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Relapse Recovery in Pharmacists
Relapse:
Road to Recovery
Dr. Jay Piland MD
Palmetto Addiction Recovery Center
Pecan Haven Adolescent Addiction Center
Objectives
1) Define the Prevalence of Addiction in the Pharmacy
Profession & other Health Care Professionals
2) Outline Factors associated with the risk of addiction in
Health Care Professionals
3) Describe the success and relapse rates in Pharmacists &
other Health Care Professionals
4) Apply the Chronic Disease Management Model (CDM) of
care, continuity, and contingency management in the
recovering Health Care Professional
5) Explore how the environmental influences can impact the
development of addiction & relapse risks for the
recovering Health Care Professional
6) Describe concepts of a Relapse Prevention Plan
Road to Recovery
Addiction
• …primary, chronically relapsing disease of the
brain reward, motivation, memory, and
related circuitry. Dysfunction in these circuits
leads to characteristic biological,
psychological, social and spiritual
manifestations. This is reflected in an
individual pathologically pursuing reward
and/or relief by substance use and other
behaviors.
Road to Recovery
Road to Recovery
Road to Recovery
• Compulsion to seek and take a drug or
stimulus, loss of control in limiting intake, and
emergence of a negative emotional state (e.g.,
dysphoria, anxiety, irritability) when access to
the drug or stimulus is prevented.
• Addiction Cycle—Binge/intoxication stage to
Withdrawal/negative affect stage to the
Preoccupation/anticipation(craving) stage
Road to Recovery
Neurocircuitry of Addiction
Derived from: Koob G, Everitt, B and Robbins T, Reward, motivation, and addiction. In: Squire LR, Berg D,
Bloom FE, du Lac S, Ghosh A, Spitzer NC (Eds.), Fundamental Neuroscience, 3rd edition,
Academic Press, Amsterdam, 2008, pp. 987-1016.
Road to Recovery
Road to Recovery
“Brain Disease”
• Brain Cells adapt to substances and the
excessive bombardment by substances
produces dysfunctional adaptations that
become embedded in the neuronal circuitry
Road to Recovery
“Brain Disease”
• Brain Cells adapt to substances and the
excessive bombardment by substances
produces dysfunctional adaptations that
become embedded in the neuronal circuitry
• New patterns of neuronal firing in the centers
of the brain reward system develop so that
the addicted brain is functionally and
morphologically different from a non-
addicted brain
Road to Recovery
Question
Question 1. The addiction cycle and neurobiology of addiction involve
long term changes which would include all except:
A. The dorsal Prefrontal Cortex functions as the “Go System” which
become overactive
B. The Ventral Prefrontal Cortex function as the “Stop System” which
is lost/diminished during addiction
C. The CRF (cortisol releasing factor) and NE/dynorphin are involved
in the Withdrawal/Negative Effect stage which produces many of
the withdrawal signs & symptoms.
D. The brain is no longer “plastic” or cannot be “rewired” after the
age of 18, so adolescence can use substances like Cannabis
without any concern of potential long-term changes in their
neuronal circuits.
Road to Recovery
Question
• Question 1. The addiction cycle and neurobiology of addiction
involve long term changes which would include all except:
A. The dorsal Prefrontal Cortex functions as the “Go System” which
become overactive
B. The Ventral Prefrontal Cortex function as the “Stop System” which
is lost/diminished during addiction
C. The CRF (cortisol releasing factor) and NE/dynorphin are involved
in the Withdrawal/Negative Effect stage which produces many of
the withdrawal signs & symptoms.
D. The brain is no longer “plastic” or cannot be “rewired” after the
age of 18, so adolescence can use substances like Cannabis
without any concern of potential long-term changes in their
neuronal circuits.
Road to Recovery
Road to Recovery
Defining Co-occurring
Disorders
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Mood Disorders Anxiety Disorders Post-Traumatic
Stress Disorders
Antisocial
Personality
Disorders
Borderline
Personality
Disorders
Severe Mental Illness
Addiction Treatment Provider Estimates
by Psychiatric Disorder
16
Lifetime Prevalence
of SUD for Each MHD
Bipolar Disorder 56%
Schizophrenia 47%
Major Depression 27%
Any Anxiety Disorder 24%
PTSD 30-75%
Borderline Personality
Disorder
23%
Eating Disorder 23-55%*
Likelihood of a
Suicide Attempt
Risk Factor
• Cocaine use
• Major Depression
• Alcohol use
• Separation or Divorce
NIMH/NIDA
Increased Odds Of
Attempting Suicide
62 times more likely
41 times more likely
8 times more likely
11 times more likely
ECA EVALUATION
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
Changing Lexicon of SUD
• DSM-V Terminology & Criteria has sought to
correct confusion regarding misperceptions
created by language in previous DSM
– ABUSE—pattern of use that results in considerable
social, interpersonal, or legal problems or hazardous
use
– DEPENDENCE/Addiction—uncontrolled use resulting
in considerable physical/psychological problems and
impairment (continual/compulsive use of self-
administered chemicals despite the problems related
to their use)
Road to Recovery
“Misuse” of Prescription Drugs
• Any deviation from Prescribed Use
– Using a medication without a prescription—No Rx
– Using more or for longer periods than prescribed
– Hoarding pills for future use—Stash
– Obtaining a Prescription fradulantly
– Changing the route of administration—to
circumvent the safety features—abuse
– Acquiring multiple prescriptions for the same or
similar medications—Doctor Shopping
Road to Recovery
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
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
Questions
• 2. All of the following are True except one—which?:
• A. There is a Higher lifetime prevalence of SUD in
patients with Schizophrenia & Bipolar Disorder
compared to Depression & Anxiety.
• B. Having a legal problem such as charges for armed
robbery (arrest) is part of the new criteria for SUD in
DSM V.
• C. Borderline Personality Disorder often interferes with
treatment in women & men.
• D. It is possible that the higher risk of suicide in the
cocaine user with SUD is due to extreme levels of
impulsivity.
Road to Recovery
Questions
• 2. All of the following are True except one—which?:
• A. There is a Higher lifetime prevalence of SUD in
patients with Schizophrenia & Bipolar Disorder
compared to Depression & Anxiety.
• B. Having a legal problem such as charges for armed
robbery (arrest) is part of the new criteria for SUD in
DSM V.
• C. Borderline Personality Disorder often interferes with
treatment in women & men.
• D. It is possible that the higher risk of suicide in the
cocaine user with SUD is due to extreme levels of
impulsivity.
Road to Recovery
Questions
Question #3 Which of the following best
characterizes substance use disorders and
recovery?
A. Acute, short-term problem
B. Chronic, Lifelong process
C. Disease with no known risk factors
D. Condition to which those with expertise are
immune.
Road to Recovery
Questions
Question #3 Which of the following best
characterizes substance use disorders and
recovery?
A. Acute, short-term problem
B. Chronic, Lifelong process
C. Disease with no known risk factors
D. Condition to which those with expertise are
immune.
Road to Recovery
“Mind you, only one doctor out of ten recommends it.”
Road to Recovery
“Sometimes it’s not so much seeing the
light as feeling the heat.”
Road to Recovery
PERCOCET
“For
distribution
to patients in
the office as
needed.”
M: 20,000
PHP Referral
Road to Recovery
From Discovery to Recovery
Addictive Disease in Pharmacists
• Substance Abuse/Dependence—SUD
– Lifetime Prevalence: 10 to 15%
– 1 in 7 Pharmacists in Lifetime
– SUD most serious illness to afflict pharmacists in their first
15 years of practice
– Versus Physicians/MD/DO
– (SUD Lifetime Prevalence: 8-10%--Self Report Response)
– Hughes PH, Brandenburg N, Prevalence of Substance Use Among US Physicians. JAMA 1992; 267:2333-8
– Prior Studies estimate Prevalence 10 to 14%
– Annual Incidence: 1 to 2 % (when alcohol excluded)
Road to Recovery
Addictive Disease in Pharmacists
• 58.7% of Pharmacists reported using a non-prescribed drug
at least once in their lifetime
• 20% of Pharmacists report that they had used a
prescription drug without a prescription at least 5 times or
more in their lifetime
• At least 20% and up to 50% of Pharmacist may misuse
prescription drugs
• Prevalence of drug use during the previous year was higher
for pharmacists (12.8%)—many reported lifetime use of
minor opiates, anxiolytics, and stimulants
Road to Recovery
“Impaired Pharmacist”
• Refers to pharmacist with psychiatric,
cognitive, behavioral, or general medical
problem that have the potential to adversely
affect the pharmacist’s ability to perform
specific duties.
