Opioid Substitution Therapy Guidelines

Opioid Substitution Therapy

Guidelines for Saskatchewan Addiction Counsellors

June 2018 saskatchewan.ca TABLE OF CONTENTS

ACKNOWLEDGEMENTS 1

INTRODUCTION 2

Roles in Opioid Substitution Therapy 3

EFFECTS OF OPIOIDS AND OPIOID USE DISORDER 4

OVERVIEW OF THE PHARMACOLOGY OF METHADONE 4

BUPRENORPHINE/NALOXONE 6

SASKATCHEWAN’S CLINICAL PRINCIPLES FOR ALCOHOL AND DRUG MISUSE SERVICES 7

CLINICAL PRINCIPLES FOR ALCOHOL AND DRUG MISUSE SERVICES IN SASKATCHEWAN 7

OPIOID SUBSTITUTION THERAPY OVERVIEW 9

STEP 1 - SCREENING PROCESS 10

Screening Process: Using Primary Mental Health and Addiction Assessment Tool 12

STEP 2 - ASSESSMENT 13

Comprehensive Assessment 15

STEP 3 - OPIOID SUBSTITUTION THERAPY 16

OTHER ISSUES RELATED TO OST 17

REFERENCES 19

RESOURCES 20

APPENDIX A 21

APPENDIX B 23

APPENDIX C 24

ii ACKNOWLEDGEMENTS Saskatchewan Ministry of Health in consultation with addiction service providers, physicians, pharmacists, clients and nurses determined that the Methadone Assisted Recovery Guidelines 2004 were in need of updating to reflect the evidence, practice and program developments that have transpired in opioid addiction/dependence treatment. Informal focus groups were conducted in Prince Albert, Regina, and Saskatoon during November and December of 2015 and changes in practice and evidence are reflected in the 2018 edition of this document. Saskatchewan Ministry of Health thanks those individuals for their time and advice.

Since 2004 the Ministry of Health has also developed the Framework for Mental Health and Alcohol and Drug Misuse, Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan and Alcohol and Drug Misuse Services Outreach Standards.

The Ministry of Health principles and standards, together with prescriber and pharmacist guidelines, provide guidance and standards for Opioid Substitution Therapy services in Saskatchewan.

1 INTRODUCTION psychological, social and spiritual factors. Clients with an Opioid Use Disorder have a An Opioid Use Disorder implies the presence high frequency of psychiatric co-morbidity. of a number of criteria (see Appendix A) that Many individuals may lack necessary coping reflect not only physiological dependency strategies and other life skills that allow them but also impaired control over use, negative to function successfully. social consequences and risky use [Diagnostic and Statistical Manual of Mental Disorders, Addiction counsellors/case managers Fifth Edition (DSM V) criteria]. Opioid play a key role in OST such as receiving Substitution Therapy (OST) provides safe, the initial referral, screening for opioid accessible, effective and consistent treatment dependency, comprehensive assessment, for individuals with opioid dependence. Two direct interventions with the individual, prescription medications are available for OST interventions on behalf of the individual, case – methadone and buprenorphine/naloxone management, counselling, providing linkages (Suboxone®). These medications allow to needed services and evaluation/outcome patients to discontinue opioid use without assessments. experiencing withdrawal symptoms. There is significant evidence that OST reduces the Methadone and buprenorphine/naloxone risk associated with behaviors that lead to may only be prescribed as per the College the transmission of human immunodeficiency of Physicians and Surgeons of Saskatchewan virus (HIV), hepatitis C virus (HCV) and (CPSS) Bylaws. other blood borne pathogens by reducing the sharing of needles and other drug Methadone and buprenorphine/naloxone paraphernalia, including spoons, filters, water, are covered by the provincial Drug Plan. etc. It reduces criminal activity associated Coverage is subject to the individual’s usual with opioid use and supports patients/clients deductible and co-payment. Key partners to participate in healthier lifestyles. In OST in OST are prescribers and pharmacists. The the addiction counsellor serves as the case Saskatchewan Opioid Substitution Therapy manager to facilitate a team approach to Guidelines and Standards for the Treatment address the barriers preventing clients from of Opioid Addiction (College of Physicians and dealing with their Opioid Use Disorder. In Surgeons of Saskatchewan, 2016) provide this document addiction counsellors will be the standards and guidelines for OST in referred to as addiction counsellors/case Saskatchewan. Guidelines for Participation in managers to reflect that role. the Methadone Program for Saskatchewan Pharmacists (Erickson, Postnikoff, Rhode, OST includes counselling, case management & Wurtz, 2001, updated 2010) provide and other medical and psychosocial services. direction to pharmacists. In collaboration with These guidelines describe the role, services, clients, addiction counsellors, pharmacists, and skills required of the addiction counsellor/ and prescribers direct OST. The professional case manager, depending on her/his level of guidelines and standards are intended to involvement with individuals who have been compliment and provide direction for safe, prescribed methadone or buprenorphine/ competent and effective OST services. naloxone for an Opioid Use Disorder. Opioid Use Disorder, and addiction generally, are a complex process involving many biological, 2 They are referenced in this document and Methadone fact sheets are available at should be reviewed by addiction counsellors/ http://www.saskatchewan.ca/residents/health/ case managers working in this program to accessing-health-care-services/mental-health- fully understand the responsibilities of all the and-addictions-support-services/alcohol-and- partners. The Clinical Principles for Alcohol drug-support/alcohol--drug-and-addictions- resources. and Drug Misuse Services in Saskatchewan, (December 2012) provide addiction counsellors with additional knowledge and skills required for supporting clients with an Opioid Use Disorder.

