<v ->Welcome to the PCSS training</v> on standard medical management for opioid use disorder in primary care. My name is Brent Moore, and I'm from Yale University School of Medicine. I'm a research scientist there in the Department of Psychiatry, and I'm a psychologist by training, and I've worked with colleagues with patients like these in primary care and other medical settings for the past 19 years. I'm very happy to be here with you today. In terms of my disclosures, I have no relevant financial relationships with ACCME-defined commercial interests to disclose. The target audience for today is folks like you because the overarching goal of PCSS is to make available the most effective medication for opioid use disorder treatments to severe patients in a variety of settings, including primary care, psychiatric care, and pain management. The educational objectives for today are as follows. The overarching goal is for you to be able to provide evidence-based treatment for opioid use disorder, or OUD, in primary care and other settings. At the conclusion of the activity today, you should be able to describe how to implement standard medical management, or SMM, for patients, and you should be able to address common issues in treating OUD in primary care. Why is it important? Well, I'll ask you to reflect on that, but what our colleagues have noted is that substance use disorder, and OUD specifically, is vastly untreated, and the problem is that serious. Over 100,000 individuals lost their lives to OUD in the last year due to overdose, translating to one every five minutes. And greater than 20 million individuals in the US have had an SUD in the past year, which is approximately 8% of the adult population. Altogether, SUD costs the nation over 600 billion annually. So let's start with whom is standard medical management intended? Well, of course it's for the patient. It's for the patient with opioid use disorder who is seen in primary care or other general medical ambulatory settings. So the psychologist, counselor, and social worker can do the psychosocial components only of standard medical management, and pharmacists can do both the psychosocial and medical components of SMM because it is a combined psychosocial and medical approach. And the physician, physician assistant, and nurse practitioner can do all of it. Let's briefly review the substance use disorder or SUD criteria. These criteria come from the DSM-V, and this is the primary way of diagnosing a substance use disorder, whether it be alcohol use disorder, cocaine use disorder, or in this case opioid use disorder. It is defined as a problematic pattern of substance use leading to clinically significant impairment or distress as manifested by at least two of the following 11 symptoms, with at least two of these symptoms needing to occur within the last 12 months. I will highlight each of the 11 symptoms. Taking opioids in larger amounts or longer than intended to, wanting to cut down but not being able to, spending a lot of time and effort getting the substance, having cravings or urges, not managing school or work or other obligations, relationships are affected negatively, giving up social or occupational activities, using substances in dangerous or potentially dangerous situations, continuing to use even when you know it causes physical or psychological problems, and then the last two have to do with physiological dependence, needing more of the substance to get the same effect, which is tolerance, or the development of withdrawal symptoms, which can be relieved by taking more of the substance. Two to three of these 11 symptoms correspond to mild opioid use disorder, four to five to moderate, and six or more to severe. Standard medical management, including a medication for the treatment of opioid use disorder, is generally used with patients with higher severity since mild OUD may be responsive to less intensive interventions. In order to put this diagnosis in context, let's look at the spectrum of substance use concerns. They start from no risk and no use to low use and then onto high risk. When we talk of high risk, we want to start with the use of substances in a hazardous way, which means they're potentially harmful. That word potentially is very important because someone may drink or use opioids and drive, but get home fine without any problem, but there still is a concern because it could have led to harm. For opioids, IV drug use in and of itself is hazardous. The next step up is use of a substance where some harm has actually been sustained. For diagnostic criteria, this wouldn't mean a single event of harm, but a pattern. So there can be a range of prediagnostic substance use behavior that includes minimal use to even some level of harmful use. Above these are noted levels of mild, moderate, and severe substance use disorder. As we know, the language we use is important, and SUD treatment has a long history of using language that may hinder rather than help patient recovery. Words like addict and junkie support stereotypes of drug use. These stigmatizing words don't help treatment and are inconsistent with the way we treat other chronic disorders, such as diabetes or heart disease. So we now emphasize the use of language that is person-first, which respects the worth and dignity of each person, that focuses on the medically and scientifically accurate nature of the substance use disorders and their assessment, diagnosis, and treatment, that promotes a positive recovery process, and that avoids perpetuating negative stereotypes, biases, and stigmatized models through the use of slang and idioms. There may be instances in which a patient uses such terms when referring to themselves or a friend. In fact, some self-help groups emphasize embracing terms such as alcoholic or addict. Although this may be the case, the evidence indicates that people are more likely to change if we, the providers, use person-first language. So I'll urge you to use person-first language with your patients, colleagues, and staff. That means saying, "A patient with moderate opioid use disorder," or, "A 45-year-old woman with severe alcohol use disorder," or, "A person with a diagnosis