Transcript Methadone Maintenance and Recovery: The Kirkbride Experience

Psychiatric Aspects of
MMT:
Integrating Medical
Model with Recovery
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What does it mean to “treat”
addiction?
Are objections to agonist therapies
valid or just ignorant?
Medical model and Recovery model:
conflictual or complementary?
The Kirkbride/CBH Model:
Methadone-assisted rehabilitation
Are Medications that reduce risk of
drinking or heavy drinking, or that
promote abstinence, of value in the
treatment of Alcohol Dependence?
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Gitlow, Willenbring: American
Journal on Addictions, Jan-Feb 2008
What is treatment?
Medical/Psychiatric model vs. Recovery
model
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Responsibility/Roles of Doctor and Patient
(passive vs. active)
Science or Spirituality
Alleviate symptoms vs. feel feelings,
tolerate unpleasure
Stabilize and maintain vs. seek higher
plane (swimming pool vs. quest)
Critiques of MMT
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: “It’s just being hooked on another
drug, a substitute addiction”
“You’re still addicted; you’re not in
recovery”
“You can never get off it”
Valid or ignorant?
Critiques of MMT
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Split “orphaned” treatment
You get what we offer
Implicit medical model combines
with system to encourage passivity
Does MMT “treat” addiction?
Holistic vs. targeted intervention
Problems with Clinics– power,
training, psychiatry, arbitrariness,
drug emporia
The Kirkbride/CBH Model:
It Takes a Village
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A new form of treatment
Collaboration with Managed Care
“Mandated” MMT– coercive?
“I want to start coming off it now”
Seeking system continuity
Carl
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37 years old, heroin addiction from
age 21, multiple rehabs, only sober
more than 60 days while
incarcerated
“I don’t want MMT, just want to be
off everything– it’s just another
addiction. I’ve never really wanted it
before, always tried to get clean for
someone else.”
JOHN
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“I don’t really want to be on mtd, I
don’t like it , but what’s my choice
really? I get 3 months clean and get
a job and start believing in myself,
and then it all goes down the
tubes. At least this way maybe I can
sustain something., even if I don’t
really want it.”
Methadone-assisted Rehab
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Physician leadership
Evaluation over time, data collection
(managed care), observation
Time for considered decision (Donna)
Management of co-occurring illness
(Ann)
Staff feedback, observation
Challenges and resistance
Donna
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20 yrs old, bright, appealing, intact family. HS
grad, wants to go to college and study nursing.
Percocet age 16 >>> Oxycontin >>> heroin past
18 months.
Admitted for detox and rehab. Methadone detox
protocol of 30 to 0 by 5 mg/day.
Intense cravings and w/d sxs, but does not want
MMT. Extended detox 5 days at 15-10-10-55. At 5 mg, same experience. Agreed to again
extend taper but no further. Still tolerating
poorly.
"If you are as honest as you can be with yourself,
what do you see happening when you leave
K?" Can't see self staying sober, agrees to MMT.
Ann
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29 yo, hx childhood sexual trauma ages 4-13,
long adult psych hx depression, self-mutilation,
mult hosp/rehabs, ECT, Thorazine, Paxil
heroin dependence from age 18.
Easily tolerates detox >>> rehab
Consulted 10 days after detox for impulses to
self-mutilate.
Overwhelming opiate cravings, no w/d sxs.
Factors: no ability to stay sober, “last chance” in
marriage described as loving and highly valued.
Opiates contain impulses to mutilate.
Initiation, panic, husband supports, completion
Agonist Therapy: controversies
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Mtd/bup as facilitator of recovery
Mtd/bup as impediment to recovery
“Is it part of your addiction or part of
your recovery?”
Agonist tx as hybrid of medical
model & recovery: Medical therapy
within context of recovery process
Long-term: reclaim autonomy
Benzos and Methadone– so happy
together
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“I got anxiety doc– I’ve been
diagnosed”
“My nerves are bad/shot”
“I’ve been on them for years”
“I’ve tried everything– nothing else
works”
“My psychiatrist says I have to take
them”
Benzos and Methadone– so happy
together
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Therapeutic use of benzos?
DOC in MMT patients. Problem for all programs
What model? Anxiety or craving? Treatment or
enabling? Symptom relief or substance abuse?
Consider: “I need dope/benzo to feel normal”
Increase MMT dosage?
Kirkbride experience-- evolved
Policies (spectrum): Individual needs vs program
integrity
Contrast with psychostimulants
Future Directions:
Why Not Buprenorphineassisted Rehab?