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

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


1
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

2
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,

3
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
4
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

5
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

6
Learning Together
  • Parallel Process

7
Learning Process Knowledge and Skills
  • Acquisition of content
  • Retention (store in memory)
  • Application (retrieve and use)
  • Proficiency (integrate and synthesize)

8
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.

9
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.

10
The Counseling Relationship in Pharmacotherapy
and OST
  • Induction to Stabilization to Maintenance

11
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

12
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.

13
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

14
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.

15
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.

16
Stages of Changing Behavior (Prochaska et al)
17
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.

18
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.

19
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

20
Stages of Changing Behavior (Prochaska et al)
21
PROCESS GOALS TECHNIQUES
22
PROCESS GOALS TECHNIQUES
23
PROCESS GOALS TECHNIQUES
24
PROCESS GOALS TECHNIQUES
25
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

26
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.

27
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

28
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?

29
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

30
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

31
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

32
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

33
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.

34
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

35
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.

36
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

37
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

38
Group Work in OST Provides
  • Support for the development of alternative social
    networks that reinforce the process of
    transformation

39
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
40
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
41
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
42
What are the norms within your drug using
relationships or informal groups?
?

-
43
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?

44
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.

45
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?

46
AMBIVALENCE AND DECISIONAL BALANCE
47
What is Motivation?
  • Motivation can be defined as the probability
    that a person will enter into, continue, and
    adhere to a specific change strategy.

48
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.

49
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

50
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

51
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.

52
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

53
Stages of Changing Behavior (Prochaska et al)
54
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

55
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

56
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

57
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
58
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.

59
Lets Come Up With Situations or Dilemmas Adapted
to Real Life Among Drug Users In Our Regions
60
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?

61
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?

62
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?

63
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.

64
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.

65
Reflective Listening
  • The fundamental tool of motivational interviewing
  • What people really need is a good listening to.
    Mary Casey

66
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.

67
Exercise
  • What is ambivalence or feeling two ways about
    something? What do you associate with it?
  • What is reflective listening?

68
Consciousness Raising
  • It begins with how I treat a client, the
    assumptions I make, the conversation we have.

69
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

70
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.

71
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.

72
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.

73
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.

74
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.

75
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.

76
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.

77
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.

78
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.

79
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.

80
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.

81
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
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