1 Oral Substitution Treatment for Opioid Dependence: A Training in Best Practices & Program Design...

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Oral Substitution Treatment for Opioid Dependence: A Training in Best Practices &

Program Design for Nepal

Richard Elovich, MPHColumbia University Mailman School of Public Health Medical SociologistConsultant, International Harm Reduction Development International Open Society Institute

March 26-28, 2006 Kathmandu, Nepal

UNDP

Day 3

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This Training is Adapted From:

Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment ProgramsCSAT/SAMSHA (Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment)

Best Practices in Methadone Maintenance TreatmentOffice of Canada’s Drug Strategy

Addiction Treatment: A Strengths PerspectiveKatherine van Wormer and Diane Rae Davis

Additional Sources: Robert Newman, MD, Alex Wodak, MD, Melinda Campopiano, M.D, Miller and Rollnick, Prochaska, DiClemente, and Norcross, Michael Smith, MD, Sharon Stancliff, MD, Ernest Drucker, PhD,

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Program DevelopmentAnd

Design

Accessibility

A MaintenanceOrientation

Integrated

Comprehensive

Services

A Client/Patient

Centered

Approach

AdequateResources

Clear Program

Philosophy and

Treatment GoalsInvolvement

Of

Wider

Community

Client/PatientInvolvement

Focus on

Engagement

and

Retention

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Training Goals

Ideally, this training will contribute to: Increased knowledge, skills and best

practices among OST practitioners and providers;

Engagement and retention of clients/patients in the OST program in Kathmandu

Improved treatment outcomes

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Six Training Modules

The Socio-Pharmacology of Opioid Use and Dependence

Introduction and background of oral substitution treatment

The pharmacology of medications used in oral substitution treatment

Information collection and service provision: ‘assessment-in-action’

Pharmacotherapy and OST

Insights from the field

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Learning Together

Parallel Process

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Learning Process: Knowledge and Skills

Acquisition of content Retention (store in memory) Application (retrieve and use) Proficiency (integrate and synthesize)

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Expectations for Certification: Training Contract

This is an 18 hour training over a 3 day period. Allowances have been made for your work schedules: Noon – 6 PM.

You must be present and participate in all 18 hours of the training to receive certification. There can be no exceptions.

Please stay focused. Be on task because we have a lot of material to cover in 3 days.

Listening is a key to this training. Listen to new ideas. Listen to what’s coming up inside you in relation to what’s being presented. Try to put your thoughts and feelings into words instead of “shutting down.”

Acknowledge and respect differences. You can “agree to disagree” on a contentious point and move on. Participate in role plays. Everyone has permission to pass. Offer feedback constructively not personally. Try to receive feedback as a gift.

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Learning Environment Try to be okay with

taking some learning risks. Stretch past your edge of what you know and what you are comfortable with.

Confidentiality. Hold the container. Don’t be leaky.

Turn off phones please.

No cross talk. Allow one person to speak at a time. Equal time over time.

Start and end on time, including breaks. Be alert to tendency to fudge this.

Use “I” statements. Can everybody agree to

this training contract? Is there anything you absolutely cannot live with?

Now we are off.

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The Counseling Relationship in Pharmacotherapy and OST

Induction to Stabilization to Maintenance

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Counseling Increases Effectiveness of OST Programs

Crisis intervention Case management, incl.

referrals to and liaison with other agencies

Individual one-on-one counseling

Group counseling Couples or family

counseling Vocational counseling

Pre- and post-test HIV counseling, and counseling related to other medical conditions

Health and other education programs

Brief, supportive contacts Long term intensive

support

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Insight from the Field

Counseling should be as-needed, rather than mandatory

When they are ready to do so, client/patients should have access to evidence-based approaches to counseling to address issues of concern to them.

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Best Practices* demonstrate:

Behavior change as it relates to drug dependence is a set of personal and social processes Professional or service provider doesn’t change the

client; we providing a ‘facilitating environment that supports their change process.

