Assessment and Treatment Planning for Cocaine-Abusing Methadone-Maintained Patients Treatment Improvement Protocol (TIP) Series10
[Front Matter]
[Title Page]
Assessment and Treatment Planning for Cocaine-Abusing Methadone-Maintained Patients Treatment Improvement Protocol (TIP) STreatment Improvement Protocol (TIP) Series10
Herbert D.
Kleber, M.D. Consensus Panel Chair
U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 DHHS Publication No. (SMA) 94-3003 Printed 1994
This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program.
The figure on page 6, the table on page 29, appendix G, and appendix I are copyrighted and are reproduced herein with permission of the copyright holders.
Further reproduction of these copyrighted materials is permitted only as part of a reprinting of the entire publication.
For any other use, the copyright holder's permission is required.
All other material appearing in this volume is in the public domain and may be reproduced or copied without permission from the Center for Substance Abuse Treatment (CSAT) or the authors.
Citation of the source is appreciated.
This publication was written under contract number ADM 270-91-0004 from CSAT. Robert Lubran served as the Government project officer.
Lynne C.
McArthur, Yvonne P.
Goldsberry, Yvonne daSilva, Anita Winters, Rebecca Horton, and Diana Schwartz served as contractor writers.
The opinions expressed herein are those of the Consensus Panel members and do not reflect the official position of the Substance Abuse and Mental Health Services Administration (SAMHSA) or any other part of the U.S.
Department of Health and Human Services (DHHS). No official support or endorsement of SAMHSA or DHHS is intended or should be inferred.
The guidelines proffered in this document should not be considered as substitutes for individualized patient care and treatment decisions.
Treatment Improvement Protocols (TIPs) are prepared by the Quality Assurance and Evaluation Branch of the Center for Substance Abuse Treatment (CSAT).
Their purpose is to facilitate the transfer of state-of-the-art protocols and guidelines for treating alcohol and other drug (AOD) abuse from acknowledged clinical, research, and administrative experts to the Nation's AOD abuse treatment resources.
Disseminating a TIP is the last step in a process that begins with the recommendation of an AOD abuse problem area for consideration by a panel of experts.
Panel members include clinicians, researchers, and program managers, as well as professionals in related fields such as social services or criminal justice.
Once a topic has been selected, CSAT creates a Federal Resource Panel, composed of members of pertinent Federal agencies and national organizations, to review the state-of-the-art treatment and program management in the area selected.
This Federal panel's recommendations are then transmitted to a second group of non-Federal experts who are intimately familiar with the topic.
This group, known as a non-Federal Consensus Panel, meets for about 3 days, makes recommendations, defines protocols, and arrives at agreement on protocols.
Its members represent AOD abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners.
The panel chair is charged with ensuring that the resulting protocol reflects true group consensus.
The next step is a review of the proposed guidelines and protocol by a third group-the expert field reviewers.
Once their recommendations and responses have been reviewed, the chair approves the document for publication.
The result is a TIP reflecting the state of the art of AOD abuse treatment in public and private programs recognized for providing high-quality and innovative AOD abuse treatment.
This TIP on assessment and treatment planning for cocaine-abusing methadone-maintained patients represents another step by CSAT toward its goal of bringing national leadership to bear in the effort to improve AOD abuse treatment.
The increasing complexity of the problems of cocaine-abusing patients in the substance abuse treatment system has created pressure on treatment providers to expand the scope of services to meet the complex needs of multidrug users.
Narcotic treatment programs (NTPs) have been successful in treating opioid addicts for their narcotic addiction but in many instances have been less successful in treating patients who are also dependent on cocaine.
The increasing prevalence of acquired immune deficiency syndrome (AIDS) and multidrug-resistant TB among drug users has further complicated treatment needs and heightened the urgency to provide effective drug treatment services.
As the Federal office responsible for providing leadership in improving substance abuse treatment services, the Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services Administration has sponsored the development of this Treatment Improvement Protocol (TIP) to address the treatment needs of patients who are abusing opioids and stimulants, especially cocaine and crack cocaine.
CSAT is committed to assisting State policy officials and treatment providers with understanding current treatment issues and improving treatment for all substance abuse patients.
