Safe prescribing practices for addictive medications and management of substance use disorders ...

123 Pages·2017·0.86 MB·English

by  Sarah Clarke

Safe prescribing practices
for addictive medications
and management of
substance use disorders in
primary care: A pocket
reference for primary care
providers

Meldon Kahan, MD

Edited by Kate Hardy, MSW and Sarah Clarke, PhD
Version date: November 15, 2017

© 2017 Women’s College Hospital

All rights reserved.
Table of Contents
Acknowledgments ............................................................................. 1
Part I: Working with patients ......................................................... 3
Introduction ........................................................................................... 3
General guidelines ................................................................................ 3
Encouraging behavioural change ....................................................... 4
Trauma-informed care ......................................................................... 7
Part II: Alcohol ................................................................................ 11
Introduction ........................................................................................ 11
Diagnostic continuum of alcohol problems .................................. 12
Screening and identification ............................................................. 16
Diagnosis: At-risk drinking, mild AUD, moderate AUD, severe
AUD .................................................................................................... 20
Management of at-risk drinking and mild AUDs ......................... 21
Management of moderate and severe AUDs ................................ 23
Management of alcohol withdrawal ................................................ 24
Anti-alcohol medications .................................................................. 31
Management of common outpatient alcohol-related problems . 36
Reporting to the Ministry of Transportation ................................. 41
Part III: Opioids .............................................................................. 43
Introduction ........................................................................................ 43
Opioids for acute pain ...................................................................... 44
Initiating opioid therapy for CNCP ................................................ 44
Opioid prescribing protocol ............................................................. 47
Opioid switching ................................................................................ 52
Opioid tapering .................................................................................. 53
Opioid misuse ..................................................................................... 57
Opioid use disorder (OUD) .............................................................. 58
Prescribing buprenorphine/naloxone ............................................. 67
Part IV: Tobacco .............................................................................. 75
Introduction ........................................................................................ 75
Ask about tobacco use ....................................................................... 76
Advise to quit ...................................................................................... 76
Assess willingness to make a quit attempt ...................................... 77
Assist in quit attempt ......................................................................... 78
Arrange follow-up .............................................................................. 82
Part V: Cannabis .............................................................................. 83
Introduction ........................................................................................ 83
Harms associated with cannabis use ................................................ 84
Screening and assessment .................................................................. 87
Managing cannabis use ...................................................................... 88
Cannabis use disorder ........................................................................ 89
Cannabis therapy ................................................................................ 93
Authorizing cannabis therapy ........................................................... 96
Part VI: Benzodiazepines .............................................................. 98
Introduction ........................................................................................ 98
Benzodiazepine therapy ..................................................................... 98
Benzodiazepine tapering ................................................................. 103
Benzodiazepine use disorders ........................................................ 106
References ....................................................................................... 109
Acknowledgments
Mentoring, Education, and Clinical Tools for Addiction: Primary
Care–Hospital Integration (META:PHI) is an ongoing initiative
to improve the experience of addiction care for both patients and
providers. The purpose of this initiative is to set up and
implement care pathways for addiction, foster mentoring
relationships between addiction physicians and other health care
providers, and create and disseminate educational materials for
addiction care. This handbook is intended as a quick-reference
tool for primary care providers to assist them in implementing
best practices for prescribing potentially addictive medications
and managing substance use disorders in primary care.

We thank Dr. Jessika Schaman, who co-authored the cannabis
section, and Leslie Molnar MSW, who co-authored the trauma
section. We also thank those who have given feedback on this
handbook: Dr. Mark Ben-Aron, Dr. Peter Butt, Dr. Delmar
Donald, Dr. Mike Franklyn, Dr. Melissa Holowaty, Dr. Anita
Srivastava, and three anonymous CFPC reviewers.

We gratefully acknowledge funding and support from the
following organizations:
 Adopting Research to Improve Care program (Health
Quality Ontario & Council of Academic Hospitals of
Ontario)
 The College of Family Physicians of Canada
 Toronto Central Local Health Integration Network
 Women’s College Hospital

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Part I: Working with patients
Introduction
A strong therapeutic alliance is integral to helping patients
recover from a substance use disorder. Talking to patients about
their substance use can be challenging for clinicians. This section
briefly outlines some general guidelines for working with patients
with substance use disorders and some therapeutic techniques
that have been shown to be useful in treating patients; clinicians
are encouraged to incorporate these techniques when treating
patients for addiction.

General guidelines
 Be aware of patients’ possible guilt/shame about
addiction.
 Reframe addiction as biomedical problem (“You
have a substance use disorder”) rather than moral
failing (“You are an addict”).
 Be non-judgmental in your approach.
 Encourage patient to take responsibility for getting help
for addiction without blame.
 Understand difficult patient behaviours as manifestations
of illness.
 Patients with substance use disorders tend to be
disorganized, late for appointments, miss
appointments, request urgent appointments, etc.
 Substance use disorders make patients’ lives much
more difficult to control.

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 Use brief intervention techniques to engage patient in
treatment (1):
1. Give feedback from assessment.
2. Inform patient about health risks and offer help.
3. Assess patient’s readiness to change.
4. Negotiate strategies for change.
5. Arrange follow-up.
 Refer patients to psychosocial treatment when indicated.
 Many options for patients to choose from: residential
vs. outpatient, individual vs. group, religious vs.
secular, etc.
 Effective psychosocial treatment models for patients
with substance use disorders include Seeking Safety
(2), structured relapse prevention (3), and cognitive
behavioural therapy (4, 5).

Encouraging behavioural change
When talking to patients about problematic substance use, the
role of the care provider is to inform patients of their options and
express willingness to help in order to enhance the patient’s
motivation. The approach taken for each individual patient
depends on the patient’s current stage of change.

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Stages of change
The transtheoretical model of behaviour change (6) recognizes
five stages of change:
1. Precontemplation
 Not ready to change pattern of substance use.
 May be unaware that their substance use is problematic.
2. Contemplation
 Becoming aware that substance use is problematic.
 Beginning to see some advantages to change.
 Considering making a change in the next six months.
3. Preparation
 Commitment to change.
 Planning, decision-making, goal-setting.
4. Action
 Change in progress.
 Encountering consequences of changing substance use,
both positive (e.g., more energy, improved relationships)
and negative (e.g., withdrawal, boredom).
 Establishing new habits and new lifestyle.
5. Maintenance
 Work to sustain new habits.
 Learn to deal with challenges and setbacks.

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Enhancing motivation
The Center for Substance Abuse Treatment recommends using
different strategies to enhance motivation depending on the
patient’s stage of change (7):
Pre-contemplation Work to establish trusting relationship
Open the door to conversations about substance use
 Present facts
 Express concern
 Ask how patient sees their substance use
 Offer help without pressure

Contemplation Acknowledge difficulty of change
Normalize ambivalence
Explore patient’s reasons for and against making a
change
Explore patient’s values and strengths
Emphasize patient’s free choice
Reiterate help and support

Preparation Work together to create a concrete plan
 What is the goal?
 What are the strategies/tools (e.g., medication,
counselling)?
 What is the timeline?
 What supports will patient use?
 How will patient address barriers/setbacks?

Action See patient frequently to check in and support
engagement
Acknowledge successes and address setbacks
Support change through small steps

Maintenance Acknowledge success
Support healthy lifestyle changes
Maintain contact

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