Client expectation/readiness needs to be matched to appropriate counseling strategy

Importance of trusting relationship with warm, inspiring, socially sanctioned counselor(s)

* Prochaska, DiClemente, Norcross Transtheoretical Model of Behavior Change

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Role of the Clinician

Counselor style is a powerful determinant of client resistance is a powerful determinant of client resistance and change.

Confrontation is a goal, not a style. Argumentation is a poor method for inducing change. When resistance is evoked, clients tend not to change. Client motivation can be increased by a variety of counselor

strategies. Even relatively brief interventions can have a substantial impact on

problem behavior. Motivation emerges from the interpersonal interaction between

client and counselor. Ambivalence is normal, not pathological. Helping people resolve ambivalence is a key to change.

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Action = Abstinence?

Many professionals are trained to help people who are in the action stage of change, and programs are geared to action. “Action” is synonymous with readiness and commitment to abstinence.

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Stages of Changing Behavior (Prochaska et al)

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Characteristics of SOC

Change is a process and happens in stages; it is not linear.

Each stage of readiness for change has its own cognitive and behavioral characteristics.

Counseling interventions need to be appropriately matched or tailored to the stage of readiness.

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Characteristics of SOC

Relapse is a normal part of the process of stage, not outside.

Thinking happens at every stage; it doesn’t start with action or preaction. It can be engaged as ambivalence.

Goals look different and evolve through stages.

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Operationalizing Health Promotion Objectives

Just because someone learns to parrot a message doesn’t mean they are committed to changing their behavior or practices

Just because someone is committed to changing does not mean this translates into what they actually do when they are confronted in their local worlds with competing variables

The role of the intravention, collective empowerment

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PROCESS GOALS TECHNIQUES

Emotional Arousal Experiencing and expressing feelings about one’s ambivalence, problems, and solutions

Self-reevaluation Assessing feelings and thoughts about self with respect to problem

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Commitment Choosing and committing to act, or belief in ability to change

Countering Consciously substituting alternative strategies for problem behaviors

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Identifying and controlling environmental effects

Avoiding stimuli (people, places, things) that elicit problem behaviors

Environmental restructuring, avoiding high-risk cues/triggers, “book-ending” with peer support in stressful

situations, assertiveness

Reward Rewarding self, or being rewarded by others, for ‘showing up’, experiencing alternatives, making

changes.

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Helping relationships

Enlisting the help of someone who cares

Increasing social capital

Joining social networks which provide personal, interpersonal, community resources that can enhance individual’s social functioning, development and access to social and material resources. Entails obligation and expectation. Social control, norms, and relationships valuable

to personal development.

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Outreach

Outreach: In order to increase access to OST, programs should consider proactive measures to reach out to potential clients/patients who are not likely to access treatment without encouragement and support.

Outreach is an area in which peer-based strategies and linkages and partnerships with NGOs working at the front-line or “street” level are particularly important.

Outreach workers can benefit from motivational interviewing (MI) training

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Advocacy

The role of a client/patient advocate includes providing clients/patients with information about the program and their rights and responsibilities, as well as intervening on clients’/patients’ behalf to help access services and support.

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Client/Patient Involvement

Client/patient participation on community advisory boards

Client/patient participation on decision-making bodies

Client /patient involvement in evaluating the program

Feedback mechanisms for clients/patients, such as suggestion boxes, surveys, and focus groups

Outreach programming Providing peer counseling

and support Clients/patients training

to become counselors

OST programs need to value, seek out, encourage and support client/patient involvement.

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Self-efficacy

Compare self-esteem and self-efficacy. The transition from I think I can to I know I can. Becoming to being.

1. Awareness of a problem or discrepancy/dissonance. 2. If I do it, there will be a benefit for me and things will be

better. 3. I have the capacity to do that. I have the skills to do that. I

can see myself doing that. I have what it takes. That is who I am. The person who does that.

