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In preparation for this week's discussion, I wanted to share some resources that might be of interest. We encourage you to share additional resources on this important topic, as well as any questions you'd like to see our panel address over the course of the week. Looking forward to a great discussion!All resources for this Expert Panel can be found at ghdonline.org/opioid-epidemic/resources
Link leads to: http://www.opioidprescribing.com/naloxone_module_1-information
Link leads to: https://www.statnews.com/2016/10/19/primary-care-doctors-opioid-treatment/
Link leads to: https://www.statnews.com/2016/03/29/obama-opiod-abuse-buprenorphine/
Link leads to: https://www.scopeofpain.com/index.php
For many years I have worked with patients who have opioid use disorder in a variety of clinical settings: community health centers, health care for the homeless programs, a publicly-funded addiction treatment hospital, etc. I have certainly seen first hand how many barriers there are for primary care teams to treat opioid use disorder. These include lack of adequate training and support, lack of team-based structures to support treatment, and pressures related to productivity and the need to see patients very rapidly. Stigma also plays a role, both among us as medical professionals and throughout the healthcare system and society at large. I have also seen how remarkably effective treatment of opioid use disorder can be in the primary care setting, and how we have the capacity to save lives and improve quality of life tremendously by learning to work with folks who are struggling with opioid use disorder.One approach to addressing some of these issues is using the ECHO model to provide further training and support to primary care teams, My team published a paper earlier this year on how this works for substance use disorder (attached). I also want to recommend the work of Colleen LaBelle, RN, in developing a nurse-led team-based model to treat opioid use disorder in primary care (attached).
A hugely important part of addressing substance use disorders is to address co-occurring mental health issues. PTSD and the impact of early childhood adverse events plague so many of my patients, and are a set-up for relapse if they aren't addressed. This can be hard to do in the primary care setting. One valuable resource is "Seeking Safety", which is an evidence-based, manualized approach to working with people who have co-occurring trauma and substance use disorders. It can be effectively delivered even by folks who do not have a behavioral health degree, and it is designed to offer as a treatment group. At the primary care clinic where I do addiction consultation we are launching a group for folks who are on Medication Treatment for opioid use disorder and have a trauma history. The psychologist will be leading a Seeking Safety group, and I will pull out patients for brief visits related to their medication.As described on the ATTC network site:Seeking Safety - Part of SAMHSA's National Registry of Evidence-based Programs andPractices is an integrated treatment designed to address the unique relationship between PTSDand substance use in either individual or group settings. This approach centers on five principlephilosophies: 1)safety is the highest priority to begin the recovery process and throughout therecovery process, specifically focusing on attaining safety in relationships, thinking, behavior,and emotions, 2) integrated treatment of PTSD and substance use concurrently, 3) focus onideals to counteract loss occurred through PTSD and substance use, 4) addressing four majorcontent areas: cognitive, behavioral, interpersonal, and case management, and 5) attention to theclinical process. The concept of safety is interwoven into each unit, with the idea that safetyallows for forward movement in the trauma-recovery process. Safety is defined as discontinuingsubstance use, eliminating suicidality and suicidal ideation, minimizing exposure to high-riskbehavior, letting go of unhealthy relationships (platonic and romantic), gaining control overPTSD symptoms (depression, dissociation, hyper-arousal, anger, etc...), and ending self-harmingbehaviors. Clients learn to both prioritize their own safety, in addition to taking responsibility fortheir own safety. Information was adapted from the sources below.For more information visit: http://www.nrepp.samhsa.govFor training and materials visit: http://seekingsafety.org/
Thank you Dr. Komaromy for the valuable resource of the "Seeking Safety" program. Have you seen this type of training implemented into a curriculum program for primary care providers? I teach primary care Family Nurse Practitioner students and as we progress into the age of increasing preventive care and value-based care, I am interested in how I teach budding PCP's to be more capable of uncovering and addressing/treating the underlying etiology of highly prevalent substance use disorder (which as you indicate is frequently linked to trauma history and/or co-occurring mental health diagnoses). We have certainly begun to have discussions and learning sessions on trauma-informed care and we are working this year on uniformly increasing and standardizing our content on substance use disorder (specifically, we have signed on with the White House as well as the Governor of MA to teach all of our students about the CDC guidelines for safer opioid prescribing as well as MA core competencies for safe opioid prescribing http://www.mass.gov/governor/press-office/press-releases/fy2017/core-competen...). In conversations about trauma-informed care I have with colleagues and students, there is a recurring hesitancy to uncover trauma as a PCP because some feel ill-equipped to function as a counselor and worry about not having co-located or accessible behavioral health services to which to refer. I believe that the act of uncovering and expressing concern and acknowledging to patients that trauma history may be adversely affecting overall health is a step in the right direction and then together as health care leaders we can work to influence and change our local systems to improve access and integrate behavioral health into our systems where it belongs. I would love to hear your thoughts about this phenomenon of hesitancy to broach the issue and what PCPs and educators of future PCPs should be doing in the here and now.Thank you!
Thanks, Jason! I agree with your observations about this--I think PCPs are scared to ask., both because they are uncertain what to do and because they are worried about it taking too much time to deal with. And yet, it is undoubtedly true that there are very high rates of trauma among patients in primary care and trauma is having a negative impact on patients' health and well-being. Seeking Safety is a wonderful approach for several reasons. First, it is focused on helping patients to develop safe approaches to life in the present, rather than digging up old traumatic memories for processing. It helps people avoid being re-victimized, and helps them to develop awareness of how to set boundaries and keep themselves safe in interpersonal relationships. Another great things about the program is that it is all laid out in a very user-friendly manual. You don't need to take a patented training or be certified in order to use Seeking Safety; simply by implementing the exercises and worksheets in the manual you can implement the program in a group or individual setting. And yes, I have worked in several plces where this has successfully been implemented in a primary care setting.I am linking to the Seeking Safety manual/workbook by Lisa Najavits.
Link leads to: https://www.amazon.com/Seeking-Safety-Treatment-Substance-Guilford/dp/1572306394
Thank you Dr. Komaromy,Just placed an order for it and I look forward to learning more about it. The concept of not re-traumatizing and focus on the present is appealing.Jason
We have been conversing with the Needle exchange program here in Miami and working with our Public Health university leaders looking at the possibility of training emergency medicine physicians for a one-dose administration and then arrange a community and mental health follow-up. The point here is that the ED is by far the only exposure these patients get to the healthcare system.