In planning treatment for patients receiving levo-alpha-acetyl-methadol (LAAM)
therapy, clinicians must address several unique considerations. First, the initial
30 days of treatment are of critical importance. Some patients find that
adjusting to LAAM is more difficult than adjusting to methadone, because of its delayed
onset of action and prolonged effect. Although persons who are being transferred
from methadone to LAAM therapy generally do not have as many difficulties as
those entering LAAM treatment directly, problems can occur in both groups. To
support patients during this transition, treatment staff need special training
in the pharmacodynamics of the drug. Flexibility and involvement of all staff
members are also important. If all staff express support for the treatment regimen,
patients will experience less anxiety and make better progress.
This chapter presents valuable guidelines for engaging and retaining patients
in LAAM treatment. The importance of patient education is reviewed, and suggestions
for issues to address in education sessions are provided. A discussion is
included of typical issues that may arise in counseling sessions, such as adapting
to dosing schedules and structuring increased time away from the clinic.
Reinforcing treatment progress may be a challenge for counselors who are used to working
with patients maintained on methadone; with methadone, patients often receive
take-home medications in recognition of their progress in treatment. However, no
take-home LAAM is permitted. This chapter presents some suggestions for reinforcing
treatment progress. Other clinical issues, such as relapse, urinalysis, and discharge
planning are also briefly addressed.
For more detailed discussions of clinical issues related to treatment planning,
the reader is referred to two other Treatment Improvement Protocols (TIPs)
in this series, State Methadone Treatment Guidelines and Matching Treatment to Patient
Needs in Opioid Substitution Therapy. The Center for Substance Abuse Treatment
(CSAT) has also prepared a valuable handbook Treatment of Opiate Addiction With Methadone: A Counselor Manual, which is part
of its Technical Assistance Publication (TAP) series. The manual includes
patient questionnaires that help focus counselor-patient discussions of important
treatment issues, such as recognizing stress, staying busy, developing healthy eating
and exercise habits, and preventing relapse. These questionnaires can be used
with both methadone- and LAAM-maintained patients.
Patient education is essential to successful outcomes for patients in LAAM therapy.
A comprehensive education plan that takes into account the patient's educational
background, ethnicity, and culture is an integral part of the treatment plan. Patient
education should be initiated early in the treatment process and should be ongoing.
Information should be presented, clarified, and reinforced at every opportunity.
Although certain principles of patient education apply to all persons being treated
for a chronic disease, individuals undergoing treatment for opiate addiction
have additional requirements. Patients may be divided into two categories:
Those who are new to the opiate addiction treatment system
Individuals who have a treatment history but who are new to LAAM therapy.
While all patients need basic information about opioid substitution therapy,
the focus of education differs for each group.
It should be noted here that clinical trials with LAAM have clearly shown
that when program staff do not accept LAAM therapy as a potential alternative
to methadone treatment or are not properly informed about counseling and casework
issues, patients also tend not to accept LAAM treatment. Therefore, even the best
efforts to educate patients can be undermined by staff with negative attitudes
about LAAM. As discussed in Chapter 5, every effort should be made to provide
staff members with appropriate training about LAAM therapy and to ensure that
their questions or fears about its use are addressed.
Although this chapter focuses primarily on patient education about LAAM therapy,
the need for patient education in numerous areas, such as human immunodeficiency
virus (HIV) risk reduction, alcohol and other drug (AOD) abuse, nutrition, health care,
parenting, and so forth should not be overlooked. The TIP Matching Treatment to Patient Needs in Opioid Substitution Therapy provides
several recommendations for patient education. In addition, patients' families
and significant others also benefit greatly from education about LAAM therapy.
Patients who have not previously participated in an opioid substitution therapy
program need to understand the treatment options that are available and how they
differ from one another. Staff should describe treatment alternatives and explain
the differences between LAAM and methadone. The nature and goals of opioid
substitution therapy should be presented. An effort should also be made to allay patients'
concerns about the social stigma associated with this type of therapy. Staff should
also be prepared to counter the prevailing idea that the sole objective of treatment
is to become drug free, an idea which tends to alienate those who need and
want continuous maintenance treatment. Patients should be helped to view LAAM
as medicine and not as a drug.
