Oral Substitution Treatment for Opioid Dependence: A Training in Best Practices

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Oral Substitution Treatment for Opioid
Dependence A Training in Best Practices
Program Design for Nepal
Day 3
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

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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 Canadas 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,

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Clear Program Philosophy and Treatment Goals
Adequate Resources
Involvement Of Wider Community
Program Development And Design
Focus on Engagement and Retention
Client/Patient Involvement
A Maintenance Orientation
Integrated Comprehensive Services
A Client/Patient Centered Approach
Accessibility
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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

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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

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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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Expectations for Certification Training Contract

• Listening is a key to this training. Listen to
  new ideas. Listen to whats coming up inside you
  in relation to whats 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.

• 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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Learning Environment

• 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.

• 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. Dont be
  leaky.
• Turn off phones please.

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The Counseling Relationship in Pharmacotherapy
and OST

• Induction to Stabilization to Maintenance

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Counseling Increases Effectiveness of OST Programs

• Crisis intervention
• Case management, incl. referrals to and liaison
  with other agencies
• Individual one-on-one counseling
• Group counseling
• Couples or family counseling
• Vocational counseling

• Pre- and post-test HIV counseling, and counseling
  related to other medical conditions
• Health and other education programs
• Brief, supportive contacts
• Long term intensive support

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Insight from the Field

• Counseling should be as-needed, rather than
  mandatory
• When they are ready to do so, client/patients
  should have access to evidence-based approaches
  to counseling to address issues of concern to
  them.

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Best Practices demonstrate

• Behavior change as it relates to drug dependence
  is a set of personal and social processes
• Professional or service provider doesnt change
  the client we providing a facilitating
  environment that supports their change process.
• Client expectation/readiness needs to be matched
  to appropriate counseling strategy
• Importance of trusting relationship with warm,
  inspiring, socially sanctioned counselor(s)
• Prochaska, DiClemente, Norcross
  Transtheoretical Model of Behavior Change

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Role of the Clinician

• Counselor style is a powerful determinant of
  client resistance is a powerful determinant of
  client resistance and change.
• Confrontation is a goal, not a style.
• Argumentation is a poor method for inducing
  change.
• When resistance is evoked, clients tend not to
  change.
• Client motivation can be increased by a variety
  of counselor strategies.
• Even relatively brief interventions can have a
  substantial impact on problem behavior.
• Motivation emerges from the interpersonal
  interaction between client and counselor.
• Ambivalence is normal, not pathological.
• Helping people resolve ambivalence is a key to
  change.

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Action Abstinence?

• Many professionals are trained to help people who
  are in the action stage of change, and programs
  are geared to action. Action is synonymous with
  readiness and commitment to abstinence.

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Stages of Changing Behavior (Prochaska et al)
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Characteristics of SOC

• Change is a process and happens in stages it is
  not linear.
• Each stage of readiness for change has its own
  cognitive and behavioral characteristics.
• Counseling interventions need to be appropriately
  matched or tailored to the stage of readiness.

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Characteristics of SOC

• Relapse is a normal part of the process of stage,
  not outside.
• Thinking happens at every stage it doesnt start
  with action or preaction. It can be engaged as
  ambivalence.
• Goals look different and evolve through stages.

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Operationalizing Health Promotion Objectives

• Just because someone learns to parrot a message
  doesnt mean they are committed to changing their
  behavior or practices
• Just because someone is committed to changing
  does not mean this translates into what they
  actually do when they are confronted in their
  local worlds with competing variables
• The role of the intravention, collective
  empowerment