Information about OST in Saskatchewan (the what, where, why, who, when, how, and how much) is routinely provided to clients and the general public by addiction counsellors, pharmacists, and physicians. Information is to be communicated in a respectful way using simple concepts and clear language. In addition, addiction counsellors have a responsibility to provide evidence based education to the public and to clients regarding the benefits and risks of OST.

ROLES IN OPIOID SUBSTITUTION THERAPY

Addiction Counsellor/ Prescriber Pharmacist Case Manager • Medical assessments • Dispensing • Screening and comprehensive • Diagnosis • Regular patient encounters assessment process (including mental health and • Prescribing medications for • Observation of daily dose suicide risk) opioid substitution therapy • Liaison with physician and • Coordinate with pharmacists, • Coordination with pharmacist counsellor/case manager prescribers, other case and counsellor/case manager • Education managers, i.e. HIV • Referrals for specialized • Education services • Intervention/referrals in social • Education and legal matters • Case management, counselling • Evaluation/outcome assessments

3 EFFECTS OF OPIOIDS AND OPIOID Naloxone is an antidote to opioid overdose USE DISORDER and improves breathing and consciousness. Take Home Naloxone (THN) kits and training Opioids briefly stimulate the higher centres are available to individuals at risk of an opioid of the brain but then depress activity of overdose. Overdose recognition and response the central nervous system. Opioids reduce training is also encouraged for friends and anxiety and pain, and produce euphoria and a family of people who use opioids. More sense of well-being. Short-term effects appear information can be found at:http://www. soon after a single dose and disappear in a few saskatchewan.ca/residents/health/accessing- hours. Immediately after injecting an opioid, health-care-services/mental-health-and- the individual feels a surge of pleasure or a addictions-support-services/alcohol-and-drug- "rush", typically followed by a profound sense support/alcohol--drug-and-addictions-resources. of detachment. The dose required to produce this effect may at first cause restlessness, OVERVIEW OF THE nausea, and vomiting. PHARMACOLOGY OF METHADONE

Opioid overdose is a particular risk with illicit Methadone is used to treat pain, an Opioid use where the actual substance and strength Use Disorder or both. Methadone is a may not be accurately known. Signs of opioid synthetic opioid with actions similar to those overdose include: the individual cannot be of morphine. Methadone has three important roused; pupils contract to pinpoints; skin functions: relief of pain for about 6 hours; is cold, moist, and bluish; and profound suppression of opioid withdrawal and craving respiratory depression. For the opioid for about 24 hours; and a mood stabilizing dependent individual, opioid withdrawal effect for longer periods. symptoms may occur within a few hours after the last dose of opioids. During withdrawal, Treating an Opioid Use Disorder involves the the individual experiences the exact opposite daily administration of methadone over an of the drug effects of opioids, including extended period of enrollment. Methadone is increased anxiety, pain, agitation, nausea, typically dispensed from a pharmacy as an oral vomiting, diarrhea, abdominal cramps and drink in a flavored juice such as orange ‘Tang’. muscle aches and pains. Opioid withdrawal For at least three months after OST begins, is generally less dangerous than alcohol, the pharmacist or individual dispensing the barbiturate, and benzodiazepine withdrawal methadone witnesses the client drinking but still causes significant health risks. For the prescribed methadone (direct observed Saskatchewan Opioid more information about opioids go to https:// therapy). The www.canada.ca/en/health-canada/services/ Substitution Therapy Guidelines and Standards healthy-living/your-health/medical-information/ for the Treatment of Opioid Addiction refer to opioid-pain-medications-frequently-asked- this as daily witnessed ingestion. Methadone questions.html. is absorbed in the gastrointestinal tract within 45 minutes and its effect usually peaks within two to three hours after ingestion.

