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Center for Substance Abuse Treatment. Matching Treatment to Patient Needs in Opioid Substitution Therapy. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1995. (Treatment Improvement Protocol (TIP) Series, No. 20.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Matching Treatment to Patient Needs in Opioid Substitution Therapy.

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Chapter 2—Assessing Patient Needs

This chapter begins with an overview of the goals of opioid substitution therapy and discusses the importance of identifying patients' individual needs. Also included is a brief description of several treatment courses available to patients over the course of opioid substitution therapy. Definitions of terms used throughout this Treatment Improvement Protocol (TIP) are presented.

The main focus of this chapter is to describe both an initial assessment, to determine whether a patient is appropriate for admission to an opioid substitution therapy program, and a comprehensive assessment, to identify a patient's individual needs after program entry. Areas included in each assessment are presented, along with procedures to maintain an ongoing assessment of patients' progress in treatment.

Opioid substitution therapy is appropriate for persons with chronic opioid dependence and addiction who have a history of repeated relapse, persons who live in environments that do not support a life-style free of substance use, and those who repeatedly engage in criminal behavior related to their chronic opioid use.

Opioid Substitution Therapy

Treatment Goals and Admission Criteria

The goals of opioid substitution therapy guide the development of a treatment system and form the foundation for the type, intensity, and elements of treatment services necessary to meet patient needs. The major components necessary to meet the goals of substitution therapy include either methadone or levo-alpha-acetyl methadol (LAAM), rehabilitative services, and support services. The primary goals of treatment are highly dependent on the specific population being treated; however, the general goals of opioid substitution therapy are

  • To eliminate objective signs and subjective symptoms of opiate withdrawal
  • To decrease craving for opioids
  • To decrease or eliminate injection drug use
  • To reduce inappropriate nonopioid drug use and dependence
  • To improve health and encourage patient to establish a relationship with a primary care clinician
  • To decrease other human immunodeficiency virus (HIV) high-risk behaviors
  • To decrease or eliminate criminal activity
  • To improve mental health and well-being
  • To increase psychosocial supports
  • To improve psychosocial functioning, including ability to gain or maintain employment.

Opioid substitution therapy is appropriate for persons with chronic opiate dependence (addiction) who have a history of repeated relapse, persons who live in environments that do not support a lifestyle free of substance use, and persons who repeatedly engage in criminal behavior related to their chronic opiate use. Criteria used to determine appropriateness include history of substance use, physical examination results, results of laboratory tests (blood and urine), Food and Drug Administration (FDA) admission criteria, and patient preference. Persons who are considered high-priority candidates for admission include

  • Pregnant opioid-dependent patients
  • Patients at high risk of HIV infection
  • Patients with life-threatening diseases, such as tuberculosis, that are made worse by injection drug use
  • Patients with serious endocarditis and septic arthritis
  • Patients receiving Interferon for hepatitis C.

Many of the basic elements of matching opioid-addicted patients to opioid substitution therapy are presented in FDA guidelines, 21 C.F.R Part 291 § 291.501, § 291.505 (1993), as well as in applicable State regulations. These documents discuss minimal standards for entry into treatment, continuing care, and discharge. The regulations are reprinted in another TIP, State Methadone Treatment Guidelines.

Patient Needs

Matching patients to treatment services is critical to the successful engagement of patients in the treatment process. Not all patients need the same type or intensity of service. People in some population groups have special needs that, if not addressed, become barriers to treatment. For example, women may have gender-related and psychosocial issues such as emotional, physical, and sexual abuse that may make them uncomfortable in male-dominated treatment programs. Further, pregnant or parenting women may have needs for childcare and other services such as transportation that, if not addressed, would interfere with attending treatment. Homeless patients need housing. Patients and their families from certain ethnic and cultural backgrounds may have religious or cultural beliefs about drug and alcohol use that affect their goals and use of treatment.

Matching patients to treatment services is critical to the successful engagement of patients in the treatment process. Not all patients need the same type or intensity of service. Patients from certain ethnic and cultural backgrounds may have religious or cultural beliefs about drug and alcohol use that affect their use of treatment.

Patients with health problems and those who are at risk of exposure to life-threatening illnesses represent another group with special needs. Providing access to a full range of medical care services is critical for successful treatment outcomes. Services should address risk factors for HIV and other sexually transmitted diseases, opportunistic infections, and tuberculosis (TB). Many patients in opioid substitution therapy need assistance to gain access to social and family services. Easily accessible services for patients with physical disabilities, chronic pain, and mental illness are necessary to support successful treatment.

A large percentage of patients who are appropriate for opioid substitution therapy either abuse or are dependent on other substances, such as cocaine, alcohol, and benzodiazepines. Opioid substitution therapy programs must address these treatment needs while focusing on the patient's primary dependence on opiates. (A separate TIP in this series, Screening, Assessment, and Treatment Planning for Patients With Dual Dependency on Opioids and Stimulants, provides guidelines for treating dependence on other substances.) Outpatient and inpatient detoxification programs should allow continued methadone maintenance while patients are being detoxified from other drugs followed by referral back to the methadone program. For patients whose environments do not support their recovery, residential treatment and half-way houses can provide elements of successful treatment.

Many patients in opioid substitution therapy need educational and vocational training. Needs range from those of patients who have not completed a high school level of education and who have varying degrees of literacy and little or no licit work history, to those of patients who are college educated with a history of successful employment. Obtaining or maintaining work is an important component of the treatment process. Whether this means they need help in developing appropriate parenting skills, completing an educational program, or pursuing employment, patients entering opioid substitution therapy need structure in their lives to make the changes necessary for recovery.

It is important to perform an assessment of the patient's educational background and employment history to plan an effective treatment experience. A brief history should be taken at admission, followed by a more comprehensive assessment once the patient is stabilized in a treatment program. Resources vary in opioid substitution programs. Some programs offer vocational counseling within programs, others develop affiliation agreements with agencies that can offer these services. Regardless of the model, identifying vocational and educational needs and matching patients to the appropriate resources are important parts of the rehabilitative and habilitative process.

The Setting and Course of Treatment

Opioid substitution therapy is usually offered in a traditional outpatient model, a narcotic treatment program approved by Federal and State authorities. For the most part, patients with chronic opioid dependence and addiction receive methadone maintenance treatment in this setting. As treatment needs become clearer and the multiplicity of their medical, psychological, social, and behavioral needs becomes evident, a full continuum of care for these patients emerges as an important contributor to a positive outcome.

Some opioid substitution therapy programs are part of a continuum of substance abuse treatment programs that includes therapeutic communities, inpatient detoxification units, day treatment, and outpatient counseling programs. Others may also be part of a mental health center. Programs that are part of a continuum of substance abuse and mental health services may have a centralized intake unit that operates as the central assessment component for all the treatment programs. The central unit places the patient in more than one program according to the patient's multiple needs. For example, if a patient is eligible for opioid substitution therapy and needs the environmental containment of a therapeutic community, placement can meet both of these needs. Similarly, if a patient appropriate for substitution therapy also needs psychiatric care, both services can be accessed. Although the programs that provide such multiple placement are rare, it is important to meet the multiple needs of patients. Regardless of the model, a clear assessment of needs is the beginning of setting the course of treatment for the patient.

Patients who enter opioid substitution therapy may eventually take several different treatment courses. Some may leave methadone treatment through medically supervised withdrawal (detoxification) and then continue in drug-free treatment. Medically supervised withdrawal is accomplished in an inpatient unit or outpatient methadone treatment program, and continued therapy involves outpatient or residential treatment, with or without the use of antagonist (naltrexone) treatment. Patients who do not remain opioid free can typically reenter opioid substitution therapy with the goal of eventually becoming drug free. Some may succeed in this goal, while others will need to remain in substitution therapy.

Some patients substantially reduce their use of opioids and need continued maintenance treatment to maintain this reduction in opioid use. However, they may require the containment and support of a residential treatment environment to address alcohol and nonopioid drug use and dependence. These patients will continue on methadone during inpatient treatment for other drug and alcohol abuse. Upon completion of inpatient treatment, they can return to outpatient treatment to continue methadone treatment.