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Stages of Changing Behavior (Prochaska et al)
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PROCESS GOALS TECHNIQUES
Emotional Arousal Experiencing and expressing feelings about ones ambivalence, problems, and solutions
Self-reevaluation Assessing feelings and thoughts about self with respect to problem
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PROCESS GOALS TECHNIQUES
Commitment Choosing and committing to act, or belief in ability to change
Countering Consciously substituting alternative strategies for problem behaviors
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PROCESS GOALS TECHNIQUES
Identifying and controlling environmental effects Avoiding stimuli (people, places, things) that elicit problem behaviors Environmental restructuring, avoiding high-risk cues/triggers, book-ending with peer support in stressful situations, assertiveness
Reward Rewarding self, or being rewarded by others, for showing up, experiencing alternatives, making changes.
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PROCESS GOALS TECHNIQUES
Helping relationships Enlisting the help of someone who cares
Increasing social capital Joining social networks which provide personal, interpersonal, community resources that can enhance individuals social functioning, development and access to social and material resources. Entails obligation and expectation. Social control, norms, and relationships valuable to personal development.
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Outreach

• Outreach In order to increase access to OST,
  programs should consider proactive measures to
  reach out to potential clients/patients who are
  not likely to access treatment without
  encouragement and support.
• Outreach is an area in which peer-based
  strategies and linkages and partnerships with
  NGOs working at the front-line or street level
  are particularly important.
• Outreach workers can benefit from motivational
  interviewing (MI) training

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Advocacy

• The role of a client/patient advocate includes
  providing clients/patients with information about
  the program and their rights and
  responsibilities, as well as intervening on
  clients/patients behalf to help access services
  and support.

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Client/Patient Involvement
OST programs need to value, seek out, encourage
and support client/patient involvement.

• Feedback mechanisms for clients/patients, such as
  suggestion boxes, surveys, and focus groups
• Outreach programming
• Providing peer counseling and support
• Clients/patients training to become counselors

• Client/patient participation on community
  advisory boards
• Client/patient participation on decision-making
  bodies
• Client /patient involvement in evaluating the
  program

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Self-efficacy

• Compare self-esteem and self-efficacy. The
  transition from I think I can to I know I can.
  Becoming to being.
• Awareness of a problem or discrepancy/dissonance.
  
• If I do it, there will be a benefit for me and
  things will be better.
• I have the capacity to do that. I have the
  skills to do that. I can see myself doing that.
  I have what it takes. That is who I am. The
  person who does that.
• If someone doesnt believe they can change, why
  should they look at it as a problem?

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Counseling and Self-Talk A Strengths
Perspective

• Informal Learning and the Notion of scaffolding
• Collective empowerment and the dynamics of group
  work
• Accurate Empathy
• Attention to Stage of Readiness for Change
• Engaging Ambivalence Motivational Interviewing
• Alternative social and physical activities
• Mutual Self-Help Groups
• Peer Driven Activities and Volunteering

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Change is a Social Process

• It is important to recognize from the start that
  change in drug practices is a complicated social
  process
• Individual change including being exposed to
  drugs and having the opportunities to use drugs
  to initiating drug use to modifying drug
  practices happens in social situations and
  proximal environments
• Behavior change is a consequence of social change
• Too often, health workers focus exclusively on
  the individual as the way to realize health
  objectives

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Working with Drug Using Youth and Young Adults A
Strengths Based Approach

• Ambivalence among youth is common
• Developing autonomy and individuation means
  pushing back against authority, institutions, and
  norms
• There is an interest in values, identities,
  roles, relationships
• Peer groups are important
• Curiosity and openness to philosophical questions

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Capacity Building in Brazil

• The key is to not to treat population as if they
  are empty bank accounts to be filled by our
  expertise.
• How to we facilitate a process that will
  collectively empower them to be more competent
  in their everyday world by enlisting them to
  describe scenes in their own words-coding
  analyze operative scripts and structures that
  condition their practices- decoding. Paiva,
  2000

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Capacity Building II

• This involves decoding and consciousness raising
  they identify problem areas from their point of
  view, e.g. acting out a skit or tableau, in which
  they have an opportunity to generate and practice
  new choices and solutions for each other.