4 When an individual is stabilized on may be necessary for these individuals. methadone, the administration of a single adequate dose (usually between 60 to 120 Side effects of methadone can vary, depending mg) will suppress withdrawal and craving for on the individual. An increase in methadone about 24 hours without causing euphoria or dosage may cause drowsiness for three sedation. Individuals can therefore function days, making driving and other activities normally and are able to perform mental requiring alertness hazardous. If methadone is and physical tasks without impairment. abruptly discontinued, withdrawal syndrome In sufficient doses, methadone “blocks” may develop with many of the symptoms the euphoric effects of other opioids. It is previously described. chemically unrelated to opiates, therefore, when required, other opiates are sometimes Abstinence-based alcohol and drug treatment also prescribed (i.e. post-op pain, chronic is only effective for a small number of pain). individuals who have an Opioid Use Disorder. It is generally recognized that for opioid- Three important functions of dependent individuals, counselling alone is Methadone: not effective because the withdrawal and cravings are so intense. Methadone alone • Pain relief for about 6 hours may work if prescribed in sufficient doses to • Suppression of opioid withdrawal control withdrawal and craving. Methadone and cravings for about 24 hours accompanied by skilled counselling has better • A mood stabilizing effect for longer outcomes than methadone alone. However, it periods is recognized that methadone should not be denied for treatment when counselling is not available. For more information on methadone Methadone can be dangerous if use in the treatment of Opioid Use Disorder misused. you may go to https://www.canada.ca/en/ health-canada/services/health-concerns/reports- • Real dangers of respiratory failure publications/alcohol-drug-prevention/best- and death exist with doses greater practices-methadone-maintenance-treatment. than 30mg for individuals not html. accustomed to methadone. A dose as little as 10mg can be fatal to a child.

Methadone is primarily metabolized by the liver. A very small percentage of individuals metabolize methadone rapidly (for example, those with specific enzyme pathways in their liver, pregnant women, those on medications that enhance the metabolism, and those involved in intense physical activity) and they can experience withdrawal even on a relatively high methadone dose. Split doses 5 According to the National Institute on Drug Take Home Medication Abuse, medication assisted treatment is also used very effectively for tobacco dependence Taking methadone or buprenorphine/ and for alcoholism. naloxone at home is referred to as “carries”. Carries promote the normalization of an BUPRENORPHINE/NALOXONE individual’s lifestyle and behavior. Addiction counsellors/case managers have a significant The partial agonist buprenorphine, a role in providing information about an proven therapy for opioid dependence, individual’s functional stability with regard to: combined with the opiate antagonist • Program participation naloxone, limits intravenous misuse and • Cognitive impairment the potential for diversion. The naloxone • Acceptable urine screens in the last three component of Suboxone®, administered months orally or sublingually, has no detectable pharmacological activity because of its almost • Social integration (e.g., employed, actively complete first pass metabolism and low caring for children or attending school) sublingual bioavailability. The prescriber decides when and if carries The Canadian Research Initiative in Substance are to be given to an individual. Provincial Misuse National Guideline for the Clinical guidelines do not allow carry privileges for Management of Opioid Use Disorder strongly the first three months of treatment. Addiction recommends buprenorphine/naloxone as the counsellors/case managers may play a role in preferred first-line treatment when possible, adjudicating requests for either exceptional or due to its demonstrated effectiveness and regular carries and communicating with the safety in the primary care setting. Suboxone® prescriber. must be dispensed on a daily basis under the supervision of a healthcare professional until the patient has sufficient clinical stability and Clients and addiction counsellors/ is able to safely store Suboxone® take-home case managers should always discuss doses. all drug use and prescription drug use with the OST prescriber and/ The Centre for Addiction and Mental Health or the pharmacist. Certain drugs can has additional information regarding the increase the effects of methadone use of Suboxone® available at https://www. and buprenorphine/naloxone so it porticonetwork.ca/documents/489955/0/ Buprenorphine+and+Naloxone+-+Clinical+Prac is important to share the complete tice+Guidelines+2012+PDF/fd1eee5d-fd7f-4b58- medication profile. 961f-b45350a8b554.

6 SASKATCHEWAN’S CLINICAL PRINCIPLES FOR ALCOHOL AND CLINICAL PRINCIPLES FOR ALCOHOL AND DRUG MISUSE DRUG MISUSE SERVICES SERVICES IN SASKATCHEWAN

OST design considerations should reflect the • Clinical Principle 1: Alcohol and drug Provincial Framework for Alcohol and Drug misuse, abuse and dependence are shaped Misuse and Mental Health Services and use as by biological, social and other factors, which a foundation for service, theClinical Principles may include family, environment, and other for Alcohol and Drug Misuse Services in extra therapeutic factors. Saskatchewan and Outreach Standards. Links to these documents can be found at http:// • Clinical Principle 2: Alcohol and drug www.sken.ca/clinical-tools/. dependence is a chronic condition.

• Clinical Principle 3: The patterns of youth Evidence based counselling practices are alcohol and drug misuse are different from the basis for counsellor/client interactions. those of adults and require specialized Clients with an Opioid Use Disorder are often treatment responses. experiencing complicated and challenging life circumstances. Special consideration • Clinical Principle 4: Treatment programs should be given to active case management need to be knowledge or evidence- of situations and circumstances such as: OST informed. and pregnancy; physical health issues and access to primary care or infectious disease • Clinical Principle 5: The needs of special care; concurrent disorders; adolescent populations are recognized and responded clients; transfers to other prescribers; hospital to appropriately and with sensitivity. admission and discharge planning; and • Clinical Principle 6: Mental health and offenders in custody. alcohol and drug services are integrated for clients with concurrent alcohol and drug Addiction counsellors/case managers misuse and mental health issues. need to be knowledgeable about: • Substance use and dependency; • Clinical Principle 7: Programs exist for clients and the community that reduce the • Opioid Use Disorder; short and long term impacts of alcohol and • Physical, mental, social health as well as drug misuse. legal aspects of opioid dependency; • Use of methadone and buprenorphine/ naloxone in the care and treatment of an Opioid Use Disorder; • OST processes and outcomes.

