Methadone and Drug FreeMethadone and Drug Free

Therapeutic CommunitiesTherapeutic Communities

Limitations and OutcomesLimitations and Outcomes

Moscow, 4 December 2015Moscow, 4 December 2015

Martien Kooyman Martien Kooyman M.D., Ph.D.M.D., Ph.D.

orientation

methadone detox day centre

project 4T.C.

EmiliehoeveT.C.

MistralT.C.

Triple-Ex

re-entry

““PPerhaps the limitations of medical erhaps the limitations of medical treatment for complex medical-social treatment for complex medical-social problems were not sufficiently problems were not sufficiently stressed. No medicine can stressed. No medicine can rehabilitate persons. But to succeed rehabilitate persons. But to succeed in bringing disadvantaged addicts to a in bringing disadvantaged addicts to a productive way of life, a treatment productive way of life, a treatment program must enable its patients to program must enable its patients to feel pride and hope in accepting feel pride and hope in accepting responsabilityresponsability””

Dole & Nyswander, 1976Dole & Nyswander, 1976

Heroin addiction is a symptom of an underlying psychological and/or social problem.Substitution with methadone does not solve these underlying problems

Definition of addictionDefinition of addiction

Addiction is a self-continuing harmfulAddiction is a self-continuing harmfulprocess resulting from the loss ofprocess resulting from the loss of

control over adaptive behaviour whichcontrol over adaptive behaviour whichthen itself becomes a problemthen itself becomes a problem

Definition of addiction

Addiction is a dependency disorder from which

recovery is possible

Calling addiction a chronic relapsing disease

gives practicioners an excuse for failing treatment

and creates a lack of motivation among addicts

and primary care physicians

50% of heroin addicts were involved in criminal behaviour

before they used their first drug

Because heroin use is illegal, serious secondary problems exist.It is questionable if prohibition solves more problems than it produces

Drug addicts are aDrug addicts are a

nuisance to others, so nuisance to others, so

- force them to give up drugs- force them to give up drugs

- lock them up- lock them up

- supply free drugs- supply free drugs

- shoot them- shoot them

All addicts should be reached by treatment

All addicts should be given methadone

Profits from methadone and crime

Drug Related Deaths in Scotland Linked to Methadone

year Total Number of Addict Deaths

Total Number of Methadone Related Deaths

% of Total Deaths linked to Methadone

2004 356 80 22

2005 336 72 21

2006 421 97 23

2007 455 114 26

2008 54 169 29

2009 545 173 32

2010 485 174 35

2011 584 275 47

2012 581 237 40www.drugmisuseresearch.org Centre for Drug

Misuse Research

2007 National Treatment Agency Client Survey England n=12,398

Drug Happy with Use Like to Reduce Use

Like to Stop Using

Heroin 11.4 8.1 80.5

Methadone 36.5 12.9 50.7

Crack Cocaine 16.3 10.5 73.2

Amphetamines 27.5 11.4 61.0

Cannabis 64.2 14.7 21.1

Alcohol 53.6 21.2 25.2

Benzodiazepines 50.4 12.7 36.9

Centre for Drug Misuse Research Scotland

Only methadone substitution programmes with sanctions regarding illegal drug use have positive effects on criminality

Qualities of methadone programs Qualities of methadone programs

- Methadone maintenance makes clients Methadone maintenance makes clients no longer dependent on black marketno longer dependent on black market

- Structured methadone programs can Structured methadone programs can improve re-socializationimprove re-socialization

- Methadone can be a first step towards Methadone can be a first step towards further treatmentfurther treatment

- Structured methadone programs are cost-Structured methadone programs are cost-effectiveeffective

Limitations of methadone programsLimitations of methadone programs

- Methadone can only be used for heroin Methadone can only be used for heroin addictsaddicts

- Availability of methadone postpones the Availability of methadone postpones the decision to stop using and entering a drug decision to stop using and entering a drug free programfree program

- Harm reduction programs without further Harm reduction programs without further rehabilitation are expensive rehabilitation are expensive

Unintended harm caused by methadoneUnintended harm caused by methadone

- Deaths in combination with alcoholDeaths in combination with alcohol

- Sudden deaths through heart arrhytmias Sudden deaths through heart arrhytmias (doses higher than 100 mg) (doses higher than 100 mg)

- Availability of methadone postpones the Availability of methadone postpones the decision to stop using and entering a drug decision to stop using and entering a drug free programfree program

- Life longe Methadone programs without Life longe Methadone programs without further rehabilitation are expensive further rehabilitation are expensive

- Selling of methadone to othersSelling of methadone to others

Contra indications for methadone Contra indications for methadone prescription prescription

- Heavy alcohol useHeavy alcohol use

- Below 21 yearsBelow 21 years

- Continuing use of opiods or other non Continuing use of opiods or other non prescribed drugsprescribed drugs

- No prior detoxification attemptNo prior detoxification attempt

СамопомощьСамопомощь

ВзаимопомощьВзаимопомощь

Ответственное отношениеОтветственное отношение

Self HelpSelf Help

Mutual Help Mutual Help

Responsible ConcernResponsible Concern

Значимость ролевых поведенческих моделей, Значимость ролевых поведенческих моделей,