A challenge remains. As mentioned in Chapter 1, continued methadone maintenance during withdrawal from alcohol or other drugs is not always available within the addiction treatment community. Opioid substitution therapy programs must work with licensing bodies and State agencies to provide education and advocacy for these services. In some cases, treatment programs must review and revise their philosophy and policies to meet the needs of patients.

Others need continued opioid substitution therapy with an emphasis on treatment of comorbid medical and psychiatric problems. Providing opioid substitution therapy in a variety of treatment settings is necessary to meet the needs of these patients. Although some States, programs, and hospitals take a multiple-problem treatment approach, access to these additional services is not universal, and changes in the system are critical for efficacious treatment.

Continued methadone maintenance during withdrawal from alcohol or other drugs is not always available within the addiction treatment community. Opioid substitution therapy programs must work with licensing bodies and State agencies to provide education and advocacy for these services.

Medically Supervised Withdrawal From Methadone

As discussed more fully in Chapter 3, careful consideration must be given to when and how withdrawal from methadone is done and what patients are appropriate for this step. The goal of voluntary withdrawal (or tapering) from methadone should be for the patient to become drug free. A patient who is being voluntarily withdrawn from methadone and who is progressively resuming illicit drug use should be strongly discouraged from completing the withdrawal process.

Age, as well as patient preferences and beliefs about the safety and side effects of methadone treatment, should be considered in decisions to withdraw from methadone. Risk of relapse after detoxification and appropriate followup treatment should also be taken into account. Should withdrawal from methadone or LAAM be accomplished on an inpatient or outpatient basis? How quickly should it occur, and from what dose? Does the patient have other medical or psychiatric needs that would affect this decision? Is the patient pregnant? Is withdrawal voluntary or involuntary? These issues must be considered to match patients to these services. Another TIP in this series, Detoxification From Alcohol and Other Drugs (in development), addresses special issues in medically supervised withdrawal, including tapering, from methadone.

Definitions

The term opiate refers to opium and derivatives of opium, a naturally occurring substance, that have effects similar to those of morphine. Heroin, codeine, and morphine are examples of opiates. The term opioid refers to all substances, both those derived from opium and those synthetically produced, that have effects similar to morphine. Examples of opioids include heroin and codeine, which are natural derivatives of opiates, and Demerol, Percodan, and methadone, which are synthetics. The more inclusive term opioid is used throughout this TIP. Narcotic is the term that was formerly used as a synonym for opiate; it is currently a synonym for opioid. Use of narcotic has been avoided in this TIP in favor of opioid.

Both agonist and antagonist agents have been used for treating opioid addiction. An agonist agent is a drug with properties very similar to those of another drug, usually from the same drug class. Methadone is a narcotic agonist, since it has many effects that are similar to morphine. An antagonist is an agent that blocks or reverses the effects of another drug. Naltrexone is an opioid antagonist because it blocks or reverses the effects of opioids like morphine, methadone, and other drugs with similar properties.

The term opioid refers to all substances, both those derived from opium (opiates) and those synthetically produced, that have effects similar to morphine. The more inclusive term opioid is used throughout this TIP.

Naltrexone is also used to treat opioid-addicted persons, but only with their permission or after they have been detoxified. Giving naltrexone to someone receiving methadone or LAAM who has not been withdrawn will cause a severe opioid withdrawal reaction that could be life threatening for some patients with concurrent medical problems (for example, hypertension and diabetes) since it reverses all opioid agonist effects of the methadone or LAAM and precipitously induces a withdrawal syndrome.

Use, Abuse, and Dependence: Evolution of Concepts and Terms

Three terms are often applied to the self-administration of abusable substances: use, abuse, and dependence. Only the latter two -- abuse and dependence -- are psychiatric disorders that justify treatment. Use in the absence of abuse or dependence is a psychosocial phenomenon that may or may not lead to abuse or dependence. Although use of abusable substances often requires attention, simple use of a substance does not qualify a person for formal treatment. However, use of substances by persons with a history of a substance use disorder may be a sign of a recurrence of the disorder.

The definitions of abuse and dependence have changed over the last 20 years, and as a result, there is often confusion about what is meant by dependence or addiction. The American Psychiatric Association publishes a manual that is widely used to diagnose mental and substance use disorders. In the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), published in 1983, dependence applied to persons with pathological patterns of abuse who also had developed tolerance and withdrawal, while abuse consisted only of a pathological pattern of use. In DSM-III, physiological dependence was the defining feature of dependence.

The World Health Organization also publishes a diagnostic and classification manual of diseases and disorders, the International Classification of Diseases (ICD). In recent years, the World Health Organization and the American Psychiatric Association have made a serious effort to make their criteria, including those for identifying substance use disorders, as similar as possible. One of the problems that arose as a consequence of the emphasis that the DSM-III placed on tolerance and withdrawal was that persons who had become physiologically dependent on a substance through the course of legitimate medical treatment (for example, taking opioids as prescribed for treatment of chronic pain) were classified as drug dependent. Many persons saw this classification as misplaced, primarily because the type of dependence seen in medical and surgical patients is usually different from that of persons who seek out and compulsively use substances for nonmedical reasons.

Additionally, in DSM-III there was significant overlap between the criteria for dependence and abuse. The only clear distinction between these two disorders was the presence or absence of tolerance or withdrawal. Based on the criteria, it was unclear whether abuse was a less severe form of dependence or if it represented a different disorder with a different course and prognosis.

With the revised version of the DSM-III, published in 1987 and referred to as the DSM-III-R, the definition of dependence was significantly changed. This definition reflected changes in views that had already been incorporated in the ICD-9 (ninth edition), published in 1977. The DSM-III-R criteria indicated a shift away from the physiological to the behavioral elements of dependence. Behavioral components indicating compulsive use and loss of control over use were emphasized. In DSM-III-R, tolerance and withdrawal continued to be important features of dependence, but they were not the defining features and were not necessary for making a diagnosis of dependence. Persons could be diagnosed with substance dependence if three or more of the nine criteria could be applied. Only three of the criteria related to tolerance or withdrawal. Abuse was a residual category, defined as a maladaptive pattern of problematic use in which compulsive use, tolerance, and withdrawal were not prominent.

The shift in focus toward behavioral elements of dependence reflected growing recognition of a definable and independent syndrome that could result after an organism learned to self-administer abusable substances. This syndrome was not dependent upon the ability of the substance to produce tolerance and withdrawal, but rather on its positive reinforcing effects. Thus, the DSM-III-R clarified the distinction between prescribed drug use by medical, surgical, or psychiatric patients that is accompanied by tolerance or withdrawal and dependence. It also developed criteria that applied to dependence on cocaine and other substances that do not always cause prominent withdrawal. In doing so, DSM-III-R significantly broadened the definition of dependence and increased the number of persons with this diagnosis.

The most recent version of the manual, DSM-IV (American Psychiatric Association, 1994), continues the emphasis on compulsive use and loss of control as the defining features of dependence (see Exhibit 2-1). The criteria items were modified slightly, and the number of criteria describing dependence was reduced from nine to seven. One of the criteria continues to be tolerance and another withdrawal. Dependence is diagnosed if three or more criteria can be applied to a patient; dependence is subtyped as being with or without physiological features, depending upon whether tolerance, withdrawal, or both are present.

Exhibit 2-1 DSM-IV Diagnostic Criteria for Substance Dependence.

Table

Exhibit 2-1 DSM-IV Diagnostic Criteria for Substance Dependence.

The major change in DSM-IV was in the definition of abuse. Criteria for abuse were clearly separated from those for dependence. This change was accomplished by identifying as abuse only items that signify problematic or hazardous use. Items that signify compulsive use, tolerance, or withdrawal are criteria of dependence.

ICD-10, the latest version, published in 1992, no longer separates drug and alcohol dependence; they are merged into a single dependence syndrome that is applied to all substances. ICD-10 has six criteria for dependence Exhibit 2-2 As in DSM-IV, a person must meet three or more to be diagnosed as dependent. ICD-10 does not have a category called "abuse." Instead, the category of "hazardous use" described in ICD-9 was changed to "harmful use." Harmful use is defined as a pattern of psychoactive substance use that causes damage to health. The damage may be physical (for example, hepatitis resulting from injection drug use) or mental (for example, episodes of depressive disorder secondary to heavy consumption of alcohol).