7 The phases of OST may be described OST has three possible outcomes: as: • Long-term treatment for those with high • Initiation – assisting the client to reduce/ function and no significant substance use; stop using illicit opioids and starting • Medically supervised withdrawal from prescribed methadone or buprenorphine/ methadone or buprenorphine/naloxone naloxone. for those who can overcome opioid • Stabilization – establishing an individual’s dependency; or therapeutic dose. • Opioid substitution to reduce the harm • Determination – identifying issues in drug associated with opioid use, with continued use and physical/mental/social/legal health. but less intense engagement in care. • Action – working on the identified issues. • Maintenance – decision time regarding During OST there may be considerable methadone or buprenorphine/naloxone use overlap and cycling between the three - primarily to reduce the harms associated outcomes and may take several years with with opioid use, long-term OST, or medically multiple relapse episodes. supervised withdrawal from methadone or buprenorphine/naloxone.

8 OPIOID SUBSTITUTION THERAPY OVERVIEW

Individuals presenting with opioid and other substance abuse

Screening Process

Assessment

Opioid Substitution Therapy

YES Methadone or Buprenorphine/ NO naloxone prescription

Stabilization of Dose Opioid use Opioid use not creating problems creating problems

Addiction Services: • Ongoing comprehensive Withdrawal from Withdrawal from assessments opioids: substances other than opioids: • Education • Addiction services • Addiction services • Crisis intervention • Harm reduction, Take Home Naloxone programs • Other health and • Case management • Other health and social social services • Evaluation/outcome services assessments • Advocacy • Referrals (i.e. harm reduction, Take Home Naloxone) Outcome: Overcome presenting problems without opioid substitution • Liaise with other health and

social services RELAPSE

Outcome: Outcome: Outcome: Opioid substitution Medically supervised Long term Opioid to reduce harms withdrawal from methadone or Substitution Therapy associated with use buprenorphine/naloxone 9 STEP 1 - SCREENING PROCESS The screening process has five components: The screening process is the first step • Gather information through interviews in the assessment process that may be with the individual, family member(s), and completed by a trained addiction counsellor/ other relevant person(s) individually and/ case manager. The complete process or together after obtaining the appropriate involves addiction and program screening, consents from the individual, as indicated in comprehensive assessment, assessment The Health Information Protection Actand feedback, and treatment/recovery your employer’s policies. planning. With good communication and planning all steps in OST can be shared by • Use appropriate screening instruments, such the prescriber and the counsellor. If the as the Substance Abuse Subtle Screening screening confirms a likelihood that the Inventory (SASSI), Drug and Alcohol individual has an Opioid Use Disorder, the Screening Test (DAST), Michigan Alcoholism addiction counsellor will refer the client to a Screening Test (MAST), Problem-Oriented prescriber with accompanying rationale and Screening Instrument (POSI), Drug Use recommendations. The prescriber retains final Screening Inventory - Revised (DUSI-R). responsibility for diagnosing and commencing • Give feedback to the individual and select OST. Other options include referring the future actions. individual to community-based treatment • Briefly intervene to deal with the presenting services such as detoxification, outpatient, crisis. or inpatient treatment. • Orient the client to available services and expectations. The addiction counsellor/case manager during screening seeks to: • Identify the opioid use problems the Health conditions associated with individual is facing. injection drug use include (but not • Determine the extent to which the problems limited to): are alcohol and/or drug related. • Endocarditis • Determine whether it is appropriate • Abscess or necessary to immediately initiate a • Blood clots and embolisms comprehensive assessment and referrals to • Septicemia additional services. • HIV • Develop rapport and trust with the • Hepatitis B, hepatitis C, and other liver individual. diseases • Engage the individual so that he/she is • Cellulitis and phlebitis motivated to meet again and continue with the assessment process. • Adverse drug interactions • Bacterial pneumonia • Pulmonary complications

10 Screening information is collected in There are many serious health issues five areas: associated with injection drug use and referral • Substance Use to a primary health care provider for the appropriate assessment, including testing for • Physical Health communicable diseases such as HIV and HCV, • Mental Health should be initiated prior to or at the same • Social Health time OST is started. This can be facilitated by • Legal Health the prescriber or the addiction counsellor. When required, the addiction counsellor may Upon intake, addiction counsellors/case follow up on the outcome of the physical managers share information from screening assessment with the family physician after interviews and comprehensive assessments appropriate consent is obtained. with prescribers. During orientation of new clients, the A prescriber conducts initial consultations addiction counsellor/case manager during intake to determine whether each seeks to: individual meets the College of Physicians • Provide information about healthcare and Surgeons of Saskatchewan OST admission providers involved in OST. criteria. Based on all available information, • Outline addiction counsellor/case manager the prescriber makes the decision to prescribe services. methadone or buprenorphine/naloxone and/ • Outline client responsibilities. or refer the individual to other health care services. Before prescribing, the prescriber • Provide education on opioid substitution must ensure the individual signs a treatment and address client expectations, questions agreement (see Appendix J - Saskatchewan and concerns. Opioid Substitution Therapy Guidelines • Educate clients on the roles of clinic and Standards for the Treatment of Opioid staff, community pharmacists, and other Addiction/Dependence). A signed treatment community service providers. agreement between the prescriber and • Inform clients of other available services client details comprehensive care for the delivered through primary care clinics, opioid dependent individual that includes participating community pharmacies, harm methadone or buprenorphine/naloxone, reduction programs, overdose prevention medical, addiction, and other health, social programs (Take Home Naloxone) and alcohol and legal services. The treatment agreement and drug services. directs those involved in the care and treatment of the individual to advise and share healthcare information as required on a need to know basis.

