The concept of treatment phases can be useful in attempting to match patients
and services. When treatment is conceptualized as occurring in phases, a patient
can be regarded as engaging in a series of successive interventions within
a single program, with each intervention building on the other and leading
to one or more well-defined goals.
The concept of treatment phasing is by no means new to the field of alcohol
and other drug (AOD) abuse treatment (Institute of Medicine, 1990a; 1990b); however, this approach has not
been widely used in methadone programs (Kreek, 1991). Nevertheless, many methadone programs operate at least partially according
to an informal phased model of treatment, and others often recognize the need
to utilize phases in developing treatment plans. The value of having treatment
phases within methadone programs has been recognized by Hoffman and Moolchan (1994), who have described a phased and highly structured
treatment model. This chapter builds on and extends that model as one important
aspect of an overall strategy for matching patients to treatment.
In this chapter, each phase of a six-phase treatment model is described.
Key issues typically arising in each phase are discussed, along with indicators
of patients' progress through each phase and strategies to facilitate their
progress. The model is not linear; patients may encounter setbacks requiring return
to an earlier treatment phase. Thus, indicators of lack of progress and strategies
for addressing setbacks are discussed. A separate section addresses transitions
between phases, discharge, and readmission. Two clinical issues -- hospitalization
of patients and decisionmaking about take-home medications -- are also discussed.
As shown in Exhibit 3-1, treatment begins with
the acute phase and progresses through the rehabilitation and supportive care
phases. The model then branches out into three separate tracks according to the
patient's progress. These tracks involve different types and intensities of treatment
services that correspond to the patient's level of functioning. Patients who have
achieved a high degree of stability but who continue to need methadone to maintain
this level of stability enter the medical maintenance phase. Some patients
may remain in this phase indefinitely. Others may be considered for methadone
detoxification (medically supervised withdrawal), which is undertaken by reducing the
dose over a period of weeks or months (tapering) under close supervision (Exhibit 3-1). Patients who complete tapering from methadone often enter a
period of readjustment, and additional counseling may be needed to reinforce coping
and relapse prevention skills. Finally, an aftercare phase in which patients
maintain periodic contact with the program is often desirable.
The phased model is based on the assumption that although most patients will
need long-term or lifetime methadone treatment, the type and intensity of services
will vary throughout the course of treatment. This assumption is based on studies
showing that most patients move between periods of remission and relapse to heroin
use and that relapse is common, especially after they leave methadone treatment
(Ball and Ross, 1991;Condelli and Dunteman, 1993;Dole and Joseph, 1978;Hubbard et al., 1989;Simpson et al., 1979).
Patients do not always move through all phases, and some move back and forth between
phases at different times. Many patients who enter the Phases of Treatment
rehabilitation phase relapse to uncontrolled use and reenter the acute
phase. Such returns should be perceived not as a failure of either the program
or the patient, but rather as a reflection of the addiction problem. For
some, this pattern of stabilization and rehabilitation continues without progress
to the medical maintenance phase. Some patients who have completed medically
supervised withdrawal from ethadone may have to resume maintenance and supportive
care.
To be most effective, phases of treatment should be established not as a fixed
series of steps that are assigned specific timeframes, but rather as a dynamic
continuum that allows each patient to progress according to his or her individual
needs. Patients move through a particular phase gradually or rapidly, depending
on a variety of biopsychosocial factors that are discussed in this and other
chapters. Treatment outcomes should be evaluated not solely in terms of how many
phases the patient has moved through, but rather by the degree to which the patient's
needs, goals, and expectations have been met by the treatment program.
Although distinct treatment phases can be identified, it is important to emphasize
that the services in any phase must also be appropriate not only to that phase
but also to individual characteristics of the patient. These needs vary according
to many factors, including age, sex, culture and ethnicity, education, and
socioeconomic level. As described in Chapter 2, assessment
of a patient's readiness for a particular phase, as well as assessment of
his or her individual needs, should also occur on an ongoing basis (Simpson and Joe, 1993).
Finally, it should be noted that for many patients attendance at self-help groups
such as Alcoholics Anonymous and Narcotics Anonymous, provides an important
source of support and structure during all phases of treatment. Opioid substitution
therapy programs should establish ties to local community groups and should encourage
patients to attend.
The acute phase of treatment generally comprises the first days, weeks, or
months of methadone maintenance. During this time, the patient is usually struggling
to reduce illicit drug use and begins work to reduce the intensity of the
psychiatric, medical, social, legal, family, and other problems that are associated
with dependence. The most immediate aim during this phase is to achieve a methadone
dosage level that suppresses withdrawal symptoms for 24 to 36 hours, does not
produce sedation, and markedly reduces heroin use. A high intensity of services
is typically needed during the acute phase of treatment, especially for patients
with serious psychiatric, social, or medical problems.
In the following sections, important clinical issues to be addressed during
the acute phase of treatment are discussed, strategies for addressing them
are offered, and indicators for transition to the next phase are described.
Exhibit 3-2 summarizes these discussions.
One of the major goals of the acute phase is to eliminate opioid use as quickly
as possible. This process involves
Initially prescribing a methadone dose that will minimize the chances of
sedation and other undesirable side effects
Assessing the safety and adequacy of the dose
Rapidly but safely increasing the dose to suppress acute withdrawal symptoms
and discourage the patient from supplementing the methadone dosage with continued
use of heroin.
As part of the stabilization process, it is critical for care providers to
know what other drugs are being used. Most patients admitted to methadone programs
have been using a variety of other substances, particularly cocaine and alcohol
(Hubbard et al., 1989). Setting limits on other
forms of illicit drug use and alcohol abuse is also a major goal of this phase.
Urine screening should be conducted at least once a week. A recent study
estimates that up to 75 percent of patients in methadone maintenance programs abuse
cocaine (Avants et al., 1994). As described in Chapter 4, group and individual counseling for cocaine abusers is an important
treatment element.
Many patients continue heavy alcohol use after they are admitted to methadone
programs (Fairbank et al., 1993). In fact, many patients,
as well as many alcohol users, do not consider alcohol to be a drug. Continued
heavy use is often a serious problem for methadone patients, and it will markedly
impair progress in treatment. Although it may not be realistic to totally eliminate
alcohol use by all methadone patients, its consumption should be strongly discouraged,
especially since it often serves as a trigger for moving on to the use of cocaine
and ther illicit substances. Many programs use Breathalyzers to detect alcohol
use and do not dispense methadone to intoxicated patients.
Treatment staff should have frequent interaction with patients and should encourage
ongoing dialogue concerning their symptoms. The counselor should make the patient
feel comfortable in sharing information about all types of drug use and should
not take a punitive approach if drugs other than opioids are used. Such interaction
allows for rapid adjustments in dosage and for other interventions as indicated.
Extended clinic hours increase the availability of treatment providers,
especially if they are needed on an emergency basis during the first few weeks of
this phase.
Frequent contact with staff should facilitate the rapid elimination of opioid and
other drug use. Extra sessions of individual or group counseling during this
period can provide an added measure of support. Intensified treatment within
the substitution therapy program is an important response to continued use
of illicit drugs and alcohol abuse. Although methadone directly affects only
opioid use, reductions in nonopioid use typically occur in the context of good
therapy and counseling during methadone maintenance.
If opioid use continues or alcohol and other drug use poses a threat to the
patient's progress and safety, a referral to inpatient treatment for a short time
may be necessary. For some patients, methadone treatment is not the most appropriate
modality, and referral to another therapy may be indicated. In other cases, the
patient may respond to a program in which detoxification from other substances
is completed while methadone maintenance is continued.
