Transcript Continued Use of Illicit Substances: A Retention Based

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
1
This Training is Adapted From:
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Medication-Assisted Treatment For Opioid
Addiction in Opioid Treatment Programs
CSAT/SAMSHA (Substance Abuse and Mental Health Services
Administration Center for Substance Abuse Treatment)
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2
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,
Adequate
Resources
Program Development
And
Design
Accessibility
3
A
Maintenance
Orientation
Training Goals
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Ideally, this training will contribute to:
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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
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5
The SocioPharmacology of Opioid
Use and Dependence
Introduction and
background of oral
substitution treatment
The pharmacology of
medications used in oral
substitution treatment
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Information collection
and service provision:
‘assessment-in-action’
Pharmacotherapy and
OST
Insights from the field
Learning Together
Parallel Process
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Learning Process: Knowledge and
Skills
Acquisition of content
 Retention (store in memory)
 Application (retrieve and use)
 Proficiency (integrate and synthesize)
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7
Expectations for Certification:
Training Contract
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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.
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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. Try to put
your thoughts and feelings into
words instead of “shutting
down.”
Acknowledge and respect
differences. You can “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 to receive
feedback as a gift.
Learning Environment
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Try to be okay with
taking some learning
risks. Stretch past
your edge of what
you know and what
you are comfortable
with.
Confidentiality. Hold
the container. Don’t
be leaky.
Turn
off
phones
please.
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No cross talk. Allow one
person to speak at a
time. Equal time over
time.
Start and end on time,
including breaks.
Be
alert to tendency to fudge
this.
Use “I” statements.
Can everybody agree to
this training contract? Is
there
anything
you
absolutely cannot live
with?
Now we are off.
III. The pharmacology of
medications used in oral
substitution treatment
10
What is Buprenorphine?
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Antagonist / High receptor affinity
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Partial receptor agonist / Low Intrinsic Activity
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Lower physical dependence
Limited development of tolerance
Ceiling effect on respiratory depression
Long Acting / Slow dissociation from receptor
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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
Long duration of action
Milder withdrawal
Buprenorphine
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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)
Buprenorphine
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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
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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
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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)
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Suboxone
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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
20
21
Melinda Campopiano, M.D. :
My Protocol for Buprenorphine
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Initial history and physical
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Follow-up phone call in 24 hours
Follow-up visit in one week
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Usually 20 minutes
Monthly evaluation for refill/follow-up and
preventive health care
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40 minutes
15 minutes
A. Monthly Evaluation for Refill and
Brief Therapeutic Interventions
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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
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Work on what’s bothering them rather than
what’s bothering me
Have low threshold access
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Same day and walk-in appointments
If at first you don’t succeed, redefine
success
Dana Davis, Allegheny General Hospital Positive Health Center,
Pittsburgh, PA
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3. Pharmacology of Medications
Used to Treat Opioid Dependence
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25
Pharmacology and Pharmacotherapy
Dosage Forms
Efficacy
Side Effects
Interactions with Other Therapeutic
Medications
Safety
Dosage Forms
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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.
Efficacy of Oral Substitution
Treatment (OST)
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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
27
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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
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Functioning, fitness and Multiple
Outcomes are Perceived as a Challenge
to Dominant Treatment Models Where
Abstinence is the Exclusive Outcome
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What is functionality and fitness?
What is multiple outcomes?
What is exclusively abstinence?
MAINTENANCE TREATMENT
WITH METHADONE
TOLERANCE LEVEL
DOSAGE LEV
DURATION OF TREATMENT
29
Robert G. Newman, MD
The Baron Edmond de Rothschild
Chemical Dependency Institute
Side Effects
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30
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)
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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
 Educating
client/patients about
the risks of drug interaction is
essential. The following
information should be
emphasized: (Next 3 Slides)
32
Client/Patient Treatment
Education
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33
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
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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
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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.
IV. Information collection and
service provision:
‘assessment-in-action’
36
Assessment in Action
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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
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38
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.
Content is the information provided, what
actually happens during the contact. Process is
how the client/patient experiences the contact.
Initial Screening 2
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Staff members should be prepared to
provide immediate, practical information
that helps potential client/patients make
decisions about OST, including:
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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.
Eligibility verification. Assurance that a
potential client/patient satisfies program criteria
for admission to an OST program.
Clarification of the treatment alliance.
Explanation of patient and program/staff
expectations and responsibilities.
Goals of Initial Screening 2
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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
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Timely Admission, Waiting Lists, Referrals
Interim Maintenance Treatment
Denial of Admission
Admission Team
Information Collection and Dissemination
Timely Admission, Waiting Lists,
Referrals
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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
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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
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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
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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.
Multidisciplinary
Program
Team
Team and
Environment
Program
Environment
48
Relationship
Building and
Support
Program Team and Environment:
Best Practices
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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
Admission Team 2
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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 cooccurring psychological and social problems.
Barriers to Engagement and
Retention of Clients/Patients
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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
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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
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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
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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.
54
What does the “Philosophy of the
Program” Mean?
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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
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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.
Focus on Engagement and
Retention
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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
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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.
What is a Client/Patient-Centered
Approach?
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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
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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
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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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61
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.
Information Collection and
Dissemination
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62
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.
Information Collection and
Dissemination 2
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63
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
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).
64
Information Collection and
Dissemination 4
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65
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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66
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
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67
Scheduling the next appointment
Medical
& HIV
Care
Methadone
Maintenance
HIV Prevention
Health Promotion
& Education
68
Key Components of a
Comprehensive Approach
Counseling
And
Support
Medical Assessment
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69
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
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70
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
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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
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71
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
Insights from the Field
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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
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Screening for women-specific
medical and psychological
concerns
Access to safety planning and
safe housing
Support and counseling to
address abuse, including posttraumatic stress services
Counseling by and for women
(individual and group)
Women specific programming
in areas including:
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73
Nutrition
Smoking
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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
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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






