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					training manual



                  Module 4

                  Clinical aspects
                                         Steps

                  •
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                      Assessment
                  •   Criteria for treatment
                  •   Treatment plan
                  •   Induction
                  •   Monitoring
                  •   Evaluation
                                 Assessment

                  • The aims of assessment are to:
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                     – Engage the patient in the treatment
                       process
                     – Ascertain valid information
                                 Issues to assess

                  • Treat emergency
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                  • Confirm patient is opiate dependent
                       •   History, physical examination, urine analysis
                       •   Degree of dependence
                       •   Previous treatment history
                       •   Identify drug related problems
                  • Identify other medical, social and mental
                    health problems
                  • Identify motivation for treatment
                  • Determine the need for substitute medication
                                     Criteria

                  • Sometimes intake criteria are adopted: ICD
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                    10 (Europe) and DSM IV (USA)
                  • Important is that anyone who wants to enter
                    substitution treatment can do so
                  • Assess and treat psychological, physiological
                    and social aspects
                                      Assessment
                  • Psychological
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                        • Strong desire or compulsion to take the substance
                        • Difficulty in controlling behaviour regarding onset,
                          termination or levels of use
                  • Physiological
                        • Characteristic withdrawing syndrome for substance
                          if not taken
                        • Evidence of tolerance and need of increased dose
                          to achieve effect
                  • Social
                        • Progressive neglect of alternative
                          interests/pleasures and increased time necessary
                          to obtain, take or recover from substance
                        • Persisting with substance use despite the negative
                          and harmful consequences
                                  Treatment plan

                  •
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                      Client goals
                  •   Current circumstances
                  •   Available recourses
                  •   Patient’s expectations of treatment
                  •   Past history and outcome
                  •   Informed consent
                  •   Evidence (safety, efficacy, effectiveness)
                                   Induction

                  • Right dose varies from person to person and
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                    from time to time
                  • Illicit heroin varies in purity
                  • Characteristics of the medication (methadone
                    is a long acting opiate)
                  • Too much medication can be fatal but too
                    little not effective
                        Information to patient about

                  • Delay of peak effect of the substitute drug
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                  • Fact that substitute drug can accumulate over
                    time resulting in a greater effect
                  • Risks of poly-drug use
                  • Risk of overdose
                  • Potential interaction with other medications
                      Importance of the correct dose

                  • World wide clinical surveys validate the
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                    importance of an adequate and effective dose
                  • Methadone between 60-120 mg
                  • Watters and Price (1885) reviewed 44
                    programmes and found that dose was the
                    single most important factor related to
                    treatment retention
                  • Ball and Ross (1991):
                    – 27% (204 pts) on <45mg used heroin in 1month period
                    – 5,4% (203 pts) on >45mg used heroin in 1month
                      period
                       ‘Steady state’ plasma levels

                  • Regular administration (same time each day)
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                    can avoid peaks and through providing a
                    steady state
                  • Reservoirs with medication can fill up in the
                    liver and other tissues
                  • Monitoring plasma levels can be useful to test
                    the individual metabolism:
                       • 150ng/ml is the lowest level that will maintain
                         the 24 hour steady state
                       • 400ng/ml is the optimal level
                           How much is enough?

                  • The amount required to produce the desired
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                    response for the desired duration of time, with
                    an allowance for a margin of effectiveness
                    and safety (Payte & Khuri, 1992)
                                  Monitoring

                  • Engagement
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                  • Drug use
                  • Physical and psychological health (sleep,
                    sex, nutrition, constipation, etc)
                  • Social functioning and life context
                                      Urinalysis

                  • Much debated
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                  • Vital part of initial medical assessment
                  • Often used as form of control during
                    treatment:
                        • Information can also be obtained by asking
                        • Expensive
                  • Positive sample should never be a reason for
                    discontinuing treatment
                        • as this is the evidence of the condition patient
                          is treated for (drug dependency)
                           Withdrawal symptoms
                  -Itching
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                  -Rhinorrhea / lacrimation / sneezing
                  -Yawning
                  -Sweating (a cold film of sweat, best touchable in the neck
                  or on the upper part of the sternum)
                  -Pupillary dilatation
                  -Piloerection
                  -Muscle and bone aches, headache
                  -„Restless legs“
                  -Hot and cold flashes
                  -Nausea / vomiting
                  -Weakness , dysphoric mood, irritability, anxiety, insomnia
                  -Abdominal discomfort, diarrhea (starting with a rumbling
                  of the colon which may be heard by stethoscope
                  -Increase in blood pressure, pulse, respiratoryrate and
                  body
                  -Fever
                                   Overdose

                  • Fatal and non-fatal OD leading cause of
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                    morbidity and mortality
                  • Fatal OD usually follows respiratory
                    depression which disrupts the oxygen supply
                    to the brain and causes cardiac arrest
                  • Likelihood increases with:
                       • Injecting
                       • Poly drug consumption
                  • Substitution treatment has shown to reduce
                    OD mortality and morbidity
                                              Welcome by one member of the staff
                                              Administrative intake of personal details
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                                      Check if individual meets intake criteria (if applicable)
                                                                  
                                                    Medical intake by doctor
                  Assessment of opioid dependence through: personal interview, medical assessment urinalysis
                                                                  
                                                Assessment of level of dependence
                                                                  
                                          Treatment plan (maintenance, detoxification)
                                                                  
                                             Induction and calculation of starting dose
                         Patient kept under supervision for a few hours to check if initial dose is correct
                             in case withdrawal symptoms reoccur, an additional dose will be given
                    Patient given detailed information on the treatment and on the risks of using other drugs
                                                                  
                                     Psycho-social intake by social worker/drug worker
                                            Assessment of problems to be addressed
                                                   Liaison with relevant services
                                  In case of co-morbidity liaison with relevant medical services
                                                                  
                         Stabilisation period to establish the right dose (may take up to six weeks)
                                                                  
                                               Maintenance or detoxification regimen
                                Regular review to set new goals (depending on type of treatment)
                        Programme characteristics
                      associated with success in MMT
                  •
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                      Comprehensive
                  •   Integrated
                  •   Individualised
                  •   Adequate dosing policies
                  •   Sufficient and stable staff
                  •   Sufficient staff training
                                   Conclusions

                  •
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                      Accurate assessment is vital
                  •   Take individual aspects into account
                  •   Induction with care
                  •   Provide health information

				
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posted:5/21/2011
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