SUBOXONE AND WELLNESS GROUP AT FAMILY PRACTICE:CHOAS THEORY ADVANCED - Bradley Samuel, Ph.D. Director, Behavioral Health Education Department of ...

SUBOXONE AND WELLNESS GROUP
  AT FAMILY PRACTICE:CHOAS
      THEORY ADVANCED
              Bradley Samuel, Ph.D.
     Director, Behavioral Health Education
  Department of Family & Community Medicine
  University of New Mexico School of Medicine

UNMH Family Practice Clinic

ONE QUESTION WE ALWAYS ASK
 “IF YOU COULD CONSTRUCT A GROUP THAT
WOULD BE HELPFUL AND YOU COULD TALK
FREELY ABOUT YOUR OWN EXPERIENCE
WHAT WOULD THAT GROUP LOOK
LIKE/SOUND LIKE?”

GOALS
• CO-CREATE A MEANINGFUL GROUP
  EXPERIENCE WITH PATIENTS BEING
  PRESCRIBED SUBOXONE IN PRIMARY CARE.
• PROVIDE A SAFE CONTEXT IN WHICH TO
  HONESTLY EXPLORE PAST HISTORY WITH
  ADDICTION, CURRENT USE, AND HOPES FOR
  THE FUTURE…
• PROVIDE A MULTIDISCIPLINARY TRAINING
  EXPERIENCE FOR PSYCHIATRY & FAMILY
  MEDICINE RESIDENTS, PA STUDENTS, AND
  PSYCHOLOGY/ SOCIAL WORK TRAINEES.

LEADERSHIP SKILLS
• PSYCHO-EDUCATION
• ASK QUESTIONS THAT DEEPEN MEANINGFUL
  NARRATIVE
• FOLLOW PROCESS (WHAT IS HAPPENING)
• PROVIDE EMOTIONAL SUPPORT
• MODEL GENEROUS LISTENING (REMEN)
• PROMOTE ENVIRONMENT OF OPENNESS AND
  RESPECT…
• ELICIT STORIES THAT MATTER

FIRST GROUP
•   MARCH 2013
•   CLINIC SOCIAL WORKER & PSYCHOLOGIST
•   NO ONE SHOWED UP
•   WE WERE NOT DISCOURAGED
•   COMMITTED TO BEING PRESENT EVERY
    WEEK UNTIL THE GROUP FROMS

SECOND GROUP
• ONE PARTICIPANT SHOWED UP
• FEMALE
• SINGLE PARENT OF TWO CHILDREN
• LIVING WITH HER MOTHER
• HISTORY OF HEROIN ADDICTION
• SUBOXONE PRESCRIBED AT FP
• HIGHLY MOTIVATED TO “STAY CLEAN”
• HOPES SOMEDAY TO NOT NEED SUBOXONE
• ATTENDED THREE GROUPS AND WAS ONLY PARTICIPANT IN
  ALL THREE/THEN STOPPED COMING
• HAS NOT RELAPSED TO DATE
• MAY BE ATTENDING OTHER GROUPS
• HAS EXPRESSED INTEREST IN RETURNING TO THIS GROUP

PARTICIPANTS
• DIVERSITY IN TERMS OF AGE, GENDER, & ETHNICITY
• ONE COUPLE WITH AMAZING STORIES/TOOK US FOR A
  RIDE/HUSBAND TRIED TO STEAL BENCH IN FRONT OF FP/BOTH
  LOVE OPIATES/DRAMA
• ONE SOCIOPATH WHO TRIED TO SABATOGE GROUP/ASKED TO
  LEAVE
• SEVEN YEAR VETERAN OF SUBOXONE
• TWO YOUNGER WOMEN WHO HAVE NOT ATTENDED FOR
  AWHILE/ONE HAS A NEW BOYFRIEND/THE OTHER HAS A
  TRAUMA STORY UNTOLD IN GROUP
• LOTS OF COMPLEX TRAUMA HISTORY/NARRATIVE GETS TOLD
  IN GROUP/FRAGMENTED/LISTENED TO…
• TWO REGULAR 37 YO MEN/BOTH PLAYING WITH THE MARGINS
  AROUND SUBOXONE/HEROIN/ETOH/MARIJUANA

MORE QUESTIONS WE ASKED
• WHAT WOULD YOU LIKE YOUR DOCTORS TO
  KNOW ABOUT YOU, ADDICTION, HEROIN,
  SUBOXONE?
• IF WE COULD USE THIS GROUP TO
  CONSTRUCT NATIONAL DRUG POLICY, WHAT
  WOULD IT LOOK LIKE?
• WHAT ABOUT THIS GROUP? WHAT HELPS?
  WHAT DON’T WE GET?
• IF YOU WERE ASKED TO TALK TO A
  CLASSROOM FULL OF CHILDREN WHAT
  WOULD YOU SAY?

