Continued Use of Illicit Substances: A Retention Based

Transcript Continued Use of Illicit Substances: A Retention Based

1 Oral Substitution Treatment for Opioid Dependence: A Training in Best Practices & Program Design for Nepal

Day 2

March 26-28, 2006 Kathmandu, Nepal UNDP Richard Elovich, MPH  Columbia University Mailman School of Public Health Medical Sociologist  Consultant, International Harm Reduction Development International Open Society Institute

This Training is Adapted From:

   

Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs

CSAT/SAMSHA (Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment)

Best Practices in Methadone Maintenance Treatment

Office of Canada’s Drug Strategy

Addiction Treatment: A Strengths Perspective

Katherine van Wormer and Diane Rae Davis Additional Sources: Robert Newman, MD, Alex Wodak, MD, Melinda Campopiano, M.D, Miller and Rollnick, Prochaska, DiClemente, and Norcross, Michael Smith, MD, Sharon Stancliff, MD, Ernest Drucker, PhD,

3 Adequate Resources Program Development And Design A Maintenance Orientation Accessibility

Training Goals

 Ideally, this training will contribute to:  Increased knowledge, skills and best practices among OST practitioners and providers;  Engagement and retention of clients/patients in the OST program in Kathmandu  Improved treatment outcomes

Six Training Modules

   The Socio Pharmacology of Opioid Use and Dependence Introduction and background of oral substitution treatment The pharmacology of medications used in oral substitution treatment    Information collection and service provision: ‘assessment-in-action’ Pharmacotherapy and OST Insights from the field

Learning Together

Parallel Process

Learning Process: Knowledge and Skills

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Acquisition of content

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Retention (store in memory)

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Application (retrieve and use)

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Proficiency (integrate and synthesize)

Expectations for Certification: Training Contract

8    This is an 18 hour training over a 3 day period. Allowances have been made for your work schedules: Noon – 6 PM.

You must be present and participate in all 18 hours of the training to receive certification.

There can be no exceptions.

Please stay focused. Be on task because we have a lot of material to cover in 3 days.

  Listening is a key to this training. Listen to new ideas.

Listen to what’s coming up inside you in relation to what’s being presented.

your thoughts and feelings into words instead of Try to put “shutting down.

” Acknowledge and differences. You can respect “agree to disagree” on a contentious point and move on. Participate in role plays. Everyone has permission to pass.

Offer feedback constructively not personally.

Try feedback as a gift.

to receive

9   

Learning Environment

Try to be okay with taking some learning risks.

with.

Stretch past your edge of what you know and what you are comfortable    No cross talk. Allow one person to speak at a time.

Equal time over time.

Start and end on time, including this.

breaks.

Be alert to tendency to fudge Use “I” statements.

Confidentiality.

the container.

be leaky.

Turn please.

off Hold Don’t phones  Can everybody agree to this training contract? Is there anything you absolutely with?

cannot live  Now we are off.

III. The pharmacology of medications used in oral substitution treatment

What is Buprenorphine?

11    Antagonist / High receptor affinity    Highest receptor affinity and receptor occupancy: 95% occupancy at 16 mg (Greenwald et al, 2003) Blockade or attenuate effect of other opioids Rapid onset of action and risk of acute opioid reversal Partial receptor agonist / Low Intrinsic Activity    Lower physical dependence Limited development of tolerance Ceiling effect on respiratory depression Long Acting / Slow dissociation from receptor   Long duration of action Milder withdrawal

Buprenorphine

 A derivative of the opiate alkaloid thebaine, is a synthetic opioid and generally is described as a partial agonist at the mu opiate receptor.

 Research has demonstrated that buprenorphine’s partial agonist effects at mu receptors, its unusually high affinity for these receptors, and its slow dissociation from them are principal determinants of its pharmacological profile (Cowan 2003) 12

Buprenorphine

  As a partial mu agonist, buprenorphine, does not activate mu receptors fully (i.e., it has low intrinsic activity) resulting in a ceiling effect that prevents larger doses of buprenorphine from producing greater agonist effects. (Walsh et al. 1994) As a result there is greater margin of safety from death when increased doses are used, compared with increased doses of full opiate agonists.

