Transcript Integrating Antagonist Medications Into Residential Treatment

Integrating Antagonist Medications
Into Residential Treatment
Jeremy King LMSW, CASAC
Justin Mitchell LMHC, CRC
Today’s Learning Objectives
After completing the training, participants will be able to:
• Explore attitudes and beliefs associated with the
use of antagonist medications
• Discuss benefits of antagonist medications
• Discuss barriers to the use of antagonist
medications in intensive residential
rehabilitation
Today’s Learning Objectives
(continued)
• Provide treatment providers with
recommendations for the integration of
antagonist medications in residential treatment.
• Explore how to address issues related to noncompliance with medication regimen
• Review the treatment process as it relates to
utilizing MAT treatment.
Attitudes and Beliefs Exercise
• On a scale from zero to ten:
▫ How important is it for your program to provide access to
medication assisted treatment to your service recipients.
▫ How confident are you in your program’s ability to
successfully integrate the use of addiction medicine into the
your treatment program.
What is Medication-Assisted Treatment
(MAT)?
• MAT is pharmacotherapy used to support
treatment and recovery efforts for people
seeking to overcome addictive disorders.
• It combines prescribed medications with
counseling and behavioral therapies,
monitoring, community-based services, and
recovery support.
What is Medication-Assisted
Treatment (MAT)?
(continued)
• This provides the client with a comprehensive
treatment approach for the bio-psycho-social
condition known as addiction.
• As suggested in its name, MAT is designed to
assist, not replace other treatment and recovery
efforts but supplements psychological,
behavioral and social interventions.
Brief Overview of What Addictive Disorders
Can be Treated by MAT
• Alcohol Use Disorders
• Opioid Use Disorders
• Tobacco Use Disorders
• (Today we are focusing on medication used to
treat the first two)
Stigma Associated with Being on MATs
• In general, individuals with substance use
disorders are viewed as making bad choices and
not having enough will-power
• Medications like Campral and Vivitrol are
viewed as “crutches”.
• “You are replacing one drug with another”
• MAT keeps you addicted – “You’ll never stop”
Addiction and the Brain
• Drugs of abuse produce their effects by altering
brain chemistry and structure.
• Neurotransmitters and associated receptors
responsible for everyday functions are altered by
the consumption of drugs.
• Problems or dysregulation of brain chemistry
cause the symptoms of mental illness (PAWS).
• Neurotransmitters and associated receptors
responsible for everyday functions are altered.
Dopamine is one of the primary
neurotransmitters in the experience of pleasure
and the maintenance of addiction.
• Many drugs of abuse
stimulate neurons in the
ventral tegmental area,
releasing dopamine in the
nucleus accumbens and
prefrontal cortex.
• Nearly all drugs of abuse
increase dopamine in the
nucleus accumbens,
which appears to be the
primary reinforcement
center of the brain.
Addiction and the Brain
• Pre-addiction brain functioning does not return
with the end of withdrawal.
• Post Acute or Protracted Withdrawal symptoms
(anhedonia, sleep problems, other depressive
symptoms) can last for months
• Neurobiological urges and cravings associated
with internal and external triggers can continue
to be
A Bio-Psycho-Social Disorder
• Substance Abuse treatment providers
incorporate a variety of interventions to help
patients change the way they think and behave,
interact socially and better manage their
environment.
• Addiction and psychiatric medications help
change biology.
MAT: Research Outcomes
• In the second year of a project conducted by the Denver
Health’s Behavioral Health Services (BHS), an average of
over 16 clients per month received Vivitrol®. Over 90
percent of clients reported that Vivitrol® helped them in
their recovery from alcohol dependence.
• Vivitrol® has demonstrated significant effects on sixmonth abstinence rates and reduced the number of days
spent drinking and the number of drinks consumed
(O’Malley et al. 2007).
MAT: Research Outcomes
(continued)
• Clinical evidence suggests that when naltrexone is combined
with psychosocial treatment models, it reduces the percentage
of days that the patient drinks, reduces the alcohol consumed
when the patient does drink, and prevents the patient from
relapsing and drinking excessively (Harris, K. M., et. al,
2004).
• Since 1994, naltrexone has been used as an adjunct in the
treatment of alcohol dependence with positive effects in
increased duration of recovery, reduced cravings, and reduced
intensity of relapse (Fudala, P. J., et. al., 2003).
Addiction Medicine Classifications
• Agonist-Replicates action of the substance at the
receptor site-Methadone, Buprenorphine
(Partial Agonist)
• Mixed Agonist-Antagonist Replicates and blocks
action of substance (Suboxone)
• Antagonist-Blocks the receptor site so that
substance cannot impact the brain▫ Oral Naltrexone (Revia),
▫ Injectable Naltrexone (Vivitrol),
▫ Acamprosate (Campral)
Case Study: Andrew A.