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Capacity Building III

• The process of conscientization is useful for
  marginalized or stigmatized people where they are
  able to see themselves and each other as
  responsible subjects capable of self-regulation
  and making change rather than passive objects
  acted upon. Freire, as cited in Paiva, 2000

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Capacity Building

• On-going experience of conscious practice, like
  strengthening a muscle, as an alternative to
  passivity or falling into something or in with
  what other people do.
• New experiences mean new experiences of
  themselves. When they reflect back on a new
  experience I can do this. I did this, I can do
  it again. That was really me, they are
  integrating or internalizing new experiences,
  into a new idea about themselves and their
  capacity, e.g. self regulation, persistence,
  achieving competence in their every day life.
• Transformation of understanding of self from a
  person things happen to to an active subject
  acting relationally in the world to take better
  care of themselves. Treatment that focuses on
  building self-efficacy, and ego strengthening
  is in plain words, building up the executive
  manager within oneself, i.e., the person who
  gets things done. Think, for example, of the
  manager of his or her own business.
• Group work can help develop language and
  communication skills that build an individuals
  confidence to have a conversation, to self manage
  the impression they leave on others with whom
  they are interacting.

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Group Work in OST Provides

• A mirroring process where individuals can observe
  or experience similarities or contrasts in their
  thoughts, feelings, actions
• An opportunity to experience oneself in the
  presence of others, breaking isolation,
  uniqueness, fear, shame

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Group Work in OST Provides

• A social arena to witness and model a peer
  transformational process
• Learning by analogy (others behavior).
• Learning by identification.
• Learn through trial and error.
• Learn by modeling.
• Amplification of positive change.
• Collective empowerment
• Clear parameters or limits for interpersonal
  interaction

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Group Work in OST Provides

• Support for the development of alternative social
  networks that reinforce the process of
  transformation

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Example First Group Session
Closing
Introductions
Check Out by participants
Summary
Ground rules
Centering
Reasons for coming to The group and concerns
What is good about injecting
What Is not So Good injecting
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Second Group Session
Welcome
Check out and closing
Summarizing
Centering
Ambivalence about relationships, values and
behaviors
Check in and Review of Second session
Values
Map of my relationships
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Third Group Session
Welcome
Check out and closing
Summarizing
Centering
Ambivalence about change
Check in and Review of Third session
Building Discrepancy
Reasons for wanting And not wanting to make a
particular change
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What are the norms within your drug using
relationships or informal groups?
?

-
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A Basic Counseling Exercise

• What is something pleasurable to me, important or
  valuable? Describe in detail.
• What is the risk? Describe in detail.
• How can I reduce the risk or cost but hold on to
  what is pleasurable or find a new alternative?

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Incremental Change

• Process of getting stuck or dependent and the
  process of getting unstuck
• Autonomy- Staff or helpers are on the sidelines.
  How do you help without encouraging dependency
• Capacity for Flexibilityadjust strategies I
  had a math teacher. I didnt understand the
  problem. She explained it again the same way.
• Progress not perfection or single outcome
• Set own goals and move at own pace. Goals evolve.

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Motivational Interviewing

• Uncertainty or ambivalence about change is at the
  heart of the difficulties many clients experience
  in treatment. This is also the challenge
  narcologists experience with clients who have
  addictive problems. 
• The question for us is how can we provide the
  client with an opportunity to articulate, explore
  and resolve this ambivalence for him/herself?

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AMBIVALENCE AND DECISIONAL BALANCE
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What is Motivation?

• Motivation can be defined as the probability
  that a person will enter into, continue, and
  adhere to a specific change strategy.

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Motivation

• Motivational interviewing assumes that the state
  of motivation may fluctuate from one time or
  situation to another (Miller Rollnick, 1991).
• Therefore, this state can be influenced.
• By providing a safe, nonconfrontational
  environment, eliciting hope, helping clients
  clarify ambivalence about their drug use and
  about making change, counselors can be helpful in
  tipping the scales in favor of readiness to
  make a positive change.

