The Hopioid Program:

A Short-Term Treatment Program for Women Who Are Combating Opioid Addiction

John Barker, An Nguyen, H. Ellie Smith, Jazz White

Department of Occupational and Recreational Therapies, University of Utah

OCTH 6340: Aging & Wellness

Lynn Farley MOT, OTR/L

June 18, 2020

 Introduction

Opioids are medications that are prescribed to treat pain but are addictive and can lead to

overdose and death. “Not taking medications as prescribed can result in poorer health outcomes,

disabilities, hospitalizations, and higher rates of all-cause mortality” (Schwartz et al., 2017, p. 1). Recent

research has shown that drug overdose is now “the leading cause of injury death in the United States”

(Saloner et. al, 2018). According to the Utah Department of Health (2015), the highest prescription opioid

overdose death rates were seen in Utahns ages 45-54 years old for both males and females. However,

women in this age group have a higher rate of prescription opioid overdose deaths. From 2014-2016,

women in Utah accounted for 64% of the overdose deaths that involved gabapentin and a prescription

opioid. (Utah Department of Health, 2018).

The Hopioid program has been designed to assist adults in Utah who are at high risk for overdose

and relapse and to help them understand their readiness to make positive changes and to commit to

making those changes so that they can manage their addiction(s). Hopioid is a term where the words

“hope” and “opioid” come together as one. In the course of this program, participants will engage in

planning for the inevitable challenges that will come up as they prepare for discharge from an opiate

addiction recovery program. Participants will also learn to initiate and sustain actions that will allow them

to better address their substance abuse problems by using the information they learned in the protocol,

over an extended period of time.

Evidence

The need for effective programs to treat opioid addiction is more urgent than ever. In 1999 there

were below 10,000 overdose deaths involving any opioid in the United States, in 2018 there were 46,802

overdose deaths (National Institute on Drug Abuse, 2020). This means that overdose death rates are 4

times higher than they were 20 years ago. Women are 1.5 times more likely than men to use or abuse

prescription medications (Green, 2009). There are a variety of programs and interventions that have been

implemented with persons who are addicted and/or who abuse opioids. As defined by Vestal (2016),

Medication-Assisted Treatment (MAT) is a treatment that uses a synthetic opioid called buprenorphine. It
is taken daily by mouth which blocks cravings and symptoms of physical withdrawal. It has been

effective, but is not easily obtainable and thousands who seek MAT are generally on a waiting list for

close to a year (Vestal, 2016).

Hazelden Betty Fords’ COR-12 (Comprehensive Opioid Response with the 12 Steps approach) is

a program that provides long-term group support therapy for those overcoming opioid addiction

(Hazelden Betty Ford Foundation, n.d.). It also incorporates contingency management and interventions

used by occupational therapists (OT) such as cognitive behavioral therapy and motivational interviewing

techniques. COR-12 involves MAT in providing buprenorphine if it is appropriate and the expectation

that they will have regular attendance to group sessions. The involvement of family, recovery support

groups, and accountability are central parts of the program (Klein & Seppala, 2019). In a study by Klein

& Seppala (2019), 259 patients with opioid use disorder (OUD) were recruited. Of the 259 patients, 91%

of those who remained compliant with their buprenorphine medications were still abstinent one month

after the treatment program. The number of patients who remained abstinent fell to 59% at 6 months post-

discharge. This drop is an expected outcome as relapse is a natural part of the addiction recovery process.

The Hopioid program can be run in as little as four-sessions, and each session has been

developed to inspire, provide tools, strategies, planning, education, and knowledge that a participant in

recovery can continue to apply after they leave a long-term treatment program. Hopioid is an

occupational therapy-based program that incorporates aspects of the Occupational Therapy Practice

Framework (OTPF) in focusing on performance patterns such as habits and routines. It is important that

participants develop healthier habits and behaviors as well as routines that not only promote healthier

routines but involve coping strategies and proper medication management. Client factors such as values

and beliefs will be addressed as well as occupations such as activities of daily living ADLs, instrumental

activities of daily living (IADLs), rest and sleep, education, work, play, leisure, and social participation

(AOTA, 2014). The promotion of health is a key factor involved in the Hopioid Program. A participant's

health, well-being, and quality of life are improved through education, the learning and application of
tertiary prevention strategies, and promoting a healthier lifestyle as defined by the AOTA Position Paper

on Health Promotion and Well-Being (AOTA, 2013).

Program Information

Hopioid has been designed as a health promotion program for middle-aged women who are in

treatment for substance abuse disorder. It is a comprehensive treatment including interventions on

education, training, advocacy, self-advocacy, and preparatory tasks. Client factors, performance patterns,

and performance skills of each participant will be used to create an individualized and occupational based

intervention. This approach is different from the medical model, which primarily relies on

pharmacological interventions that address bodily functions, whereas Hopioid primarily focuses on

engagement in meaningful occupations as a means of creating lasting changes (Palis et. al, 2017). The

Hopioid program will take place in four, one-hour sessions over a span of two weeks. Research shows

that addiction recovery occurs over an extended period of time, spanning many months, sometimes years

(The Recovery Village, 2020). Because this program consists of only four sessions, it will be one

component of a comprehensive plan at a treatment facility center, and will be a requirement to complete

the course before individuals are discharged.

