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Lucie Manden: VR is a fantastic intervention for addiction

Lucie Manden has been working for the addiction care Noord Nederland for 11 years, and for the past three years as a Nurse Specialist GGZ. VNN is committed to helping people who experience problems as a result of addiction. Almost 2 years ago, Lucie started implementing the Reducept VR training in her process to help patients regain control over their lives and reduce addictive pain medication. In the interview below, Lucie explains how this has been an impactful experience for her and the patients. 

Can you tell me a little more about your career as a nurse specialist at VNN. You have been a nurse for over 20 years, how did it all start?

I applied for a job at VNN eleven years ago, then I started at the Heroin Treatment Unit in Groningen. I saw many people there with a Heroin and Methadone addiction. Then I transferred to the FACT team here in Leeuwarden. Five years ago I started the training to become a nurse specialist. I started the course because I thought I had a higher plan for myself and that I wanted to develop more. It was through this training that I ended up here in the outpatient clinic. Many people have their lives in order, but they don't have the drugs under control, so they come to me for an appointment. I have been doing this work for three years now. During my studies I had to study and describe a particularity and do a literature study and write a thesis about it. Then I came across quite a lot here that people who have had gastric bypass then become alcohol addicts. I then found out that if you have that link, that actually maybe the gastric bypass and Oxycodone addiction is also made very easy. And so I got a little bit wrapped up in pain management, medication and addiction. In 2018, we also got a lot of referrals about Oxycodone addiction and I kind of raked all of that together and thought, "how can we provide good treatment for these people?" Then I actually started looking into that and that's when I came across Reducept.

I think that's a really great story. And what is your main work goal for your clients right now?

I think quality of life is paramount. Especially when it comes to pain, most people don't acknowledge the addiction nor do they think they belong to our target group. But yet they're arguing with the family doctor, arguing with the pharmacy, they can't handle any more prescribed medication that they have and they're suffering from that. Then they suffer a lot of physical and cognitive complaints, so improving the quality of life is my biggest goal.

Does that happen often, patients arguing with the pharmacy because of disagreements?

Yes. People who take more than they are prescribed, they get their tablets on Monday for up to and including Monday, but then they have finished it on Friday and then they go to the pharmacy and want more pills. And yeah, you don't become a nice people when you're in withdrawal.

Yes, I can understand that.

Sometimes people still underestimate that. And if someone says: you can't have it, then they cross borders, even though they don't want to because it doesn't fit their own character. Sometimes they also threaten: "It's because of you if I'm dead tomorrow." Those are not nice wishes that you get as a pharmacist or as a general practitioner. To stay out of that fight, they are then referred to us, because we have a little more experience with that.

If you could change something in your work process, what would it be?

I would actually like to change something in the work process of GPs and hospitals! I would like to see the prescription of painkillers done with more care and that a GP would refer patients to a hospital sooner rather than later, because they certainly do their best, but that action is taken before the conflict escalates. I would like that very much, because that would make my work a little easier. And in my work process I think it's more about the stigma. People don't consider themselves addicted, because it is prescribed by general practitioners. So if it is prescribed, then it's not my fault, they think. Then I wish there would be a little more attention to that.

I think that's a very good point! What are the common expectations that patients with chronic pain and addiction have when they come to you?

Very often they expect me to have a miracle cure for the pain! That's my first sentence always, "I don't know about pain, that's not my expertise, unfortunately I can't help with that either." Often we are the last station though, hey, people have been to the pain clinic ten times and to all the specialists and are now so conflicted with everyone that they do give in a little. We don't make judgements in addiction care, we have to listen to them, see where we can help and if they don't want to, they don't have to, it's all discussed with them in the treatment plan. So there you have a completely different entrance, which gives you a different working relationship. They actually expect you to help them and support them and I always say that I'll do what I can, and it must also be clear that I don't prescribe more than the dosage.

I guess that's different for everyone then, right?

Definitely! With some you have to go to a clinic and others you can do it on an outpatient basis. Some people switch to another drug, others reduce it. Then you start looking very much individually to see what fits. We also don't just look at the patients, you also look at the environment. Perhaps the partner is the facilitator in the use, so you also look at what is going well in life and focus on that instead of just talking about what is not going well.

Lucie vnn

I have noticed that many patients complain that they hardly get any information about pain in the medical institution. Can you relate to that?

I think so, I've also looked into it. I also attended a course with Louis Zantema and I also have his book. I think a lot of people are not yet aware of how pain works and that opiates, because that's what we often talk about, don't help at all or even make the pain worse. That's a lack and also a bit of a mission for me, to at least spread the word within VNN. I think I should start with psycho-education. I bought some children's books that explain what pain is, then I tell my patients: "You're not a child, but it's quite a difficult subject and this book explains it nicely so take it home and read it." I also always ask, "can I tell you something about pain?" I'm not going to say they have to listen to me. That gives them opening, but like I said earlier, we are the last stage, so they want to listen to me too. For example, I can't say of: "let's take another picture" or "we'll take a scan," because I don't have those resources. I think that also makes the difference with the hospital, where they want to have a cause for their pain and therefore don't have time or space to include psycho-education. In the hospital, of course, they have different expectation, because the hospital makes you "better", to put it briefly. So I think that mindset when people come in here is also totally different. Do you understand what I mean?

I definitely understand. Pain is a complex process, and also not always easy to explain to others. I get that that can be a challenge.

You know, just the other day we had someone who had cancer and was undergoing treatment for it, but the morphine was so high that that no longer stood in place with his symptoms and with his diagnosis, that he almost attacked the mailman if he was half an hour late. He was going to order it on the black market, so he was also using too much. But then there are still colleagues who think: "Yes, but he can do it, because he has cancer, and if you have cancer, you also have pain, so you can do it." So I can understand that too.