Road to Recovery
Pharmacists
• NIDA SUD Numbers—Prevalence
– General US Population Chemical Dependency 10 to 15 %
– Health Care Professionals SUD 8 to 12 %
– Pharmacists Chemical Addiction 11 to 15%
Road to Recovery
Specific Greater Risk Factors for Addictive Disease in
HCP—Health Care Professionals
-Genetic Predisposition (FH of dependence)
-Environmental Stressors (shift work, high level of job responsibility, job
dissatisfaction)
-Inadequate Education & Training on AD regarding the psychological aspects of
addiction, criteria for addiction, and recovery from addiction
-Omnipotence & Belief that knowledge of the pharmacodynamics of medications
will ensure safety from AD
-Greater Accessibility
-Social Factors—lack of peer, academic, or occupational discouragement
-Peer Reinforcement of self-medication practices
-Dual Diagnosis (relapse risk) & Comorbid Medical Diagnosis
Road to Recovery
Road to Recovery
Road to Recovery
Road to Recovery
“Occupational Hazard”
Recovering substance-impaired pharmacists’ views regarding occupational risks for addiction
J Am Pharm Assoc 2012;52 (4): 480-491
• 6 groups comprised of pharmacists N=32
• 32 of 37 pharmacists participated (86.5%) and represented 22% of Washington States Pharmacists
under monitoring contract
• 27 Reported how they had been introduced to misuse of drugs (4 had
been referred to PRN for alcohol and illicit drug use)
• Common Reasons:
– Recreational Purposes “a high was always welcome”—Positive experiences
– Prescription drugs easier to manage than…
– Legitimate medical use of the drugs
– Lead to Pleasurable sensations (recreate)
– Denial that they might be vulnerable to addiction (valid Rx)
– Misuse of psychotropic medications
– Self-medicate for stress or other mental health symptoms
– Co-occurring Disorders particularly at risk
– Stressful career and associated problems “Privileged to have such a job”
– Using Recreational Drugs in place of psychiatric medications prescribed
Road to Recovery
“Occupational Hazard”
Recovering substance-impaired pharmacists’ views regarding occupational risks for addiction
J Am Pharm Assoc 2012;52 (4): 480-491
• 6 groups comprised of pharmacists N=32
• 32 of 37 pharmacists participated (86.5%) and represented 22% of Washington States Pharmacists
under monitoring contract
• 27 Reported how they had been introduced to misuse of drugs (4 had
been referred to PRN for alcohol and illicit drug use)
• Common Reasons:
– Recreational Purposes “a high was always welcome”—Positive experiences
– Prescription drugs easier to manage than…
– Legitimate medical use of the drugs
– Lead to Pleasurable sensations (recreate)
– Denial that they might be vulnerable to addiction (valid Rx)
– Misuse of psychotropic medications
– Self-medicate for stress or other mental health symptoms
– Co-occurring Disorders particularly at risk
– Stressful career and associated problems “Privileged to have such a job”
– Using Recreational Drugs in place of psychiatric medications prescribed
Road to Recovery
“Occupational Hazard”
Recovering substance-impaired pharmacists’ views regarding occupational risks for addiction
J Am Pharm Assoc 2012;52 (4): 480-491
• Risks Associated with the Pharmacy
Profession:
– Access to Prescription Drugs
– Stressful Work Environment
– Culture
– Barriers to Treatment Access
– Education
Road to Recovery
Barriers for HCP’s seeking and
receiving assistance
Road to Recovery
The Addicted Pharmacist and the Effect of Their Environment
University of Findlay College of Pharmacy
PRN Survey (N 171—25%)
• Demographics
– Race 94% White, 1% African American, 0.5% Asian, 2% American Indian, 2%
Preferred not to say
– Males 74% Females 26%
– Ages(years) 3% 20-29, 21% 30-39, 21% 40-49, 49% 50-64, 6% >65
– Marital Status 56% married, 21% divorced, 14% single/never married, 3.5%
widowed, 2% domestic partnership, 2% preferred not to say
– Currently Practicing 67% Yes 33% No
– Geographical area of Practice 38% Metropolitan, 33% Rural, 28% Suburban
– Current Alcohol/Tobacco use: 25% Tobacco Products, 2% drink alcohol, and
73% do not use
Road to Recovery
The Addicted Pharmacist and the Effect of Their Environment
University of Findlay College of Pharmacy
PRN Survey (N 171—25%)
• Prior to becoming a Pharmacist
– 68% found to be abusing drugs or alcohol
• Of those 33% abused Illicit Drugs
• Of those 20% abused Prescription Drugs
• Of those 59% abused Alcohol
Road to Recovery
The Addicted Pharmacist and the Effect of Their Environment
University of Findlay College of Pharmacy
PRN Survey (N 171—25%)
• Age of First Use
– Between 16 and 20 years old 42%
– With 16 being the average overall age of first use
– Between ages 13 to 15 years old 30%
Road to Recovery
The Addicted Pharmacist and the Effect of
Their Environment
University of Findlay College of Pharmacy
PRN Survey (N 171—25%)
95% (164 of 171) participants specified setting
Road to Recovery
The Addicted Pharmacist and the Effect of Their Environment
University of Findlay College of Pharmacy
PRN Survey (N 171—25%)
40%
30%
4%
12%
8%
6%
Class of Substance Used
Opiates
Alcohol
other
Benzodiazepines
Stimulants
Muscle Relaxers/Barb.
Road to Recovery
The Addicted Pharmacist and the Effect of Their Environment
University of Findlay College of Pharmacy
PRN Survey (N 171—25%)
• Reasons for starting Use:
– 22% Stress
– 16% Experimenting & Liked Feeling it gave them
– 13% Social Inhibition
– 12% Depression/Anxiety/Escape
– 10% Major Life Event (Sexual Trauma, Death, etc)
Road to Recovery
The Addicted Pharmacist and the Effect of Their Environment
University of Findlay College of Pharmacy
PRN Survey (N 171—25%)
• From Discovery To Recovery
11%
1 to 5 Years
42%5 to 10 Years
23%
> 10 Years
24%
LENGTH OF PRACTICE WITH ACTIVE
ADDICTION
Road to Recovery
The Addicted Pharmacist and the Effect of Their Environment
University of Findlay College of Pharmacy
PRN Survey (N 171—25%)
• From Discovery to Recovery
– 29% Sought Treatment on their Own
– 71% Intervened Upon
– 38% Attempted Suicide
Road to Recovery
Signs and Symptoms of Possible
SUD in Pharmacists
Professional
• Work performance alternates between periods of high and low
productivity
• Absence from work without notice, frequent absenteeism or tardiness
• Unexplained, lengthy disappearance during work hours
• Sleeping or dozing while on duty
• Unreliable in keeping appointments, meeting deadlines
• Inappropriate prescriptions for large doses of narcotics
• Heavy drug waste and/or drug shortages in the pharmacy
• Sloppy record keeping, increase in medication order entry errors
• Volunteering for overtime, coming to work when not scheduled
• Poor interpersonal relations with colleagues, staff, and patients
• Increasing personal and professional isolation
Road to Recovery
Signs and Symptoms of Possible
SUD in Pharmacists
Physical
• Changes in sleeping patterns, eating habits
• Deterioration in appearance and personal hygiene
• Changes in speech patterns (e.g., slurred, faster or slower speech)
• Frequent bathroom breaks
• Excessive perspiration
• Confusion, memory loss, difficulty concentrating
• Personality changes, mood swings
• Wearing long sleeves when inappropriate
• Odor of alcohol on the breath or strong odor of mouthwash or
mints to mask the alcohol
• Hand tremor resulting from alcohol withdrawal (as in the morning)
Road to Recovery
• 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
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
The Addicted Pharmacist and the Effect of Their Environment
University of Findlay College of Pharmacy
PRN Survey (N 171—25%)
• Three Most Common Triggers
– Stress
– Depression/Unhappiness
– Pain (Emotional and/or Physical)
Road to Recovery
Questions
Question #4 For which of the following are
pharmacists at higher risk than non-health care
professionals?
A. Alcohol Abuse
B. Abuse of Illicit Drugs
C. Prescription Drug Abuse
D. Nonprescription Drug Abuse
Road to Recovery
Questions
Question #4 For which of the following are
pharmacists at higher risk than non-health care
professionals?
A. Alcohol Abuse
B. Abuse of Illicit Drugs
C. Prescription Drug Abuse
D. Nonprescription Drug Abuse
Road to Recovery
Questions
Question #5 Which of the following might
increase an individual’s risk of substance use
disorder?
A. Low Stress Job
B. Colleagues who condone self-medication
C. Female Sex
D. Limited Knowledge of Medications
Road to Recovery
Questions
Question #5 Which of the following might
increase an individual’s risk of substance use
disorder?
A. Low Stress Job
B. Colleagues who condone self-medication
C. Female Sex
D. Limited Knowledge of Medications
Road to Recovery
Questions
Question #6 Which of the following is True
regarding pharmacists who are affected by
substance use disorders?
A. Most are identified by law enforcement
B. There are no telltale outward signs to watch
for
C. They are an anomaly since knowledge of
drug therapy prevents substance abuse
D. Peers are important in their discovery
Road to Recovery
Questions
Question #6 Which of the following is True
regarding pharmacists who are affected by
substance use disorders?
A. Most are identified by law enforcement
B. There are no telltale outward signs to watch
for
C. They are an anomaly since knowledge of
drug therapy prevents substance abuse
D. Peers are important in their discovery
Road to Recovery
Not your usual Pharmacist
• The New Republic
Going Under by Jason Zengerle
A doctor's downfall, and a profession's struggle with addiction.
Post Date Wednesday, December 31, 2008
14
Road to Recovery
Road to Recovery
J.C. Pharmacist at Medicap
• J.C. 46 year old male retail pharmacist from Baton Rouge, LA
• Developed recurrent back pain after a strain upon lifting a heavy
box. Had a HNP L1-L3 diagnosed at 40 with RX (hydrocodone).
• At age 44 had Disc Surgery at L1-L3, with fair results and was
abruptly “cut-off” from hydrocodone after surgery.
• Received DUI (BAL 0.12%) after LSU Football Game for which
reported to his Board at age 45
• At age 45, he “reinjured” his back after his surgical recovery so he
began taking some of his wife’s hydrocodone so that he could work
better—made him “feel better” about his troubled marriage and
gave him “extra energy” to work.
• Asked to go for AME/APE—Addiction Assessment
• Thinks that his life has been going very well, except for his recent
surgery and it’s resultant “damage” to his marriage.
