Welcome back again to the online PCSS training. Again my name is Dr. William Wright. I'm addiction psychiatrist, then I look at Module 3 on Patient Evaluation. So let's jump in and get started. So you can have quite a few objectives this time around. So now we want to describing the goals of initial evaluation for patients with an opioid use disorder. Identifying important components of history-taking for patients with opioid use disorder. Explaining the rationale for physical examination of patients with opioid use disorder, OUD, and identifying appropriate lab tests for a new patient. Describing factors to consider in treatment planning to determine if someone is appropriate for Office-Based Opioid Treatment, OBOT, and also lastly, describing patient selection for full agonists i.e Methadone or antagonist i.e Naltrexone-ER therapy. So starting it off. One of the most important things that any patient, physician encounter is building that therapeutic alliance, building that trust with your patient, and especially when it comes to someone who has an issue with substances and addiction. They've already been assuming that most folks have interacted with other folks and told them they need to get help, they themselves and tried to get help and have run up against barriers. They've run up against folks that they look at them with the stigma that we still unfortunately have in this country, in this world, when it comes to the mental health as well as those that are battling with substance use problems. So it's so very important in order to have this person get into the best treatment on the coverage they can by having a good therapeutic alliance to start with. So how do we do that? How do we make sure that happens? The first thing is our attitude. It goes without saying that just being very non-judgmental, being very empathic, trying to see out of their shoes and living their life and what's going on. Actually being interested and not just assuming that you know all the ins and outs just because somebody has a substance use issue. Again, becoming and being very respectful of somebody should be given, recognizing that people have gone through all issues and early life adversity struggles. Also recognizing that each individual has their own unique strengths, things that enable them to get to this point of life. Nobody's without strengths. Everybody has something that has been official that they can rely on that is a strength for them. As we mentioned the very beginning, non-stigmatizing language. Words matter. How we use words, what we say, the word choices that we have it's so important. You may think it is just a euphemism or turn of phrase, but for somebody else, that can be a very derogatory or hurtful statement, and that can also disrupt the therapeutic alliance you're trying to build. Being honest both patient to you, but also you to a patient, and not trying to cover anything up. Knowing that we both have goals that we're trying to achieve, but it's important to be mindful that you may have a set of goals and they may have a totally different set of goals. So being open, being honest, being cummunicative as far as what those goals are. Why is this person coming to you? What is it that is causing them to say, okay, I need to do something about this? So also with sharing the goals, it's important to know their own language, in their own terms, their own vernacular, what is their goal is. So this is where, and especially when I'm writing patients up, this is where I use a lot of quotation values and try to hear from them what they're wanting to achieve. Again, I can have a particular mindset, but they may have some totally different. If we haven't communicated those goals together, then we may miss them both, and they may think they're doing poorly or because they're not meeting their goals, but you think they're doing great because they're meeting yours and vice versa. Reassurance. Those are concerned a little about the confidentiality. They're concerned that they're coming to you, people will see them coming to receive help that the cat maybe out of bag, that they're actually receiving help for their substance use and they may not think that other people know about it. So we assuring them that no, just like every doctor-patient relationship that their confidentiality is sacrosanct. But and this is a big but, caveat being that there are some caveats for that. That in cases where their safety, their expressing self-harm, ideations or otherwise harming of others, tells of. But also if there's issues of loving to others such as children, but also depending on the state, elderly as well. So keeping in mind that in those situations and being upfront and honest for the end because again, it's not on duty as a physician that a mandatory reporter that if those things are present, those may be the times where confidentiality may be broken. But again, it's due to safety of a person. What are our goals for this first evaluation? What are we trying to accomplish ourselves? There's quite a bit of thing that we want on special inquire. So like, man, it's a lot of things to do in one evaluation and you write. But just like most medical evaluations, lobby things are going on concurrently. So as we mentioned, the importance of trying to develop therapeutic alliance and trust that you have with the patient, which regardless of modality and treatments, you may find yourselves working on this study saying that alliance, that relationship, it's one of the most important prognostic indicators for somebody doing well. So it's really important and it may be overlooked a lot, but it is very important as far as one of the goals of setting this up. Does this person trust that I am here to help them? If they don't, then it's hard for them to come back to continue to receive treatment and get an early coverage. Also, about saying that I'm trying to get as much information as we can from more than one source. As the cliches go, there's more than one side of the story. So we're trying to get all the different components of that story that we can, so we can have a clear picture of what's going on, and there's that one little piece that may turn the entire scenario wanted and be very beneficial or let us know that, "Hey man, things aren't going as well as we thought." Then comprehensive assessment. Again, the medical psychiatric