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Relapse Prevention

Relapse Prevention
Dr. Jay Piland MD

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Relapse Prevention

  1. 1. Relapse: Road to Recovery Dr. Jay Piland MD Palmetto Addiction Recovery Center Pecan Haven Adolescent Addiction Center
  2. 2. Spectrum of Substance Use Disorders Misuse 20% 65% ?% Regular Use Zero use Mild Moderate Severe “Pickle Line” adapted from Ray Baker MD Healthy No Problem Use Related Problem Substance Use Disorders Road to Recovery
  3. 3. DSM 5 Diagnostic Criteria 11 Criteria in 4 groupings (2-3=mild, 4-5=moderate, 6+=severe) Impaired Control Inability to quit or cut down, using more than intended, time spent, craving Social (Functional) Impairment School, Work, Home Obligations Not Met Social and Relationship Problems Social, Occupational, Recreational Activities Abandoned Risky Use (Using Despite) Hazardous Situations Physical or Mental Illness/Psychological Problems Pharmacological (Physiological) Tolerance and Withdrawal Road to Recovery
  4. 4. “Sometimes it’s not so much seeing the light as feeling the heat.” Road to Recovery
  5. 5. Barriers for HCP’s seeking and receiving assistance Road to Recovery
  6. 6. • 2/3 of pharmacists in recovery treatment programs are discovered by their state board of pharmacy, a peer, or another HCP • Some discovered by law enforcement caught abusing a substance or engaging in a related illegal activity • Many may actually believe their own knowledge of medications will somehow prevent them from becoming addicted or dependent • Many studies show that HCP’s may believe their knowledge of drug therapy justifies self-treatment Road to Recovery
  7. 7. The Addicted Pharmacist and the Effect of Their Environment University of Findlay College of Pharmacy PRN Survey (N 171—25%) • From Discovery to Recovery • 93% attended Some form of Rehabilitation – Of which 63% Successful on First Attempt – Of which 18% Successful on Second Attempt – Of which 11% Successful on Third Attempt Road to Recovery
  8. 8. CDM: Performance Measures Help Guide Care Road to Recovery
  9. 9. “Blueprint” Study McLellan et.al., BMJ, Nov. 2008 • 16 American PHPs retrospective longitudinal study • 904 consecutive MDs with SUDs, 647 monitored • 81% never relapsed over five years • 79% licensed and working after five years • 11% revoked • 3.5% retired • 3.5% died • 3% status unknown Road to Recovery
  10. 10. Relapse Risk (Washington State PHP) (Domino, et. al. JAMA, Mar 23, 2005) Retrospective Cohort Study • Relapse rate: 25% (74 of 292 cases between 1991- 2001) • Increased relapse risk if:– Concurrent psychiatric disorder (HR 5.79) – Family history of substance use disorder (HR 2.29) – Previous major relapse (HR 1.69) – Combinations of these adds to cumulative risk – Major Opioid/Dual Diagnosis/Family History (HR 13.25) • No increased relapse risk: – Drug of choice • Including major opioid as long as above factors absent – Specialty – Gender Road to Recovery
  11. 11. OMA PHP Relapses - 5 Year Program First 100 monitored participants Brewster, Kaufmann et al; BMJ Nov 2008 Road to Recovery
  12. 12. LIFE SATISFACTION* BY PROGRAM YEAR - OMA PHP YEAR IN PROGRAM * Mean of 14-items: 4-Very satisfied; 3-Satisfied; 2-Dissatisfied; 1-Very dissatisfied R2 = .813; Regression constant = 3.266; Slope = 0.0498 (p = .037) Road to Recovery
  13. 13. PFSP Program Evaluation 2008: Did PFSP make a difference for participants in case coordination? 90% of responding participants reported that the problem that had caused them to access the program had improved (46% responded) • Overall wellness • Job effectiveness • Relationships with others full 76% partial 14% full 71% partial 14% full 71% partial 24% Overall life satisfaction • Beginning of case coordination3.7/10 • Conclusion of last interaction 8.1/10 Road to Recovery
  14. 14. Special Issues of Return to Work • PHP/PRNs usually spell out the conditions for a HCP’s return to practice via a contract. • Most Regulator’s specify only that the HCP return to work should be based on her/his ability to practice with “reasonable skill and safety”—leaving judgement up to treatment team Road to Recovery