Road to Recovery
J.C.’s Comprehensive Assessment
• Multidisciplinary Treatment Team for a
“Biopsychosocialspiritual Assessment”
– AME/APE, H&P
– Psychological/Neuropsychological Testing
– Family Assessment
– Collection of Collateral Information
– Hair and Body Fluid Drug Testing
– Spiritual History
– Pain Evaluation
Road to Recovery
J.C.’s Comprehensive Assessment
• Multidisciplinary Treatment Team for a
“Biopsychosocialspiritual Assessment”
– AME/APE, H&P
– Psychological/Neuropsychological Testing
– Family Assessment
– Collection of Collateral Information
– Hair and Body Fluid Drug Testing
– Spiritual History
– Pain Evaluation
Road to Recovery
J.C.’s Comprehensive Assessment
• Multidisciplinary Treatment Team for a
“Biopsychosocialspiritual Assessment”
– AME/APE, H&P
– Psychological/Neuropsychological Testing
– Family Assessment
– Collection of Collateral Information
– Hair and Body Fluid Drug Testing
– Spiritual History
– Pain Evaluation
Road to Recovery
J.C.’s Comprehensive Assessment
• Multidisciplinary Treatment Team for a
“Biopsychosocialspiritual Assessment”
– AME/APE, H&P
– Psychological/Neuropsychological Testing
– Family Assessment
– Collection of Collateral Information
– Hair and Body Fluid Drug Testing
– Spiritual History
– Pain Evaluation
Road to Recovery
J.C.’s Findings
• Smoked at age 12 and Drank alcohol at age 15 with binge pattern of drinking 18 to 25.
• Family History of Alcoholism in Paternal GF & GM
• Early Childhood Trauma—at age 8 to 9.
• “Slow Learner” between 7 to 12, but no testing for ADHD
• Began Hydrocodone for back pain by MD at age 40 which was ‘chronic’ until surgical intervention at
age 44—with nausea, diarrhea, body aches, and insomnia upon stopping.
• Hair Sample Analysis revealed high levels of hydrocodone and amphetamine throughout last 4
months at age 46 and his UDS is positive for Ambien.
• Has Never been spiritual despite having been raised in a “strict Baptist home”
• Drug Use Hx—social alcohol drinker with prior “binge pattern” of drinking until age 25. Took
Hydrocodone as prescribed every six hours until age 44.
• Collateral History: Jerry’s work supervisor has seen his concentration shorten and his patience has
shortened with his coworkers and clients—over the last two years. Wife reports that Jerry isolates
himself when at home and often “volunteers” to work extra hours. He used to coach his son’s
baseball team, but over the past four years has not coached and rarely goes to games. She has had
only two prescriptions for hydrocodone in the last year (#30 each) and did not know he took her
meds. Jerry has not been able to sleep since his DUI about six weeks ago. She thinks that Jerry
became very depressed after his back surgery which resolved after six months, but he began
isolating himself again about six weeks ago when he suddenly became more depressed again.
Road to Recovery
J.C.’s Findings
• Smoked at age 12 and Drank alcohol at age 15 with binge pattern of drinking 18 to 25.
• Family History of Alcoholism in Paternal GF & GM
• Early Childhood Trauma—at age 8 to 9.
• “Slow Learner” between 7 to 12, but no testing for ADHD
• Began Hydrocodone for back pain by MD at age 40 which was ‘chronic’ until surgical intervention at age
44—with nausea, diarrhea, body aches, and insomnia upon stopping.
• Hair Sample Analysis revealed high levels of hydrocodone and amphetamine throughout last 4 months at
age 46 and his UDS is positive for Ambien.
• Has Never been spiritual despite having been raised in a “strict Baptist home”
• Drug Use Hx—social alcohol drinker with prior “binge pattern” of drinking until age 40. Took Hydrocodone
as prescribed every six hours until age 44.
• Collateral History: Wife reports that Jerry isolates himself when at home and often “volunteers” to work
extra hours. She has had only two prescriptions for hydrocodone in the last year (#30 each) and did not
know he took her meds. Jerry has not been able to sleep since his DUI about six weeks ago. She thinks
that Jerry became very depressed after his back surgery which resolved after six months, but he began
isolating himself again until about six weeks ago when he suddenly became more depressed again.
• Later in Treatment (after six weeks): Jerry admits that he had significant
pain while taking the hydrocodone (increasing his dose) up to 80 to
100mg daily, after stopping the opioids he noticed all of his pain
symptoms resolved after about four to six weeks.
Road to Recovery
CDM
Chronic Disease Definition
• A chronic disease is one last 3 months or more
(US National Center for Health Statistics)
• A disease that is long lasting or recurrent
– Recurrent diseases relapse repeatedly, with
periods of remission in between.
Road to Recovery
• Conceptualization of addiction as a chronic
disease is supported by comparison of its
manifestations, course, etiologic factors
(genetic and environment), pathophysiology,
and response to treatment with other chronic
medical illnesses (DM II, asthma, HTN).
Road to Recovery
Principles of Chronic Disease Management CDM
adapted from: Dr. Richard Lewanczuk, Senior Medical Director, Primary Care, Chronic
Disease Management, Alberta Health Services
• Population stratified by risk
• Case finding, (screening)
• Continuum of care options
• Patient defined goals
• Multidisciplinary approach
• Care coordination and system supports
• Range of disease management strategies with
education
• Ongoing, long-term follow-up
Road to Recovery
Principles of Chronic Disease Management CDM
adapted from: Dr. Richard Lewanczuk, Senior Medical Director,Primary Care, Chronic
Disease Management, Alberta Health Services
• Population stratified by risk (FH/Childhood/Co-occurring/exposure to
substances)
• Case finding, (screening)—H&P/AME/Tox/CAGE/Collateral
• Continuum of care options—Customization/self-management
skills/Linkages to community support/Systematic monitoring of clinical
status & relapse risk—Clinic/IOP/Residential
• Patient defined goals—engage patient—system defined
abstinence/Lifestyle and Health/Reduced Disease-related Morbidity
• Multidisciplinary approach—Continum of Providers
• Care coordination and system supports—PRN/Providers
• Range of disease management strategies—
Stabilization,Education,Lifestyle Counseling,Relapse
Prevention,Counseling,Pharmacotherapy,Long-term monitoring
– Toxicology
• Ongoing, long-term follow-up
Road to Recovery
Chronic Care Model CDM
• Continuing contact over time between patients
and service providers, rather than short-term
intervention during acute episodes.
• Interventions to promote patient self-
management of his/her addiction
• Links to patient oriented community resources
• Using accurate and timely patient data to
monitor progress and guide intervention
Road to Recovery
Community Support Services—CDM
Diabetes Mellitus
• Family Counseling and
support
• More
Addiction
• Aftercare Groups
• Family Counseling and
support
• 12 Step Programs
• More
Road to Recovery
Relapse ?—CDM
Diabetes Mellitus
• Yes!
– Poor glucose control
– Target organ pathology
possible
– Family and occupational
consequences
• But good control possible
with life-long adherence to
treatment strategies
Addiction
• Yes!
– Relapse to substance use
– End Organ Pathology possible
– Family, Social, Occupational
consequences
• But long-term abstinence
possible with life-long
adherence to recovery
strategies
Road to Recovery
Cure?—CDM
Diabetes Mellitus
• No!
• Good Control possible
• ?Remission
Addiction
• No!
• Good Control Possible
• Remission possible
Road to Recovery
CDM Levels of Care
(Lewanczuk)
Case
Management
Specialty Clinics
Provide Care for
Complex Cases
Primary Care Physicians, teams, PCNS are supported
to supply the best care for the largest number of
people
Road to Recovery
PHP’s/PRN’s
Tertiary
Interventions and
Treatment
Coordination, Case
Management, and
CDM Monitoring
Secondary Access to
Services for Early
Intervention and
Treament
Primary Prevention and Education
Road to Recovery
PHP/PRN Services:
• Information and Advice
• Intervention Services
• Assessment
• Referral for Treatment
• Case Management
Monitoring
• Advocacy
• Family support
• Education and Prevention
• Not Treatment
Road to Recovery
Intervention
• Important considerations for intervention and
treatment
– Patient safety
– Prompt response and resource availability
– Medical Stabilization/withdrawal management
– Support (Family Support)
– Suicide Risk
– Work Responsibilities covered
– Reporting obligations—accountability
Road to Recovery
Assessment
• Community Based Clinical Resources
– Comprehensive Assessment Services
– Addiction Treatment Services
• Individual clinicians, outpatient programs, residential
treatment
– Psychiatrist
– GP psychotherapist
– Psychologists
– Mental Health Treatment Services
– Family Doctors
– Addiction and Family counselors
Road to Recovery
Treatment of Addiction HCP’s
• Abstinence Based
• Often Inpatient
• Detox
• Education
• Group Support
• Twelve Step Facilitation
• Pharmacotherapy (NB. Opioid agonist Rx seldom
needed)
• Identification of co-morbid disorders
• Family Support
• Long-Term monitoring/case management
Road to Recovery
•American Society of Addiction Medicine Patient Placement Criteria – 2nd
Edition Revised (ASAM PPC-2R) dimensions of care
 Dimension 1: Acute Intoxication and/or Withdrawal Potential
 Dimension 2: Biomedical Conditions and Complications
 Dimension 3: Emotional, Behavioral or Cognitive Conditions and
Complications (suicidality)
 Dimension 4: Readiness to Change
 Dimension 5: Relapse, Continued Use or Continued Problem Potential
 Dimension 6: Recovery/Living Environment
DETERMINING LEVEL OF CARE
Road to Recovery
DETERMINING LEVEL OF CARE
Road to Recovery
 Level I: Outpatient treatment.
 Level II: Intensive outpatient treatment, including
partial hospitalization.
 Level III: Residential/medically monitored intensive
inpatient treatment.
 Level IV: Medically managed intensive inpatient
treatment.