If someone doesn’t believe they can change, why should they look at it as a problem?

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Counseling and ‘Self-Talk’ : A Strengths Perspective

Informal Learning and the Notion of ‘scaffolding’ Collective empowerment and the dynamics of

group work Accurate Empathy Attention to Stage of Readiness for Change Engaging Ambivalence: Motivational

Interviewing Alternative social and physical activities Mutual Self-Help Groups Peer Driven Activities and Volunteering

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Change is a Social Process

It is important to recognize from the start that change in drug practices is a complicated social process

Individual change including being exposed to drugs and having the opportunities to use drugs to initiating drug use to modifying drug practices happens in social situations and proximal environments

Behavior change is a consequence of social change Too often, health workers focus exclusively on the

individual as the way to realize health objectives

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Working with Drug Using Youth and Young

Adults: A Strengths Based Approach Ambivalence among youth is common Developing autonomy and individuation

means pushing back against authority, institutions, and norms

There is an interest in values, identities, roles, relationships

Peer groups are important Curiosity and openness to philosophical

questions

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Capacity Building in Brazil*

The key is to not to treat population as if they are empty bank accounts to be filled by our expertise.

How to we facilitate a process that will collectively empower them to be more competent in their everyday world by enlisting them to: describe “scenes” in their own words-coding; analyze operative scripts and structures that condition their practices- decoding. * Paiva, 2000

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Capacity Building II

This involves decoding and consciousness raising; they identify problem areas from their point of view, e.g. acting out a skit or tableau, in which they have an opportunity to generate and practice new choices and solutions for each other.

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Capacity Building III

The process of “conscientization”* is useful for marginalized or stigmatized people where they are able to see themselves and each other as responsible subjects capable of self-regulation and making change rather than passive objects acted upon. *Freire, as cited in Paiva, 2000

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Capacity Building On-going experience of conscious practice, like strengthening a muscle, as an

alternative to passivity or falling into something or in with what other people do. New experiences mean new experiences of themselves. When they reflect

back on a new experience: ‘I can do this. I did this, I can do it again. That was really me,’ they are integrating or internalizing new experiences, into a new idea about themselves and their capacity, e.g. self regulation, persistence, achieving competence in their every day life.

Transformation of understanding of self from a person ‘things happen to’ to an

active subject acting relationally in the world to take better care of themselves. Treatment that focuses on building self-efficacy, and ego strengthening is in plain words, building up the ‘executive manager’ within oneself, i.e., the person who ‘gets things done.’ Think, for example, of the manager of his or her own business.

Group work can help develop language and communication skills that build an individual’s confidence to have a conversation, to self manage the impression they leave on others with whom they are interacting.

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Group Work in OST Provides:

A mirroring process where individuals can observe or experience similarities or contrasts in their thoughts, feelings, actions;

An opportunity to experience oneself in the presence of others, breaking isolation, uniqueness, fear, shame;

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A social arena to witness and model a peer transformational process:

Learning by analogy (other’s behavior). Learning by identification. Learn through trial and error. Learn by modeling. Amplification of positive change. Collective empowerment

Clear parameters or limits for interpersonal interaction

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Support for the development of alternative social networks that reinforce the process of transformation

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Introductions

Ground rules

CenteringWhatis goodaboutinjecting

What Is notSo Goodinjecting

Reasons for coming toThe group and concerns

Summary

CheckOut by participants

Closing

Example: First Group Session

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Welcome

Centering

Check in and Review of Second session

Map of my relationshipsValues

Ambivalence about relationships, values and behaviors

Summarizing

Check out and closing

Second Group Session

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Welcome

Centering

Check in and Review of Third session

Reasons for wantingAnd not wanting to make a particular change

Building Discrepancy

Ambivalence about change

Summarizing

Check out and closing

Third Group Session

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What are the norms within your drug using relationships or informal groups?