Issues specific to the individual program, especially those relating to clinic
management, services, hours of operation, and administrative matters, should be thoroughly
discussed. Policies governing involuntary withdrawal from treatment should also be
explained. The program's policies should be posted in public areas throughout the
facility. All information should be continually reinforced in individual sessions
with the patient. New patients should be given a copy of the program's policies
and rules. Ample opportunity should be allowed for patients' questions. When
available, programs should provide patients with a patient handbook that includes
all relevant program-specific information necessary for patient compliance.
The handbook should be written so that all patients can understand the
expectations and the rules. The handbook should be available in the patient's first
language, where applicable.
Patients who have received or are currently receiving treatment for opiate addiction
and who are being inducted onto LAAM therapy also need to be educated about
the unique aspects of LAAM and how it differs from methadone. For these patients,
the first issue to be addressed is the action of LAAM, particularly with regard
to its delayed onset and duration of effect. It is of utmost importance to
warn patients about the dangers of using other drugs while waiting for the onset
of action of LAAM.
The change from daily dosing to every-other-day or Monday-Wednesday-Friday
dosing has broad implications for patients. Many patients may be initially unaware
of how the schedule change will affect them. Counselors should help patients
explore in detail the lifestyle changes that will accompany the LAAM dosing schedule.
Patients will have more unstructured time and less clinic contact; they
may need support in finding ways to deal with this new situation. The involvement
of the patient's family and significant others, although not essential, should
be encouraged, if appropriate. In addition, the issue of LAAM dosing during
vacations, emergencies, and other unanticipated interruptions in treatment should
also be explored. (See Chapter 3 for approaches to handling planned and unplanned interruptions
in treatment.)
Because of the reduced dosing frequency of LAAM, many patients may view this therapy
as a kind of quick-and-easy solution. Staff should emphasize that LAAM, like
methadone, is a maintenance medication, and that success in treatment requires that
the patient make significant changes, often over an extended period of time.
As described in Chapter 3, the rationale for not using LAAM for women who
are pregnant or nursing and the need for monthly pregnancy tests for women
of childbearing potential should be explained to both male and female patients.
These issues should be explored in detail with female patients.
Patients should be reassured about the efficacy of LAAM. Although newly approved,
LAAM is not a new drug and is no longer experimental. Staff should explain
that LAAM has been successfully used with nearly 6,000 persons enrolled in programs
across the country over the last several decades and that, when used as approved,
it is safe and effective.
Patients being treated for opiate addiction may not remember information presented
during the early stages of treatment, before their condition has stabilized.
Constant and consistent reinforcement by all members of the staff is critical, and
opportunities should be sought to review treatment goals and other issues that affect
a patient's progress. For example, when female patients of childbearing
potential elect to try LAAM therapy, the monthly pregnancy test provides an opportunity
not only to assess a woman's progress in treatment but also to explore issues
related to sexuality, family planning, and reproductive health.
Patient education can be delivered in an individual meeting or a group session.
Programs may find it helpful to schedule group orientation and education
sessions, as well as discussion groups, for patients who are beginning LAAM therapy;
the groups will help them establish appropriate expectations and allow
patients to share experiences and problem-solving strategies.
Written materials can reinforce and supplement oral messages. All clinics should
provide simple, patient-appropriate educational materials. They may develop their
own materials or use those developed by others. All materials should be reviewed
for appropriateness for the specific population being served. Non-English
versions should be available if appropriate for the clinic population.
The emotional and psychological needs of patients during the initial phases
of treatment for opiate addiction are often considerable and intense. Treatment
programs that offer medications such as LAAM should be focused on the patient, with
a positive, trusting, hopeful philosophy. Counselors should not be policing
or punishing, but rather motivating in their approach. Most patients experience
marked differences in their physical and emotional feelings while on LAAM therapy.
There may be a danger that patients will begin to feel "too well too fast.
