receive evidence based interventions and seek alternative treatment options as needed.
25Collaboration of CareThe Collaboration of Care Procedure was developed as a way to inform patients of the new treatment philosophy indicating: use of benzodiazepines and opiates while on methadone is no longer permissible.With the understanding that tapering from these type of medication can be a difficult and lengthy process with potential for relapse, NATP developed a procedural guideline to assist both patients and staff through this new process.
27Barriers to addressing bzd use: Difficult tapering process, risk related to withdrawal symptoms, and potential need for medically supervised detoxification.High Relapse rates with benzodiazepines.Concurrent rates of psychiatric comorbidity and the need to address/treat underlying mental health conditions.Collaborating with providers (prescribing physicians) vs. illicit street use.Addressing diversion…How does this fit?
28Let the collaboration begin…. Step 1: Staff EducationDevelopment of Procedural Guideline highlighting philosophy, procedures and interventions, and processes for team to follow.Step 2: Patient EducationAn FAQ was developed and handed out to all patients indicating the new Collaboration of Care and Program Philosophy regarding Concurrent use of benzodiazepines while in treatment.
30Step 3: Patient Acknowledgement and Responsibilities: Reviewing the new philosophy and Collaboration of Care with patients, and asking them to acknowledge with their signatures that they have been informed.A part of this process is also to explain to patients, the risks, as well as their rights. Albeit patients may reserve the right to refuse collaboration, they are also informed how this may directly impact their ability to remain in treatment.
31Step 4: InterventionsOnce the Collaboration of Care is initiated, the following procedures /interventions may be followed:Urine Drug Screens and CCBHO Report reviewed.Contact with the prescribing physician (physician to physician) to discuss recommendations and to create a tapering regimen.Pill CountsIllicit Street Use: Assessing need for medically supervised detoxification. Resources: Mercy Hospital Emergency Room, WPIC DEC (Diagnostic Evaluation Center).UDS Confirmatory tests to determine if “levels” are decreasing- indicating progress/regression.
32Interventions Continued: Assessing underlying mental health and psychiatric disorders such as anxiety, depression, mood disorder, bipolar disorder, etc. Choosing a modality to effectively work with and treat these disorders in addition to addiction.CBT, REBT, Gestalt Therapy, DBT, Motivational Interviewing, Person Centered etc.Modifying treatment plans: Increasing therapy, regular appointments with Psychiatrist, following a medication regimen, ongoing collaboration.Maintaining focus on individualized care through individualized recommendations. Assessing Progress: How is this done? Regular team meetings and supervision.
33Response to Interventions What happened after the Collaboration of Care was initiated?NATP experienced responses similarly associated with the Change Curve (Kubhler-Ross)Shock, Denial, Anger, Acceptance, Integration
34Response to Interventions How long did it take before a change was noticeable?Integration took time and CONSISTENCY IS KEYResponse to change implementation included:Compliance and Collaboration.Increase in individual/group therapy- engagement in regular psychotherapy.Increase in psychiatric treatment and psychopharmacology.Exacerbation of symptoms/negative behaviors.Increase in referrals to Higher LOC’s.Decrease in bzd rates.Increase in compliance/privilege status.
35Evaluating Effectiveness Establishing pre and post intervention baselines:Rates of bzd use/abuse among patients.Urine Drug Screen Results (including break-down of levels)Individualized ProgressRelapse ratesDecrease in attaining prescriptions.Patient DischargesSustained abstinence
36SummaryAddressing concurrent use/abuse of benzodiazepines through the following steps:Develop Program PhilosophyIdentify Perceived BarriersEducation StaffEducate PatientsIdentify intervention strategies and evidenced based practicesIdentify pre and post intervention baseline data
37Enrolled in methadone programs” “Meeting Needs …..Renewing Life”Timothy H. Reese, M.D., MRO, SAPMedical Director1425 Beaver AvenuePittsburgh, PAPhone: Ext. 109Fax: /“Decreasing the use of prescription opiates and benzodiazepines among individualsEnrolled in methadone programs”
38HISTORY OF TADISOESTABLISHED IN 1968 AS NON-PROFIT700 PATIENTS—24 FULL TIME COUNSELORS—1 MEDICAL DIRECTOR1 PA.POPULATION: 2/3 NON-HISPANIC WHITE AND 1/3 AFRO-AMERICAN AND OTHER
39DEMOGRAPHICSNON-HISPANIC WHITES YEARS…….FASTESTNON-HISPANIC WHITES YEARS………FASTEST OF THE FASTNON-HISPANIC WHITES YEARS………SHOOTING MORENON-HISPANIC WHITES YEARS……….INHALING MORE
40PENNSYLVANIAPERSONS ENROLLED IN SUBSTANCE ABUSE TREATMENT PROGRAMS WHICH PRESCRIBED METHADONE INCREASED 18.9%
41MESSAGEWE ARE IN THE MIDST OF AN EPIDEMIC OF OPIOID ADDICTION AND ITS DEVASTATING TOLL ON SOCIETY!METHADONE IS AND CAN BE AN EVEN GREATER PART OF OUR ARSENAL AGAINST THIS DEADLY FOE!