DETERMINING LEVEL OF CARE
Road to Recovery
Case Management/Coordination
• Clinical case coordinator for each HCP
• Receive Reports from all monitoring components
including workplace
• Random Toxicology Testing (urine, hair, other)
• Facilitate communication amongst treatment
providers
• Resource identification as needed
• Prompt response to relapse or prodrome
• Routine interviews and annual review with participant
• Progress and advocacy reports for third parties
• Identify and respond to family and other concerns
Road to Recovery
CDM—Coordination & Monitoring
• Contact with Colleagues
• Referral AME/Treatment
• Acting as intermediary with Board, employer,
colleagues, or staff to facilitate return to work
• UDS
• Monitoring of HCP’s Behavior
– (Phone contacts, his/her attendance at weekly
monitoring meetings/aftercare, workplace monitor
with regular reports regarding functioning on the job)
Road to Recovery
Behavioral
1%
SUD--Mild
2%
SUD--Moderate to
Severe
39%
Psychiatric
33%
Concurrent Disorders
22%
Substance Use
3%
Contracts by Type 2013 N=177 OMA
Behavioral SUD--Mild SUD--Moderate to Severe Psychiatric Concurrent Disorders Substance Use
Road to Recovery
Concurrent Problems and Disorders
• SUD seldom present in isolation
– Psychiatric Disorders
– Trauma
– Behavioral Dependencies (Sex, gambling, etc.)
– Physical Health problems (chronic pain
syndromes)
– Family Problems
Road to Recovery
Family: Addiction is a Family Disease
• Support
• Psychoeducation
• Recovery Services in support of Physician
spouse
• Referral for personal services
Road to Recovery
Road to Recovery
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
Questions
• Question #7 Pharmacists who develop SUD are
more likely to have had certain earlier life experiences,
all of the following are true except:
• A. Very few Pharmacist with SUD ever experienced use
of drugs/alcohol prior to the age of 18.
• B. Many would have had a family history of SUD.
• C. Early Life Trauma would have been a risk factor for
SUD later in life.
• D. Adolescence who are treated with Stimulants for
ADHD (which is “misdiagnosed” in childhood), will have
a greater risk for SUD than if they had not received
Stimulants.
Road to Recovery
Questions
• Question #7 Pharmacists who develop SUD are
more likely to have had certain earlier life experiences,
all of the following are true except:
• A. Very few Pharmacist with SUD ever experienced
use of drugs/alcohol prior to the age of 18.
• B. Many would have had a family history of SUD.
• C. Early Life Trauma would have been a risk factor for
SUD later in life.
• D. Adolescence who are treated with Stimulants for
“misdiagnosed” ADHD in childhood), will have a
greater risk for SUD versus those adolescence who had
never received stimulants.
Road to Recovery
Questions
• Questions #8. : Find the correct Answer(s):
• T/F The majority of referrals to PHP’s who ultimately sign
monitoring contracts have some form of psychiatric
diagnosis.
• T/F The PHP/PRN’s are the only entity that makes return
to work recommendations.
• T/F The PHP/PRN are seldom involved in any form of
intervention with professionals.
• T/F The PHP/PRN is a participants advocate, as long as
that participant is engaged in his program of recovery and
meeting his monitoring requirements.
• T/F In the CDM of care for addiction—Relapse is rarely a
concern and the goal is to achieve a cure.
Road to Recovery
Questions
• Questions #8. : Find the correct Answer(s):
• T/F The majority of referrals to PHP’s who ultimately sign
monitoring contracts have some form of psychiatric
diagnosis.
• T/F The PHP/PRN’s are the only entity that makes return
to work recommendations.
• T/F The PHP/PRN are seldom involved in any form of
intervention with professionals.
• T/F The PHP/PRN is a participant’s advocate, as long as
that participant is engaged in his program of recovery and
meeting his monitoring requirements.
• T/F In the CDM of care for addiction—Relapse is rarely a
concern and the goal is to achieve a cure.
Road to Recovery
Relapse:
Road to Recovery
Dr. Jay Piland MD
Palmetto Addiction Recovery Center
Pecan Haven Adolescent Addiction Center
CDM: Performance Measures
Help Guide Care
Road to Recovery
“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
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
OMA PHP Relapses - 5 Year Program
First 100 monitored participants
Brewster, Kaufmann et al; BMJ Nov 2008
Road to Recovery
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
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
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
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
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
Special Issues of Return to Work
• Risk Factors for Relapse in HCP’s
• Use of Potent Opioids (Fentanyl, Sufentanil,
morphine, and meperidine)-especially IV
opioids
• Co-occurring Mental Disorders
• Family History of Addiction
• Use of Multiple Drugs
Road to Recovery
Behaviors and Beliefs associated with
Higher Rates of Recovery—HCP’s
• Involvement in or strong sense of affiliation
with Alcoholic Anonymous
• Acceptance of addiction as a disease
• Ability to be Honest
• Acceptance of Spiritual Principles
Road to Recovery
Contingency Contracts
• Typically five years or more in duration and impose
conditions upon the physicians behavior in return for
a pathway to recovery and return to practice (provides
the basis for subsequent actions—eval/assessments):
– Withdrawal from practice until can return safely
– Avoidance of all addicting substances & Behaviors
– Participation in adequate Treatment
– Participation in weekly group sessions—facilitated
– Random Drug Testing
– Regular contact with PHP/PRN to monitor behaviors
– Factors determining readiness to return to practice safely
Road to Recovery
“Effective” Treatment Involves:
• Monitoring
• Monitoring
• Monitoring
– During and after Treatment
– And during Return to Work
– Fortified by Swift & Meaningful Interventions if
components of the contract are not maintained
Road to Recovery
Questions
Question #9 What percentage of pharmacists
can be expected to recover from substance use
disorders with participation in formal recovery
programs?
A. 25%
B. 45%
C. 65%
D. 85%
Road to Recovery
Questions
Question #9 What percentage of pharmacists
can be expected to recover from substance use
disorders with participation in formal recovery
programs?
A. 25%
B. 45%
C. 65%
D. 85%
Road to Recovery
Questions
Question #10 Which of the following might be
most likely to increase the risk of relapse in
pharmacists affected by substance abuse?
A. A Brief Relapse
B. Skipping group meetings
C. Acceptance of the diagnosis
D. Extended Treatment
Road to Recovery
Questions
Question #10 Which of the following might be
most likely to increase the risk of relapse in
pharmacists affected by substance abuse?
A. A Brief Relapse
B. Skipping group meetings
C. Acceptance of the diagnosis
D. Extended Treatment
Road to Recovery
Questions
Question #11 Pharmacists can access their
state’s recovery program through which of the
following?
A. www.na.org
B. www.aa.org
C. www.drugabuse.gov
D. www.usaprn.org
Road to Recovery
Questions
Question #11 Pharmacists can access their
state’s recovery program through which of the
following?
A. www.na.org
B. www.aa.org
C. www.drugabuse.gov
D. www.usaprn.org
Road to Recovery
Questions
• Question #12 Early reporting of addiction and related
disorders in HCP’s are important for which of the
following reasons?
A. Minimization of risk of harm to patients.
B. Delay can increase the risk of progression of the
condition for the HCP.
C. Avoidance of multiple legal issues (licensure, civil
liability, or liability of employer, or criminal liability of
the impaired HCP in the case of a medication error).
D. Minimization of “collateral” damage to HCP family
and personal relationships.
Road to Recovery
Questions
• Question #12 Early reporting of addiction and related
disorders in HCP’s are important for which of the
following reasons?
A. Minimization of risk of harm to patients.
B. Delay can increase the risk of progression of the
condition for the HCP.
C. Avoidance of multiple legal issues (licensure, civil
liability, or liability of employer, or criminal liability
of the impaired HCP in the case of a medication
error).
D. Minimization of “collateral” damage to HCP family
and personal relationships.
Road to Recovery
Questions
• Question #13 Relapse Risk for HCPs is
significantly increased by all of the following
except:
• A. Use of Major Opioid and Dual Diagnosis
• B. Family History of Substance Use Disorder
• C. Male Gender
• D. A History of a Prior Relapse
Road to Recovery
Questions
• Question #13 Relapse Risk for HCP is
significantly increased by all of the following
except:
• A. Use of Major Opioid and Dual Diagnosis
• B. Family History of Substance Use Disorder
• C. Male Gender
• D. A History of a Prior Relapse
Road to Recovery
Questions
• Question #14. Use of Contingency Management
(contracts) in the chronic disease model/management
of PRN’s:
• A. Involve giving rewards for negative drug screens
• B. Involve applying swift & strict enforcement of
contractual consequences for a positive drug screen
• C. Do not motivate meeting attendance by PRN
participants.
• D. Seldom are effective in the Professional population
Road to Recovery
Questions
• Question #14. Use of Contingency Management
(contracts) in the chronic disease model/management
of PRN’s:
• A. Involve giving rewards for negative drug screens
• B. Involves applying swift & strict enforcement of
contractual consequences for a positive drug screen
• C. Do not motivate meeting attendance by PRN
participants.
• D. Seldom are effective in the Professional population
Road to Recovery
Relapse:
Road to Recovery
Dr. Jay Piland MD
Palmetto Addiction Recovery Center
Pecan Haven Adolescent Addiction Center
Road to Recovery
Road to Recovery
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
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
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
Road to Recovery
Interventions Do Work
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
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
Road to Recovery
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
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
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
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
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
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
Determinants of Relapse
• Marlatt’s Relapse Taxonomy:
• Intrapersonal Determinants
– Self Efficacy
– Outcome Expectancies
– Cravings
– Motivation
– Coping
– Emotional States
• Interpersonal Determinants
Road to Recovery
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
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
Road to Recovery
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
Road to Recovery
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
Road to Recovery
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
Road to Recovery
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
Road to Recovery
Road to Recovery
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
Road to Recovery
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
Road to Recovery
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
RP
• 2) Help patients identify their high risk
situations and develop effective cognitive and
behavioral coping.
Road to Recovery
RP
• 3) Help patients enhance their communication
skills, interpersonal relationships, and develop
a recovery social network.
Road to Recovery
RP
• 4) Help patients reduce, identify, and manage
negative emotional states.
Road to Recovery
RP
• 5) Help patients identify and manage cravings
and cues that precede cravings.