labs, I mean your physical exam or on the part of this initial evaluation as well. As we said in Module 2, going over in assessing the signs of withdrawal. I'm specifically using tools of measurements like the Clinical Opioid Withdrawal Scale or COWS scale to objectively categorize where somebody is in their withdrawal phase. Using the DSM criteria as we call it in earlier modules, it's important. Again, words matter. Diagnosing and being as specific as we can matters. Evaluating for risk, potential harmful themselves to others, or they had a potential risk for overdosing with either past behaviors and what overdose or current behaviors that are going on now. Then of course the first thing you note, are they a perfect candidate for this type of treatment? Is there anything that would prevent them from doing well is appropriate cast scenario for this patient? Then finally, coming up with a plan, that very last part, there's going to be MAT therapy. Just therapy. Going to be just there, What's going to go on? What's going to be the plan? Having all these, especially the plan communicated to the patient. So before somebody even comes in during the moment, Reviewing the Prescription Drug Monitoring Program. These are still up and coming. For some places they are still constantly being tweaked and modify that include, but there are a valuable resource to us when we're trying to evaluate to help somebody. It Is being able to see are they getting any control substance? Where are they getting it from? Who are they getting it from? Are they filling early? What are the patterns? So I use PDMPs on regular day in, day out basis. It can actually help you guide the interview in treatment planning. Not in a computational manner, but you can just say, I see that you've been getting X, Y, and Z from these different folks and what can you tell me about that? So sometimes you get even prevent some miscommunication or flat-out denial or even attempted subterfuge and diversion by having this information available. Now, PDMP registrations may vary state by state as far as what you need to do to be able to register and login to PDMP. However, I would highly recommend it, and honestly, I couldn't do day-in-and-day-out treatment of folks if I didn't have access to a PDMP in United States. A lot of states are coming together and finally collaborating with our PDMPs and so they may communicate with each other. Here in North Carolina, our PDMP has mutual agreements with multiple different states and so I can actually let the same persons demographics search different states to see if they're traveling and getting medications and other places which may be specialty, especially if you practice on the border between two states or three states. Having different signed forms such as it allows you consenting for treatment and what that treatment is going to be like, releases for other entities, whether that's family with other conditions, getting that collateral information again, we said, it's so important. Then the agreement, what it is? What this treatment is going to look like? Different clinics may have different policies as far as what that treatment agreement looks like, well, even documenting certain things like diagnoses are. So it's important to understand if you are working on a system what those requirements are. Some examples can be found at the link as it's posted, or on a PCSS website as well. So the team, is it just you? Are you working with other folks? Who are on your clinical teams? So there's multiple different models, there's many models and many different teammates as the stars in the sky it appears. So are you solo? Are you by yourself? Are you going to be just a medication manager and prescriber? Are you going to do that as well as therapy? Are you going to refer out for therapy? Do you have a multidisciplinary team? Do you have nursing stock? Do you have nursing assistant? Do you have CNAs and CMAs? Do you have counselors and therapists involved? Social workers, case managers, front office staff? All these things though it may not appear important, are important when you think about the patient experience and how the person is coming in to you for help is being addressed and maybe what they're saying. So it's important to know for yourself who's a part of that team and part of your team and a patient's team, as well as their interaction and their roles and that patient's recover in that treatment. So because of that, you can either have some false starts, but also you have some really good care. Again, everybody's role in a treatment team is important because that little piece is getting somebody hopefully doing better. So all staff really need to be on the same page. They all need to know that they are part of the care for a patient, they're part of the process and that no position or role is minimum. But it's always a focus on what the patients need., what can we do and help the patient get better? So because of that, especially in a multidisciplinary teams or even if you have referred out that you have regular process reviews as well as interactions with those different teammates and different parts of the team structure to make sure that you're on the same page, that things aren't being missed and then falling through the cracks. Moving on to objective two, identifying important components of history-taking for those with opioid disorders. So there's always a good thorough medical history is very important. Reviewing symptoms, reviewing labs, relationships with medical symptoms, and their substance use for trying to potentially get a chronology, a temporality, what came first? Chicken or the egg. Are they happening on at the same time? Have they had this problem before or just their symptoms that can definitely help you understand the patient better, as well as what they've been through, what they've done for treatment, be it a medical intervention, a surgical intervention. Getting a thorough medical history is not just part of documentation and billing, but also to help you understand the patient, where they've been, what they've been through, what their body has been through. It's so important to have a good understanding of that. But the folks that are able to give birth in a understanding where they are. Are they trying to have more children or not? Are they unfortunately infertile or