Editor's note: This text-based course is a transcript of the Occupational Therapy's Role In Opioid Recovery Podcast, presented by Monica Robinson, OTD, MS, OT/L, BCMH, FAOTA, and Dennis Cleary, MS, OTD, OTR/L.
- After this course, participants will be able to:
- Compare and contrast how opioid use impacts populations across the life span.
- Describe the unique occupational profile characteristics of heroin and opiate use disorder clients.
- Develop and implement occupation-focused interventions based on evidence for addressing the unique needs of those impacted by opioid use.
Dennis: Welcome, everyone. I am happy that Dr. Monica Robinson from the Ohio State University is with us today on the podcast. We are going to be talking about opioids and occupational therapy. Monica, could you tell us a little bit about your venture into occupational therapy and how you came to speak to us today about opioids?
Monica: When I first became a therapist, I worked in mental health for the first several years and have been interested in mental health throughout my career. Hence I am board certified in mental health occupational therapy. Ohio is one of the epidemic centers for the opioid crisis. My brother-in-law was a city safety director. He often spoke to me about the opioid crisis because I worked at Talbot Hall, The Ohio State University's detox unit. More and more people were coming in with opioid use disorder. I often talked to him about what the city was doing to address this issue. As a member of AOTA's committee on opioid use disorders, I have continued my interest in this topic and subsequently became the chair of that ad hoc committee. We are trying to help occupational therapists identify how they can work with individuals with substance use disorder and recover from pain.
Dennis: Can you talk about some of your history with working with this population? When you first started, did the patients have similar issues around opioids or other street medications?
Monica: This is an interesting conversation. In the 1970s, there was an increase in the use of heroin. And then, when I was practicing, crack was the substance of choice. People are dying from using these substances at unprecedented rates, unlike in the 70s, 80s, and early 90s, due to the addition of fentanyl and carfentanil into the drugs.
Dennis: My oldest brother, Rick, passed away a few years ago but had schizophrenia and grew up in the 70s. There were undoubtedly street drugs as part of that. What is the connection between mental health diagnoses and the opioid crisis currently?
Monica: One of the critical aspects of substance use disorder is the genetic link. The other component is considering what diagnoses are more likely to use substances. Bipolar disorder has a very high link to substance use disorder, as do individuals with attention deficit disorder. Individuals that suffer from anxiety may self-medicate to manage their anxiety and depression.
Dennis: As you said, Ohio is at the forefront of the opioid pandemic. What are the numbers that we're seeing in this population?
Monica: Specific states have more issues with the opioid crisis than others. Ohio is a state of significant concern, as are West Virginia, New Hampshire, Massachusetts, and Maryland. These all seem to be states where the epidemic is concentrated. The CDC National Center for Health Statistics indicated an increase in overdoses by 28.5% during the COVID pandemic from April 2020 to April 2021. These numbers are unprecedented compared to the previous year during that same span. The epidemic has had a significant impact on the increase in overdose deaths.
Dennis: Can you speculate as to why that might be?
Monica: I cannot speak to what that might be, but certainly, there's been plenty of research that has demonstrated that mental health deteriorated in many populations during this time.
Dennis: My first degree was in journalism. I was in college at the beginning of the HIV/AIDS pandemic. I worked for the college newspaper and went to the Department of Health to talk to them about this crisis. I was worried about using the correct language as I wanted to support individuals with HIV/AIDS. Similar to this opioid crisis, we want to use the correct terminology. Would you mind going over some basic vocabulary and what language we should use when referring to patients, family members, or children who might be dealing with this?
Monica: I'm so glad you brought this up, as I am sensitive to language related to any substance use disorder. Stigma about people with substance use disorder might include inaccurate or unfounded thoughts, and it stereotypes individuals. Individuals may not be willing to seek treatment because of the stereotyping language. Stigmatizing language can negatively influence their seeking and receiving healthcare and ultimately being in recovery.
