Transcript Residential Treatment: What’s Methadone Got To Do With It?

Residential Treatment:
What’s Methadone Got To
Do With It?
Siara Andrews, Psy.D.1
Yong S. Song, Ph.D.1
Steve Myers2
University of California at San Francisco1
Walden House, Inc.2
Presentation at American Association for the Treatment of Opioid Dependence
October 16-20, 2004
Acknowledgements
 Support from NIDA: R01DA14922
 Staff of Walden House
 Staff of Methadone Programs: SFGH,
BAART, Westside
 Co-investigators & Consultants on the
Project
 Research Staff
Preview
 Objectives
 Methadone Clinic-Overview
 Therapeutic Community-Overview
 Research to Practice: Methadone-Enhanced
Recovery in the Therapeutic Community
 Improving collaboration between methadone
clinic and residential treatment
 Discussion, Q & A
Objectives: What you can
expect to learn today
 How the TC is adapted to integrate methadone
treatment.
 How methadone clinics work with other treatment
providers.
 Review of identified challenges and how to
overcome these challenges to integrating
methadone into residential treatment.
Opiate Treatment Outpatient Program
San Francisco General Hospital
OTOP Methadone Clinic
 History of OTOP MMT
– Opened in 1972
– County Hospital based program
– Serves medically indigent population
– HIV epidemic in 1980s
 Components of treatment
– Methadone maintenance
– Psychiatric Care
– HIV Primary Care
– Nursing Services
– Social Services
OTOP Methadone Clinic
 Patient population
– Licensed capacity of 750
– Provider of last resort in SF
– Medically & psychiatrically severe
– Many homeless
 Demand surpassing Capacity
– 15,000 to 17,000 IDU heroin users in SF
– SF top 4 in heroin-related hospital admissions
– Approximately 3500 methadone treatment slots
– Long waits for access to MMT
OTOP and Walden House
 Expansion of treatment
– Mobile Methadone Program
– Expansion of 150 additional treatment slots
– Cooperative agreement with WH
– Transfer of WH patients from other methadone
programs to Mobile program at WH
– Receipt of medical services at main clinic
– Methadone counselor onsite at WH
Walden House, Inc.
Walden House, Inc.
Walden House
 History of the TC
– 1976 - First methadone clients in Walden House, clients
had to be on 30mgs or less to get into treatment.
– 1997 – 30mg requirement was dismissed and client’s
doses are now and have been accepted on an individual
basis with no dose limit requirements.
– Clients must be on methadone when entering treatment
as Walden House does not put anyone on while in
treatment.
– Clients must sign a treatment agreement before entering
treatment.
Research to Practice: MERIT
1. Determine the effectiveness of treating ORT
patients in a TC.
2. Investigate challenges to the acceptance of ORT in
the TC environment.
3. Develop a manual for integrating ORT into TC’s.
MERIT: Design & Methods
Follow two groups of residents entering
a TC, comparing:
1. Residents receiving ORT (n=125)
2. Residents with heroin history but
NOT receiving ORT (n=125)
Medication Use in the TC?
 Evolutionary perspective: To survive, we change,
but also maintain the essential elements of the TC.
 Historically: Use of medications is incompatible
with TC perspective.
 TC Policy is changing to allow
–
–
–
–
HIV medications: non-psychoactive
Psychiatric medications: Mood stabilizing
Maintenance medications: Methadone, buprenorphine
Pain medications: vicodin, oxycontin
*De Leon, George (2000).
Use of Medications in USA TCs
•Very few residential programs provide medication
(26%).
•Almost no residential programs provide ORT (2%).
•
Uniform Facilities Data Set (1998)
TC staff familiarity with
substance abuse
pharmacotherapies
Medication
No extent
Methadone
7%
Buprenorphine 38%
(Univ. of Georgia, NIDA R01-DA-14976, from Paul Roman)
Very great extent
37% of staff
4%
TC Staff Use of Methadone
 Ever use methadone? 11%
 Using methadone now? 7% (n=21)
 Provide methadone in own clinic? N=6 TC’s
Investigating Challenges: Stigma
about Methadone among TC Staff
 Investigated TC staff beliefs & knowledge of
methadone
 Surveyed staff (N=87)in the 4 SF WH programs
 Administered Surveys:
– Abstinence Orientation Scale1
– Methadone Knowledge Scale2
1Caplehorn, et al. (1996).