not? Again, those maybe important key components both for their psychological and physical health, but also for you. If somebody gets pregnant what are we going to do? Are you are planning on getting pregnant? If not, what are you doing to prevent that? It's also an important part of this processing in questions. One thing that is often overlooked is the middle choppers. Those white teeth you got there. When folks are tend to having significant issues, we're overlooking reaching care for ourselves. We're probably not going to the doctor regularly. You're probably not having the best nutrition, probably not taking care of ourselves the way we should. One of the things that even as medical professionals, physicians sometimes overlook is also that dental care, so encouraging, addressing where the status is with your dental hygiene. Have you gone to the MSRE or not? How long has it been? If they start feeling better, that's going to be an important aspect if there is tremendous amount of pain or they're having a lot of issues with eating, that's going to possibly interfere and interact with your treatments. So it's important to keep that in mind, but not have overlooked portion of their medical history. Of course, it goes without saying the medications. What are you doing? What have you not? What reactions have you had? How long have you been on medications? But a lot of folks they'll say that my love x, y, z didn't work. It just didn't work. Okay. You may take that place value. How long did you take that medicine? I took it for a day, it didn't do anything, so it didn't work. We know that most medications don't work within a day. You've got to give it time. So somebody did not have a good bit therapeutic trial, don't necessarily prove that the baby out about water. We may be able to revisit that with some coaching, with some education on the patient's stamp like that this is possibly something that we need to look into. Also important, do they have a history, self-reported or not of losing their medications or having it stolen? Have they ever been in treatment agreements with other providers before they gone through that process? It's also important pieces of the puzzle. As a psychiatrist at the end of the day, obviously dig into the psychiatric history and I think that's so vitally important as well, and so a good psychiatric review of systems. What's going on currently and what's happened in the past has been my medical issues. There may be some timeline issues. Did somebody start using and then develop significant mood disorders or a psychotic disorders or even anxiety disorders, all of these things. Which came first, the chicken or the egg? If we just throw it against the wall and just assume, we may be missing a boat and treating things unnecessarily or the wrong thing. So it's very important to get a good sense for that as well. Have they again been diagnosed in the past before coming to see you? As we mentioned in module two, adverse childhood events and experiences or just trauma in general, how they'd been through significant issues in life that affect how they respond and how they react. Stressors, life is full of stress. Nobody's got a perfect life and if you do, I'm not sure I believe you. So also understanding what things stress them out, what things are beneficial is important, and also can help as far as coping strategies and mechanism in the future. Much like the medication had they tried different things in the past? Have they been an inpatient medically assisted withdrawal? Have they been in a residential programs? Have they been in IOPs or partials? Are they just an outpatient or have they done none of that? They were truly brand-new and naive in the entire system. Understanding that and where they're coming from, potential biases can be very beneficial. Let's see whether psychotropic medications, are they also concurrently on a benzodiazepine? Rather medication is important for you when you're thinking about interactions and treatment. So we're getting these histories to, the last thing I'll say before moving on is, getting these particulars can also help you, especially where they've been on a treatment, outpatient versus inpatient versus residential versus PHP, can also give you a sense if things escalate, if things deteriorate, things don't go where we'd like to go, how open is this patient and possibly getting a next level or a different level of care? If they are staunchly say no, this is all never going do, that's going to be important for you to know to. Maybe use some resistance there or things may need to be I'll handle differently if they're unwilling to say go into a detox because you can't and it's not safe to be managed on outpatient basis. Social family history, again important aspects of the overall good thorough assessment. Family history, as we mentioned in module 2, there's that 50-50 nature nurture component to this disease we call addiction, and so do they have a family history of addiction, especially in primary relatives, mom, dad, brother, sister, kids? It's important to see that picture of loving a family. But again, with the high concurrence of psychiatric disorders and substance use problems and the high genetic heritability of psychiatrical illnesses. Does your family have psychiatric issues? It's also an important question to be asking. So we mark up their source of work. It could be one of those that we take for granted, skip over quickly, but again, these details give us a sense of who this person is, where they have been, what they want to do, what their goals and aspirations are, and that's vitally important in my opinion in order to fully treat them, fully recognize this full character that we have front of us. They are not just a substance use patient. They are a patient that has substance use, yes, but they're also among them. They're our college graduate. They are someone who loves giving back to the community or volunteering, those are important aspects to understand what's driving, what is making up who they are. So these components are not something to check off a check box. It's important to understand who we are because we also may impact and help us in the future in treatment. Of course, a biggie, the substance use history. What patterns are present? Are they a long-term user with significant certain patterns? Are they just starting out on their