Criteria for transition from the acute phase into the next phase of treatment are
The amelioration of signs of withdrawal
Reduction in drug craving
Demonstrable reduction in opioid and nonopioid drug use.
Some signs that the acute phase has ended are
A subjective feeling that the methadone is stabilizing or "holding"
An increased sense of well-being
Changes in bowel function (decrease in or resolution of diarrhea or possible
constipation)
At least a few opioid-free urine tests.
Signs that a change in methadone dosage is needed include
Continued opioid or other drug use to relieve subtle withdrawal symptoms
Subjective complaints that the dose is not stabilizing or "holding" in
the absence of signs and
symptoms of sedation
Continued illicit activities that reflect drug-seeking behavior.
The signs and symptoms that a dosage of methadone is too high include
Acute symptoms of depression and anxiety are common among persons applying for
treatment of substance use disorders. These symptoms are often markedly reduced
or disappear after methadone stabilization, but sometimes they represent independent
disorders that persist and need more specialized treatment. Post Traumatic Stress
Disorder (PTSD), anxiety disorders, schizophrenia, bipolar disorder, antisocial
personality disorder, and the entire range of psychiatric disorders that are seen in
non-substance-abusing populations are seen among persons with opioid dependence. It is extremely
difficult to diagnose independent psychiatric disorders during the early part of
the acute phase of treatment, and a definitive diagnosis must often wait until
the patient is stabilized.
When psychiatric disorders are present, there is usually increased difficulty
in treating the substance use disorder. When the psychiatric disorder is
treated with pharmacotherapy, psychotherapy, or a combination of these approaches,
the substance use disorder is more likely to improve than when the psychiatric
disorder is not treated (Woody et al., 1984).
Identification of persistent, independent psychiatric disorders that need ongoing therapy
should be a focus during the acute phase so that the appropriate matching strategies
can be formulated and implemented. Acute, substance-induced psychiatric disorders
that do not need ongoing treatment should also be identified. Although these
disorders usually resolve when the substance use disorder is under control, they
can be very disruptive at the start of methadone maintenance, and patients
may also need focused, short-term pharmacotherapy or psychotherapy. Since
their course usually follows that of the substance use disorder, they typically
do not require ongoing psychiatric treatment.
The acute phase of treatment is often characterized by catastrophic medical
problems requiring the use of significant and costly resources. These medical conditions
must be stabilized before effective treatment can begin. Long-standing medical
problems that may have been neglected during periods of drug use and prior to treatment
entry must be addressed immediately. Such problems may include tuberculosis
(TB), cellulitis, human immunodeficiency virus (HIV) infection, renal disease,
diabetes, sickle cell trait or anemia, or cardiopulmonary diseases. Skin or organ
abscesses secondary to repeated needle use or infection may require skin grafting,
surgical correction, or aggressive pharmacotherapy. Any of these conditions may
require hospitalization and incur substantial medical costs in a population that
is typically lacking in financial resources.
Treatment programs should have arrangements in place to provide referral for hospitalization
on short notice (see section later in this chapter on Hospitalization of Methadone Patients). In the absence of linkages to available resources,
case management between the referring physician and hospital can facilitate
this process. As in the case of psychiatric problems, stabilization of acute
conditions and the institution of ongoing care for chronic conditions are mandatory
before a patient can move out of the acute phase of treatment.
In communities where jails and prisons do not allow opioid substitution therapy,
it is important to address a patient's legal problems as soon as possible
after treatment is initiated. Ongoing criminal activity may result in a patient's
abrupt removal from the community -- and from opioid substitution therapy. On
behalf of those who are on probation or parole, program staff should make efforts
to cooperate with criminal justice agencies. Staff can thus help clients
to avoid incarceration, if appropriate, by making continued treatment one
condition of probation or parole.
Patients' needs for basic necessities such as food, clothing, housing, and safety
should be determined and referrals made to appropriate agencies. At the time
of treatment entry, the chaotic lives led by many patients with opioid addiction
often create legal, financial, and safety concerns that threaten survival. Homeless
individuals should be referred to transitional shelters until more permanent housing
can be secured.
Studies show that ease of access to the treatment facility is a predictor of retention
in methadone programs (Condelli, 1993). Transportation
problems may be addressed by introducing a new patient to other patients. It may
also be helpful to keep a small transportation fund at the treatment site for
new patients who lack resources or for emergency situations.
Treatment providers can help patients determine the extent of debts, financial or
otherwise, that they may have accumulated in response to legal problems. They can
also help patients deal with threats to their safety, giving special attention
to threats from drug dealers or other individuals to whom they owe money.
A legal advocate, eligibility case manager, or social worker can be very
helpful during this phase in identifying critically needed financial resources.
Linkage with a law firm that provides pro bono services can also
be helpful.
Before a patient can be appropriately moved out of the acute phase of treatment,
his or her basic need for food, clothing, shelter, and safety must be provided.
The patient's living situation, if not entirely drug free, should at least
be relatively stable and secure if treatment is to move beyond the acute phase
of crisis management.
For transition from the acute phase into the rehabilitation phase, patients
should also begin to develop skills to remove themselves from situations in which
drug use is inevitable. If a patient is unable to gain this level of control,
short-term inpatient treatment may be indicated.
Some patients may initially view methadone treatment as a short-term solution
to opioid addiction (Lipton et al., 1992).
Other patients may believe that methadone has deleterious side effects and that
it is almost impossible to detoxify from this medication (Beschner and Walters, 1985;Goldsmith et al., 1984;Hunt et al., 1986;Magura et al., 1993). These and other myths must be dispelled before meaningful
treatment can begin, as they may influence treatment engagement and compliance.
In addition to correcting misconceptions about treatment, the major task of
the staff, particularly the treatment counselor, is to begin to educate patients
about the goals of methadone treatment, the program, and the benefits that are
possible as a result of compliance. The first step in this process is to build
a relationship of trust. Simple psychotherapeutic listening techniques elicit
the patient's views and feelings about his or her relationship with the program
and the treatment providers. Providers can help patients create their own
support systems by encouraging them to be involved in appropriate social and recreational
activities.
Positive reinforcement of the patient's treatment engagement and compliance is important
in eliciting commitment to the therapeutic process. The Center for Substance
Abuse Treatment (CSAT) has published a manual Treatment of Opiate Addiction
With Methadone: A Counselor Manual, which addresses the importance of the
therapeutic bond between counselor and patient.
The treatment provider can help the patient make a commitment to the treatment
process by
Pointing out the negative aspects of the patient's former situation
Identifying the benefits of treatment in terms of financial advantages,
improved self-esteem, and enhanced sense of well-being
Exploring and clarifying the patient's goals in treatment.
Patients should be introduced to key staff members of the treatment program as early
as possible to foster an atmosphere of safety, trust, and familiarity. Relationships
with other patients can also increase the patients' level of comfort within
the program. During scheduled appointments, treatment providers should minimize
waiting times whenever possible to demonstrate that patients' time is valued.
In addition, when the provider remains flexible and available during acute
situations, he or she contributes to the patient's sense of security.
Key signs of the beginning of a positive therapeutic relationship include regular
attendance at group and individual counseling sessions and positive interactions with
treatment providers. Signs that patients are progressing toward the next phase of
treatment include their demonstrating compliance with the recommended treatment and
then beginning to define and focus on the goals of treatment. Khantzian and
associates did important work in developing effective therapeutic interventions for
substance abusers (Dodes and Khantzian, 1991;Khantzian et al., 1990). Measures of therapeutic helpfulness, which can be used
as indicators of the strength of the therapeutic relationship, were developed
by Simpson and associates (1995).