+ ? -

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A Basic Counseling Exercise

What is something pleasurable to me, important or valuable? Describe in detail.

What is the risk? Describe in detail.

How can I reduce the risk or cost but hold on to what is pleasurable or find a new alternative?

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Incremental Change

Process of getting stuck or dependent and the process of getting unstuck

Autonomy- Staff or helpers are on the sidelines. How do you help without encouraging dependency

Capacity for Flexibility—adjust strategies: “I had a math teacher. I didn’t understand the problem. She explained it again the same way.”

Progress not perfection or single outcome Set own goals and move at own pace. Goals evolve.

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Motivational Interviewing

Uncertainty or ambivalence about change is at the heart of the difficulties many clients experience in treatment. This is also the challenge narcologists experience with clients who have addictive problems.

The question for us is how can we provide the client with an opportunity to articulate, explore and resolve this ambivalence for him/herself?

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AMBIVALENCE AND DECISIONAL BALANCE

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What is Motivation?

“Motivation” can be defined as the probability that a person will enter into, continue, and adhere to a specific change strategy.

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Motivation

Motivational interviewing assumes that the state of motivation may fluctuate from one time or situation to another (Miller & Rollnick, 1991).

Therefore, this “state” can be influenced. By providing a safe, nonconfrontational

environment, eliciting hope, helping clients clarify ambivalence about their drug use and about making change, counselors can be helpful in ‘tipping the scales’ in favor of readiness to make a positive change.

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Spirit of Motivational Interviewing

Developing a collaborative partnership Counselor facilitates rather than coerces

ambivalence and change Client is assumed to have resources and

motivation for change Ambivalence is enhanced by drawing on

client’s own perceptions, goals and values Counselor supports client’s capacity for self-

directed change

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Review: 7 Early Strategies

Ask open-ended questions Listen reflectively. Elicit ambivalence. Do not project your ideas onto the client. Affirm. Focus on eliciting strengths not on

pathologies or what is wrong with the person. Foster a sense of collaboration with the person. Summarize at key intervals and ask for their

comments

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A Working definition

We can define motivational interviewing as “a client-centered , directive method for enhancing intrinsic motivation to change by expressing, exploring, and resolving about problematic behaviors and behavioral change.”

It is “a way of being with people”. It is directive in terms of the process and techniques of

addressing ambivalence, not directive about the outcome of the counseling.

It is client centered because all the benefits and consequences of making a change are elicited from the client.

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Engagement of People who are highly ambivalent

The largest group of people who are using and are at risk are outside the action stage, yet majority of services are directed to action.

Passive recruitment Proactive recruitment

use of ambivalence and identification, avoid labeling, be positive and tangible

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‘Sanjar’: On the One Hand:

His use provides excitement, a change in feeling and thinking, relief

Finding ways to obtain and afford the drug provides him with adventure and achievement

Preparing and administering may provide a sense of competence and even looking out for others in his group

Interpersonal reinforcement as he negotiates successfully various networks in which he interacts to obtain money, acquire the drug, share the drug, play a role, earn respect and recognition.

Using is a reward for successfully completing the ‘mission’.

Euphoric properties add to positive feelings

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‘Sanjar’: On the Other Hand

Once he is down, he feels shame that he has neglected his familial obligations

He sees himself in how neighbors look at him or avert their eyes

He may feel used/depleted from the social interactions involved in the ‘mission’.

He may feel he has let himself down and others He may hate needing his need for the drug He may feel wasted, depressed, low energy

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Best Practices* demonstrate:

Behavior change as it relates to drug dependence is a set of personal and social processes Professional or service provider doesn’t change the

client; we providing a ‘facilitating environment that supports their change process.