Exhibit 2-2 ICD-10 Criteria for Substance Use Dependence.

Table

Exhibit 2-2 ICD-10 Criteria for Substance Use Dependence.

In this TIP, the term addiction is frequently used to describe patients with opioid dependence who are appropriate candidates for substitution therapy. Although these individuals generally meet the criteria for opioid dependence as described in DSM-III-R or DSM-IV, the term addiction, rather than dependence, is often used in this TIP because it is commonly used in the field. In DSM-III-R or DSM-IV terms, addiction as used here describes someone who meets three or more of the items for dependence, including criterion item 1 (tolerance) and item 2 (withdrawal). Thus, in DSM-IV terms, someone with addiction is classified as having dependence, with physiological features.

Persons who have developed physiological adaptation to chronic opioid use as a consequence of pain treatment -- even though they exhibit tolerance and withdrawal -- are to be distinguished from opioid-addicted persons as the term is used here, unless they also develop signs and symptoms of compulsive use and loss of control. They typically do not need the structure and drug-focused therapy that are part of an opioid substitution treatment program and should not be confused with persons who have an addiction simply because they share some of the symptoms.

The Preliminary Assessment: Determining Eligibility for Opioid Substitution Therapy

Despite myriad regulations governing opioid substitution therapy, little attention is given to the quality of services and to the clinical judgments that are critical in matching patients to the most appropriate treatment. Matching begins with the preliminary assessment, which may take place in a variety of settings. Common locations are hospital emergency rooms and central intake units; however, the final assessment of eligibility for opioid substitution therapy must be completed by the treatment program staff.

The primary purpose of the preliminary assessment is to determine whether an individual is eligible for entry into opioid substitution therapy and whether such treatment would be appropriate for that person. The preliminary assessment should include five areas:

  • Determining the need for emergency care
  • Diagnosing the presence and severity of opioid dependence
  • Determining the extent of alcohol and other drug (AOD) abuse
  • Screening for medical and psychiatric comorbid conditions
  • Evaluating the individual's living situation, family and social problems, and legal problems.

The Need for Emergency Care

Any patient who has an acute or severe medical problem, who is suicidal or psychotic, or who exhibits other symptoms that jeopardize his or her safety or that of others must be referred immediately for inpatient medical or psychiatric care. Persons doing the initial assessment should rule out such conditions before referral for outpatient substitution therapy.

Presence of Opioid Dependence

Federal guidelines restrict entry into methadone programs to individuals who have been dependent on opioids for the better part of the year prior to application for admission and who manifest symptoms of physical dependence on opioids. Pregnant women who are opiate dependent and persons released from an institutional environment who are on the verge of relapse are exempted from the rule regarding 1-year duration of opioid dependence (see details in FDA regulations reprinted in the TIP State Methadone Treatment Guidelines). Criteria for diagnosing psychoactive substance dependence, such as those set forth in the DSM-IV or the ICD-10, should be used to assess the presence of opioid dependence. It should be noted that, although such criteria are useful, Federal regulations do not specify a DSM-IV or ICD-10 diagnosis of opioid dependence for admission to opioid substitution therapy, although such a diagnosis is required de facto, according to the way the regulations are written.

When applying criteria during the preliminary assessment of a person who uses opioids, the clinician must give special attention to several areas. Individuals who use opioids only occasionally, who can control their use, and who are not physically dependent are not appropriate candidates for opioid substitution therapy unless they meet the special conditions defined below (Zinberg and Harding, 1982; Zinberg et al., 1981). Given the wide variations in patterns of heroin and other opioid use, it is helpful to begin the preliminary assessment by reviewing these broad distinctions.

To determine whether a prospective patient meets Federal requirements, one must secure a complete history of the patient's drug use, focusing on the length of time that opioids have been used, the quantity and type of drugs used, the route of administration, and physical signs and symptoms of dependence. Application of diagnostic criteria will elicit information on intensity, duration, and pattern of use that is needed to establish the presence of dependence. Pattern of use is especially important because it is a subtler and potentially more revealing indicator of problems than duration or intensity of use alone. Determination of opioid dependence is discussed in more detail in the section in this chapter on The Medical Assessment.

If the patient's reported drug history and physical examination are inadequate to substantiate a diagnosis of chronic opioid dependence, it may be necessary to gather data from outpatient observation, with a more extended assessment, or from material submitted by other medical and healthcare professionals, family members, a legal guardian, or a significant other.

A patient may insist he or she is addicted, but the clinician may remain uncertain. In these cases, it is appropriate to administer a naloxone (Narcan) challenge test. The patient is administered slowly .4 or .8 mg of naloxone intramuscularly or intravenously. If physical dependence on opioids is present, the patient will develop opioid withdrawal symptoms within 30 to 60 seconds if naloxone is given intravenously, or within 2 to 5 minutes if it is given intramuscularly. If withdrawal does not occur, the person is not physically dependent and probably does not qualify for opioid substitution therapy. If the naloxone test is positive, withdrawal symptoms can be marked; however, since naloxone is a short-acting drug, they disappear within 30 to 60 minutes. The Narcan challenge is inappropriate for certain individuals; it should not be used with pregnant women or who persons who have heart disease.

Adolescents

The majority of adolescents drink alcohol, but the use of marijuana, cocaine, and crack, as well as tranquilizers and sedatives, is also prevalent and varies with geographic location. Opiate use is less common. In a 1983 national survey, only 6 percent of senior high school students reported ever using opioids; opioid use, when it occurs, usually comes later in the use progression (Johnson et al., 1984). For the most part, adolescents who come to treatment programs are heavily involved in substance use and may use alcohol or drugs daily. They tend to have started drug use at an early age, have endured many negative experiences within a brief span of time, and have problems functioning at home and in school.

Although assessment is similar in many ways for adolescents and adults, an adolescent's age, psychosocial development, environment, and family supports are critical factors in assessing opioid dependence.

Adolescence marks a time of great physical, social, cognitive, psychological, and emotional changes. Struggling to cope with these changes can stir up feelings of powerlessness, alienation, and rebellion. Adolescents often assess their emotions and behaviors by the reaction of their peers and are highly vulnerable to the influence of their peer group. Therefore, experimentation and recreational use of drugs are common, often associated with pleasure and euphoria, and not perceived as bad or dangerous (Dusenbury et al., 1992).

Although assessment is similar in many ways for adolescents and adults, an adolescent's age, psychosocial development, environment, and family supports are critical factors in assessing opioid dependence. (Another TIP in this series, Screening and Assessment of Alcohol- and Other Drug-Abusing Adolescents, addresses issues unique to adolescents.) Most adolescents who use opioids sniff or snort heroin; few inject. Some have access to opioids from physicians for treatment of menstrual pain or migraine headaches. These issues should all be considered in the assessment process.

A range and variety of drug treatment programs are available for adolescents. Opioid substitution therapy may be considered for adolescents, but admission depends on the patient's having tried and failed two prior treatment interventions before he or she is eligible for admission. Most methadone treatment programs do not accept patients unless they are over 18 years old, but admission is possible for patients under 18 with parental consent. When exploring the option of opioid substitution therapy for an adolescent, careful consideration should be given to referral to programs that specialize in the treatment of heroin addiction in this age group. The Adolescent Development Program in New York City has developed such a program, which could serve as a model for others (Millman et al., 1978).

Extent of AOD Use

From 30 to 70 percent of opioid-dependent patients use other drugs. The most common AOD use disorders among opioid users involve cocaine, benzodiazepines, and alcohol. A recent study estimated that up to 75 percent of persons being treated in methadone programs might be abusing cocaine (Avants et al., 1994). Nicotine dependence is also extremely prevalent. Marijuana use is common, and some patients seek treatment for marijuana abuse or dependence. Abuse of alcohol and drugs other than opioids creates major life problems among patients in methadone treatment. A urine toxicological screening test is very helpful in documenting current opioid use and identifying other substances being used. It is critical to note that, unlike withdrawal from opioids, withdrawal from alcohol and sedatives can be life threatening.

The most common AOD use disorders among opioid users involve cocaine, benzodiazepines, and alcohol. A recent study estimated that up to 75 percent of persons being treated in methadone programs might be abusing cocaine.