So you see that there is also some disagreement within the organisation itself, and between colleagues. Is that right?

I think not so much disagreement, but more ignorance, and from that ignorance you then start acting. But if I can tell them my story, they will understand me.

Aha, I get it.

This subject is minimally discussed in the training as a nurse, while it is quite a big issue. Everyone who comes into the hospital, everyone who receives care, experiences some degree of pain.

Sure! So that would be something that you feel should be discussed more during training

Yes, I think that should definitely be addressed in training.

How do you see VR therapy improving your treatment outcomes? What do you see the future of therapy looking like.

Well, I think VR is going to take over a lot in the future and it's really still in its infancy. It contributes in this treatment that I can offer a patient something. In very black and white terms, I take the pills away from them, which is their way of receiving peace of mind: not feeling for a while, not experiencing for a while and just relaxing. Through the VR glasses you give them something back. It is the game element of Reducept. I see people come in here with hunched shoulders and I put on the VR VR glasses and within fifteen minutes their shoulders drop for the first time in ten years. I then see them sigh and realize they are almost falling asleep. Then they say: "I experience peace" and that makes me very happy.

Yes that must be very nice to see.

Yes, and people have sleeping problems, people have all kinds of things and then I say: "take the glasses to bed, put them on, just fall asleep" and that is very nice and the greatest contribution of the glasses, you can use them anywhere and anytime. And, that's the whole game of course, to get the feeling of control back. They get to decide: am I going to put those glasses on? What am I going to do? How am I going to do that? And when you're back in control, then you can move forward. 

You are absolutely right about that. I wonder what treatment methods and what kind of therapy you think would go well in conjunction with the Reducept method? 

The Reducept is a fantastic, supportive intervention in treatment when it comes to cognitive behavioral therapy, pain and addiction. It's not a stand-alone treatment, because you still have to pay attention to how you deal with those pills and the 75 rule, for example, or how you deal with your energy. So that cognitive behavioral therapy along with the Reducept VR goggles and the medication, those three elements form a very nice treatment.

How did you actually start working with Reducept? What initially sparked your interest?

We were already looking for something to offer the population, so you google "pain" and you think, gee, this guy is right around the corner from us in Leeuwarden. Then I started reading up and contacting and I thought, "yeah, this is nice". A very big plus is that it's approachable. So it's not like it costs so much money that our company can't invest in it. Then we started talking to see how we could implement this at our place. At first it took some getting used to, we don't know a lot about technology. Sometimes patients had problems with the telephone not working and you notice that if it doesn't work the first time and the second time, the patient thinks, never mind and that was a pity.  But they have fought their way back into technology and support and I can always call the help desk if there is a problem. It was a bumpy road for everyone at first, but now it just works well and I can follow them remotely in the program. I can see how many times they've played and what pain scores they have. And based on those scores, I can then also say, "hey you're doing well, we're tapering off the medication, I see that your pain scores aren't getting higher from that but rather less." Then we take that medication one step further and that again gives control and power. Because I'm not saying it's going well, they themselves are indicating that it's going well, and I think that's heartbreaking, heartbreaking. That just works well, so in that way it can be put to good use. 

Definitely! Of course, it doesn't work for everyone either. We've also had some feedback from people who say, yes, I've tried it, but it doesn't work. That's okay. That also happens sometimes.

True, we have too, but I generally have very positive stories and then I think: yes, if you don't achieve two out of ten, you have achieved eight, and that's fantastic, isn't it!  

Surely! I'm curious about how many patients you have already treated with Reducept.

Well, we started just before corona then we had, I think, about ten at the first step and then, with corona we stopped doing it because people couldn't come into the office and it stopped for a while. Now we've started again, I think in total we might go towards 50.

Oh wow! As a matter of fact, I had also heard in your video about a patient with phantom limb pain. Do you often have patients with similar stories, or was this a special case?

This was a very special case. This man, of course, had already had all the specialties and done everything. He was on four to six different medications and he came here that day like: "Well, enlighten me.” I just started a calm conversation with him, gave him psycho-education, showed him those beautiful videos that you have on your website, and at a certain point he said "I think I understand" and then I said "that's good, now we're going to put the glasses on", and really, after three weeks I got an email: my pain is gone!  Normally it takes a little longer but he was just so excited and he was really like... "you changed my life!" 

That’s wonderful!

Yes, it really is! Of course, there are more of those stories, but they are not as enthusiastic and not as skeptical at the beginning. So this was really a unique case.

It is indeed very unique, because being pain free after three weeks is not very common. The average patients take a few weeks or even months before they see changes. 

Yes, and I can enjoy that for months and then think: I did my job well.

Yes, I believe that! But is there anything you would like to change about Reducept?

Good question... well I don't think so actually. As I said earlier, this program is just so accessible! There are also programs made specifically for addiction, but they're just not affordable. They're beautifully made, but if we can't work with it, then who are they making it for? 

Well, that's very nice to hear. Then I have one last question for you: How do you take care of your own emotional and physical well-being, and what would be your advice to our readers?

By staying fit... I do try to walk or get out every day. I always walk to the train station and to work, and I think you should mostly do things that make you happy and give you energy. So if you're always going to a neighbor's house that doesn't give you energy, with you wondering if you should still go there. That's kind of how I go about life, thinking about what I get energy from and what makes me happy and that's how I keep things in balance a little bit.

Lucie Manden: VR is a fantastic intervention for addiction