We are in the midst of an opioid epidemic. In 2017, 47,000 Americans died of opioid overdose; 35% of those from prescription opioids. (Scholl et al 2018.) There is now a growing recognition that healthcare providers need to do much better in their approaches to managing pain, as well as screening and managing opioid use disorders.

Opioids, including Morphine and Opium, became commercially available in the 1800’s. Since then, newer versions have been developed to last longer and/or be more potent. At first, these newer versions were marketed as being “safer” and having less risk of addiction and overdose. Around that same time, in the 1990’s, there was a new campaign in medicine to use pain as the “5th vital sign.” It is likely a combination of these two changes that dramatically increased the use of opioid medications in America. Unfortunately, the the safety statements were based on biased and poorly done studies. Also, our focus on pain didn’t increase patient satisfaction or improve patient morbidity or mortality. Instead, a growing population of patients became dependent on chronic opioids. Sadly, this has led to an epidemic of opioid use disorder (OUD) and staggering rates of overdose (Substance Abuse and Mental Health Services Administration, 2018; Centers for Disease Control and Prevention (CDC), 2011).

The medical community finally started to focus on the opioid epidemic in the last few years. New studies have been done to show the risk of addiction and overdose with use of opioids. Use of opioids for longer than a week substantially increases the chances of chronic use. Patients given more than a week of opiates after surgery or for treatment of acute back pain were 44% more likely to become chronic users (Alam, 2012). Also, chronic use of opioids does not seem to improve pain or quality of life. Newer research shows better pain management with other medications and treatment modalities (Chou et al, 2016; Dowell, 2016). These other treatments are explained in detail in Module 30 Part 3. There has also been an increase into research on methods to improve treatment for OUD (Substance Abuse and Mental Health Services Administration, 2018).

This module will briefly review the effects of opioid medications on the brain. You will learn to diagnose OUD and evidence-based techniques to help manage OUD. Lastly, you will learn a methodology for creating effective patient-provider relationships through motivational interviewing (MI) and trauma-informed care. By employing the information in this module, you will be able to join the forefront of the fight against the

When diagnosing OUD, it is crucial to get a thorough history of the patient. The history should include identifying risk factors, comorbidities, the physiological effects of the opioids on the patient, and any negative impacts that the use of opioids has had on his or her life.

OUD is a loss of control of the use of opioids coupled with physiological evidence of dependence. The severity is associated with how many symptoms and consequences the patient has endured due to this loss of control. Diagnosing OUD requires use of the DSM 5 criteria as outlined below.

A patient must have 2 or more of the symptoms below. It is important to note that physiological dependence is not enough for diagnosis.

• Opioids are often taken in larger amounts or over a longer period than intended.
• There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
• A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
• Craving, or a strong desire to use opioids.
• Recurrent opioid use resulting in failure to fulfill major role obligations at work, school or home.
• Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
• Important social, occupational or recreational activities are given up or reduced because of opioid use.
• Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids.
• Tolerance, as defined by either of the following:
• a need for markedly increased amounts of opioids to achieve intoxication or desired effect
• markedly diminished effect with continued use of the same amount of an opioid
• Withdrawal, as manifested by either of the following:
• the characteristic opioid withdrawal syndrome
• the same (or a closely related) substance are taken to relieve or avoid withdrawal symptoms

Patients are considered mild if they have 2-3 of the above symptoms, moderate if they have 4-5, and severe if they have more than 6 (American Psychiatric Association, 2013.) How would you diagnose our patient? Does he have Opioid Use Disorder? Is it mild, moderate, or severe?

Telling your patient a diagnosis of OUD is the same as telling a patient about any other diagnosis:

Creation of official techniques for management of OUD started in the Mid 1900s. The lead model was one of abstinence called the Minnesota model and started in the 1950s. The techniques employed in this 28-day inpatient intensive program were adopted from the Alcoholic anonymous (AA) groups. This doctrine preached that the only path to sobriety was through complete cessation of a substance and was taught by a combination of professional staff and those in recovery themselves. This model is the basis for 90% of today’s rehab programs (Clark, 2015; Baylor, 2020).

Then came Methadone. Starting in the 1960’s methadone was used to help patients refrain from illicit opioid use. In 1970 the FDA approved Methadone for detoxification and in 1972 it was approved for Medication Assisted Treatment (MAT). Methadone started to be included in opioid treatment programs (OTP) in 1974. These treatment programs combined daily dosing of the medication with group and individual counseling (Clark, 2015; Baylor, 2020).

