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Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 43.)

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Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs.

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Chapter 7. Phases of Treatment

In This Chapter …

Rationale for a Phased-Treatment Approach and Duration

Phases of MAT

Transition Between Treatment Phases in MAT

Readmission to the OTP

The consensus panel recommends that medication-assisted treatment for opioid addiction (MAT) as provided in opioid treatment programs (OTPs) be conceptualized in terms of phases of treatment so that interventions are matched to levels of patient progress and intended outcomes. The sequential treatment phases described in this chapter apply primarily to comprehensive maintenance treatment, rather than other treatment options such as detoxification or medically supervised withdrawal. When MAT is organized in phases, patients and staff better understand that it is an outcome-oriented treatment approach comprising successive, integrated interventions, with each phase built on another and directly related to patient progress. Such a model helps staff understand the complex dynamics of MAT and the potential sticking points and helps counselors organize interventions based on patient needs.

The model described in this chapter comprises either five or six patient-centered phases for planning and providing MAT services and evaluating treatment outcomes in an OTP, including the (1) acute, (2) rehabilitative, (3) supportive-care, (4) medical maintenance, (5) tapering (optional), and (6) continuing-care phases.

Rationale for a Phased-Treatment Approach and Duration

Research on the effectiveness of organizing MAT into phases is limited, partly because MAT is a relatively long-term process, often with no fixed endpoint and with a variety of possible approaches, and partly because patients often leave and then return to MAT, which makes systematic studies difficult. Although research is limited, the consensus panel believes that the notion of phased progression is implicit in treatment and underlies most of a patient's time in MAT. Many OTPs operate according to an informal phased-treatment model, and others use phases at least to develop treatment plans.

Hoffman and Moolchan (1994) recognized the value of treatment phases in OTPs and described a highly structured model. This chapter builds on, adapts, and extends their model as part of an overall strategy for matching patients with treatments. The phases described below are suggested as guidelines—a way of organizing treatment and looking at progress on a care continuum—and as an adjunct to the levels of care specified by the American Society of Addiction Medicine in its patient placement criteria (Mee-Lee et al. 2001a ) and referred to by accreditation agencies.

The model is not one directional; at any point, patients can encounter setbacks that require a return to an earlier treatment phase. Therefore, the chapter includes strategies for addressing setbacks and recommendations for handling transitions between phases, discharge, and readmission. In terms of medication, the model includes two distinct tracks, one of continuing medication maintenance and the other of medication tapering (medically supervised withdrawal). The implications of both tracks are discussed. Although most patients would prefer to be medication free, this goal is difficult for many people who are opioid addicted. Maintaining abstinence from illicit opioids and other substances of abuse, even if that requires ongoing MAT, should be the primary objective.

Variations Within Treatment Phases

The phase model assumes that, although many patients need long-term MAT, the types and intensity of services they need vary throughout treatment and should be determined by individual circumstances. For many patients, MAT is the entry point for diagnosis and treatment of, or referral for, other health care and psychosocial needs. In general, most patients need more intensive treatment services at entry, more diversified services during stabilization, and fewer, less intensive services after benchmarks of recovery begin to be met (McLellan et al. 1993; Moolchan and Hoffman 1994).

The consensus panel emphasizes that treatment phases should not be viewed as fixed steps with specific timeframes and boundaries but regarded as a dynamic continuum that allows patients to progress according to individual capacity. Some patients progress rapidly and some gradually. Some progress through only some phases, and some return to previous phases. Treatment outcomes should be evaluated not only on how many phases have been completed or whether a patient has had to return to an earlier phase but also on the degree to which the patient's needs, goals, and expectations have been met. As described in chapter 4, assessment of patient readiness for a particular phase and assessment of individual needs should be ongoing.

Duration of Treatment Within and Across Phases

Decisions concerning treatment duration (time spent in each phase of treatment) should be made jointly by OTP physicians, other members of the treatment team, and patients. Decisions should be based on accumulated data and medical experience, as well as patient participation in treatment, rather than on regulatory or general administrative policy.

Phases of MAT

Acute Phase

Patients admitted for detoxification

Although the phases of treatment model is structured for patients admitted for comprehensive maintenance treatment, some patients may be admitted specifically for detoxification from opioids (see 42 Code of Federal Regulations [CFR], Part 8 § 12(e)(4)). These patients usually do not wish to be admitted for or do not meet Federal or State criteria for maintenance treatment. Patients admitted for detoxification may be treated for up to 180 days in an OTP. The goals of detoxification are consistent with those of the acute treatment phase as described below, except that detoxification has specific timeframes and MAT endpoints. Detoxification focuses primarily on stabilization with medication (traditionally using methadone but buprenorphine-naloxone tablets are now available), tapering from this medication, and referral for continuing care, usually outside the OTP. During this process, patients' basic living needs and their other substance use, co-occurring, and medical disorders are identified and addressed. Patients also may be educated about the high-risk health concerns and problems associated with continued substance use. They usually are referred to community resources for ongoing medical and mental health care.

Patients admitted for detoxification should have access to maintenance treatment if their tapering from treatment medication is unsuccessful or they change their minds and wish to be admitted for comprehensive MAT. If these patients meet Federal and State admission criteria, their medically supervised withdrawal from treatment medication should end, their medication should be restabilized at a dosage that eliminates withdrawal and craving, and their treatment plans should be revised for long-term treatment.

