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.