Results of urine, breath, or blood tests are only one consideration for determining appropriateness for opioid substitution therapy. No patient should automatically be excluded from substitution therapy because he or she has a positive test for (or uses) other drugs. One essential purpose of the preliminary assessment is to identify individuals whose AOD use is so out of control that they are physically dependent. Another purpose is to determine if they need detoxification from other drugs or other inpatient treatments before opioid substitution therapy may begin. For example, a patient who uses benzodiazepines but is otherwise stable may enter opioid substitution therapy immediately. However, an individual whose use of benzodiazepines cannot be controlled may have to be detoxified from benzodiazepines before admission to an opioid substitution therapy program. Hospitalization may not be available in some cases, and it should not be required for entry into an opioid substitution therapy program. For programs with adequate medical staff, medically supervised outpatient detoxification from benzodiazepines is an option.

Comorbid Conditions

Medical Conditions

A number of comorbid medical conditions are relatively common among opioid users. They include cellulitis, tuberculosis (TB), HIV infection, hepatitis (A, B, C, and D), cirrhosis, and syphilis and other sexually transmitted diseases (STDs). In some communities, more than 50 percent of injection drug users are HIV infected. TB is a growing problem among substance abusers, and almost half of the patients in some treatment programs have positive tuberculin skin tests. HIV-infected opioid addicts who become infected with TB are significant contributors to the increasing prevalence of TB and to the emergence of antibiotic-resistant strains of the tubercle bacillus.

Many programs report that 90 percent or more of their patients test positive for infection with the hepatitis C virus. This problem is only recently becoming well documented and is extremely serious because mortality rates can be as high as 20 percent over the long-term course of the disease. Hepatitis C infection probably explains the mild to moderate elevations in liver function tests that are commonly observed among opioid addicts. Identification of this viral infection is important from a treatment standpoint because Interferon has been shown to be effective in suppressing the progress of hepatitis C infection in 20 percent of cases.

Other common medical conditions among opioid addicts are related to the effects of a chaotic lifestyle or the use of other abused substances. These conditions include nutritional deficiencies and anemia caused by poor eating habits, chronic obstructive pulmonary disease secondary to cigarette smoking, and cirrhosis, neuropathies, or cardiomyopathy secondary to alcohol dependence. In addition, opioid addicts have the same chronic diseases that are seen in the general population. Especially significant are diabetes and hypertension, which are among several chronic conditions that require treatment throughout all AOD treatment phases. Other conditions, such as cellulitis, are acute and require much shorter periods of treatment, or they resolve without intervention.

In some communities, more than 50 percent of injection drug users are HIV infected. TB is a growing problem among substance abusers, and almost half of the patients in some treatment programs have positive tuberculin skin tests.

At a minimum, the initial medical evaluation should determine the presence of physical dependence and inquire about a history of AIDS or HIV infection, cirrhosis, hepatitis, and TB. Women of childbearing age should be questioned about the possibility of pregnancy.

Psychiatric Conditions

Most psychiatric conditions found in the general population are also found among persons dependent on opioids. Compared with the general population, opioid-dependent persons are more likely to have other substance use disorders; depressive disorders; Post Traumatic Stress Disorder (PTSD); substance- induced psychotic, mood, and anxiety disorders; and antisocial personality disorder. Mood disorders (major depression and dysthymia), anxiety disorders, and antisocial personality disorder are the conditions most commonly encountered. This pattern of comorbidity has been reported in numerous studies (O'Brien et al., 1984; Rounsaville et al., 1982b). Another TIP in this series, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse, describes many commonly occurring mental disorders and provides guidelines for treating dually diagnosed patients.

Comorbid psychiatric disorders should not exclude a patient from admission to opioid substitution therapy, but identification of the presence of a disorder and a current diagnosis are critical to matching the patient to appropriate services for successful treatment. A preliminary assessment should include a mental status examination and a drug history. The results of the initial examination can determine whether further assessment and additional services are needed. For example, if a patient reports a history of suicide attempts or presents vegetative signs of depression, including helplessness, hopelessness, and thoughts about suicide, then hospitalization for protection and containment or prescription of antidepressant medication may be indicated. Further, if a patient presents with manic symptoms, it should be determined whether the symptoms are substance induced or whether the etiology is an undiagnosed primary mood disorder. In either case, lack of attention to these presentations may result in the patient's receiving ineffective or inappropriate treatment, or even in the patient's doing harm to him- or herself or to others.

Polydrug use and psychiatric problems are both associated with negative treatment outcomes unless they are identified and treated. Most substances of abuse produce moderate to severe psychiatric symptoms, and in most patients there is a complex association between substance use and psychiatric status. Therefore, assessment is critical to determining whether such symptoms represent primary psychiatric disorders or substance-induced conditions, since the former do not dissipate with abstinence and require longer-term treatment. Program staff often focus on the condition that is most severe and threatening; however, it is usually important to simultaneously address the other disorder since each problem can exert a negative influence on the other.

Attention deficit-hyperactivity disorder (ADHD), although not as common as other psychiatric disorders, can be found in this population. In patients with this disorder, stimulants may have an adaptive effect, especially if taken consistently and in low doses. Use of cocaine by such patients may be an attempt to control symptoms of ADHD. Adult ADHD is difficult to diagnose. Patients with ADHD can usually be identified by taking a careful history, performing a mental status examination, and administering neuropsychological tests. Such tests are not typically carried out by treatment programs; rather, patients are referred for testing to outside clinical psychologists or psychiatrists.

If ADHD exists and is severe, treatment with stimulant drugs such as methylphenidate (Ritalin) or pemoline should be considered since treatment may improve the ADHD as well as address the cocaine or other stimulant use disorder. However, Ritalin use should be carefully monitored, since some patients will abuse the drug by injecting it, and medical complications can result from such long-term injection use.

Housing, Family, and Social Problems

Substance abuse and alcoholism are found in 30 to 40 percent of the homeless population; severe mental illness affects about 30 percent. Heroin, cocaine, and crack use are major causes of homelessness for 10 to 20 percent of the homeless population nationwide. The incidence of AIDS among the homeless is significantly higher than in the general population (Wright, 1990). Health conditions such as vascular disease, trauma, hypertension, poor dental health, gastrointestinal disorders, liver disease, neurological and seizure disorders, arthritis, tuberculosis, and syphilis are also more prevalent. In addition, homeless patients are usually undereducated and in need of vocational assessments and services (Joseph, 1992).

Many patients entering opioid substitution therapy programs are homeless. Addressing their needs at the time of admission is a high priority. If these needs are not addressed, such patients are unlikely to engage successfully in treatment. Patients living with other addicted individuals or in buildings or neighborhoods where the use of drugs is commonplace require special support services or help to secure more appropriate living arrangements. Programs should screen for these problems and must establish referral relationships with housing agencies or other programs that address the special needs of the homeless.

Many patients entering opioid substitution therapy programs are homeless. Addressing their needs for housing at the time of admission is a high priority. If these needs are not addressed, such patients are unlikely to engage successfully in treatment.

Family conflict secondary to drug abuse and to many other problems should be expected for all patients entering treatment. The preliminary assessment should include questions about family relationships and problems (including domestic violence); whenever possible, relatives and sexual partners should be included in the assessment process. Program staff must also be sensitive to special issues related to atypical family arrangements. For example, programs with significant numbers of single parents should consider establishing childcare programs onsite to facilitate treatment participation by the parents. Because family problems are so common, every opioid substitution therapy program should have at least one staff member skilled in family evaluation and family therapy.

Review of Treatment Options

Once the initial assessment has been completed in the areas indicated above, treatment options should be developed and reviewed with the patient. In most cases, these options include

  • Opioid substitution therapy
  • Therapeutic community
  • Inpatient or outpatient detoxification programs
  • Inpatient or outpatient psychiatric treatment
  • Rehabilitative day hospital treatment
  • Outpatient drug-free counseling programs, often with the use of naltrexone
  • Acupuncture (see Chapter 4).

The interviewer should begin by familiarizing the patient with the range of treatment possibilities. The ensuing negotiations should focus on five questions:

  • What is the most appropriate option?
  • What is realistic?
  • What is available?
  • What does the patient want?
  • What will the patient accept?