Patients admitted for comprehensive maintenance treatment

The acute phase is the initial period, ranging from days to months, during which treatment focuses on eliminating use of illicit opioids and abuse of other psychoactive substances while lessening the intensity of the co-occurring disorders and medical, social, legal, family, and other problems associated with addiction. The consensus panel believes that front-loading highly intensive services during the acute phase, especially for patients with serious co-occurring disorders or social or medical problems, engages patients in treatment and conveys that the OTP is concerned about all the issues connected to patients' addiction. Exhibit 7-1 summarizes the main treatment considerations, strategies, and indicators of progress during the acute phase.

Exhibit 7-1. Acute Phase of MAT

Treatment IssueStrategies To Address IssueIndications for Transition to Rehabilitative Phase
Alcohol and drug use• Schedule weekly drug and alcohol testing• Elimination of opioid-withdrawal symptoms, including craving
• Educate about effects of alcohol and drugs; discourage their consumption• Sense of well-being
• Ensure ongoing patient dialog with staff• Ability to avoid situations that might trigger or perpetuate substance use
• Intensify treatment when necessary• Acknowledgment of addiction as a problem and motivation to effect lifestyle changes
• Meet with program physician to ensure adequate dosage of treatment medication
Medical concerns• Refer patients immediately to medical providers• Resolution of acute medical crises
• Infectious diseases (e.g., HIV/AIDS, hepatitis, tuberculosis [TB])• Vaccinate as appropriate (e.g., for hepatitis A and B)• Established, ongoing care for chronic medical conditions
• Sickle cell disease
• Surgical needs, such as skin or lung abscesses
Co-occurring disorders• Identify acute co-occurring disorders that may need immediate intervention• Resolution of acute mental crises
• Psychotic, anxiety, mood, or personality disorders• Identify chronic disorders that need ongoing therapy• Established, ongoing care for chronic disorders
Basic living concerns• Assess needs• Satisfaction of basic food, clothing, shelter, and safety needs
• Legal and financial concerns• Refer patient to appropriate services• Stabilization of living situation
• Threats to personal safety• Work cooperatively with criminal justice system• Stabilization of financial assistance
• Inadequate housing• Explore transportation options• Resolution of transportation and childcare needs
• Lack of transportation• Link to legal advocate, caseworker, or social worker
• Childcare needs• Identify financial resources
• Pregnancy• Provide ongoing case management
• Advocacy
Therapeutic relationship• Advocate adequate dosage• Regular attendance at counseling sessions
• Establishing trust and feeling of support• Remain consistent, flexible, and available; minimize waiting times• Positive interaction with treatment providers
• Addressing myths about MAT• Provide incentives and emphasize benefits of treatment• Focus on treatment goals
• Dispel myths about MAT
• Educate patient about goals of MAT
• Build support system
• Build trust
Motivation and readiness for change• Ensure adequate dosage• Commitment to treatment process
• Ambivalent attitudes about substance use• Address ambivalence• Acknowledgment of addiction as a problem
• Avoidance of counseling (noncompliance)• Empower patient• Lifestyle changes and addressing addiction-related issues
• Negative relationships with staff• Emphasize treatment benefits
• Inadequate dosage• Emphasize importance of making a fresh start
• Negative attitude about treatment
• Involuntary discharge

Goals of the acute phase

A major goal during the acute phase is to eliminate use of illicit opioids for at least 24 hours, as well as inappropriate use of other psychoactive substances. This process involves

  • Initially prescribing a medication dosage that minimizes sedation and other undesirable side effects
  • Assessing the safety and adequacy of each dose after administration
  • Rapidly but safely increasing dosage to suppress withdrawal symptoms and cravings and discourage patients from self-medicating with illicit drugs or alcohol or by abusing prescription medications
  • Providing or referring patients for services to lessen the intensity of co-occurring disorders and medical, social, legal, family, and other problems associated with opioid addiction
  • Helping patients identify high-risk situations for drug and alcohol use and develop alternative strategies for coping with cravings or compulsions to abuse substances.

Chapter 5 details the procedures for determining medication dosage.

Indications that patients have reached the goals of the acute phase can include

  • Elimination of symptoms of withdrawal, discomfort, or craving for opioids and stabilization
  • Expressed feelings of comfort and wellness throughout the day
  • Abstinence from illicit opioids and from abuse of opioids normally obtained by prescription, as evidenced by drug tests
  • Engagement with treatment staff in assessment of medical, mental health, and psychosocial issues
  • Satisfaction of basic needs for food, shelter, and safety.

Alcohol, opioid, and other drug abuse

During the acute phase, OTP staff members should pay attention both to patients' continuing opioid abuse and to their use of other addictive and psychoactive substances. Patients should receive information about how other drugs, nicotine, and alcohol interact with treatment medications and why medication must be reduced or withheld when intoxication is evident. When substance abuse continues during the acute phase, the treatment team should review patients' presenting problems and revise plans to address them, including changes in dosage, increased drug testing, or other intensified interventions. Chapter 11 discusses treatment options to address multiple substance use.

In addition, the consensus panel believes that frequent contact with knowledgeable and caring staff members who can motivate patients to become engaged in program activities, especially in the acute phase, facilitates the elimination of opioid abuse. Engaging the patient by scheduling extra individual or group counseling sessions provides additional support and communicates staff concern for the patient. Intensified treatment in the OTP is an effective response and provides improved outcomes when compared with more infrequent counseling sessions (Woody 2003).

