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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 6. Patient-Treatment Matching: Types of Services and Levels of Care

In This Chapter …

Steps in Patient–Treatment Matching

Patients With Special Needs

Treatment Planning

This chapter describes a multidimensional, clinically driven strategy for matching patients in medication-assisted treatment for opioid addiction (MAT) with the types of treatment services and levels of care that optimize treatment outcomes, primarily within or in conjunction with opioid treatment programs (OTPs). Level of care refers to the intensity of a treatment (in terms of frequency, type of service—individual, group, family—and medication) and the type of setting needed for treatment delivery. For information on criteria and methods to determine levels of care in substance abuse treatment, see the American Society of Addiction Medicine (ASAM) patient placement criteria (Mee-Lee et al. 2001b ). As explained by Mee Lee and colleagues (2001b), the ASAM model conceptualizes opioid pharmacotherapy as a service that can be provided at any level of care, although it is delivered most often in an outpatient setting (i.e., ASAM level I).

The chapter also provides information on developing a treatment plan with short- and long-range goals for each patient. In some cases, patient-treatment matching and treatment planning involve changes that can move a patient out of comprehensive MAT to a setting that better meets the patient's needs. Because this TIP is primarily about outpatient MAT in OTPs, other settings and programs are discussed only briefly.

In general, patient-treatment matching involves individualizing, to the extent possible, the choice and application of treatment resources to each patient's needs. The chapter explains recommended elements of a patient-treatment-matching process, including ways to accommodate special populations with distinct needs and orientations that affect their responses to specific treatments and settings.

Patients enter OTPs at various points along a continuum of substance abuse and addiction. Many also have co-occurring medical and mental health conditions that can be lifelong. Because of the complexity of patients' circumstances and needs and the range of services required to address these needs, MAT includes not only opioid pharmacotherapy but also other forms of treatment in a comprehensive treatment program designed to address multiple disorders and needs (see chapter 8).

The consensus panel believes that OTPs not already offering comprehensive MAT services and those lacking resources to adjust levels of care to patient needs either should augment basic opioid pharmacotherapy with services that meet the mental health, medical, and social needs of patients who are opioid addicted—at the level of care each patient needs—or should provide referrals to programs that provide such services.

Steps in Patient–Treatment Matching

Patient Assessment

Patient–treatment matching begins with a thorough assessment to determine each patient's service needs (see chapter 4); then these needs are matched to appropriate levels of care and types of services. Assessment should include the extent, nature, and duration of patients' opioid and other substance use and their treatment histories, as well as their medical, psychiatric, and psychosocial needs and functional status. A comprehensive assessment should include a patient's gender, culture, ethnicity, language, motivation to comply with treatment, and recovery support outside the OTP.

Type and Intensity of Treatment Services Needed

Psychosocial treatment services

In a comprehensive MAT setting, patients often have access to a variety of psychosocial services, including individual, family, and group counseling, as well as case management (see chapter 8). Some programs may provide psychosocial services to patients in other settings. Both residential and outpatient programs may offer intensive individual and group counseling or counseling on a periodic or as-needed basis (De Leon 1994; Margolis and Zweben 1998). Ideally, service intensity should depend on the level of care required to help patients achieve and maintain successful treatment outcomes. Most patients in the acute phase of treatment need to see a counselor daily for counseling or case management, just to become stabilized, whereas others, who may be highly functioning with less severe addiction-related psychosocial problems, require fewer counseling services.

Mutual-help programs

Although not a form of treatment, mutual-help programs (e.g., 12-Step programs, Secular Organization for Sobriety groups, Women for Sobriety groups) offer effective reinforcement and motivation for individuals during and after discontinuation of active treatment. Such programs provide social support from others who are in recovery from addiction (Washton 1988). Many patients in MAT participate in mutual-help groups. However, patients with opioid addiction who are maintained on treatment medication can feel out of place in some group settings where continued opioid pharmacotherapy may be misunderstood. Researchers have described a variety of specialized groups and inventive strategies for mutual-help programs that meet the support needs of patients in MAT (Zweben 1991). Chapter 8 presents some of these strategies.

