Substance Abuse Treatment for Persons With HIV/AIDS
Treatment Improvement Protocol (TIP) Series 37

General Expectations and Interventions for Methadone/LAAM Maintenance Clients

1. Attendance

1a) Target Behavior:

Clients are expected to attend (or cancel with advance notice) 90 percent or more of scheduled clinic visits each month. This includes dosing, counseling, and other visits (e.g., social services, psychiatric services, or medical services).

1b) Initial Interventions:

Clients who attend less than 90 percent of scheduled visits for 1 month will receive counseling and behavior contracts to help them reduce unscheduled absences.

1c) Clinic Response to Continued Nonadherence:

Clients who continue to attend less than 90 percent of scheduled visits despite 6 months of the interventions above will be considered for discharge.

2. Giving Urine Samples Upon Request

2a) Target Behavior:

Clients are expected to provide urine samples and Breathalyzer_ tests upon request.

2b) Initial Interventions:

Clients who refuse urine samples or Breathalyzers_ or who no-show on urine collection days once or more per month will receive counseling and behavior contracts to help them reduce refusals and/or no-shows.

2c) Clinic Response to Continued Nonadherence:

Clients who continually refuse urine samples or Breathalyzers_ or who no-show on urine collection days after 6 months of the interventions above will be considered for discharge.

3. Drug and Alcohol Use

3a) Target Behavior:

Clients are expected to provide urine samples free of illicit drugs (including opiates and non-opiates) and Breathalyzer_ tests indicating nonsignificant alcohol use no later than after 1 year in the program. Prescribed medications and medicinal marijuana are not counted as illicit drugs.

3b) Initial Interventions:

Clients who provide drug/alcohol positive samples will receive counseling and behavior contracts to help them reduce and stop their drug/alcohol use.

3c) Clinic Response to Continued Nonadherence:

Clients who continue to provide drug/alcohol positive samples for several consecutive months at 2 years in the program, AND show no progress in other areas of their life, will be considered for discharge.

Note:

Clients who are discharged may apply after 1 month to be placed on the waiting list for readmission.

Standards of Care for Clients at Various Levels of Functioning

1. Is Physical Health = 2 or less? (disabled, severe disease, weekly medical care, assistance several times per week)

IF YES -- Use Palliative Care Model

These severely medically ill clients are generally expected to meet the expectations above. There areseveral modifications with these clients:

1a) Modified expectations regarding attendance and urine samples:

On rare occasions, medical problems prevent these clients from attending clinic or providing urine samples.

1b) Modified response to continued use of illicit drugs or alcohol:

Counseling focuses on reducing substance use as well as increasing access to and adherence to medical treatment.

These clients are rarely discharged for continued drug use. This is because methadone/LAAM can prevent the serious health effects of return to heavy heroin use by medically ill clients.

IF NO -- Go to 2

2. Is Mental Health = 2 or less? (moderate to severe psychiatric impairment)

IF YES -- Use Psychiatric Model

These severely mentally ill clients are generally expected to meet the expectations above. There are several modifications with these clients:

2a) Modified expectations regarding attendance:

The expected clinic attendance is lower for clients with severe psychiatric symptoms such as cognitiveimpairment, thought disorder, or mood disorder.

2b) Modified response to continued drug or alcohol use:

Counseling focuses on reducing substance use as well as increasing access and adherence to treatment of psychiatric disorder or cognitive deficit.

These clients are rarely discharged for continued drug use. This is because methadone/LAAM can help to maintain functioning and connection to services among clients with severe psychiatric symptoms.

IF NO -- Go to 3

3. Are Social Resources = 2 or less? (insufficient or high-risk social support, housing, and/or finances)

IF YES -- Use Psychosocial Model

These clients are generally expected to meet the expectations above. There are several modifications with these clients:

3a) Modified expectations regarding attendance:

The expected attendance is lower for clients with severely deficient housing, financial, ortransportation resources.

3b) Response to continued drug or alcohol use:

Counseling focuses on reducing substance use as well as accessing housing, finances, and transportation.

Clients who, despite efforts to access housing and other basic resources, continue to be homeless and impoverished are rarely discharged for continued drug use. This is because for these clients, the methadone/LAAM clinic is often one of the last remaining resources, the loss of which may be life threatening.

IF NO -- Go to 4

4. If no scale scores are 2 or less, use Standard Treatment Model

These clients are expected to meet the general expectations above.