реализуемых более старшими резидентами и реализуемых более старшими резидентами и

штатными сотрудниками, штатными сотрудниками,

имеющими опыт аддиктивности в прошлом имеющими опыт аддиктивности в прошлом

The importance of role models of older residentsThe importance of role models of older residents

and ex addicts in the staffand ex addicts in the staff

Только ТЫ САМ можешь сделать это,Только ТЫ САМ можешь сделать это,

но ты не сможешь сделать это ОДИН, без но ты не сможешь сделать это ОДИН, без

поддержкиподдержки

You alone can do itYou alone can do it

but you can not do it alonebut you can not do it alone

Медицинская модельМедицинская модель

Medical ModelMedical Model

врачврачdoctordoctor

пациент пациент patientpatient

Врач несет ответственность за лечениеВрач несет ответственность за лечение

The doctor is responsible for the treatmentThe doctor is responsible for the treatment

Пациент не отвечает за свое заболеваниеПациент не отвечает за свое заболевание

The patient is not responsible for the diseaseThe patient is not responsible for the disease

George De Leon

Собственность Наш дом

Ownership Our House

Все виды деятельности, которые выполняются Все виды деятельности, которые выполняются

в Терапевтическом Сообществе, включая в Терапевтическом Сообществе, включая уборку, уборку,

приготовление пищи, приготовление пищи,

организационные вопросы – являются терапиейорганизационные вопросы – являются терапией

AAll T.C. activities includingll T.C. activities including

cleaning, cooking andcleaning, cooking and

administration are administration are

therapytherapy

Обучение умению помогать самому себе

с помощью других людей

learning to help yourself

with the help of others

ГОВОРИ О ТОМ,ЧТО ЧУВСТВУЕШЬ, И

ПРОЧУВСТВУЙ ТО, О ЧЕМ ГОВОРИШЬ

say what you feel

and feel what you say

«Группы столкновений»Encounter groups

Отношение к гневуюмор

angry concern

humor

В Терапевтическом Сообществе В Терапевтическом Сообществе участникиучастники

могут обрестимогут обрести самоощущение, самоощущение, благодаря которому получают возможность благодаря которому получают возможность использовать свои использовать свои

собственные внутренниесобственные внутренние ресурсы, ресурсы, находясь при этом находясь при этом

в безопасной и стимулирующей среде в безопасной и стимулирующей среде и следуя здоровому образу жизнии следуя здоровому образу жизни

In the therapeutic communityIn the therapeutic community

residents can find a sense of self from which they can use their own residents can find a sense of self from which they can use their own

power in a safe and stimulating environment promoting a heathy lifepower in a safe and stimulating environment promoting a heathy life

Терапевтическое Сообщество дает людям с разрушенной Терапевтическое Сообщество дает людям с разрушенной идентичностьюидентичностью

шанс на преодоление своего страхашанс на преодоление своего страхаблизких контактов и отверженностиблизких контактов и отверженности посредством коррекции посредством коррекции состояния эмоциональной сферы и повышения самооценки, состояния эмоциональной сферы и повышения самооценки, делая их способными делая их способными выстраивать стабильные отношения выстраивать стабильные отношения

The therapeutic community gives people wth a failure identityThe therapeutic community gives people wth a failure identity

a possibility to overcome their fear a possibility to overcome their fear

of closeness and rejection through corrective emotional experiences and increase their self of closeness and rejection through corrective emotional experiences and increase their self

esteem enabeling them to have stable relationshipsesteem enabeling them to have stable relationships

Терапевтическое сообществоТерапевтическое сообщество является является терапевтическим по сути.терапевтическим по сути.

Сообщество – это метод.Сообщество – это метод.

The therapeutic community isThe therapeutic community is

therapeutic in itselftherapeutic in itself

The community is the methodThe community is the method

Criteria for success Criteria for success

- no use of hard drugs- no use of hard drugs

- no alcohol problems- no alcohol problems

- less than once a week cannabis,- less than once a week cannabis,

tranquillizerstranquillizers or sleeping pills usedor sleeping pills used

- no drug related arrests or convictions- no drug related arrests or convictions

- no treatment for addiction- no treatment for addiction

- no admission to a psychiatric hospital- no admission to a psychiatric hospital

EH N= 172

ES N= 47

NA N= 62

N Success

85 20 10

% 49,4 42,6 16,1

Success half year before interview ofSuccess half year before interview of

all clients two years out of program all clients two years out of program

with follow-upwith follow-up

Вовлеченность родителей в работу (ВР) позволяет

добиться более продолжительного пребывания на

программе (БПП) и делает ее более

результативной и успешной (РУ)

Parent participation (PP) is related to longer time in the

programme (TIP) and gives therefore more successful

outcome (SO)

ВР PP

БППlonger TIP РУ

more SO

Triple Ex Triple Ex

- ex-addict- ex-addict

- ex-unemployed- ex-unemployed

- ex-prisoner- ex-prisoner

Relapse after Triple-Ex(FU of 116 ex-clients (76%) after average 2 years)

