Residential Treatment What’s Methadone Got To Do With It by eqb11969


									 Residential Treatment:
What’s Methadone Got To
      Do With It?
                  Siara Andrews, Psy.D.1
                   Yong S. Song, Ph.D.1
                       Steve Myers2
            University of California at San Francisco1
                       Walden House, Inc.2

Presentation at American Association for the Treatment of Opioid Dependence
                            October 16-20, 2004
 Support from NIDA: R01DA14922
 Staff of Walden House
 Staff of Methadone Programs: SFGH,
  BAART, Westside
 Co-investigators & Consultants on the
 Research Staff
 Objectives
 Methadone Clinic-Overview
 Therapeutic Community-Overview
 Research to Practice: Methadone-Enhanced
  Recovery in the Therapeutic Community
 Improving collaboration between methadone
  clinic and residential treatment
 Discussion, Q & A
    Objectives: What you can
     expect to learn today
 How the TC is adapted to integrate methadone
 How methadone clinics work with other treatment
 Review of identified challenges and how to
  overcome these challenges to integrating
  methadone into residential treatment.
Opiate Treatment Outpatient Program
  San Francisco General Hospital
      OTOP Methadone Clinic
 History of OTOP MMT
  – Opened in 1972
  – County Hospital based program
  – Serves medically indigent population
  – HIV epidemic in 1980s
 Components of treatment
  – Methadone maintenance
  – Psychiatric Care
  – HIV Primary Care
  – Nursing Services
  – Social Services
     OTOP Methadone Clinic
 Patient population
   – Licensed capacity of 750
   – Provider of last resort in SF
   – Medically & psychiatrically severe
   – Many homeless
 Demand surpassing Capacity
  – 15,000 to 17,000 IDU heroin users in SF
  – SF top 4 in heroin-related hospital admissions
  – Approximately 3500 methadone treatment slots
  – Long waits for access to MMT
     OTOP and Walden House
 Expansion of treatment
  – Mobile Methadone Program
  – Expansion of 150 additional treatment slots
  – Cooperative agreement with WH
  – Transfer of WH patients from other methadone
    programs to Mobile program at WH
  – Receipt of medical services at main clinic
  – Methadone counselor onsite at WH
Walden House, Inc.
Walden House, Inc.
               Walden House
 History of the TC
  – 1976 - First methadone clients in Walden House, clients
    had to be on 30mgs or less to get into treatment.
  – 1997 – 30mg requirement was dismissed and client’s
    doses are now and have been accepted on an individual
    basis with no dose limit requirements.
  – Clients must be on methadone when entering treatment
    as Walden House does not put anyone on while in
  – Clients must sign a treatment agreement before entering
 Research to Practice: MERIT
1. Determine the effectiveness of treating ORT
   patients in a TC.

2. Investigate challenges to the acceptance of ORT in
   the TC environment.

3. Develop a manual for integrating ORT into TC’s.
  MERIT: Design & Methods
Follow two groups of residents entering
 a TC, comparing:
 1. Residents receiving ORT (n=125)
 2. Residents with heroin history but
    NOT receiving ORT (n=125)
 Medication Use in the TC?
 Evolutionary perspective: To survive, we
  change, but also maintain the essential elements of
  the TC.
 Historically: Use of medications is incompatible
  with TC perspective.
 TC Policy is changing to allow
         –   HIV medications: non-psychoactive
         –   Psychiatric medications: Mood stabilizing
         –   Maintenance medications: Methadone, buprenorphine
         –   Pain medications: vicodin, oxycontin
         *De Leon, George (2000).
Use of Medications in USA TCs
•Very few residential programs provide medication
•Almost no residential programs provide ORT (2%).