11 SCREENING PROCESS: USING PRIMARY MENTAL HEALTH AND ADDICTION ASSESSMENT TOOL http://www.publications.gov.sk.ca/freelaw/partners/mental-health/PrimaryAssessment.pdf (see Appendix C)

Alcohol and Drug, Mental Who Physician, legal Health or Public Health initiates Self, family friend services, educator, Services; Community process (no employer agencies; Acute Care, wrong door) Corrections

How to Conduct initial interview - build trust and rapport; define role of addiction conduct counsellor/case manager, prescriber, pharmacist, registered nurse and process other clinical treatment team members.

Gather Information: Client Describes: Educate: Process • Past/present substance • Opioid use • Opioid Substitution use • Polysubstance Therapy • Polysubstance use use • Available services- • Past attempts at detox/ • Method of use alcohol/drug, harm treatment and/or • Strengths reduction, social, legal, public health, housing, abstinence • Current crisis mental health, primary • Medical information • Opportunities including mental health care, etc.

Identification of appropriate Determination that there referral to other services is sufficient likelihood of required including crisis Opioid Use Disorder. interventions.

Identify clients that meet the To provide assistance to people Outcome CPSS OST criteria and refer to presenting with opioid use for objective prescriber. immediate crisis.

12 STEP 2 - ASSESSMENT therefore more effective, once an individual is medically stabilized on a therapeutic The comprehensive assessment is the methadone or buprenorphine/naloxone dose. second step of the assessment process that Comprehensive assessment is an ongoing is to be completed by a trained addiction process between the addiction counsellor/ counsellor/case manager. It is recommended case manager and the individual in OST. that the addiction counsellor continue with the comprehensive assessment only when The assessment process provides an individual is sufficiently stabilized on opportunities for the addiction prescribed methadone or buprenorphine/ counsellor/case manager to: naloxone to meaningfully engage in the • Give feedback to the individual. process. • Outline options for recovery planning. • Briefly intervene to deal with current crisis. • Select future recovery actions and plans. OST GOALS: • Reduce harms of drug use Interventions on behalf of the • Treat medical and psychiatric co- individual could include: morbidity • Liaison with the treatment team. • Bring substance dependence into • Co-ordination of care/case management. remission • Liaison with outside agencies with whom • Achieve the highest possible level the individual is involved. of psycho-social function • Referrals to outside agencies (funding, therapy, upgrading, vocation work, legal counsel). The comprehensive assessment has • Advocacy over non-medical issues (social or two purposes: legal). • To collect information about the effect of • Education of family members. alcohol or drug use on the individual’s life. • To identify strengths that can provide a foundation for recovery.

Like the screening process, the comprehensive assessment includes obtaining information through interviews and discussions with the individual and collateral contacts on their substance use, physical health, mental health, social health and legal health. Ongoing comprehensive assessment, case management, and evaluation/outcome assessment can be better defined, and

13 Co-Management of Record Keeping in Sharing Information for Transfers OST A transfer should be initiated in situations The medical chart is the primary record and is where clients are temporarily re-locating required to include the following information (work, visiting relatives, etc.) or permanently from the addiction counsellor’s file: relocating to another community. • Screening information that may include recommendation and treatment plan. Transfer and pharmacy arrangements should • On-going addiction counsellor progress be set up ahead of time whenever possible notes. to avoid interruption of OST and to minimize inconvenience to the client, other prescribers, • Release of Information/Consent forms. dispensing pharmacies and institutions. • Copies of referrals made by the addiction Addiction counsellors/case managers may be counsellor. required to co-ordinate the transfer of a client • Saskatchewan Ministry of Health, Alcohol to another prescriber. and Drug Admission/Discharge Forms. The following information should be Good communication among prescribers, forwarded to facilitate a transfer: addiction counsellors/case managers, • Addiction counsellor screening form. pharmacists, and other healthcare providers • Copy of most recent prescription with expiry is essential to protect the privacy and date. confidentiality of health information in the co- management of individuals involved in OST. • List of any other prescribed medications. The addiction counsellor/case manager will • Witnessed drink/carry information. comply with federal and provincial regulatory • Prescriber’s treatment plan/evaluation requirements (The Health Information documentation. Protection Act). The sharing of information • Motivational assessment report and other between addiction counsellors/case managers information regarding the individual’s and prescribers, requires a signed client recovery plan. consent form authorizing communication and release of information. The information that is to be shared shall be on a need to know basis and applicable to the medical management and treatment of the client.