Co-occurring disorders

Many people entering OTPs have mental disorders. Persistent, independent co-occurring disorders (i.e., mental disorders that arise from causes other than substance use and need ongoing therapy) and substance-induced co-occurring disorders (i.e., mental disorders directly related to substance use and addiction that probably will improve as the addiction is controlled) should be identified during initial assessment and the acute phase of treatment so that appropriate treatment or referral can be arranged. Patients should be monitored closely for symptoms that interfere with treatment because immediate intervention might prevent patient dropout. Such disorders can be disruptive at the start of MAT, requiring immediate treatment. The course of recovery from substance-induced co-occurring disorders usually follows that of the substance use disorder itself, and these co-occurring disorders typically do not require ongoing treatment after the acute phase. Some patients may require focused, short-term pharmacotherapy, psychotherapy, or both. However, many patients may have co-occurring disorders requiring a thorough psychiatric evaluation and long-term treatment to improve their quality of life. (See chapters 4 and 12 for more information on assessing these conditions and chapter 12 for more information on psychiatric diagnosis and treatment in MAT.)

Medical and dental problems

Patients often present with longstanding, neglected medical problems. These problems might require hospitalization or extensive treatment and could incur substantial costs for people often lacking financial resources. In addition, many patients in MAT have neglected their dental health (Titsas and Ferguson 2002). Once opioid abuse is stopped, these patients often experience pain because the analgesic effects of the opioids have been removed. Such conditions must be recognized, assessed, and treated, either within an OTP or via referral. (See chapter 10 for discussion of the diagnosis and treatment of medical problems for patients in MAT.)

Legal problems

Most correctional systems do not allow MAT. The consensus panel believes that sudden, severe opioid withdrawal caused by precipitous incarceration can endanger health, especially that of patients already experiencing comorbid medical illness, and can increase the risk of suicide in individuals with co-occurring disorders. Therefore, it is critical to address patients' legal problems and any ongoing criminal activity as soon as possible, preferably in the acute phase. On behalf of those on probation or parole or referred by drug courts, program staff members should work cooperatively with criminal justice agencies, educating them about MAT and, with patients' informed consent (see CSAT 2004b ), reporting patient progress and incorporating continuing addiction treatment into the probation or parole plan. OTPs should work with local prisons and jails to provide as much support and consultation as possible. When medical care is provided in jails or prisons by contracted health agencies, OTPs should establish contacts directly with these medical providers to improve the care of incarcerated patients in MAT. (See TIP 44, Substance Abuse Treatment for Adults in the Criminal Justice System [CSAT 2005a ].)

Basic needs

The consensus panel recommends that patients' basic needs such as food, clothing, housing, and safety be determined during the acute phase, if possible, as discussed in chapter 4, and that referrals be made to appropriate agencies to address these needs.

Patients' living situations should be relatively stable and secure so that treatment can move beyond the acute phase. Before they transition to the rehabilitative phase, patients should begin to develop the coping skills needed to remove themselves from situations of inevitable substance use. A patient's inability to gain this control may necessitate revision of the treatment plan to assist the patient in moving past the acute phase. The process often includes meeting directly with the patient to assess motivation and adequacy of dosage and to define treatment goals clearly.

Therapeutic relationships

Positive reinforcement of a patient's treatment engagement and compliance, especially in the acute phase, is important to elicit a commitment to therapy. Chapter 8 addresses the importance of the therapeutic bond between patients and treatment providers and reviews practical techniques to address common problems in counseling.

Furthermore, participation in peer support services and mutual-help groups (provided that these groups support MAT) can be helpful to patients. OTPs can provide information about appropriate meetings and peer support.

The consensus panel recommends that patients be introduced to key OTP staff members as early as possible during the acute phase to foster an atmosphere of safety, trust, and familiarity. Patients consistently report that a strong therapeutic relationship is one of the most critical factors influencing treatment outcomes and that therapists' warmth, positive regard, and acceptance are major elements in relationship development (Metcalf et al. 1996). Treatment providers should minimize waiting times during scheduled appointments to demonstrate that they value patients' time. In addition, when providers remain flexible and available during the acute phase, they contribute to patients' sense of security. Knowing how to reach staff in an emergency can foster patients' trust in treatment providers.

Motivation and patient readiness

As discussed in chapter 4, patient motivation to engage in treatment is a predictor of retention and should be reassessed continually. Counselors should explore and address patients' negative treatment experiences. It might help to acknowledge the weaknesses of past staff efforts and to focus on future actions to move treatment forward. Counseling and motivational enhancement are discussed in detail in chapter 8.

The level of patient engagement during the acute phase is critical. Research has shown that patient motivation, staff engagement, and the trust developed during orientation and the acute phase are linked more closely to treatment outcomes than patients' initial reasons for entering an OTP (Kwiatkowski et al. 2000; Marlowe et al. 2001).

Transition to the rehabilitative phase

The panel recommends the following criteria for transition from the acute to the rehabilitative phase:

  • Amelioration of signs of opioid withdrawal
  • Reduction in physical drug craving
  • Elimination of illicit-opioid use and reduction in other substance use, including abuse of prescription drugs and alcohol
  • Completion of medical and mental health assessment
  • Development of a treatment plan to address psychosocial issues such as education, vocational goals, and involvement with criminal justice and child welfare or other social service agencies as needed
  • Satisfaction of basic needs for food, clothing, shelter, and safety.

Rehabilitative Phase

The primary goal of the rehabilitative phase of treatment is to empower patients to cope with their major life problems—drug or alcohol abuse, medical problems, co-occurring disorders, vocational and educational needs, family problems, and legal issues—so that they can pursue longer term goals such as education, employment, and family reconciliation. Stabilization of dosage for opioid treatment medication should be complete, although adjustments might be needed later, and patients should be comfortable at the established dosage for at least 24 hours before the rehabilitative phase can proceed. Exhibit 7-2 summarizes the treatment issues addressed during the rehabilitative phase, strategies for addressing them, and indicators for subsequent transition to the supportive-care phase.