Client expectation/readiness needs to be matched to appropriate counseling strategy

Importance of trusting relationship with warm, inspiring, socially sanctioned counselor(s)

* Prochaska, DiClemente, Norcross Transtheoretical Model of Behavior Change

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Benefits and Costs

Short term things that are good, okay or acceptable to me

Short term things that are not so good, okay or acceptable to me

Long term things that are good, okay or acceptable to me

Long term things that are not so good, okay or acceptable to me

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Benefits and Costs

Use Motivational Interviewing approach, which aims to decrease the participant’s perception about the costs of changing.

Change here depends on the pros (of change) outweighing the cons. Individuals can see that the cons of changing are different short and long-term, just as there are not many long-term benefits to continuing a problematic behavior.

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Let’s Come Up With Situations or Dilemmas Adapted to Real

Life Among Drug Users In Our Regions

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Agenda Setting

An outreach worker to an active drug user(s) in a ‘natural’ setting:

“As you know, there are a number of things that we could discuss today– HIV, preventing overdoses, injecting practices and relations with others, any concerns you have generally about drug use– but what are you most concerned about? What would you like to talk about today? Perhaps there is something especially important or something that is immediate?”

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Is It an Open or Closed Question

What do you like about injecting? Where did you grow up? Would you tell me what was good and maybe not so

good about your first experience injecting? Isn’t it important that you have the respect of your

family? Have you ever had an overdose or witnessed someone

overdosing? Are you willing to meet with me again? What happens with an overdose? What brings you here today? Do you want to stay in this relationship?

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Is it an Open or Closed Question?

Have you ever thought about getting work? What do you want to do about your overdoses: not inject

alone, test the dose first, stop injecting, or just do what you are doing?

In the past, how have you overcome an important obstacle in your life?

Will you try for a week to avoid talking about injecting with non-injectors, not injecting in front of non-injectors, and not giving people their first hit?

What are the most important reasons for avoiding talking about injecting with non-injectors, not injecting in front of non-injectors, and not giving people their first hit?

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Empathy

The principle of empathy is acceptance. Through respectful reflective listening the counselor

seeks to understand the client’s perspective without judging, criticizing or blaming.

Acceptance is not the same thing as approval or agreement.

Ironically, this kind of acceptance of people as they are seems to free them to change, whereas insistent nonacceptance tends to immobilize the change process. The person focuses on defending, arguing, winning the argument or the counselor’s acceptance, rather than self- reflection and self-assessment.

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Summary of Accurate Empathy

Express empathy, which helps create the safe and non-judgmental setting for the participant, regardless of the setting

Skillful reflective listening is a fundamental tool of motivational interviewing

Ambivalence is accepted as a normal part of human experience and change, rather than a pathology or sign of incapability or defensiveness or resistance.

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Reflective Listening

The fundamental tool of motivational interviewing

“What people really need is a good listening to.” Mary Casey

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Listen Reflectively

Overview: You all know it but it is an art. We’re going to open it open for examination over the next exercises. It’s not one note but scales. Repeating, rephrasing, paraphrasing, identifying underlying feeling.

Referring back to what we discussed yesterday about reflective listening— when a client listens to you reflect back on what s/he just said, s/he is now listening to see:

if you are really paying attention if it’s accurate if s/he hears something new about him/herself How it feels to hear his/her own thoughts expressed by

another In these exercises try to self observe how you feel about limits. Try to

find your authenticity within structure of each form.

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Exercise

What is ambivalence or feeling two ways about something? What do you associate with it?

What is reflective listening?

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Consciousness Raising

It begins with how I treat a client, the assumptions I make, the conversation we have.

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Needs Improvement:

Lack of Drug Dependence Training of Physicians, Psychiatrists, Nurses, and Social Workers

Lack of willing providers Lack of awareness in Primary Care Professional turf issues Fear of regulation

Cost Medication Profiteering

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Capacity Building Expanding the team to address drugs and drug

practices appropriately: The client can identify a drug issue with me The client can talk about drug use within our

services The client can get supportive services to stay

healthy The OST can respond more effectively to drug

related health issues.