of methamphetamine use disorder." For additional description and explanation, I would suggest the PCSS SUD 101 core curriculum module, Changing Language to Change Care: Stigma and Substance Use Disorders. So what is standard medical management? It is an individual counseling approach for medication maintained patients with OUD. Medication options include agonist medications such as methadone, buprenorphine, also called suboxone, and long-acting injection of buprenorphine, also known as SUBLOCADE. Methadone is usually restricted to clinics, and thus the buprenorphine formulations are commonly used in primary care settings. It can also include antagonist medications such as naltrexone, including the long-acting injection form Vivitrol. SMM also includes a psychosocial component of a brief 15 minute per visit after the initial longer visit. It is protocol guided, medically focused, and evidence-based, so it's really a nice blend of the most minimally evidence-based effective approach to working with these patients in primary care. So who may not benefit from SMM? Patients with medical contraindications, such as opioid pain management. Antagonist or agonist medications would be contraindicated if other long-term opioids are maintained. Although there is some promising new research on transferring patients on long-term opioids for pain to buprenorphine maintenance. Others would include patients who are not able to minimally adhere to some guidelines, and it may not benefit patients with other poorly managed substance use disorders, especially sedative or alcohol use disorders. Now, this does not rule out folks with psychiatric disorders. Their psychiatric concerns need to be managed well just as if they had another medical condition which should be managed. In addition, these issues can be addressed outside of the SMM platform such as through referral. So who can do SMM? Well, any trained medical professional. What constitutes SMM training? Well, physicians, PAs, and APRNs can receive the X-Waiver for for up to 30 patients simply by signing up on the SAMHSA website. To treat more than 30 patients, those providers must take either an 8 or a 16 hour waiver course depending on your profession. This training focuses on providing specific guidance in implementing SMM by waivered providers, and I would suggest referring to the website listed here for the most up-to-date information on training requirements and waiver trainings. What would we like to have happen if we're doing SMM? Well, the first thing is safety. We want provision of treatment to help the patient and his or her loved ones be safer with regard to their opioid use disorder. We would like for the patient to be educated and motivated, and we would like for them to be less stigmatized by this more positive process. It's not just the language that we use, but simply bringing OUD treatment to general medical settings, especially primary care, is in and of itself destigmatizing. We would also like for them to receive the full complement of the treatment components and ultimately for them to achieve abstinence from all illicit opioids, or at least a significant reduction of use and problems associated. It is generally important for the provider to recommend abstinence because it provides the most harm reduction. However, patients may have different goals, so a collaborative patient care approach is often needed, focusing on reduction of use and associated problems. Where and when can you do SMM? Well, any medical setting and on demand to the extent possible. So here are the six things one needs to know about in order to determine the level of care and whether SMM is appropriate for a given client. This is an overview based on the American Society of Addiction Medicine guidelines, and I encourage you to get the full documents and trainings around this criteria. The criteria are the degree of intoxication or withdrawal potential, other medical conditions and complications, emotional or psychiatric conditions, their readiness to change, that is, their motivation, the potential for relapse and continued use, and the recovery environment or how much social support exists for this patient. So if someone's withdrawal potential is high, that is generally fine for agonist maintenance, which is methadone or buprenorphine, because of the nature of the medication they are provided. Antagonist medications such as naltrexone may not be a good option, particularly in an outpatient setting. If they have other medical conditions, those need to be managed, such as good management of hypertension, diabetes, asthma, and the same for comorbid psychiatric conditions, which may be managed within primary care or through external or specialty care. In terms of readiness to change, a patient does not need to be 100% motivated to completely and immediately become abstinent. Rather, targets or goals of reduced use can also lead to effective treatment. They just need to be motivated to adhere to the SMM protocol guidelines, which we will address shortly. It is important to take into account a patient's relapse potential. However, the most effective way to help someone from relapsing to opioids is by providing medication for that purpose. With regard to the recovery environment, if someone does not have at least some social support or that they're in settings where the opportunity and triggers to use are pervasive, they may first need to find a better recovery environment before initiating SMM. While these factors are important in considering level of care, a step care approach would generally start with a primary care standard medical management, and then higher levels of care would be considered if that treatment was found to be insufficient. So why are you thinking about doing SMM? Of course, we can't have that conversation right now, but there are discussion boards where you can write about it and talk about it with other people. But at this moment I'd like you to take just 10 seconds or so and think about why you're considering doing this, why you are learning about SMM at this particular time, and why it might be helpful to you and to your patients. So take a moment. Good. Now, some things you