  15. 15. Special Issues of Return to Work • Assessment of her/his: – Acceptance of SUD diagnosis – Understanding of addiction as a chronic disease requiring lifelong attention – Completion of SUD treatment, with support of treatment team to resume work – Documentation of sustained abstinence(UDS). – Treatment and status of Co-occurring Mental Disorders – Judgment and cognition (neuropsychological testing) – HCP’s ability to manage stress and triggers – Support Network including Family support – Estimated risk of Relapse – Motivation to follow an established continuing care plan – Occupational Factors: • Legal/Licensure Requirements Satisfied • Workplace monitor/supervisor identified and accepts responsibilities • Necessary Workplace modification or practice restrictions have been agreed to Road to Recovery
  16. 16. Special Issues of Return to Work • Staged Process • May have limited work hours, tasks, time of day, or settings • May face restrictions to access to mood-altering medications • Workplace monitor in contact with PHP/PRN (release for communication in effect at all times) • Settings of practice limited to provide for easier monitoring/better accountability • Accountability System for dispensing/administering addicting drugs to patients – Not being the person in the practice to check a patient’s medications for compliance – Keeping track of prescriptions written for controlled substances – Using double locked systems for addicting substances on premises – Periodic checking of wastage from injectable opioids to assure all vials and their contents are properly accounted for & have not been diverted Road to Recovery
  17. 17. Applying Occupational Health Principles • Safety-Sensitive Profession • Workplace education and accommodations are often required • Participate in return to work planning with the participant and the workplace • Fitness for work measured by performance on a range of work tasks from low to higher risk • Scrutiny and accountability in the workplace is necessary • Monitor long-term for Health and Recovery Road to Recovery
  18. 18. Relapse: Road to Recovery Dr. Jay Piland MD Palmetto Addiction Recovery Center Pecan Haven Adolescent Addiction Center
  19. 19. Road to Recovery
  20. 20. Road to Recovery
  21. 21. Relapse: • Definition varies according to source text. • Addiction Medicine-Fourth Edition 2009: • Uses terms Lapse, Relapse, and Recovery. • Some argument over what constitutes a Relapse-but not from PHP programs. Use a higher standard of complete abstinence from mood altering substances. Road to Recovery
  22. 22. Lapse • Marlatt defines as the initial episode of use of a substance after a period of abstinence. • Not really recognized for professionals. Road to Recovery
  23. 23. Relapse: • “ a discrete phenomenon or a process of behavioral change” • “an unfolding process in which the resumption of substance use is the LAST event in a long series of maladaptive responses to internal or external stressors or stimuli” • “ a continuous process defined by a series of transgressive behaviors” Road to Recovery
  24. 24. Road to Recovery
  25. 25. Road to Recovery
  26. 26. Interventions Do Work
  27. 27. Behavior Patterns • It’s the behavior stupid. • Mechanism of response to stressors and stimuli—I.E.—LIFE. • Response can be healthy or maladaptive Road to Recovery
  28. 28. Recovery • Recovery is defined as a long-term and ongoing process rather than an endpoint. • Specific areas of change during the process of recovery include physical, psychologic, spiritual, behavioral, interpersonal, sociocultural, familial, and financial. • Recovery tasks and areas of clinical focus are contingent on the phase of recovery . Road to Recovery
  29. 29. Stages of Relapse: • Used by PHP and RNP programs nationwide. • 3 stages of relapse. • Evidence shows progression over time. • Measurement of severity of relapse but not necessarily indicative of recommended corrective actions from monitoring programs. Road to Recovery
  30. 30. Level 1 Relapse • A level 1 relapse consists of missing therapy meetings, support groups, dishonesty, or other behavioral infractions. • Note-no mention of substances. Road to Recovery
  31. 31. Level 2 Relapse • A level 2 relapse involves the reuse of drugs or alcohol but outside the context of medical practice. • Not necessarily a person’s drug of choice. Road to Recovery
  32. 32. Level 3 Relapse • Involves the use of drugs or alcohol within the context of medical practice. • Main goal of PHP programs is to prevent this occurence. • PHP’s, PRN’s, and RNP’s primary directive: Protect the Public. Road to Recovery
  33. 33. Consequences • Different for professionals than the general public because we present a greater danger than just to ourselves. • “Physicians who have difficulty maintaining abstinence should be removed from the workforce until treatment providers….feel that the physician is safe to return to work.” Road to Recovery
