Matching Treatment to Patient Needs in Opioid Substitution Therapy Treatment Improvement Protocol (TIP) Series 20
Exhibits
Exhibit 2-1 DSM-IV Diagnostic Criteria for Substance Dependence
The DSM-IV defines alcohol and other drug addiction as "substance dependence" and describes the diagnostic criteria as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three or more of the following occurring at any time in the same 12-month period:
Tolerance, as defined by either of the following
The need for markedly increased amounts of the substance to achieve intoxication or desired effect
Markedly diminished effect with continued use of the same amount of the substance
Withdrawal, as manifested by either of the following
The characteristic withdrawal syndrome for the substance
Use of the same (or closely related) substance to relieve or avoid withdrawal symptoms
The substance often taken in larger amounts or over a longer period than was intended
A persistent desire or unsuccessful efforts to cut down or control substance use
A great deal of time spent in activities necessary to obtain or use the substance or to recover from its effects
Important social, occupational, or recreational activities given up or reduced because of substance use
Continued substance use despite knowledge of having had a persistent or recurrent physical or psychological problem that was likely to have been caused or exacerbated by the substance.
Adapted with permission from the Diagnostic and Statistical Manual, Fourth Edition (American Psychiatric Association, 1994).
Exhibit 2-2 ICD-10 Criteria for Substance Use Dependence
A strong desire or sense of compulsion to take the substance
Difficulties in controlling substance-taking behavior in terms of its onset, termination, or level of use
A physiological withdrawal state when substance use has ceased or been reduced, as evidenced by the characteristic withdrawal syndrome for the substance or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms
Evidence of tolerance that requires increased doses of the psychoactive substances in order to achieve effects originally produced by lower doses
Progressive neglect of alternative pleasures or interests because of psychoactive substance use, or increased amounts of time necessary to obtain, take, or recover from the substance's effects
Persistence in the use of the substance despite clear evidence of harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning.
Adapted with permission from the International Classification of Diseases (World Health Organization, 1992).
Psychotic, anxiety, mood, and personality disorders
High-risk behaviors
Linkages to available resources, including medical/psychiatric and emergency services, between physician and hospital
Ongoing counseling to reduce risk
Stabilization of acute medical crises
Ongoing established care for chronic conditions
Basic Needs
Concerns over legal and financial issues
Threats to personal safety
Housing
Transportation
Lack of financial resources
Childcare
Pregnancy
Advocacy
Referrals to appropriate agencies
Establish linkages and quick referral sources to obtain needed services
Transportation arranged with other patients
Maintain travel resources, including bus tokens and travel vouchers
Identify legal advocate, eligibility case manager, or social worker to identify financial resources
Provisions made for food, clothing, housing, and safety needs and financial assistance if necessary
Relatively stable and secure living conditions
Receives prenatal care
Childcare resources established
Transportation resources available
Therapeutic Relationship
Establishing trust and feeling of support
Myths surrounding methadone treatment (e.g., "Methadone gets into your bones.")
Ensure that methadone dosage is adequate (60-120 mg)
Foster atmosphere of trust, familiarity (e.g., introduce patients to key staff members, encourage acquaintance with other patients)
Remain consistent yet flexible and readily available during acute situations
Nonjudgmental attitude
Address relationships (drug, lifestyle, etc.) that have negative influence on patient
Provide incentives, stress benefits of treatment:
Financial concerns
Self-esteem and sense of well-being
Freedom from drug cravings
Minimize waiting times during scheduled appointments to demonstrate that the patient's time is valued
Help create support system (e.g., encourage patient involvement in self-help, social, and recreational activities)
Dispel myths surrounding methadone treatment (include family as indicated)
Regular attendance at group, individual, or (if indicated) family counseling
Positive interaction with treatment providers
Focus on appropriate range of treatment goals
Motivation/Patient Readiness
Ambivalent attitudes about stopping illicit drugs
Involuntary discharge
Negative relationships with staff
Introduction of methadone treatment without needed adjunctive support services
Inadequate dosing
Perception that methadone is a medication, not a means of social control
Developing positive attitude for treatment
Ensure that methadone dosage is adequate (60-120 mg)
Address ambivalence about giving up drugs, fears of making major life changes (Miller and Rollnick, 1991)
Stress benefits of methadone treatment:
Preventing needle-borne infections
Avoiding arrest and incarceration
Peace of mind, relief of concerns over obtaining next fix
Encourage patient to control his/her addiction
Commitment to the treatment process
Acknowledgement of addiction as a problem
Beginning of changes in lifestyle and of addressing issues surrounding drug abuse
Exhibit 3-3 Rehabilitation Phase of Methadone Treatment: Clinical Issues, Strategies, and Issues for Transition to Supportive Care
Clinical Issues