might be thinking is, "I'm already treating these patients for other conditions, and they're already in my practice. Why not be able to comprehensively treat them?" Or you might be thinking about the opioid crisis and how I could do my part, or you may be asking, "Is it true that maintenance does work and it's just as easy to do in a primary care setting as the treatment of other chronic medical conditions?" The evidence for that suggests that it is. Those might be our reasons, or they may not be, but I want you to consider what your reasons are as we progress through the webinar. We realize that providers considering implementing MOUD often face many barriers and obstacles. These can be internal, such as confusion and uncertainty about how to provide care, low motivation to treat the population, and stigma both internal, team members, family, as well as the patients themselves. There are also external or structural barriers to providing care, such as lack of support, disagreements with clinic priorities or treatment plans, and lack of resources. Although this webinar can't address all obstacles or barriers, it should address concerns about providing care. There are other PCSS webinars on these topics that may also be helpful. So the first goal of the webinar is how to implement SMM, and here's an overview. We have goals, elements, roles, and the sequence of SMM. So what are the goals of SMM? What are the elements that comprise it? Who is to do what? What are the roles? And what's the order or the sequence? Let's start with the goals. The two main goals are abstinence of opioid use as well as a reduction of use and problems. The ordering of that can vary from patient to patient, and as noted, this is often a collaborative goal with a patient. Someone may feel that for them, any use at all will result in them returning to full use, while others may continue to use infrequently but have reduced their use in a way that causes fewer problems to the point of remission. Remission is the absence of those 11 symptoms which we discussed when we went over the DSM-V diagnosis, so I would encourage you to refer back to that as needed. The absence of those symptoms over three months or greater is early remission, and 12 months or later is prolonged remission. As far as the elements of SMM, there's a long list in front of you. I won't read each of them, but I'll summarize them into three areas. First, providing the medication, motivating patients, and advising them. So providing the medication is prescribing the medication for OUD, providing support for medication initiation if it's needed, and maintaining the patient on the appropriate dose. Providing also includes educating them about OUD and its treatment, and then monitoring both their compliance and adherence as well as their drug use and symptoms as they progress. Motivation initially focuses on encouraging patients. We found that even minimal encouragement goes a long way when done correctly. This involves encouraging patients to shoot for abstinence and treatment adherence and also encouraging them to get the support that they need through friends and family or mutual support groups, of which there are many now, and they can be both in person and online as well as self-help. Treatment rapport and a collaborative care approach are important. Later, we'll address some strategies about motivational enhancement that can be helpful when simple encouragement has limited effect. The last three items concern advice. First, brief advice based on a standard drug counseling model focused on their drug use, then advice to address medical complications of opioid use, and then advising them to follow up on referrals for other specialty services such as additional psychotherapy, perhaps for comorbid conditions, or employment or housing services. Now let's discuss the roles of SMM. For the physician, the PA, or APRN who are X-Waivered, they can do all the elements of SMM. Nurses need continued supervision by the physician, and that's the one caveat, but they can meet with patients for the initial and subsequent monthly appointments. A nurse can also do all the elements of SMM except the actual prescribing. They can meet with the patient weekly and do all of the other SMM components. Counselors, psychologists, et cetera, can only do the psychosocial components, but them being involved can help provide support to the rest of the team. Counselors may also meet with patients weekly or as needed for additional counseling such as CBT. But in general the evidence suggests that there is no extra benefit beyond providing SMM. That said, there still may be individual patients who can benefit from additional counseling. Let's talk about the order or the sequence of SMM. First, you have an initial session which is 45 to 60 minutes, and then you have subsequent sessions which are around 15 to 20 minutes. The initial session is 45 to 60 minutes long, and although it may seem like a long list here, it provides a scaffold for not only the session but for subsequent sessions as well. The lists here can just be treated as a checklist, and many of these activities you'll find familiar and you'll see that they are used for treating patients with other chronic medical conditions such as diabetes, asthma, or hypertension. The first thing is to establish rapport with the patient. That is to not jump right in to discussing opioids or other drug use, but treating them as a regular medical patient and taking a few seconds to ask them how they're doing, how's it going, what's on their mind, how they're feeling in general. This is important because OUD, and likely their opioid use, has been so stigmatized in the past that it's often the only thing others focus on. Next, you want to review the medical, psychiatric, and substance use treatment history, and then quickly review who they are aside from their substances, such as their place of birth, education, employment, family supports, et cetera. This extends the rapport with an emphasis on a patient first approach. Next, you want to review the diagnosis of opioid use disorder and take a few seconds educating the patient on the medical diagnostic language, including the