Words like a drug addict, user, addict, junkie, substance or drug abuser, former addict, recovering addict, drunk, and alcoholic are all stigmatizing terms. We want to try to avoid these. It's more popular currently to use language like substance use and the descriptor of mild, moderate, or severe, regardless of the substance of choice. I often use substance use disorder or opioid use disorder. I have also been known to use heroin use disorder. Even to this day, I'll read in the medical record, and they'll write "alcoholic" or "heroin addict." Using person-first language is important. You would use something like a person with a substance use disorder. It has a more neutral tone and doesn't define the person as the diagnosis.
Dennis: I was fortunate to attend a Canadian Occupational Therapy Association meeting. I remember talking to a young occupational therapist who is Canadian trained and has an American fiance. She was interested in moving to the United States and being an occupational therapist. Her area of practice was community mental health, specifically heroin substance users. As part of the team she was on, she provided heroin to users in Canada, one of their interventions to try to decrease crime and increase safety. With this program, individuals were not overdosing as much, and if they did, they had access to medical care. How are we as a country compared to that?
Monica: This is called "clean use." Clean heroin is not cut with fentanyl or other substances, reducing the risk of death. This is similar to the 1970s when they didn't have other substances added to the heroin to the same extent. Clean needle exchange and clean places to use substances are probably as far as our country goes, and still, this is very controversial. And a few places have sites where people can use their substance of choice and receive care, recommendations, or services for recovery if they want that. They also test the substance before they use it.
Dennis: From a social medicine standpoint, community acceptance of substance use is very different. Canada also has a higher percentage of therapists working in community mental health, and specifically mental health within inpatient settings. So she should look closely at the state she wishes to move to see the services provided.
Monica: Yes, it depends on the legislature and policies of the state and to what extent they provide more broad approaches to the care. It could be specific to a state or a region.
Dennis: A couple of Ohio State University students died of Adderall laced with fentanyl. It was tragic for everyone.
Monica: Well, it was interesting that you said Adderall. We are seeing fentanyl mixed into many different substances, especially meth. We're seeing more individuals using meth than heroin than three or four years ago, as it's cheaper.
Dennis: Gotcha. Is meth also cheaper than opioids?
Monica: Meth is a stimulant and cheaper than heroin. They are both more affordable than any prescription pill.
Dennis: As occupational therapists, how are we approaching this problem? If we're looking at occupations, how are we supporting them?
Monica: I'd like to start with how I approach clients. I begin by looking at the occupational profile. Rigg and Monnat (2015), in a large study (10,000 subjects), compared characteristics of prescription drug-only users, heroin-only users, and then polysubstance use. They found that these individuals had different features, which can help us target our treatments.
For example, prescription-only substance users typically use opioids for pain management. They also tend to be engaged in church and their community, live in a household with their children in rural or suburban areas, and have higher incomes. They have full-time jobs and predominantly use pain pills for pain and maybe a mood disorder. Whereas heroin-only or polysubstance users tend to have poor health outcomes. They're more likely not to have a social network or custody of their children. They might be manual laborers, in sales or the food industry, or unemployed. They're more likely to seek the emergency room for healthcare than have a primary care provider. Looking at these two different populations allows you to think about how you will approach the occupational profile and work with that individual.
Using the Occupational Therapy Practice Framework, I like to look at the context of their personal and environmental factors, including where they physically live, their social supports, and their attitude towards recovery. This is foundational when deciding the course of treatment I might do with that individual. I predominantly work with individuals that are polysubstance users.
Dennis: You're talking about multiple substances?
Monica: Yes, polysubstance is multiple substances. They may use an opioid and various street drugs, like amphetamines, cocaine, and alcohol. Opioid use disorder is almost an occupation in and of itself in that the individuals often spend their time seeking, using, and feeling the effects of the drug of choice. The duration of a street drug may be much shorter than a prescription pill, so seeking the drug may be all-consuming. They may also participate in illicit activities to obtain money and have a criminal record. And often, these substances are tainted with fentanyl.
My primary approach to working with this population is working on a schedule and a routine. Questions can be as basic as when you go to bed, wake up, eat, and have meals. We can review the basics of scheduling a routine, as their previous schedule focused on drug use and misuse.
Dennis: For those that do not have a home or an apartment, where do you start with a routine?