Patient motivation to engage in treatment is a predictor of early retention (Simpson and Joe, 1993). The treatment provider may encounter obstacles to
the development of self-motivation arising from negative attitudes toward treatment.
Some of these attitudes may arise from past experiences, such as negative
relationships with treatment staff, introduction of methadone treatment without needed
support services, and inadequate methadone dosing.
Other potential obstacles to effective treatment include patients' ambivalence
about giving up illicit drug use and fears of making major life changes. As
mentioned above, many opioid users have mistaken beliefs about methadone and its
effects, beliefs that can be serious obstacles to entering treatment. Even positive
life changes can cause anxiety and stress when a patient is confronted with
unfamiliar attitudes and situations. Several strategies have been developed to use
the counselor-patient relationship to increase patient motivation (Miller and Rollnick, 1991).
Counselors should explore and openly address patients' past negative treatment experiences.
It is helpful to suggest that many factors may have been responsible for
such experiences and that these factors may no longer be as relevant as they
once were. Emphasis should be placed on making a fresh start, letting go of
old grievances, and focusing on current realities and goals. It may also help
to acknowledge that the treatment staff may not have been as helpful as they
could have been on previous occasions. To address patients' ambivalence about
giving up drugs, providers should stress the benefits of methadone treatment in
terms of preventing needle-borne infections, avoiding arrest and incarceration,
and gaining peace of mind and relief of concerns over obtaining the next fix.
Patients must be encouraged to recognize that, rather than being controlled
by methadone, they can be empowered to gain better control over their addiction.
A commitment to the treatment process may be manifested by the patient's
acknowledgment that his or her addiction is a problem. Before moving out of the acute
phase, the patient must be motivated to make changes in his or her lifestyle and
to address issues surrounding drug use.
The primary goal of the rehabilitation phase of treatment is to empower patients
to function in the major life domains. The methadone dosage must be stabilized
at a comfortable level prior to entering this phase. During the rehabilitation
phase the patient undertakes efforts to become a responsible, functioning member
of society.
Exhibit 3-3 summarizes the clinical issues that
should be addressed during the rehabilitation phase, strategies for addressing
them, and indicators for the transition from rehabilitation to the stabilization
phase.
Early in the rehabilitation phase, treatment providers can assist or refer patients
who need help with legal, educational, employment, and financial problems.
If not addressed with high-quality services, these problems can result
in patients' dropping out of treatment (Condelli,
1993). As described in the previous section, serious problems that threaten a
patient's continued treatment, such as ongoing criminal activity and serious financial
problems, should be addressed as soon as possible after treatment is initiated.
In the rehabilitation phase, efforts should begin toward productive participation
in constructive activities such as full- or part-time employment, education,
vocational training, childbearing or homemaking, or volunteer work.
Continued use of alcohol and other abusable substances, including nonopioids such
as cocaine, amphetamines, benzodiazepines, and sedatives, poses obstacles
to patient progress in any phase of treatment. During the rehabilitation
phase, use of illicit drugs and alcohol may even precipitate a patient's regression
to the acute phase. A previous Treatment Improvement Protocol (TIP) State
Methadone Treatment Guidelines has a chapter on treating alcohol and other drug
use in methadone patients, while this TIP provides only a brief overview.
Continued use of opioids must also be identified and adequately addressed to discourage
the use of other drugs (Dunteman et al., 1992;Fairbank et al., 1993) and prevent relapse.
The frequency of urinalysis during this phase should depend upon the patient's
progress in treatment. Once a patient is stabilized and is progressing well in
the rehabilitation phase, with a series of negative urinalyses, the frequency
of random urinalyses can be decreased to once or twice a month. Such decisions
should be part of the overall treatment plan.
Behavioral contracting is a useful strategy to address continued drug use in the rehabilitation
phase (Chambers et al., 1972;Condelli et al., 1991;Glosser, 1983; Stitzer
et al., 1986;1992
). Essentially, this strategy requires the patient and treatment provider
to identify and discuss treatment goals and expectations. Generally, the
patient is then asked to sign an agreement that specifically outlines the objectives
to be achieved, the behaviors to be avoided, and the consequences that will
occur if the patient fails to comply with the agreement. To be effective, the
details in such a behavioral contract must be worked out with the patient and mutually
agreed upon.
Strategies for reducing various types of drug use among methadone patients have been
described, including the use of disulfiram (Antabuse), prescribed as a deterrent to
alcohol use; short-term inpatient treatment for detoxification to achieve stabilization;
and intensified treatment services, such as more individual and group counseling
sessions (Kosten, 1991;Kreek, 1991). Other strategies include confrontation of negative behaviors
and use of unprescribed drugs (Chambers et al., 1972)
and provision of positive incentives in the form of take-home medication
and recognition of progress (Stitzer et al., 1992).
In the rehabilitation phase, information about outside support groups that
was first introduced during the acute phase should be periodically reviewed.
Providers should also cultivate relationships with churches and community
groups to provide support and facilities for methadone patients and, in the process,
to educate the community and dispel myths about methadone.
To be eligible for transition from the rehabilitation phase, patients should
be able to identify relapse triggers that remain after some of the more troublesome
ones have been eliminated during the acute phase. Examples of triggers are
boredom, passing by specific locations, spending time with specific individuals,
having unresolved family problems, or experiencing psychiatric symptoms. Emphasis
should be given to helping patients develop and maintain coping skills to deal
with these triggers (Sandberg and Marlatt, 1991).
These skills often involve anticipating responses when confronted with
relapse triggers and rehearsing appropriate responses with the help of the counselor.
A related and very important activity is to begin to make proactive changes
in lifestyle and circumstances that will reduce the chances for relapse.
Discontinuation of all illicit drug use is mandatory by the end of the rehabilitation phase.
Continued heavy alcohol use that is problematic and interferes with functioning
will prevent the patient from moving beyond the rehabilitation phase and, for
some patients, will require return to the acute phase.
Opioid users admitted to methadone programs are those who are at a notably increased
risk of HIV infection and acquired immunodeficiency syndrome (AIDS), multidrug-resistant
tuberculosis, and other infectious diseases (Chaisson et al., 1989; Graham et al., 1992; Novick et al., 1990;Schoenbaum et al., 1989).
They may also have chronic medical conditions such as diabetes, hypertension,
or seizure disorders that require them to be referred for ongoing treatment.
In addition, many opioid users neglect dental care. Once heroin use is
reduced, they may experience dental pain because the pain-killing effects of opioids
have been eliminated.
In general, medical care for methadone patients should be identical to that
provided for other patients. In some cases, however, dosages of medications for
medical conditions may need to be adjusted because of interactions with methadone.
For example, Dilantin (diphenhydantoin, phenytoin) and rifampin both tend
to lower serum methadone levels and may thus require the methadone dosage
to be adjusted upward. Onsite primary healthcare is optimal. When inadequate
resources prohibit onsite medical services, linkages to other services should be
in place. A holistic approach addressing all aspects of the patient's health
will facilitate attention to neglected medical problems. Education and training
about diet, exercise, personal hygiene, and smoking cessation are important.
The counseling staff can use printed educational material or videotapes
to present these messages.
Patients must adhere to medical care for chronic diseases and such conditions must
be under control before patients can be considered for transition to subsequent
phases of treatment. Improved overall health status, as well as improved dental
health and hygiene, is a criterion for transition to a subsequent phase of treatment.