criterion and pointing out which ones they met. We have found that simply providing and explaining the diagnosis can be a motivating and sometimes inspiring event for the patient because they're being treated like a, quote, "regular patient" with a medical disorder. The next component is to develop the treatment plan, and we'll go over a model treatment plan for you that includes advising abstinence but also incorporating the patient's goals. And referral to mutual support groups, especially for patients with limited family or friends for social support. The next task is motivational enhancement as needed, but a lot of that boils down to encouragement as the first and often most important step. And finally providing other referrals, delineating and reinforcing the program guidelines, and answering any questions the patient may have. I'll address each of the tasks in more detail, but let's start with a review of foundational communication skills. What I'm talking about here are reflective listening and asking open-ended questions. Reflective listening can be simply mirroring back what a patient says, and this alone can be helpful in validating, but we often extend or paraphrase what is said. So if a patient says, "You know, I'm glad I'm here, but it was hard to get myself to try this," you might say, "It sounds like this was a bit of a challenge for you, but you're happy you came." Open ended questions are questions that are asked with a WH or H words, such as what brings you here, why did you think this might be a good idea, how do you feel about being here? And you can even ask them to, "Tell me about why you decided to come back," which is open-ended, although it's not strictly a question. Part of what we're trying to elicit from patients to increase their motivation are questions that lead them to explain and provide justification for changing their substance use and engaging in treatment. That is, the more they talk about the benefits, the more motivated they will be. So questions like, "Why did you choose to come in today to start treatment?" Then the provider can reflect back the positive statements for change. This doesn't mean that you would never reflect ambivalence or resistance. It's okay to reflect that, but the strategy here is to reflect more selectively positive rather than negative so that the patient may say, "You know, I really didn't want to come, but ultimately my husband convinced me." The positive part is that she was convinced and the negative part was she didn't want to come. So you could reflect, "So even though at first you didn't want to come, ultimately there was something that happened in your conversation with your husband that made you decide, yes, I want to come." Paraphrasing like that emphasizes her coming to treatment, the positive, while acknowledging her ambivalence. It also reflects her freedom of choice, which is important. The fact that she decided is important for her own motivation. The main reason that I'm discussing ways to elicit statements and reasons from the patient is because patient statements about themselves are stronger predictors of success than statements of the provider. That is, people are more likely to listen to themselves than to someone else. Now we're going to go into each component in detail. First, establish rapport. So here you're going to introduce yourself and ask permission. If you like scripts, here they are, and you could transfer them and use them in any way that you'd like. If you don't, then these are simply examples and feel free to modify them as you see fit as long as you keep the essence of the approach. So, "Hello, I'm Dr. Moore, and I'd like to talk to you today about how you're feeling. Would that be okay?" So it's an introduction, but it's also that building of rapport that does not immediately highlight the opioid use disorder. Or you could say, "You don't have to, that's up to you, but do you mind if I ask you a few questions?" So you might be wondering why would I be suggesting that you ask permission to do something that the patient has tacitly given you permission to do by virtue of their attendance? This is because many, and maybe even most of these patients, prior to coming to you have probably been confronted, pushed, coerced, forced, or strongly urged to go to treatment. So asking permission can help correct that perceived removal of their freedom by reinforcing their autonomy and saying, "You don't have to do this even though you're here, but if you'd like to, we can proceed." So when you ask them that, ask permission to ask questions, they may say to you, "Yeah, that's okay," or they may say, "Well, yeah, that's why I'm here," which is totally fine. It doesn't diminish the impact of asking permission. So reviewing their problems. So we're going to again ask some questions, reflect on what they say, and give them some information. And here's a sample script. "Tell me a little bit about your health in general, your past medical history. Tell me about what medical problems you have related to your use of opioids." Preferably they will have discussed their opioid use when you first asked the question, but this helps address the problem specifically. Also, "What other problems might be related to your opioid use?" You might suggest, or they might tell you, that there are mood or psychiatric issues such as anxiety or depression, social or family conflicts or issues, and legal issues. Next, we'll review the diagnosis. As I mentioned before, you would go over the DSM, providing the evidence for the symptoms that they exhibit, and then summarizing, which is basically, "Based on your intake and the information that you've given me, you meet criteria for opioid use disorder." You might trace their history to some degree, but remember that the diagnosis is based on the symptoms during the previous 12 months. You can end by saying something like, "Taken together, these problems would be classified as opioid use disorder, severe." Developing a treatment plan. The single most important thing to say at this point is that OUD is highly treatable. You can review any evidence if they would like it, and there will be some references at the end that you can