This TIP is one of a series written with the assistance of substance abuse treatment experts throughout the United States that serve as guidelines to help substance abuse treatment providers meet treatment challenges of the 1990s.
Furthermore, the TIP is intended to assist State alcohol and drug agencies in implementing 45 CFR, § Part 96, which requires States to provide for independent peer review to assess the quality, appropriateness, and efficacy of treatment services by entities that receive State Substance Abuse Prevention and Treatment Block Grant funds.
This TIP provides guidelines to assist States in developing criteria for State independent peer review.
The TIP was developed as an initiative of CSAT's Methadone Treatment Improvement Project (MTIP), which is designed to assist States and methadone treatment providers in effectively identifying and addressing technical assistance needs.
The problem of patients who are dependent on multiple drugs and stimulants has become increasingly apparent.
This TIP provides recommendations for using effective treatment practices as demonstrated by the scientific community and treatment providers.
While the issue of concurrent dependency on narcotics and cocaine is sometimes viewed as a concern specific to narcotic treatment programs, the strategies recommended herein may be applied to many other treatment settings.
We hope that the substance abuse treatment community will use this TIP and will join CSAT in our commitment to enhancing the quality and integrity of treatment services to drug-dependent patients.
Patients who abuse opioids and cocaine present a unique challenge to substance abuse treatment providers.
Traditional treatment strategies have focused on one addiction or the other without noting the implications of opioid treatment on the use of cocaine or cocaine treatment on the use of opioids.1 In many treatment settings, the problem of multidrug dependence creates pressures on providers to work with patients through more intensified approaches than those required for patients abusing one substance.
The combination of opioids and cocaine is particularly difficult because treatment approaches developed for opioids and cocaine individually have not been successful in helping concurrently dependent persons.
This Treatment Improvement Protocol (TIP) is intended to examine the physical and psychosocial sequelae associated with the abuse of opioids in combination with cocaine and offer assessment and treatment planning protocols for staff to use in substance abuse treatment programs.
To the extent possible, the document is based on available research information.
However, many of the clinical issues facing providers of treatment to concurrently dependent persons have yet to be fully assessed.
Few data exist on treating concurrent cocaine abuse, and even less information exists on treating concurrent abuse of other stimulants.
This TIP is a reflection of the treatment modalities that are being used in various treatment centers throughout the Nation and should be viewed as such, rather than as a document that purports to have definitive solutions to what has become an extraordinarily difficult problem.
Where clinical research is lacking, the TIP makes recommendations for treatment strategies based on clinical models developed by successful treatment programs.
These recommendations should be considered guides, and their use should be tailored to the specific needs of an individual program's patient population.
Methadone patients with concurrent dependency on cocaine are often admitted for treatment in methadone treatment programs (MTPs).2 Difficulties in determining whether cocaine use increases once patients are enrolled in an MTP, or is unrelated to methadone use, have prompted studies of methadone treatment patients.
At the same time, already overburdened programs are struggling to create treatment approaches effective for concurrently dependent persons.
Because of these issues, much of the information in this document is directly applicable to MTPs.
Levo-alpha-acetylmethadol (LAAM) therapy may be an appropriate substitute for methadone maintenance treatment.
Increasingly, methadone treatment centers are treating patients with LAAM as an alternative to methadone.
It is important to read this TIP with the understanding that its recommendations may also apply to LAAM therapy, as well as other substitution therapies that are developed.
The Consensus Panel convened to create this document included some of the most distinguished clinicians, researchers, and policy officials in the field of substance abuse.
All have a specific area of expertise in the problems of patients dependent on opioids or cocaine.
Convening the group provided a unique opportunity to bring together substance abuse professionals from across the Nation to develop a document for the substance abuse treatment field that includes state-of-the-art information.
We hope you find this TIP useful in exploring the treatment needs of methadone patients concurrently dependent on cocaine.
Herbert D.
Kleber, M.D.
Chair, TIP Consensus Panel
1Use of the word "opioids" in this TIP usually refers to heroin, although other opioid agonists are also included in this category. The discussion also includes all routes of administration.
2Although the language used in the Federal regulations (21 CFR 291.505) refers to narcotic treatment programs (NTPs), most, if not all, NTPs are in fact methadone treatment programs (MTPs).
The language of this TIP reflects that reality and will use the term "MTPs" when discussing programs.
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