Road to Recovery
RP
• 6) Help patients identify and challenge
cognitive distortions.
Road to Recovery
RP
• 7) Help patients work toward a more balanced
lifestyle.
Road to Recovery
RP
• 8) Consider the use of medications in
combination with psychosocial treatments.
Road to Recovery
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
RP
• 10) Incorporate strategies to improve
adherence to treatment and medication.
Road to Recovery
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
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
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
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
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
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
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
Relapse:
Road to Recovery
Dr. Jay Piland MD
Palmetto Addiction Recovery Center
Pecan Haven Adolescent Addiction Center

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Relapse Recovery in Pharmacists

  • 2. Relapse: Road to Recovery Dr. Jay Piland MD Palmetto Addiction Recovery Center Pecan Haven Adolescent Addiction Center
  • 3. Objectives 1) Define the Prevalence of Addiction in the Pharmacy Profession & other Health Care Professionals 2) Outline Factors associated with the risk of addiction in Health Care Professionals 3) Describe the success and relapse rates in Pharmacists & other Health Care Professionals 4) Apply the Chronic Disease Management Model (CDM) of care, continuity, and contingency management in the recovering Health Care Professional 5) Explore how the environmental influences can impact the development of addiction & relapse risks for the recovering Health Care Professional 6) Describe concepts of a Relapse Prevention Plan Road to Recovery
  • 4. Addiction • …primary, chronically relapsing disease of the brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Road to Recovery
  • 7. • Compulsion to seek and take a drug or stimulus, loss of control in limiting intake, and emergence of a negative emotional state (e.g., dysphoria, anxiety, irritability) when access to the drug or stimulus is prevented. • Addiction Cycle—Binge/intoxication stage to Withdrawal/negative affect stage to the Preoccupation/anticipation(craving) stage Road to Recovery
  • 8. Neurocircuitry of Addiction Derived from: Koob G, Everitt, B and Robbins T, Reward, motivation, and addiction. In: Squire LR, Berg D, Bloom FE, du Lac S, Ghosh A, Spitzer NC (Eds.), Fundamental Neuroscience, 3rd edition, Academic Press, Amsterdam, 2008, pp. 987-1016. Road to Recovery
  • 10. “Brain Disease” • Brain Cells adapt to substances and the excessive bombardment by substances produces dysfunctional adaptations that become embedded in the neuronal circuitry Road to Recovery
  • 11. “Brain Disease” • Brain Cells adapt to substances and the excessive bombardment by substances produces dysfunctional adaptations that become embedded in the neuronal circuitry • New patterns of neuronal firing in the centers of the brain reward system develop so that the addicted brain is functionally and morphologically different from a non- addicted brain Road to Recovery
  • 12. Question Question 1. The addiction cycle and neurobiology of addiction involve long term changes which would include all except: A. The dorsal Prefrontal Cortex functions as the “Go System” which become overactive B. The Ventral Prefrontal Cortex function as the “Stop System” which is lost/diminished during addiction C. The CRF (cortisol releasing factor) and NE/dynorphin are involved in the Withdrawal/Negative Effect stage which produces many of the withdrawal signs & symptoms. D. The brain is no longer “plastic” or cannot be “rewired” after the age of 18, so adolescence can use substances like Cannabis without any concern of potential long-term changes in their neuronal circuits. Road to Recovery
  • 13. Question • Question 1. The addiction cycle and neurobiology of addiction involve long term changes which would include all except: A. The dorsal Prefrontal Cortex functions as the “Go System” which become overactive B. The Ventral Prefrontal Cortex function as the “Stop System” which is lost/diminished during addiction C. The CRF (cortisol releasing factor) and NE/dynorphin are involved in the Withdrawal/Negative Effect stage which produces many of the withdrawal signs & symptoms. D. The brain is no longer “plastic” or cannot be “rewired” after the age of 18, so adolescence can use substances like Cannabis without any concern of potential long-term changes in their neuronal circuits. Road to Recovery
  • 15. Defining Co-occurring Disorders 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Mood Disorders Anxiety Disorders Post-Traumatic Stress Disorders Antisocial Personality Disorders Borderline Personality Disorders Severe Mental Illness Addiction Treatment Provider Estimates by Psychiatric Disorder
  • 16. 16 Lifetime Prevalence of SUD for Each MHD Bipolar Disorder 56% Schizophrenia 47% Major Depression 27% Any Anxiety Disorder 24% PTSD 30-75% Borderline Personality Disorder 23% Eating Disorder 23-55%*
  • 17. Likelihood of a Suicide Attempt Risk Factor • Cocaine use • Major Depression • Alcohol use • Separation or Divorce NIMH/NIDA Increased Odds Of Attempting Suicide 62 times more likely 41 times more likely 8 times more likely 11 times more likely ECA EVALUATION
  • 18. 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
  • 19. Changing Lexicon of SUD • DSM-V Terminology & Criteria has sought to correct confusion regarding misperceptions created by language in previous DSM – ABUSE—pattern of use that results in considerable social, interpersonal, or legal problems or hazardous use – DEPENDENCE/Addiction—uncontrolled use resulting in considerable physical/psychological problems and impairment (continual/compulsive use of self- administered chemicals despite the problems related to their use) Road to Recovery
  • 20. “Misuse” of Prescription Drugs • Any deviation from Prescribed Use – Using a medication without a prescription—No Rx – Using more or for longer periods than prescribed – Hoarding pills for future use—Stash – Obtaining a Prescription fradulantly – Changing the route of administration—to circumvent the safety features—abuse – Acquiring multiple prescriptions for the same or similar medications—Doctor Shopping Road to Recovery
  • 21. 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
  • 22. 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
  • 23. Questions • 2. All of the following are True except one—which?: • A. There is a Higher lifetime prevalence of SUD in patients with Schizophrenia & Bipolar Disorder compared to Depression & Anxiety. • B. Having a legal problem such as charges for armed robbery (arrest) is part of the new criteria for SUD in DSM V. • C. Borderline Personality Disorder often interferes with treatment in women & men. • D. It is possible that the higher risk of suicide in the cocaine user with SUD is due to extreme levels of impulsivity. Road to Recovery
  • 24. Questions • 2. All of the following are True except one—which?: • A. There is a Higher lifetime prevalence of SUD in patients with Schizophrenia & Bipolar Disorder compared to Depression & Anxiety. • B. Having a legal problem such as charges for armed robbery (arrest) is part of the new criteria for SUD in DSM V. • C. Borderline Personality Disorder often interferes with treatment in women & men. • D. It is possible that the higher risk of suicide in the cocaine user with SUD is due to extreme levels of impulsivity. Road to Recovery
  • 25. Questions Question #3 Which of the following best characterizes substance use disorders and recovery? A. Acute, short-term problem B. Chronic, Lifelong process C. Disease with no known risk factors D. Condition to which those with expertise are immune. Road to Recovery
  • 26. Questions Question #3 Which of the following best characterizes substance use disorders and recovery? A. Acute, short-term problem B. Chronic, Lifelong process C. Disease with no known risk factors D. Condition to which those with expertise are immune. Road to Recovery
  • 27. “Mind you, only one doctor out of ten recommends it.” Road to Recovery
  • 28. “Sometimes it’s not so much seeing the light as feeling the heat.” Road to Recovery
  • 29. PERCOCET “For distribution to patients in the office as needed.” M: 20,000 PHP Referral Road to Recovery
  • 30. From Discovery to Recovery Addictive Disease in Pharmacists • Substance Abuse/Dependence—SUD – Lifetime Prevalence: 10 to 15% – 1 in 7 Pharmacists in Lifetime – SUD most serious illness to afflict pharmacists in their first 15 years of practice – Versus Physicians/MD/DO – (SUD Lifetime Prevalence: 8-10%--Self Report Response) – Hughes PH, Brandenburg N, Prevalence of Substance Use Among US Physicians. JAMA 1992; 267:2333-8 – Prior Studies estimate Prevalence 10 to 14% – Annual Incidence: 1 to 2 % (when alcohol excluded) Road to Recovery
  • 31. Addictive Disease in Pharmacists • 58.7% of Pharmacists reported using a non-prescribed drug at least once in their lifetime • 20% of Pharmacists report that they had used a prescription drug without a prescription at least 5 times or more in their lifetime • At least 20% and up to 50% of Pharmacist may misuse prescription drugs • Prevalence of drug use during the previous year was higher for pharmacists (12.8%)—many reported lifetime use of minor opiates, anxiolytics, and stimulants Road to Recovery
  • 32. “Impaired Pharmacist” • Refers to pharmacist with psychiatric, cognitive, behavioral, or general medical problem that have the potential to adversely affect the pharmacist’s ability to perform specific duties. Road to Recovery
  • 33. Pharmacists • NIDA SUD Numbers—Prevalence – General US Population Chemical Dependency 10 to 15 % – Health Care Professionals SUD 8 to 12 % – Pharmacists Chemical Addiction 11 to 15% Road to Recovery
  • 34. Specific Greater Risk Factors for Addictive Disease in HCP—Health Care Professionals -Genetic Predisposition (FH of dependence) -Environmental Stressors (shift work, high level of job responsibility, job dissatisfaction) -Inadequate Education & Training on AD regarding the psychological aspects of addiction, criteria for addiction, and recovery from addiction -Omnipotence & Belief that knowledge of the pharmacodynamics of medications will ensure safety from AD -Greater Accessibility -Social Factors—lack of peer, academic, or occupational discouragement -Peer Reinforcement of self-medication practices -Dual Diagnosis (relapse risk) & Comorbid Medical Diagnosis Road to Recovery