Buprenorphine

 Another feature of buprenorphine is that it can be used on a daily or less than daily basis, alternate day, thrice weekly, because, although larger doses do not increase its agonist activity, they do lengthen its duration of action (Chawarski et al. 1999)

Buprenorphine

 Buprenorphine overdose is uncommon. When instances were reported in France, they were almost always associated with uptake of high doses of benzodiazepines, alcohol, or other sedative –type substances (Klintz 2001, 2002)

Suboxone

 A form of buprenorphine formulated with naloxone as a sublingual tablet  (Subutex or) Suboxone is absorbed sublingually  Naloxone is minimally absorbed and not biologically available  If the tablet is dissolved and injected the user will experience acute withdrawal

Melinda Campopiano, M.D. : My Protocol for Buprenorphine

22  Initial history and physical  40 minutes  Follow-up phone call in 24 hours  Follow-up visit in one week  Usually 20 minutes  Monthly evaluation for refill/follow-up and preventive health care  15 minutes

A. Monthly Evaluation for Refill and Brief Therapeutic Interventions

 Motivational interviewing / Problem Solving Therapy  Relapse Prevention  Management of other medical problems  Health maintenance  Coordination of inpatient rehab care

Harm Reduction in Practice

Meet them where they’re at  Work on what’s bothering them rather than what’s bothering me Have low threshold access  Same day and walk-in appointments If at first you don’t succeed, redefine success 24 Dana Davis, Allegheny General Hospital Positive Health Center, Pittsburgh, PA

3. Pharmacology of Medications Used to Treat Opioid Dependence

25  Pharmacology and Pharmacotherapy  Dosage Forms  Efficacy  Side Effects  Interactions with Other Therapeutic Medications  Safety

Dosage Forms

    Diskettes/tablets, oral solutions, liquid concentrate, and powder. Currently in the U.S. methadone is usually administered in liquid form. Other forms are available on the basis of clinic and patient preference.

Advantages to the diskette form (scored tablets, dissolved in water, taken orally with flavored liquid) are easy inventory, and the ability for patients to see what they are taking before liquid is added. 26

Efficacy of Oral Substitution Treatment (OST)

  Use less heroin Share fewer needles   Less risky injection thus reducing risk of HIV and possibly Hepatitis C Increases tolerance to opioids thus reducing the risk of overdose  De Castro S 2003, Sporer 2003     Reduction in need for risky financial activities and Needs less income from crime Have improved social interaction Reduced HIV seroconversion  (2000 Drug Misuse Statistic Scotland) Improves compliance with medical therapy for other medical conditions

Multiple Outcomes vs. Single or Exclusive Outcome

 Functioning, fitness and Multiple Outcomes are Perceived as a Challenge to Dominant Treatment Models Where Abstinence is the Exclusive Outcome  What is functionality and fitness?

 What is multiple outcomes?

 What is exclusively abstinence?

MAINTENANCE TREATMENT WITH METHADONE TOLERANCE LEVEL DOSAGE LEVEL DURATION OF TREATMENT Robert G. Newman, MD The Baron Edmond de Rothschild Chemical Dependency Institute

Side Effects

 Constipation, caused by slowed gastric motility  Sweating (similar with buprenorphine)  Other side effects can include: insomnia or early awakening, decreased libido or sexual performance (Hardman et al, 2001)  See handout

Interactions with other Medications (Hand out 34-42)

  Because methadone (as well as buprenorphine) is metabolized chiefly by the CYP3A4 enzyme system (a part of the CYP450 system), drugs that inhibit or induce the CYP450 can alter the pharmacokinetic properties of these medications.

Drugs that inhibit or induce this system can cause clinically significant increases or decreases, respectively, in serum and tissue levels of opioid medications.

Safety

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Educating client/patients about the risks of drug interaction is essential. The following information should be emphasized: (Next 3 Slides)

Client/Patient Treatment Education

  During any agonist-based pharmacotherapy, using drugs or medications that are respiratory depressants (e.g., alcohol, other opioid agonists, benzodiazepines) may be fatal.

Current or potential cardiovascular risk factors may be aggravated by opioid agonist pharmacotherapy, but certain treatment strategies reduce cardiovascular risk (and should be included as needed in patients’ treatment plans).

Client/Patient Treatment Education 2

 Other drugs – illicit, prescribed, or over the counter – have potential to interact with opioid agonist medications (specific, relevant information should be provided).

 Patients should know the symptoms of arrhythmia, such as palpitations, dizziness, lightheadedness, or seizures, and should seek immediate medical attention when they occur.

Client/Patient Treatment Education 3

  Maintaining and not exceeding dosage schedules, amounts, and other medication regimens are important to avoid adverse drug interactions.