Some of the most difficult obstacles faced by patients attempting to stabilize
their lifestyle include unemployment and inadequate funds for living. Poor reading
skills and lack of education contribute to the difficulties they face in obtaining
stable employment. Employment opportunities in the patient's community may be
lacking, even for individuals who are not handicapped by a history of AOD use.
Research suggests that males with less than a high school education have particular
difficulty in negotiating for and obtaining high-quality social services (Condelli, 1993). Access to services may be a problem for many patients, both
males and females, who have been addicted to drugs for years. These individuals
should be targeted for educational, literacy, and vocational programs to equip
them with the skills necessary to function independently. Included in these
programs should be education and training about budgeting personal funds and setting
up bank accounts.
Ideally, treatment programs should provide onsite counseling for the general equivalency
diploma (GED). This service is rarely available onsite because of resource limitations.
Therefore, a program should be able to make referrals to local adult education
programs. Local businesses and industries can be encouraged to set up apprenticeships
or entry-level positions. Efforts can be made to bring together business,
industry, and government leaders to set up income-generating business enterprises
that can provide clients with job skills and create opportunities for their
entry into the job market.
By the end of the rehabilitation phase, patients should be employed, actively
seeking employment, or involved in a productive activity such as school, childrearing,
or regular volunteer work. It is most important that patients have a stable
source of legal income, whether from employment or other sources, to ensure that
they will not resort to drug dealing or other criminal activities.
No family can escape the stress and conflict that are brought on by another
family member's addiction to drugs. Broken trust, disappointment, anger, and
conflict are the realities that patients in treatment must come to face during the
rehabilitation phase. Many of these individuals have been cast out of their families
and have been surviving in the absence of a family support system.
During the rehabilitation phase, the counselor should help the patient build social
supports and relationships, as well as rebuild and heal what are often severely
damaged family relationships. The patient can gain social support by becoming
involved in community or church groups or by joining a fellowship or a recreational
or other peer group. It is important for these groups to understand and accept
methadone therapy so that patients are not stigmatized. Increased involvement in
family life should also be encouraged, in the absence of major family conflicts
or dysfunction that might impede the patient's progress in treatment.
In addition, family problems that may have contributed toward the addiction
will often emerge in the context of counseling during the rehabilitation phase.
In such cases, staff must help patients attempt to come to terms with
the impact of these traumatic family histories. Referral for family therapy
may be appropriate in some cases.
Transition out of the rehabilitation phase requires that patients have a social support
system in place that is free of major conflicts. Another positive indicator for
transition emerges when the patient assumes increased responsibility for dependents
(such as reliably paying or providing child support).
Criminal charges, custody suits, and ongoing illegal activities are among the legal
issues faced by many patients in treatment. Any of these problems can easily
precipitate a relapse to illicit drug use, and all must be addressed as thoroughly
as possible.
Counselors may have to probe into personal legal issues such as custody status and
obligations. Many patients ignore these issues during periods of addiction; however,
these issues may pose a serious threat to ongoing recovery. Patients should
be encouraged to take responsibility for their own legal problems. The counselor
may need to help the patient overcome guilt, fear, or uncertainty in relation
to these problems. In addition, the treatment program must ensure that patients
have access to adequate counsel to handle their legal problems. These services
are often provided by the public defender's office.
It may be difficult for some patients to extricate themselves from continued
illegal activities, for either economic or social reasons. Nevertheless, efforts
must be made to identify obstacles to eliminating these activities and finding
ways to replace them with constructive, legal activities. All major legal problems
should be resolved -- or be in the process of resolution -- and all illegal activities
should cease before patients can move beyond the rehabilitation phase.
Depression, anxiety, and insomnia are common in patients undergoing treatment for opioid
addiction in any phase of treatment. As discussed earlier, these problems may pose
obstacles to progress in treatment. Complaints of boredom are often a signal of
depression. A wide range of other psychiatric problems may emerge during methadone
treatment and may need to be addressed concomitantly with problems of substance use.
Patients should be taught coping skills to deal with frustration, anxiety, and boredom.
Treatment staff should provide individualized care and should be sensitive
to each patient's mental health status. Particular problems should be identified
early and referrals made to appropriate resources. When indicated, a referral
should be made for psychotropic medication, and patients' psychiatric status
and use of medications should be evaluated on an ongoing basis. Because of
the abuse potential of benzodiazepines, caution should be used when prescribing
this type of medication (see Chapter 4). Anxiety disorders
in this population have been effectively treated using tricyclic antidepressants
rather than benzodiazepines. The latest edition of the Diagnostic and Statistical
Manual for Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994) describes a wide range of substance-induced
psychiatric disorders and presents guidelines for determining when symptoms represent
an independent disorder.
Before a patient can move out of the rehabilitation phase, psychiatric problems
must be alleviated or stabilized. Although many psychiatric symptoms may continue
to arise throughout the course of a patient's life, he or she should have
adequate coping skills to prevent these symptoms from precipitating a relapse to
drug addiction.
Finally, it is important to note that in many cases, when patients report persistent
difficulties in several life areas, such as family and social relationships and employment,
they may have a personality problem. Often, the patient is not aware of the
role of his or her personal style in creating problems. The patient's irritable
behavior or suspicious, aggressive attitude may create a host of problems. Other
personality problems that have been described in this population include low self-esteem
and self-confidence, low tolerance for distress, impaired regulation of emotion,
chronic anxiety and anger, and antisocial attitudes. Often these serious and disabling
personality problems do not meet the diagnostic criteria for psychiatric disorders.
Observation and interaction with the patient over a period of time is often required
to detect personality problems. Information from family members, employers,
probation and parole officers, and others may be needed to clarify the problem.
Most patients with these kinds of problems are not interested in or accessible
to psychotherapy. A long-term therapeutic relationship with an understanding
counselor can sometimes help them gain insight. Counselors working with these types
of patients can be greatly helped by periodic psychiatric consultation. A
previous TIP in this series, Assessment and Treatment of Patients With Coexisting
Mental Illness and Alcohol and Other Drug Abuse, provides guidelines for working
with AOD-abusing patients who have been diagnosed as having personality disorders,
especially antisocial and borderline personality disorders.
After meeting the criteria for transition out of the rehabilitation phase, patients
enter a phase in which they receive mainly supportive care. During this phase,
most patients begin to receive take-home medication for longer periods and have
less frequent contact with treatment staff. As the patient is getting ready
to receive take-home medications, it may be a good idea to increase the frequency
of urinalyses for a brief period. Similarly, once take-home privileges are
granted, more frequent urinalyses during the initial stages may help the patient
maintain progress.
After remaining abstinent (as confirmed by negative urine tests) for a specified
period, some patients may be considered for transition into medical maintenance
or medication tapering (medically supervised withdrawal from methadone).
The period of time that a patient should remain in supportive care is entirely
dependent on his or her individual needs. The domains and issues described above
for ongoing assessment during the acute phase and rehabilitation should continue
to be assessed at least quarterly to determine whether the patient is eligible
and appropriate for transition into medical maintenance or methadone tapering.
Some patients may have stopped opioid use and demonstrated compliance with program
rules, but have not made progress in other areas. Although they may be doing
well in treatment, these patients need the ongoing support and pharmacotherapy
provided by the program. They are ineligible or inappropriate candidates for either
medical maintenance or methadone tapering, even after an extended period of time
in supportive care. These patients should remain in the supportive care phase,
receiving take-home medication and a reduced level of services in accordance with
their needs. This option is usually appropriate for patients who are functioning
relatively well with methadone treatment but who have mild to moderate problems that
make them poor candidates for the markedly reduced level of services associated
with medical maintenance or for the reduction in methadone dosage that is part
of tapering.