Information Information gathering with Collaborate other agencies

Past/present Past/present issues legal Previous incarceration Past/pending convictions/ charges court Upcoming appearance(s) Parole/probation condition(s) • • Legal Health: Health: Legal • • • • • Individual Environment • • Build on strengths: Build

Education Education Advocacy Assess risk/safety Assess barriers Educate networks situation of children Care Housing source Income Transportation Education security Food Employment Cultural/spiritual practices interests Leisure Current family Current • • • • • • • • • • • • • • Social health: • To identify strengths that can provide a can provide that strengths identify To foundation for Opioid Substitution Therapy for Opioid Substitution foundation Liaison Referrals Education and Collaborate information share interaction Client Presence of co- Presence occurring mental disorders health Program expectations use Past/present health of mental services Past/present to prescription(s) conditions treat risk Suicide assessment Trauma • • • • • Mental health: Mental • • • • • •

Opioid Substitution Therapy plan Therapy Opioid Substitution plan Recovery Summarize goals: Summarize • • Collaborate and Collaborate Education share information information share Document Community Referral prescription(s) to prescription(s) conditions treat use Past/present of alternative medicine Current physical physical Current concerns health Injection drug use issues status HCV/HIV Pregnancy Immunizations Past/present use of medical services Past/present • • • • • Physical health: Physical • • • • • • • ing Past/present Past/present use substance(s) of onset at Age use substance of onset at Age opioid use Past/present use of addiction services of opioid Route administration of use Frequency use over Control at Attempts abstinence Substance use: Substance • • • • • • • • Document Document about use Education Counselling Collaborative shar information • • • • and other drug use on the individual’s life individual’s drug use on the and other Identify stage of change of change stage Identify and motivation To collect information about the effect of opioid effect about the information collect To

COMPREHENSIVE ASSESSMENT COMPREHENSIVE Goals Outcome Objectives Process health coverage health and Strengths opportunities Medical information including mental health Safety access to Barriers services Crisis intervention Trauma Supplementary • • Special considerations: • • • • • 15 STEP 3 - OPIOID SUBSTITUTION Role of Residential Detoxification and THERAPY Inpatient Treatment Residential detoxification and inpatient Research suggests that it takes two or more services are required at timely points in years to go through OST phases and arrive individualized treatment and recovery plans. at one of three outcomes: long-term OST; OST is to be maintained as an integral part medically supervised withdrawal from of the treatment process when individuals methadone or buprenorphine/naloxone; require detoxification from substances or OST used to reduce the harm associated other than opioids. During episodes of with drug dependency with continued but inpatient care, the continuance of prescribed less intense engagement in care. During OST, methadone or buprenorphine/naloxone is there may be considerable overlap and cycling to be maintained as an integral part of the between the three outcomes. client’s recovery program. The logistics of managing this function are to be accomplished Strengths, skills, experiences and resources between the community case manager vary considerably from individual to individual. and the facility. As prescribed methadone It is important and sensible to focus on goals or buprenorphine/naloxone is part of the that the individual is willing to work towards. ongoing recovery plan, the individual needs Clinical Principle 4 (see page 7) provides to maintain connection with a prescriber, a direction for evidence informed treatment dispensing pharmacy, and her/his community and recovery approaches that addiction case manager throughout their stay in an counsellors/case managers can use to provide inpatient facility. It is generally not therapeutic the right help at the right time. These will to discontinue methadone or buprenorphine/ include paying attention to: naloxone during detoxification and treatment • Discovery/recovery of function, purpose and for other substance use. goals • Development of an individual’s recovery plan • Motivation to change • Current needs/crisis interventions required • Case management and coordination • Relapse prevention • Life skills enhancement • Aftercare

16 OTHER ISSUES RELATED TO OST states, currently prescribed medications, illicit drug use to manage symptoms, assessing risk OST and Pregnancy to the individual or others, and contact with The primary intent of OST for a pregnant psychiatry. woman with an Opioid Use Disorder is to create a stable environment for the pregnancy Stabilization on prescribed methadone or and to improve maternal and neonatal buprenorphine/naloxone allows for a clearer, outcomes. Individuals who are pregnant more accurate assessment of mental health and have an Opioid Use Disorder should be symptomology. Accurate assessment allows given priority for service. Women who are for appropriate diagnosis, treatment and/ addicted or abusing opioids do better with or referral for treatment. Research supports OST than with no treatment as it prevents providing treatment for addiction and them from going in and out of withdrawal, mental health issues simultaneously thus which in turn decreases the risk of miscarriage coordination of care is imperative. The goal for or spontaneous abortion. It also decreases individuals is to achieve stability and return the risk of infection from injection drug use, of function in both areas. In some cases, OST provides medical and psychosocial stability alone will lead to the eradication of substance and engages them in care. Information on induced disorder. the role of OST in pregnancy and questions regarding the effects on the baby should be Youth directed to a physician. Best practice information identifies a need for older youth and emerging adults to Concurrent Disorders have access to OST. They require safe living Research indicates that mental health issues, environments in order to participate in including trauma, are to be expected in any treatment services and to maintain regular individual with a Substance Use Disorder. appointments with the services required as Many clients in OST may have mental part of a recovery plan. As youth may distrust health issues that have been undiagnosed, systems, significant effort is needed to build misdiagnosed, untreated or ineffectively trust with youth and engage them in accessing treated due in part to ongoing drug use. services.