When opioid medication dosage must be adjusted to compensate for the effects of interacting drugs, patients should be observed for signs or symptoms of opioid withdrawal or sedation to determine whether they are under medicated or overmedicated. 35

IV. Information collection and service provision: ‘assessment-in-action’

Assessment in Action

 A-in-A: No single moment, no single assessment instrument, no single staff person  Initial Screening  Admission Procedures and Initial Evaluation  Medical Assessment  Induction Assessment  Comprehensive Assessment

Initial Screening

 The screening process begins when individual or relative first contacts OST.

 This contact, even by telephone, is the first opportunity for treatment providers to establish an effective

therapeutic alliance

among staff members, client/patients, and their families.

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Content

is the information provided, what actually happens during the contact.

Process

is how the client/patient experiences the contact. 38

Initial Screening 2

39  Staff members should be prepared to provide immediate, practical information that helps potential client/patients make decisions about OST, including:  The approximate length of time from first contact to admission  What to expect during the admission process  Types of services offered

Goals of Initial Screening

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Crisis intervention

. Identification of and immediate assistance with crisis and emergency situations.

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Eligibility verification

. Assurance that a potential client/patient satisfies program criteria for admission to an OST program.

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Clarification of the treatment alliance

. Explanation of patient and program/staff expectations and responsibilities.

Goals of Initial Screening 2

41 

Education

. Communication of essential information about OST operation and procedures: dosing schedules, OST hours, treatment requirements, key/lock analogy and explanation of agonist therapy. Discussion of the benefits and drawbacks (costs) of OST to help potential client/patients make informed decisions about this mode of drug treatment.

Goals of Initial Screening 3

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Identification of treatment barriers

. Determination, through open-ended questions and reflective listening of factors that might hinder a potential client/patient’s ability to meet treatment requirements, for example, lack of childcare or transportation, commitments and schedule at work.

Admission Procedures and Initial Evaluation

 Timely Admission, Waiting Lists, Referrals  Interim Maintenance Treatment  Denial of Admission  Admission Team  Information Collection and Dissemination

Timely Admission, Waiting Lists, Referrals

   After initial screening, the admission process should be thorough and facilitate timely enrollment in the OST program. This process is characterized by the client/patients’ first exposure to the treatment system: its personnel, including ombudsman, other patients, available services, expectations (rules and requirements).

The Admission process should be designed to engage new client/patients positively and empathically.

Timely Admission

 The longer the delays between first contact, initial screening, and admission and the more appointments required to complete these procedures, the fewer potential client/patients enter treatment.

 Prompt, efficient orientation and evaluation, along with accurate empathy, contribute to the therapeutic nature of the admission process.

Denial of Admission

 Denial of admission to an OST should be based on sound clinical practices and the best interests of the drug user and the OST program.

  Admission denial might be considered if the individual is threatening or violent.

Due process and attention to drug users’ rights minimize the possibility that decisions to deny admission to OST are abusive, arbitrary or discriminatory.

Admission Team

   OST programs should have qualified, compassionate, well-trained, and multidisciplinary teams that efficiently collect applicant’s information and histories, evaluate their needs as client/patients.

Team members should be cross-trained in treating dependence and co-occurring problems and disorders.

Team members should be able to communicate about OST program services, policies and procedures, as well as make appropriate referrals.

48 Multidisciplinary Program Team Team and Environment Program Environment Relationship Building and Support

Program Team and Environment: Best Practices

          Multidisciplinary Team Approach to Program Delivery Adequate Human Resources Competence, Attitudes and Behaviors in Practice Relationship Building and Support Adequate Ongoing Training Program Environment Organized Structured Approach to Treatment Safety Flexible Routines Information Collection and Sharing 49

Admission Team 2

  Those conducting admission interviews should employ MI techniques, including accurate empathy, and their interactions with applicants should not be stigmatizing, and should avoid a vertical or “expert” character to the therapeutic alliance. Interview style should be respectful and encourage trust, so that rapport is established and client/patient can speak honestly and realistically about his/her experience of drug use, dependence, personal matters and co occurring psychological and social problems.

Barriers to Engagement and Retention of Clients/Patients

      Attitudinal barriers to treatment including fear and misinformation Philosophical differences among practitioners within program Insufficient resources for treatment Lack of trained practitioners with experience working with opioid users Over regulation of programs by government or funders Uneven or fragmented access to service across sectors or provinces      Lack of access in rural or remote areas Lack of effective outreach Program policies (admission criteria, dosing levels, etc.) Lack of supports for clients/patients (costs of treatment, access to and cost of transportation, access to and cost of child care, etc.) Lack of supports for team members resulting in burn out, poor attitudes, frequent turn-over of staff, etc.