Responses to each of these questions will narrow the range of options. If, for example, a female candidate for treatment is pregnant, a program that offers comprehensive resources for pregnant and postpartum women should be recommended. Other factors that should be incorporated into decisionmaking include the patient's living arrangements, family and peer support systems, sexual orientation, and employment and legal history.

As stated earlier, treatment modalities may be combined. For some patients, residential treatment or day treatment and opioid substitution therapy may be appropriate if available. A patient addicted to opioids and alcohol, benzodiazepines, or cocaine may need inpatient detoxification from these substances in a facility that can initiate or maintain opioid substitution therapy prior to discharge to an opioid substitution therapy program. Some patients may elect to combine substitution therapy with acupuncture.

Selecting an Option

For many patients with chronic opioid dependence, the best options are admission to outpatient substitution therapy or entry into a therapeutic community. A small proportion of voluntary admissions will elect to use naltrexone; court-mandated patients tend to choose naltrexone more frequently than other patients (Brahen et al., 1984; Cornish et al., 1993).

Despite 25 years of demonstrated success using methadone for the treatment of chronic opioid dependence, some treatment providers still question its efficacy. For example, services sometimes mandate withdrawal from methadone as a condition of admission. Some residential programs allow methadone-maintained patients to enter treatment on the condition that they become methadone free within 6 months. For many patients, this condition represents an unfair and unjust pressure that can sabotage long-term treatment outcomes.

When considering treatment options for this patient population, creativity is important. Although patients should be encouraged to detoxify when they are stable and motivated, it must be recognized that some patients will need to remain in substitution therapy for an extended period. Programs that require withdrawal from methadone should be avoided whenever possible; however, gaining access to programs that provide environmental support, or additional detoxification services with continued methadone treatment, is not always possible. Opioid substitution therapy programs can offer treatment alternatives for patients who need containment and methadone treatment when both are not available. For example, the program can develop a contract with the patient stipulating that the patient has the option of returning to the program after completing residential or inpatient treatment. This option may help the patient access the services needed without feeling abandoned by the methadone treatment program.

Final Determination of Eligibility for Opioid Substibution Therapy

The Medical Assessment

The purpose of the medical evaluation is to gain more information about impressions revealed by the initial assessment and to determine the existence of objective evidence of opioid dependence, as reflected by signs and symptoms of opioid tolerance and withdrawal and other signs of chronic opioid use, such as needle marks.

When considering treatment options for this patient population, services that mandate detoxification as a condition of admission should be avoided. For example, some residential treatment programs allow methadone-maintained patients to enter treatment on the condition that they become methadone free within 6 months. For many patients, this condition represents an unfair and unjust pressure that can sabotage treatment response.

The Dimensional Admission Criteria for Acute Intoxication and/or Withdrawal that are contained in the Massachusetts Criteria: Admission, Continuing Care, and Discharge, developed by the Massachusetts Methadone Treatment Providers Association and the Massachusetts Department of Public Health, are recommended for guidance during the medical evaluation (Massachusetts Department of Public Health, 1992) (see Appendix B). These criteria, which pertain exclusively to methadone treatment, are based on the generic placement criteria defined in Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders developed by the American Society of Addiction Medicine (1991).

As described in more detail in an earlier TIP State Methadone Treatment Guidelines, one key element is the physician's determination that the patient is "currently physiologically dependent on an opioid drug and became physiologically dependent at least 1 year before admission for comprehensive maintenance treatment." A 1-year history of addiction, the regulations note, means that an applicant was "physiologically addicted to a narcotic at a time at least 1 year before admission to a program and was addicted, continuously or episodically, for most of the year immediately before admission to a program," FDA, March 2, 1989; updated in 21 C.F.R. Part 291 § 291.505 at 129 (1993).

Criteria to determine the patient's current physiological dependence and history of addiction include but are not limited to vital signs, early physical signs of opioid withdrawal, a positive urine screen for opioids, presence of old or fresh needle marks, documented medical or AOD treatment history, patient and family reports, medical records, and so forth (see Appendix B).

Exceptions may be made for the following three groups of patients:

  • Pregnant women with a documented history of opioid dependence, current use, or imminent relapse.
  • Persons who have resided in a penal institution or chronic care facility for 1 month or longer and
    • Have been admitted to methadone treatment within 14 days prior to release or discharge or within 6 months of release or discharge without documented evidence of physiological dependence
    • Would have been eligible for admission before their incarceration or institutionalization
    • Are, in the clinician's judgment, about to relapse.
  • Persons who have completed voluntary detoxification from methadone maintenance within the last 2 years and have relapsed or are at high risk of relapsing.

Another important element is the ability to provide or obtain a comprehensive medical history, medical evaluation, and laboratory tests. Laboratory tests must include routine blood work and a serological test for syphilis and hepatitis, a tuberculin skin test, and a test for determining recent use of drugs. The program must ensure that HIV counseling and testing are available to patients upon request. The physical examination must include an investigation of the organ systems, determination of vital signs, and an assessment of the patient's overall health status, FDA, March 2, 1989, and updated in 21 C.F.R. Part 291 § 291.505 at 132 (1993).

Clinical Decisionmaking

Although all patients admitted to opioid substitution therapy must fulfill the criteria set forth in Federal regulations, individual States and third-party payers such as managed care systems may also impose additional admission criteria. It is ultimately the responsibility of the program physician to decide whether to recommend an individual for admission to treatment; thus, clinical judgment is vital to initiating substitution therapy.

Certain patients are not good candidates for opioid substitution therapy, including

  • Individuals who have abused opioids episodically but who are not dependent
  • Individuals with acute opioid dependence (for less than 1 year) with no prior treatment history
  • Chronic opioid-dependent individuals who do not want opioid substitution therapy
  • Patients living in areas where opioid substitution therapy is unavailable or not easily accessible.

Inclusion, rather than exclusion, should be a guiding principle of clinical decisionmaking. Few psychiatric or medical diagnoses automatically rule out the possibility of admission. Cross-addiction, as noted above, should not eliminate a person from consideration for opioid substitution therapy; however, it might delay admission if the patient requires inpatient detoxification from alcohol, benzodiazepines, or other sedatives, or a period of stabilization to control cocaine use. An inclusionary admission policy generally requires greater resource availability and program flexibility. Many parenting women, for example, will be able to enter treatment only if day care is available for young children. Many persons with chronic psychiatric problems can be effectively treated in opioid substitution therapy programs if psychiatric consultation is available.

Admission to Substitution Therapy

Admission to treatment marks the beginning of a collaborative relationship between the patient and the clinical team. It may in some cases signal a crisis in the patient's life that, if appropriately managed, will become an opportunity for positive change. Initial impressions strongly influence the patient's motivation and future treatment course. While many agencies or clinics may eventually share responsibility for meeting the multiple needs of the patient, the treatment program holds primary responsibility for developing and monitoring the treatment plan and coordinating ancillary services.

Patients who are not good candidates for opioid substitution therapy include individuals who have abused opioids episodically but who are not dependent, have acute opioid dependence (for less than 1 year) with no prior treatment history, are chronically opioid dependent but do not want opioid substitution therapy, or live where opioid substitution therapy is unavailable or not easily accessible.

The therapeutic relationship should begin with a discussion of the preliminary or initial treatment plan, which is based on the findings of the screening assessment and a review of program rules. The preliminary treatment plan should set forth short- and long-term goals. Methods of measuring patient progress also should be explained. The program rules should cover policies pertaining to patient rights and protection of confidentiality. Protocols governing disciplinary proceedings should be explained, and circumstances under which a patient may be placed on probationary status or involuntarily discharged from treatment should be defined. The counselor must be confident that the patient understands the goals and rationale for the treatment plan and program rules. A written statement of program rules and treatment expectations should be given to every patient.

Before being formally accepted into the treatment program, the patient should sign the "Consent to Treatment With An Approved Narcotic Drug" (Form FDA 2635 [7/93]), the program rules, and the preliminary treatment plan.

Matching Patient Needs for An Array of Services: The Comprehensive Assessment

As described further in Chapter 3, the first 4 to 6 weeks in opioid substitution therapy are a critical period for patient and counselor. This is an excellent opportunity to observe the patient and to develop a comprehensive treatment plan. Original treatment goals may change after the patient can be observed when he or she is no longer intoxicated or experiencing withdrawal. Although assessment is ongoing throughout the course of treatment, it is especially important during the initial weeks.