addiction journey? So I'm asking about all kinds of things and not just opioids, but other substances as well. So obviously opioids. That's prescription. This is elicit. Things like heroin, but also even if it is prescription, is it prescribed to you? Are you getting it from somebody else? Are you getting what you think is a prescription? Or has it actually been pressed? Do you know that or not. Also the concurrent substances, don't forget alcohol and tobacco have killed more folks yearly than even our opioid epidemic. So those are really important to ask about as well, for the safety of our patients. Of course, marijuana being a big topic as far as different states having different legal statuses of it and different perceptions and perspectives from patients as far as they're on going on marijuana use. So it's important to not discount but also get a full good history of all the substances they may use. That includes when did you first use anything? When did you first use each individual substance? Is there patterns that are emerging? Are you using a particular frequency, a particular amount, a particular way? Have you progressed in your use? Did you start out with just pills and now we're injecting and now mainline injecting? Did you jump into injecting? It's important to know those patterns as well. Obviously assessing recent use, how much. When you sit them, any withdrawals for somebody actually in front of you. Are they suffering from cravings? Again, that's a big component as we've mentioned. Put this on withdrawal and trying to prevent withdraw but the cravings and the control afterwards are just as important if not more so than getting somebody through withdrawal. The cravings and lack of control is going what's going to have them going back into use. So again, all these components of the use history are important. Also is there a relapse treatment? As we mentioned with their previous history, have they tried multiple times and have had multiple relapses? What's their longest period of time in abstinence? They may have unfortunately slipped and maybe relapsed, what happened? What was going on? Could they put their finger on exactly what happened or if it was totally out of the blue? When they were successful, also, what was helping them be successful. Sometimes people overlook those successes they've had and think of just because well that was then, it's not going to work now. That's not necessarily true either. So in doing those things, we can sometimes identify triggers and choose to folks having their relapse. Treatment episodes, how have they done in the past? Have they had good responses to different types of treatments? Have they gone to treatment and absolutely hated it? That's important as well. That didn't do well for me. I didn't get anything out of that. I didn't like it because of blank. Figuring out what blank is can help you then modify your treatment on going forward. Especially when it comes to support groups, the anonymous groups. Folks can have a very strong opinion about those groups. However, some of those opinions may be influenced by a single episode. So it's good to know how and how frequently they've been using those. So as we discussed the module 1 especially on the consequences of their substance use. That is sometimes the breaking point when somebody goes from dabbling and experimenting into having significant issues and used to the effects and consequences of our use for ourselves. That includes physiological effects. Again, as we mentioned in module 2 that tolerance and intoxication as withdrawal of these things. Had they experienced those things? Had they not? Have they had major issues when they come off or they had complications. Have they had an overdosed when they were in the ICU. Something had happened and they they fell and hit their head and started having seizures. All these complications coming from these [inaudible] and also the other consequences, has it impaired your functioning? Have you started doing things that you wouldn't normally do? There's unusual behaviors. Have you started nodding off? Have you found yourself withdrawing and having some negative stuff. Have you started having problems with work family, with your regular family, with paying bills, with the legal? All those issues, all those consequences are important to understand and get a understanding or handle of this person because again, that may be some triggers and also, some hooks that we can have to help and get them motivated and getting into recovery and treatment. Now again, different clinics may have different policies and protocols for documenting and stuff. So all these components may look differently depending on where you go. But remember, covering the process and changing behaviors, changing mindsets into a more recovery-oriented habit takes time. It's not going to happen overnight. Also, relaying that during this evaluation of the patient, we have empathic motivational interview in files. So substance use screening for diagnosis and assessment. So goals, so we're trying to identify those individuals that are at risk with active substance use, with other substances that may need some additional evaluation or additional levels of care. Diagnosing patients who meet criteria for substance use disorder. Developing that recommendation, that plan, that treatment mindset, that [inaudible] that we're going to implement to get somebody into recovery. As I've hopefully have been reiterating and iterating over and over again, the biopsychosocial needs of the patient. Again, this is not just a patient that has a substance use problem. This is a full person with goals, issues, and problems and also strengths and character and people that care about them. So sometimes in the full process or the initial direction, we do use screening tools for different substances. So there is a drug abuse screening test the (DAST-10). There's specific things for withdrawal like the COWS that we mentioned earlier. For alcohol, there's things like the AUDIT, the alcohol use disorders identification test, and for obviously as a psychiatrist, [inaudible] , scales for things like depression, the PHQ-9. There's also scales for anxiety like the GAD-7. There's multiple ways of getting some of this information both in an interview one-on-one with the patient as well as from the patient themselves without