Patients who have achieved a high degree of stability and are able to function effectively
but who continue to need methadone to maintain this level of stability can
be considered for medical maintenance. In this phase, patients can maintain
stability on methadone and have a lifestyle that does not revolve around frequent
visits to the clinic. Patients receiving medical maintenance typically are seen
by their counselor or therapist once or twice a month and receive up to 6
days' supply of take-home methadone.
If the patient remains stable, productive, and drug free in this phase for
several months or longer, the amount of take-home medication can be increased to
a 2-week supply under some circumstances. Under current regulations, such
a schedule is an exception and must be approved in advance by the methadone
monitoring office of the Food and Drug Administration (FDA). Two-week take-home doses
must also be approved by the State Methadone Authority. When dispensing take-home
medication, it should be kept in mind that patients can deteriorate quickly, and thus
regular visits to the clinic and urine tests are important parts of treatment during
this phase.
The following criteria should be considered to determine a patient's eligibility
for medical maintenance:
Number of years in methadone treatment (at least 3 years under current
FDA guidelines)
Elimination of drug use for at least 1 year
Noninterfering alcohol use (as assessed by use of the CAGE questionnaire,
liver function test results within normal parameters, and leukocyte and erythrocyte
elevations or decreases)
Stable living conditions in a drug-free environment
Source of stable income
Involvement in productive activities (employment, school, volunteer work)
No criminal or legal involvement (such as facing charges) for the last
3 years; not on parole or probation
Adequate social support system and absence of significant psychiatric problems.
In addition, ongoing evaluation of the domains outlined in the descriptions
of the acute and rehabilitation phases should take place during medical maintenance.
Also recommended during this phase are random urine testing and random
callbacks of medication. Callbacks involve requesting patients to bring in their
remaining supply of take-home medication once every 3 to 6 months. This procedure
allows treatment staff to take an inventory of medication to ensure that it has
not been diverted to others. However, such callbacks are not required by FDA
regulations. If evidence of diversion is found, the patient should return to the appropriate
earlier phase of treatment. Reinstatement into medical maintenance should not
be implemented until program staff have closely observed the patient over
an extended period (3 to 12 months or longer) in the appropriate earlier phase,
and the patient has again demonstrated the required level of progress in treatment
and appropriateness for medical maintenance.
Some patients may need indefinite or lifetime methadone maintenance, along with
concurrent psychosocial and rehabilitative services. Some long-term stable patients
can eventually be managed on lower dosages (20-60 mg), with fewer side effects
than the higher dosages required at the start of treatment. Others may need
to continue taking the same dosage of methadone but may not require ongoing
rehabilitative services. These patients may be appropriate for medical maintenance, and
they should be permitted to continue in this phase indefinitely provided they
continue to meet its inclusion criteria.
Most patients who choose to detoxify from methadone do so gradually. Successful
rapid detoxification has been reported using naloxone to precipitate withdrawal,
and clonidine to suppress acute symptoms; the patient is then inducted onto
naltrexone (Kleber et al., 1987;Resnick et al., 1976).Tapering is a term commonly used to describe
the gradual reduction and elimination of methadone treatment. Medically
supervised withdrawal is another term for this process.
In determining patients' eligibility for methadone tapering, their preferences
and desires should be taken into account, with the understanding that they
can return to their previous methadone dosage if tapering is not successful.
Some level of discomfort during this process is inevitable, even if the
dose is reduced very slowly over a period of months. A dose of 20 to 30 mg
is the level below which symptoms are usually most problematic.
As medication is being tapered, services should be intensified in the form
of increased monitoring of behavioral and emotional signs and increased counseling
sessions. A patient being considered for methadone tapering should be sufficiently
motivated to undertake this process, with the intensified counseling and increased
participation in therapy sessions that it entails. Putting pressure on patients to enter
this phase of treatment can have very negative results.
Counseling on the issue of tapering may consist of helping the patient to differentiate
between excessive or even phobic fears of withdrawal symptoms (Milby et al., 1987) and the normal concerns that are a part of detoxification.
Examples of the former are fears that one cannot live without methadone,
or excessive anxiety at even the thought of detoxification. Normal concerns
include worry about relapsing, how to structure activities when daily clinic attendance
is no longer necessary, and how to create support for a drug-free lifestyle
in the absence of regular ingestion of methadone.
In addition to physiological symptoms associated with detoxification, many
patients develop a psychological dependence on the treatment program. Issues regarding
loss of support may arise. These problems are usually identified in the early
phases of detoxification or even before it begins.
The risk of relapse during and after tapering is significant, owing to the
physical and emotional stress involved in attempting to discontinue methadone treatment.
Patients should be strongly encouraged to discuss any difficulties they
experience with tapering and readjustment so that appropriate action can be taken
if this approach fails and relapse can be prevented. The patient should be
encouraged to return to a previous phase if it is indicated at any time during tapering.
Important factors in a decision to taper medication include
Withdrawal symptoms such as insomnia, anxiety, cravings, or dysphoria are common,
and the patient should be told to expect these symptoms during tapering, especially
when lower dosages are reached (below 20-30 mg a day). Patients should be instructed
about the normal course of these symptoms and the importance of tolerating them
without recourse to opioid use. Several options exist for the amelioration of
these symptoms. Medication can be tapered more slowly, lengthening the intervals
between decreasing dosages, or the current dosage can be held at a steady level
until symptoms abate. Other medications can be used to address specific symptoms.
Clonidine may be instituted to control generalized withdrawal symptoms,
both during or after methadone treatment. However, it should be used with caution
because of its ability to reduce blood pressure.
In some cases single, low methadone doses (5 to 10 mg) can be given once or
twice after completing the taper to reduce the intensity of symptoms and give
the patient temporary relief from the peak of symptoms that occurs during the
several days following discontinuation of daily methadone. Acupuncture has also
been used to address withdrawal symptoms during methadone tapering, although
its efficacy has not been adequately evaluated as of this writing (see Chapter 4). Finally, inpatient treatment may be indicated for addressing
withdrawal in some patients, while others may participate in intensive outpatient
rehabilitation.
For a minority of opioid-addicted persons, use of opioids helps reduce relapse
to an underlying psychosis. In the past, the use of opioids and opioid blockers
in the acute treatment of schizophrenia was explored (unsuccessfully) because
clinicians had observed these antipsychotic effects. However, opioids seem able to
help stabilize remissions in people whose acute psychotic symptoms have been
controlled. Psychiatric assessment should be ongoing throughout all treatment phases.
Patients who complete tapering from methadone enter a period of readjustment. The
reduced contact with the clinic often creates anxiety. Additional counseling is
usually needed at this time. Emphasis should be placed on reinforcing the patient's
coping and relapse prevention skills. The patient's primary goal during readjustment
is to develop greater self-sufficiency and to create and maintain a balanced,
stable, and productive lifestyle. Participation in self-help or support groups
is continued during the readjustment period as dependence on the treatment
program is gradually reduced. After successful completion of tapering, some patients
may be helped by continued naltrexone therapy, an effective, long-lasting opioid
antagonist that will block opioid effects for 2 to 3 days when given in appropriate
doses. It may help motivated patients remain opioid free by creating a chemical
barrier and behavioral disincentive.