No relapse: 41%

< 1 month: 3%

1-3 months: 7%

3-6 months: 4%

> 6 months: 45%

period of drug useperiod of drug useafter Triple-Exafter Triple-Ex

91% received after care

Social integration after Triple-ExSocial integration after Triple-Ex(FU of 116 ex-clients (76%) after average 2 years)

Dominant social situationDominant social situation

- study- study 7% 7%- job (part/full-time)job (part/full-time) 47%47%- unemployedunemployed 31%31%- disabillity allowancedisabillity allowance 4% 4%- residential treatmentresidential treatment or prisonor prison 11%11%

Social integration after Triple-ExSocial integration after Triple-Ex(FU of 116 ex-clients (76%) after average 2 years)

Crime after dischargeCrime after discharge

Arrests after dischargeArrests after discharge (before admission)(before admission)

dealing drugsdealing drugs 8% 8% (55%) (55%)stealingstealing 36% 36% (92%) (92%)violenceviolence 14% 14% (49%) (49%)

Month before interviewMonth before interview

illegal activitiesillegal activities 17% 17%detention, prison 19%detention, prison 19%

5 year follow-up Donovan PrisonProgram - Amity TC California

0

10

20

30

40

50

60

70

80

90

% Gearresteerd

8386

42

Contr gr Gev. TG Gev. TG+ nazorg TG

(Prendergast, c.s., 2004)

EHN= costs benefits

a year 1,500,000after care 300,000in-/out 60in treatment 30 1,200,000success yr 1 20 800,000success yr 2 18 720,000success yr 3 16 640,000success yr 4 12 480,000long success 12 1,440,000

total 1,800,000 5,280,000C-B ratio 2.9

total before 50,000after 10,000 (success)

long = 7 yr

Cost-Benefit Ratio Emiliehoeve TCCost-Benefit Ratio Emiliehoeve TC

Benefits each per yearBenefits each per year

EmiliehoeveEmiliehoeve 3,5 million Euro3,5 million Euro

Triple-ExTriple-Ex 3,5 million Euro3,5 million Euro

Longer term success4 year follow-

up of Treatment

Leavers2005/06

(n= 41,475)

NDTMSCJS:

Prison & Commun

ity

Drug Test

Did notre-

present

54%

46%

What constitutes successful treatment? (present)

Contra indication for Therapeutic Contra indication for Therapeutic communitiescommunities

- Non drug related psychosisNon drug related psychosis

- (Need double diagnosis TC or psychiatric (Need double diagnosis TC or psychiatric clinic)clinic)

Qualities of drug free T.C.’sQualities of drug free T.C.’s

- T.C.’s can treat clients addicted to any drugsT.C.’s can treat clients addicted to any drugs- 30% of all admissions have a successful long term 30% of all admissions have a successful long term

outcome outcome - Longer time spent in the program improves Longer time spent in the program improves

outcome successoutcome success- Parent participation improves successful outcomeParent participation improves successful outcome- Treatment in a T.C. can be an alternative for prisonTreatment in a T.C. can be an alternative for prison- Treatment in a T.C. is cost-effective Treatment in a T.C. is cost-effective

Limitations of drug free T.C.’sLimitations of drug free T.C.’s

- Highly structured programs are not Highly structured programs are not popular with the addicts and helperspopular with the addicts and helpers

- High drop-out rate in first monthsHigh drop-out rate in first months- Not all addicts can sustain the pressure of Not all addicts can sustain the pressure of

a T.C. a T.C.

Minimun Standards of drug free T.C.’sMinimun Standards of drug free T.C.’s- Basic rules:Basic rules:

No Drugs No Alcohol No Violence or Threat of Violence No Drugs No Alcohol No Violence or Threat of Violence Breaking can lead to dischargeBreaking can lead to discharge

- - A job structure A job structure

- - Groups on behavior here and nowGroups on behavior here and now

- Consequences for negative behaviorConsequences for negative behavior

- Clear procedures for admission and Clear procedures for admission and discharge discharge - Meetings for parents and relativesMeetings for parents and relatives- Develop a staement on the philosophy of the programDevelop a staement on the philosophy of the program

- Protection from negative use of powerProtection from negative use of power

Best Practices of drug free T.C.’sBest Practices of drug free T.C.’s- Specific groups: (, extended groups (marathons, thematic Specific groups: (, extended groups (marathons, thematic

groups, separate groups for females and males, groups, separate groups for females and males, mindfulness, peer groups, (dynamic) meditations, mindfulness, peer groups, (dynamic) meditations, psychodrama, bonding groupspsychodrama, bonding groups

- Family therapyFamily therapy

- Sport, outward bound activitiesSport, outward bound activities

- Education classesEducation classes

- Creativity Creativity

- Separate re-entry program and after care - Separate re-entry program and after care - Training and adequate supervision for staff Training and adequate supervision for staff

- Accountability to an external or community boardAccountability to an external or community board

- Evaluation of the programEvaluation of the program

- AA and NA meetings - AA and NA meetings

Harm reduction is not treatment.

Treatment is harm reduction

Treatment in any form will never solve

the total drug problem

Treatment is cost effective and

part of the solutoion

Thank you