interaction. But it's all information and information is good. It's also as we said we had yet to get a handle on co-occurring substance because they're prevalent on at-least roughly 10 percent of those have, if not more so, co-occurring substance use disorders, on top of therapies and all this. Of course, those may interfere and impact your treatment on someone who has [inaudible] So folks, they can't just use the CAGE questionnaire. Well, that's for alcohol. Well, sometimes the CAGE can fail to notify a lot of folks that are at the at-risk drinking level who don't necessarily have any alcohol use disorder, severe moderate level. So it's important that we also speak about those folks that are at the at-risk level. So the CAGE does well for picking up the dependent folks, but the AUDIT uses a better job of picking up books and maybe on the border of the average drinking. As we mentioned, Clinical Opiate Withdrawal Scale, also known as COWS objective scale, I know that's very tiny and blurry to see, but trust me, there are multiple different portions of the scale that you can find online too. But again as the objective scale, with different Likert scaling in there. As far as sunlight there, the pulse rate there, the sweating, restlessness, that pupil size, are they having bone and joint aches? Though they haven't that rhinorrhea, tearing of the eyes. Are they starting to have that GI rumble? Are they starting to have some looser bowels? They're having any kind of tremor shakes? Are they having any angst, anxiety, or irritability? This was the piloerection, goose bumps, and then you can score that and then as you can see, I'm a little less depending on what the score is, where they are in the COWS rating. So obviously when we think about the future, in induction stuff, we definitely have a few warnings to aim for that 5-12 at least but more often or not, probably closer to that 13-24 range. As mentioned, the AUDIT scale for alcohol use with 10 questions. So again, not very long, not green, [inaudible] but it can definitely start picking out so that at risk level is not just the dependent drinkers and okay, just quicker and filling up all questions. But seriously, think about using things like the AUDIT instead. PHQ-9, at the end board, hope it's a little visible for you guys, Patient Help Questionnaire 9 to assess where folks are with regards to depression. Again, getting a sense of where folks are, chicken or egg, it's important. Moving on to our next objective, explain the rationale for the physical exam and as well as labs. So why should we care about a physical exam? Well, hopefully it should be self-explanatory, but it may not. So the physical exam can give us a lot of good information as far as potential medical complications that are happening now, but also medical complications that we keep in mind going forward if somebody has been using it in different manners, or just ramifications of sequelae from somebody's use. Now, maybe with injecting in part. Something else is coming up. Do they have abscesses and things like that that we need to look on. They've been injecting them, then are we listening for murmurs? Are we finding any infective endocarditis issues? It's so vitally important to you to keep in mind the physical exam because it can give us things that a patient may not be aware of themselves that we as physicians and medical providers understand being very serious. So don't overlook a physical exam and document it as such. So as we mentioned in module two, we honestly stay on this line for very long but just continue to remember what the signs of intoxication as well as withdrawal. Remember intoxication can be more of on the depressed side of things. Withdrawal, I like to think about, I'm a pretty big sci-fi nerds Star Wars fan. So think about it like going into hyperdrive. We go from depressed to hyperdrive. So the intoxication withdrawal. Lab testing especially in initial evaluation, it can be beneficial. Sometimes not always done at the very first but definitely recommended again. Data is data is data, that can help us understand where somebody is right now and also potentially things where people are going. So things like a pregnancy test. Folks that are able to bear children, are you currently pregnant or are you not? Urine drug screens. Again, part and parcel of substance treatment is kind of monitoring drug screens you have on the outset. Once again, a piece of information to see if somebody is actually using, but also a talking point and yet if it's still positive, what happens? Drug screen, discuss it right away. But other things can be helpful. CBC, CMP. One thing that is definitely starting to creep back up more and more, especially with more injections nowadays is blood-borne pathogens such as Hepatitis C and HIV. So next objective, describing factors. Are they considering treatment planning to determine if some believe this person's trying to be a good candidate for office-based opioid treatment? Move up. This level of care, what is it? So what goes into it? So some of the factors should be kept in mind when thinking is this patient going to be a good candidate for this type of treatment? So obviously never want to lose their diagnosis. They don't have diagnosis for it, hopefully you're not going to be prescribing for it. Do they have other issues going on? But keep in mind other issues that are going to interfere and potentially make this patient not admissible or able to do this type of work? The physiological state or the high-risk for everybody else, are they not? Stability, insurance, again, the rather big health care. Is trying to offer this treatment going to cause more harm than good? Maybe actually first even harm. Are there available options for these treatment? Are you doing an assessment but you are not going to be the one that's going to get changes type of care? If not, is that care available where they are? Can they actually obtain that too? Does the patient want it? Again, that whole goals thing we mentioned in module two. Is your goal for them being honest or is it there's? Is it shared? If they don't want it, you've got a patient bogus. Just logistical, can somebody actually adhere to the appointments that you are recommending and requiring drug testing recommendations? All the either these are they going to cost, are they able to do that and complete