Monica: That's a good question. People without stable housing must be discharged to inpatient rehab or community-based centers funded through Medicaid after detox. Secure housing is one of our objectives. Even if they have somewhere to go, they may live with someone using or supplying them with the drugs. This is going to be a significant problem for sustained recovery. Ideally, we want to get them out of that environment and start a routine. The routine can be simple: going to a support meeting where they can get free meals. It can also be basic routines around sleeping, eating, and attending meetings and outpatient appointments.
Dennis: You mentioned supportive meetings. I think people have heard of Alcoholics Anonymous and other similar organizations. Have those changed in the last 20 years?
Monica: They haven't changed their philosophy. In the last five years, a fantastic Cochran study found a strong, efficacious base for these peer support programs. They found peer support and accountability to be productive. It doesn't matter if they're using the AA or NA model or if they're using some other non-spiritually based models. They all were equally efficacious in holding someone responsible and accountable for the recovery and knowing they were not going through this alone.
Dennis: When working on treatment teams with nurses, social workers, and physicians, how do we delineate our role as occupational therapists?
Monica: That's a great question. When we first became involved in the detox unit, Dr. Weaver and I took a mindful approach to what services we provided. We identified what services were being provided and where there were gaps. We also looked at the Occupational Therapy Practice Framework (OTPF) to inform how we developed our groups. We also looked at evidence-based research to see where occupational therapy was most effective in recovery. We looked at our clients' occupational dysfunction and lack of structure in their life, like possibly not being engaged in employment.
We chose to step away from the drug recovery side and look at how to boost their occupations. If they had trouble filling their time, we looked at leisure or work exploration, sleep hygiene, value exploration, what was important to them, and where their values fell.
We also took from Wilcox the idea of belonging and how to support that. We know from a social context that if someone feels like they belong, as in the AA and NA models, they are more likely sustain recovery. We stepped away from how to manage triggers, for example, and taught them skills within the context of the OTPF and occupations.
Dennis: You were trying to help them identify some strengths and build on those?
Dennis: Related to that, I think about parents that are substance users. Can you talk about how that complicates or disincentivizes their ability to seek treatment?
Monica: I am going to step to the left of that question and think about OTs working in recovery. Most of my clients have lost custody of their children, or their kids are with their parents. Thus, their main goal is to get custody of their children. I walk them back and say, "Let's try to string two days together and get visitation rights back."
Some mothers are pregnant and have children that have natal abstinence syndrome (NAS). Opioid use disorder occurs across the lifespan. In 2019, every 15 minutes, a baby was born suffering from opioid withdrawal, NAS, or opioid withdrawal syndrome. This is becoming a significant issue for those working in children's hospitals and NICUs. These children have severe symptoms, and they are essentially inconsolable. Many of these children end up in the foster care system with an unfamiliar family, or it might be with a kinship caregiver. We may encounter these parents in acute care hospitals, NICUs, and school systems. Many kids suffering from developmental issues, like attention deficit disorder, are now being identified as being born with a substance in their system.
Dennis: I am sure this can be pretty challenging. With your mental health background, how can we best support a child in that situation that is not judgemental towards the parent?
Monica: As practitioners, we assume that the caregiver is a parent, and we don't consider that the child may be in foster or kinship care and the challenges that come with that. All practitioners should have training in trauma-informed care to help these children because they have endured a lot of physical and social damage.
Dennis: Mental health first aid is another training in which you can be certified as an occupational therapist.
Monica: I'm glad you mentioned that. I am certified in mental health first aid, and it's imperative to have this training when working with these children.
Dennis: Are Ohio State students trained in mental health first aid?
Monica: They're being trained in the youth version of mental health first aid for adolescents.
Dennis: Can you discuss how youth injuries may lead to a prescription opioid and how that can cause problems down the road?
Monica: There was a concern that youth had too much access to prescription opioids. Indeed, that can happen, and children can quickly become addicted to substances, particularly opioids. Those working in a school system, like teachers and athletic trainers, need to be mindful of ways to deal with pain in youths. Another concern is that once they become addicted, they may start taking drugs they find elsewhere, like at grandma and grandpa's house. Those types of medications need to be locked up.