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Medically Supervised Withdrawal

When stable client/patients in the maintenance stage ask for dosage reductions, it is important to explore their reasons. They may believe they can get by on less medication

or may be responding to external pressures. Client/patients on lower dosages may consciously or

unconsciously be perceived as “better patients”. Counseling and education is key to exploring the

short and long term benefits and costs of current dosage and then of dosage reduction.

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Voluntary Tapering and Dosage Reduction

Some studies indicate high relapse rates, often 80% or more, for client/patients who attempt cessation of maintenance medication, including those judged to be rehabilitated before tapering (e.g., Magura and Rosenblum, 2001).

However, likelihood of successful tapering also depends on individual factors such as motivation, family support, and other ‘social protections’ such as employment, etc.

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Clients/patients may consider leaving treatment for a variety of reasons including:

Unrealistic expectations for recovery

Pressure from family members and others, including program team members

The social stigma associated with methadone

Program team members’ beliefs about the desirability of abstinence from methadone as a goal of treatment

The inconvenience of regular attendance to obtain methadone and other program requirements

Financial reasons (cost of treatment)

Demands of work Travel restrictions To find out if they can manage

without methadone or not, e.g. for individuals who have become stabilized on methadone, and have not used opioids in a long time, a decision to attempt tapering may be wise and appropriate.

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As part of informed consent process, the possibility of relapse should be discussed with client/patients, especially those who are not stable on their current dosage.

They and their families should be aware of risk factors for relapse during and after tapering.

Client/patients who choose tapering should be monitored closely and have access to individual and group relapse prevention counseling, education, and support that accompanies and extends beyond period of tapering.

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If relapse occurs or is likely, additional therapeutic measures can be taken, including rapid resumption of OST when appropriate (American Society of Addiction Medicine 1997).

Clients/Patients being tapered off methadone should have access to an increased dose– to get through a “rough patch”– without having to go through a program re-entry process.

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Methadone Dosage Reduction

A common practice of graded methadone reduction is to reduce daily does in roughly 5-to-10 percent increments with 1 to 2 weeks between reductions, adjusting as needed for client/patient conditions.

Because reductions become smaller but intervals remain about the same, many months may be spent in such graded reductions.

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A slow withdrawal gives client/patients time to stop the tapering or resume maintenance based on individual client/patient response, especially if relapse seems likely.

Regardless of rate of tapering, a point usually is reached at which steady-state occupancy of opiate receptors is no longer complete, and discomfort, often with drug hunger and craving, desperate feelings or panic, emerges.

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This point may occur at any dosage but is more common with methadone when the dosage is below 40 mg per day.

Highly motivated client/patients with good support systems can continue withdrawal despite these symptoms by tightly embracing structural supports as dose decreases.

Some client/patients appear to have specific thresholds at which further dosage reductions become difficult.

Blind dosage reduction is appropriate only if requested by the client/patient, discussed and agreed upon before it is implemented.

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SAMHSA’s Treatment Improvement Protocol (TIP) 43 strongly recommends that OST staff always disclose dosing information unless individual client/patients have given specific informed consent and have requested that providers not tell them their exact dosages.

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Methadone Detoxification

For client/patients who prefer detoxification to maintenance, there are two kinds of detoxification: Short-term treatment of less than 30 days Long-term treatment of 30 to 180 days

Patients who fail two detoxification attempts in 12 months should be evaluated for different treatment or mode of treatment.

Two factors should be considered in short-term detox: the brief duration of initial dose may preclude achievement of steady state; tapering may be too steep if it begins at a dose greater than 40 mg.

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Involuntary Tapering or Dosage Reduction

When clients/patients violate program rules or no longer meet treatment criteria, involuntary tapering should be avoided if at all possible.

Treatment decisions should be made in the client/patients best interest rather than as punitive measure.