it satisfactorily? So as I mentioned, insurance. It goes to the room when it comes to healthcare coverage, especially here in the states. So it can definitely be state-specific, and vary state by state. So somebody may be coming from out of state and they had great treatment options and insurance coverage from the state they were coming from coming to you. It may not be as good or vice versa. Insurance policies may vary, what types of treatment and how long treatment they are covering. So again, understanding the ins and outs of the patient's insurance and then maybe more than you understand, a lot of times more than I could keep up. So sometimes having, again, part of the treatment team, interdisciplinary team, having somebody who understands, these ins are ins and outs may be beneficial because most policies will cover one or more of the following, can definitely given the healthcare purity laws now. So some may fully cover assessments and detoxes or magnitude wise withdrawal or outpatient treatment. But depending on other factors, they may or may not cover this formulation medication. They may not cover residential. So as sometimes the pain is real as it is, insurances are a big component of the process and other factors to consider. Like I mentioned, can they can actually adhere to this stuff? Are they stable? Are they in a position in life where things outside of them are stable enough where they can be part of it or not? Are they taking other medications that are going to also interfere, such as naltrexone? Honestly, an agonist and antagonist at the same time, you've got to spit on the wind. Are there any other substance like benzos or other sedative-hypnotics that mean to concurrent treatment with medication like buprenorphine. For you and your setting, do you have call coverage? Do you have resources available to adequately provide treatment for this patient? Are there treatment programs available that will accept your referral? If again, this person is been in our treatment for outpatients for X number of times and things have escalated and we need to go to that next level. Are the people are going to accept your referrals? Do you know where these referrals are? Again, is the patient willing to possibly do that? Some general principles before even starting this office-based treatment. Again, first meeting/assessment is to give individual information about what MAT is and the educational part of what we do day in and day out. The proper use of medication, are they diverting it? Are they sharing it? Honestly, that's misuse and we want the patient to only use it for themselves. Avoiding continued drug use and alcohol while in treatment. Again, all these people have some psycho-education and even taught to let you know if at any time other medications are being prescribed to keep in mind. Well now this person is going to be on some more lung blood pressure medicines. So initially they may have some reactions to that. If I don't know if they're on that medication, I may unfortunately wrongly assume maybe they're being over medicated or not using it because I'm seeing them kind of sleepy and soundless. So again, that data, the list of information and communication [inaudible] How was the education of how to safely store the medication? How the patient is going to do that? How they plan on making sure that their medication is not stolen or lost or washed in a washing machine? How many times I've heard that particular story. Doc it was in my pocket and I washed it. What are we going to do about that? During this initial evaluation assessment on principles going forward, are they prepared to be inducted? Do they know that they need to be in mild to moderate withdrawal. Did they assume I could just go from one to the other, back-to-back. These kinds of factors, psycho-education standpoint. So big topic is the concurrent substance use in office-based treatment, is this suitable? What do we do? How should we handle these different scenarios? So alcohol and obviously, again, it's another depressant kind of family as well and being a sedative-hypnotics. So patient should obviously be caution to avoid alcohol use when taking buprenorphine because again they're both depressants, they can both lower things including blood pressures and heart rates. So those that have active or current alcohol use disorders may need to have your medically managed withdrawal, i.e. detox themselves before starting, depending on their level at least maybe cutting back on their alcohol use to prevent interference. So it's also important to assessing again for use, intoxication, withdrawal from sedative-hypnotics. If there are risks for withdrawal seizures, it's important that they get the appropriate level of treatment to make sure that the complicated phenomena do not happen. But also sometimes the new misconception and misnomer and misunderstandings from the folks is that because you're on buprenorphine, it's not going to stop you from having those withdrawal seizures because it is not an anti-epileptic. Patients may say, well, I was going to be okay because I'm taking this medicine. That medicine is not going to be covering for that. So again, that's why initial getting a good substance use history all substance is important. The big one, other drugs, especially things like marijuana and cocaine. So it's not an absolute contraindication to treatment, but it is definitely one of those things to have significant ongoing conversations about and you will have them problem regardless of whether you want to or not. So again, the harm reduction mindset in exploring why they're continuing to use, are they willing to abstain? Are they not? I wish you documenting this discussion. I know you're going to hear a lot of arguments with, well, it's legal on my state. Well, it's illegal on this other state it's a natural product. Again, that is an entirely different lecture that we can have a long discussion about as far as Cannabis use and where it is, but it is a very prominent and prevalence co-occurring substance. So having knowledge about where clinical policies stand for you and your organization are important. But again, knowing that it shouldn't be an absolute contraindication, definitely have folks that had co-occurring cannabis use disorder as well as opioid use disorder. In the process of treating their opioid use disorder