74
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.


75
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

Exemptions from 1-year dependence
duration guideline




76
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.


77
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



78
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




80
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
OST and PLWHAs
Program Delivery:






81
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


82
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


83
Necrotizing fasciitis, sometimes called flesheating 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
Medical Assessment

84
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


85
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.
OST Programs may be able to
Provide:



86
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



87
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.
Co-morbid Mental Health
Disorders



Mood disorders
Anxiety disorders
Personality disorders (most common)






Other Mental Health Disorders



88
Antisocial personality disorder
Borderline personality disorder
Avoidant disorder
Passive-aggressive disorder
Paranoid disorder
Schizophrenia
Posttraumatic stress disorder
Attention deficit hyperactivity disorder
OST and Mental Health


89
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

90
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



91
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 nonjudgmental 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







92
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
Information Collection and
Dissemination 3

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).
93
Information Collection and
Dissemination 4



94
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


95
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

96
Scheduling the next appointment
Ongoing Assessment: Best
Practices



97
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
98
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


100
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.
Induction Considerations



101
Timing
Other substance use
Directly observed therapy
Initial Dosing


102
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.
Steady State


103
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.
Steady State 2

104
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.
Steady State 3


105
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.
Steady State 4



106
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– the time at
which a relatively constant blood level should
remain present in the body– 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.
Initial Dosing


107
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.
Variations in Individual Response
and Optimal Dosing

108
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.
Variations in Individual Response
and Optimal Dosing 2

109
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.
Variations in Individual Response
and Optimal Dosing 3


110
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.
Variations in Individual Response
and Optimal Dosing 4


111
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.
Maintenance Pharmacotherapy 5


112
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.
Desired Responses to Optimal
Dosage Determinations:



113
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
The Importance of Adequate
Dosing


114
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).
The Importance of Adequate
Dosing 2



115
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’.
Adequate Dosing and Treatment
Retention


116
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.
Maintenance Pharmacotherapy


117
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 shortterm opioids and other substances and have
turned now to improving functionality and
stabilizing their lives.
Maintenance Pharmacotherapy 2


118
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.
Maintenance Pharmacotherapy 3


119
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.
Maintenance Pharmacotherapy 4

120
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.
Maintenance Pharmacotherapy 5


121
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.
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