Strategies to Address Issues
Indicators for Transition Into Supportive Care
Alcohol and Drug Use
Continued use of abusable drugs (alcohol, cocaine, and others)
Continued opioid use
Behavioral contracting
Short-term inpatient treatment
Disulfiram for alcohol abuse
Intensification of treatment services
Positive incentives: take-home medication, recognition of progress
Intensified individual or group counseling
Adjustments in dosage as necessary for continued opioid use
Support groups
Ability to identify and manage relapse triggers
Repertoire of coping skills
Demonstrated changes in life circumstances to prevent relapse
Discontinuation of opioid and other drug use
Absence of problematic alcohol use
Medical and Psychiatric Problems and Concerns
Chronic medical diseases: diabetes, hypertension, HIV infection, tuberculosis, seizure disorders
Psychotic, anxiety, mood, and personality disorders
Pregnancy, dental problems, nicotine dependence
Onsite primary care or linkage to other services
Holistic approach
Training on diet, exercise, smoking cessation
Adjustments in other medications interacting with methadone
Teach coping skills
Individualized psychiatric care
Early identification and referral for special psychiatric problems
Referral for psychotropic medication or psychotherapy as indicated
Ongoing evaluation of psychiatric status
Compliance with treatment for chronic diseases
Improved overall health status
Improved dental health and hygiene
Regular prenatal care
Stable medical and mental health status
Vocational and Educational Needs
Unemployment/underemployment
Low reading skills
Literacy
Learning disabilities
Targeting of patients with less than high school education
Onsite GED counseling or referral
Literacy and vocational programs
Encourage local businesses to set up apprenticeships or entry-level positions
Bring together business, government, and industry leaders to set up income-generating enterprise
Training on budgeting of personal finances
Stable source of income
Actively seeking employment
Involvement in productive activity: school, employment, volunteer work
Family Issues
Absence of family support system
Emergence of family problems (e.g., traumatic family history, problematic current situations)
Involvement in community or church groups
Join fellowship, recreation, or other peer group
Increased involvement in family life (in absence of family dysfunction that impedes progress)
Encourage well-baby care
Social support system in place
Absence of major conflict within support system
Increased responsibility for dependents
Legal Issues
Criminal charges
Custody battles
Ongoing illegal activities
Access to legal counsel
Encourage patient to take responsibility for legal problems
Identify obstacles to eliminating illegal activities and replacing them with constructive activities
Resolution of, or ongoing efforts to resolve, legal problems
Absence of illegal activities
Exhibits
Exhibit 2-1 DSM-IV Diagnostic Criteria for Substance Dependence
The DSM-IV defines alcohol and other drug addiction as "substance dependence" and describes the diagnostic criteria as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three or more of the following occurring at any time in the same 12-month period:
Tolerance, as defined by either of the following
The need for markedly increased amounts of the substance to achieve intoxication or desired effect
Markedly diminished effect with continued use of the same amount of the substance
Withdrawal, as manifested by either of the following
The characteristic withdrawal syndrome for the substance
Use of the same (or closely related) substance to relieve or avoid withdrawal symptoms
The substance often taken in larger amounts or over a longer period than was intended
A persistent desire or unsuccessful efforts to cut down or control substance use
A great deal of time spent in activities necessary to obtain or use the substance or to recover from its effects
Important social, occupational, or recreational activities given up or reduced because of substance use
Continued substance use despite knowledge of having had a persistent or recurrent physical or psychological problem that was likely to have been caused or exacerbated by the substance.
Adapted with permission from the Diagnostic and Statistical Manual, Fourth Edition (American Psychiatric Association, 1994).
Exhibit 2-2 ICD-10 Criteria for Substance Use Dependence
A strong desire or sense of compulsion to take the substance
Difficulties in controlling substance-taking behavior in terms of its onset, termination, or level of use
A physiological withdrawal state when substance use has ceased or been reduced, as evidenced by the characteristic withdrawal syndrome for the substance or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms
Evidence of tolerance that requires increased doses of the psychoactive substances in order to achieve effects originally produced by lower doses
Progressive neglect of alternative pleasures or interests because of psychoactive substance use, or increased amounts of time necessary to obtain, take, or recover from the substance's effects
Persistence in the use of the substance despite clear evidence of harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning.
Adapted with permission from the International Classification of Diseases (World Health Organization, 1992).
A 300-slot community methadone program that collects and tests urine samples, but has little previous evaluation experience, wants to find out
How common is moderate to severe psychopathology in our population?
How effective are we in treating patients with high levels of psychopathology?
How often are patients with high levels of psychopathology referred for mental health services?
