Counseling Opioid Dependent PatientsCounseling Opioid Dependent Patients
Information and Treatment Approaches for Counselors
Michael J. McCann, MAMatrix Institute on Addictions
Overview of Presentation Overview of Presentation
Background informationSome general issues in treating
opioid dependent patients Some treatment approaches
Opioids Opioids
Relieve painProduce and alleviate morphine-like
withdrawalMorphine, heroin, methadone,
codeine, hydrododone (Vicodin), oxycodone (Percodan), Darvon, Demerol
Opioid DependenceOpioid Dependence
Repeated use results in tolerance (more is required for desired effect)
• and,
Withdrawal upon cessation of use– Chills, gooseflesh, sweating, yawning– Runny nose, tearing eyes, dilated pupils,– Nausea, diarrhea, – Insomnia, anxiety, craving
Range of Counselor ExperienceRange of Counselor Experience
Broad experience with SA dependence treatment, including opioid dependence
SA treatment experience, but not with opioid dependence
Counselors with no SA treatment experience
Counseling Opioid Dependent Counseling Opioid Dependent Patients: Some General Issues Patients: Some General Issues
1. Recovery and pharmacotherapy
2. Patient orientation towards recovery
3. 12-Step meetings
4. Patient management
5. A Cog/Behavioral approach
Recovery and PharmacotherapyRecovery and Pharmacotherapy
Patients may have ambivalence regarding medication
The recovery community may ostracize patients taking medication
Counselors need to have accurate information
Recovery and PharmacotherapyRecovery and Pharmacotherapy
Focus on “getting off” medication may convey taking medication is “bad”
Suggesting recovery requires cessation of medication is wrong
Support patient’s medication-taking “Medication,” not “drug”
Recovery and Pharmacotherapy: FactRecovery and Pharmacotherapy: Fact Methadone treatment efficacyMethadone treatment efficacy% of sample, n=727, Hubbard et al. 1997% of sample, n=727, Hubbard et al. 1997
89%
28%
42%
22%29%
14%
0%10%20%30%40%50%60%70%80%90%
100%
Heroin use(weekly)
Cocaine use(weekly)
I llegalactivities
PretreatmentPosttreatment
Recovery and Pharmacotherapy: FactRecovery and Pharmacotherapy: Fact
Methadone treatment results in a 4-fold decrease in mortality
– John Caplehorn, 1996
“Just substituting one drug for another”
“Patients are still addicted”But, –Medications are legal– Oral vs injected– Taken under medical supervision– Inexpensive
Recovery and Pharmacotherapy: Recovery and Pharmacotherapy: Facts and MythsFacts and Myths
“Patients are getting high”But,– Long acting, slow onset–Matches level of addiction
Recovery and Pharmacotherapy: Recovery and Pharmacotherapy: Facts and MythsFacts and Myths
Often a narrow focus; physical relief is sufficient
Focus on not using illicit opiates vs. new behaviors
Counseling may be viewed as an unnecessary imposition
Patient orientation towards Patient orientation towards recoveryrecovery
Patient orientation towards recoveryPatient orientation towards recovery
Patient orientation, counselor response– Impatience, confrontation, “you’re not
ready for treatment”
or,– Deal with patients at their stage of
acceptance and readiness
Patient orientation towards Patient orientation towards recoveryrecovery
Patient orientation, counselor response– Be flexible– Don’t impose high expectations– Don’t confront– Non-judgmental acceptance– A motivational interviewing approach
What is the 12-Step Program?Benefits: peer support, widely
available, social outlet, freeMeetings: speaker, discussion, Step
study, Big Book readingsSelf-help vs treatment
12-Step Meetings12-Step Meetings
Medication and the 12-Step program– Program policy
• “The AA Member: Medications and Other Drugs”• NA: “The ultimate responsibility for making medical
decisions rests with each individual”
Some meetings are more accepting of medications than others
12-Step Meetings12-Step Meetings
Urine TestingUrine Testing
A standard treatment component A tool to prevent drug use Does not reflect assumption of patient
dishonesty Ideally monitored (temperature strips) Minimize tampering: containers, purses,
backpacks, hot water, etc Detection times
Urine Testing: Dealing with a Urine Testing: Dealing with a positive test positive test
Re-evaluate the circumstances prior to the test
Don’t discuss validity of the result (lab error, etc.)
Don’t confront; provide an opportunity for the patient to explain
Urine Testing: Dealing with a Urine Testing: Dealing with a positive test positive test
Reinforce honesty Partial confession is good enough; move
onProceed with assumption of drug useCommunicate with physician
Urine Testing: Other IssuesUrine Testing: Other Issues
Falsified specimens; avoiding voiding– Indicators: cold, clear, Gatorade, apple juice– Ask the patient about it– Observed test is an option– Avoidance excuses: “can’t go”; “just went”
Patient ManagementPatient Management
“Manipulation”– A vestige of the drug-using lifestyle– An old survival skill– An unlikable quality in the world – A manifestation of the disorder in
treatment (cardiologists don’t criticize patients having chest pains)
Patient ManagementPatient Management
“Manipulation”– Counselor’s responses• Protective cynicism• Trust and openness
Patient ManagementPatient Management
Pushing Boundaries– Inappropriate familiarity– Reflexive “manipulation”?–May result from past counseling
experiences
Patient ManagementPatient Management
Intoxication– Manage the situation, don’t counsel– Ensure patient safety– Arrange transportation
Patient ManagementPatient Management
Loitering– May have been acceptable in prior
treatments– Creates opportunities for dealing– Not the best use of time– Not well tolerated by neighbors– May reflect problems at home
Counseling ApproachesCounseling Approaches
Provide information and skills– Conditioning Process: you can’t “will”
cravings away; modify behavior– Addiction as a brain disease
Counseling ApproachesCounseling Approaches
Information and Skills– Get rid of paraphernalia– Scheduling time– Thought-Stopping for cravings– Evaluate people and places (fools rush
in)
Counseling ApproachesCounseling Approaches
Relapse Prevention– Patients need to develop new
behaviors– Learn to monitor signs of vulnerability
to relapse– Recovery is more than not using illicit
opioids– Recovery is more than not using drugs
and alcohol
Counseling ApproachesCounseling Approaches
Relapse Prevention Topics– Relapse Prevention Overview
• Overview of the concept: things don't “just happen”
– Using Behavior• Old behaviors need to change• Re-emergence signals relapse risk
– Relapse Justification• “Stinking thinking”• Recognize and stop
A Good Counseling SessionA Good Counseling Session
Patients ultimately may need to understand why they became addicted
More important early on:– Understanding the addiction disorder– Making changes in day-to-day life
A good session: the patients leaves knowing more about addiction and recovery