Special attention and support should be provided during the first 3 to 12 months
following medically supervised withdrawal, when most relapses occur. Support should
be focused on fostering self-sufficiency and reinforcing the goals of treatment.
Other strategies to help patients after the completion of tapering include
Problem-solving counseling approaches
Reinforcement of positive behaviors and attitudes
Maintenance of an open-door policy to maximize
the availability of counselors and providers
Use of the patient's support system, such as self-help groups, to benefit
the recovery process.
Even under the best of circumstances -- with a highly motivated and stable patient
and with strong family and social support systems in place -- there is no guarantee
that tapering will be successful. Because many patients find that they cannot
complete tapering, all patients in this phase should be carefully counseled to understand
that a return to a higher methadone dosage does not represent a failure, either
of the treatment program or of the individual. A return to a previous phase
may simply be an indication that the ongoing use of methadone may be more appropriate,
at least for the present time. For many patients, the optimum outcome that
can be achieved is continued functioning on methadone. Patients also need
to understand that tapering can be restarted at any time, when both patient
and staff feel it is appropriate.
Successful discontinuation of methadone is the key indicator for transition from the
tapering phase. Another primary indicator for transition is the patient's transformed
identity. Development of a positive self-view as functioning well without methadone
and adoption of a socially productive lifestyle without involvement in drugs
or alcohol is critical to the completion of this phase and to continued recovery.
The absence of signs and symptoms of dependence or abuse, as defined by
the DSM-IV or the International Classification of Diseases, Tenth Edition
(ICD-10) (see Chapter 2), and negative urinalyses
and breath tests for nonprescribed abusab le substances are criteria that must
be met before the tasks and goals of this phase are complete. Continued participation
in self-help groups is often helpful for the reinforcement of coping and relapse
prevention skills. Finally, the patient should have achieved and maintained relative
stability in all of the life domains discussed above.
Aftercare is a phase that follows successful tapering and readjustment; it is based
on clear evidence that recovery is well under way. As discussed above, the
patient has adopted a socially productive lifestyle, is no longer involved with
drugs or alcohol, and has demonstrated appropriate coping skills over a period
of at least 1 year. Persons in this phase are often involved in regular attendance
at self-help groups, and regular treatment is no longer necessary, except
to keep open contact with treatment providers and to ensure that recovery
continues. During this phase, appointments may be scheduled every 1 to 3 months,
although many programs prefer that patients maintain monthly contact. The period
for which patients are monitored in aftercare varies among programs, but many
consider 6 to 12 months to be a reasonable time.
Some patients may not need aftercare services, preferring a complete break
from the clinic. Others may need more extensive aftercare and a referral to
a nonmethadone outpatient treatment program. As with any chronic condition,
an unfortunate tendency exists for care providers not to see patients until
their condition is out of control again (a full-blown relapse). It is helpful
to develop a structure to reduce the chances of such an adverse event. Periodic
recall of patients, perhaps annually or semiannually, is one effective method
that some programs use to keep in touch with patients. Another way to maintain
regular contact with patients, if resources permit, is to set up a monthly or quarterly
"alumni" group that brings together former patients of the program. As in the treatment
of all addictions, treatment effectiveness is usually improved if the patient
becomes involved in self-help groups, such as Narcotics Anonymous and Methadone
Anonymous.
The treatment system must be flexible enough to allow for transition from one
phase to another according to the patient's progress. For example, crises or
stressful life circumstances, such as financial debt or psychosocial stressors, may
overwhelm a patient who resumes drug use in the belief that he or she is now "cured"
and can control this behavior. Patients are often presented with opportunities
for opioid use in their social environment. They may be tempted to test themselves
to find out whether they are able to use opioids only once. Such individuals
often rapidly regress to addictive behaviors that warrant transfer to the acute
phase.
Occasional relapses to drug use may not require that a patient reenter the acute phase,
but intensified counseling, loss of take-home privileges, dosage adjustments,
or all of these interventions may be needed. If a patient is in the medical
maintenance phase or the tapering and readjustment phase, a relapse almost always requires
an immediate change of phase. In such cases, the patient would be considered
in the rehabilitation phase once again. After providing evidence that the
problems are well under control, the patient may be able to return to supportive
care or medical maintenance.
A simple checklist, based on seven basic spheres of functioning (see Exhibit 3-4), that can be completed by case managers on a regular basis
may facilitate monitoring of treatment progress. Factors warranting consideration
of transfer to another phase can be recorded and periodically reviewed. Such
a record can also be referred to in later treatment phases for information
about a patient's earlier treatment experience.
If a patient-requested voluntary discharge is against the advice and judgment
of the treatment provider, a note should be made to that effect in the discharge
plan. If the patient has made substantial progress and is in good standing with
the program, efforts should be made to determine why he or she is requesting
a discharge. Patients who are using heroin or other illicit drugs should
be strongly discouraged from undergoing voluntary detoxification.
Efforts to resolve problems should be made to retain the patient in treatment.
A referral can be made to another program that is more appropriate for
the patient's needs at that time. Patients with a history of failed attempts
at medically supervised withdrawal who request discharge should be counseled
and educated about their risk of relapse and encouraged to stay. It may also
be helpful to review the patient's treatment and relapse history to help the
patient realistically assess his or her situation.
When these measures fail and a patient insists on leaving treatment, the discharge
plan should allow him or her to reverse the decision at any point. The patient
should be given the opportunity to return after discharge, and reentry into the
program should be made as easy as possible.
All programs must develop, disseminate, and consistently enforce guidelines
for the management of patients who fail to comply with program rules. Program
rules and the terms under which patients can be involuntarily discharged from
the treatment program should be explained clearly to the patient. These rules
should also be posted within the clinic, along with a description of the mechanism
to appeal such decisions. Staff members should identify problems as they
emerge and respond to them promptly.
The response must be tailored to the degree of severity of the problem. Patients
should not be disciplined by having their methadone dosage lowered, nor should
they be rewarded for good conduct by having the dosage raised. Programs are
encouraged to develop nonpunitive ways to set limits and to contain problematic behavior.
However, in some cases, involuntary discharge becomes necessary. Program
staff are responsible for ensuring the safety and security of all patients and
employees. This responsibility entails a clear need to maintain order, safety, and
discipline within the building and grounds of the treatment program.
The terms for involuntary discharge vary among programs. Infraction of some
rules may mean mandatory discharge, whereas other cases must be clinically evaluated
in light of individual circumstances. Generally, behaviors that threaten
the safety of the staff, patients, or the integrity of the program lead to
automatic discharge. Examples are fighting, making threats, bringing weapons into
the program, falsifying urine specimens, drug dealing, or diverting methadone.
If the offense is not one for which suspension is mandatory, the patient's
motivation and progress in treatment should be taken into account in determining whether
he or she should be discharged, placed on probation, or merely warned. No
patient should be discharged for minimal drug use.
Each treatment program must decide what level of drug use, over what period
of time, is grounds for discharge. This decision will vary among programs.
Some may allow only minimal drug use, whereas others may tolerate some
repeated use unless the patient fails to comply with the treatment or counseling
program or breaks program rules. Other clinics operate on the philosophy that,
regardless of the level of drug use, patients should be kept in treatment, where they
can be continually encouraged to stop their drug use.
It may be necessary to set some limits on patients who continue illicit drug
use. The types of drugs used and their potential for serious adverse effects
should be considered. For example, a patient who is dependent on large doses
of alcohol, barbiturates, benzodiazepines, or other nonbenzodiazepine sedatives
is at high risk of overdose or accidental injury and should immediately be
considered for transfer out of methadone treatment until the sedative dependence is
better controlled. Another important consideration in cases of unremitting drug
use is its impact on other patients. A program's excessive tolerance of continued
illicit drug use or total reluctance to set limits on use can diminish patients'
respect for the overall program, as well as the respect of the community and other
agencies.