Progress to Overcoming Barriers

   A growing awareness in the field that ongoing dialogue – at all levels– as well as a commitment to collaboration and coordination will be needed to overcome barriers and increase access to OST in Nepal An increased recognition among practitioners of the need for flexible and individualized services, driven by client/patient needs An increased recognition among medical practitioners that social workers and outreach workers are key to effective program delivery

Progress to Overcoming Barriers

   An increasing emphasis in the field on the role of methadone maintenance treatment programs within a harm reduction approach to opioid dependence International recognition of methadone maintenance treatment – particularly low threshold approaches– as an important strategy to combat transmission of HIV – and to help prevent and control the transmission of HCV and other blood borne pathogens among drug users and their relatives.

International recognition of methadone maintenance treatment as an excellent site for HIV treatment services

Presentation of the Program to Potential Clients/Patients

OST programs should:  Respect and protect the dignity of clients/patients    Empower clients/patients Be no “mixed messages”– e.g. all members of the program should ascribe to a maintenance orientation and “sing off the same page” Clients/patients should be able to be honest about their reasons for entering, staying in or leaving OST – rather than having to give “the right answers” in order to comply with arbitrary program requirements or appear as a “good” patient in order to get staff approval.

What does the “Philosophy of the Program” Mean?

   Programs should examine and clarify their underlying assumptions – about drug use, about the people who use drugs, about opioid dependence, about people who are opioid dependent, and about the goals of treatment.

The specific policies and procedures of the program should be consistent with the overall philosophy.

The program policies, procedures, and philosophy should be made clear to all members of the program team and to clients/patients.

A Maintenance Orientation

  Methadone maintenance programs or OST more broadly should focus on reducing HIV and other harms associated with injection opioid use by retaining clients/patients in treatment.

The evidence indicates that a long-term maintenance philosophy increases retention in treatment, even though the individual client/patient will determine their duration in treatment, their goals for treatment, and their own pace of change related to the goals. 56

Focus on Engagement and Retention

 Engagement in OST is critical – when the small window of opportunity appears, the moment of client/patient interest, programs should seize the moment and focus on engaging people who are dependent on opioids in treatment in as short a period of time as possible (SAMSHA 2005)

Retention in Treatment is Essential

 If clients/patients don’t remain in treatment, they have little opportunity to achieve any potential gains from OST (see slide 24, day 2).

 Retention is also important over the long-term, given that length of time in treatment has been affirmed repeatedly by researchers as positively associated with achieving good treatment outcomes, including achieving other positive outcomes and benefits of OST. 58

What is a Client/Patient-Centered Approach?

     59 Accessibility Outreach and proactive (rather than passive) recruitment of clients/patients Recognition and acknowledgement that opioid dependent individuals have ‘practice’ knowledge, competencies, strategies, and interest in program transparency based in their experience and ‘street expertise’ with opioid use Recognition and acceptance that each client/patient has widely varying life and drug experiences, expectations, strengths, capacities, and needs Recognition of the impact of marginalization and stigmatization and emphasizing individual and collective empowerment     Respect for client/patients’ dignity Respect for clients’/patients’ choices, particularly concerning their expectations and their treatment goals Encouragement and facilitation of client/patient involvement in decision-making at the individual and program levels Fostering a collaborative, relationship-building approach between clients/patients and program team members

The Admission and Assessment Process

60  Client/patients entering treatment may be in crisis and/or feeling very ill – the admission and assessment process should be as sensitive and timely as possible – an overly extensive assessment can produce fatigue and frustration and encourage clients/patients to try to “say the right thing to get through it”.

Information Collection and Dissemination

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Treatment history

: including previous episodes of treatment including dates and durations; patterns of use of treatment; perspectives on ‘successes’ and ‘failures’; what was helpful and not so helpful; written consent should be provided by client/patient before contacting another treatment provider

Orientation to OST

: extending over several sessions, a transparent explanation of treatment methods, options, and requirements and the roles and responsibilities of those involved; client rights, confidentiality, and access to information should be discussed and documented. If possible, a new client/patient should receive a handbook or written materials on all relevant program specific information to comply with treatment requirements and to fully understand treatment options. 61

Information Collection and Dissemination

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Treatment history

Orientation to OST

Information Collection and Dissemination 2

 Age of Applicant  Recovery environment  Patient personal recovery resources  Suicide and other emergency risks  Substances of abuse  Prescription drug and over-the-counter medication use  Impulse control and self-regulation 63

Information Collection and Dissemination 3

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Method and level of opioid use

: frequency, amounts, route of administration; client/patient reporting helps staff to assess dependence, tolerance levels, and providing a starting point to prescribe appropriate OST for stabilization (American Psychiatric Association, 2000).