" Education is important for both staff and patients, and its goals should
include fostering an understanding of the chronicity of the disease of addiction.
Feelings of physical well-being, although desirable, do not always equate
with cure.
During the first few weeks of treatment, efforts to relieve the patient's anxiety
concerning the effects of LAAM and to reassure the patient about the efficacy of treatment
are of paramount importance. Group counseling can play an important role in
this area. Individual counseling sessions during this period may have to be
longer or more frequent than those that follow. The frequency and duration of
visits, both during the first weeks of care and throughout the treatment course,
should be dictated by patients' individual needs. Because use of LAAM eliminates
the need for discussing arrangements for take-home doses, this time may be
used to address other substantive concerns of the patient.
Patients who have recently entered LAAM treatment often have questions about dosages
and dosing intervals. When a patient maintains that his or her dosage is inadequate,
the reason may not be purely medical. All staff members should be aware of
the many factors that can cause a patient to feel that his or her dosage is
inadequate. The patient's dosage should be reevaluated, and the treatment team should
discuss the issue. However, Federal regulations stipulate that only a physician
may prescribe or adjust a patient's dosage. Each team member should be aware
of his or her specific role in medication ordering, administration, and monitoring.
Regardless of occasional differences of opinion over what is best for
a patient, the team should speak to the patient in a consistent voice that
mirrors the program philosophy and mission statement.
Staff who counsel patients maintained on LAAM should be prepared to deal with
some issues that differ from those faced by methadone counselors. A few of
the most prominent issues are discussed here.
Dosing issues are more complex with patients receiving LAAM than with those receiving
methadone. As described in Chapter 3, the physician often must order two doses, a
Monday-Wednesday dose and a Friday dose. Dosage determinations should be based on an assessment
of medical need. Arbitrary guidelines such as "lower is better" are inadvisable.
The patient's psychological concerns are valid considerations in dosage
determination, particularly if dosing is done on Monday, Wednesday, and Friday, rather
than every other day.
Some treatment programs are slow to accede to a patient's request for a higher
dose. Reliable information about LAAM levels in the patient's blood is of significant
benefit to clinicians who are concerned about increasing a patient's dosage.
The 72-hour interval between Friday and Monday is a common source of anxiety
and discomfort. For some patients, oral reassurance will help ease the psychological
distress. Many patients will need an increased dose of LAAM on Friday. If the patient
continues to experience discomfort during the 72-hour interval, methadone can be
introduced for the interval.
Patient preference for scheduling is not predictable. Some prefer an every-other-day
schedule if the program is open 7 days a week. Many patients who are relatively
stable prefer the three-times- weekly schedule, which eliminates weekend visits.
Variations such as these underscore the need to respect patient preferences
whenever incentives that are consistent with their style and the characteristics
of their patients.
Compliance with LAAM treatment counts toward methadone take-home privileges. For
some patients, this privilege will be an incentive for them to comply with LAAM
treatment. Staff should be sure that patients have this information. A patient who
has been maintained on LAAM for 2 years may be eligible for five take-home
doses of methadone a week (that is, a twice-weekly visit schedule); upon completing
3 years, a weekly methadone visit schedule may be possible.
Incentives may be financial. Some programs, for example, reduce patient fees by a
set amount for every educational session attended; others offer vouchers or
food coupons (Silverman et al., 1993). Another incentive, albeit one that should be used with
great discretion, may be increased program privileges, such as being excused
from attending a group session. If a patient is employed, for example, an appropriate
incentive might be to excuse him or her from participating in a vocational counseling
group. If a patient has family problems, however, he or she should not be excused
from family counseling, no matter how remarkable his or her progress in other
areas of rehabilitation. The counselor should never overlook the obvious fact
that a patient may be doing well only because of faithful attendance at counseling
sessions and that removing that opportunity may be counterproductive.
Increased vacation time may also be used as an incentive. There are two ways to
provide medication for vacation. The patient can be transferred to methadone temporarily,
and take-home doses can be provided or a courtesy visit can be arranged to
a clinic in the area that the patient will be visiting. The LAAM can be
dispensed by a clinic there.