Matching Treatment Service Needs to Settings

After the types and intensities of services that patients need are defined, the next crucial step in patient-treatment matching is to identify the most appropriate available setting or settings for these services. MAT has been offered primarily in a dedicated outpatient OTP. However, as the importance of treating patients' varied medical, psychological, social, and behavioral needs as part of addiction recovery has become evident, more varied programs and settings have emerged.

Throughout this TIP, the consensus panel recommends that OTPs lacking the resources to accommodate all their patients' needs develop cooperative relationships with and refer patients to other treatment providers as appropriate. However, OTPs should coordinate these services. Based on its assessments of patients, the treatment team should collaborate with patients to determine the most appropriate treatment services, intensities of services, and settings needed to meet patient needs. This collaboration should continue throughout MAT, and patient progress should be the basis for adjustments in treatment services and intensities.

Patients' service needs may change throughout MAT. For example, one patient may need referral to an inpatient program for detoxification from alcohol or benzodiazepines and then return to the OTP setting. Another may need the environment of a residential treatment program while continuing MAT. Therefore, treatment matching in some cases can lead to multiple settings for an individual's treatment. In most cases, the originating OTP should provide case management and liaison for all treatment services.

Types of settings and programs offering opioid addiction treatment services

The following are examples of treatment programs and settings that offer some or all of the comprehensive services recommended in MAT.

Outpatient OTPs. Outpatient OTPs ideally treat patients who are opioid addicted during all phases of treatment and at most levels of care. In reality, many OTPs have capacity or resource limitations or payment requirements that cause them to refer at least some patients to other specialized treatment providers and settings, such as those described below, for services that match patient needs. Either on site or through other care providers, OTPs offer a wide spectrum of treatment services and levels of care for diverse patients.

Appropriate patients for treatment in outpatient OTPs are those who meet Federal and State requirements for opioid addiction treatment (e.g., 42 Code of Federal Regulations, Part 8), those who have done poorly in other types of programs (e.g., medically supervised withdrawal or residential treatment programs), and those who require opioid pharmacotherapy for long-term stabilization.

OTPs in hospital-based outpatient settings may provide a more enhanced continuum of care than freestanding OTPs because access to medical and psychosocial services is readily available. This availability, in turn, increases the likelihood that patients in MAT will engage in and adhere to other medical and psychosocial treatment regimens.

Hospital-based MAT programs are appropriate for some patients who also are medically ill and require coordinated services or care by special teams. In addition, because hospitals can provide a one-stop-shopping model of care by incorporating some primary care services with MAT, some patients with histories of poor treatment compliance may be more likely to adhere to medical treatment. For example, one report from a 16-month prospective study of nearly 500 persons in a hospital-based outpatient methadone program found that 81 percent also used onsite primary care services (Selwyn et al. 1993). At this writing, the number of hospital-based programs offering MAT is limited in the United States.

Residential treatment programs. Residential treatment programs offer cooperative living arrangements for patients in recovery, but they vary in their willingness or ability to accept MAT patients (Margolis and Zweben 1998). A residential treatment setting is indicated for patients who require residential placement to support treatment and ensure their physical or psychological safety and who are unlikely to continue MAT otherwise. Such patients generally exhibit high relapse potential, evidenced by an inability to control substance use despite active participation in less intensive outpatient programs (Margolis and Zweben 1998). On completion of treatment in these settings, patients should return to an outpatient setting to continue MAT.

If a patient in an OTP is referred to a residential program that does not offer or allow onsite opioid pharmacotherapy (i.e., when other residential options are unavailable) or methadone or buprenorphine dispensing or administration, some programs allow resident patients to travel to the OTP for medication. Some States allow exceptions to regulations governing OTP attendance and take-home medications so that concurrent treatment is possible.

Mobile treatment units. The success of mobile treatment units—that is, mobile vans—in such cities as Baltimore, Boston, San Francisco, and Seattle (Greenfield et al. 1996; Schmoke 1995) highlights the importance of program accessibility as a factor affecting length of stay in treatment and positive treatment outcomes (Greenfield et al. 1996). Mobile substance abuse treatment programs either offer comprehensive maintenance services (with medication, collection of samples for drug testing, and counseling provided in one or several mobile units) or work in conjunction with fixed-site outpatient programs that offer medical care and counseling and other psychosocial services, while medication is delivered via the mobile units.