Exhibit 7-2. Rehabilitative Phase of MAT

Treatment IssueStrategies To Address IssueIndications for Transition to Supportive-Care Phase
Alcohol and drug use• Begin behavioral contracting• Ability to identify and manage relapse triggers
• Continued opioid use• Start short-term inpatient treatment• Repertoire of coping skills
• Continued abuse of other substances (e.g., alcohol, cocaine, nicotine)• Introduce disulfiram for alcohol abuse• Demonstrated changes in life circumstances to prevent relapse
• Provide pharmacotherapy and cessation groups for tobacco use• Discontinuation of opioid and other drug use
• Intensify treatment services• Absence of problem alcohol use
• Introduce positive incentives: take-home medication, recognition of progress• Smoking cessation plan
• Adjust dosage as necessary to prevent continued opioid use
• Encourage participation in support groups and family therapy
Medical concerns• Ensure onsite primary care or link to other services• Compliance with treatment for chronic diseases
• Chronic diseases (e.g., diabetes, hypertension, seizure disorders, cardiovascular disease)• Provide integrated treatment approach• Improved overall health status
• Infectious diseases (e.g., HIV/AIDS, TB, hepatitis B and C, sexually transmitted diseases)• Provide routine TB testing as appropriate• Improved dental health and hygiene
• Susceptibility to vaccine-preventable diseases• Provide education on diet, exercise, smoking cessation• Regular prenatal care
• Dental problems, nicotine dependence• Provide vaccinations as indicated• Stable medical and mental health status
• Women's health issues (e.g., pregnancy, family planning services)• Adjust other medications that interfere with treatment medication or adjust dosage of treatment medication
• Assess need and refer patient for pain management
Co-occurring disorders• Evaluate status• Stable mental status and compliance with psychiatric care
• Psychotic, anxiety, mood, posttraumatic stress, or personality disorders• Teach coping skills
• Ensure early identification and referral for co-occurring disorders
• Refer for psychotropic medication or psychotherapy as indicated
Vocational and educational needs• Identify education deficiencies• Stable source of income
• Unemployment/underemployment• Provide onsite general equivalency diploma (GED) counseling or referral• Active employment search
• Low reading skills• Provide literacy and vocational training with community involvement• Involvement in productive activity: school, employment, volunteer work
• Illiteracy• Provide training on budgeting of personal finances
• Learning disabilities• Provide employment opportunities or referral to a job developer
Family issues• Involve community or faith-based, fellowship, recreation, or other peer group• Social support system in place
• Absence of family support system• Increase involvement in family life (in absence of family dysfunction that impedes progress)• Absence of major conflict within support system
• Emergence of family problems (e.g., traumatic family history, divorce, other problem situations)• Provide for well-child care• Increased responsibility for dependents
Legal problems• Provide access to legal counsel• Resolution of, or ongoing efforts to solve, legal problems
• Criminal charges• Encourage patient to take responsibility for legal problems• Absence of illegal activities
• Custody battles• Identify obstacles to eliminating illegal activities and replace them with constructive activities
• Ongoing illegal activities

As stated for the acute phase, during the rehabilitation phase treatment, providers should continue to assist or provide referrals for patients who need help with legal, educational, employment, medical, and financial problems that threaten treatment retention (Condelli 1993).

Throughout this phase, efforts should increase to promote participation in constructive activities such as full- or part-time employment, education, vocational training, child rearing, homemaking, and volunteer work. As patients attend to other life domains, requirements for frequent OTP attendance or group participation should not become barriers to employment, education, or other constructive activities or medical regimens. Consequently, program policies in areas such as take-home medications and dosing hours should be more flexible in the rehabilitative phase, especially when patients must travel long distances to their OTP or receive medication at restricted hours.

The consensus panel recommends that information about outside support groups, including faith-based, community, and 12-Step groups, be reviewed with patients in the rehabilitative phase and that patients be urged to participate in such groups, assuming that these groups support MAT. As discussed in chapter 14, OTPs also should cultivate direct relationships with organizations that might lend support for patient recovery. Faith-based organizations can provide spiritual assistance, a sense of belonging, and emotional support, as well as opportunities for patients to contribute to their communities, and in the process can educate community members about MAT.

Relapse triggers or cues such as boredom, certain locations, specific individuals, family problems, pain, or symptoms of co-occurring disorders might recur during the rehabilitative phase and trigger the use of illicit drugs or abuse of prescription drugs or alcohol. Helping patients develop skills to cope with triggers should be emphasized in this phase (Sandberg and Marlatt 1991) and might involve individual, group, or family counseling or participation in groups focused on relapse prevention. (For a discussion of relapse prevention, see chapter 8.)

Many factors that receive emphasis in the acute phase should continue to be addressed in the rehabilitative phase:

  • Continued alcohol and prescription drug abuse and use of illicit drugs
  • Ongoing health concerns
  • Acute and chronic pain management
  • Employment, formal education, and other income-related areas
  • Family relationships and other social supports
  • Legal problems
  • Co-occurring disorders
  • Financial problems.