There were "candy parties" where kids would bring prescription medications and place them in a candy dish. They would then take turns taking the medicines to see their effect. We know that youth don't always make the best decisions, so there's a lot of concern with youth and addiction. Additionally, the genetic component is a concern.
Dennis: You were a college and a professional athlete in field hockey if I'm not mistaken. Getting more young women (and men) involved in sports is terrific. However, these kids can feel a lot of pressure to do well in their sport, especially if it helps them finance college.
Back to genetic factors for a moment, is that a concern for an individual if a sibling or parent has issues around substance use?
Monica: At least half of the people susceptible to drug addiction can be linked to genetics. If you have a parent with a substance use disorder, you have a 50% chance of having a substance use disorder. The genetic connection is not as related to siblings as the direct bloodline with your parents and grandparents. And if you have a parent or grandparent on both sides of the family, that increases your risk substantially.
Dennis: Is that nature or nurture? I'm not familiar with the literature in terms of that.
Monica: Recent science says there is a genetic link, but substance use exposure can increase the likelihood of using. I've had clients whose parents shot them up when they were in elementary school and others when they were in high school. Though it is appalling to hear these stories, it's not unheard of for parents introducing substances to children and young adults.
Dennis: More states are legalizing medical and recreational marijuana. I believe Ohio now has legal medical marijuana.
Dennis: Recreational is not legal here yet. Have you seen any uptick or any correlation with other drug use because of this?
Monica: No, I have not seen any change in substance use. While plenty of research says marijuana is a gateway drug to other illicit drugs, I don't know if they have found this connection. Someone that uses heroin may be more likely to have smoked marijuana, but did smoking marijuana lead to heroin use? I haven't seen any evidence that has strongly linked this.
Dennis: What about pain and the use of opioids? I have back pain, and my back pain gets better when I do my stretches and strengthening exercises, but I'm not always great about doing those back exercises. Can you talk about occupational therapy's role in pain and how we deal with it?
Monica: Those with chronic pain conditions are a significant population for OTs to use non-pharmaceutical approaches to managing pain as the first step. When occupational therapists are working with pain, one of the things I suggest is to do an occupational profile as usual but also to take a pain history of pain. You can then match what activities caused the pain and what activities mitigated the pain.
There are a variety of different population-specific pain assessments that OTs can use that are accessible online. Additionally, models like the PEO (person-environment-occupation), MOHO (The Model of Human Occupation), and the COPM (Canadian Occupational Performance Measure) are all assessments that are very helpful in addressing pain.
Non-pharmacological interventions like heat and cold, vibration, guided imagery, relaxation, cognitive behavioral techniques, expressive writing, and movement activities like pilates, yoga, and Tai Chi have all been efficacious. One of the most effective techniques, if people take the time to do it, is mindfulness-based chronic pain management training. It typically takes about 13 weeks to be trained in this intervention.
Dennis: What individual treatment or groups do you run?
Monica: I like to run meaningful groups looking at leisure engagement. Individuals often find barriers as to why they can't engage in something. In one of the groups, we discuss obstacles and come up with solutions. For example, if money is a barrier, they identify the day the city's museum, zoo, and transportation are free. This activity seems helpful to the clients because they're coming up with activities and solutions they can relate to as a group.
We also have leisure interest surveys looking at activities in which they used to participate and those they wanted to attend in the future. And by giving them a list of activities, they often discover new activities they hadn't thought of, for example, singing or playing the guitar. Many in Ohio like to fish.
Dennis: You give them fishing lines and bait?
Monica: Right. In another group, we address sleep. Clients like this because sleep and rest are disrupted when using substances. Those that use opioids tend to be awake for days at a time, whereas those with alcohol use disorder pass out instead of "going to bed." Then, once you stop using substances, your sleep is still disrupted but differently. Clients find education and sleep hygiene helpful.
We also do a leisure exploration group to help them find what is important to them. This is a fun group. We have them outline their hands on a sheet of paper with one hand listing things they want to let go and, on the other hand, something they want to keep. Instead of putting words on their hands, they draw images to tap into their sense of self. We share with them that they might want to hold on to certain friends and family, and others may want to let go as they are the source of substance use. It is an interesting way of looking at their values very concretely. It is holding onto self-respect and letting go of anger and shame. It could be a feeling, a thought, or a place. Even my guys that do not like to "craft" like this activity. We play music, and they talk amongst themselves.