Appropriate patients for treatment in mobile treatment units are those in locations where fixed-site programs are unavailable, those with ambulatory disabilities, and those initially stabilized in an OTP and then transferred to a mobile unit for continued treatment. Mobile units not staffed on weekends are appropriate only for patients who meet State and Federal regulations for weekend take-home medications.

Office-based opioid treatment settings. After achieving biomedical and psychosocial stabilization in an OTP, some patients might be eligible for referral to less intensive physician's office-based opioid treatment (OBOT) for medical maintenance. In these settings, patients receive the same level of monitoring and intervention as patients receiving other types of health care. When available, OBOT programs offer several advantages (Fiellin and O'Connor 2002), including

  • Less intensive service requirements for stable patients (e.g., less restrictive environments, focus on maintenance with stable doses of opioid medication, provision of only those psychosocial services needed to prevent relapse)
  • Minimized stigma associated with addiction treatment
  • Increased opportunity for new treatment admissions to OTPs
  • Expansion of treatment to geographic areas where there are no OTPs or there are waiting lists for admission to OTPs.

Criminal justice settings. At this writing, relatively few jails or prisons offer comprehensive MAT or selected MAT services, but these numbers are likely to increase (for information about substance abuse treatment in criminal justice settings, see TIP 44, Substance Abuse Treatment for Adults in the Criminal Justice System [CSAT 2005a ]). As a result, MAT services are often interrupted or discontinued when patients are incarcerated. Rikers Island, New York City's central jail facility, is an example of a model program that provides comprehensive MAT for this patient group (Magura et al. 1993). Patients who receive MAT there are guaranteed a slot at a community-based program in New York City after their incarceration. Other corrections facilities provide rapid medically supervised withdrawal from maintenance medication to patients. When this withdrawal is the only option, OTPs should work with criminal justice institutions to ensure that appropriate dose-tapering procedures are followed. Patients released from a criminal justice setting should be offered referral to an OTP when referral is desirable and feasible.

Other treatment settings. Numerous other settings and specialized programs offer some services and levels of care needed by patients who are opioid addicted. Any of these programs can be sources of referral by OTPs or can function as satellite OTPs to ensure that patients receive services and levels of care they need.

Choice of Medications

The consensus panel recommends that OTPs offer a variety of treatment medications. Chapters 3 and 5 provide more details about the pharmacology and appropriate use of methadone, levo-alpha acetyl methadol, buprenorphine, and naltrexone.

Patients With Special Needs

Effective treatment for opioid addiction should address the unique needs of each patient (O'Connor and Fiellin 2000; Rowan-Szal et al. 2000a ). Culturally competent and creative treatment planning, implementation, and referrals should address the distinct needs of patients from different backgrounds. More staff training and research are required on the unique constellations of treatment needs for various populations served by OTPs. Findings for particular groups are summarized below. Other treatment groupings may be identified, for example, high-profile persons for whom unique treatment schedules and settings may be needed to protect confidentiality (CSAT forthcoming e ).

Patients With Serious Medical Disorders

If a serious medical condition is discovered during medical evaluation or patient assessment, the patient should receive appropriate medical treatment either on site or by referral to a medical center. Chapter 10 describes medical conditions commonly encountered among patients in MAT and provides treatment recommendations. Most OTPs offer only basic medical services. OTPs should develop and maintain referral networks for patients who present for MAT and have other medical conditions. Moreover, OTP staff should coordinate referrals and follow up as needed to ensure compliance with medical treatments and to act as consultants about MAT and medication interactions.

Patients With Serious Co-Occurring Disorders

Many studies have focused on the co-occurrence of substance use and mental disorders (see chapter 12). The existence of co-occurring disorders should not prevent patients' admission to an OTP; however, diagnosis of these disorders is critical to match patients with appropriate services and settings. Therefore, OTPs should include professional staff trained to screen for the presence of co-occurring disorders, develop appropriate referrals to services (e.g., psychopharmacology or psychotherapy) for these disorders, and provide coordination of care (CSAT 2005b ). Most staff members can be trained to recognize and flag major symptoms of co-occurring disorders. The OTP should maintain communication and followup with referral resources.

