Residential Treatment: What’s Methadone Got To Do With It?

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

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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.