provide to them or that you can summarize. It's definitely helpful to explain how the medication works and how it acts on opioid receptors to prevent withdrawal, and that taken regularly and as directed at the therapeutic dose that they will experience much less, if any, of the need for heroin, fentanyl, or whatever opioid that they use. This would also be a point at which you can offer them different treatment options, such as sublingual or extended release injection, or buprenorphine versus naltrexone, whatever choices or options you plan to have in your clinic. Next, you want to discuss the counseling component. SMM will address how to cope with triggers, urges, and cravings to use opioids, and how to change their immediate environment or lifestyle in order to help them towards use reduction and ultimately abstinence. This would also be a time to discuss other referrals that may be available. So here's a sample treatment plan that covers each of these components that we list in the initial session. Again, we go over the goals in a concrete and immediate manner. For this example, the goal could be for the patient to provide urine samples negative for illicit opioids within one week. The short term goal may take longer, so sometimes tracking the quantitative urine results could be helpful if you have access to that. The next goal is to dramatically reduce or cease illicit opioid use based on patient self-report and urine toxicology tests. Again, the goal should be developed in collaboration with the patient. An achievable goal they agree to is more important than only emphasizing abstinence. However, abstinence is still the standard medical recommendation. The methods covers the rationale for MOUD, the medication itself, and the other treatment components, including regular appointments for SMM sessions, whether with a different provider or not, other medical visits, and regular urine screens. The other components are about providing advice, advising patients to work towards achieving abstinence, to take their medication regularly as prescribed, to attend all other components of SMM, including the psychosocial counseling, and to attend all referrals. You'll also want to advise them to either avoid or cope differently with triggers to use opioids and to attend mutual support groups. With regard to standard drug counseling, one of the things that we want to advise patients about is how to handle triggers. Triggers are the antecedent, or the thing that happens before someone uses, such that they lead to or cause the drug use. They can produce increased cravings or urge to use. Anything and everything that happens before someone uses is a potential trigger. An important skill for patients recovering from opioid use disorder is breaking the chain from a trigger to opioid use. This skill or process can be summarized with the acronym RACE: recognize, avoid, cope, and escape. Recognize triggers as early as possible. So having patients think about and understand the context or situations of their use. That is, the people, places, and things that are associated with their use. In the context of their everyday life, the sooner they recognize a trigger, the sooner they can do something about that. The three main things that we advise patients to do with triggers is to avoid them, cope with them differently, or escape from them. Places are common triggers, such as a place where someone uses or buys the substance. So avoiding going to those places can reduce the likelihood of use. A classic example is for someone with alcohol use disorder on the way home from work passing a liquor store where they usually buy their alcohol. Avoiding would mean finding a different route home. Many triggers can simply be avoided, such as not seeing people with who an individual uses or used to use drugs with. However, not all triggers can be avoided. For those, it's important to cope with the situation differently. For example, talking to a friend who they used to use with and telling them that they're in treatment or that they don't use anymore. For triggers such as emotions or moods, coping can involve dealing with the emotion in a different way. For example, if anxiety is a trigger, then advising them to use relaxation exercises or yoga or meditation or calling someone can be very helpful. There are even apps that can help patients deal with common negative emotions. A final approach to dealing with triggers can be simply escaping a situation, which can be thought of as avoiding the situation but being late about it. So even though someone may find themselves in the liquor store or at the friend's house when they're about to use, they can still escape the situation. And although this can feel socially awkward for patients, it's important for them to know that it is perfectly acceptable to do that. So additional counseling and self-help group attendance has been shown to improve recovery in the context of MOUD with SMM. However, there's no specific treatment approach that's been shown to be effective on its own, nor better or worse than any other option. Listed here are a range of counseling approaches that may be used with OUD and that you may have heard of or had questions about. These can be helpful for some patients. An important component of whether these approaches seem to work seems to be the extent to which patients choose and engage in this specific treatment. For example, patients forced to go to mutual support groups, such as AA or NA, which would be Narcotics Anonymous, or to other groups such as Smart Recovery, likely won't do any better than those who just have SMM alone. However, for those who engage and become committed to these groups, their participation can have a positive lifelong impact. Okay, so the next thing that you advise patients about in this initial session and in an ongoing way is referrals. As with all other patients in primary care, you may make referrals for housing, transportation, food, et cetera. The notion that patients with OUD are so difficult to treat stems from the concept that somehow primary care providers are supposed to provide all services to these patients, which would be absurd. This wouldn't be true for