  • 38. “Occupational Hazard” Recovering substance-impaired pharmacists’ views regarding occupational risks for addiction J Am Pharm Assoc 2012;52 (4): 480-491 • 6 groups comprised of pharmacists N=32 • 32 of 37 pharmacists participated (86.5%) and represented 22% of Washington States Pharmacists under monitoring contract • 27 Reported how they had been introduced to misuse of drugs (4 had been referred to PRN for alcohol and illicit drug use) • Common Reasons: – Recreational Purposes “a high was always welcome”—Positive experiences – Prescription drugs easier to manage than… – Legitimate medical use of the drugs – Lead to Pleasurable sensations (recreate) – Denial that they might be vulnerable to addiction (valid Rx) – Misuse of psychotropic medications – Self-medicate for stress or other mental health symptoms – Co-occurring Disorders particularly at risk – Stressful career and associated problems “Privileged to have such a job” – Using Recreational Drugs in place of psychiatric medications prescribed Road to Recovery
  • 39. “Occupational Hazard” Recovering substance-impaired pharmacists’ views regarding occupational risks for addiction J Am Pharm Assoc 2012;52 (4): 480-491 • 6 groups comprised of pharmacists N=32 • 32 of 37 pharmacists participated (86.5%) and represented 22% of Washington States Pharmacists under monitoring contract • 27 Reported how they had been introduced to misuse of drugs (4 had been referred to PRN for alcohol and illicit drug use) • Common Reasons: – Recreational Purposes “a high was always welcome”—Positive experiences – Prescription drugs easier to manage than… – Legitimate medical use of the drugs – Lead to Pleasurable sensations (recreate) – Denial that they might be vulnerable to addiction (valid Rx) – Misuse of psychotropic medications – Self-medicate for stress or other mental health symptoms – Co-occurring Disorders particularly at risk – Stressful career and associated problems “Privileged to have such a job” – Using Recreational Drugs in place of psychiatric medications prescribed Road to Recovery
  • 40. “Occupational Hazard” Recovering substance-impaired pharmacists’ views regarding occupational risks for addiction J Am Pharm Assoc 2012;52 (4): 480-491 • Risks Associated with the Pharmacy Profession: – Access to Prescription Drugs – Stressful Work Environment – Culture – Barriers to Treatment Access – Education Road to Recovery
  • 41. Barriers for HCP’s seeking and receiving assistance Road to Recovery
  • 42. The Addicted Pharmacist and the Effect of Their Environment University of Findlay College of Pharmacy PRN Survey (N 171—25%) • Demographics – Race 94% White, 1% African American, 0.5% Asian, 2% American Indian, 2% Preferred not to say – Males 74% Females 26% – Ages(years) 3% 20-29, 21% 30-39, 21% 40-49, 49% 50-64, 6% >65 – Marital Status 56% married, 21% divorced, 14% single/never married, 3.5% widowed, 2% domestic partnership, 2% preferred not to say – Currently Practicing 67% Yes 33% No – Geographical area of Practice 38% Metropolitan, 33% Rural, 28% Suburban – Current Alcohol/Tobacco use: 25% Tobacco Products, 2% drink alcohol, and 73% do not use Road to Recovery
  • 43. The Addicted Pharmacist and the Effect of Their Environment University of Findlay College of Pharmacy PRN Survey (N 171—25%) • Prior to becoming a Pharmacist – 68% found to be abusing drugs or alcohol • Of those 33% abused Illicit Drugs • Of those 20% abused Prescription Drugs • Of those 59% abused Alcohol Road to Recovery
  • 44. The Addicted Pharmacist and the Effect of Their Environment University of Findlay College of Pharmacy PRN Survey (N 171—25%) • Age of First Use – Between 16 and 20 years old 42% – With 16 being the average overall age of first use – Between ages 13 to 15 years old 30% Road to Recovery
  • 45. The Addicted Pharmacist and the Effect of Their Environment University of Findlay College of Pharmacy PRN Survey (N 171—25%) 95% (164 of 171) participants specified setting Road to Recovery
  • 46. The Addicted Pharmacist and the Effect of Their Environment University of Findlay College of Pharmacy PRN Survey (N 171—25%) 40% 30% 4% 12% 8% 6% Class of Substance Used Opiates Alcohol other Benzodiazepines Stimulants Muscle Relaxers/Barb. Road to Recovery
  • 47. The Addicted Pharmacist and the Effect of Their Environment University of Findlay College of Pharmacy PRN Survey (N 171—25%) • Reasons for starting Use: – 22% Stress – 16% Experimenting & Liked Feeling it gave them – 13% Social Inhibition – 12% Depression/Anxiety/Escape – 10% Major Life Event (Sexual Trauma, Death, etc) Road to Recovery
  • 48. The Addicted Pharmacist and the Effect of Their Environment University of Findlay College of Pharmacy PRN Survey (N 171—25%) • From Discovery To Recovery 11% 1 to 5 Years 42%5 to 10 Years 23% > 10 Years 24% LENGTH OF PRACTICE WITH ACTIVE ADDICTION Road to Recovery
  • 49. The Addicted Pharmacist and the Effect of Their Environment University of Findlay College of Pharmacy PRN Survey (N 171—25%) • From Discovery to Recovery – 29% Sought Treatment on their Own – 71% Intervened Upon – 38% Attempted Suicide Road to Recovery
  • 50. Signs and Symptoms of Possible SUD in Pharmacists Professional • Work performance alternates between periods of high and low productivity • Absence from work without notice, frequent absenteeism or tardiness • Unexplained, lengthy disappearance during work hours • Sleeping or dozing while on duty • Unreliable in keeping appointments, meeting deadlines • Inappropriate prescriptions for large doses of narcotics • Heavy drug waste and/or drug shortages in the pharmacy • Sloppy record keeping, increase in medication order entry errors • Volunteering for overtime, coming to work when not scheduled • Poor interpersonal relations with colleagues, staff, and patients • Increasing personal and professional isolation Road to Recovery
  • 51. Signs and Symptoms of Possible SUD in Pharmacists Physical • Changes in sleeping patterns, eating habits • Deterioration in appearance and personal hygiene • Changes in speech patterns (e.g., slurred, faster or slower speech) • Frequent bathroom breaks • Excessive perspiration • Confusion, memory loss, difficulty concentrating • Personality changes, mood swings • Wearing long sleeves when inappropriate • Odor of alcohol on the breath or strong odor of mouthwash or mints to mask the alcohol • Hand tremor resulting from alcohol withdrawal (as in the morning) Road to Recovery
  • 52. • 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
  • 53. 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
  • 54. The Addicted Pharmacist and the Effect of Their Environment University of Findlay College of Pharmacy PRN Survey (N 171—25%) • Three Most Common Triggers – Stress – Depression/Unhappiness – Pain (Emotional and/or Physical) Road to Recovery
  • 55. Questions Question #4 For which of the following are pharmacists at higher risk than non-health care professionals? A. Alcohol Abuse B. Abuse of Illicit Drugs C. Prescription Drug Abuse D. Nonprescription Drug Abuse Road to Recovery
  • 56. Questions Question #4 For which of the following are pharmacists at higher risk than non-health care professionals? A. Alcohol Abuse B. Abuse of Illicit Drugs C. Prescription Drug Abuse D. Nonprescription Drug Abuse Road to Recovery
  • 57. Questions Question #5 Which of the following might increase an individual’s risk of substance use disorder? A. Low Stress Job B. Colleagues who condone self-medication C. Female Sex D. Limited Knowledge of Medications Road to Recovery
  • 58. Questions Question #5 Which of the following might increase an individual’s risk of substance use disorder? A. Low Stress Job B. Colleagues who condone self-medication C. Female Sex D. Limited Knowledge of Medications Road to Recovery
  • 59. Questions Question #6 Which of the following is True regarding pharmacists who are affected by substance use disorders? A. Most are identified by law enforcement B. There are no telltale outward signs to watch for C. They are an anomaly since knowledge of drug therapy prevents substance abuse D. Peers are important in their discovery Road to Recovery
  • 60. Questions Question #6 Which of the following is True regarding pharmacists who are affected by substance use disorders? A. Most are identified by law enforcement B. There are no telltale outward signs to watch for C. They are an anomaly since knowledge of drug therapy prevents substance abuse D. Peers are important in their discovery Road to Recovery
  • 61. Not your usual Pharmacist • The New Republic Going Under by Jason Zengerle A doctor's downfall, and a profession's struggle with addiction. Post Date Wednesday, December 31, 2008 14 Road to Recovery
  • 63. J.C. Pharmacist at Medicap • J.C. 46 year old male retail pharmacist from Baton Rouge, LA • Developed recurrent back pain after a strain upon lifting a heavy box. Had a HNP L1-L3 diagnosed at 40 with RX (hydrocodone). • At age 44 had Disc Surgery at L1-L3, with fair results and was abruptly “cut-off” from hydrocodone after surgery. • Received DUI (BAL 0.12%) after LSU Football Game for which reported to his Board at age 45 • At age 45, he “reinjured” his back after his surgical recovery so he began taking some of his wife’s hydrocodone so that he could work better—made him “feel better” about his troubled marriage and gave him “extra energy” to work. • Asked to go for AME/APE—Addiction Assessment • Thinks that his life has been going very well, except for his recent surgery and it’s resultant “damage” to his marriage. Road to Recovery
  • 64. J.C.’s Comprehensive Assessment • Multidisciplinary Treatment Team for a “Biopsychosocialspiritual Assessment” – AME/APE, H&P – Psychological/Neuropsychological Testing – Family Assessment – Collection of Collateral Information – Hair and Body Fluid Drug Testing – Spiritual History – Pain Evaluation Road to Recovery
  • 65. J.C.’s Comprehensive Assessment • Multidisciplinary Treatment Team for a “Biopsychosocialspiritual Assessment” – AME/APE, H&P – Psychological/Neuropsychological Testing – Family Assessment – Collection of Collateral Information – Hair and Body Fluid Drug Testing – Spiritual History – Pain Evaluation Road to Recovery
  • 66. J.C.’s Comprehensive Assessment • Multidisciplinary Treatment Team for a “Biopsychosocialspiritual Assessment” – AME/APE, H&P – Psychological/Neuropsychological Testing – Family Assessment – Collection of Collateral Information – Hair and Body Fluid Drug Testing – Spiritual History – Pain Evaluation Road to Recovery
  • 67. J.C.’s Comprehensive Assessment • Multidisciplinary Treatment Team for a “Biopsychosocialspiritual Assessment” – AME/APE, H&P – Psychological/Neuropsychological Testing – Family Assessment – Collection of Collateral Information – Hair and Body Fluid Drug Testing – Spiritual History – Pain Evaluation Road to Recovery