with buprenorphine and learning coping strategies and coping mechanisms and the other non-pharmacological parts of the treatment which are important value more so than even medications. They found that they didn't need, they didn't require, they didn't desire to use as much of the substances as they thought. It may turn out to be a good thing for them. Nonprescribed medications and outpatient treatment. Again, they may benefit from completion of something a more intense like an IOP or even Residential Treatment. Sometimes when they're having co-occurring non prescribed use of other things. But it's also important to know that buprenorphine as a treatment for opioid use disorders and not specifically other drug use disorders. As I mentioned in the previous example, you're treating the opioid use disorder with the buprenorphine, but there was a positive quality that kind of misuse got better. But we were not specifically telling them these people who's been going be treating with cannabis use. So it doesn't have any direct impact on cocaine, amphetamine, cannabis, alcohol use though again, as we said, you may see some reduction, otherwise. Misuse of other stuff especially stimulants. Amphetamines can be pretty prevalent among those with opioid issues. Again, as you can imagine, you can't sometimes interfere with ongoing treatment. Don't ever look prescribed stuff. There's definitely [inaudible] folks talking about gabapentin as well as other substances that folks have. Some folks with quality and prescriptions may have issues as well. So don't look even overlooking prescribed medications. So almost diversionary set of things, examples, so how can we discover, how can we know somebody is diverting? So I was used to make this lab results. If you were sitting up for confirmatory testing, do you find Buprenorphine or Norbuprenorphine as the metabolite in that sample. If not, let me give an indication that the person may or may not be slack of you using the prescribed substance. Is Buprenorphine only in that sample without the presence of Norbuprenorphine could mean that the person was tampering with the sample. Just putting a little bit of a Buprenorphine in the urine to try to mask that they're not using. Is the consistent film have full counts? Again we can have random tool count days bringing pill bottles in, then film strips in the account to see are they matching up your CATs? Are they filling early again? Going back to that PDMP, are they using that to see if they are consistently coming in early? Are they using more than what they're saying or they're not even asking for refills. So how do you manage that? Sometimes we need more frequent testing, sometimes decreasing the dosing intervals, going from a month script back down to a two week script to a week script maybe beneficial. Observing administration of these medications can be important, but also increasing support. Do they need more frequent appointments? Do they need different types of counseling? Do they need more family therapy. Other alternative modalities, maybe [inaudible] as well. Then, if we have specially we're trying to opioid treatment program for either continuing being a mom, initiating Methadone or alternatives maybe the next step. So again, referring to a more intensive levels of care. Again, this goes back to the willingness to comply what we've been talking about but having clear discussions, clear guidelines between you and the patient so that they understand if this happens, we may need to consider alternatives for your safety and for your goal of recovery. So other level of care now include intensive outpatient programmings, partial hospitalization, opioid treatment programs i.e Methadone maintenance programs, in-patients psych facility if they're trying to express self harm or harm to other behaviors at all, even residential the one returned them facilities So actually, the last objective, describing patient selection for full agonist either Methadone or antagonist treatment. So who's most likely to benefit from some Naltrexone. So some of the prognostic indicators that is having, again, a good therapy [inaudible] that is building on that trust that you've established with [inaudible] When they're highly motivated, they want to be on the side of medication, they engage in treatment, have been adherent to the different particulars out of the treatment protocols which you have in place. So they prefer it. Again, patient's preference should always be take into consideration. If they want to be on an antagonist versus an agonist. If again, you're trying to have your goal of one and they have the other, that just sets you up for potential failure. So if they want it and they are appropriate, it's not a bad recommendation. Is there a job preventing them from being on an agonist? So needing to be on an antagonist was important, but able to actually access in paperwork, are they currently asked that [inaudible] towards but still at a pretty high risk of relapse. Did they fail at previous treatments such as obviously continuing to use heroin, nothing improved, they drop out. Was there those kinds of breaks in the treatment? So Methadone gets a bad rep. Methadone can be a very beneficial medication for some folks. Nobody is [inaudible] by the same. So what may work great for one person may work abysmally for the next, and vice versa. So not everyone is cut out for buprenorphine and not everybody's cut out for Methadone. But not to overlook that as a potential option for anybody. So again, if somebody is preferring more of the agonist therapy, Methadone may be a good option. Do they need more of an intense structure with some finite rules and day in and day out structure of observed dosing. Do they prefer having services all in one location? Sometimes, with outpatient's buprenorphine therapy, now you may be the prescriber and they may be getting their therapy from a different location and different provider all together. So some folks may do better because Methadone clinics have the medication as well the therapy in the same facility. Are these people in some unstable psychosocial situations? Are they not able to ensure the security of that medication? Whether that's being homeless or in a conflict from moving from home to home or living in areas where there's frequent break in and they can't secure their belongings, much less