Model/Frame of Reference

The Model of Human Occupation (MOHO) and the Transtheoretical Model (TTM) are

appropriate models for populations with substance abuse disorder. MOHO can help clinicians understand

participant’s volition, habituation, and performance capacity, leading to their occupational identity needs

and occupational adaptation (Taylor, 2017). With the MOHO model, participants will share their health

story using a river metaphor to examine the factors that can facilitate or impede the harmony in their lives

and form a part of a person’s occupational being. The Transtheoretical Model helps a person identify their

readiness for change. The program will help clients move to the action stage through evidence-based and

client specific interventions. The session activities are designed for participants who are in the

contemplation stage (intent to change) or planning stages (taking steps towards changing). Examples of
activities include educating participants about opioids, as well as activities about pharmacological and

nonpharmacological intervention topics.

Program Value

The Hopioid program is client-centered and empowers participants by adopting a holistic

approach. In addition, the program is cost-effective, simple, and evidence-based. Clients take active

ownership as they collaborate with the therapists on a plan to address their situation. Current interventions

for medication adherence can be costly, complex, and ineffective. In addition, physicians often do not

have the time nor the expertise for teaching clients proper behaviors for medication management

adherence (Schwartz, 2017). Learning the skills and strategies can help reduce relapse and recidivism,

thus improving client quality of life and reducing costly medical complications (Stoffel & Moyers, 2004).

Objectives

The overall objective of the Hopioid program is to facilitate participants transition towards the

action stage, as defined in the TTM.

Long Term Goal #1: By the end of the program, 75% of participants will independently adhere to proper

medication management for two consecutive weeks, as prescribed by their physician.

Long Term Goal #2: By the end of the program, participants score on the “Medication & Me” survey

will increase by two points toward the action stage in order to address their substance abuse disorder.

Outcome Evaluation

Prior to the start of the program, participants will complete an adapted “Readiness to Change

Questionnaire” (Hannover et. al, 2001) renamed “Medication & Me” specific to prescription drug abuse.

This survey will be administered one week before the start of the program, one week after the last session

and three months after completion of the program.

In order to measure medication compliance, participants will be interviewed in a welcome

conversation over the phone in which they will be asked about their current medication compliance.

Participants will be interviewed over the phone again upon completion of the program and in coordination

with the three-month follow-up interview.

Session Descriptions

Title: Session #1, Truths and Lies: The Opioid Epidemic (Education)

Short-term-goal #1: By the end of the session, participants will be able to state three facts concerning the

opioid epidemic in the state of Utah.

Short-term-goal #2: By the end of this session, participants will identify their readiness to change

addictive behaviors with new healthy behaviors.

Session Description: The first session of the Hopiate program will be based on the planning stages of the

TTM as well as incorporation of the MOHO model. The planning stage of the TTM is when one is

making the plans and preparations necessary so that they have the tools, strategies, and social support to

maintain their new lifestyle and establish healthier behaviors (Scaffa et al., 2020). Evidence has shown

that group-based educational interventions through lecture or interactive groups have a beneficial impact

on the stages of change as well as lifestyle changes and healthy behaviors (Reusch et al. 2011). This

session will educate patients about opioids, the nature of relapse, and what they can expect to happen on

their journey toward recovery. This session’s purpose is to help participants understand their level of

readiness to change, and increase their volition and internal desires to change. Becoming aware of the

dangers of opioid addiction and building relationships in a support group during this session will create a

foundation for participants through the duration of this program as well as afterward.

At the beginning of the session, the program will be introduced and participants will present

themselves to the group and get to know each other. The education about the overall statistics and issues

of the opioid epidemic in the United State and Utah will be given through the activity called “Truth and a

Lie.” The group will be split into four teams and each team will be given a specific topic with information

regarding opioids. Teams will learn together about their given topics and need to come up with a truth and

a lie for three bits of information. When the teams are ready, the game of “Truth and a Lie” will begin.

One side of the room will represent “Truth” and the other side of the room will represent “Lies”. All

participants will stand up and one team will stand in front of the entire group and give their truths and

lies. Participants who believe the information the team gives is true will walk to the “Truth” side of the
room and those who believe it is a lie will go to the “Lies” side of the room. The correct answer will then

be given by the team. After each team has had the opportunity to present their truths and lies the game

will end. The OTs will pass out a flyer to each participant that summarizes the topics each team was given

during the game and a brief discussion about the topics and the answering of questions will take place to

solidify the session.

After the educational section, the OTs will show the video, Stop the Opidemic: Lizzy’s Story,

made by Utah Department of Health for the Stop The Opidemic campaign. After the video, an open

discussion about Lizzy's Story will take place about the participant’s thoughts, how they might relate to

her, and some differences that they have. Discussion will lead into how relapse is a natural part of

recovery and not to give up and continue applying what they have learned. The OTs will then ask the

following questions: “How has your addiction negatively impacted your life?” and “How can overcoming

your addiction benefit your life?” The OTs will explain how occupations such as activities of daily living

(ADLs), instrumental activities of daily living (IADLs), rest and sleep, education, work, play, leisure, and

social participation can be negatively affected by opioid abuse as well as the positive outcomes of

recovery.