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Spirit of Motivational Interviewing

• Developing a collaborative partnership
• Counselor facilitates rather than coerces
  ambivalence and change
• Client is assumed to have resources and
  motivation for change
• Ambivalence is enhanced by drawing on clients
  own perceptions, goals and values
• Counselor supports clients capacity for
  self-directed change

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Review 7 Early Strategies

• Ask open-ended questions
• Listen reflectively.
• Elicit ambivalence.
• Do not project your ideas onto the client.
• Affirm. Focus on eliciting strengths not on
  pathologies or what is wrong with the person.
• Foster a sense of collaboration with the person.
• Summarize at key intervals and ask for their
  comments

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A Working definition

• We can define motivational interviewing as a
  client-centered , directive method for enhancing
  intrinsic motivation to change by expressing,
  exploring, and resolving about problematic
  behaviors and behavioral change.
• It is a way of being with people.
• It is directive in terms of the process and
  techniques of addressing ambivalence, not
  directive about the outcome of the counseling.
• It is client centered because all the benefits
  and consequences of making a change are elicited
  from the client.

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Engagement of People who are highly ambivalent

• The largest group of people who are using and are
  at risk are outside the action stage, yet
  majority of services are directed to action.
• Passive recruitment
• Proactive recruitment
• use of ambivalence and identification, avoid
  labeling, be positive and tangible

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Stages of Changing Behavior (Prochaska et al)
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Sanjar On the One Hand

• His use provides excitement, a change in feeling
  and thinking, relief
• Finding ways to obtain and afford the drug
  provides him with adventure and achievement
• Preparing and administering may provide a sense
  of competence and even looking out for others in
  his group
• Interpersonal reinforcement as he negotiates
  successfully various networks in which he
  interacts to obtain money, acquire the drug,
  share the drug, play a role, earn respect and
  recognition.
• Using is a reward for successfully completing the
  mission.
• Euphoric properties add to positive feelings

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Sanjar On the Other Hand

• Once he is down, he feels shame that he has
  neglected his familial obligations
• He sees himself in how neighbors look at him or
  avert their eyes
• He may feel used/depleted from the social
  interactions involved in the mission.
• He may feel he has let himself down and others
• He may hate needing his need for the drug
• He may feel wasted, depressed, low energy

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Best Practices demonstrate

• Behavior change as it relates to drug dependence
  is a set of personal and social processes
• Professional or service provider doesnt change
  the client we providing a facilitating
  environment that supports their change process.
• Client expectation/readiness needs to be matched
  to appropriate counseling strategy
• Importance of trusting relationship with warm,
  inspiring, socially sanctioned counselor(s)
• Prochaska, DiClemente, Norcross
  Transtheoretical Model of Behavior Change

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Benefits and Costs
Short term things that are not so good, okay or
acceptable to me
Short term things that are good, okay or
acceptable to me
Long term things that are good, okay or
acceptable to me
Long term things that are not so good, okay or
acceptable to me
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Benefits and Costs

• Use Motivational Interviewing approach, which
  aims to decrease the participants perception
  about the costs of changing.
• Change here depends on the pros (of change)
  outweighing the cons. Individuals can see that
  the cons of changing are different short and
  long-term, just as there are not many long-term
  benefits to continuing a problematic behavior.

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Lets Come Up With Situations or Dilemmas Adapted
to Real Life Among Drug Users In Our Regions
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Agenda Setting

• An outreach worker to an active drug user(s) in a
  natural setting
• As you know, there are a number of things that
  we could discuss today HIV, preventing
  overdoses, injecting practices and relations with
  others, any concerns you have generally about
  drug use but what are you most concerned about?
  What would you like to talk about today? Perhaps
  there is something especially important or
  something that is immediate?

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Is It an Open or Closed Question

• What do you like about injecting?
• Where did you grow up?
• Would you tell me what was good and maybe not so
  good about your first experience injecting?
• Isnt it important that you have the respect of
  your family?
• Have you ever had an overdose or witnessed
  someone overdosing?
• Are you willing to meet with me again?
• What happens with an overdose?
• What brings you here today?
• Do you want to stay in this relationship?