Continued alcohol and prescription drug abuse and use of illicit drugs

The consensus panel recommends that elimination of alcohol abuse, illicit-drug use, and inappropriate use of other substances be required to complete the rehabilitative phase. Evidence of heavy alcohol use might warrant that a patient return to the acute phase. If a patient is using medications, particularly drugs of potential abuse prescribed by a nonprogram physician, the patient should be counseled to advise his or her OTP physician of these prescriptions and should sign an informed consent statement permitting OTP staff and the outside physician to discuss these prescriptions. If drug use is illicit or unapproved by the OTP physician, then group, family, and individual counseling should continue, and the patient should remain in the rehabilitative phase. Patients who continue to use illicit drugs or demonstrate alcohol use problems are not eligible for take-home medication. Take-home medication should not be considered until these patients have demonstrated a period of abstinence. Patients also should receive information on the risks of smoking, both for their own recovery and for the health of those around them. (See chapter 11 for techniques to treat continued substance use during MAT and chapter 8 for counseling and behavior modification strategies.)

The frequency of drug testing during the rehabilitative phase and all subsequent phases should depend on a patient's progress in treatment. The consensus panel recommends that, once a patient is progressing well and has consistently negative drug tests, the frequency of random testing be decreased to once or twice per month. The criteria for this should be part of the treatment plan. (See chapter 9 for a detailed discussion of drug testing.)

Ongoing health concerns

As patients advance in the rehabilitative phase, they should attend to other medical problems, and OTP staff should help them navigate the medical- and dental-care systems, while educating practitioners about MAT. Onsite primary health care is optimal and has been instituted successfully in many OTPs and can result in better outcomes for patients (Weisner et al. 2001), although it requires careful coordination of activities and staff (Herman and Gourevitch 1997). When lack of resources precludes onsite medical services in an OTP, referral arrangements with other service providers should be in place.

The consensus panel recommends a more integrated approach to patient health in the rehabilitative phase. A patient's health needs should be diagnosed and treated immediately. Education about topics with longer term benefits, such as nutrition, exercise, personal hygiene, sleep, and smoking cessation, can be started. Eventually, patients should demonstrate adherence to medical regimens for their chronic conditions and address any acute conditions before they are considered for transition from the rehabilitative phase to subsequent treatment phases.

Acute and chronic pain management

Patients in OTPs are at high risk of undertreatment for pain (Jamison et al. 2000; Rosenblum et al. 2003; Scimeca et al. 2000). Chapter 10 provides recommendations for pain management. Because acute pain treatment usually involves opioid medications, programs should work with patients to recognize the risk of relapse and provide supports to prevent it (Jamison et al. 2000).

Employment, formal education, and other income-related issues

The consensus panel believes that some of the most difficult obstacles to a stable life for MAT patients include unemployment and inadequate funds to live comfortably and safely. Most such limitations should be addressed during the rehabilitative phase. (See chapter 8 for detailed discussion.)

Individuals who need access to high-quality social services should be identified during the rehabilitative phase for educational, literacy, and vocational programs that will equip them with the skills needed to function independently. Chapters 6 and 8 discuss such assistance. TIP 38, Integrating Substance Abuse Treatment and Vocational Services (CSAT 2000c ), provides more information on this topic.

Ideally, OTPs should provide onsite GED counseling and assistance or make referrals to local adult education programs that are sensitive to the needs of patients in MAT. Efforts can be made to encourage business, industry, and government leaders to create income-generating enterprises that provide patients with job skills and opportunities for entry into the job market and to preclude employment discrimination for patients.

Patients in MAT face unique employment challenges, especially as employers increasingly impose preemployment drug testing and patients must wrestle with whether to disclose their status. The panel recommends that vocational training provided in an OTP include basic education about drug testing, including the fact that methadone may be detected. Patients should be advised to answer all job application questions honestly and should be counseled on ways to manage disclosure of their treatment status. Patients with disabilities should be educated about the basics of the Americans with Disabilities Act and any local antidiscrimination legislation and enforcement.

By the end of the rehabilitative phase, patients should be employed, actively seeking employment, or involved in a productive activity such as school, child rearing, or regular volunteer work. They should have a stable source of legal income, whether from employment, disability benefits, or other legitimate sources, ensuring that they can avoid drug dealing or other criminal activities to obtain money.

Family relationships and other social supports

Broken trust, disappointment, anger, and conflict with family members and acquaintances are realities that patients should face during the rehabilitative phase. Many need to reconcile with their families, reunite with or regain custody of their children, and handle other family issues. Some patients have had little or no family contact during the period of their opioid addiction. Counselors need to help patients improve their social supports and relationships and begin to rebuild and heal severely damaged family relationships. Chapter 8 expands on these goals for patients in MAT.

Transition from the rehabilitative phase should require that patients have a social support system in place that is free of major conflicts and that they assume increased responsibility for their dependents (e.g., by reliably providing child support).

Legal problems

The stress associated with patients' legal problems can precipitate relapse to illicit drug use or abuse of alcohol or prescription drugs. Counselors should probe patients' legal circumstances, such as child custody obligations, and patients should be encouraged to take responsibility for their actions; however, counselors should help patients remain in treatment while resolving pending legal problems. During the rehabilitative phase, counselors should help patients overcome guilt, fear, or uncertainty stemming from their legal problems. In addition, OTP staff should ensure that patients have access to adequate legal counsel, for instance, through a public defender. All major legal problems should be in the process of resolution before patients move beyond the rehabilitative phase. Drug courts' referrals of patients can result in reporting requirements and specialized protocols (see CSAT 2005a ).

Co-occurring disorders

The consensus panel recommends that, before patients move beyond the rehabilitative phase, co-occurring disorders be alleviated or stabilized. Although symptoms might continue to arise, patients should have adequate coping skills to avoid relapse to opioid abuse. Chapter 12 provides specific information about co-occurring disorders in MAT.