Among the most important decisions made during this period is the selection of an appropriate methadone dosage, which is described more fully in Chapter 4 and in a previous TIP in this series, State Methadone Treatment Guidelines. Adequate dosages have been shown to be a primary determinant of retention in treatment. The methadone dosage, like that of all prescribed drugs, should be individualized and based primarily on the patient's response to the medication. Although the reliability of measuring blood levels of methadone as a means of determining adequate dosage is controversial, such tests may be helpful in identifying patients who metabolize methadone rapidly (a peak level within normal limits, 400 nanogram/mililiter [ng/ml], and a trough level of less than 150 ng/ml). Methadone's effectiveness is dose dependent, and higher doses generally are more effective than lower doses.

After the patient is formally admitted to the opioid substitution therapy program, a comprehensive assessment should be conducted. Specific instruments should be used to collect quantitative data about the patient's problems and range of needs. A primary evaluation instrument and, in some cases, selected secondary instruments, are used. The assessment, which may take place over several sessions, should also include a detailed interview about the patient's treatment history, as well as his or her expectations about treatment and motivation to participate. The information gathered during the comprehensive assessment process can be used to refine the preliminary treatment plan, to set more individualized treatment goals, and to establish a baseline of functioning that can be used to measure progress. Assessment is essential to appropriately match patients to type and level of care.

The methadone dosage, like that of all prescribed drugs, should be individualized and based primarily on the patient's response to the medication. Although the reliability of measuring blood levels of methadone as a means of determining adequate dosage is controversial, such tests may be helpful in identifying patients who metabolize methadone rapidly.

The Primary Assessment Instrument

Patient status should be assessed with a comprehensive and reliable instrument. The National Institute on Drug Abuse has published a useful resource book -- the Diagnostic Source Book on Drug Abuse Research and Treatment -- to assist substance abuse treatment personnel in choosing appropriate instruments. The book describes and evaluates a variety of tools for assessing patients' needs in many areas.

The Addiction Severity Index (ASI) (McLellan et al., 1980; 1990) or the Intake Form developed under the Drug Abuse Treatment for AIDS-Risk Reduction (DATAR) Project at Texas Christian University (Rounsaville et al., 1993; Simpson, 1992) are among the comprehensive instruments used 1 .

A valid assessment tool must contain quantifiable indicators used to measure progress in specific domains and to track the patient through treatment. The instrument also should be useful to program managers who wish to assess program effectiveness.

The ASI assesses seven domains: drug use, alcohol use, medical needs, psychiatric needs, family and social support systems, legal needs, and vocational needs. Patients are asked specific questions within each domain, and scores indicating the need for treatment or intervention are then formulated. Persons administering the ASI must receive training in its use; refresher training and reevaluation must be conducted periodically.

Principal areas included in the DATAR Intake Form are sociodemographic background, family background, peer relations, criminal history, health and psychological status, drug history, and acquired immunodeficiency syndrome (AIDS) risk. The form provides a comprehensive assessment of these areas but does not include standardized scoring procedures or clinical norms.

The area of AIDS risk, which is not separately covered in the ASI, is an essential part of the assessment. Questions about needle use and sexual practices that increase the risk of HIV infection, as well as questions about domestic violence and sexual abuse history, must be asked of all candidates for opioid substitution therapy.

The panel recommends that whatever assessment tools are used cover at least the following areas

  • Drug use (injection and noninjection)
  • Alcohol use
  • Medical history and status
  • HIV serostatus or risk
  • Psychiatric history and mental status
  • Family relations and supports
  • History of domestic violence and sexual abuse
  • Community and peer relations and supports
  • Housing status
  • Criminal history and legal status
  • Educational history
  • Employment history and status
  • Military or other service history.

An assessment of the patient's treatment history, a cultural assessment, and a determination of the patient's expectations and motivation are also key elements of the biopsychosocial assessment and are described in this chapter.

When selecting an assessment tool, program staff should be reminded of the difficulty in developing a reliable and comprehensive assessment instrument. Existing instruments should be used or tailored, when necessary, to a specific population or program.

Secondary Assessment Instruments

The initial assessment often reveals the need for a more focused evaluation in one or more domains. Clinical staff should be familiar with diagnostic instruments available in each of the assessment areas. They may then select the instrument(s) that best meet the patient's needs. The Diagnostic Source Book on Drug Abuse Research and Treatment (Rounsaville et al., 1993) also contains descriptions of recommended secondary instruments or measures to use in six areas:

  1. Demographic characteristics, employment history, and legal history
  2. Alcohol and drug use history
  3. Medical history and medical consequences of AOD abuse
  4. Psychiatric diagnosis
  5. Family functioning
  6. Social adjustment and social supports.

Need for Quantitative Data

Assessment data traditionally have been recorded in narrative form. While use of clinical treatment notes will undoubtedly continue, program staff should ensure that data also are recorded in quantitative form. Collecting data on specific dimensions can provide valuable information about a program's patient population and can assist clinicians in matching patient needs to program services. For example, collecting data about patient health status on admission and at specific intervals throughout treatment can provide valuable information to the program about the health status of the patients served and their progress or changing needs throughout treatment.

Quantitative data can assist clinicians in program planning, advocating for funds, and developing relationships with affiliated agencies. Monitoring program operations and treatment outcomes is increasingly important in an era of scarce resources and managed care. (The TIP Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment provides guidelines for gathering useful data.)

Evaluation of Earlier Treatment Experiences

The patient's treatment history is a useful indicator of future treatment needs. For this reason, the clinician should solicit as much information as possible concerning this subject. To supplement the patient's self-reports, summaries and records should be requested from programs in which the patient previously has been enrolled. This information will give the clinical team an understanding of approaches that have and have not worked well for the patient.

Of particular importance is information about psychiatric symptomatology during periods of abstinence, which may help the clinician differentiate symptoms induced by drugs from primary psychopathology. An exploration of past periods of abstinence also may reveal important clues to effective management approaches. An awareness of the patient's response to mandatory abstinence (for example, during periods of incarceration) may provide valuable insight into character structure and coping skills.

Physical and Sexual Abuse

Some information important in treatment planning is not easily accessible using a specific assessment tool. For example, some patients may have significant histories of physical and sexual abuse, which they may deny during the interview process or in responding to a question on an assessment tool. Gathering this kind of information is a delicate process, and extreme care must be taken when pursuing this line of questioning. For example, a battered woman may deny being abused even when questioned about a visible injury. The patient may not be ready to address the problem, or may be concerned that revealing this information will put her at further risk.

Creating a safe atmosphere is important, and respecting the patient's hesitancy to reveal information is critical. An important initial step is for the clinician to let the patient know that he or she is aware that a problem might exist and that the clinician is available to discuss it. As the therapeutic relationship develops, the patient may be more willing to reveal and discuss abuse issues. Making resources such as shelters and support groups available to the patient is also helpful.

Cultural Assessment

A key part of a biopsychosocial assessment is a cultural assessment, that looks at cultural values and assumptions of various populations. For example, some Native Americans, Asian Americans, and new immigrants have strong traditional and religious ties. Other members of these groups may have been assimilated into the "mainstream" American culture. Knowledge of how different cultural groups define a family unit or work through problems is important to providing services to multicultural and ethnic groups. For example, a desire to confine knowledge about problems just to family members may be part of a patient's culture and may result in resistance to counseling or family therapy, even when obvious personal or family problems are contributing to AOD use. Some patients who will not confide in treatment providers may, however, seek counseling from someone at their church. Cultural and ethnic considerations should inform the design of programs and individual patient treatment plans.

Gathering information about domestic violence and sexual abuse is a delicate process, and extreme care must be taken when pursuing this line of questioning. Creating a safe atmosphere is important, and respecting the patient's hesitancy to reveal information is critical.

Limited knowledge of the cultural context of substance use disorders has resulted in treatment approaches that sometimes seem irrelevant or conflictive to specific populations. It is important to understand that how a minority cultural group views illness and treatment may have an influence on group members' entering treatment and using services. For example, an awareness that one is addicted may be unacceptable to some Asian patients. Asian Americans may enter treatment late because personal loss of control runs against the norm of many Asian cultures. Many ethnic healing traditions are focused on brief, magical cures with consultation from many healers. Such a belief system may make it difficult for some individuals to accept the long-term focus of opioid substitution therapy.