Many days of dosing missed, client progress is unsatisfactory, unwillingness to comply with treatment contract, nonpayment of fees are some reasons for a change in strategy.

Continued maintenance at an adjusted rate along with increased and focused counseling and support is recommended.

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Impact of discharge

Deaths following involuntary discharge or drop outs from methadone treatment: 1 year follow- up

In treatment DischargedDeaths 4/397 9/110(%) (1%) (8.2%)

Zanis, 1998

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Involuntary Tapering or Dosage Reduction

“Efforts should be made to retain these at-risk clients/patients in methadone treatment even though their treatment response may be suboptimal.”

Zanis 1998

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Take-Home Medications: Unsupervised Doses

Absence of recent drug and alcohol abuse

Regular OST attendance Absence of behavior

problems at OST Absence of recent

criminal activities outside OST

Stable home environment and social relationships

Acceptable length of time in comprehensive maintenance treatment

Assurance of safe storage of take-home medication

Determination that rehabilitative benefits of decreased OST attendance outweigh the potential risk of diversion

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Take-Home Medications: Once Clinical Criteria (Above) are Met

First 90 days: 1 take-home per week

Second 90 days: 2 take-home per week

Third 90 days: 3 take-home per week

Fourth 90 days: 6 days’ supply of take-home doses per week

After 1 year of continuous treatment: 2 weeks’ supply of take-home medication

After 2 years of continuous treatment: 1 month’s supply of take-home medication, but monthly visits to OST are still required.

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5. Best Practices in MMT- Program Policies and Reducing the Barriers

Open Admission Procedures Timely Assessment and First Medication Immediate Crisis Management Initial Assessment Informed Consent Ongoing Assessment-in Action Comprehensive Assessment Adequate Individualized Dosage Unlimited Duration of Treatment Clear Criteria for Involuntary Discharge Non-Punitive Use of Urine Toxicology Screening Client/Patient-Centered Tapering

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OST Goal: Engagement

Distinguish between response to illicit drugs and response to people who use illicit drugs

Drugs trafficked across borders and circulated locally are objects

There is tendency to objectify people using those drugs, dehumanize them, deprive them of rights to treatment and assistance

We distance ourselves from people who use these drugs and forget that they are part of families, communities, societies

Most People who need treatment stay away

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Maslow Needs/Values Pyramid

Sustenance of biological needs, protection and safety frompain or danger, facilitation of pleasure

Acceptance by others, sense of belonging, receipt of attention, approval, praise

Achievement, knowledge, understanding, psychology

Self-actualization, Creation, transcendence of identity barriers

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Engagement of People who are highly ambivalent

The largest group of people who are using and are at risk are outside the action stage, yet majority of services are directed to action.

Passive recruitment Proactive recruitment

use of ambivalence and identification, avoid labeling, be positive and tangible

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Reducing Barriers

Program location inaccessible to or remote from target group or community

Fear of or perception of ‘registration’, stigma, professionals

Lack of availability of treatment Lack of confidence in treatment effectiveness Financial Costs Requirement that abstinence be the exclusive

goal of treatment

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Reducing Barriers:

“Low threshold” access to services where the requirement of abstinence is not a precondition for receiving treatment.

Recruit, train and hire members of target group (users and former users) to do community-based outreach: “They have insider access to drug-using (networks),

they know the rules governing the social systems of the streets, and they are able to develop trusting relationships with the target population of active drug users” (Booth et al, 1998)

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Meeting Drug Users on Their Own Ground

The labeling of clients is avoided Clients provide the definition of the situation as they see

it Clients who wish it are given advice on how to reduce

the harms associated with their drug use Counselor and client collaborate on a broad range of

solutions to the client-defined problem Resources are gathered or located to meet the individual

needs of the client Change can be incremental and clients are viewed as

amenable to change, if abstinence is not the only option.

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WHAT IS A STRENGTHS-BASED APPROACH?