In 1984, the FDA approved Naltrexone. The next big change in addiction treatment came in 2000. The DATA 2000 law allowed expansion of OUD treatment to outpatient offices. In 2002, Buprenorphine was approved for use. It was made available to doctors when they complete a training course and could be offered outside of the OTPs. Since then, long acting formulations of Naltrexone and buprenorphine have been approved. Access has also been improved by allowing advanced practice providers to get the waiver to provide. Now, the standard of care is a combination of MAT and counseling. In the next section we will dive deeper into each of these options (Clark 2015; Baylor, 2020).

Methadone, buprenorphine and naltrexone are now the foundation for management of OUD. Each works by a different interaction with the mu receptors and all three come with risks and benefits (Clark, 2015; Baylor, 2020).

Miller and Rollnick described clinical approaches using MI in 1991 (Miller, 1991), and since then many studies have proven its efficacy in more than 25,000 clinical trials. MI is a technique that will help patients successfully change their lifestyles. Whether a patient is trying to stop eating sugary foods, quit smoking, or stop using heroin, this is a technique that can help. There are many ways to teach MI. However, all technique encourages the creation of a trusting patient-provider relationship, a patient-directed focus on change, patient-centered reflection and a detailed action plan. Overall, MI is a collaborative conversation based on open-ended questions that help to strength a patient’s motivation.

Motivational interviewing is based on the following assumptions:

• Ambivalence about substance use (and change) is normal and constitutes an important motivational obstacle in recovery.
• Ambivalence can be resolved by working with your client's intrinsic motivations and values.
• The alliance between you and your client is a collaborative partnership to which you each bring important expertise.
• An empathic, supportive, yet directive, counseling style provides conditions under which change can occur. (Direct argument and aggressive confrontation may tend to increase client defensiveness and reduce the likelihood of behavioral change.)

• Express empathy through reflective listening.
• Develop discrepancy between clients' goals or values and their current behavior.
• Avoid argument and direct confrontation.
• Adjust to client resistance rather than opposing it directly
• Support self-efficacy and optimism.

We distill these assumptions and principles in the following steps:

First, create the relationship with the patient by engaging their trust. Ask questions that allow you to see the patient as a complete human being with a history and desires for the future.

Next, ask the patient questions to help them focus on one area of their lifestyle that they both want and can change. This can be done by asking a patient “If you could change one this about your life, what would it be?” Let the patient guide the conversation. Reflect what you hear from the patient.

It is crucial to help a patient develop a deeper “why” for what is driving them to change. This will help the patient when they are struggling to make the healthier choice. Ask the patient “What is important to you?” “What do you want to be able to do?” “What identity do you want to have?” or “What motivates you?” Once a patient answers, ask them “why” until you get to a deeper understanding of what is driving their desire to change. This is illustrated in the video clip below.

Once the patient has picked an area to focus on for change and evoked a reason to make that change, it is time to iron out the details of “how.” Patients may make a vague statement of “I want to be healthier.” It is important for the provider to help them develop a “SMART” plan. “SMART” is an acronym that stands for: Specific, measurable, attainable, realistic, and time bound. These goals allow the patient to focus on how to make a goal achievable. For example, instead of saying “I want to be healthier” a “SMART” goal would be, “Instead of eating cupcakes or donuts, I will substitute nut mixes for my mid-afternoon snack.” Instead of “I want to abstain from heroin” say, “I will not use heroin during the week until our next follow up visit.” It is important for these goals to be attainable so that the patient feels the positive reinforcement of the sense of success at their follow up visit.

A plan should also include a discussion about barriers to success. When a person goes on a difficult hike, they make sure they are prepared for a variety of things. The hiker will bring water, a jacket, a map, a phone, and will go through the hike to make sure they have contingency plans should something go wrong. A patient with OUD is about to go on the hardest hike they have been on, and they need to be prepared. Ask the patient “what barriers do you see for your success with your plan?” Once they have identified them, ask the patient to come up with contingency plans. They can even create statements. “If I feel a craving, I will go for a 15-minute walk.” To help them feel prepared to achieve their goal.

Occasionally, a patient will struggle to identify any barriers. At that time, you can offer common barriers to sobriety. For example “What would you do if you were offered your drug of choice?” It is important for the patient to be the source of plan to overcome the barrier in order to ensure success.

Overcoming barriers can be hard to do alone. Patients should also receive the offer of counseling services and support groups in addition to medications. Still, although counseling tends to improve the chances of retention in a recovery program, a patients lack of accessing counseling services should never stop that patient from continuing to receive their medication. Narcotics anonymous and rehabilitation program are also an option for further support. It is important to note that not all programs promote use of MAT so educate your patient to advocate for themselves or not use programs that will make them feel bad due to their use of medication assisted treatment.