  • 68. J.C.’s Findings • Smoked at age 12 and Drank alcohol at age 15 with binge pattern of drinking 18 to 25. • Family History of Alcoholism in Paternal GF & GM • Early Childhood Trauma—at age 8 to 9. • “Slow Learner” between 7 to 12, but no testing for ADHD • Began Hydrocodone for back pain by MD at age 40 which was ‘chronic’ until surgical intervention at age 44—with nausea, diarrhea, body aches, and insomnia upon stopping. • Hair Sample Analysis revealed high levels of hydrocodone and amphetamine throughout last 4 months at age 46 and his UDS is positive for Ambien. • Has Never been spiritual despite having been raised in a “strict Baptist home” • Drug Use Hx—social alcohol drinker with prior “binge pattern” of drinking until age 25. Took Hydrocodone as prescribed every six hours until age 44. • Collateral History: Jerry’s work supervisor has seen his concentration shorten and his patience has shortened with his coworkers and clients—over the last two years. Wife reports that Jerry isolates himself when at home and often “volunteers” to work extra hours. He used to coach his son’s baseball team, but over the past four years has not coached and rarely goes to games. She has had only two prescriptions for hydrocodone in the last year (#30 each) and did not know he took her meds. Jerry has not been able to sleep since his DUI about six weeks ago. She thinks that Jerry became very depressed after his back surgery which resolved after six months, but he began isolating himself again about six weeks ago when he suddenly became more depressed again. Road to Recovery
  • 69. J.C.’s Findings • Smoked at age 12 and Drank alcohol at age 15 with binge pattern of drinking 18 to 25. • Family History of Alcoholism in Paternal GF & GM • Early Childhood Trauma—at age 8 to 9. • “Slow Learner” between 7 to 12, but no testing for ADHD • Began Hydrocodone for back pain by MD at age 40 which was ‘chronic’ until surgical intervention at age 44—with nausea, diarrhea, body aches, and insomnia upon stopping. • Hair Sample Analysis revealed high levels of hydrocodone and amphetamine throughout last 4 months at age 46 and his UDS is positive for Ambien. • Has Never been spiritual despite having been raised in a “strict Baptist home” • Drug Use Hx—social alcohol drinker with prior “binge pattern” of drinking until age 40. Took Hydrocodone as prescribed every six hours until age 44. • Collateral History: Wife reports that Jerry isolates himself when at home and often “volunteers” to work extra hours. She has had only two prescriptions for hydrocodone in the last year (#30 each) and did not know he took her meds. Jerry has not been able to sleep since his DUI about six weeks ago. She thinks that Jerry became very depressed after his back surgery which resolved after six months, but he began isolating himself again until about six weeks ago when he suddenly became more depressed again. • Later in Treatment (after six weeks): Jerry admits that he had significant pain while taking the hydrocodone (increasing his dose) up to 80 to 100mg daily, after stopping the opioids he noticed all of his pain symptoms resolved after about four to six weeks. Road to Recovery
  • 70. CDM Chronic Disease Definition • A chronic disease is one last 3 months or more (US National Center for Health Statistics) • A disease that is long lasting or recurrent – Recurrent diseases relapse repeatedly, with periods of remission in between. Road to Recovery
  • 71. • Conceptualization of addiction as a chronic disease is supported by comparison of its manifestations, course, etiologic factors (genetic and environment), pathophysiology, and response to treatment with other chronic medical illnesses (DM II, asthma, HTN). Road to Recovery
  • 72. Principles of Chronic Disease Management CDM adapted from: Dr. Richard Lewanczuk, Senior Medical Director, Primary Care, Chronic Disease Management, Alberta Health Services • Population stratified by risk • Case finding, (screening) • Continuum of care options • Patient defined goals • Multidisciplinary approach • Care coordination and system supports • Range of disease management strategies with education • Ongoing, long-term follow-up Road to Recovery
  • 73. Principles of Chronic Disease Management CDM adapted from: Dr. Richard Lewanczuk, Senior Medical Director,Primary Care, Chronic Disease Management, Alberta Health Services • Population stratified by risk (FH/Childhood/Co-occurring/exposure to substances) • Case finding, (screening)—H&P/AME/Tox/CAGE/Collateral • Continuum of care options—Customization/self-management skills/Linkages to community support/Systematic monitoring of clinical status & relapse risk—Clinic/IOP/Residential • Patient defined goals—engage patient—system defined abstinence/Lifestyle and Health/Reduced Disease-related Morbidity • Multidisciplinary approach—Continum of Providers • Care coordination and system supports—PRN/Providers • Range of disease management strategies— Stabilization,Education,Lifestyle Counseling,Relapse Prevention,Counseling,Pharmacotherapy,Long-term monitoring – Toxicology • Ongoing, long-term follow-up Road to Recovery
  • 74. Chronic Care Model CDM • Continuing contact over time between patients and service providers, rather than short-term intervention during acute episodes. • Interventions to promote patient self- management of his/her addiction • Links to patient oriented community resources • Using accurate and timely patient data to monitor progress and guide intervention Road to Recovery
  • 75. Community Support Services—CDM Diabetes Mellitus • Family Counseling and support • More Addiction • Aftercare Groups • Family Counseling and support • 12 Step Programs • More Road to Recovery
  • 76. Relapse ?—CDM Diabetes Mellitus • Yes! – Poor glucose control – Target organ pathology possible – Family and occupational consequences • But good control possible with life-long adherence to treatment strategies Addiction • Yes! – Relapse to substance use – End Organ Pathology possible – Family, Social, Occupational consequences • But long-term abstinence possible with life-long adherence to recovery strategies Road to Recovery
  • 77. Cure?—CDM Diabetes Mellitus • No! • Good Control possible • ?Remission Addiction • No! • Good Control Possible • Remission possible Road to Recovery
  • 78. CDM Levels of Care (Lewanczuk) Case Management Specialty Clinics Provide Care for Complex Cases Primary Care Physicians, teams, PCNS are supported to supply the best care for the largest number of people Road to Recovery
  • 79. PHP’s/PRN’s Tertiary Interventions and Treatment Coordination, Case Management, and CDM Monitoring Secondary Access to Services for Early Intervention and Treament Primary Prevention and Education Road to Recovery
  • 80. PHP/PRN Services: • Information and Advice • Intervention Services • Assessment • Referral for Treatment • Case Management Monitoring • Advocacy • Family support • Education and Prevention • Not Treatment Road to Recovery
  • 81. Intervention • Important considerations for intervention and treatment – Patient safety – Prompt response and resource availability – Medical Stabilization/withdrawal management – Support (Family Support) – Suicide Risk – Work Responsibilities covered – Reporting obligations—accountability Road to Recovery
  • 82. Assessment • Community Based Clinical Resources – Comprehensive Assessment Services – Addiction Treatment Services • Individual clinicians, outpatient programs, residential treatment – Psychiatrist – GP psychotherapist – Psychologists – Mental Health Treatment Services – Family Doctors – Addiction and Family counselors Road to Recovery
  • 83. Treatment of Addiction HCP’s • Abstinence Based • Often Inpatient • Detox • Education • Group Support • Twelve Step Facilitation • Pharmacotherapy (NB. Opioid agonist Rx seldom needed) • Identification of co-morbid disorders • Family Support • Long-Term monitoring/case management Road to Recovery
  • 84. •American Society of Addiction Medicine Patient Placement Criteria – 2nd Edition Revised (ASAM PPC-2R) dimensions of care  Dimension 1: Acute Intoxication and/or Withdrawal Potential  Dimension 2: Biomedical Conditions and Complications  Dimension 3: Emotional, Behavioral or Cognitive Conditions and Complications (suicidality)  Dimension 4: Readiness to Change  Dimension 5: Relapse, Continued Use or Continued Problem Potential  Dimension 6: Recovery/Living Environment DETERMINING LEVEL OF CARE Road to Recovery
  • 85. DETERMINING LEVEL OF CARE Road to Recovery
  • 86.  Level I: Outpatient treatment.  Level II: Intensive outpatient treatment, including partial hospitalization.  Level III: Residential/medically monitored intensive inpatient treatment.  Level IV: Medically managed intensive inpatient treatment. DETERMINING LEVEL OF CARE Road to Recovery
  • 87. Case Management/Coordination • Clinical case coordinator for each HCP • Receive Reports from all monitoring components including workplace • Random Toxicology Testing (urine, hair, other) • Facilitate communication amongst treatment providers • Resource identification as needed • Prompt response to relapse or prodrome • Routine interviews and annual review with participant • Progress and advocacy reports for third parties • Identify and respond to family and other concerns Road to Recovery
  • 88. CDM—Coordination & Monitoring • Contact with Colleagues • Referral AME/Treatment • Acting as intermediary with Board, employer, colleagues, or staff to facilitate return to work • UDS • Monitoring of HCP’s Behavior – (Phone contacts, his/her attendance at weekly monitoring meetings/aftercare, workplace monitor with regular reports regarding functioning on the job) Road to Recovery
  • 89. Behavioral 1% SUD--Mild 2% SUD--Moderate to Severe 39% Psychiatric 33% Concurrent Disorders 22% Substance Use 3% Contracts by Type 2013 N=177 OMA Behavioral SUD--Mild SUD--Moderate to Severe Psychiatric Concurrent Disorders Substance Use Road to Recovery
  • 90. Concurrent Problems and Disorders • SUD seldom present in isolation – Psychiatric Disorders – Trauma – Behavioral Dependencies (Sex, gambling, etc.) – Physical Health problems (chronic pain syndromes) – Family Problems Road to Recovery
  • 91. Family: Addiction is a Family Disease • Support • Psychoeducation • Recovery Services in support of Physician spouse • Referral for personal services Road to Recovery
  • 93. 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
  • 94. Questions • Question #7 Pharmacists who develop SUD are more likely to have had certain earlier life experiences, all of the following are true except: • A. Very few Pharmacist with SUD ever experienced use of drugs/alcohol prior to the age of 18. • B. Many would have had a family history of SUD. • C. Early Life Trauma would have been a risk factor for SUD later in life. • D. Adolescence who are treated with Stimulants for ADHD (which is “misdiagnosed” in childhood), will have a greater risk for SUD than if they had not received Stimulants. Road to Recovery