other disorders and it isn't true for OUD. SMM makes this explicit by incorporating questions of what other services the patient may need, whether it might be helpful to provide referrals for help with housing, transportation, relationship counseling, or other things. You don't have to push any services, but you want to listen for it and explicitly ask, "What else can I do to help you with?" This doesn't mean that you need to be an expert in all possible referrals, but you likely have a wide range of referrals that you already use. Referral options can be from a wide range of medical and psychiatric issues, and include medications for other disorders, comorbid conditions such as other psychiatric disorders, depression, PTSD, et cetera, or evaluation and diagnosis for other emergent issues. The one thing I would like to emphasize is that all referrals should be evidence-based, just as they would be for any medical condition. So whether it's for medication for alcohol use disorder, physical therapy for chronic pain, or a counseling approach for depression, insomnia, or other substance use, they should all be evidence-based. And what I mean by evidence-based is that its use is supported by a sufficient body of impartial, robust research, including randomized controlled trials with each of the following components: clearly diagnosed and assessed participants, manualized treatment, attention to confounding factors, operationally defined outcomes, measurement of the integrity of the treatment that's offered, and statistical control of dropout and other confounding factors. Okay, so reinforcing program guidelines is another important component here, especially the visits. So here's a script. "In order to recover effectively, we suggest you attend all scheduled sessions, take the medication as prescribed, adhere to all referrals, provide urine toxicology samples when asked, and cooperate with medical procedures." Answer any question that patients may have, and here it's important to pause after you ask the question, making it clear that addressing their questions at this point is important, and that addressing questions now will likely make subsequent visits easier. For example, "What questions might you have for me?", pausing. Or an approach I sometimes use, "It's okay to have questions. Take a minute to consider what we've gone over and think of what I haven't explained well or what I wasn't clear enough about." For subsequent sessions, there's a lot of reviewing, but again, it falls within the provision of the same steps used previously: reviewing where the patient is, motivating them, and advising them. You're going to review their medication adherence and substance use, their response to the medication, and changes or participation in mutual support groups. Then you're going to motivate the patient to be abstinent or to severely reduce their use and to motivate them to get support for this and encourage them to remember the education that you've given them. Formal motivational enhancement strategies can be used to address non-adherence in this context, which we'll address shortly. You'll also continue advising them to adhere to referrals or make new referrals as needed, and then prescribe or dispense the medication. So let's go through each component in turn. This will go a little quicker than before because it's similar to the initial session. Let's review adherence and use, again starting with an open-ended prompt, such as, "How did it go with taking your medication last week?" or, "When were you not able to take it?" or, "When did you forget to take it?" This second question can be helpful for modeling openness and transparency and giving them permission to reveal non-adherence. You can then use problem solving to help them improve. For reviewing use, you can say, "Tell me about your last drug use since we met." This again gives them permission to be honest about their drug use, and that use is a common component of this disorder rather than a failure on their part. If they say, "I didn't use at all," well, that's great and you can positively reinforce this, but then you can also follow up by saying, "When might you have been tempted, or when did you think about using?" This is also an appropriate time to review their utox results and use those results as prompts to discuss their use. It's very important to end the component with some positive feedback, and everyone should get some positive feedback. It's also important to give positive feedback first, even if there's some negative feedback as well. So you can fill in the blank here and say, "You seem to be doing well in that you came today. The most important thing is that you're here." It is again okay to reflect negative information such as, "It was hard for you to take the medication," but starting with positive makes patients more receptive to other feedback. So let's review their responses to the medication. Again, both positive and negative. "How's the medication working for you?" "Tell me more about what's working and what's working less well for you." "Is there anything more serious about your response that we should talk about?" That is, are they having any side effects and how are those affecting them? If they are, it's important to address those immediately. Following the discussion of the medication, you review how the program is working for them overall and address any of those issues as well. Finally, we end again with positive feedback. "You seem to be doing well with the medication and the program as a whole. I'm really pleased for you." As you review their progress down the road, it's helpful to keep two different things in mind. First, as far as our language goes, we use now the term returning to use rather than relapse. Relapse has some stigmatized attention to it, and so we're avoiding that phrase now. Also, early remission means no symptoms from that list of 11 in the DSM. The exception to that is that they can still have craving. So the absence of the remaining 10 for three months or more gives a diagnosis of early remission, or if it's been 12 months sustained remission. Meeting this criteria of diagnostic change can be very inspiring and motivating