42PATHOPHYSIOLOGYOFOPIOID ADDICTION--MEDULLA LOCUS CAERULEUS---90% OF CATECHOLAMINES IN CNS--RESPONSIBLE FOR THE VEGETATIVE FUNCTIONS OF THE ORGANISM (SUPPORT LIFE)--THERMOSTAT ANALOGY AND THE OPIOID WITHDRAWAL SYNDROME
48CLINICAL MANIFESTATIONS OFOPIOID WITHDRAWAL*ACCIDENTAL OVERDOSE AFTER A SUCCESSFUL DETOXIFICATION*
49CLINCAL MANIFESTATIONS OF OPIOID WITHDRAWALMU-AGONIST EFFECT WITH BEGINNERS!
50DOPAMINE----VTA/NUCLEUS ACCUMBENS (FOREBRAIN)DRUG ABUSE DUMPS MASSIVE AMOUNTS OF DOPAMINE INTO THIS AREA.REINFORCES BEHAVIOUR THAT IS PARAMOUNT TO SURVIVAL OF THE SPECIES
51UP-REGULATIONOFDOPANINERGIC NEURONS--AFTER REPEATED EXPOSURE (DRUG ABUSE) TO THESE MASSIVE AMOUNTSOF DOPAMINE THE TARGET NEURONS BECOME PROGRESSIVELY LESSRESPONSIVE! NET RESULT MORE STIMULATION GIVE LESS RESPONSE THUSPROPELLING THE ADDICTION PROCESS!
52BENZODIAZEPINESINTERNEURONS IN THE VTA APPLY INHIBITORY EFFECTS ON DOPAMINERGIC NEURONSTHESE INHIBITORY INTERNEURONS EXERT THEIR EFFECT ON THE DOPAMINERGIC NEURONS BY WAY OF GABA (GAMMA AMINO BUTYRIC ACID)BENZODIAZEPINES INHIBIT THIS INHIBITORY EFFECT. THIS INHIBITION RESULTS IN A MASSIVE RELEASE OF DOPAMINE FROM THE DOPAMINERGIC NEURONS.THIS IS THE SYNERGISM WHICH OCCURS WHEN BENZODIAZEPINES ARE GIVEN WITH AN OPIOID; E.G., METHADONE.
53OPIOIDSIN A STABILIZED METHADONE PATIENT ANY ADDITIONAL OPIOID WILL CAUSE DESTABLIZATION ;IF THE OPIOIDS ARE TAKEN TO AN ANALGESIC LEVEL ONLY THE DESTABILIZATION WILL MAINLY AFFECT THE MEDULLA LOCUS CAERULEUS.IF THE OPIOIDS ARE TAKEN TO THE EUPHORIC LEVEL THE DESTABILIZATION WILL AFFECT THE DOPAMINERGIC NEURONS AS WELL.
54CLONIDINEINSEARCH OF DOPAMINESINCE THE OPIOID WITHDRAWAL SYNDROME IS DUE IN PART TO HYPERACTIVITY OF THE MEDULLA LOCUS CAERULEUS AND EXCESSIVE CATECHOLAMINES, A DRUG WHICH BLOCKS THIS EFFECT SHOULD TREAT THIS PART OF THE OPIOID WITHDRAWAL SYNDROME.CLONIDINE( CATAPRESS) IS A CENTRALLY ACTING ALPHA-2 BLOCKER AND DOES THIS WELL.WHAT ABOUT THE DOPAMINE DEFICIENCY? A BENZODIAZEPINE WAS NEEDED TO BE ADDED TO THE ABOVE REGIMEN TO MAKE THE TREATMENT PALABLE TO THE PATIENT. THIS BENZODIAZEPINE VIA INHIBITING GABA IN INTERNEURONS OF THE VTA SUPPLIED THE DOPAMINE.
55REPRESENTATIVE VIGNETTES DR. COMPLETELY COOPERATIVE—MOST COMMON SCENARIODR. COOPERATIVE BUT DILATORY---NEEDS SOME PRODINGDR. COOPERATIVE BUT SELECTIVE---”NOT TO YOUR PATIENT”DR. COOPERTIVE BUT NOT REALLY---REDUCE BUT WON’T STOP!
56CCBHO INITIATIVETHE EXPRESSED PURPOSE OF THIS INITIATIVE WAS TO DECREASE THE USE OF BENZODIAZEPINES AND OPIOIDS IN METHADONE CENTERS….AND IT WORKED!CCBHO GIVES THE METHADONE CLINICS A LISTING OF PATIENTS WHO ARE GETTING BENZODIAZEPINE AND/OR OPIOID SCRIPTS. THESE PRESCRIPTIONS WOULD NOT BE REGISTERED AT THE CLINIC NOR WOULD EVIDENCE OF THE DRUGS SHOW IN THE ROUTINE URINES.
57CCBHO INITIATIVETHIS SCENARIO WAS VIRTUALLY UNCHANGED.DOCTOR TO DOCTOR COMMUNICATION SPOILED THE ENTERPRISE.