residential treatment: what’s methadone got to do with it?
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Residential Treatment: What’s Methadone Got To Do With It?. Siara Andrews, Psy.D. 1 Yong S. Song, Ph.D. 1 Steve Myers 2 University of California at San Francisco 1 Walden House, Inc. 2 Presentation at American Association for the Treatment of Opioid Dependence October 16-20, 2004. - PowerPoint PPT PresentationTRANSCRIPT
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
Acknowledgements
Support from NIDA: R01DA14922 Staff of Walden House Staff of Methadone Programs: SFGH,
BAART, Westside Co-investigators & Consultants on the
Project Research Staff
Preview
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 treatment.
How methadone clinics work with other treatment providers.
Review of identified challenges and how to overcome these challenges to integrating methadone into residential treatment.
Opiate Treatment Outpatient ProgramSan 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 treatment.
– Clients must sign a treatment agreement before entering treatment.
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
• Uniform Facilities Data Set (1998)
•Very few residential programs provide medication (26%).•Almost no residential programs provide ORT (2%).
TC staff familiarity with substance abuse
pharmacotherapies
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
methadone 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
other
– 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 treatment
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
treatment Intensity
– Methadone - outpatient - use motivation– TC - inpatient - use behavioral intervention with structure
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 Philosophy
(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 Model
Challenges
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 Collaboration
Training/Inservices– Tours
Policy– Fast Track Admissions to Methadone
Communication– Collaborative work groups
Suggested Accommodations in TC
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 There, I think I ’ve bounced enough ideas off you f or now…off you f or now…
Discussion/Questions
???
Therapeutic Community as Treatment
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.