  34. 34. Consequences 2 • “ The point in time when a physician is safe to practice is best determined by a joint decision of the physician’s treatment provider and the monitoring PHP.” Road to Recovery
  35. 35. Determinants of Relapse • Marlatt’s Relapse Taxonomy: • Intrapersonal Determinants – Self Efficacy – Outcome Expectancies – Cravings – Motivation – Coping – Emotional States • Interpersonal Determinants Road to Recovery
  36. 36. Intrapersonal Determinants • Self-efficacy: refers to the individuals beliefs in their capabilities to organize and carry out specific courses of action to attain some goal or situation specific task. • This construct is intimately related to the individual’s coping abilities. • The patient’s personal belief in his or her ability to control substance use is a reliable predictor of relapse. Road to Recovery
  37. 37. Self-Efficacy • If you believe you can you will. • Confidence in your ability to control your substance use is intimately related with your coping skills. • Coping behaviors should be thoroughly assessed during treatment and appropriately targeted for interventions. Road to Recovery
  38. 38. Road to Recovery
  39. 39. Outcome Expectancy • A factor enhancing the likelihood of relapse is the set of cognitive expectancies that individuals develop regarding the expected outcomes of substance use. • If it feels good do it. Not a good plan. • Treatment should focus to some extent on changing the individual’s outcome expectancies regarding substance use. Road to Recovery
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  41. 41. Craving • Defined as a cognitive experience focused on the desire to use a substance. • Closely related to outcome expectancies. • Different from behavioral urges. • Treatment should also include an evaluation of cravings and appropriate readjustment based on outcome expectancies. Road to Recovery
  42. 42. Road to Recovery
  43. 43. Motivation • Gorski: The degree to which a person’s behavior differs from their ideal behavior beliefs is the degree of that person’s insanity. • The person’s desire for self improvement and commitment to change is a strong predictor of relapse. • Ambivalence toward change is the enemy of recovery. Road to Recovery
  44. 44. Road to Recovery
  45. 45. Coping • “Based upon cognitive-behavioral model of relapse, the most critical predictor of relapse is the individuals ability to utilize adequate coping strategies in dealing with high-risk situations.” • One of the most effective coping strategies available is mindfulness and meditation. • Foundation of behavioral change. Road to Recovery
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  47. 47. Road to Recovery
  48. 48. Emotional States • Studies show a strong link between negative affect and relapse to substance abuse. • It is the cornerstone of effective recovery; affect is a strong determinant of subsequent behavior. • Two things you can control: Attitude and Behavior. They are intimately associated. Road to Recovery
  49. 49. Road to Recovery
  50. 50. Interpersonal Determinants • Functional support or the level of emotional support is highly predictive of long term abstinence and recovery. • Behavioral therapy which incorporates partner support in treatment goals is one of the top three empirically supported treatment methods for alcohol problems. • Al-Anon is born. Road to Recovery
  51. 51. Road to Recovery
  52. 52. Top 10 ways to Prevent Relapse • 1) Help patients understand relapse as a process and event, and learn to identify warning signs. Road to Recovery
  53. 53. RP • 2) Help patients identify their high risk situations and develop effective cognitive and behavioral coping. Road to Recovery
  54. 54. RP • 3) Help patients enhance their communication skills, interpersonal relationships, and develop a recovery social network. Road to Recovery
  55. 55. RP • 4) Help patients reduce, identify, and manage negative emotional states. Road to Recovery
  56. 56. RP • 5) Help patients identify and manage cravings and cues that precede cravings. Road to Recovery
  57. 57. RP • 6) Help patients identify and challenge cognitive distortions. Road to Recovery
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  59. 59. RP • 7) Help patients work toward a more balanced lifestyle. Road to Recovery
  60. 60. RP • 8) Consider the use of medications in combination with psychosocial treatments. Road to Recovery
