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Mary Lee Roberts, PhD, RN

Washington State University

Informing Recovery-Oriented Care:

A Theory of the Transition from Pain Initiation to Medication-Assisted

Treatment

Research Team

Marian Wilson, PhD, MPH, RN-BCAssistant Professor, WSU College of Nursing

Michele Rose Shaw, PhD, RNAssociate Professor, WSU College of Nursing

Mary Lee Roberts, PhD, RNResearch Associate, WSU College of Nursing

No conflicts of interest

Educational Objectives:Educational Objectives:Educational Objectives:Educational Objectives:

• Relate the unique challenges patients with chronic pain in medication-assisted treatment (MAT) face in their struggle to access resources to support their recovery from opioid use disorder.

• Report how resources such as social support, healthcare services, and pain management therapies can be critical to the recovery of patients with chronic pain in MAT.

• Discuss how new approaches to recovery-oriented care can be developed that address the resources patients with chronic pain in MAT need to successfully recover from opioid use disorder.

(Spencer, 2017)

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Topics addressedTopics addressedTopics addressedTopics addressed: : : :

BackgroundResponse to the opioid crisis/epidemic, medication-assisted treatment.

Our StudyAdults with chronic pain: Journey

from opioid initiation to medication-

assisted treatment.

Recovery-Oriented ResourcesSocial support, healthcare services, pain management.

(Staines, 2017)

I. Background

The Opioid Crisis/Epidemic and Medication-Assisted Treatment for

Opioid Use Disorder.

Chronic Pain and Opioid Misuse)

[CATEG[CATEG[CATEG[CATEG

ORY ORY ORY ORY

NAME]NAME]NAME]NAME]

62.3%62.3%62.3%62.3%

[CATEGOR[CATEGOR[CATEGOR[CATEGOR

Y NAME]Y NAME]Y NAME]Y NAME]

12.9%12.9%12.9%12.9%

Other Other Other Other

24.8% 24.8% 24.8% 24.8%

(e.g. (e.g. (e.g. (e.g.

Relax, Relax, Relax, Relax,

Ease Ease Ease Ease …………

(CDC, 2016; SAMHSA, 2017)

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Overlapping Terms Re: Overlapping Terms Re: Overlapping Terms Re: Overlapping Terms Re: “Problematic Use” “Problematic Use” “Problematic Use” “Problematic Use”

• Misuse/abuse

• Addiction

• Nonmedical/aberrant use

• Physical and psychological dependence

Opioid Misuse: Opioid Misuse: Opioid Misuse: Opioid Misuse:

(Ahmad , Rossen, Spencer, Warner, & Sutton, 2018; CDC, 2016, 2017; NIDA, 2014)

Opioid Use Disorder

(Robinson, S. M., & Adinoff, B., 2016; SAMHSA, 2017, 2015; CDC, 2017)

(HHS Press Office, 2017)

Response to the Opioid Crisis

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Treatment

(Drugrehab.org, 2015; Fingerhood, et al., 2014; Mattick, 2009; NIDA, 2012, Pierce et al., 2016;

President’s commission on combating drug addiction and the opioid crisis, 2017; WHO, 2014)

Medication-Assisted Treatment with Methadone

Treatment

(Bart, G., 2012; Fingerhood, et al., 2014; Mattick, 2009; Spach, D., et al., 2015)

II. Our Study

Living with Persistent Pain:From Opioid Initiation

to Substance Use Treatment

(Wilson, Shaw, & Roberts, 2018)

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Participants:

• 10 adults in medication-assisted treatment (MAT) at an out-patient methadone program who had started taking opioids for pain.

• Grounded theory qualitative approach (Corbin & Strauss, 2015)

• Uncover participants’ perspectives on:• Living with chronic pain

• Addiction and opioid medications

• Working toward recovery in MAT

Research Design:

(Wilson, Shaw, & Roberts, 2018)

� Development of a new theory:

Living with Persistent Pain: Living with Persistent Pain: Living with Persistent Pain: Living with Persistent Pain: From Opioid Initiation to Substance Use Treatment From Opioid Initiation to Substance Use Treatment From Opioid Initiation to Substance Use Treatment From Opioid Initiation to Substance Use Treatment

Study Findings:

(Hackethal, 2017; McCabe & Brady, 2015)

(Wilson, Shaw, & Roberts, 2018)

Core category/overarching theme:Core category/overarching theme:Core category/overarching theme:Core category/overarching theme:

Living with PainLiving with PainLiving with PainLiving with Pain

Study Findings:

(Wilson, Shaw, & Roberts, 2018)

Southeastern Spine Institute, 2018)

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(Wilson, Shaw, & Roberts, 2018)

III. Recovery-Oriented Resources

Social Support, Healthcare Services,

Pain Management

Essential resources for chronic pain patients in MAT at Essential resources for chronic pain patients in MAT at Essential resources for chronic pain patients in MAT at Essential resources for chronic pain patients in MAT at an outan outan outan out----patient methadone program:patient methadone program:patient methadone program:patient methadone program:

1) Social support• Family

• Methadone clinic staff

and peers

2) Healthcare services

3) Pain management

Recovery-Oriented Resources

(New Hampshire Bureau of Drug and Alcohol Services, 2013)

(Wilson, Shaw, & Roberts, 2018)

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And my husband was coming here [methadone program], and he kept telling me for five months, “Get on it [medication-assisted treatment] ‘Cause I’m serious. They saved my life…and it feels like my life is back again. I’m back in my life again.”