Recognizes and supports incremental change: sees possibility of change in everyone

Allows choices: the goal of the helping relationship (harm reduction,

substitution therapy, treatment readiness, abstinence) informed choice about a variety of treatment contexts

(same gender group, outpatient, inpatient, mutual help groups)

Informed choice about treatment methods Pays attention to client’s expectations and

stage of readiness for change

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VARIETIES OF MT CAN BE CLIENT-CENTERED(WHO, 1990)

Short-term detoxification decreasing doses during one month or more

Prolonged detoxification decreasing doses while more than one month

Short-term maintenance treatment: stable prescription methadone during a six month or less period

Long-term maintenance therapy using methadone in the time frame of longer than one year and possibly ongoing

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Harm Reduction in Practice

Meet them where they’re at Work on what’s bothering them rather than

what’s bothering me

Have low threshold access Same day and walk-in appointments

If at first you don’t succeed, redefine success

Dana Davis, Allegheny General Hospital Positive Health Center, Pittsburgh, PA

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Best Practices in MMT- Program Development and Design

Clear Program Philosophy and Treatment Goals Focus on Engagement, Retention, and Improved

functionality and fitness A Maintenance Orientation A Client/Patient-Centered Approach Accessibility Integrated Comprehensive Services Client/Patient Involvement Involvement of Wider Community Adequate Resources

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Setting Realistic Treatment Goals

Retention is important because research has affirmed that again and again, the longer opiate users stay in treatment, the better the outcomes

The goal of drug treatment can be increased quality and quantity of life, functionality and fitness, as they describe those, rather than abstinence

Both individual and societal benefit is achieved in maintenance even if abstinence is not an outcome

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Treatment Readiness

Brings Treatment to Where People Are “Stepped” Approach to Treatment Abstinence is Not the Exclusive Outcome Avoids Labeling Recognizes Stages of Change Uses Motivational Interviewing,

Acupuncture, Individual and Group Counseling

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Recognize success

•Success in medical treatment•Obtaining employment•Recognition of all life improvements•Family relationships

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DRUG- SUBSTITUTION THERAPY IN KYRGYZSTAN

In the MMTP in Bishkek, patients interacted comfortably with staff who treated them with respect; they took individual and group counseling, and family members also had an opportunity to be involved throughout treatment process.

Family members of methadone clients reported that they had ‘returned’ to themselves, they looked, spoke and acted differently and were able to resume their roles within the family.

Drug users talked animatedly about the impact the methadone treatment experience on their lives with families and their work

It was apparent that this form of substitution therapy, provided within this context, from the perspective of the users and the family members was treatment.

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INTEGRATION WITH OTHER APPROACHES

Nearby the narcological dispensary in Kyrgyzstan, where MMTP was offered, NGO “Sotsium,” run by another narcologist, provided an array of services including syringe exchange, medical services, a hot line, volunteer and training opportunities, a variety of self-run 12 step meetings open to the community, and a pilot inpatient treatment and rehabilitation program

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Research and Evaluation

Increase the understanding, acceptance of and level of support for OST in Nepal

Refine Program Delivery on an Ongoing Basis Identify the Most Effective Ways to Address the

Needs of Diverse Client/Patient Groups Improve Treatment Outcomes Reduce the Harms Associated with Opiate

Dependence Expanding OST in Nepal and Adapting OST to

Other Settings Across Nepal

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ProgramPolicies

Clear CriteriaFor Involuntary

Discharge

MethadoneDosage during

Pregnancy

Non-punitive

Approach to

Drug UseDuring

Treatment

Unlimited

Duration of

Treatment

OpenAdmission

TimelyAssessment

Ongoing Client/patient

Input into

Services

Client/patientCenteredTapering

Adequate

Individualized

Dose

Summarizing Best Practices in OST

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12. Next Steps

1 Oral Substitution Treatment for Opioid Dependence: A Training in Best Practices & Program Design...

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