to patients, and it is important to keep track of. Assessing behavior change has to do with the behaviors outside of the protocol of the SMM. So you ask things like, "How are the the mutual support groups going?" As noted before, there are a wide range of groups in addition to AA and NA, and they can be accessed in person and online. It's worth taking a look and seeing what sort of mutual support groups there are available in your area and also online. However, what I would say is that the most important component is that for the patient to be engaged and excited about the group. Next, you can ask them what they like about the group, what's helpful for them, or you may need to ask them why they didn't go. And if they didn't go, you may want to suggest other options that may be a better match for them, or if you can set them up with a different referral. Perhaps the most important component of this step is to ask about what has helped with reducing use and avoiding triggers or coping with them differently. Each session should have some discussion about triggers, cravings, and urges, and what they're doing in a productive way to respond. So again, the acronym RACE is helpful to remember. One somewhat technical point is the difference between cravings and urges. Craving is an internal wanting or a desire. Even a memory of a desire of drug use is a craving. While urges include some behavior or planning that moves towards use. So a trigger of stress can lead to a craving or internal desire to use opioids, while an urge would be developing a plan and contacting someone who can get them the substance. Again, "You're doing very well, you should be proud, and you want to keep it up." Your advice should center around the same things as before, and in fact, to some degree you'll sound like a broken record each session, but it's reassuring and a good structure for you and the patient. So advising them to adhere to SMM visits, abstain or at least reduce their use or problems around their use, advise them about support groups, support group attendance, advise them to follow up on referrals or other next steps, and advise them to avoid all triggers. And if they can't avoid them, to spend some time figuring out how to cope with those triggers. We'll now spend a bit more time on the topic of motivational enhancement, which we've discussed briefly before. In addition to the foundational listening skills, we'll add one specific tool that can be helpful in increasing patient motivation. If your advice doesn't lead to adherence, then for each non-adherent behavior, you could do this brief motivational enhancement. Let's imagine that they're not avoiding their triggers, that they keep returning to use because they keep facing the same trigger. So for example, that they continue to hang out with a friend who uses and they end up using with them each time. So for that specific behavior, you can focus this motivational enhancement approach. You can't address multiple behaviors with this approach. You can't motivate them to come to SMM sessions, go to NA support groups, and avoid this friend. You actually need to do each of them individually. So this strategy is called the Readiness Ruler. You start by providing positive feedback and also encourage them to avoid the trigger. In this case, hanging out with that friend. Then you ask them, "How ready are you to avoid hanging out with this friend?" And you ask them to give you a number from 1 to 10, with 1 meaning not ready at all to 10 meaning completely or totally ready to. When they give you the number, our tendency is to want to ask why didn't they pick a number that was higher, or why aren't they more motivated? Instead, you want to ask them why they didn't choose a lower number. If you ask them about a higher number, it actually makes them feel judged and they'll likely make excuses for it, while asking them why they didn't choose a lower number makes them provide reasons for making the changes that will help them avoid that trigger. It makes them think of why and how they're motivated to change their behavior, and this enhances their motivation to make that change. So they're more likely to say, "I could do the same things with someone else, and then I wouldn't feel like I had to get high with them." This can be a very powerful tool for increasing motivation. And finally, we want to talk about new referrals just as we were doing before. And again, it's important to ask and then pause. When we ask and pause, it gives people enough time to respond and gives them a chance to think about what they might need. This gives us time to discuss what else they might need help with. So the second webinar goal, it's actually much lighter in terms of its load. We are nearing the end, so this goal will focus on a discussion of our general strategies, frequently asked questions, and then transition and step up. So our general strategies are to be positive, empathic, hopeful, patient-centered, and motivational. And in brief, what this means is no matter what's going on, your stance is that there's always something we can do to improve things, even if that ultimately means a transfer to some other level of care. That stance will keep the patient positive. Empathic doesn't mean that you're okay with everything, it means that you understand that this can be a struggle. And even when they're not doing well, that there is a part of them that wants to do well. To be hopeful. The people who stay in treatment are the people who ultimately do well, but there's always a reason to hope for better. That doesn't necessarily mean perfect or complete abstinence, but there's always reason to hope for better. And it's important to focus on the patient's perspective and their goals, even if they want to tell you what you could do that could be more helpful. Motivational means not asking why they aren't more motivated or how they could be more motivated, but by persistently asking why they have the motivation that they have, why they are there, not in a sarcastic way, but being generally interested in their motivation rather than why they don't have motivation. And it's helpful to use the Readiness Ruler again from 1 to 10 and