A Hispanic-American patient may view compulsory urine testing as indicative of the program's mistrust of the patient's word; testing may offend his or her sense of dignity, a highly relevant and strongly defended principle among many members of this ethnic group. The prospect of long-term substitution is seen as a modern form of "slavery" by some African Americans. Some Puerto Rican patients who have been forced to assimilate into the Anglo culture suffer from an identity crisis. They often feel that their culture is devalued, that they have been fragmented from their extended family networks and polarized between generations. These issues, along with language barriers, should be considered in the assessment and treatment planning process (Ruiz et al.).

A shared staff-patient cultural identity is more attractive to some patients entering treatment. To the extent possible, staffing should reflect the population being served by the program. Use of bilingual educational materials and display of materials in the program waiting room can be helpful in making patients feel comfortable when English is not the primary language.

Determination of Patient Expectations and Motivation

Because effective matching must take into account patient preferences, the clinician should carefully explore the patient's wishes and expectations from opioid substitution therapy. During this process, the patient should be treated with dignity and respect. Clinician-patient interchanges should take the form of negotiations between two parties working toward a mutual goal.

Limited knowledge of the cultural context of substance use disorders has resulted in treatment approaches that seem irrelevant or conflictive to specific populations. It is important to understand that how a minority cultural group views illness and treatment may have an impact on group members' entering treatment and using services.

The role of patient motivation, readiness, and suitability for treatment cannot be overemphasized. Poor motivation has been found to be a predictor of early dropout from AOD abuse treatment (De Leon and Jainchill, 1986; Simpson and Joe, 1993). Clinicians should be able to assess the patient's motivation and readiness for change (De Leon and Jainchill, 1986); mastery of the techniques of motivational interviewing is an invaluable clinical skill (Miller and Rollnick, 1991).

The Process of Change

The clinical team can benefit from an understanding of the stages of change and their impact on patient progress. Building on the work of Cashdan (1973), and Egan (1975), and Horn and Waingrow (1966), Prochaska and colleagues (1982; 1986; 1992) formulated a model that explained how people change. Applying their model to the treatment of addictive behavior, these authors proposed five stages of change:

  • Precontemplation
  • Contemplation
  • Preparation
  • Action
  • Maintenance.

Change begins as a cognitive process and moves incrementally toward the behavioral domain. Movement through these changes is similar to the process of recovery; a period of progress may be followed by a retrenchment. Just as a majority of patients will relapse one or more times before recovery from AOD dependence, most patients will return to a previous stage before moving definitively to the next stage.

A treatment intervention may be appropriate or inappropriate, depending on the patient's position on the change continuum. Interventions that are appropriate to the patient's current stage of change enhance the possibility of positive treatment outcomes; in other words, one must do the right thing at the right time. Patients in the contemplative stage of change, for example, are usually ambivalent about stopping AOD use; consequently, a nondirective, client-centered technique designed to help the patient resolve such ambivalence may be helpful. A patient in the active stage of change, by contrast, is generally amenable to a directive intervention that may include recommendations for specific therapeutic activities.

Finally, assessment of motivation requires that the clinician know when to encourage the patient and when to realize that limits have been reached. While movement toward recovery remains the foremost goal, the clinician also must realize that progress must come at a pace with which the patient is comfortable.

Patient Matching: Two Examples

Once needs have been assessed and internal and referral resources identified, the second step in the patient matching process -- identifying needed health, mental health, and ancillary services -- can begin. The following examples, one using the Addiction Severity Index for assessment of psychological status and one using the Massachusetts Methadone Treatment Criteria (Appendix B), illustrate how specific tools can assist in problem identification, treatment planning, and the matching process.

Example 1: Mr. G

Mr. G, who is 38 years old, is applying for admission to a methadone maintenance program. He reports that he has experienced hopelessness and loss of interest in everything. He spends most of the day in bed except for buying and using heroin to prevent withdrawal. He recently lost his job because of poor attendance. He reports that since his early teens he has experienced pervasive anxiety, periods of depression, and trouble concentrating. These conditions predate his drug use. In fact, he believes that drugs have helped him feel less anxious and more focused so he can work. However, he reports that drugs no longer have this effect. He has made two serious suicide attempts (a deliberate overdose and crashing his car into a tree). He has transient thoughts of suicide now but no specific plan. He has used antidepressants in the past, but had to discontinue use because he couldn't afford the medication.

The ASI (or a comparable assessment tool) is administered upon admission to assess, among other indicators, Mr. G's psychological status. He scores higher than 5 on the psychiatric scale. Identifying specific indicators for depression is an important part of this patient's initial assessment. The counselor could further investigate Mr. G's psychiatric complaints and should refer the patient for a more comprehensive psychiatric evaluation. If the evaluation reveals a specific condition, such as major depression, Mr. G should be referred to a psychiatrist, who can determine whether antidepressant medication, psychotherapy, or a combination of these treatments is appropriate. Identification and treatment of the patient's comorbid condition could be a critical factor in retaining Mr. G in the opioid substitution therapy program.

Assessment of motivation requires that the clinician know when to encourage the patient and when to realize that limits have been reached. While movement toward recovery remains the foremost goal, the clinician also must realize that progress must come at a pace with which the patient is comfortable.

Example 2: Ms. J

Ms. J is a 45-year-old divorced mother of two (a 10-year-old son and a 5-year-old daughter), who has been in methadone maintenance treatment for 10 months. Her children are currently living with a relative. Ms. J is receiving 85 mg of methadone and has stopped using heroin. In the last 2 months, her urine test results have been positive for cocaine, and she reports that her current partner deals and uses cocaine. Upon admission, her liver function tests are elevated and she tests positive for hepatitis B and C. Although she had not shared needles in the last 18 months, she has done so with her partner a few times in recent weeks. She has not been HIV tested because she is afraid to learn her status.

Ms. J attends counseling on a regular basis but is hesitant to attend community support groups such as Narcotics Anonymous. She recognizes the severity of her opioid addiction and minimizes her cocaine use. She has learned to recognize some of her relapse triggers, but she does not have sufficient coping skills to interrupt cravings or impulsive use at this time.

According to the Massachusetts Methadone Treatment Criteria, Ms. J demonstrates the need for continued care in all of the outlined dimensions for methadone maintenance. For example, she needs ongoing medical monitoring for her hepatitis and medical problems, while demonstrating her ability to make use of the treatment environment. She has biomedical complications, specifically for her liver problems and hepatitis, and is at risk of HIV infection. Her episodic use of cocaine is also a problem. Once her biomedical needs have been identified, Ms. J should be referred to a primary care physician for blood work and continued medical followup. A counselor should attempt to explore her resistance to HIV testing and describe pre- and posttest counseling that may help motivate, support, and provide further education about HIV risk factors.

Indicators of emotional-behavioral conditions provide evidence that Ms. J has responded to treatment and has made some life-change progress, but she continues to manifest risk behaviors such as needle sharing. She recognizes the severity of her addiction to heroin but demonstrates minimal understanding of her cocaine use and its relationship to her risk of relapse to heroin use. Ms. J requires continued treatment to begin to address her AOD use. She recognizes some relapse triggers for heroin use but has not developed sufficient skills to resist AOD use. In addition, Ms. J's living environment is not conducive to recovery, and she has not developed the socialization skills to establish a supportive network.

Groups focusing on cocaine use, identifying risk factors, and exploring ambivalence to change might be helpful. Further discussion and understanding of her relationships with her partner and her children, of her home environment, and of her goals for change may help identify the specific services that can assist her in this effort.

Identifying the issues for Ms. J according to the dimensions in the Massachusetts criteria can be helpful in identifying specific areas for treatment planning and recognizing and documenting progress in treatment. Uniform documentation, whether using the ASI, the Massachusetts criteria, or other assessment tools, can help quantify progress and identify specific needs for further assessment and continued treatment.

Assessing Patient Progress

Patient progress is monitored against baseline functioning as identified during the initial assessment. Progress should be assessed and confirmed by subsequent medical and psychosocial evaluations from the perspectives of the patient and the program. Patient assessment is discussed here; program assessment is covered in Chapter 5.