Programs should consider for discharge only those persons judged to be "nonresponders"
to methadone treatment despite the best efforts of the staff. If these patients
do not keep appointments, do not comply with other aspects of the program,
and do not put forth even minimal efforts to work with the staff toward appropriate
treatment goals, discharge or transfer to another treatment modality is probably
indicated. Essentially, such cases involve individuals who are not trying, whose
progress in reducing drug use and achieving other goals is minimal or absent, and
who would probably be doing about as well even without treatment.
However, it is important to note here that discharge in cases of treatment nonresponse
is the last step in a long series of careful assessments and interventions.
When a patient fails to improve, the first response should be to review
the treatment plan and intensify treatment to match the patient's clinical
status. Most programs have at least a limited capacity to intensify treatment
by adding an extra 30-minute session of individual counseling or by requiring
a group session weekly. Seeing poorly performing patients more frequently,
even for less time each
session, enhances the overall structure of treatment, which is a critical factor
for many patients in opioid substitution therapy.
In any case, the decision to discharge for drug use should not be made solely
on the results of urine testing; rather, a range of factors should be considered.
Each clinic should set standards and be consistent, keeping in mind the
benefits and drawbacks of the chosen approach. Clinics that are more tolerant may
have higher rates of drug use and greater retention of patients in treatment,
but they may risk fostering negative attitudes in non-drug-using patients.
Programs that are less tolerant will have less drug use but may also risk
losing patients who have the potential to benefit from treatment, especially over
the longer term. Such patients are likely to be those with significant psychiatric
or other associated problems and who may eventually respond to treatment,
provided the appropriate blend of counseling and additional services can be arranged.
Another reason for involuntary discharge may be inability to continue to pay for
program services. Discharge for nonpayment of program fees should be preceded
by formal warnings from the program and efforts to help the patient change
his or her behavior. For example, to prevent discharge for failure to pay,
the patient should be advised to inform the program of impending financial
problems as soon as possible. Staff will then have time to investigate other treatment,
payment, or program alternatives. In any case, discharge should not occur until
all efforts to secure reimbursement have been exhausted. Whenever possible,
discharge should occur within the context of referral to another center with a sliding
fee scale or to a State-subsidized program.
Involuntary discharge of patients who are HIV positive or who have AIDS creates a dilemma
for staff. Concerns that the HIV-positive patient will resume needle sharing
and transmit the virus often lead staff to ignore noncompliance issues in this
patient group to retain the patient in the program. However, if staff suspect
that the patient is continuing to share needles while attending the program,
they also have strong concerns that ignoring noncompliance is "enabling" the
patient to put others at risk. As discussed below, programs should make every
effort to retain patients in treatment regardless of their HIV status. If a patient
must be discharged, referrals should be made to a more appropriate level of
treatment or to other substitution therapy programs. These considerations are especially
important with HIV-positive patients and those with AIDS. The TIP Providing Treatment
for HIV-Infected Alcohol and Other Drug Abusers provides further discussion
of these issues.
Regardless of individual clinic policies, however, drug-using patients should not
be allowed the same privileges (such as take-home medication) as other patients.
Neither should their behavior be tolerated indefinitely without some type
of intervention. Before discharging a patient for nonresponse to treatment,
every effort should be made to provide the most appropriate treatment available
for that individual's specific problems, and to persuade him or her to become
fully engaged in treatment and to discontinue drug use. Approaches may include
Intensive counseling
Additional psychotherapy, pharmacotherapy, or combinations of both for
psychiatric disorders
Treatment of medical or other associated problems
Inpatient detoxification with return to methadone treatment
Change of counselors, if clinically indicated
Alternative medications (for example, levo-alpha-acetyl-methadol [LAAM])
If a decision is made to discharge a patient, discharge procedures should
be initiated and withdrawal of methadone begun. Involuntary discharges should
be made with the understanding that the patient may return to the program,
provided that identified preconditions have been met, within a specified period
of time. Obstacles to reentry should be minimized if the requirements are
met. Even when a patient is discharged for drug use, the door should still
remain open for his or her return, provided that the patient demonstrates that
methadone treatment can help (for example, by doing well in another program). It
may be advisable in some cases to schedule a date to invite the patient back
to talk about whether he or she may reenter the program. Patients in treatment
often fare better when their care is provided by a single provider group, even
if treatment is episodic rather than continual.
Serious medical or psychiatric problems sometimes make it inadvisable or impossible
for a patient to continue in a particular program. Ideally, patients benefiting
from methadone therapy should be permitted to continue with this treatment in
other settings, whether medical or psychiatric. Toward this end, treatment staff
should work closely with other providers who treat the patient after transfer
from the methadone program.
If attempts to facilitate continued medication in another setting are unsuccessful,
a program of detoxification may have to be started. The facility to which
the patient was transferred should make a referral back to the methadone treatment
program as part of the patient's discharge plan. In such cases, the patient should
be reassessed before resuming opioid substitution therapy, because his or
her status may have changed.
Methadone treatment is almost always discontinued for patients who become incarcerated.
Only one methadone maintenance program for incarcerated opioid-addicted
offenders is known to exist in the United States, and that is at Rikers Island, New
York City's central jail facility (Magura et al.,
1993).
The treatment program should extend its best efforts to work with the penal
facility and ensure that the appropriate detoxification procedures are used. Upon
release from incarceration, patients who desire readmission should be reassessed
to determine the appropriate treatment phase.
Readmission to methadone treatment is a common issue that must be anticipated. Marsh and associates (1990) reported that among the addicted patients they
studied, multiple treatment admissions occurred over a 12-year followup period,
with an average of more than six program admissions for each patient, most often
involving methadone treatment. Patients being readmitted, whether from the same
program or from other programs, should be placed in the phase of treatment that
offers the most appropriate level of care.
To determine the appropriate phase, all key domains of functioning should
be assessed to identify any factors warranting the patient's placement in
a particular phase. The length of time the patient has been out of treatment
should be taken into account. A complete reintake assessment is likely to be
in order if this period is longer than 1 month, but is probably not necessary
if the patient has had a shorter absence from treatment. The patient's history
of drug use and performance while outside the treatment program, as well as
any legal requirements, are also important factors to consider in this decision.
Opioid substitution therapy programs should have written guidelines under which
cases of involuntary discharge may be appealed and examined by staff -- generally,
clinical staff. Some States have developed regulations to guide this process, partly
to ensure that it will be impartially conducted. In these States, the reviews
and appeals are administrative rather than clinical procedures. Whether the
process is regulated by the State or not, most programs have established a formal
mechanism whereby the appeal is referred to consecutively higher levels of program
authority. Staff members who are directly involved with the disciplinary action should
not conduct the review procedure. Appeals should be handled promptly.
A variety of clinical issues arise during methadone treatment, and some may
arise during more than one phase. Dispensing take-home medication and ensuring
continued medication for patients who enter the hospital are discussed here.
Medication dispensed for patients to take home may begin on a gradual basis during
the rehabilitation phase for patients who meet Federal eligibility criteria.
These criteria require that the person demonstrate the absence of drug
use by urine testing and attend the clinic and counseling sessions regularly.