their medication. They had co-occurring pain that was not being really adequately treated otherwise and aren't able to abstain from opioids on a partial [inaudible] Have they tried and it's just still not working. So the Treatment Agreement, multi-party releases are often very beneficial for improving the coordination of care. So before getting started with the treatment, again, making goals and expectations clearly defined, clearly understood so that way, there's no misunderstanding, it's in black and white, you both know what's going on. Considering those multi-disciplinary releases, as we mentioned, helps keep everyone on the same page. So using treatment agreements, in my opinion, a very important part because again, it's setting up the framework, it's setting up the dynamic. Both should be successful in this is partnership. So what can a patient expect from you and from the treatment? What are then you can expect from the patient? Again, this is a give and take, this is a partnership so understanding both ends of that spectrum. See information for patients about buprenorphine, that safety should also be included as far as what it is, how it is, safe use of it, as far as you have also a hard copy of it. We've been talking about it, we've been discussing it, we've boldly been communicating it, but you've also got it in your hand. Informed consent as far as being in treatment and you can find some of these tools, I'll have the link in this module. Also, knowing referral sources in the community if they're unable follow this agreements and again, meeting that more in terms of [inaudible] care. Again, some of these examples can be found in the TIP-40 book as well as the website that's on the module there. So Treatment Agreement, some key components. So like most relationships, most appointments, making sure that everybody is arriving on time punctually. If they're consistently late, that's going to make it pretty hard to make the relationship work. Being courteous in the office, not just to you, and this is important, but also to every member of the team as well. So they are just totally smiles and nice to you but they are rude and obstructionists to your clinical staff, that needs to be addressed because again, every part of the staff is important and plays a role in recovery for this patient. So then not becoming intoxicated or under the influence of drugs. Sometimes it may be subtle, but if you pick up on it, having a discussion and say we may need that to reschedule this appointment, it appears that you are under the influence. Now, of course, if you do discover that and making sure that they can get home safely. So if they drove themselves, maybe they have alternatives in placed. Having an agreement that they will not sell, share, or give the medication to others. Again, in the misuse standpoint, this medication is prescribed for this person and this person only. Agreeing not to deal, steal, or conduct other illegal or disruptive activities both on as well as offsite, because being in jail makes it pretty hard to continue this treatment with you. Medications may be provided only during scheduled office visits, you're not going to do in between, you're not going to have a phone call in. That the patient is responsible for the safe storage of the medications. Again, sometimes, we lost them. Stolen medications may not have refills called in, they just call that. Agreeing not to obtain medications with providers, physician, or other sources without talking to you first and then discussing it. Somebody may be going into a surgery but if they don't tell you beforehand that they're going to surgery, that can cause a problem. They may be getting opioids and that treatment provider that's doing the surgery may not know that they're on this. So again, that release for information, that collaboration, knowing that they're going to get potentially medications from other sources is important to you to work through. Then of course, agreeing to follow instructions with the prescription and not taking it into their own hands. A lot of folks will try whether they have experience in tinkering with different dosing, but knowing and telling them that, no, if there's a need for medication adjustments that are going to be made, it's going to be made after a conversation with you as the physician and sometimes, even may not them. So hence, summary, the initial eval is comprised of the significantly important therapeutic alliance that can have [inaudible] Also, obtaining other data for the treatment, planning, and initiation services. So the important concepts, and components, medical history, psychiatric history, substance use history. How you document may vary depending on practice with letters, but the knowledge that you need to obtain from those key areas is so important. Also, don't forget physical exam can tell you what's going on now, but also to continue to keep in mind some of the medical complications in the future that's sequelae from somebody's substance use. So Office-Based Opioid Treatment can be appropriate for the patients that are able to receive this level of care, it can be provided in an outpatient setting. However, some patients may benefit from stabilization either before or even sometimes, during treatment and may need higher levels of care before it's fully therapeutic. Methadone or Naltrexone are also options for medication-assisted therapy and so don't overlook those. I went around when I'm reviewing and discussing treatment recommendations and options, I lay everything out to you so that way, again, patient can have their preference input as far as what they feel is going to be most beneficial to them. Again, you may have recommendations and may disagree. Having that discussions are important too but when you have a patient have [inaudible] if their preference of hearing [inaudible] type their input seriously. Again, that goes back to and helping that therapeutic alliance to get them to do what they want to do. So other folks may be more suitable for one of these other alternatives, and that's okay because even [inaudible] it's not as effective for everybody and may not be appropriate to everybody. So keep an eye on what is important. So I appreciate you listening and hopefully, learned a lot during this module and continue to learn more so on the modules to come. So thank you very much.