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Is it an Open or Closed Question?

• Have you ever thought about getting work?
• What do you want to do about your overdoses not
  inject alone, test the dose first, stop
  injecting, or just do what you are doing?
• In the past, how have you overcome an important
  obstacle in your life?
• Will you try for a week to avoid talking about
  injecting with non-injectors, not injecting in
  front of non-injectors, and not giving people
  their first hit?
• What are the most important reasons for avoiding
  talking about injecting with non-injectors, not
  injecting in front of non-injectors, and not
  giving people their first hit?

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Empathy

• The principle of empathy is acceptance.
• Through respectful reflective listening the
  counselor seeks to understand the clients
  perspective without judging, criticizing or
  blaming.
• Acceptance is not the same thing as approval or
  agreement.
• Ironically, this kind of acceptance of people as
  they are seems to free them to change, whereas
  insistent nonacceptance tends to immobilize the
  change process. The person focuses on defending,
  arguing, winning the argument or the counselors
  acceptance, rather than self- reflection and
  self-assessment.

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Summary of Accurate Empathy

• Express empathy, which helps create the safe and
  non-judgmental setting for the participant,
  regardless of the setting
• Skillful reflective listening is a fundamental
  tool of motivational interviewing
• Ambivalence is accepted as a normal part of human
  experience and change, rather than a pathology or
  sign of incapability or defensiveness or
  resistance.

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Reflective Listening

• The fundamental tool of motivational interviewing
• What people really need is a good listening to.
  Mary Casey

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Listen Reflectively

• Overview You all know it but it is an art.
  Were going to open it open for examination over
  the next exercises. Its not one note but
  scales. Repeating, rephrasing, paraphrasing,
  identifying underlying feeling.
• Referring back to what we discussed yesterday
  about reflective listening when a client listens
  to you reflect back on what s/he just said, s/he
  is now listening to see
• if you are really paying attention
• if its accurate
• if s/he hears something new about him/herself
• How it feels to hear his/her own thoughts
  expressed by another
• In these exercises try to self observe how you
  feel about limits. Try to find your authenticity
  within structure of each form.

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Exercise

• What is ambivalence or feeling two ways about
  something? What do you associate with it?
• What is reflective listening?

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Consciousness Raising

• It begins with how I treat a client, the
  assumptions I make, the conversation we have.

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Needs Improvement

• Lack of Drug Dependence Training of Physicians,
  Psychiatrists, Nurses, and Social Workers
• Lack of willing providers
• Lack of awareness in Primary Care
• Professional turf issues
• Fear of regulation
• Cost
• Medication
• Profiteering

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Capacity Building

• Expanding the team to address drugs and drug
  practices appropriately
• The client can identify a drug issue with me
• The client can talk about drug use within our
  services
• The client can get supportive services to stay
  healthy
• The OST can respond more effectively to drug
  related health issues.

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Medically Supervised Withdrawal

• When stable client/patients in the maintenance
  stage ask for dosage reductions, it is important
  to explore their reasons.
• They may believe they can get by on less
  medication or may be responding to external
  pressures.
• Client/patients on lower dosages may consciously
  or unconsciously be perceived as better
  patients.
• Counseling and education is key to exploring the
  short and long term benefits and costs of current
  dosage and then of dosage reduction.

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Voluntary Tapering and Dosage Reduction

• Some studies indicate high relapse rates, often
  80 or more, for client/patients who attempt
  cessation of maintenance medication, including
  those judged to be rehabilitated before tapering
  (e.g., Magura and Rosenblum, 2001).
• However, likelihood of successful tapering also
  depends on individual factors such as motivation,
  family support, and other social protections
  such as employment, etc.