THE WHITE BOARD
• ASKED FOR A WHITE BOARD
  – COMMUNICATE IDEAS
  – ENHANCE GROUP PARTICIPATION
  – ANYBODY CAN GO UP TO THE BOARD/WRITE
    OR DRAW…
  – MODELS OF ADDICTION AND RECOVERY…

WHAT WOULD YOU LIKE YOUR DOCTOR TO KNOW ABOUT
          YOU? ADDICTION? HEROIN? SUBOXONE?

•   “If it were not for Suboxone, I’d still be stuck on Methadone still continually
    abusing it along with heroin. I’ve been on a a taper for around 2 months now. It
    seems as if no matter how much I increase or decrease from Suboxone I seem to
    feel completely empty within. I tend to self medicate to attempt to void out this
    emptyness within…”
•   “I’d want my doctors to know that though emotions and wants are extreme, the
    reactions probably won’t be. I think honesty is hard to obtain between people in
    average social setting, let alone an interaction with a doctor and patient.”
•   “I would want my Dr. to know that she’s doing an awesome job with me and mor
    discipline will not make me better but it will drive me further away and ultimately
    into full blown use. (eternal locus of control/relational variables)
•   “Punishing an addict for relapsing by withholding treatment is like taking away
    someone’s anti-depressant b/c they are sad. Treating addiction takes patience.
    There is no on/off switch but rather a gradual process of enlightenment.”
•   “Be cautious with NM’s patients. Management of addiction is delicate. Become
    aware of NM’s history with heroin, culture, and addiction.

IF WE COULD USE THIS GROUP TO CONSTRUCT
  NATIONAL DRUG POLICY, WHAT WOULD IT
              LOOK LIKE?
• “Drug policies to help and empower users and addicts instead of
  criminalizing and profiting off these people.”
• “Take it completely out of the criminal justice system. Cigarette
  use has dropped dramatically in a way in never would have if
  cigarettes had been criminalized…”
• “I would de-criminalize drugs in general. Provide more access to
  clean needles. More education and community outreach. This
  would lead to a decrease in the violence throughout the world
  especially in Latin America. The desire to consume in the US is
  insatiable not just drugs but with everything…”
• “Drugs? Recommend policy…All drugs legal! Stop proliferation of
  for-profit prison system, laws tailored to target and subject certain
  demographics and keeping them locked in the system.
  Perpetuating legal death spiral…”

WHAT ABOUT THIS GROUP? WHAT HELPS?
         WHAT DON’T WE GET?
• “I think most people are too insecure to be
  sincere, but this group allows others to be
  vulnerable in a way that is difficult to find.”
• “I thought the way we did introductions today
  where everybody had a chance to speak and
  even felt like they should say a little something
  has the potential to be a very good ritual that I
  could see people looking forward to. Make sure
  each person gets a chance to speak with the
  group’s full attention…”

IF YOU WERE TO TALK TO A CLASSROOM OF
   CHILDREN WHAT WOULD YOU WANT TO SAY?

• “My sense is that people who feel powerless
  to affect their own future will do drugs.”
• “find the sweet spot between
  experimentation and addiction…”
• “A person is a person even if others are trying
  to de-humanize them.”
• “Talking to children about social
  reality…empowerment for children.
  Compassion for others.”

HOW PATIENT’S HAVE DESCRIBED
 THEIR EXPERIENCE ON HEROIN
• “FIRST TIME IN MY LIFE I FELT OK….ALWAYS
  ANXIOUS, ALWAYS SAD…HEROIN MAKES THE
  WORLD GO AWAY…”
• “FAMILY USED/UNCLE FORCED ME TO TAKE
  HEROIN/GREW UP AROUND IT/FAILED IN
  SCHOOL/KNEW I WAS SMART/ENDED UP ON
  THE STREET/INTENSIVE TREAMENT IN SAN
  FRANCISCO/GOT CLEAN/CRAVE IT EVERY
  DAY…”
• “FIRST TIME I FELT CALM AND PEACEFUL WAS
  THE FIRST TIME I USED…”

ASSESSMENT
•   CORE GROUP IS GROWING
•   NEW PARTICIPANTS ALMOST EVERY WEEK
•   PROVIDERS ARE REFERRING TO THE GROUP
•   PARTICIPANTS ARE BONDING WITH ONE ANOTHER AND
    PROVIDING PEER SUPPORT.
•   WE EAT GOOD DONUTS
•   WE PLAY MUSIC
•   PATIENT’S ARE ABLE TO ASSESS THEIR OWN RELAPSE
    PATTERNS
•   PARTICIPANT’S REPORT THEYARE USING TOOLS LEARNED IN
    GROUP TO MAKE CHOICES ABOUT USING.
•   CORE PARTICIPANTS HAVE ASSUMED OWNERSHIP OF THE
    GROUP.