Recovery-Oriented Resources:

• Social support from family

“So they [my family] have their ups and their downs where every once in a while I hear, ‘When are you finally going to get off that stuff?’

And I tell ‘em, I might not ever be able to get off that stuff [methadone], so – You know, they don’t understand the maintenance part of the methadone.”

Recovery-Oriented Resources:

• Social support from family

“The methadone clinic staff as well as the patients…we bond in a certain way and share stories about recovery.”

“Here at the methadone clinic, I get support from my counselor. He always asks me every session: ‘Are you okay with your [methadone] levels?’ He just wants me to be okay so I don’t go out and look for anything else [e.g. buy opioids on the street].”

Recovery-Oriented Resources:

• Social support from methadone clinic staff and peers

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“A lot of people seem to get hassled because [I’m] on methadone. I put in for an apartment [and I was] declined to rent because I’m on methadone. And I’m like, I didn’t know you could do that. Isn’t that illegal? Isn’t that discrimination?”

“Stop being so – so frickin’ judgmental. ‘Cause we’re not all, ah – yes, by definition, we are addicts. That doesn’t mean we’re practicing. That doesn’t mean that the pain is going to go away. And it definitely doesn’t mean that we’re a bunch of drug seekers lookin’ to get high.”

Non-Supportive Social Interactions

“Especially being on the methadone program, they [healthcare professionals] automatically think you’re drug seeking or whatever when you you go to the doctor. So that’s probably the biggest barrier.”

Recovery-Oriented Resources:

• Healthcare Services

(healthcare.gov, 2018)

“The first thing he [my provider] told me was, ‘Don’t expect to get anything from me,” pretty much. Which is wrong, I mean, that’s totally wrong. I have a problem with acid reflux. I can’t get past [the stigma] to address all of my pain issues. And I can’t sleep because of the acid reflux.”

“But they [providers and nurses] – everything from going in for a minor cold or something where you might need some antibiotics or something, the way that they respond...I still get those accusatory looks.”

Recovery-Oriented Resources:

• Healthcare Services

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“It [the pain] wasn’t just physical. It was more emotional for me, too, you know?

I suffer from abuse at home – emotional as well as physical and [the opioids] really numbed that. “

Recovery-Oriented Resources:

• Pain Management

(CDC, 2017)

“Here at the methadone program, I’ve gotten answers about what triggers me off [to relapse into illicit opioid use]. My pain triggers me off. And if I can avoid that it helps me to know that.”

“We [methadone patients] have that stigma around us with most doctors. That’s why I usually don’t ask for anything when I talk to the doctor ‘cause I’m not there to get high. I’m there to get well.

But [doctors] don’t understand. And most people who are in pain would agree with me. They don’t care about getting high. They just want to kill the pain.”

Recovery-Oriented Resources:

• Pain Management

“There’s breathing techniques and there’s journaling. The best exercise for my chronic pain is to ride bikes and swim.

Finding the motivation to do it is the biggest thing. You have to be determined to do it.”

Recovery-Oriented Resources:• Pain Management/Alternative Therapies

“Anything that would relieve the pain, especially if it was an [alternative treatment] and not drugs, that would be nice.”

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“If you choose not to give pain a good foundation, it can’t grow. If you’re good at it, you can very easily put it [pain] down to a point where it’s not dominating your life.”

Recovery-Oriented Resources:• Pain Management Strategies

(CDC, 2017)

Summary

Emotional and physical pain were major factors in participants’ struggles with addiction, and negatively impacted their recovery in medication assisted treatment (MAT).

Recovery-oriented resources including social support, healthcare services, and pain management were critically important to participants’ efforts to remain in MAT and overcome opioid use disorder.

Social stigma in healthcare settings can put up barriers to recovery-oriented resources and undermine the health and well-being of patients in MAT living with pain.

Further research is needed on the efficacy of pain management as a recovery-oriented resource for MAT patients.

(Wilson, Shaw, & Roberts, 2018)

Implications for Nurses and Healthcare Professionals: Recovery-oriented Care

• Discuss with patients the specific resources they need to sustain their recovery.

• Ensure that MAT patients with chronic pain have adequate access to healthcare and resources for pain management.

• Educate nurses and providers on social stigma and its impact on the health and well-being of MAT patients with chronic pain.

• Develop therapeutic relationships with chronic pain patients in MAT and support their efforts to access the resources they need to recover from opioid use disorder.

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CONTACT: Mary Lee Roberts, PhD, RN

marylee.roberts@wsu.edu

509-324-7360

References

References

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References