Patients With Housing, Family, or Social Problems

The following psychosocial problems should be addressed during or directly after admission to increase the likelihood that patients will engage successfully in treatment:

  • Lack of stable housing
  • Broken ties with family members; nonexistent or dysfunctional family relationships
  • Poor social skills and lack of a supportive social network
  • Unemployment; lack of employable skills.

Once these needs are identified during assessment, referrals can be made. Although some OTPs have social workers on site to manage the assessment and referral processes, most OTPs rely on counselors to assume this role. Case management duties should include arrangements for provision of psychosocial care when indicated. Family members need education about MAT, including information on how to support a partner or loved one in recovery, self-care of family members, signs and symptoms of active addiction, and support and assistance from family members willing to participate in family counseling. Programs can offer monthly classes to patients, their families, and the community, which can reduce the stigma connected with MAT.

Patients With Disabilities

OTPs should try to provide access for patients with physical disabilities. Treatment interventions for these patients usually include vocational rehabilitation, physical therapy, and social services that help procure prosthetic limbs, wheelchairs, and other assistive devices (CSAT 1998c ). Alternative approaches in MAT, specifically those that reduce OTP visits, include take-home dosing and requests for medical exceptions through visiting-nurse services to provide equal access to treatment for persons with disabilities (see chapter 10).

Mobile medication units and office-based or home-nursing services may offer viable treatment options for patients with disabilities (Fiellin and O'Connor 2002; Greenfield et al. 1996). OTP staff should address these challenges with patients so that barriers to treatment are overcome.

The consensus panel recommends that OTPs engage in discussions with their Federal and State agencies to develop solutions for treating patients with disabilities. Such discussions should balance the medical needs of these patients and the safety issues involved in providing take-home medications for patients with disabilities who continue to engage in substance abuse or create a risk of medication diversion.

Adolescents and Young Adults

Adolescents and young adults present a unique challenge for MAT. Often, ethnic background, peer affiliations, and aspects of the “youth culture” require staff training and special expectations from both staff and patients. Differences in routes of administration for heroin or prescription opioids and in treatment needs between adolescents or young adults and older adults who are opioid addicted might be attributable in part to generational characteristics and life experiences. For example, older adults typically present for treatment after years (sometimes decades) of chronic substance abuse accompanied by loss of family, health, and employment and deterioration in other psychosocial domains. Youth who are opioid addicted tend to present after only a few years of addiction and with different attitudes toward addiction and the recovery process and distinct treatment needs. These youth may be more difficult to evaluate, because, as a result of other modes of administration (i.e., intranasally and by smoking), they do not exhibit some physical markers of opioid use (e.g., track marks).

Treatment for adolescents and young adults should integrate knowledge of their specific developmental and psychosocial concerns and needs. Some needs are related to identity formation and peer group preoccupation (e.g., the strong desire to be viewed as fearless or to feel invincible), legal complications regarding consent for treatment (see CSAT 2004b ), and, often, factors leading them to run away from their homes. TIP 32, Treatment of Adolescents With Substance Use Disorders (CSAT 1999d ), provides background information.

Other risk factors for this group include possible sexual and physical abuse, young age at first sexual experience, incidents of trading sex for drugs (Astemborski et al. 1994; Fullilove et al. 1990), and co-occurring disorders (Fuller et al. 2002; Hawkins et al. 1992). These risk factors also can contribute to increased risk for HIV infection (Doherty et al. 2000; Fuller et al. 2001) and other sexually transmitted diseases (STDs).

The interaction of developmental and psychosocial factors affects the ability of adolescents and young adults to engage in MAT and therefore complicates the recovery process. OTPs should provide psychosocial services that address the unique needs of this age group, especially those needs that affect their substance use and recovery, or they should establish referrals and links to youth-oriented psychosocial counseling services.

Buprenorphine may be a particularly satisfactory treatment for some adolescents. Because buprenorphine can be administered in an OBOT setting, it should become more widely available and offer more privacy and less stigma for young patients (see CSAT 2004a ).

Women

Pregnancy

The special needs of women who are opioid addicted and pregnant should be assessed thoroughly through a comprehensive medical evaluation, as discussed in chapter 13. Treatment matching for pregnant patients in MAT should provide optimal, comprehensive, and intensive services related to pregnancy and birth including prenatal care, maternal nutrition, and psychosocial rehabilitation, along with MAT. The integration of a women's overall health initiative into MAT improves an OTP's capacity to meet the special needs of these patients, to address potential biomedical and obstetrical complications, and to avoid adverse effects of substance use on the fetus (Finnegan and Kandall 1992). Chapter 13 offers a detailed overview of MAT for pregnant women (also see CSAT forthcoming f ).