Information Collection and Dissemination 4

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Pattern of daily preoccupation with opioids

: A client/patient’s daily pattern of opioid use and dependence should be determined.  Regular and frequent use to offset withdrawal is a clear indicator of physiological dependence.

 People who are opioid dependent generally spend increasing amounts of time and energy obtaining, using, experiencing and responding to the effects of these drugs.

Information Collection and Dissemination 5

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Patient motivation and reasons for seeking treatment

: prospective client/patients typically present for treatment because they are in withdrawal and want relief. They often are preoccupied with whether and when they can receive medication. Because successful OST entails not only short-term relief but a steady, long-term commitment, client patients should be asked why they are seeking treatment, why they chose OST, and whether they fully understand all available treatment options, options related to OST, and the nature of OST. This inquiry is ongoing and not restricted to admission.

Information Collection and Dissemination 6

 Scheduling the next appointment

68 Medical & HIV Care Methadone Maintenance HIV Prevention Health Promotion & Education Key Components of a Comprehensive Approach Counseling And Support

Medical Assessment

   Each client/patient should undergo a complete, fully documented physical examination (overall health status/functioning) by a physician before admission to the OST.

However, key elements can be done during admission, while some aspects of examination can be conducted within first 14 days of admission. Women should receive a pregnancy test and a gynecological examination by an OBGYN at the OST or at a Women’s Health Center.

Barriers that Limit Women’s Access to Treatment

   Insufficient women focused outreach Social stigmatization of women drug users, including by medical community Lack of gender specific treatment to address women’s issues, i.e. lack of attention to psychosocial issues, relational and family issues, and exclusive focus on abstinence oriented counseling     Gender or cultural insensitivity in treatment programs Fear of losing custody of their children Intimidation by relatives including mothers-in-law, husband, etc. Lack of child care or care for other dependent family members  What else can you think of?

Insights from the Field

  At birth, infants should not be assumed to be dependent on opioids, but should be properly assessed.

There needs to be ‘continuity of care’ and close coordination between OST program and perinatal services  Pregnant women who are dependent on opioids should have priority access to OST, and access from multiple and low stigmatization entry points 71

Insights from the Field

72  OST should directly or indirectly (NGO) provide women only group work and psychosocial counseling on a wide range of issues driven by the expressed needs of women drug users  OST should directly or indirectly (NGO) provide women with couples or family group work

To Improve Treatment for Women

     Screening for women-specific medical and psychological concerns Access to safety planning and safe housing Support and counseling to address abuse, including post traumatic stress services Counseling by and for women (individual and group) Women specific programming in areas including:  Nutrition  Smoking        Health, with particular attention and sensitivity to reproductive health issues, relational and control issues around injecting, issues related to sex work Parenting Assertiveness training Improved self-esteem Building self-efficacy in relation to particular issues Healthy relationships Employment

Potential Benefits of Women Supportive Services in OST

      Safer, medically supervised uptake of opioid Better perinatal care Increased fetal growth Reduced fetal and infant mortality Increased likelihood of carrying pregnancy to term Greater likelihood of women accessing services that are not exclusively ‘crisis’ oriented       Fewer birth complications Better outcomes among HIV positive women for opportunistic infections Decreased transmission of HIV, HCV, and other STIs Decreased cases of preeclampsia and neonatal abstinence syndrome Increased retention in treatment Improved family situations

Medical Assessment 2

 Determination of opioid dependence and verification of admission eligibility  In general, opioid pharmacotherapy is appropriate for persons who are currently dependent and became dependent at least 1 year before admission.

  Documentation of past dependence might include treatment records or a primary physician’s oral or written report.

When an applicant’s status is uncertain, admission decisions should be based on drug test results and consultation with the client/patient.

Medical Assessment 3

76  Exemptions from 1-year dependence duration guideline  Client/Patients released from correctional facilities (within 6 months of release)  Pregnant client/patients  Previously treated client/patients  A person under the age of 18, who has two documented attempts at detoxification, and is accompanied by a parent

Medical Assessment 4

 Cases of Uncertainty  Administration of naloxone can result in severe withdrawal and is not recommended and can undermine development of positive therapeutic alliance; there are less invasive ways. Naloxone should be reserved to treat opioid overdose emergencies.   Patient can be observed for the effects of withdrawal after he/she has not used an opioid for 6-8 hours.

