Patient Assessment for
Methadone Dec 2012
ASSESSMENT OF PATIENTS FOR
POTENTIAL METHADONE
THERAPY.
REGINA 08 DEC 2012
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
1
Assessment for Methadone 2012.
• Credentials / Conflicts :
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•
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Qualifications – experience only
Conflicts – talks for the College
Drug companies – fed and watered - rarely
Opioid companies – no involvement.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
2
Assessment for Methadone 2012.
• OBJECTIVES :
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1. To understand - Who methadone is for
2. To understand - Intent of treatment.
3. To understand - What to assess.
4. To understand - MMT duration and components.
5. To understand - Assessment in five areas.
6. To understand - Assessment Criteria for admission to MMT.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
3
Assessment for Methadone 2012.
• Methadone can help those with :
• You will be asked to consult about :
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•
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1. Palliative Care
2. Chronic Pain
3. Opioid Dependency
4. Chronic pain + opioid dependency
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
4
Assessment for Methadone 2012.
• Applicants will include :
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1. Some who are not dependent
2. Some with Ltd education / intelligence etc
3. 50/50 mix of M/F, and 50/50 Aboriginals
4. Occasional outright criminals
5. University educated, mostly by prescription
6. Everything in between.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• Applicants vary in :
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1. Maturity - from childlike to full adult
2. Education - formal and social
3. Attitude and personality
4. Understanding of opiates and methadone
5. Expectations of treatment and outcomes
6. Social function in many areas
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• There’s also a social factor :
• Chronic relapsing conditions affects patients, family, and society.
• Palliative Care and Chronic Pain issues are often normal people.
• Society has good structures and often infrastructures to help them.
• “Addicts”, or Opioid Dependents, are less well served.
• We thus have a social obligation to treat patients so they are most
able to function properly and legally in society.
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Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• Some we do not see :
• Those without consequences (as they see it) :
• 1. Wealthy (they can afford it)
• 2. Those who can wean off opiates.
• 3. Those who think they don’t have a problem
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• The intent of treatment
• To enhance function / self esteem / etc
• It is not to cure opioid dependency or addiction
or chronic pain.
• Awareness of this affects the way we assess.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• We need to assess applicants for :
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•
•
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1. Palliative care
2. Chronic Pain
3. Opioid dependency and consequences
4. Chronic pain plus opioid dependency
• And treat them all as necessary.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• Palliative Care :
• Usually normal people with end-of-life situations and
no features of addiction or dependency.
• Many of them have good support structures and a well
developed care system.
• Separate talk on this later in programme.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
11
Assessment for Methadone 2012.
• Chronic Pain without dependency :
• Usually normal people with no features of addiction or
dependency.
• 1. Physical causes. Easy to get supporting info.
• 2. Emotional causes / PTSD / etc.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• Opioid Dependency :
• Opioid Dependency is :
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•
•
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1. Irreversible and incurable
2. Ultimately dysfunctional
3. But function can usually be restored.
4. Major stigma component / self esteem
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
13
Assessment for Methadone 2012.
• Chronic pain + Opioid Dependency :
• This can be challenging to sort out.
• Assess both conditions as separate issues.
• You will end up treating both in time.
• Over the last 20-30 years in our province most are
dependent on prescription opiates.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• DSM III and IV do not help :
• Any 3 in 12 months of :
• 1. Tolerance
• 2. Withdrawal
- objective scientific fact
- objective scientific fact
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- social behaviour
- social behaviour
- social behaviour
- social behaviour
- social behaviour
3. Larger / longer amounts
4. Can’t cut down
5. XS time spent
6. Activities given up
7. Continued use.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• What can and cannot we treat :
• Physicians can treat or arrange treatment for palliative
care and chronic pain, in particular their Physical and
Mental problems.
• For the opioid dependents we are useful for the drug
component too but not skilled at social and legal issues
which are the common causes or consequences of their
core medical problems.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
16
Assessment for Methadone 2012.
• Patient histories :
• 1. Palliative Care - usually straightforward.
• 2. Chronic pain - usually straightforward.
• 3. Opioid Dependency - vary a lot.
• 4. CP + Opioid dependency - vary and difficult.
• Consequences have often affected them
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
17
Assessment for Methadone 2012.
• Methadone and Counselling :
• Depends on our definition of counselling. Normal people need
normal education such as we would employ for any chronic
condition. This education could be considered counselling.
• In our field this applies to :
• Palliative Care patients - usually normal people
• Chronic Pain patients - usually normal people
• This is not the counselling we hear all addicts should receive.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
18
Assessment for Methadone 2012.
• Methadone and Counselling :
• For the Opioid dependent with consequences and those
with Chronic pain plus opioid dependency, counselling
has a totally different meaning.
• These patients often certainly need help; but mostly in
facilitating access to societal agencies which can help
them move ahead in life. Which is much less than they
receive in many cases.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
19
Assessment for Methadone 2012.
• Methadone and Counselling :
• Methadone alone is the key ingredient. Methadone
works with or without counselling.
• And the corollary : For opioid dependents counselling
on its own is not effective without methadone.
• Ball and Ross - The Effectiveness of Methadone
Maintenance Treatment. 1991. Verlag Springer.
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Saskatoon, 08 Dec 2012
20
Assessment for Methadone 2012.
• MMT Duration and Components :
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In general MMT take at least two years.