Title: Session #2: Medication Management (IADL: Health Management and Maintenance)

Short-term goal #1: By the end of the session, participants will have created at least three strategies to

help manage their medication.

Short-term goal #2: By the end of the session, participants will have an increased ability and perception

of self to manage their medication, per client report.

Session Description: Session two corresponds with the TTM focusing on participants emotional arousal,

self-reevaluation, and commitment or self-liberation (Scaffa et al., 2020). Types of OT interventions used

during the session include preparatory methods, education, and training (AOTA, 2014). Quality of life

(QOL), self-efficacy, satisfaction, and beliefs about the medications that participants are taking will be

surveyed at baseline and during a follow-up interview. Participants will be coached to complete a

medication diary, consisting of the time medication is taken and which medications are taken each day,
two weeks before the session. During the session, participants will review their medication diary with the

help of the OTs and reflect on their past performance of medication management. Next, the participants

will create at least one Smart, Measurable, Attainable, Realistic and Timely (SMART) goal related to

medication management with the help of the OTs. After, OTs will help participants with generating

strategies in order to reach their goal. The strategies created will consider six different areas including

altering the activity, education, assistive technology, advocacy, environmental modifications, and

securing timely refills. This step will help alter the routines and habits of participants, leading to an

increase in medication management adherence. Lastly, a brief semi-structured exit interview will be

completed over the phone with each participant (Schwartz et al., 2017).

Title: Session # 3: Coping strategies to manage cravings

Short-term goal# 1: By the end of the session, participants will identify five coping strategies for

managing addiction as measured by a worksheet.

Short-term goal #2: By the end of the session, participants will sort their social interactions by order of

importance in their recovery journey as measured by a worksheet.

Session Description: The third session will incorporate the TTM with strategies and interventions aimed

at users in the planning stage of TTM. Education and training are the intervention types used to target the

interventions of health management/maintenance and social participation. Participants will examine their

performance patterns as it pertains to their environmental contexts. The OT will open the session with a

TEDX presentation about shame and how it acts as an obstacle that impedes a person’s recovery journey.

Following the presentation, participants will engage in an activity about shame as the OT includes ideas

taken from the Shame Resilience Theory and Positive Psychology (Brown, 2006).

Next, the participants will receive education and training on actively overcoming their feelings of

shame. After a facilitated discussion about addiction cravings, the OT will oversee an activity in which

the participants identify different coping strategies to combat incidents in which the participant has an

intense craving for their addiction. Cravings never completely go away with an addiction disorder, and

regulating internal stimuli is a change process strategy in the TTM (Tejero et al., 1997). Finally, the
participants will complete an activity that examines the performance patterns of an individual as it relates

to their social environmental context. Peer support is a key component of the recovery process (Bassuk et

al., 2016). The participants will actively sort through their various peer and family relationships in the last

few years as demonstrated by using the “rose, bud, thorn” worksheet as a reference. This activity will be

intended to assist the participants in recognizing their crucial support system for the recovery journey

versus negative influences that impede recovery.

Title: Session 4: Writing Your Health Story

Short-term goal #1: Each participant will identify three assets and three barriers to sobriety in their lives.

Short-term goal #2: Each participant will write her personal health story and submit it to the “Story

Bank” website.

Session Description: The final session of the Hopioid program will incorporate the Kawa Model as an

intervention. The Kawa Model utilizes the premise of a story with a river for people to recognize the

barriers and assets that facilitate or impede the harmony in their lives (Iwama et al., 2009). The

participants will identify each of these aspects in their lives in order to gain insight into where to make

changes so that they can function in the wider context of their environment.

After completing the Kawa Model intervention, participants will be introduced to the Utah

Department of Health “Story Bank” website (Utah Department of Health, n.d.). The “Story Bank” offers a

platform for Utah residents to share their health stories and submit them on the website. The stories are

then organized so that they may be used for future use. The stories are confidential and any identifying

information is only shared after receiving permission from the writer. The idea of the project is to

transform the numbers to faces of real people so that the state legislature can know the human side of

health issues. The stories can also be used for public health promotion surrounding a specific public

health issue. A systematic review by Cicero & Ellis (2017), showed evidence that learning people’s

stories around drug abuse can raise awareness to reasons for addiction that are often unexpected. If

lawmakers can learn the varied reasons that cause drug abuse, then appropriate legislation can be put in

place in order to fund appropriate prevention and intervention measures.

 Submitting personal health stories to the “Story Bank” website will empower participants to

become self-advocates and to potentially connect with legislators who have the power to dedicate funding

to treatment and recovery programs that will address the specific issues related to the reasons that the

participants became and are opioid addicts. These efforts will encourage the health of the participants and

will facilitate more participation in daily life occupations (AOTA, 2014).

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