During the initial screening interview, it is As more knowledge and experience has been important to explore and document the gained through OST programs, individual individual’s mental health and/or psychiatric circumstances have introduced the question history. This may include any past diagnoses, of prescribing methadone or buprenorphine/ contacts with a psychiatrist or mental health naloxone to youth. These individuals are professionals, hospitalizations, medications typically “emancipated”, actively injecting, taken and perceived effect by client, personal may be involved in the sex trade or criminal struggles with stress, anxiety, depression, activity, have significant social instability and childhood trauma, head trauma, suicide come from family situations with significant attempts and major losses/grief. It is also challenges and an inability to provide important to examine present issues, mood appropriate support.

17 Detoxification, stabilization, support, and It is important that individuals on prescribed outreach services have been shown to be methadone or buprenorphine/naloxone effective strategies with youth presenting with while incarcerated are referred to community substance use. These services are particularly based agencies prior to or at discharge. It important for marginalized youth who inject is preferable to plan the referral, but at drugs. The Alcohol and Drug Misuse Services a minimum, to send a notification to the Youth Outreach Standards provide direction community-based agency when an unplanned for programming. release occurs. Health care providers prescribing to patients in the corrections Offenders in Custody setting have a professional duty to ensure Evidence shows there is a significant treatment bridging occurs until care can be reduction of injection drug use in prisons assumed in the community. among offenders prescribed methadone or buprenorphine/naloxone for an Opioid Use Disorder. Studies have shown that increased use of OST in prison was associated with less injection drug use, a fact that is consistent with community studies.

18 REFERENCES

Brands B, Marsh D, Hart L, & Jamieson W. (2002) Literature review methadone maintenance treatment. Ottawa, ON: Health Canada, Office of Canada’s Drug Strategy. British Columbia Centre on Substance Use and B.C. Ministry of Health. A Guideline for the Clinical Management of Opioid Use Disorder. Published June 5, 2017. Available at: http://www. bccsu.ca/care-guidance-publications/

The College of Physicians and Surgeons of Ontario (2011, February) Methadone Maintenance Treatment Program Standards and Clinical Guidelines retrieved from http://www.cpso.on.ca/ policies-publications/cpgs-other-guidelines/methadone-program/mmt-program-standards-and- clinical-guidelines

College of Physicians and Surgeons of Saskatchewan. (2015, May). Saskatchewan Methadone Guidelines and Standards for the Treatment of Opioid Addiction/Dependence; retrieved from https://www.cps.sk.ca/Documents/Programs%20and%20Services/Methadone/SK-Methadone- Guidelines-2015-Mar-FINAL.pdf Correctional Service of Canada [CSC]. (2002). Specific national methadone maintenance treatment guidelines. Ottawa, ON: Author.

Erickson J, Postnikoff L, Rhode L, & Wurtz W. (2001, October, updated Sept. 2010). Guidelines for participation in the Methadone program for Saskatchewan pharmacists, in Saskatchewan Pharmaceutical Association Standards, Guidelines & Policy Statements (36-67). Regina, SK: retrieved from http://saskpharm.ca/site/manual?nav=03

The Canadian Research Initiative in Substance Misuse National Guideline for the Clinical Management of Opioid Use Disorder (2018). https://crismprairies.ca/home/projects-2/national- opioid-use-disorder-guidelines

Saskatchewan Health. (2000). Meeting the challenges: Saskatchewan model of recovery services. Regina, SK: Saskatchewan Health, Community Care Branch.

19 RESOURCES

About Opioids. Retrieved September 2017. Government of Canada. https://www.canada.ca/en/ health-canada/services/substance-abuse/prescription-drug-abuse/opioids.html

Best Practices Methadone Maintenance Treatment (2002) Prepared by Jamieson, Beals, Lalonde and Associates, Inc. for the Office of Canada’s Drug Strategy Health Canada; retrieved from http://www.hc-sc.gc.ca/hc-ps/pubs/adp-apd/methadone-bp-mp/index-eng.php

Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan, (2012, December), Outreach Standards, (2013 February); Saskatchewan Ministry of Health retrieved from http:// www.sken.ca/clinical-mhas-standardsframeworkprinciples-in-saskatchewan/

A Cross‐Canada Scan of Methadone Maintenance Treatment Policy Developments: A Report Prepared for the Canadian Executive Council on Addictions, (2011, April) Luce, J, Strike, C; retrieved from http://www.ceca-cect.ca/pdf/CECA%20MMT%20Policy%20Scan%20April%202011. pdf