The provider should help guide this discussion using questions to help the patient create a plan to change their lifestyle. At the end of the discussion, the provider can summarize what they have heard. This process does not have to be very lengthy. It can be done within the confines of a 15-minute office visit. As a patient becomes familiar with it, the discussions will become easier and more efficient. (Glynn, 2010).

Trauma is any physically or emotionally damaging event in a person’s life. Many people by the age of 18 will have experienced trauma. The number increases when you do not give an age cut off. This is true across ethnicities, races, and socioeconomic classes. Given the prevalence of trauma, it is likely that many patients seen every day are survivors of traumas. Having survived trauma puts people at risk for being “triggered” in which an event, word, or action activates their amygdala (the fear center of the brain) and causes them to become reactive. This can put strain on the provider-patient relationship. It can also cause these patients to become secluded and not access the care that they need. To better serve these patients we need to practice Trauma-Informed Care (TIC). (Purkey, 2018)

Practicing TIC means recognizing that many patients, staff, and providers have experienced trauma at some point in their lives. This realization encourages providers to be mindful of their language, offer understanding and support, and resist the urge to be reactive.

Many patients suffering from OUD have experienced trauma in their lives. They also will likely have experienced stigma due to their condition from family, friends, and the medical community. It is important to recognize this and modify behavior to build a trusting, non-judgmental environment during interactions with these patients.

It can often be helpful to gain an understanding of the nature of patients’ trauma histories. If you ask in a non-judgmental and curious way, and give your patients the space to answer, they will often reveal their difficult and still painful experiences. Say, “I get the feeling you have suffered a great deal in your life. Can you bear to tell me about it?” Or, “Has anything really bad happened to you, like physical or sexual abuse?” Sometimes people will tell you things they haven’t told anyone else. It is important to know that you don’t have to “fix” their problems in the moment, and in fact you cannot. But if you don’t have the counselling skills necessary to address their emotional pain, you can refer them to psychiatrists and/or counselors who can work with them over time.

Language is a critical area to TIC. Words have power. Providers should really choose language that keeps the patient first, for example, referring to your patient as a patient with OUD, not an addict. It also means asking permission before any exam or intimate line of questions. “Is it okay if I listen to your heart?” These simple acts empower the patient to guide the visit.

It is also important to connect with the patient by offering them words of support and understanding. Do not judge them by using phrases like “You should have known better” or “why would you put yourself in that position?” Instead, offer kind words like “that must have been hard/scary/intimidating” or “I am sorry that you experienced that.”

Hurt people hurt people. People who have experienced trauma will become triggered and many may lash out. Becoming defensive will only escalate the problem. To best serve the patient, practice nonreactivity. When a patient becomes aggressive, simply remain calm and encourage the patient to breath or separate themselves from the trigger. Create space for a pause. Once the patients have calmed down, debrief the moment to figure out what triggered the patient. This may require the patient returning for another visit or having an extended time alone in the room.

It is also important to recognize that as providers, we too have experience trauma and can be triggered. It may be experienced as frustration or even anger towards a patient. When you notice this, pause. Separate yourself from the situation and take a breath. See if you can figure out what has triggered you so that you are aware of it for future interactions. It can be a simple thing such as a patient not taking medication that you have prescribed. This may not be the first time that patient has ever done that but perhaps you have a history of a patient who never took the medication you prescribed and then had a bad outcome that the patient blamed you for. Now, when a patient acts in a similar way, you are triggered to assume that history is going to repeat itself. You may feel frustrated or agitated. It is important to recognize your own triggers and trauma to be able to practice TIC.

OUD is currently an epidemic in America. It is crucial to recognize the signs and symptoms of OUD. OUD is a chronic condition that requires a harm reduction model for successful treatment. Once a patient is diagnosed, they should be offered management options. Evidence has shown that abstinence only programs are only successful for 5-10% of patients. Use of MAT, especially when coupled with counseling, is successful at increasing periods of abstinence from drugs. MAT consists of the use of methadone, BUP, or naltrexone. Each of these medications comes with pros and cons and the decision on which treatment should be decided using a patient directed conversation.

Along with MAT, it is important to offer counseling techniques to patient to help them successfully make lifestyle changes. One of these techniques is called MI. MI involves an open-ended patient driven discussion that gets a patient to engage in treatment, focus on an area for change, evoke a reason for that change, and negotiate a plan to achieve the change.

TIC allows us to focus on ways to create a safe and supportive relationship for our patients that have experienced trauma. It encourages mindful word choices, being supportive, and deescalating moments when a patient, staff, or provider may be triggered.

By utilizing this knowledge, a provider will be able to offer the best tools to help patients with OUD abstain from use and work towards creating the quality of life for which the patient is striving.

You have seen parts of our interview as we went through the module. Now, feel free to watch the entire interview to solidify the use of these frameworks in managing patients with OUD.