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Clients/patients may consider leaving treatment
for a variety of reasons including

• Unrealistic expectations for recovery
• Pressure from family members and others,
  including program team members
• The social stigma associated with methadone
• Program team members beliefs about the
  desirability of abstinence from methadone as a
  goal of treatment
• The inconvenience of regular attendance to obtain
  methadone and other program requirements

• Financial reasons (cost of treatment)
• Demands of work
• Travel restrictions
• To find out if they can manage without methadone
  or not, e.g. for individuals who have become
  stabilized on methadone, and have not used
  opioids in a long time, a decision to attempt
  tapering may be wise and appropriate.

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Voluntary Tapering and Dosage Reduction

• As part of informed consent process, the
  possibility of relapse should be discussed with
  client/patients, especially those who are not
  stable on their current dosage.
• They and their families should be aware of risk
  factors for relapse during and after tapering.
• Client/patients who choose tapering should be
  monitored closely and have access to individual
  and group relapse prevention counseling,
  education, and support that accompanies and
  extends beyond period of tapering.

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Voluntary Tapering and Dosage Reduction

• If relapse occurs or is likely, additional
  therapeutic measures can be taken, including
  rapid resumption of OST when appropriate
  (American Society of Addiction Medicine 1997).
• Clients/Patients being tapered off methadone
  should have access to an increased dose to get
  through a rough patch without having to go
  through a program re-entry process.

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Methadone Dosage Reduction

• A common practice of graded methadone reduction
  is to reduce daily does in roughly 5-to-10
  percent increments with 1 to 2 weeks between
  reductions, adjusting as needed for
  client/patient conditions.
• Because reductions become smaller but intervals
  remain about the same, many months may be spent
  in such graded reductions.

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Methadone Dosage Reduction

• A slow withdrawal gives client/patients time to
  stop the tapering or resume maintenance based on
  individual client/patient response, especially if
  relapse seems likely.
• Regardless of rate of tapering, a point usually
  is reached at which steady-state occupancy of
  opiate receptors is no longer complete, and
  discomfort, often with drug hunger and craving,
  desperate feelings or panic, emerges.

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Methadone Dosage Reduction

• This point may occur at any dosage but is more
  common with methadone when the dosage is below 40
  mg per day.
• Highly motivated client/patients with good
  support systems can continue withdrawal despite
  these symptoms by tightly embracing structural
  supports as dose decreases.
• Some client/patients appear to have specific
  thresholds at which further dosage reductions
  become difficult.
• Blind dosage reduction is appropriate only if
  requested by the client/patient, discussed and
  agreed upon before it is implemented.

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Methadone Dosage Reduction

• SAMHSAs Treatment Improvement Protocol (TIP) 43
  strongly recommends that OST staff always
  disclose dosing information unless individual
  client/patients have given specific informed
  consent and have requested that providers not
  tell them their exact dosages.

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Methadone Detoxification

• For client/patients who prefer detoxification to
  maintenance, there are two kinds of
  detoxification
• Short-term treatment of less than 30 days
• Long-term treatment of 30 to 180 days
• Patients who fail two detoxification attempts in
  12 months should be evaluated for different
  treatment or mode of treatment.
• Two factors should be considered in short-term
  detox the brief duration of initial dose may
  preclude achievement of steady state tapering
  may be too steep if it begins at a dose greater
  than 40 mg.

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Involuntary Tapering or Dosage Reduction

• When clients/patients violate program rules or no
  longer meet treatment criteria, involuntary
  tapering should be avoided if at all possible.
• Treatment decisions should be made in the
  client/patients best interest rather than as
  punitive measure.
• Many days of dosing missed, client progress is
  unsatisfactory, unwillingness to comply with
  treatment contract, nonpayment of fees are some
  reasons for a change in strategy.
• Continued maintenance at an adjusted rate along
  with increased and focused counseling and support
  is recommended.

