Opiate Treatment Best Practices
Written by and for people with Lived Experience Pt Alberni CAT Families Helping Families
Today’s Learning Moment – 10 19 26 Issue: Opiate Treatment Best Practices.
All our past articles can be found here: https://ptalbcat.blogspot.com/
There is a belief or a kind of knee jerk reaction that people who struggle with opiate dependence disorder should be sent to “treatment” either willfully or forcefully. This would be incredibly wonderful if it were this easy. Unfortunately, it is not. As a counsellor for over 30 years, I can testify quite confidently that the answer is as diverse as the people who struggle and the families struggling alongside them.
First of all, most of us see treatment from a traditional 12 step point of view. Most of us think that this is the only model of treatment that exists. Many, many residential programs also approach treatment from this model. And this model works….for many…but not everyone. While the 12 step model is exemplary in providing unrivalled support, it also has one flaw that could be fatal for those who use and/or are dependent on opiates. It is based in abstinence-only ideology.
Abstinence-only traditionally means no substances of any kind. Many programs, even still, do not recognize any type of medically assisted therapy. In other words, no medicinal assistance with withdrawal for instance. This is particularly dangerous not only with opiates but with alcohol and benzodiazepines as well. Many people do not realize that withdrawal symptoms form both alcohol and benzos can lead to a fatal elevation in respiratory and cardiac activity. Many people have heard of DT’s. Delirium Tremens is a result of this elevation and can be the sole cause of death during withdrawal from these two substances. Withdrawal from opiates in itself has not been a sole cause of death but has been associated with other health issues. Regardless, withdrawal from opiates feels like death knocking on your door. This is the danger of abstinence-only based therapy for opiates. Many will relapse more often than not when trying to withdraw cold turkey. Today, with the poisoning of the illicit supply of heroin and unpredictable tainting of other street drugs, the desperation to ease the overwhelming sickness of opiate withdrawal is now more dangerous than ever before and leads to sudden death. Thus, abstinence-only is a very ineffective therapy regarding opiates. That doesn’t mean that abstinence is not a goal. For most, it is. However, it is not the first step nor should it be the go-to solution in an initial intervention.
So a best-practices template has been developed by the Canadian Center on Substance Use and Addiction (CCSA). I can, from my experience over the years, endorse this template. I’ve tried abstinence-only therapy and as I said it can work for some but is especially dangerous with today’s tainted supply. So here is the recommended spectrum or continuum of care of treatment for opiate use and dependence.
“Throughout the treatment process, there are fundamental principles and best practices to take into consideration. The first principle is that the person living with an opioid use disorder should determine the goals of their treatment with support from an experienced care provider”.
“Every person’s pathway through the continuum of care may look different. The components can overlap and are most effective when used together. Some people may use all services in the continuum of care whereas others might not. Some people might revisit different components as needed”. (2018, CCSA “Best Practices Across the Continuum of Care for Treatment of Opioid use Disorder)
Here is the continuum:
·
Screening and assessment
·
Brief interventions
·
Rapid access clinics
·
Community Outreach
·
Withdrawal Management (different than simple detox)
·
Pharmacological interventions
·
Psychosocial interventions
· Recovery, wellness sustaining and ongoing care
Note that harm reduction strategies are to be included throughout this continuum.
As care providers, my colleagues and I would practice these steps:
·
Work in partnership with the individual to figure out his/her needs and
goals.
·
Always assess the person’s well-being for any issues that could prevent
successful outcomes, including physical and mental health, stress, housing
concerns, financial barriers, pharmacological assistance and so on. Medications may not only be necessary to curb
cravings such as opiate agonists but also to assist with the natural depression
and anxiety that occurs with withdrawal both immediate and long term withdrawal
(Post Acute Withdrawal Syndrome).
·
Provide services that are culturally competent and safe. Cultural needs are vitally important to be
aware of. Not everyone will embrace
their culture and others will not succeed without it.
·
Provide services that are trauma and gender-informed. Practices and strategies need to be sensitive
to previous traumas and any ongoing trauma experienced because of use and/or
stigma due to gender identification.
·
All efforts should be made to reduce stigma, which is a major barrier to
seeking treatment and maintaining recovery.
This is where including family and supports in treatment planning is
very useful and necessary. Education is
crucial as problems with the person’s environment and/or relationships can
trigger a relapse. With opiates, relapse
can be fatal as we know. So it is
crucial that the family and supports also be trauma-informed as well as aware
of stigmatizing attitudes and behaviours.
·
Having a peer group that can relate or empathize with the person can be
very helpful. Peer-led services
establish trust and help people sustain positive changes in their substance
use. Here is where a self-help group can
be very useful with support. There are
also organizations of peers that continue to use in many communities that can
be helpful, especially in initial stages of seeking help.
· While recovery is the focus, as stated above, it can look different for different people. It may not necessarily mean abstinence, especially at first. This brings us back to the first point of identifying and constantly reviewing needs and goals as they will often change throughout the person’s journey. Remember, recovery is not a place or a destination, it is a journey and continues throughout a lifetime.
I need to add that practices now include regulated safe supply of diacetylmorphine and include other approaches such as monitored intravenous and oral opiate replacement therapies. These therapies are employed when other opiate agonist therapies such as suboxone and methadone have not been successful.
So here is a basic template of best practices for opiate use and dependence disorder. The CCSA has published their report and can help in better understanding how these services work and help in determining a direction for your loved one. Here is a link to the report.
Author: Ben
Goerner
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