OTPs are required by regulation or accreditation standards to test for pregnancy, but the provision of prenatal care and ancillary services for pregnant women varies depending on the treatment setting. Hospital-based programs may be better suited for pregnant women in some cases because hospitals offer easy access to referrals and links to specialty care (on or off site).

Sexual or physical abuse

Patients' risks of ongoing abuse in their current relationships should be addressed, and appropriate plans or referrals made. Co-occurring disorders such as posttraumatic stress disorder can occur among both women and men who have experienced sexual or physical abuse. The best treatment settings to address women's needs in these cases include OTPs with onsite care provided by psychiatrists, psychologists, licensed social workers, or mental health professionals with special training in this area. In lieu of onsite services, OTPs should establish referral links to programs offering such services. Many social service agencies, as well as agencies responsible for domestic violence, offer training and support to OTP staff. TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (CSAT 2000d ), provides further details.

Complex medical problems

The complex medical problems commonly diagnosed in women in MAT include gynecological infections, amenorrhea, hypertension, and pneumonia (Brown et al. 1992). It is optimal to provide primary care services on site; hospital-based programs and OTPs with formalized medical referral systems are best equipped to deliver such services. Chapter 10 of this TIP and the forthcoming TIP Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT forthcoming f ) provide additional information.

Parents

Because many patients in MAT are parents, the lack of adequate childcare services is often a barrier to OTP attendance and successful treatment. One solution is supervised onsite childcare services, which also may provide opportunities to observe how patients relate to their children. Problems in parenting skills can be addressed in treatment planning and through parenting groups for patients with children. However, onsite childcare services are available in few programs because of limited resources and licensing and insurance requirements. These obstacles might cause missed appointments or lack of privacy and concentration for parents who must bring their children to treatment and counseling sessions. Insufficient treatment may result.

The consensus panel recommends that OTPs seek opportunities and funding for onsite childcare where appropriate and feasible to help patients with children engage successfully in psychosocial services. Where childcare is unavailable, program staff should offer referrals to community daycare agencies.

In most States, OTPs are mandated reporters of child abuse and neglect. When children are at imminent risk of harm or appear neglected, OTPs are required to notify local children's protective services (CPS) agencies so that an investigation can be conducted. This requirement can create conflict between an OTP and a patient, and the OTP should try to address this issue in a supportive way. Programs and treatment providers should not discriminate against patients because they have entered into pretreatment agreements or have difficulties with CPS agencies (see chapter 13).

Lesbian, Gay, and Bisexual Patients

Just as important as sensitivity to cultural differences based on race or ethnicity is providing a treatment climate that is available and sensitive to lesbian, gay, or bisexual (LGB) patients by openly acknowledging their heterogeneity and variations in sexual orientation and treating these individuals with dignity and respect (CSAT 2001b ; Lombardi and van Servellen 2000). OTP staff should be prepared to assist LGB patients in coping with problems related to their sexual orientation and the need for HIV/AIDS and STD risk avoidance. Providers should help patients obtain appropriate medical care and secure their safety if, for example, they are threatened. OTPs also should acknowledge the unique social support structures of LGB patients, which can provide a way to counteract isolation and separation from community, peers, and immediate and extended family members (Hughes and Eliason 2002; also see CSAT 2001b ). Finally, the consensus panel recommends that OTPs identify and refer LGB patients to community counseling, support, and spiritual and religious organizations that are sensitive to these groups and address any sexual- or gender-orientation concerns these patients have that could affect treatment.