Administering a low dose of methadone and then observing the patient also is appropriate

Medical Assessment 5

  Testing for hepatitis A, B, and C; syphilis, other sexually transmitted infections (STIs), and chlamydia and gonococcus infections; tuberculosis; hypertension; and diabetes. HIV infection should require a client/patient’s written informed consent, along with pre and post test counseling  Liver and Kidney functions.

Specific Risks for PLWHAs*

    The risks of morbidity that is specifically related to ID use (endocarditis, absesses and co-infection with HCV and other blood borne pathogens) The higher rates of bacterial pneumonia and tuberculosis and greater risk of mortality given compromised immune system The potential to develop drug-resistant strains of HIV, in the event of poor compliance with ARV meds.

Potential for drug interactions * People living with HIV and AIDS 79

OST and PLWHAs

    Program delivery should include testing for HCV infection. HCV is 10 to 15 times more infectious through blood contact than HIV (Health Canada 2000) Outreach is key Should be priority access to OST for people dependent on opioids and LWHA Should engage clients/patients in OST through STD programs and low threshold and low stigma points of entry, i.e. NGOs engaged in harm reduction and other forms of drug treatment. If an individual drops out or is asked to leave an abstinence oriented treatment program, he or she should be referred to both NGO needle exchange and OST 80

OST and PLWHAs

Program Delivery:       Include testing for HIV Include direct or indirect provision of primary care for HIV Combined treatment for opioid and HIV, given drug interactions, etc.

Pain management Client/patient education on harm and risk reduction, including overdose Appropriate protocols concerning liaison with public health, notification, client/patient confidentiality Education   Sensitize people working in the area of HIV/AIDS to the needs of people receiving OST and people who are opioid dependent Expand current efforts to develop linkages and exchanges between people and NGOs working in HIV/AIDS, e.g. needle exchange programs, with providers of OST and health ministry agency dedicated to HIV/AIDS

Acute, Life Threatening Infections

 Endocarditis, infection, usually bacterial, of the inner lining of the heart and its valves.

 Soft-tissue infections, such as abscesses and cellulitis, involve inflammation of skin and subcutaneous tissue, including muscle.

Acute, Life Threatening Infections 2

  Necrotizing fasciitis, sometimes called flesh eating infection, usually is caused by introduction of the bacterium

Streptococcus pyogenes

into subcutaneous tissue via a contaminated needle.

Wound Botulism is caused by the neurotoxin of Clostridium botulinum, a bacterium usually found in contaminated food, but botulism poisoning has occurred among people who inject drugs 83

Medical Assessment

 The results of medical assessment, including toxicology tests, other laboratory results, and psychosocial assessment, usually are reviewed by a program physician and then submitted to the medical director in preparation for pharmacotherapy.

OST and Mental Health

 Research consistently documents that people with mental health disorders are at increased risk of drug use, including cigarettes, opioids, and other substances used for self-medicating.

 Identifying and providing treatment for mental health disorders can help improve OST outcomes, including retention, reduction of use of short-term opioids, self-regulation, functionality, and stabilization of living situation. 85

86  

OST Programs may be able to Provide:

Access to mental health evaluations and treatment services, psychotherapy and counseling A stable environment and consistent mental structure (daily attendance, clear rules, structured social interaction, sensitivity to self-management issues)      Dispensing of other medications along with methadone doses Access to medical care Opportunities to establish positive relationships with OST and health care providers Involvement in volunteer activities and work Involvement in psychosocial rehabilitation programs

OST and Mental Health

   Stabilize clients/patients on methadone first, and then assess primary vs. secondary mental health disorders (Which comes first, the chicken or the egg?) In order to diagnose and treat independent mental health disorders, the presence of symptoms that stem from other medical conditions or from use of drugs should be ruled out. For example, use of some drugs may either cause symptoms which present as depression, or else interfere with the management of a mood disorder. To rule out substance induced disorders, a skilled assessment can take into account how symptoms respond to increases or decreases in drug use, or periods of abstinence. 87

Co-morbid Mental Health Disorders

    Mood disorders Anxiety disorders Personality disorders (most common)      Antisocial personality disorder Borderline personality disorder Avoidant disorder Passive-aggressive disorder Paranoid disorder Other Mental Health Disorders    Schizophrenia Posttraumatic stress disorder Attention deficit hyperactivity disorder

OST and Mental Health

 Involve relatives and family support from the beginning of and throughout treatment  Ensure good and clear communication among all team members and linkage specialists or programs.

Medical Assessment

 Programs should minimize delay in administering the first dose of medication because, in most cases, applicants will present in some degree of opioid withdrawal.