asking why they didn't pick a lower number. As far as general suggestions of what we do and do not do, you want to reinforce their autonomy. They have choices and the fact that they are there making them is a positive for their health. It's also fine to agree to disagree about goals or specific issues, but letting the patient retain their autonomy. And it's important to always leave the door open if things come to a halt so that they can return and pick up treatment again later. In the overall context of SMM, it's important to avoid some what may be termed old school addiction treatment approaches. Things like shaming and blaming and preaching and confronting and guilting don't help people change, so those should be avoided. You may have feelings of frustration or irritation about their behavior or ambivalence, which are normal and common to have, but simply because you have those feelings doesn't mean that it's evidence-based thing to do. Catastrophizing, threatening, or withholding help will ultimately damage the relationship and lead to dropout or worse outcomes. So frequently asked questions. Patients have a number of questions that commonly come up in this context from, "I've tried NA, it doesn't work for me," "I don't want to totally quit, I just want to cut down," "I'm worried the medication isn't holding me," et cetera, as you can see on this slide. So how do you deal with these? Well, the first thing is that you do as you did before, you remain open-ended and you reflect back what they've asked or what they've told you. And be understanding and understand that this is a part of the process for them and that you want to do things to help increase their motivation to make those changes. So from questions like, "I'm worried that the medication isn't holding me," it may be that you want to consider an increase in their dose. For questions such as, "I've tried NA and it doesn't work for me," you can suggest a number of other things. You can say, "Did you go to different meetings?" Because each meeting can be different and is different. You can also suggest other types of self-help groups or support groups. For questions such as, "I don't want to totally quit, I just want to cut down," you can talk about that as a shared goal for the person and let's start with that and let's see where it goes. So it doesn't have to be a final, what they say in the first time doesn't have to be the final thing that they ever need. So for each of these, the goal is to use the same general approach that you've used throughout SMM to address any of these questions. So for transition and step up, for some patients, MOUD and SMM as a standard medical setting may be insufficient for their recovery. Step up options include residential treatment, methadone, or daily or more frequent contact treatments, or intensive outpatient treatment. Options will vary by location. Maintenance in MOUD with SMM would still be indicated if other step up options are not available, even if it seems that the patient isn't doing well as you would or they would hope. So here's your SMM cheat sheet, and because it's a cheat sheet, you can print it out or use a screenshot to access it regularly. I'm not going to go over all of this, but it has the same general approach, the initial session elements, and example script components, which can be very helpful, especially when you're starting out. I encourage you to use and engage with this material. In our in-person trainings, we conduct simulations or role plays where we take on the role of the provider or the patient and then we swap and we act out the components of SMM. This is really helpful for getting over the initial discomfort many folks still feel, since some of the skills, such as the motivational enhancement tool, can feel awkward at first. I also encourage you to discuss this with your colleagues as frequently as you can and to reflect on it and reflect on your reasons for implementing this in your practice. A final note on the treatment of OUD. This webinar goes through a lot of material, and much of it addresses potential problems in treating individuals with OUD so that you can address those directly. However, I also want to tell you that working with these individuals can be extremely rewarding. New providers are often overwhelmed when they start treating this population, not because of the negative aspects or patient problems, but by how well patients can do and how profound an impact this treatment can have on their lives. Here's some references that can be helpful for you to provide to patients or to read yourself and summarize for them. I also want to make you aware of our PCSS Mentor Program. The Mentor Program is designed to offer you general information, especially for clinicians. It's a national network of providers with expertise in addictions, pain, evidence-based treatment, including medications for opioid use disorder. It has a three tiered approach and allows every mentor-mentee relationship to be unique, and it's as needed so that it is tailored to your specific needs. And there's no cost. So if you want more information, go to pcssnow.org/mentoring. And we also have a PCSS discussion form, so if you have a clinical question you can ask a colleague there. This is a quicker, less involved way than the Mentor Program, but we encourage you to use both services. For the forum, you can just post a question and then you can get an answer to your medication for opioid use disorder questions or read questions from other providers. They're prompt and to the point. And finally, I want to let you know that PCSS is a consortium and collaboration among many members that you see listed here, not least of which is the American Academy of Addiction Psychiatry in partnership with Addiction Technology Transfer Centers, and many, many others. So please take a look at this, and for more information you can go to the website, www.pcssnow.org. Thank you very much for your time and attention. I wish you and your patients all the best.

medical management

opioid use disorder

primary care

evidence-based treatment

medication options

psychosocial components

person-first language

healthcare professionals

support