Involving patients in decisionmaking and giving them opportunities to make choices
are empowerment techniques that will enable them to feel confident to take
charge of other aspects of their lives. The beneficial effects of empowerment
techniques may be particularly noticeable for LAAM-maintained women when counseling
on pregnancy and related issues is provided. Empowerment may also strengthen
the patient's ability to develop vocational goals or to take action to improve
dysfunctional family relationships.
Patients' families and significant others should be educated about the same issues
for LAAM as for methadone. For patients switching from methadone to LAAM,
the change in dosing schedule may allow patients to spend more time with family
and friends.
Because addiction is a chronic, relapsing condition, many LAAM patients will relapse
to heroin use (or the use of other drugs, including alcohol). When relapse
occurs, staff members' first concern should be to determine what triggered the
relapse. The first question that should be asked is whether the patient's LAAM
dosage is adequately blocking the effects of heroin. Relapse to heroin use does
not necessarily signify the need for a change to methadone. Patience, understanding
of the patient's needs, and a thorough reexamination of the patient's clinical
status and treatment plan are necessary before any change is made.
The process of tapering the LAAM dosage to achieve drug-free status is not
substantially different from the process used for methadone. As with methadone, patients
who express the desire to discontinue LAAM therapy should be fully evaluated
for their social environment, clinical status, and personal reasons for wanting
to discontinue maintenance treatment.
Withdrawal from LAAM is not the termination of treatment but the beginning of a new
phase of treatment. Some patients may benefit from naltrexone after discontinuation
of medication. Naltrexone can be used to prevent relapse in some patients.
However, clinicians must be aware of lingering abstinence symptoms and
be sure that the patient is free of all opioid substances.
Like medication, psychosocial support should be tapered rather than suddenly
withdrawn. These two components of therapy may not always work in tandem. Some patients
may need psychosocial support long after opioid substitution has been discontinued.
Issues such as treatment phasing and ensuring that patients receive appropriate
levels of psychosocial support and services during all phases of treatment are
addressed in more detail in another TIP in this series, Matching Treatment to Patient Needs in Opioid Substitution Therapy.
No reagent is commercially available for screening urine for the presence
of LAAM. (LAAM can be detected in urine using thin-layer chromatography and
gas chromatography/mass spectrometry). Therefore, patients should be observed
taking their medication and should speak to the dispensing nurse after swallowing.
Anecdotal evidence exists for possible cross-reactivity of LAAM with methadone
reagents in one enzyme immunoassay, the Abbott ADX, which could lead to misinterpretation
of results.
Some States may not approve LAAM until there is a screen for it. The pharmacokinetic
profile of LAAM makes "double dipping"--receiving treatment from two programs--a
potential danger, but the use of registries, sufficient informed consent, and adequate
patient tracking should prevent this problem. If regulations eventually permit
take-home doses of LAAM, urine tests will become important to ensure that patients
are taking LAAM properly.
Urine screening of LAAM patients for drugs of abuse is recommended. A positive
screen can prompt a discussion with the patient that may lead to an adjustment
in the treatment plan or resolution of another issue that is jeopardizing
compliance. (See State methadone guidelines for a thorough discussion of urinalysis.
)
The required monthly pregnancy tests for women of childbearing potential present
an additional issue in treatment planning for female patients receiving LAAM.
As discussed in Chapter 3, such testing can add a positive dimension to
treatment if it is offered within the context of concern for the woman's overall
health and, should she desire pregnancy, for that of her fetus.
Treatment plans should be individualized to meet patient needs and rate of recovery.
Patients should be familiar with the components of their treatment plan
and agree to work toward the stated goals and objectives. Federal regulations
require that treatment plans be reviewed every 90 days for the first year and every
180 days thereafter. These are regulatory minimums and may not reflect individual
patient needs. Regular reviews and revisions should be made to ensure that all
services are being provided, progress is evident, and needs are met.
Site Map
Help
Account
Cart
Home