  61. 61. RP • 9) Facilitate the transition between levels of care for patients completing residential or hospital based inpatient treatment programs, or structured partial hospital or intensive outpatient programs. • PRN’s PHP’s RNP’s CM Road to Recovery
  62. 62. RP • 10) Incorporate strategies to improve adherence to treatment and medication. Road to Recovery
  63. 63. Susan P. Rx Relapse ? • Susan is a 35 year old Pharmacist who was treated for alcohol SUD at the age of 24. After treatment she enrolled in the PRN monitoring and signed a 5 year monitoring contract. • After the completion of her five year contract at the age of 29 she had been very engaged in her peer support recovery program (AA, Caduceus, Continuing Care, and UDS monitoring) but stopped going about six months before the end of her contract. • Three months prior to completion of her contract, Susan discovered she was pregnant—she had noticed a significant mood change(depression) and an increase in her anxiety level due to difficulty with her supervisor at work (Hospital Pharmacy). She also was increasingly anxious due to her infidelities which occurred with another coworker who was a 22 year old pharmacy student—which she ended at 8 months into her pregnancy—after being involved with him for several months. Road to Recovery
  64. 64. Susan P Rx Relapse ? • Is Susan P. in Relapse? • Would she benefit from being in a social recovery Network? • How could she be better managing her “negative emotional state”? • What emotions are driving that “state”? Road to Recovery
  65. 65. Susan P Rx Relapse? • She had a child (son) who was born about six months after completing her monitoring contract(out of meetings for about 1 year. She did have to undergo a C-section and the birth was complicated with some fetal distress prior to delivery—yet no anomalies were noted in the infant. Susan received a Rx for Percocet 10mg after the C-section and took three refills. (when taking the Percocet—she began to think about a repeated dose within 1 hour of last dose and could not get it off her mind) • Susan returned to work after only 8 weeks at home after the C- section. She had stopped having contact with her sponsor as she was no longing attending AA meetings (not enough time). Also her sponsor had advised her to end the previous relationship after Susan had only one sexual encounter with him at age 33—she did not follow the suggestions—the relationship continued for several months. She had been working with a girl in early recovery but stopped working with her after stopping the meetings. Road to Recovery
  66. 66. Susan P. Rx Relapse • Is Susan in Relapse? • What Level? • What did she not do with her pregnancy/delivery? • What could Susan have done with Cravings? Road to Recovery
  67. 67. Susan P Rx Relapse ? • Susan returned to her habit of smoking cigarettes (she had stopped at age 24) only two weeks after her son was born. Susan also began to experience recurring episodes of dysphoria within that same time frame, she also experienced recurring “flash-backs” of early childhood sexual trauma she experienced at the age of 8 by an “uncle”. She would have recurrent thoughts of being worthless and not being able to do anything right—she began to think that her tendency to “gamble” was the reason for sexual trauma “flash-backs”. • She was responsible for filling the Pyxis machines with all of the narcotics when she returned to work from maternity leave—so she progressively increased her use up to 25 Percocet tablets daily. She took “50 Percocet capsules” in a “suicide attempt” when her supervisor began to perform internal Pyxis pharmacy audits. She now presents for an addiction assessment after getting out of the acute care hospital. • Road to Recovery
  68. 68. Susan P Rx Relapse? • 15. Does Cigarette Smoking increase her risk of relapse? • 16. What should she do about “flash-backs”? • 17. What should she do about cognitive distortions? • 18. Should she be on MAT? Vivitrol? • 19. What is most appropriate next step? Road to Recovery
  69. 69. Susan P. Rx Relapse? True/False? 21. Relapse Prevention plans should always be started at the middle/end of treatment. 22. Performing a relapse autopsy is always useful. 23. Most HCP’s who relapse, always loose their license and ability to practice their profession. 24. Many HCP’s who have an early relapse, often are able to achieve and improved footing/foundation of a recovery program. 25. IDAA. Look us up www.ida.org Road to Recovery
  70. 70. Relapse: Road to Recovery Dr. Jay Piland MD Palmetto Addiction Recovery Center Pecan Haven Adolescent Addiction Center