Relationship Building and Support

   Regardless of setting, program should offer a “zone of tolerance” for clients/patients often highly marginalized outside The quality of relationships will affect compliance, attitude, motivation of clients/patients. Therapeutically induced resistance.

Team members’ view of their work will be enhanced by having positive relationships with clients/patients.    Since relationships are a pivotal factor in how well treatment works, they should be a point of focus for measuring outcomes.

It is essential for clients/patients to have a non judgmental person, such as an ombudsman, to talk with.

Physicians, nurses, social workers in the team need supports such as training, mentorship, supervision,etc.

Information Collection and Dissemination 2

Information Collection and Dissemination 3

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Method and level of opioid use

Information Collection and Dissemination 4

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Pattern of daily preoccupation with opioids

: A client/patient’s daily pattern of opioid use and dependence should be determined.  Regular and frequent use to offset withdrawal is a clear indicator of physiological dependence.

 People who are opioid dependent generally spend increasing amounts of time and energy obtaining, using, experiencing and responding to the effects of these drugs.

Information Collection and Dissemination 5

 

Patient motivation and reasons for seeking treatment

Information Collection and Dissemination 6

 Scheduling the next appointment

Ongoing Assessment: Best Practices

   Consider client/patient goals and expectations for treatment, not just those of the program Create resource rooms containing food and clothing items (see Maslow) Use a partnership approach – some physicians administer Addiction Severity Index & the Opiate Treatment Index themselves, while others work with trained personnel, or partner with social workers experienced in drug dependence   Balance assessment (information gathering) with provision of information to clients/patients and responses to their questions (flexibility) Assessment may be seen as either intrusive – some client/patients have been through many prior assessments – or threatening, e.g., some client/patients fear consequences of their truthful answers

V. Stages of Pharmacotherapy

Stages of Pharmacotherapy

99  Induction  Stabilization and Dosage Determination  Maintenance  Studies of the Importance of Dosing  Take-Home Medications  Medically Supervised Withdrawal After Detoxification, Tapering, or Dosage Reduction

Induction

 Induction procedures depend on the unique pharmacological properties of each OST type of medication, prevailing regulatory requirements, and patient characteristics and expectations.

 Regardless of the medication, safety is the key during the induction phase.

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Induction Considerations

 Timing  Other substance use  Directly observed therapy 101

Initial Dosing

  The first dose of any opioid treatment medication should be lower if a patient’s opioid tolerance is believed to be low, the history of opioid use is uncertain, or no signs of opioid withdrawal are evident.

Dosage adjustments in the first week of treatment should be based on how patients feel at the peak period for their medication (e.g., 2 to 4 hours after a dose of methadone is administered), not on how long the effects of a medication last. As stores of medication accumulate in body tissues, the effects begin to last longer.

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Steady State

 Initial dosing should be followed by dosage increases over subsequent days until withdrawal symptoms are suppressed at the peak of action for the medication.

 Methadone and buprenorphine are stored in body tissues, including the liver, from which their slow release keeps blood levels of medication steady between doses. 103

Steady State 2

 It is important for physicians, staff members, and client/patients to understand that doses of medication are eliminated more quickly from the bloodstream and medication effects wear off sooner than might be expected until sufficient levels are attained in the tissues.

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Steady State 3

 During induction, even without dosage increases, each successive dose adds to what is present already in tissues until steady state is reached.  Steady state refers to the condition in which the level of medication in a client/patient’s blood remains fairly steady because that drug’s rate of intake equals the rate of its breakdown and excretion.

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Steady State 4

   Steady state is based on multiples of the elimination half-life. Approximately 4-5 half-life times are needed to establish a steady state for most drugs. For example, because methadone has a half-life of 24-36 hours, its steady state remain present in the body – the time at which a relatively constant blood level should – is achieved in 5 to 7.5 days after dosage change for most patients. However, individuals may differ significantly in how long it takes to achieve steady state.

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Initial Dosing

 For a client/patient actively dependent on opioids, a typical first dose of methadone is 20 to 30 mg (Joseph et al. 2000).

 If withdrawal symptoms persist after 2 to 4 hours, the initial dose can be supplemented with another 5-10 mg. (Joseph et al. 2000) up to 40 mg.

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Variations in Individual Response and Optimal Dosing

 Most differences in client/patient response to methadone can be explained by variations in individual rates of absorption, digestion, and excretion of the drug, which in turn are caused by such factors as body weight and size, other substance use, diet, co-occurring disorders and medical diseases, and genetic factors.