• Client is 54 year old male with a 20 year history
of problematic opiate use. Client entered
treatment in 07/2014 and left against clinical
advice later in the month. Received call from
client’s son that the client had overdosed and
nearly died. Client’s son requested that we readmit the client.
Using MAT in Residential Treatment
Antagonists: Why In Residential?
• Many clients in residential have histories of
chronic use and failed treatment episodes.
• High percentage of admissions with
alcohol/opiate use disorder
Benefits of Antagonist Use In
Residential Treatment
• No abuse potential-store/monitor medication
like any other non-narcotic medication.
• Fits well with abstinence only program
philosophies.
• Potential to engage/retain service recipients who
might otherwise separate.
Integrating MAT: Barriers
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Lack of buy-in from staff (medical and clinical)
Lack of education among program participants
Resistance from criminal justice referral sources.
Coordinating MAT interventions between
medical and clinical staff.
Addressing Barriers: Staff Resistance
• Staff receive training:
Stigma and bias associated with MAT
Types of MAT (Agonist Vs. Antagonist)
Clinical appropriateness for MAT
Tx planning and individual counseling for MAT
Medication compliance/non-compliance with
MAT
• Discharge planning for individuals receiving MAT
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Addressing Barriers: Client Education
• Clients receive education from point of first
contact.
• MAT has been integrated into psychoeducational seminars (delivered by both SW and
RN from clinical and medical perspectives)
• Clients meet with RN, SW, PC, and MD/NP for
exploration/education on MAT
Addressing Barriers: Criminal Justice
Resistance
• Many CJ referral sources did not understand the
difference between agonist and antagonist
medications.
• CJ sources threatened to remove clients from
program at beginning.
• Provided education/free training to CJ CM’s.
• All court letters reflect MAT progress
(Induction/compliance/non-compliance)
Addressing Barriers: Coordinating
Service
• Clinical staff (PC or SW) refers client to onsite
RN.
• RN has brief session with client and makes
referral to medical clinic.
• Each program keeps a log of clients referred and
outcome of referral.
• Medical clinical keeps master log of all client
referrals and outcomes.
Addressing Barriers: Coordinating Service
(Continued)
• Log includes client name, drug of choice, date of
referral, type of medication, date of next
refill/injection.
• RN/PT communicates to clinical and medical
staff in cases of non-compliance/need for
medication refill.
• Medical staff communicates to clinical staff
when client fails to keep injection appointment.
MAT Screening and Assessment
• Beginning with admission process:
▫ What is client’s drug of choice?
▫ Has client used Medication Assisted Treatment in the
past?
▫ Does client have history of relapse/failed treatment
episodes?
MAT Screening and Assessment
Continued
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Comprehensive Evaluation
What substance is the client recovering from?
Can MAT help this client abstain from use?
Does the client express some interest in utilizing
medication to abstain from use?
• Has the client used this type of treatment in the
past?
▫ How did it work for the client?
Case Study: Andrew A.
• Phone screen was performed on client. Client
was assessed to be motivated to enter back into
treatment. Client was experiencing urges and
cravings for heroin. Client was asked about
antagonist therapy and stated he was interested
in taking medication.
MAT in Treatment Planning
• Problem: Client has severe heroin use disorder
that has negatively impacted functioning in
several life areas.
• Goal: To live a life free of problematic substance
use.
• Short Term Goal: Client will identify three
positive and three negative aspects of MAT use
over 90 day period (Amb. Client)
MAT in Treatment Planning (Continued)
• Intervention: Brief intervention with RN to
address client’s concerns regarding use of
medication.
• Intervention: Referral to medical clinical to
discuss medical aspects of MAT.
• Intervention: Individual counseling with SW/PC
to discuss clinical benefits of using MAT.
MAT Treatment Interventions
• Individual Counseling-Check in with client re:
▫ Medication compliance
▫ Urges and cravings
▫ Medication side effects
▫ Motivation to continue using medication
(SW and/or RN can also use brief treatment episodes to
check in on the aforementioned areas).
MAT Treatment Interventions
• Group Counseling
▫ Integrate MAT into relapse prevention curriculum
▫ Group psycho-education specific to the
medication offered in your program.
▫ Allow clients opportunities to discuss MAT during
groups/seminars (client word of mouth has been
one of the biggest factors in client engagement in
this area).
▫ Currently discussing MAT specific group for
clients on medications.
Working through Ambivalence Related
to Beginning and/or Continuing MAT
Using the Decisional Balance
• What are the benefits of beginning MAT?
• What are the consequences of beginning MAT?
• What are the benefits of not beginning MAT?
• What are the consequences of not beginning MAT?
