The care of methadone patients concurrently dependent on cocaine is one of the most important issues facing the substance abuse treatment community.
It is critical because of the complexity of patient problems and lack of one clear and effective treatment strategy.
This document was developed to begin to address this problem.
This Treatment Improvement Protocol (TIP) is written principally for use by administrative, medical, and counseling staff.
Clinic or program managers and Federal, State, and private-sector officials responsible for program development, fundraising, monitoring, and regulatory oversight may also find this document useful to ensure effective service provision in methadone treatment programs (MTPs).
The TIP should help define appropriate treatment interventions and improve the quality of treatment and treatment outcomes through the following:
Increasing staff and patient information about opioids and cocaine and the impact of drug use on patient health and treatment outcomes
Increasing staff knowledge about appropriate medical interventions, including pharmacological interventions
Improving the ability of clinical and counseling staff to assess and treat concurrent dependency, promote retention in treatment, and prevent relapse
Suggesting strategies and guidelines that programs can use to assist in preventing and treating concurrent use of cocaine and opioids
Providing resources for additional assistance
Providing guidance for States about Federal independent peer review regulations (45 CFR, § Part 06), effective March 10, 1993, which implement the independent peer review requirement of Section 1943(a)(1)(A)(B) of the Public Health Service Act. (These regulations require States to assess the quality, appropriateness, and efficacy of treatment services provided by entities that receive State funds.)
A three-phase process was used to develop this document:
A Federal Resource Panel of representatives of various Federal agencies met to review the TIP prospectus, identify resource materials to use during TIP development, and nominate members of the Consensus Panel.
A non-Federal Consensus Panel of 20 experts in the substance abuse field convened to produce a draft protocol document and develop recommendations for treatment strategies.
A Field Review Group of treatment providers and State and Federal policy officials commented in writing on the protocol prepared by the Consensus Panel.
These comments were incorporated into the final document.
Over 95 nominations were received from State Alcohol and Other Drug (AOD) agencies and Federal agencies for participation on the Consensus Panel.
In collaboration with the TIP chairperson, participants were selected by the Center for Substance Abuse Treatment (CSAT), on the basis of their area of expertise and location, to reflect racial, ethnic, and gender diversity.
The Panel met on two occasions, with much of the policy deliberation taking place in small groups.
The available literature indicates that research on issues of concurrent dependency on opioids and stimulants largely focuses on either heroin or cocaine use.
In addition, several studies have specifically reviewed treatment issues relating to patients treated in narcotic treatment programs with methadone.
Recognizing this lack of research, the information presented in this document draws primarily on literature discussing heroin and cocaine use and, when possible, extrapolates conclusions about other opioids and stimulants from these two bodies of literature.
Note that cocaine is only one of several substances that may appear as a concurrent dependency in MTPs.
Other abused substances may include alcohol, nicotine, benzodiazepines, and stimulants other than cocaine.
However, the purpose of this document is to address the issues surrounding methadone patients concurrently dependent on cocaine.
In creating this document, the Consensus Panel described treatment strategies and reviewed research findings for treating concurrent dependency on opioids and cocaine in MTPs.
Because extensive empirical research on this patient population is lacking, many of the strategies identified in this document are based on available clinical models.
The treatment strategies presented here are intended to provide guides for treatment: many of the treatment modalities and facilities discussed present an ideal.
The Consensus Panel recognized that this ideal may not always be feasible given the scarcity of adequate resources and the budgetary constraints programs face.
Each program should adapt treatment strategies to its resources and the needs of the population it serves.
The Consensus Panel participants held a range of views, summarized below, that provided guiding principles for using the treatment strategies identified in this TIP:
It is clinically appropriate to treat patients with concurrent dependencies within methadone programs.
Patients who abuse cocaine will benefit most from a comprehensive treatment program (McLellan et al. 1993).
Given that patients with concurrent dependencies require an increased intensity of comprehensive treatment interventions, program staff should be thoroughly trained to implement cocaine-specific treatment.
Physicians should be present at methadone clinics to attend to medical problems related to cocaine and heroin use.
Physicians should play a leadership role in planning the medical treatment of the patient.
Issues such as addiction severity, medical status, psychiatric status, treatment history, and social support network play an important role in determining treatment.
Treatment modalities should be responsive to the needs of specific patients.
If a particular treatment is not available on site, efforts should be made to refer the patient to an appropriate setting.
Employing cultural and other relevant belief systems in treatment can positively affect the treatment process, and efforts should focus on creating and promoting culturally appropriate services.
A program's design, content, and staffing should respond to the values, belief systems, and behaviors of the group served.
Lowering methadone doses as part of a contingency management protocol does not appear to be effective in managing cocaine use and may increase heroin use.
Controversy remains over the conflicting approaches of harm reduction versus limit setting for methadone patients concurrently dependent on cocaine. (See the Retention Versus Discharge section of Chapter 5.)
Finally, alcohol dependency is a serious problem among narcotic addicts and must be carefully explored as treatment plans are carried out.
This TIP, while recognizing the impact of alcohol abuse on methadone patients, focuses on abuse of cocaine among these patients.
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