Supportive-Care Phase

After meeting the criteria for transition from the rehabilitative phase, patients should progress to the supportive-care phase, in which they continue opioid pharmacotherapy, participate in counseling, receive medical care, and resume primary responsibility for their lives. During this phase, patients should begin to receive take-home medication for longer periods and be permitted to make fewer OTP visits. Depending on regulations (State regulations often are more stringent than Federal), these patients might visit their OTP as infrequently as every other week. Often, supportive care provided in an OTP can be augmented by supportive activities through mutual-help, community, faith-based, peer, and acculturation groups.

Exhibit 7-3 summarizes the treatment issues that should be addressed during the supportive-care phase, strategies for addressing them, and indicators for the subsequent transition from the supportive-care phase to medical maintenance or tapering.

Exhibit 7-3. Supportive-Care Phase of MAT

Treatment IssueStrategies To Address IssueIndications for Transition to Next Phase
Alcohol and drug use• Monitor use• Discontinued drug use and no problems with alcohol use
• Increase frequency of drug screening
Medical and mental health concerns• Monitor compliance with medical/psychiatric regimens• Stability
• Maintain communication with patients' health care and mental health care providers
Vocational and educational needs• Monitor vocational status and progress toward educational goals• Stable source of income
• Assist in addressing workplace problems
Family issues• Monitor family stability and relationships• Stability
• Refer for family therapy as needed
Legal issues• Monitor ongoing legal issues• Resolution
• Provide needed support

Patients should have discontinued alcohol and prescription drug abuse and all illicit-drug use, as well as any involvement in criminal activities, before entering the supportive-care phase. Heavy or problem substance use should result in patients' return to the acute phase. Patients in supportive care should be employed, actively seeking employment, or involved in other productive activities, and they should have legal, stable incomes. Even though all treatment plans and patients' progress should be assessed individually, if any requirements largely are unmet, counselors should consider returning these patients to the rehabilitative phase to address areas of renewed concern rather than advancing them to the medical maintenance or tapering phase.

After patients in supportive care are abstinent from illicit drugs or are no longer abusing prescription drugs (as confirmed by treatment observation and negative drug tests) for a specified period, they should be considered for transition to either the medical maintenance or the tapering phase. Opinions vary on the length of time patients should be free from illicit-drug use and abuse of prescription drugs before being allowed to move to the next phase. However, to receive the maximum 30-day supply of take-home medication, a patient must be demonstrably free from illicit substances for at least 2 years of continuous treatment (42 CFR, Part 8 § 12(i)(3)(vi)). The consensus panel believes that a period of treatment compliance lasting between 2 and 3 years usually is appropriate. However, the length of time a patient remains in supportive care should be based entirely on his or her needs and progress, not on an imposed timetable. Patients' progress in coping with their life domains should be assessed at least quarterly to determine whether patients are eligible and ready for transition from supportive care to either the medical maintenance or tapering phase.

In some cases, patients who stop opioid abuse and demonstrate compliance with program rules do not make progress in other life domains. Although such patients might do well in MAT, they still need the ongoing support and pharmacotherapy provided by the OTP and, in the opinion of the consensus panel, should be deemed ineligible or inappropriate candidates for either medical maintenance or tapering. Instead, these patients should continue to receive take-home medication for brief periods (e.g., 1 to several days) along with other services as needed.

The criteria for transitioning to the next phase of treatment depend on whether the patient is entering the medical maintenance phase or the tapering and readjustment phase.

Medical Maintenance Phase

In the medical maintenance phase, stabilized patients who continue to require medication to remain stable are allowed longer term (up to 30-day) supplies of take-home medication and further reductions in the frequency of treatment visits, generally without the suite of services included in comprehensive MAT. Medical maintenance with methadone can be administered through an OTP or through the office of a qualified physician who operates under Substance Abuse and Mental Health Services Administration (SAMHSA) approval as a “medication unit” (42 CFR, Part 8 § 11(h)) and is linked formally to an OTP. Federal regulations (42 CFR, Part 8 § 12(i)(3)(vi); 42 CFR, Part 8 § 11(h)) permit various levels of take-home medication for unsupervised use, with the amount linked to the length of time that patients have been abstinent from illicit opioids or have stopped abusing prescription opioids and to other specified conditions. Some State regulations (e.g., New York) further restrict the amount of take-home opioid treatment medication and supersede Federal regulations.

The consensus panel recommends the following criteria to determine a patient's eligibility for the medical maintenance phase of treatment:

  • 2 years of continuous treatment
  • Abstinence from illicit drugs and from abuse of prescription drugs for the period indicated by Federal and State regulations (at least 2 years for a full 30-day maintenance dosage)
  • No alcohol use problem
  • Stable living conditions in an environment free of substance use
  • Stable and legal source of income
  • Involvement in productive activities (e.g., employment, school, volunteer work)
  • No criminal or legal involvement for at least 3 years and no current parole or probation status
  • Adequate social support system and absence of significant unstabilized co-occurring disorders.

During the medical maintenance phase, OTPs may play various roles in patients' primary medical and mental health care. OTPs that provide only limited health care services should integrate their services with those of other health care providers (see chapters 10 and 12 about related medical problems and co-occurring disorders, respectively). Exhibit 7-4 summarizes treatment issues and strategies in the medical maintenance phase of MAT and provides indicators for transition to physician's office-based opioid treatment (OBOT) or the tapering or continuing-care phases.