Working through Ambivalence Related
to Beginning and/or Continuing MAT
• Reflect the client’s feelings regarding engaging in
MAT
• Gently express discrepancies between what the
client has communicated and his or her
behaviors
• Ask open ended questions which assist the client
in exploring his or her ambivalence
• Affirm the client’s efforts thus far
Strategies for Psychoeducation in MAT
• Introduce psycho-education at the beginning of
treatment so that it serves as an orientation to both MAT
operational and recovery processes.
• Involve family members and selected friends, with a
patient’s informed consent. Provide guidance in how to
support the patient’s recovery efforts.
• Adapt educational strategies and materials to the
patient’s culture and family.
• Discuss medications used for MATs, and dispel the
myths related to their use (e.g., “methadone rots the
bones,” “Naltrexone gets you high”).
Strategies for Psychoeducation in MAT
(continued)
• Discuss the power of triggers with patients and
families. For example, merely discussing heroin
can be a trigger for resuming its use.
• Incorporate special groups to discuss parenting,
childcare, women’s issues, and coping with
HIV/AIDS and HCV infection. Use generic
names for HIV/AIDS groups (e.g., “health care
issues” group) to avoid stigma.
Case Study: Andrew A.
• Client was determined to be clinically
appropriate for medication and received medical
clearance within 7 days of return. Client
received medication injection (Vivitrol) on day
ten. Client reported a decrease in cravings that
he attributed to medication. Client received
weekly brief interventions from RN to monitor
motivation, cravings and efficacy of medication.
MAT Treatment: Evaluation of Efficacy
• Assess change in client’s attitudes, beliefs, and
behaviors
• Identify change in client as defined in the
agreed upon plan
• Modify plan as necessary based on client’s
needs
• If minimal change has occurred, identified
barriers to change
Signs a Client May Not be Complying with
His or Her Medication Regimen
• Client’s urine is positive for his or her substance(s) of
addiction
• Client misses his or her appointment to renew his or her
prescribed medication
• Use Medication Administration Record to monitor
compliance with oral medication (create system for
communicating non-compliance)
• Track dates of injection and set up system for
communicating date of next injection (not enough to rely
on medical staff to track dates of injections).
MAT: Special Considerations for
the Helping Process
Intervention or Implementation
• Is the client attending his/her appointments
with the provider who is prescribing the
medications?
• Does the client communicate concerns about not
being able to access the medication?
• Is the medication helping the client to sustain
sobriety?
MAT Treatment: Relapse
• Was the client on MAT?
▫ If so, did client stop taking medication?
▫ Was clinical staff aware that client stopped taking
medication?
▫ Unmotivated clients should not be “forced” to take
medication.
▫ If client was not on medication, is client interested
in medication after relapse?
▫ If not, what are the barriers that the client
verbalizes with regard to taking medication?
MAT Treatment: Relapse
• Can be used to “intensify” treatment
• Alternative to service recipient discharge for
treatment non-compliance
• Can be used to justify continued treatment with
referral agencies including CJ referrals
• Managed care implications?
• Warning on working with unmotivated clients.
MAT Treatment: Termination
Terminating Counseling, but continuing MAT
• Have aftercare arrangements been made?
▫ Where will the client go for continued MAT?
• Is the client’s funding sources accepted by the
provider?
• Does the client have resources to utilize if he or
she requires additional support?
Case Study: Andrew A.
• The client left treatment against clinical advise
after six months. Client received referral to
outpatient treatment provider were MAT
treatment was available. Client verbalized
reduced cravings and increased motivation to
remain in recovery throughout his treatment
stay.
• Was this a positive outcome?
MAT In Residential: Areas for
Exploration
• Outcomes: How has this impacted our 30 day
retention rates, rates of relapse, treatment
compliance?
• Therapeutic Milieu: Has introducing this
medication impacted staff/client perception
about the treatment environment?
• Treatment Services: How has providing MAT
impacted the assessment, treatment planning,
intervention and discharge planning processes?
Resources
www.samhsa.gov
• TIP 43: Medication-Assisted Treatment for Opioid
Addiction in Opioid Treatment Programs
• Medication-Assisted Treatment for Opioid Addiction:
Facts for Families and Friends
• The Facts about Buprenorphine for Treatment of Opioid
Addiction
• The Facts about Naltrexone for Treatment of Opioid
Addiction
• Acamprosate: A New Medication for Alcohol Use
Disorders
Resources
(continued)
www.niatx.net
• Getting Started with Medication-Assisted Treatment
with Lessons from Advancing Recovery
www.rsat-tta.com
• RSAT Training Tool: Medication Assisted Training
(MAT) for Offender Populations
www.suboxone.com
• The Here to Help Program
www.vivitrol.com
• Information for Patients
Resources
(continued)
National Institute on Drug Abuse
• www.nida.nih.gov
National Alliance of Advocates for Buprenorphine
treatment
• www.naabt.org
National Alliance of Methadone Advocates
• www.methadone.org or 212-595-NAMA (6262)