Other signs of rehabilitation such as working or being in school should
also be evident, and program staff must judge the patient to be responsible
for taking the medication as prescribed. Although not required by FDA regulations,
negative breath tests for alcohol constitute an important sign that rehabilitation
is under way, and demonstration of consistent negative results is strongly
recommended as a criterion for eligibility for take-home medication. The amount of
medication dispensed for take-home purposes gradually increases in accordance with
program policy and FDA regulations throughout the rehabilitation, supportive care,
and medical maintenance phases.
Throughout treatment, providers should monitor patients for stresses or life changes
that could lead to relapse. When such stressors are identified or anticipated,
more frequent clinic visits, closer monitoring, and increased support often
prevent relapse. In such situations, patients who are not required to attend the
clinic frequently (such as those on medical maintenance) can continue to receive
their take-home medication but may be required to come to the clinic to take
it or to receive additional counseling until the crisis passes. In this way,
patients retain a sense of control, while providers ensure that medication is not
diverted.
In supportive care, the length of time for which take-home medication is dispensed
varies according to individual needs but is usually not longer than 6 days. Before
a patient is considered for transition into medical maintenance, he or she
has generally been receiving take-home medication in supportive care. LAAM,
which has a longer duration of action than methadone, may be useful during supportive
care or even earlier in treatment to limit take-home medication while maintaining
the patient's contact with the clinic. (See the TIP LAAM in the Treatment of Opiate Addiction.)
During tapering of methadone, take-home medication is continued until lower doses
are reached. At this point, patients must be seen more frequently and should
be required to come to the clinic for each dose. Clinic policies concerning
take-home medications during the tapering phase must be tailored to individual needs.
During a medical crisis requiring hospitalization, it is important for the physician
providing methadone treatment to communicate with the hospital attending physician
and other members of the healthcare team. The team should be informed of the
patient's methadone dosage and the date on which methadone was last received.
It is extremely important that the treating physician be aware that the patient
will probably require larger amounts of medication for anesthesia, and that
adequate pain relief will require that the patient receive the normal methadone
dose (or its equivalent) plus additional medication. Communicating these facts
to the healthcare team will usually ensure that appropriate care is administered.
In addition, the healthcare team should be advised to institute appropriate
behavioral controls to prevent the patient from using illicit substances while in
the hospital. These controls are especially important for unstable methadone
patients who are in the acute phase of treatment. They may include limiting visitors,
preventing the patient from wandering through the hospital, and scheduling regular
urine drug screens. It is usually helpful to provide psychiatric consultation
to medical or surgical staff, especially in the case of patients with comorbid
psychiatric disorders.
The use of a phased model of methadone treatment assists patients in setting
goals and establishing markers for progress. Each patient's needs, however,
rather than the phases themselves, should dictate the specific course of treatment.
The phases should simply facilitate the natural course of the recovery
process.
This chapter provides a framework for a phased model of treatment that must
be adapted to the needs of each patient population and treatment setting.
As this model evolves, each component must undergo critical evaluation
from the perspective of patient outcome, cost-effectiveness, and quality improvement
so that its advantages and shortcomings can be clearly documented.
Recommendations of the panel are also summarized in Exhibits 3-2
and 3-3 (see especially the columns headed
"Indicators for Transition . . .").
Phases of treatment should be established as a dynamic continuum that allows each
patient to progress according to his or her individual needs.
Treatment outcomes should be evaluated not solely in terms of how many phases the
patient has moved through, but rather by the degree to which the patient's needs,
goals, and expectations have been met by the treatment program.
Staff should have frequent interaction with patients, should encourage ongoing
dialogue concerning their symptoms, and should not take a punitive approach if drugs
other than opioids are being used.
Independent psychiatric disorders and substance-induced psychiatric disorders should
be identified and addressed.
Long-standing medical problems should be addressed immediately. Stabilization of acute
conditions and the institution of ongoing care for chronic conditions are mandatory
before a patient can move out of the acute phase.
Patients' needs for basic necessities such as food, clothing, housing, and safety
should be determined and referrals made to appropriate agencies.
A patient's legal problems should be addressed as soon as possible after
treatment is initiated.
The counselor should correct misconceptions about treatment and educate patients
about the program and the benefits and goals of treatment.
Patients should be introduced to key staff members of the treatment program as early
as possible to foster an atmosphere of safety, trust, and familiarity.
Waiting times should be minimized to demonstrate that patients' time is valued.
Counselors should explore and openly address patients' past negative treatment experiences.
The methadone dosage must be stabilized at a comfortable level prior to entering
this phase.
Efforts should begin toward productive participation in constructive activities
such as full- or part-time employment, education, vocational training, childrearing
or homemaking, or volunteer work.
Information about outside support groups introduced during the acute phase should be
periodically reviewed.
Providers should cultivate relationships with churches and community groups to provide
support and facilities for methadone patients.
Providers should help patients develop and maintain coping skills to deal with relapse
triggers.
Medical care for methadone patients should be identical to that provided for other
patients.
Educational, literacy, and vocational programs should be provided to help patients build
the skills they need to function independently. Information about budgeting
personal funds and setting up bank accounts should be included.
Providers should help patients gain a stable source of legal income to ensure that
they will not resort to criminal activities.
Patients should be encouraged to take responsibility for their own legal problems.
Patients should be taught coping skills to deal with frustration, anxiety, and boredom.
Patients' preferences and desires about tapering should be taken into account, with
the understanding that they can return to their previous methadone dosage if
tapering is not successful.
Patients should be strongly encouraged to discuss any difficulties they experience
with tapering and readjustment so that appropriate action can be taken if this
approach fails and relapse can be prevented.
Patients should be instructed about normal withdrawal symptoms and the importance
of tolerating them without recourse to opioid use.
Emphasis should be placed on reinforcing the patient's coping and relapse prevention
skills.
Special attention and support should be provided during the first 3 to 12 months
following detoxification, when most relapses occur. Support should focus on fostering
self-sufficiency and reinforcing the goals of treatment.
Program rules and the terms under which patients can be involuntarily discharged
from the treatment program should be explained clearly to the patient.
Staff members should identify problems as they emerge and respond to them promptly.
Patients with a history of failed attempts at detoxification who request discharge
should be counseled, educated about their risk of relapse, and encouraged to stay.
Patients who are using opioids or other illicit drugs should be strongly discouraged
from undergoing voluntary detoxification.
The discharge plan should allow the patient to reverse the decision at any
point. The patient should be given the opportunity to return after discharge,
and reentry into the program should be as easy as possible.
Involuntary discharges should be made with the understanding that the patient may return
to the program, provided that identified preconditions have been met, within
a specified period of time.
The decision to discharge for drug use should not be made solely on the results
of urine testing; rather, a range of factors should be considered.
Programs should consider for discharge only those persons judged to be "nonresponders"
to methadone treatment despite the best efforts of the staff.
Drug-using patients should not be allowed thesame privileges (such as take-home medication)
as other patients.
Ideally, patients should be readmitted within 30 days to avoid their seeking admission
to another program and perpetuating the revolving-door syndrome.
For readmitted patients, a complete reintake assessment is probably in order
if this period is longer than 1 month but is probably not necessary if the
patient has had a shorter absence from treatment.
Opioid substitution therapy programs should have written guidelines under which
cases of involuntary discharge may be appealed and examined by staff.
During a medical crisis requiring hospitalization, it is important for the physician
providing methadone treatment to communicate with the hospital attending physician
and other members of the healthcare team.
It is important to communicate to the treating physician that the patient
should continue to receive his or her normal methadone dose, plus additional medication
for pain relief.
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