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Impact of discharge
Deaths following involuntary discharge or drop
outs from methadone treatment 1 year follow- up
In treatment Discharged Deaths 4/397 9/11
0 () (1) (8.2)
Zanis, 1998
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Involuntary Tapering or Dosage Reduction

• Efforts should be made to retain these at-risk
  clients/patients in methadone treatment even
  though their treatment response may be
  suboptimal.
• Zanis 1998

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Take-Home Medications Unsupervised Doses

• Absence of recent drug and alcohol abuse
• Regular OST attendance
• Absence of behavior problems at OST
• Absence of recent criminal activities outside OST
• Stable home environment and social relationships

• Acceptable length of time in comprehensive
  maintenance treatment
• Assurance of safe storage of take-home medication
• Determination that rehabilitative benefits of
  decreased OST attendance outweigh the potential
  risk of diversion

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Take-Home Medications Once Clinical Criteria
(Above) are Met

• First 90 days 1 take-home per week
• Second 90 days 2 take-home per week
• Third 90 days 3 take-home per week
• Fourth 90 days 6 days supply of take-home doses
  per week

• After 1 year of continuous treatment 2 weeks
  supply of take-home medication
• After 2 years of continuous treatment 1 months
  supply of take-home medication, but monthly
  visits to OST are still required.

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5. Best Practices in MMT- Program Policies and
Reducing the Barriers

• Open Admission Procedures
• Timely Assessment and First Medication
• Immediate Crisis Management
• Initial Assessment
• Informed Consent
• Ongoing Assessment-in Action
• Comprehensive Assessment
• Adequate Individualized Dosage
• Unlimited Duration of Treatment
• Clear Criteria for Involuntary Discharge
• Non-Punitive Use of Urine Toxicology Screening
• Client/Patient-Centered Tapering

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OST Goal Engagement

• Distinguish between response to illicit drugs and
  response to people who use illicit drugs
• Drugs trafficked across borders and circulated
  locally are objects
• There is tendency to objectify people using those
  drugs, dehumanize them, deprive them of rights to
  treatment and assistance
• We distance ourselves from people who use these
  drugs and forget that they are part of families,
  communities, societies
• Most People who need treatment stay away

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Maslow Needs/Values Pyramid
Self-actualization, Creation, transcendence of
identity barriers
Achievement, knowledge, understanding, psychology
Acceptance by others, sense of belonging, receipt
of attention, approval, praise
Sustenance of biological needs, protection and
safety from pain or danger, facilitation of
pleasure
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Engagement of People who are highly ambivalent

• The largest group of people who are using and are
  at risk are outside the action stage, yet
  majority of services are directed to action.
• Passive recruitment
• Proactive recruitment
• use of ambivalence and identification, avoid
  labeling, be positive and tangible

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Reducing Barriers

• Program location inaccessible to or remote from
  target group or community
• Fear of or perception of registration, stigma,
  professionals
• Lack of availability of treatment
• Lack of confidence in treatment effectiveness
• Financial Costs
• Requirement that abstinence be the exclusive goal
  of treatment

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Reducing Barriers

• Low threshold access to services where the
  requirement of abstinence is not a precondition
  for receiving treatment.
• Recruit, train and hire members of target group
  (users and former users) to do community-based
  outreach
• They have insider access to drug-using
  (networks), they know the rules governing the
  social systems of the streets, and they are able
  to develop trusting relationships with the target
  population of active drug users (Booth et al,
  1998)

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Meeting Drug Users on Their Own Ground

• The labeling of clients is avoided
• Clients provide the definition of the situation
  as they see it
• Clients who wish it are given advice on how to
  reduce the harms associated with their drug use
• Counselor and client collaborate on a broad range
  of solutions to the client-defined problem
• Resources are gathered or located to meet the
  individual needs of the client
• Change can be incremental and clients are viewed
  as amenable to change, if abstinence is not the
  only option.

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WHAT IS A STRENGTHS-BASED APPROACH?