It is medicine’s least convenient therapy.
Phase 1 is Induction - 4 - 6 weeks.
Phase 2 is Stabilisation 7 - 12 weeks.
Phase 3 is Maintenance - 13 - 100 weeks.
Phase 4 is MSW however long thereafter.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• Drug History :
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1. Rx / street / both.
2. Age first use, reason, route, any drugs at all.
3. Drug sequence / routes.
4. Which up / down / inhale / methadone.
5. Current preferences.
6. Payment by / family history.
7. Effect of no use. (ie withdrawal ..?)
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• Physical Health History :
• 1. Past – drug consequences / domestic trauma.
• 2. Current – chronic conditions diabetes / pain / HPC /
HIV / Asthma / COPD / sleep apnoea.
• 3. Send for collateral information.
• 4. PIP.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
23
Assessment for Methadone 2012.
• Mental Health History :
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1. Normal / anx / dep / PTSD / Bipolar / Schizoid.
2. Chronic mental / emotional pain.
3. Personalities often difficult to read.
4. Drug Induced Psychoses common on stimulants.
5. Opioids do not produce drug induced psychoses.
6. When stable on meth many disorders easier assess.
7. Send for collateral information.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
24
Assessment for Methadone 2012.
• Mental Health Section :
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Psychiatric “Axes” :
I - General mental disorders
II - Personality disorders
III - Medical co-morbidity
IV - Social co-morbidity
V - Global Assessment of Functioning “GAF”
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
25
Assessment for Methadone 2012.
• Social Health History :
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1. Genetics predispose, environment aggravates.
2. Severe social poverty usual endpoint.
3. Domestic relationships, children, locations.
4. Education / skills / work / potential income.
5. Partner on drugs or methadone.
6. Financial status, support, debts, welfare status.
7. Methadone identifies these people to authorities.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
26
Assessment for Methadone 2012.
• Legal Health Section :
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1. Normal patients usually have no legal records.
2. “Illegal” patients often have records.
3. Ask about any prior record.
4. Ask about maximum / total gaol time.
5. Check current status - pending / breachable.
6. Likely outcome – CSO / fines / gaol, etc.
7. All these can affect your Rx.
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Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• Physical Examination :
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1. No respiratory contraindications
2. Evidence of drug use / tracks / withdrawal.
3. Urine Drug Screen.
4. Some do a full check, bloods. I defer them.
5. ECG ..? QTc ..? Dose related torsade, >200.
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Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• Criteria for MMT :
• Anyone trained could take the history and make most
diagnoses.
• The decision to prescribe methadone is entirely medical
• This applies to start, stop, revise, restart, expel, etc.
• The intent is to prescribe a restricted toxic opioid. No
other participants are needed at this stage.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• Contraindications to Induction :
• 1. Acute Respiratory distress - almost absolute.
• 2. Acute pain syndromes - relative.
• 3. Unexplained fever - relative.
• Deal with these conditions first.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
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Assessment for Methadone 2012.
• Therapist - Priorising candidates :
• Most are seen as consults - hospital or clinic. Eg :
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1. Acute bacterial infections Endocarditis/osteomyelitis
2. Chronic viral infections - HIV / HPC
3. Pregnant IVDU
4. Chronic pain +/- dependency
• Depends on who one wishes to be involved with.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
31
Assessment for Methadone 2012.
• Patient opioid categories seen :
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•
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CATEGORY
1. Not dependent
2. Not dependent
3. Early dependent
Tol
N
+
+
W/D
N
N
+
MGT
Wean/detox
Wean/detox
Wean/detox
•
•
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4. Palliative care
5. Chronic Pain alone
6. Opioid dependent
7. Pain +/- dependency
++
++
++
++
++
++
++
++
Methadone
Methadone
Methadone
Methadone
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Saskatoon, 08 Dec 2012
32
Assessment for Methadone 2012.
• Agreements - Patient understands :
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1. Recognises his problem, methadone will help.
2. We can provide that service.
3. Methadone can be dangerous.
4. Federal law, provincial law, clinic regulations.
5. Other conditions need Rx too, can consult other professionals.
6. Rehab / function is the aim; patient must do most of the work.
7. Patient works, doc works; patient quits, doc quits too.
8. Documents confidential subject to law.
9. Patient competent to sign agreement.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
33
Assessment for Methadone 2012.
• Consult report sequence :
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1. Reason for consult
2. Collateral info supplied
3. Patient presentation
4. Patient self history
5. Exam and tests ordered / received
6. Identify the patient category
7. Recommendations
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
34
Assessment for Methadone 2012.
• Assessments Summary :
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1. Correctly select patients (ie dependents)
2. Assess all their problems
3. Priorise them so you can handle them
4. Start safely and effectively
5. Retain them by good induction and stabilisation
6. Within 2 years address all other problems
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
35
Assessment for Methadone 2012.
• OBJECTIVES :
•
•
•
•
•
•
1. To understand - Who methadone is for
2. To understand - Intent of treatment.
3. To understand - What to assess.
4. To understand - MMT duration and components.
5. To understand - Assessment in five areas.
6. To understand - Assessment Criteria for admission to MMT.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
36
Assessment for Methadone.
Many thanks for your attention.
I trust the objectives were covered
and have provided some
understanding of the intent and
processes of MMT.
Copyright (c) Meth Made Easy, FML,
Saskatoon, 08 Dec 2012
37