The Fundamentals of Methadone Maintenance Treatment, Centre for Addiction and Mental Health (2003) retrieved from https://www.porticonetwork.ca/web/knowledgex-archive/amh- specialists/the-fundamentals-of-methadone-maintenance-treatment

Methadone Assisted Recovery Guidelines for Addiction Counsellors (2004), Saskatchewan Health. Methadone maintenance treatment for offenders (2006). Saskatchewan Corrections and Public Safety, Regina, SK. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) (2012), National Institute on Drug Abuse, retrieved from https://www.drugabuse.gov/publications/principles-drug- addiction-treatment-research-based-guide-third-edition/principles-effective-treatment

Provincial Framework for Alcohol and Drug Misuse and Mental Health Services (2012, May); Saskatchewan Ministry of Health; retrieved from http://www.sken.ca/wp-content/ uploads/2014/10/Foundationa-_Framework.pdf

Trauma Informed Practice and the Opioid Crsis: A Discussion Guide for Health Care and Social Service Providers (April 2018). Vancouver, B.C.: Centre of Excellence for Women’s Health. www.bccewh.bc.ca

20 APPENDIX A 10. Tolerance, as defined by either of the following: Diagnostic Criteria for Opioid Use Disorder a. A need for markedly increased amounts of Adapted from the Saskatchewan Opioid opioids to achieve intoxication or desired Substitution Therapy Guidelines and Standards for effect. the Treatment of Opioid Addiction/Dependence b. A markedly diminished effect with (College of Physicians and Surgeons of continued use of the same amount of an Saskatchewan, 2016) opioid. Reprinted with permission from the Diagnostic Note: This criterion is not considered to be and Statistical Manual of Mental Disorders V, Text met for those taking opioids solely under Revision, Copyright 2013, American Psychiatric appropriate medical supervision. Association. 9. Withdrawal, as manifested by either of the A problematic pattern of opioid use leading following: to clinically significant impairment or distress, a. The characteristic opioid withdrawal as manifested by at least two of the following, syndrome (refer to Criteria A and B of the occurring within a 12-month period: criteria set for opioid withdrawal). 1. Opioids are often taken in larger amounts or b. Opioids (or a closely related substance) over a longer period than was intended. are taken to relieve or avoid withdrawal 2. There is a persistent desire or unsuccessful symptoms. efforts to cut down or control opioid use. Note: This criterion is not considered to be met 3. A great deal of time is spent in activities for those individuals taking opioids solely under necessary to obtain the opioid, use the opioid, appropriate medical supervision. or recover from its effects. Specify if: 4. Craving, or a strong desire or urge to use • In early remission: After full criteria for opioid opioids. use disorder were previously met, none of 5. Recurrent opioid use resulting in a failure to the criteria for opioid use disorder have been fulfill major role obligations at work, school, or met for at least 3 months but for less than home. 12 months (with the exception that Criterion 6. Continued opioid use despite having A4, “Craving, or a strong desire or urge to use persistent or recurrent social or interpersonal opioids,” may be met). problems caused or exacerbated by the effects • In sustained remission: After full criteria for of opioids. opioid use disorder were previously met, none 7. Important social, occupational, or recreational of the criteria for opioid use disorder have been activities are given up or reduced because of met at any time during a period of 12 months opioid use. or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use 8. Recurrent opioid use in situations in which it is opioids,” may be met). physically hazardous. • On maintenance therapy: This additional 9. Continued opioid use despite knowledge of specifier is used if the individual is taking having a persistent or recurrent physical or a prescribed agonist medication such as psychological problem that is likely to have methadone or buprenorphine and none of the been caused or exacerbated by the substance. 21 criteria for opioid use disorder have been met tal Disorders, DSM-V, was published. The section for that class of medication (except tolerance Substance Use Disorders now combines substance to, or withdrawal from, the agonist). This abuse and substance dependence into a single category also applies to those individuals being disorder measured on a continuum from mild to maintained on a partial agonist, an agonist/ severe. Each specific substance is addressed as a antagonist, or a full antagonist such as oral separate use disorder (e.g. opioid use disorder). naltrexone or depot naltrexone. For more information on the revised chapter of • In a controlled environment: This additional “Substance Use Disorder), please see the follow- specifier is used if the individual is in an ing link: http://www.dsm5.org/Documents/Sub- environment where access to opioids is stance%20Use%20Disorder%20Fact%20Sheet.pdf restricted. *Please note that in May 2013, the fifth edition of the Diagnostic and Statistical Manual of Men-

22 APPENDIX B Contact Information Directory of Mental Health and Addictions Services http://www.saskatchewan.ca/residents/health/accessing-health-care-services/mental-health-and-addictions- support-services

College of Physicians & Surgeons of Saskatchewan Opioid Agonist Therapy Program http://www.cps.sk.ca/imis/CPSS/Programs_and_Services/Opioid_Agonist_Therapy_Program. aspx?OATPCCO=1#OATPCCO

23 APPENDIX C Provincial Mental Health and Addictions Primary Assessment

24 25 26 saskatchewan.ca/addictions 27