•   Uniform Facilities Data Set (1998)
                TC staff familiarity with
                    substance abuse
Medication                                     No extent   Very great extent

     Methadone     7%                                      37% of staff
     Buprenorphine 38%                                     4%
(Univ. of Georgia, NIDA R01-DA-14976, from Paul Roman)
   TC Staff Use of Methadone

 Ever use methadone? 11%

 Using methadone now? 7% (n=21)

 Provide methadone in own clinic? N=6 TC’s
Investigating Challenges: Stigma
about Methadone among TC Staff
 Investigated TC staff beliefs & knowledge of
 Surveyed staff (N=87)in the 4 SF WH programs
 Administered Surveys:
  – Abstinence Orientation Scale1
  – Methadone Knowledge Scale2
  1Caplehorn, et al. (1996).
  2Caplehorn, et al. (1998).
Stigma Study: Results
 Higher abstinence orientation than among
  methadone clinic staff in NYC and Australia
 Greater methadone knowledge among TC staff
  who had been in drug/alcohol treatment
 Especially among staff who had been in MMT
 Taking methadone sensitivity training was
  correlated with lower abstinence orientation and
  greater methadone knowledge.
  Investigating Challenges: TC
 client beliefs about methadone
 Focus Groups conducted separately with clients on
  methadone and clients not on methadone
   – Clients from both groups expressed jealousy toward the
   – Clients from both groups had similar suggestions for
     improving the integration of treatment:
      • Add client and staff education about methadone
      • Make methadone more accessible at the TC
 Challenges to integrating
 methadone and residential
 Differences in structure
 Difference in staff
 Differences in treatment philosophy model
       Differences in Structure
 Time:
   – Methadone clinic: 1 hour/day or less, depending on
     counseling required, take-home doses
   – Residential treatment: 24 hours/day
 Interaction with other clients:
   – Methadone clinic: limited to groups
   – Residential TC: relationships in the community serve as
 Intensity
   – Methadone - outpatient - use motivation
   – TC - inpatient - use behavioral intervention with
 Confidentiality and rapport-building
 Differences in Staff
 Methadone Clinic
  – Greater medical focus
  – Some staff in recovery
  – University based program
  – Smaller staff
 Therapeutic Community
  – Less medical focus
  – Most WH staff in recovery
  – Most staff are certified counselors
     Differences in Treatment
(1) Client Centered Approach vs. Consensus Model

(2) Abstinence vs. Harm Reduction Model
   – Abstinence philosophy: historically actively discouraged use of
     most mood altering drugs including prescription medications.
   – Harm reduction: the reduction, even to a small degree, of the
     harm caused by the use of drugs (Parry, 1989).

(3) Biopsychosocial model vs. Social Rehabilitation
 Staff have differing ideas of what treatment
  goals are
 Clients may get mixed messages from
  different programs
 Some behaviors are tolerated in one
  environment, but not another (relapse, nodding,
  dose increase)
 Opportunity for staff splitting
 Recommendations to Improve

 Training/Inservices
  – Tours
 Policy
   – Fast Track Admissions to Methadone
 Communication
  – Collaborative work groups
 Suggested Accommodations in
 Modifications for Residents
  – Methadone Group
    (Separate groups for clients tapering vs. maintaining
  – Alternative Therapies (e.g., acupuncture)
  – Medical Support while tapering
  – Coordination of medication issues with methadone
    clinic staff
  – Education for non-ORT residents
  – Include methadone goals in treatment plans
 Modifications for Staff
  – Methadone sensitivity training
  – Policies regarding residents on ORT
Suggested Accommodations for
     Methadone Clinics
 Modifications for Clinic Clients
  – Flexibility in psychosocial treatment requirements
  – Ease of access: Mobile Program/Take home doses
  – Coordination of medication issues with TC Staff
 Modifications for Clinic Staff
  – Policies regarding residents in TC
       • Take homes, etc.
   – Training on TC’s, facility tour
   – Focused supervision with counselors
       • Common treatment goals, cultural integration, communication
   – Active role in education & bridging relationships
There, I think I’ve bounced enough ideas
            off you for now…

Therapeutic Community as
1. In the TC, the relationship is the treatment.

2. The TC is community-centered, not client-centered.

3. The TC goal is always to get patients off all Opioid
   Replacement Therapies.

4. TCs do not use a harm-reduction approach.

5. Use of medication is incompatible with TC policies.

6. In the TC, confrontation is a necessary part of treatment.

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