Aging Patients

MAT treatment planners should consider the stressors common to the aging patient, such as loss of family, retirement, loneliness, and boredom, which can contribute to high risk of self-overmedication and addiction to alcohol and medications. The consensus panel recommends that OTPs focus on the following areas when working with elderly patients:

  • Monitoring the increased risk for dangerous drug interactions; elderly patients often are prescribed multiple medications.
  • Differentiating between co-occurring disorders and symptoms and disorders associated with aging (including dementia) (Lawson 1989).
  • Differentiating between depression and dementia.
  • Screening for and treating physical and sexual abuse (see chapter 4).
  • Developing referral sources that meet the needs of elderly patients. Relationships with skilled nursing facilities and nursing homes are particularly important (Lawson 1989).
  • Training staff to be sensitive to the elderly patient population.
  • Providing psychosocial treatment for age-associated stressors and medical screening and referral for common medical conditions affected by the aging process (see CSAT 1998b ).
  • Assessing and adjusting dosage levels of medication for the slowed metabolism of many elderly patients.

Patients With Pain

Patients in MAT often are undertreated or denied medication for acute or chronic pain management (Compton and Athanasos 2003). Health care workers may misperceive pain medication requests by patients in MAT as drug-seeking behavior, in part because of patients' higher tolerance for opioids and, usually, their need for higher doses. Many physicians who treat pain do not have the necessary education to treat pain in this population (Prater et al. 2002). MAT providers should evaluate patient treatment needs for pain management and assist patients directly in obtaining optimal pain treatment. Medical providers in MAT should work collaboratively with primary care providers and pain and palliative-care clinicians to ensure establishment of appropriate pain interventions for patients in MAT. Providers need education about maintaining current opioid levels while adding sufficient immediate-release treatment agents to manage acute or chronic pain. More frequent dosing and short-term increased demand for pain treatment medication should be expected. Referrals to specialty pain clinics often provide patients a full spectrum of pain care, including pharmacological and psychological or behavioral treatments to alleviate pain symptoms. These services most often are accessible through hospital-based programs or referral linkages. Most patients can be maintained on their MAT dosage while taking short-acting opioids for pain relief; however, individualized pain treatment is usually necessary.

Treatment Planning

After patients' individual needs are assessed and the best available treatment services and most appropriate levels of care are determined, a treatment plan should be developed with the patient, as required by accreditation guidelines (CSAT 1999b ).

Developing a Treatment Plan

Treatment planning for MAT should involve a multidisciplinary team, including physicians, counselors, nurses, case managers, social workers, and patients. Based on a thorough patient history and assessment, a treatment plan should be realistic and tailored to each patient's needs, strengths, goals, and objectives. Good treatment plans contain both short- and long-term goals and specify the actions needed to reach each goal. Treatment plans should indicate which goals and objectives require referral to and followup with outside resources and which are provided by the OTP itself. Treatment plans should contain specific, measurable treatment objectives that can be evaluated for degree of accomplishment.

Role of the counselor in plan formulation

Counselors should ensure that treatment plans incorporate strategies to develop therapeutic relationships with patients, based on respect for patients' autonomy and dignity, while motivating patients to become willing partners in the change process (CSAT 1999a ). This role, which places great responsibility on the counselor, usually incorporates cognitive behavioral approaches in which providers strive to enhance patient motivation for change by focusing on patient strengths and respecting patient decisions (CSAT 1999a ). To engage patients in the process of treatment planning, counselors should encourage the inclusion of motivational enhancement strategies that highlight appropriate, realistic treatment goals (Di Clemente 1991). Research has shown that confrontational counseling or the use of negative contingencies often predicts treatment failure (Miller and Rollnick 2002).

Role of the patient in plan formulation

A patient in MAT should be an integral member of the treatment team with his or her needs and expectations considered respectfully and incorporated into the treatment plan. Patients who agree with the treatment rationale or therapeutic approach tend to experience increased determination to improve (Hubble et al. 1999). A patient's participation in treatment planning can enhance motivation to adhere to change strategies, leading to positive treatment outcomes such as higher rates of abstinence and better social adjustment (CSAT 1999a ). When possible, the treatment plan should be written in a patient's own words to describe his or her unique strengths, needs, abilities, and preferences as well as his or her challenges and problems. The plan also should contain mutually approved goals that reflect awareness of and sensitivity to a patient's informed choices, cultural background, age, and medical status or disability.

Other factors in plan formulation

Treatment plans should incorporate an assessment of linguistic and cultural factors that might affect treatment and recovery either positively or negatively (U.S. Department of Health and Human Services 2001). Treatment providers should work collaboratively with patients to identify health-related cultural beliefs, values, and practices and to decide how to address these factors in the treatment plan (U.S. Department of Health and Human Services 2001).