Exhibit 7-4. Medical Maintenance Phase of MAT

Treatment IssueStrategies To Address IssueIndications for Transition to OBOT or Tapering or Continuing-Care Phase
Alcohol and drug use• Monitor use• Continuous stability for 2 years
• Perform drug testing
Medical and mental health concerns• Monitor compliance• Stability
• Maintain communication
Vocational and educational needs• Monitor progress• Stability
• Remain available to address workplace problems
Family issues• Monitor family stability• Stability
• Refer to family therapy as needed
Legal issues• Monitor ongoing legal issues• Stability
• Provide support as needed

In addition, evaluation of life domains including substance use, co-occurring medical and mental problems, vocational and educational needs, family circumstances, and legal issues should continue during the medical maintenance phase, regardless of the setting. Although patients in medical maintenance may not require psychological services, they may need occasional dosage adjustments based on their use of other prescription medication or on such factors as a change in metabolism of methadone (see chapter 5).

The consensus panel recommends random drug testing and callbacks of medication during the medical maintenance phase to make sure that patients are adhering to their medication schedules (see chapter 9). Patients in medical maintenance should be monitored for risk of relapse. Positive drug test results should be addressed without delay, and patients should be returned to the rehabilitative phase when appropriate.

The consensus panel recommends that, as part of the diversion control plan required for all OTPs by SAMHSA (see chapters 5 and 14), evidence of medication diversion by a patient in medical maintenance result in reclassification of that patient to the most appropriate previous phase of treatment and in adjustment of treatment, other services, and privileges. Reinstatement into medical maintenance should occur only after the phase-regressed patient is observed over a reasonable period (at least 3 to 6 months) and has demonstrated required progress.

Considerations for OBOT with methadone

OBOT may be considered for patients receiving methadone in MAT in an OTP who have demonstrated stability in all domains for at least 2 consecutive years of treatment. If a patient in medical maintenance who is receiving treatment through OBOT relapses (to opioid, other drug, or alcohol abuse) or needs the structure of an OTP for psychosocial reasons, the treating physician is responsible for referring the patient back to an OTP. There are some exceptions in which patients, early in treatment, can be transferred from an OTP to OBOT with methadone (e.g., when travel to an OTP is impossible or there are medical reasons), but these exceptions must be preapproved by SAMHSA (see chapter 5).

Coordination of care is critical in the OBOT model so that patients get the full range of services needed to remain abstinent. Treatment issues listed in Exhibits 7-1, 7-2, and 7-3 also are applicable to patients who receive OBOT. Regardless of the opioid treatment medication used, treatment of opioid addiction requires a comprehensive and individualized treatment approach that includes medication and counseling services. Even for patients who are rehabilitated and stable enough to qualify for medical maintenance, medication alone often is inadequate to treat their opioid addiction (Joseph et al. 2000).

Tapering and Readjustment Phase

“Tapering” and “medically supervised withdrawal” are terms commonly used to describe the gradual reduction and elimination of maintenance medication during opioid addiction treatment. (The term “detoxification” in this TIP refers to tapering from illicit drugs, from inappropriate use of prescription drugs, or from alcohol abuse, not to tapering from treatment medication, to avoid the implication that treatment medications are toxic.) Studies show that most patients who are opioid addicted try to taper from treatment medication one or more times after reaching and maintaining stability. With proper support systems and skills, many patients succeed in remaining abstinent from opioids without treatment medication for years or even life, but studies have shown that some relapse to opioid abuse (Condelli and Dunteman 1993; Hubbard et al. 1989; Kreek 1987). Chapter 5 describes procedures and other key considerations in tapering. In the phased model presented here, tapering is considered an optional branch.

It is important that any decision to taper from opioid treatment medication be made without coercion and include careful consideration of a patient's wishes and preferences, level of motivation, length of addiction, results of previous attempts at tapering, family involvement and stability, and disengagement from activities with others who use substances. A patient considering dose tapering should understand that the chance of relapse to drug use remains (Magura and Rosenblum 2001) and some level of discomfort exists even if the dose is reduced slowly over months (Moolchan and Hoffman 1994). Patients should be assured that they temporarily can halt the reductions or return to a previous methadone dosage if tapering causes problems.

As medication is being tapered, intensified services should be provided, including counseling and monitoring of patients' behavioral and emotional conditions. Patients considered for medication tapering should demonstrate sufficient motivation to undertake this process, including acceptance of the need for increased counseling. Tapering from medication can be difficult, and patients should understand the advantages and disadvantages of both tapering from and continuing on medication maintenance as they decide which path is best for them. Exhibit 7-5 presents treatment issues during the tapering phase, strategies to address these issues, and indicators for return to a previous phase.

Exhibit 7-5. Tapering Phase of MAT

Treatment IssueStrategies To Address IssueIndications for Return to a Previous Treatment Phase
Alcohol and drug use• Monitor use• Relapse or concern about relapse to opioid use
• Increase drug testing• Positive drug test for an illicit substance
• Increase counseling support
Medical and mental health concerns• Monitor compliance• Unstable health issues
• Maintain communication with health care providers
• Continue education
Vocational and educational needs• Monitor progress• Instability
• Be available to address workplace problems• Loss of employment
Family issues• Monitor family stability• Instability
• Refer to family therapy as needed• Death or loss of loved one
• Unstable housing
Legal issues• Monitor ongoing legal issues• New criminal involvement
• Provide support as needed

Reasons for tapering

Sometimes decisions to taper are motivated by the hardships of OTP attendance and other requirements or by the stigma often associated with MAT. The consensus panel urges OTPs to identify such situational motives and ensure that patients who choose medically supervised withdrawal from MAT are motivated instead by legitimate concerns about health and relapse.