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Variations in Individual Response and Optimal Dosing 2

 Because variation in response to methadone is considerable, SAMSHA believes that the notion of a uniformly suitable dosage range or an upper dosage limit for all patients is unsupported scientifically.

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Variations in Individual Response and Optimal Dosing 3

 Whereas 60 mg of methadone per day may be adequate for some, it has been reported that some client/patients require much more for optimal effect.

 Treatment providers should avoid thinking of ‘high dosage’ as being above a certain uniform threshold; however, there are few data on the safety of methadone doses above 120 mg/day. 110

Variations in Individual Response and Optimal Dosing 4

 Looking for clinical signs and listening to client/patient reported symptoms related to daily doses or changes in dosage can lead to adjustments and more favorable outcomes (Leavitt et al. 2000).

 Generally, the disappearance of opioid withdrawal symptoms indicates adequate dosing and serum methadone levels (SMLs) within the therapeutic comfort zone. 111

Maintenance Pharmacotherapy 5

 The goal of methadone maintenance treatment can be increased functionality, quality, and quantity of life rather than abstinence.

 Both individual and societal benefits are achieved in maintenance even if abstinence is not an outcome.

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Desired Responses to Optimal Dosage Determinations:

   Prevention of opioid withdrawal for 24 hrs. or longer, including both early subjective symptoms and objective signs typical of abstinence.

Elimination of drug hunger or craving Blockade of euphoric effects of self administered opioids (not a true block but reflects cross tolerance for other opioids, attenuating or eliminating desired sensations from self administered of street opioids.

  Tolerance for the sedative effects of treatment medication, creating a state in which client/patients can function normally without impairment of perception or physical or emotional response.

Tolerance for most analgesic effects produced by treatment medication 113

The Importance of Adequate Dosing

 Strong evidence supports the use of daily methadone doses in the range of 80mg or more for most patients (Strain et al. 1999), but considerably variability exists in patient responses.  Some do well on dosages below 80 to 120 mg per day, and others require significantly higher dosages (Joseph et al. 2000).

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The Importance of Adequate Dosing 2

   Much evidence shows a positive correlation between medication dosage during OST and treatment response (e.g., Strain et al. 1999).

Higher dosages in some studies appeared to produce greater cross tolerance.

Cross tolerance occurs when medication diminishes or prevents the euphoric effects of heroin or other short-acting opioids, so that patients who continue use of street opioids no longer feel ‘high’.

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Adequate Dosing and Treatment Retention

 An Australian study connected the importance of dosage with patient retention in OST (Caplehorn and Bell, 1991).

 Benefits include eliminating short-term opioids, reductions in the threats of HIV and hepatitis B and C.

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Maintenance Pharmacotherapy

 The maintenance stage of opioid pharmacotherapy begins when a patient is responding optimally to medication treatment and routine dosage adjustments are no longer needed.

 Patients at this stage have stopped using short term opioids and other substances and have turned now to improving functionality and stabilizing their lives.

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Maintenance Pharmacotherapy 2

 Client/patients in maintenance may turn away from the people, places, and things associated with their use of short-term opioids and dependence.

 Patients who continue to use short-term opioids or other illicit substances may benefit from intensified counseling and other services to help them achieve the maintenance stage.

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Maintenance Pharmacotherapy 3

  During the maintenance stage, many client/patients remain on the same dosage of treatment medication for many months, whereas others may need frequent or occasional adjustments.

Periods of increased stress, serious emotional crises, physical problems, negative environmental factors, greater drug availability, pregnancy, or increased drug hunger can reawaken the need for increased dosage over short or extended periods. 119

Maintenance Pharmacotherapy 4

 Although the counseling relationship and patient interview are paramount, drug test reports and medication blood levels are useful for dosage determination and adjustment during and after transition from stabilization to the maintenance stage. 120

Maintenance Pharmacotherapy 5

 The goal of methadone maintenance treatment can be increased functionality, quality, and quantity of life rather than abstinence.

 Both individual and societal benefits are achieved in maintenance even if abstinence is not an outcome.

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Comprehensive Services

  According to research reviewed by NIDA* (1995) two of the program characteristics associated with treatment success are: “providing comprehensive services” and “integrating medical, counseling, and administrative services.” According to NIDA: “At 24 weeks, methadone alone resulted in minimal improvements; methadone plus counseling resulted in significant improvements over methadone alone; and enhanced methadone services, including a broad range of psychosocial services plus methadone, had the best outcomes of all.” * National Institute for Drug Abuse, U.S. Government 122