Motivation for treatment

Patient motivational strategies should be incorporated throughout the treatment plan. As part of this process, the treatment team can benefit from an understanding of stages of change and their effects on patient progress. Prochaska and colleagues (1982, 1986, 1992), who formulated a useful model that explains how people change, observed five stages of readiness for change during addiction treatment: contemplation, determination, action, maintenance, and relapse. An earlier stage (precontemplation) also plays a role. Patients and treatment providers ideally should develop recommended treatment options in the plan based on each patient's readiness for treatment, which can be determined by identifying the patient's stage-of-change readiness. The stages-of-change model and corresponding counseling responsibilities are described in TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999a ).

Elements of a Treatment Plan

Because some patients require assistance in many functional areas, treatment plans should address measurable, achievable goals relevant to the patient's current situation. Short-term goals, such as vocational rehabilitation assessment or computer training, can evolve from a long-term goal, such as full-time employment. However, treatment plans should be simple and not so comprehensive that they overpower a patient with the tasks that must be achieved. Although both short- and long-term goals should be considered, the patient's involvement in defining measurable, achievable goals is important. Treatment plans should be modified periodically when progress can be assessed. Most OTPs have forms to use for treatment planning, many of which were developed to meet regulatory and accreditation requirements, specifying goals, actions, responsible parties, and measurable outcomes. The panel urges that these forms not be overly complex or overwhelming to the patient. Patients should receive a copy of the plan. Exhibit 6-1 provides a case study and an example of a treatment plan.