Patients and treatment providers might fail to realize or understand that continuing or long-term MAT is the best choice for some patients. OTP staff members consciously or inadvertently might convey that tapering is more desirable or expected than continuing opioid pharmacotherapy, through such practices as celebrating patients' tapering but not the accomplishments of others who successfully continue in MAT. The consensus panel believes that a basic grounding in MAT pharmacology, the biology of addiction, and the endorphin system helps patients and treatment providers understand that both successful tapering from and continued compliance with medical maintenance treatment are legitimate goals and commendable accomplishments.

Relapse after tapering

The risk of relapse during and after tapering is significant because of the physical and emotional stress of attempting to discontinue medication (Magura and Rosenblum 2001). The consensus panel recommends that patients be encouraged to discuss any difficulties they experience with tapering and readjustment so that appropriate action can be taken to avoid relapse. Patients should be persuaded to return to a previous phase if the need is indicated at any time during tapering. Patients also should be told that they can taper at their own rate, that successful tapering sometimes takes many months, and that they can stop tapering or increase their dosage at any time without a sense of failure. Patients should be educated about how to reenter MAT if they believe that relapse is imminent.

Readjustment

Many patients who complete tapering from opioid medication continue to need support and assistance, especially during the first 3 to 12 months, to readjust to a lifestyle that is free of both maintenance medication and substances of abuse. During this period, treatment providers should focus on reinforcing patients' coping and relapse prevention skills. Patients' primary goals should be to increase self-sufficiency and maintain balanced, stable, and productive lifestyles. Participation in 12-Step or other mutual-help groups is recommended as reliance on the OTP is gradually reduced. Motivated patients might be helped by continued naltrexone therapy (see chapter 3), which blocks opioid effects for 2 to 3 days in appropriate doses. Care must be taken to initiate naltrexone well after tapering is completed to avoid precipitating withdrawal symptoms. Other patients might benefit from continued counseling to strengthen relapse prevention skills. Some patients might find the support of continued drug testing helpful after tapering. Other recommended strategies include problemsolving counseling approaches, reinforcement of positive behaviors and attitudes, an open-door policy to maximize availability of counselors and providers, steps to strengthen patients' own support systems, and development of a relapse prevention plan, including how to return to MAT if necessary.

Reversion to MAT

The consensus panel recommends that all patients attempting tapering be counseled that a return to medication and a previous phase does not represent failure but simply that medical maintenance is more appropriate for some patients in general and for others at particular times in their lives.

Indicators for transition

Successful discontinuation of medication is a key indicator for transition from the tapering phase to the continuing-care phase. Another key indicator is a positive self-image as someone who feels and functions well without medication. Adoption of a socially productive lifestyle without involvement with substances of abuse also is critical to completing this phase and to continued recovery. The absence of signs and symptoms of abuse or dependence, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (DSM-IV-TR) (American Psychiatric Association 2000) indicates successful completion of tapering.

Continuing-Care Phase

Continuing care is the phase that follows successful tapering and readjustment. Treatment at this stage comprises ongoing medical followup by a primary care physician, occasional check-ins with an OTP counselor, and participation in recovery groups. Ongoing treatment, although less intense, often is necessary because the chronic nature of opioid addiction can mean continuous potential for relapse to opioid abuse for some patients.

Patients in continuing care should have a socially productive lifestyle, no involvement with drugs or problem involvement with alcohol, and improved coping skills demonstrated over at least 1 year. Significant co-occurring disorders should be well under control. People in this phase should continue to participate regularly in mutual-help groups, but regular attendance at an OTP should be unnecessary, except to return to a more intensive level of treatment if necessary for continuation of recovery.

The panel recommends that appointments with the OTP continue to be scheduled every 1 to 3 months, although many programs prefer that patients in continuing care maintain at least monthly contact. Although many programs curtail this contact after 6 to 12 months, others maintain ongoing contact with patients to assist them in maintaining their medication-free lifestyle. Some patients might not need continuing-care services after tapering, preferring instead a complete break from the OTP. Others might need more extensive continuing care, perhaps including referral to a non-MAT outpatient program that more closely fits their needs.

Transition Between Treatment Phases in MAT

Characteristics of the recommended treatment phases are not immutable, and the criteria for transition between phases are not intended to be rigidly interpreted or enforced. The treatment system should be flexible enough to allow for transition according to a patient's progress and circumstances. The program should modify treatment based on the best interests of patients, rather than infractions of program rules.

Occasional relapses to drug use might not require that a patient return to the acute phase but instead that he or she receive intensified counseling, lose take-home privileges, or receive a dosage adjustment. If a patient is in the medical maintenance phase or the tapering and readjustment phase, a relapse often requires a rapid response and change of phase. In these cases, the patient might be reclassified into the rehabilitative phase. After providing evidence that problems are under control, the patient might be able to return to the supportive-care or medical maintenance phase.

Readmission to the OTP

The consensus panel emphasizes that patients almost always should be encouraged to remain in treatment at some level and that pharmacotherapy should be reinstituted unreservedly for most previously discharged patients if and when relapse occurs or seems likely. Feelings of shame, disappointment, and relapse-related guilt, especially for rehabilitated patients who have close relationships with staff members, should not be allowed to inhibit patients from seeking reentry to treatment. The consensus panel recommends that all patients be informed at entry to the OTP that subsequent reentry is common and can be accomplished more quickly than initial intake because regulations waive documentation of past addiction for returning patients (42 CFR, Part 8 § 12(e)(3)). All obstacles to reentry should be minimized.

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