2Caplehorn, et al. (1998).
Stigma Study: Results
 Higher abstinence orientation than among
methadone clinic staff in NYC and Australia
 Greater methadone knowledge among TC staff
who had been in drug/alcohol treatment
 Especially among staff who had been in MMT
 Taking methadone sensitivity training was
correlated with lower abstinence orientation and
greater methadone knowledge.
Investigating Challenges: TC
client beliefs about methadone
 Focus Groups conducted separately with clients on
methadone and clients not on methadone
– Clients from both groups expressed jealousy toward the
other
– Clients from both groups had similar suggestions for
improving the integration of treatment:
• Add client and staff education about methadone
• Make methadone more accessible at the TC
Challenges to integrating
methadone and residential
treatment
 Differences in structure
 Difference in staff
 Differences in treatment philosophy model
Differences in Structure
 Time:
– Methadone clinic: 1 hour/day or less, depending on
counseling required, take-home doses
– Residential treatment: 24 hours/day
 Interaction with other clients:
– Methadone clinic: limited to groups
– Residential TC: relationships in the community serve as
treatment
 Intensity
– Methadone - outpatient - use motivation
– TC - inpatient - use behavioral intervention with
structure
 Confidentiality and rapport-building
Differences in Staff
 Methadone Clinic
– Greater medical focus
– Some staff in recovery
– University based program
– Smaller staff
 Therapeutic Community
– Less medical focus
– Most WH staff in recovery
– Most staff are certified counselors
Differences in Treatment
Philosophy
(1) Client Centered Approach vs. Consensus Model
(2) Abstinence vs. Harm Reduction Model
– Abstinence philosophy: historically actively discouraged use of
most mood altering drugs including prescription medications.
– Harm reduction: the reduction, even to a small degree, of the
harm caused by the use of drugs (Parry, 1989).
(3) Biopsychosocial model vs. Social Rehabilitation
Model
Challenges
 Staff have differing ideas of what treatment
goals are
 Clients may get mixed messages from
different programs
 Some behaviors are tolerated in one
environment, but not another (relapse, nodding,
dose increase)
 Opportunity for staff splitting
Recommendations to Improve
Collaboration
 Training/Inservices
– Tours
 Policy
– Fast Track Admissions to Methadone
 Communication
– Collaborative work groups
Suggested Accommodations in
TC
 Modifications for Residents
– Methadone Group
(Separate groups for clients tapering vs. maintaining
– Alternative Therapies (e.g., acupuncture)
– Medical Support while tapering
– Coordination of medication issues with methadone
clinic staff
– Education for non-ORT residents
– Include methadone goals in treatment plans
 Modifications for Staff
– Methadone sensitivity training
– Policies regarding residents on ORT
Suggested Accommodations for
Methadone Clinics
 Modifications for Clinic Clients
– Flexibility in psychosocial treatment requirements
– Ease of access: Mobile Program/Take home doses
– Coordination of medication issues with TC Staff
 Modifications for Clinic Staff
– Policies regarding residents in TC
• Take homes, etc.
– Training on TC’s, facility tour
– Focused supervision with counselors
• Common treatment goals, cultural integration, communication
– Active role in education & bridging relationships
There, I think I’ve bounced enough ideas
off you for now…
Discussion/Questions
???
Therapeutic Community as
Treatment
1. In the TC, the relationship is the treatment.
2. The TC is community-centered, not client-centered.
3. The TC goal is always to get patients off all Opioid
Replacement Therapies.
4. TCs do not use a harm-reduction approach.
5. Use of medication is incompatible with TC policies.
6. In the TC, confrontation is a necessary part of treatment.