  • 95. Questions • Question #7 Pharmacists who develop SUD are more likely to have had certain earlier life experiences, all of the following are true except: • A. Very few Pharmacist with SUD ever experienced use of drugs/alcohol prior to the age of 18. • B. Many would have had a family history of SUD. • C. Early Life Trauma would have been a risk factor for SUD later in life. • D. Adolescence who are treated with Stimulants for “misdiagnosed” ADHD in childhood), will have a greater risk for SUD versus those adolescence who had never received stimulants. Road to Recovery
  • 96. Questions • Questions #8. : Find the correct Answer(s): • T/F The majority of referrals to PHP’s who ultimately sign monitoring contracts have some form of psychiatric diagnosis. • T/F The PHP/PRN’s are the only entity that makes return to work recommendations. • T/F The PHP/PRN are seldom involved in any form of intervention with professionals. • T/F The PHP/PRN is a participants advocate, as long as that participant is engaged in his program of recovery and meeting his monitoring requirements. • T/F In the CDM of care for addiction—Relapse is rarely a concern and the goal is to achieve a cure. Road to Recovery
  • 97. Questions • Questions #8. : Find the correct Answer(s): • T/F The majority of referrals to PHP’s who ultimately sign monitoring contracts have some form of psychiatric diagnosis. • T/F The PHP/PRN’s are the only entity that makes return to work recommendations. • T/F The PHP/PRN are seldom involved in any form of intervention with professionals. • T/F The PHP/PRN is a participant’s advocate, as long as that participant is engaged in his program of recovery and meeting his monitoring requirements. • T/F In the CDM of care for addiction—Relapse is rarely a concern and the goal is to achieve a cure. Road to Recovery
  • 98. Relapse: Road to Recovery Dr. Jay Piland MD Palmetto Addiction Recovery Center Pecan Haven Adolescent Addiction Center
  • 99. CDM: Performance Measures Help Guide Care Road to Recovery
  • 100. “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
  • 101. 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
  • 102. OMA PHP Relapses - 5 Year Program First 100 monitored participants Brewster, Kaufmann et al; BMJ Nov 2008 Road to Recovery
  • 103. 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
  • 104. 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
  • 105. 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
  • 106. 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
  • 107. 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
  • 108. Special Issues of Return to Work • Risk Factors for Relapse in HCP’s • Use of Potent Opioids (Fentanyl, Sufentanil, morphine, and meperidine)-especially IV opioids • Co-occurring Mental Disorders • Family History of Addiction • Use of Multiple Drugs Road to Recovery
  • 109. Behaviors and Beliefs associated with Higher Rates of Recovery—HCP’s • Involvement in or strong sense of affiliation with Alcoholic Anonymous • Acceptance of addiction as a disease • Ability to be Honest • Acceptance of Spiritual Principles Road to Recovery
  • 110. Contingency Contracts • Typically five years or more in duration and impose conditions upon the physicians behavior in return for a pathway to recovery and return to practice (provides the basis for subsequent actions—eval/assessments): – Withdrawal from practice until can return safely – Avoidance of all addicting substances & Behaviors – Participation in adequate Treatment – Participation in weekly group sessions—facilitated – Random Drug Testing – Regular contact with PHP/PRN to monitor behaviors – Factors determining readiness to return to practice safely Road to Recovery
  • 111. “Effective” Treatment Involves: • Monitoring • Monitoring • Monitoring – During and after Treatment – And during Return to Work – Fortified by Swift & Meaningful Interventions if components of the contract are not maintained Road to Recovery
  • 112. Questions Question #9 What percentage of pharmacists can be expected to recover from substance use disorders with participation in formal recovery programs? A. 25% B. 45% C. 65% D. 85% Road to Recovery
  • 113. Questions Question #9 What percentage of pharmacists can be expected to recover from substance use disorders with participation in formal recovery programs? A. 25% B. 45% C. 65% D. 85% Road to Recovery
  • 114. Questions Question #10 Which of the following might be most likely to increase the risk of relapse in pharmacists affected by substance abuse? A. A Brief Relapse B. Skipping group meetings C. Acceptance of the diagnosis D. Extended Treatment Road to Recovery
  • 115. Questions Question #10 Which of the following might be most likely to increase the risk of relapse in pharmacists affected by substance abuse? A. A Brief Relapse B. Skipping group meetings C. Acceptance of the diagnosis D. Extended Treatment Road to Recovery
  • 116. Questions Question #11 Pharmacists can access their state’s recovery program through which of the following? A. www.na.org B. www.aa.org C. www.drugabuse.gov D. www.usaprn.org Road to Recovery
  • 117. Questions Question #11 Pharmacists can access their state’s recovery program through which of the following? A. www.na.org B. www.aa.org C. www.drugabuse.gov D. www.usaprn.org Road to Recovery
  • 118. Questions • Question #12 Early reporting of addiction and related disorders in HCP’s are important for which of the following reasons? A. Minimization of risk of harm to patients. B. Delay can increase the risk of progression of the condition for the HCP. C. Avoidance of multiple legal issues (licensure, civil liability, or liability of employer, or criminal liability of the impaired HCP in the case of a medication error). D. Minimization of “collateral” damage to HCP family and personal relationships. Road to Recovery
  • 119. Questions • Question #12 Early reporting of addiction and related disorders in HCP’s are important for which of the following reasons? A. Minimization of risk of harm to patients. B. Delay can increase the risk of progression of the condition for the HCP. C. Avoidance of multiple legal issues (licensure, civil liability, or liability of employer, or criminal liability of the impaired HCP in the case of a medication error). D. Minimization of “collateral” damage to HCP family and personal relationships. Road to Recovery
  • 120. Questions • Question #13 Relapse Risk for HCPs is significantly increased by all of the following except: • A. Use of Major Opioid and Dual Diagnosis • B. Family History of Substance Use Disorder • C. Male Gender • D. A History of a Prior Relapse Road to Recovery
  • 121. Questions • Question #13 Relapse Risk for HCP is significantly increased by all of the following except: • A. Use of Major Opioid and Dual Diagnosis • B. Family History of Substance Use Disorder • C. Male Gender • D. A History of a Prior Relapse Road to Recovery
  • 122. Questions • Question #14. Use of Contingency Management (contracts) in the chronic disease model/management of PRN’s: • A. Involve giving rewards for negative drug screens • B. Involve applying swift & strict enforcement of contractual consequences for a positive drug screen • C. Do not motivate meeting attendance by PRN participants. • D. Seldom are effective in the Professional population Road to Recovery
  • 123. Questions • Question #14. Use of Contingency Management (contracts) in the chronic disease model/management of PRN’s: • A. Involve giving rewards for negative drug screens • B. Involves applying swift & strict enforcement of contractual consequences for a positive drug screen • C. Do not motivate meeting attendance by PRN participants. • D. Seldom are effective in the Professional population Road to Recovery
  • 124. Relapse: Road to Recovery Dr. Jay Piland MD Palmetto Addiction Recovery Center Pecan Haven Adolescent Addiction Center
  • 127. 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
  • 128. 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
  • 129. 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
  • 132. 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
  • 133. 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
  • 135. 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
  • 136. 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
  • 137. 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
  • 138. 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
  • 139. 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
  • 140. 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
  • 141. Determinants of Relapse • Marlatt’s Relapse Taxonomy: • Intrapersonal Determinants – Self Efficacy – Outcome Expectancies – Cravings – Motivation – Coping – Emotional States • Interpersonal Determinants Road to Recovery
  • 142. 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
  • 143. 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
  • 145. 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
  • 147. 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
  • 149. 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
  • 151. 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
  • 154. 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
  • 156. 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
  • 158. 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
  • 159. RP • 2) Help patients identify their high risk situations and develop effective cognitive and behavioral coping. Road to Recovery
  • 160. RP • 3) Help patients enhance their communication skills, interpersonal relationships, and develop a recovery social network. Road to Recovery
  • 161. RP • 4) Help patients reduce, identify, and manage negative emotional states. Road to Recovery
  • 162. RP • 5) Help patients identify and manage cravings and cues that precede cravings. Road to Recovery
  • 163. RP • 6) Help patients identify and challenge cognitive distortions. Road to Recovery
  • 164. RP • 7) Help patients work toward a more balanced lifestyle. Road to Recovery
  • 165. RP • 8) Consider the use of medications in combination with psychosocial treatments. Road to Recovery
  • 166. 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
  • 167. RP • 10) Incorporate strategies to improve adherence to treatment and medication. Road to Recovery
  • 168. 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
  • 169. 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
  • 170. 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
  • 171. 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
  • 172. 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
  • 173. 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
  • 174. 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
  • 175. Relapse: Road to Recovery Dr. Jay Piland MD Palmetto Addiction Recovery Center Pecan Haven Adolescent Addiction Center