Exhibit 6-1. Case Study: Patient-Treatment Planning in MAT

Patient is a 30-year-old Hispanic mother of two children who has been divorced for 3 years. She dropped out of high school at age 15 when she became pregnant. As a single mother on public assistance, she first began using heroin intranasally at age 17 and began injecting 1 year later.
Patient was born in Puerto Rico, and her family came to the United States when she was 10 years old. She is the youngest of five children. Her father was an unemployed painter and alcoholic who physically abused her mother. He died in Puerto Rico from cirrhosis of the liver. Patient's relationship with her mother always has been strained. Her mother has had numerous relationships that the patient resented. Patient stated that, as the youngest child, she feels that she never received enough attention or love from her mother.
To support her lifestyle, which includes alcohol, cocaine, and heroin use, patient earned money through prostitution, which led to selling drugs, theft, and other criminal activities. Patient married after giving birth to her second child. Patient has an arrest history and a pending case for selling cocaine. After a divorce, patient lived with her mother. An anonymous call was made to CPS reporting her chronic drug abuse and criminal history. As a result, her children were placed in foster care. After the patient's arrest and the removal of her children, patient's mother asked her to move out of the house; she then lived with whomever she could.
Patient has enrolled in an OTP, motivated by her desire to regain custody of her children. She considers cessation of her cocaine habit secondary to cessation of her heroin abuse. She initially stated that she wanted to change her life, including having her own permanent housing, and she wanted to stop prostituting. Although stabilized on methadone, she continued to use cocaine on a regular basis during her first 6 months in treatment. While in the program, she tested positive for HIV infection. She was assessed as having severe depression, with suicidal ideation, and escalation of cocaine abuse.
Although attempts have been made to motivate patient to stop cocaine use, these attempts have been unsuccessful.
Patient's treatment plan might include the following short- and long-term goals:
Short-term goals
1. Address imminent danger of suicide by developing a service plan in conjunction with mental health provider.
• Objective: To rule out suicide; to overcome patient's depression and assess need for medication.
• Action: Have patient sign a consent form for a psychiatric evaluation and communication between provider and OTP staff; set up appointment with psychiatrist; obtain evaluation, diagnosis, and treatment recommendations from the psychiatrist.
• Target date: Immediately for suicidal ideation; within 1 month for ongoing mental health needs.
• Responsible persons: Patient, counselor or caseworker, and psychiatrist.
• Measurable outcome: Patient is stable and no longer at high risk; medication needs are assessed.
• Long-term goal: Stable mental health status with ongoing treatment plan.
2. Obtain housing for patient, with long-term goal of stable permanent housing.
• Objective: To refer to a shelter.
• Action: Make appointment to apply for housing assistance program.
• Target date: Immediately.
• Responsible persons: Patient, counselor or caseworker, and housing staff.
• Measurable outcome: Copy of lease, patient self-report, or both.
• Long-term goal: Access to stable housing.
3. Obtain HIV counseling.
• Objective: To provide support and education about HIV status.
• Action: Provide education, resources, and counseling about safe sex and spread of HIV.
• Target date: 4 to 6 months.
• Responsible persons: Medical staff, counselor, and patient.
• Measurable outcome: Patient has obtained and integrated accurate information; myths are dispelled; patient reports readiness to explore treatment options.
• Long-term goal: Initiation of antiretroviral treatment.
4. Address cocaine abuse.
• Objective: To educate the patient on the psychological and physiological effects of cocaine abuse; to develop a recovery intervention.
• Action: Assess level of use and readiness for change; develop plan with patient to address use (e.g., motivational groups, Cocaine Anonymous, skill-building interventions, drug testing).
• Target date: 2 to 4 months.
• Responsible persons: Patient, counselor, group leader, and medical staff members.
• Measurable outcome: Patient decreases cocaine use, based on self-report, observable behavior, drug testing, and attendance to counseling plan.
Long-term goals
1. Manage or eliminate depression.
• Objective: To stabilize depression; to increase self-esteem and motivation to work on treatment goals.
• Action: Provide regular psychiatric treatment on site or by referral; communicate with providers.
• Target date: 6 months.
• Responsible persons: Patient, counselor, and psychiatric providers.
• Measurable outcomes: Patient regularly attends to psychiatric treatment plan, adherence to medication regimen if prescribed, elimination of or reduction in depression (as assessed by patient report, depression assessment tools, observed behavior).
2. Regain custody of children once in stable housing situation.
• Objective: To reconcile the patient with her family; to maintain a stable living situation.
• Action: Assist patient in obtaining public assistance to ensure stable, safe, appropriate environment for children; access legal assistance for custody issues; obtain permission to communicate with CPS; assist patient in remaining abstinent from substance use.
• Target date: 1 year.
• Responsible persons: Patient, counselor or caseworkers, internal or external social services worker, and lawyer.
• Measurable outcomes: Patient self-report, family and CPS agency reports, rent receipts, progress toward obtaining custody of children.
3. Continue HIV medical care.
• Objective: To obtain ongoing HIV education and treatment.
• Action: Provide access and communication with HIV and primary care providers; provide referral to support group meetings for individuals who are HIV positive.
• Target date: Ongoing.
• Responsible persons: Patient, health care providers, counselor and caseworkers, and group counselor or facilitator.
• Measurable outcomes: Patient self-report, health care providers' report, laboratory reports, and group leader reports about adherence to health care needs.

The Multidisciplinary Team Approach

The complexities of treatment planning for patients who receive MAT require a multidisciplinary treatment team, the composition of which varies with OTP resources and the population being treated. The consensus panel recommends that the treatment team consist of the following:

  • A physician trained in addiction psychiatry, who provides leadership, health care, and medical stabilization; conducts detailed evaluations of the patient; monitors medications; and provides needed substance abuse interventions when indicated
  • Nonphysician medical staff members (e.g., registered nurse, nurse practitioner, physician's assistant), who administer medications, assist in medical evaluations, maintain records, and facilitate referrals for medical and psychiatric treatments
  • A pharmacist or pharmacy assistant, who dispenses (and sometimes administers) medications, orders controlled substances, maintains records, and consults with program staff on all aspects of patient care, particularly drug interactions
  • Nonmedical professional staff members (e.g., case coordinator, social worker, psychologist, vocational and educational specialist), who provide a range of psychosocial services, including counseling and case management, psychotherapy and family therapy, psychological testing and evaluation, health education, and vocational skills assessment and training
  • A certified or licensed addiction specialist or drug counselor
  • Nontreatment and administrative staff members (e.g., office manager, clerical staff, receptionist, secretary), who often provide information to treatment teams and whose responsibilities include operational management, billing, receipt of payments, review of records, observation of patient interactions, and telephone coverage
  • Security personnel, who ensure the safety and well-being of patients and staff on site.

More information on the multidisciplinary team approach is presented in chapter 14.

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