A belonging group can teach them that belonging isn't just with people; it could be a sense of community like being a Buckeye. You live in Indiana, but you're still a Buckeye. We can walk in nature as this also gives a sense of belonging. The spiritual aspect of praying may also help someone feel like they belong. We can teach clients that there are other ways of belonging and have them share what belonging means and how they can foster that once they leave.
Dennis: Great. I also appreciate having people draw those images instead of cutting them out of the magazine. As you know, I have a long-term distaste for the magazine picture collage. How do you manage when you're working with clients who don't see their substance use as a problem?
Monica: There are a couple of ways. Sometimes in individual treatments, we'll explore how substance use has helped and supported them. We discuss the benefits of using and some of the things they have lost. People come to recovery when they're ready. So there isn't much anyone can say or do to help someone succeed and sustain their recovery. I have to be okay with someone not being ready. I can't be more ready than they are. Does that make sense? I can hold a candle for them and be a shining light, but I can't drag them to recovery.
Dennis: Sure. What would you say are the most rewarding and the most challenging parts of working with this population?
Monica: The most rewarding part is that I can make a difference. Occupational therapy is uniquely positioned to assist with examining and reestablishing those occupations, habits, behaviors, routines, roles, and identities that are so deeply meaningful to the individuals. Seeing the light bulb go off and our clients committed to recovery is extremely rewarding. What's difficult is seeing the same clients or sadly hearing that they passed from an overdose. Everyone has a right to recovery and treatment, and we don't have enough long-term treatment sites for folks.
Dennis: Does your workplace bill for OT services, or is that part of the room rate?
Monica: Our services are based on the room rate. Some places bill under Medicare Part B, and most places bill as a bed rate for occupational therapy.
Dennis: Services are reimbursed per day that the individual is there.
Dennis: There's some freedom that the facility administration has regarding who they will hire. They need nurses and physicians but may also hire OTs and social workers.
Monica: There was a substance recovery place in Columbus deciding between hiring a clinical nurse practitioner or an OT. They opted for an occupational therapist because of the services that we can provide. A lot of my service involves level one fieldwork sites. Students come into treatments with me but then continue the treatments once they're done with the rotations.
Dennis: Ohio State's had several students that have pursued mental health careers, even in substance abuse, because of those experiences. What advice do you have for OT practitioners interested in learning more about this population or who want to pursue this line of work?
Monica: There's a role for occupational therapists across the lifespan for addressing the opioid crisis, even for children, adolescents, and those people with pain. There is a rule for us throughout. If you're interested in working in mental health, I would advocate for having an occupational therapist in a mental health setting. For example, we've approached settings and recommended that they embed an occupational therapist in their behavioral health setting.
Occupational therapists have to be okay with having a job title that might not say occupational therapist. It might be a health coach, but you're an occupational therapist acting as a health coach and doing occupational therapy. Sometimes sites don't have an occupational therapist job opening but an opening for a healthcare provider.
Dennis: It's about being able to confidently articulate the value and beauty of our profession. My primary work is with employment for young adults with intellectual disabilities. I knew a person in Florida that ran Goodwill or something similar. He had an OT that applied off the street, and he hired them because I talked so much about how great OT is with that population. The value of occupation and how we spend our time is what matters.
Monica: A short article titled Recovery with Purpose: Occupational Therapy and Drug and Alcohol Abuse from AOTA says, "Occupational therapy goes beyond helping clients to stop drug use. It prepares clients to fill whatever void the substance leaves behind with productive occupations." We bring a distinctive value to the table.
Dennis: Well, Dr. Robinson, thank you so much. I've enjoyed our time together and know our listeners also have.
Monica: Thank you, Dennis. It's been a joy to have this conversation with you.
Please refer to the outline and handout.
Robinson, M., and Cleary, D. (2022). Occupational therapy's role in opioid recovery podcast. OccupationalTherapy.com, Article 5525. Available at www.occupationaltherapy.com