Clearly Defining Initial Treatment Goals

Patient progress can be assessed only after treatment goals have been clearly articulated, shared with the patient, and jointly accepted. The treatment plan should balance program requirements and patient needs. It should define short- and long-term goals and set forth information on the level, duration, and frequency of counseling and other services. Pertinent information related to treatment goals must be clearly reflected in the assessment forms.

Patient progress cannot be assessed effectively if treatment goals have not been articulated clearly, shared with the patient, and jointly accepted.

Assessing Patient Progress and Services Received

Selection of the Ongoing Assessment Instrument

A simple, well-structured instrument that captures the full range of patient variables is essential to ongoing assessment of patient progress. The assessment instrument, which should be integrated with the program's management information system, must be not only scientifically accurate but also user friendly. Staff must feel comfortable administering it, and patients must not feel that it is intrusive or time consuming.

For periodic assessment of patient progress, programs may use the same instrument that is used for initial assessment. Ideally, whatever tool is used for ongoing assessment should gather data that can be compared to the data gathered at baseline. Data collected by instruments used to assess patient progress, like data collected during the initial assessment, should be quantifiable. Maintaining information in this format makes it easier to establish objective signs of progress and to evaluate program effectiveness. Several assessment instruments are available for use in opioid substitution therapy programs. They vary considerably in length and scope. As mentioned previously, the National Institute on Drug Abuse has also published a helpful document, Diagnostic Source Book on Drug Abuse Research and Treatment, which describes a variety of assessment instruments.

To adequately track services being delivered and patient progress toward treatment goals, the chosen assessment instrument(s) should cover a minimum of three of the areas described below.

Ongoing measures of use of heroin, opioids, alcohol, and other drugs. These include self-reports, urine toxicology screens, Breathalyzer reports, or other tests. Alcohol problems are common among patients with opioid addiction and sometimes precipitate or indicate relapse to opioid use. Programs are encouraged to use Breathalyzer tests to supplement urinalysis. Such tests provide immediate feedback on blood alcohol levels, making it possible to respond promptly to indications of alcohol use. For example, in some programs it is a policy that a patient's blood alcohol content must be zero before a methadone dose can be given. Withholding of doses in such cases is not punitive; rather, it is part of treatment and provides an important clinical message to patients.

Service delivery and compliance. This can be measured in terms of session attendance, tracking missed appointments, and other signs of patient engagement.

Psychosocial and behavioral functioning. Functioning is generally monitored by the counselor during patient interviews.

The patient's role in assessing treatment progress. Instruments for collecting patient feedback are necessary components of the assessment battery. The patient's input concerning his or her treatment course must be sought regularly; 3-month intervals are generally appropriate. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that treatment plans be made every 90 days. Federal regulations require 90-day treatment reviews during the first year of treatment, and 6-month reviews thereafter. Instruments that document the patient's view of his or her progress must be included in the treatment plan.

Program forms should be designed so that patients are not required to comment on individual staff members; many patients may be reluctant to provide information that is too personalized. Rather than asking the patient how he or she feels about a counselor, the question should be posed in terms of the counseling.

Interpreting Patient Progress

Any significant change in patient status revealed by the assessment, whether positive or negative, should be viewed as an opportunity to reassess the treatment plan and determine whether the mix and intensity of services are appropriate. As described in Chapter 3, services may need to be more intensive during times of crisis and decreased when sufficient progress is made. For example, increased counseling services provided to a patient after the death of a partner, family member, or friend may provide the support needed to prevent relapse. Requiring attendance at a specialized group for those struggling with cocaine use can help a patient attain the skills and support to control or stop use. Responding to a positive urinalysis by developing a more responsive treatment plan can work to ensure good treatment outcomes. Providing positive feedback, readjusting counseling services, and increasing privileges can demonstrate to the patient that progress has been made and less monitoring is needed. Programs should be ready to increase services in response to acute crises, even for patients who have been stable for a long time.

Conclusions and Recommendations

Opioid substitution therapy is an effective means of managing opioid addiction. Although not all patients completely stop drug use, the great majority substantially reduce use and show progress in one or more other areas as well. Opioid substitution therapy is best provided within a treatment program offering a range of services and in an atmosphere of structure and support. Adequate dosage, delivery of ancillary services as needed, and retention in treatment are the key determinants of positive outcomes for persons who are addicted to opioids. Matching patients to treatment services increases the probability of their retention in treatment and of a positive outcome, and therefore has an essential role in opioid substitution therapy.

Any significant change in patient status revealed by the assessment, whether positive or negative, should be viewed as an opportunity to reassess the treatment plan and to determine whether the mix and intensity of services are appropriate.

Several recommendations have been made in this chapter and are summarized below:

  1. The preliminary assessment to determine eligibility for opioid substitution therapy should include a minimum of five areas:
    • Determining the need for emergency care
    • Diagnosing the presence and severity of opioid dependence
    • Determining the extent of AOD use
    • Screening for medical and psychiatric comorbid conditions
    • Evaluating the individual's living situation, family and social issues, and legal problems.
  2. At a minimum, the initial medical evaluation should determine the presence of physical dependence on opioids and inquire about a history of AIDS or HIV infection, cirrhosis, hepatitis, and TB. Women of childbearing age should be questioned about the possibility of pregnancy.
  3. Inclusion, rather than exclusion, should be a guiding principle of clinical decisionmaking about admission to substitution therapy. Few psychiatric or medical diagnoses automatically rule out the possibility of admission.
  4. After formal admission to opioid substitution therapy, a comprehensive assessment should examine the following areas:
    • Drug use (injection and noninjection)
    • Alcohol use
    • Medical history and status
    • HIV serostatus or risk
    • Psychiatric history and status
    • Family relations and supports
    • History of physical, emotional, and sexual abuse
    • Community and peer relations and supports
    • Housing status
    • Legal status
    • Educational history
    • Employment history and status
    • Military and service history
  5. An assessment of the patient's treatment history, a cultural assessment, and a determination of the patient's expectations and motivation are key elements of the biopsychosocial assessment.
  6. The assessment instrument, which should be integrated with the program's management information system, must be not only scientifically accurate but also user friendly. Staff must feel comfortable administering it, and patients must not feel that it is intrusive or time consuming.
  7. Developing a reliable and comprehensive assessment instrument is difficult. Existing instruments should be used or tailored, when necessary, to a specific population or program.
  8. Clinical staff should be familiar with secondary assessment instruments that focus on particular life areas.
  9. Assessment data should be recorded in quantitative form.
  10. To adequately track services being delivered and patient progress toward treatment goals, the ongoing assessment instrument(s) should cover a minimum of three areas:
    • Continued use of heroin, opioids, alcohol, and other drugs
    • Service delivery and compliance
    • Psychosocial and behavioral functioning.
  11. The patient's wishes and expectations of opioid substitution therapy should be carefully explored. During this process, the patient should be treated with dignity and respect.
  12. The opioid substitution therapy program should have primary responsibility for developing and monitoring the treatment plan and coordinating ancillary services.
  13. The methadone dosage should be individualized and based primarily on the patient's response to the medication.
  14. Any significant change in patient status revealed by ongoing assessment should be viewed as an opportunity to reassess the treatment plan and to determine whether the mix and intensity of services are appropriate.
  15. Providing opioid substitution therapy in a variety of treatment settings is necessary to meet patient needs. For example, residential and inpatient detoxification programs should allow the patient to continue methadone maintenance, if clinically indicated.
  16. The goal of voluntary withdrawal from methadone should be for the patient to become drug free. For example, a patient who is progressively resuming illicit drug use should be strongly discouraged from completing the detoxification process.
  17. Because psychiatric and family problems are so common, every opioid substitution therapy program should have at least one staff member skilled in psychiatric assessment and treatment and in family evaluation and family therapy.

Endnote

Footnotes

1. The DATAR Forms Manual (Simpson, 1992) includes copies of several useful instruments. The 13-page clinical version of the 5th edition of the Addiction Severity Index is reprinted in TIP number 7 in this series, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System. The 28-page DATAR Intake Form is reprinted in full in Appendix C of the Diagnostic Source Book on Drug Abuse Research and Treatment, published by the National Institute on Drug Abuse.

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