How often do patients referred for these services receive them?
2. What data are needed?
A measure of psychopathology
A measure of patient outcome
List of services patients are receiving
3. What will be studied?
Psychopathology and outcomes will be measured in all patients.
Services received will be examined in a 10 percent random sample of patients with a high level of psychopathology.
NOTE: This measurement may change depending on the number of such patients found. The idea is to sample enough patients to obtain meaningful data, without being overwhelmed by the task.
4. How will the data be collected?
Instruments:
To measure psychopathology, use the psychological status section of the Addiction Severity Index.
NOTE: There is a need to set a cut-off score for severity. The ASI is a summary measure of the need for treatment in a given area. The recommended cut-off score is 5 on a scale of 1 to 9, but other cut-offs may be chosen, depending on the degree of sensitivity desired.
To measure outcome, determine the number of weeks with at least one urine toxicology screen positive for illicit drugs during the past 6 months. (This information has already been tracked by the program and is available.)
NOTE: Some programs may not obtain weekly urine samples. A project like this could be modified to accommodate longer intervals between urine screens.
To measure process (services received), chart review determining whether a referral was made for mental health services and whether such services were delivered.
5. What are the results?
Determine percentage of patients with ASI psychiatric scores greater than 5 (for example, 120 of 300 patients, or 40 percent).
Calculate mean number of patients with positive urine screens for groups with low and high levels of pscyhopathology. (Low: 4.2; High: 12.6)
Determine the significance of any difference observed (may need statistical consultant).
Determine the proportion of patients with a high level of psychopathology who were referred for mental health services (15 percent), and the percentage who received services (5 percent).
NOTE: Determine significance by using any standard statistics program for personal computers. While not essential, determining statistical significance can add weight to the findings. If needed, consider obtaining technical assistance from your State agency, a local university, or a graduate student.
6. Do the results answer the questions?
Yes. The results are the following:
High levels of psychopathology are common (40 percent).
The program is much less effective in reducing illicit drug use in the group with high levels of psychopathology than in the group with low levels of psychopathology. Patients with high levels of psychopathology have three times as many positive urine screens as those with low levels.
This difference may be due to the fact that very few (15 percent) of the patients with a high level of psychopathology are being referred for mental health services or are receiving them (5 percent).
7. What is next?
Examine ways to improve identification of patients with a high level of psychopathology; for example, begin routine use of ASI or the ASI psychological status section.
Examine barriers to referring patients to mental health services and to their receiving services. These barriers may include lack of funding, lack of mental health services, and obstructions to admission to mental health programs. Initiate staff discussion about problems and barriers; conduct patient focus groups.
Did patients with a high level of psychopathology receive services?
What problems arose when attempting to implement the intervention?
What strategies were used to overcome the barriers?
Did obtaining mental health services reduce illicit drug use?
NOTE: Questions 1 to 3 are a process evaluation, examining service delivery. This examination includes an implementation analysis (questions 2 and 3). Question 4 is the second outcome analysis.
2. What data is needed?
Implementation analysis: Meeting notes, personal log of program director, interviews with case managers and patients.
Services received: Chart review of 20 of 120 patients with a high level of psychopathology selected at random.
Outcomes: Urine drug toxicology screens (number of weeks of positive urines during last 6 months).
3. Who will be studied?
Sample of patients with a high level of psychopathology.
4. How do you collect data?
Data is collected from existing program sources for all of these processes:
Implementation: Analysis of narrative, logs, and meeting and interview notes
Services received: Chart review on data collection forms from first study
Outcome: Urinalysis data (already tracked and available).
5. What are the results?
Implementation analysis:
Required meeting with program staff to discuss importance of referral and to solve problems related to referral.
Some barriers are encountered with staff resistance at mental health agency. These are lessened after an inservice training program conducted by the methadone program staff.
Another problem arose with funding. This problem was resolved by the methadone program's agreeing to collect information needed to apply for financial assistance and arranging for rapid processing by the county benefits agency.
Patients needed to be educated and reassured about mental health services and persistently encouraged and supported to attend them.
Services:
Eighteen of 20 patients with high psychopathology received mental health services; 2 of 20 did not, because of persistent refusal to accept referral.
Outcome:
Average number of positive drug tests went from baseline of 12.6 to 8.2. This was significantly lower than baseline, although still higher than the group with low psychopathology.
6. What do the results mean?
It is feasible to screen for and successfully refer patients for mental health services who have a high level of psychopathology.
Receiving mental health services resulted in a significant reduction in positive urine drug screens.
7. What is next?
Continue screening and referral procedures.
Periodically monitor referrals and problems with referrals.
Site Map
Help
Account
Cart
Home