• Recognizes and supports incremental change sees
  possibility of change in everyone
• Allows choices
• the goal of the helping relationship (harm
  reduction, substitution therapy, treatment
  readiness, abstinence)
• informed choice about a variety of treatment
  contexts (same gender group, outpatient,
  inpatient, mutual help groups)
• Informed choice about treatment methods
• Pays attention to clients expectations and stage
  of readiness for change

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VARIETIES OF MT CAN BE CLIENT-CENTERED(WHO, 1990)

• Short-term detoxification decreasing doses during
  one month or more
• Prolonged detoxification decreasing doses while
  more than one month
• Short-term maintenance treatment stable
  prescription methadone during a six month or less
  period
• Long-term maintenance therapy using methadone in
  the time frame of longer than one year and
  possibly ongoing

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Harm Reduction in Practice

• Meet them where theyre at
• Work on whats bothering them rather than whats
  bothering me
• Have low threshold access
• Same day and walk-in appointments
• If at first you dont succeed, redefine success
• Dana Davis, Allegheny General Hospital Positive
  Health Center, Pittsburgh, PA

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Best Practices in MMT- Program Development and
Design

• Clear Program Philosophy and Treatment Goals
• Focus on Engagement, Retention, and Improved
  functionality and fitness
• A Maintenance Orientation
• A Client/Patient-Centered Approach
• Accessibility
• Integrated Comprehensive Services
• Client/Patient Involvement
• Involvement of Wider Community
• Adequate Resources

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Setting Realistic Treatment Goals

• Retention is important because research has
  affirmed that again and again, the longer opiate
  users stay in treatment, the better the outcomes
• The goal of drug treatment can be increased
  quality and quantity of life, functionality and
  fitness, as they describe those, rather than
  abstinence
• Both individual and societal benefit is achieved
  in maintenance even if abstinence is not an
  outcome

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Treatment Readiness

• Brings Treatment to Where People Are
• Stepped Approach to Treatment
• Abstinence is Not the Exclusive Outcome
• Avoids Labeling
• Recognizes Stages of Change
• Uses Motivational Interviewing, Acupuncture,
  Individual and Group Counseling

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Recognize success

• Success in medical treatment
• Obtaining employment
• Recognition of all life improvements
• Family relationships

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DRUG- SUBSTITUTION THERAPY IN KYRGYZSTAN

• In the MMTP in Bishkek, patients interacted
  comfortably with staff who treated them with
  respect they took individual and group
  counseling, and family members also had an
  opportunity to be involved throughout treatment
  process.
• Family members of methadone clients reported that
  they had returned to themselves, they looked,
  spoke and acted differently and were able to
  resume their roles within the family.
• Drug users talked animatedly about the impact the
  methadone treatment experience on their lives
  with families and their work
• It was apparent that this form of substitution
  therapy, provided within this context, from the
  perspective of the users and the family members
  was treatment.

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INTEGRATION WITH OTHER APPROACHES

• Nearby the narcological dispensary in Kyrgyzstan,
  where MMTP was offered, NGO Sotsium, run by
  another narcologist, provided an array of
  services including syringe exchange, medical
  services, a hot line, volunteer and training
  opportunities, a variety of self-run 12 step
  meetings open to the community, and a pilot
  inpatient treatment and rehabilitation program

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Research and Evaluation

• Increase the understanding, acceptance of and
  level of support for OST in Nepal
• Refine Program Delivery on an Ongoing Basis
• Identify the Most Effective Ways to Address the
  Needs of Diverse Client/Patient Groups
• Improve Treatment Outcomes
• Reduce the Harms Associated with Opiate
  Dependence
• Expanding OST in Nepal and Adapting OST to Other
  Settings Across Nepal

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Timely Assessment
Open Admission
Ongoing Client/patient Input into Services
Program Policies
Adequate Individualized Dose
Client/patient Centered Tapering
Methadone Dosage during Pregnancy
Non-punitive Approach to Drug Use During Treatmen
t
Unlimited Duration of Treatment
Clear Criteria For Involuntary Discharge
Summarizing Best Practices in OST
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12. Next Steps