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Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2004. (Treatment Improvement Protocol (TIP) Series, No. 40.)

Cover of Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction.

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Appendix E Clinical Toolbox: Chapter 3 Supplemental Information

Motivational Interviewing and Motivational Enhancement Therapy

A number of engagement and motivation strategies have been employed successfully in opioid addiction therapy. This section discusses briefly one such approach: motivational interviewing and motivational enhancement therapy (MET).

MET assumes that a patient is responsible for and capable of changing his or her behavior, and the MET therapist focuses on helping a patient mobilize his or her own inner resources. The basic motivational principles utilized in MET are expression of empathy, the development of discrepancy, avoiding argumentation, rolling with resistance, and supporting self‐efficacy. Motivation for change is developed by eliciting self‐motivational statements, listening with empathy, questioning, presenting personal feedback, affirming the patient, handling resistance, and reframing.

MET is a specific application of motivational interviewing that was developed for use in the treatment of alcohol abuse. In this brief, two‐ to four‐session treatment approach, counselors first guide patients through an examination of the pros and cons of their drug use and of the difference between where they are and where they want to be, in an attempt to lead them to state their desire to change—the first step in recovery. Counselors then strengthen patients’ commitment to change by helping them to identify their goals for recovery and to determine ways to reach these goals. Motivational interviewing can be used as a stand‐alone counseling approach, but more often it is used as a first step in the recovery process and is followed by other interventions. It can also be incorporated into subsequent treatment sessions to bolster patients’ motivation as needed.

Additional information about motivational interviewing and MET can be found on the Motivational Interviewing Page at http://www.motivationalinterview.org and in Center for Substance Abuse Treatment (CSAT) TIP 35, Enhancing Motivation for Change in Substance Use Disorder Treatment (CSAT 1999b ). (See http://www.kap.samhsa.gov/products/manuals/index.htm.)

FRAMES

Brief interventions by physicians or allied health professionals can be effective measures in opioid addiction therapy. Effective brief interventions should include the following six elements: feedback, responsibility, advice, menu of strategies, empathy, and self‐efficacy (Miller and Sanchez 1994). These elements are commonly referred to using the acronym FRAMES, and are further described in figure E–1. Additional information about brief interventions is found in CSAT TIP 34, Brief Intervention and Brief Therapies for Substance Abuse (CSAT 1999a ). (See http://www.kap.samhsa.gov/products/manuals/index.htm.)

Details of Taking a Comprehensive Patient History in Opioid Addiction Assessment

History of Drug Use

What substances have been used over time? Begin with the first psychoactive substance used (licit or illicit, prescribed or nonprescribed), including nicotine and caffeine. Ask about the first use of all drugs: age at first use, drugs used, description of the experiences and the situations, amounts used, feelings, complications, and results. “How old were you when you first tried alcohol or any other drugs? Describe the experience to me.”

Ask about all psychoactive substances: alcohol, amphetamines, caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine (PCP), sedatives, hypnotics, anxiolytics, and others. What substances has the patient ever used? When were each of these first used? What were the effects? What has happened over time? Focus on opioid use, progression of problems, and recent symptoms in patients being considered for buprenorphine treatment.

Effects of the Drugs Over Time

Explore the pattern of use of each substance. What has been the evolution and progression of use over time? Determine the frequency of use, amount of drugs used, route(s) used, progression of symptoms, and social context(s) of use. Has the patient attempted to cut down or control use; taken greater amounts of drugs or over a longer period than intended; spent much time using, obtaining drugs, or recovering from use? Has the patient had blackouts, shakes, withdrawal symptoms, compulsivity of use, and/or craving? Has he or she injected drugs; reduced or abandoned important activities as a consequence of use; and/or continued to use despite problems or consequences? If so, give examples.

When did regular opioid use begin? Does the patient have to use to feel “normal”? Describe periods of heaviest use. Explore in detail the pattern of use during the weeks prior to evaluation, including the amount and time of last use. When did he or she last consume alcohol or ingest or inject drugs? What was used? How much? What were the effects of the last drugs used?

Tolerance, Intoxication, and Withdrawal

For each drug ever used, explore tolerance, intoxication, and withdrawal syndromes. Especially focus on opioid‐related syndromes.

Tolerance is the need for markedly increased amounts of the substance to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount of the substance.

  • Has tolerance developed to any drugs of abuse? How has tolerance manifested in this patient? Has any decrease in tolerance occurred? Quantify tolerance by the amount used and/or the cost of drugs needed to achieve effects.
  • What is the most of each substance the patient can consume in a 24‐hour period now? What is the most ever consumed in a 24‐hour period?

Intoxication and Overdose

  • Explore symptoms of intoxication for each drug used.
  • Intoxication. What was the patient’s age at first intoxication? What drug(s) were involved in that intoxication? How have intoxication episodes progressed over time? Describe recent intoxication episodes.
  • For opioids, has the patient experienced drowsiness (“nodding out”), slurred speech, impaired memory or attention, respiratory depression, and/or coma?
  • Overdose. Have there been any episodes of intentional or nonintentional overdose with any drug or drug combinations? What symptoms did the individual have? What treatments were received? How did the episodes resolve?

Withdrawal

  • Withdrawal is the characteristic withdrawal syndrome for the substance. The same (or a closely related) substance may be taken to relieve or avoid withdrawal symptoms. (The signs and symptoms of opioid withdrawal are shown in figure 3-7.)
  • Describe withdrawal symptoms or syndromes the patient has ever experienced. What is the pattern of withdrawal symptoms? What relieves the symptoms (e.g., more of the drug and/or a cross‐tolerant drug)? Describe the characteristics of withdrawal episodes over time.
  • What signs of opioid withdrawal occurred after discontinuation of use (e.g., dysphoria, nausea or vomiting, aching muscles, tearing, rhinorrhea, dilated pupils, piloerection, sweating, diarrhea, yawning, fever, and insomnia)?
  • What treatments for withdrawal or its complications have been received in the past?
  • Withdrawal complications. Is there any history of withdrawal complications (e.g., seizures—from withdrawal with sedative‐hypnotics or intoxication with stimulants or opioids, delirium tremens, hallucinations)? What treatment was received for these past complications, and what was the treatment response?

Relapse or Attempts at Abstinence

  • Has the patient had a persistent desire or made unsuccessful efforts to cut down or control substance use? How many times has the patient attempted to become abstinent? How was the patient able to achieve abstinence? Quantify the longest time completely abstinent from all psychoactive drugs. What was going on during the time of abstinence? To what does the patient attribute his or her abstinence?
  • What is the patient’s relapse history? What happened to end any abstinent periods? What triggered or preceded relapses? What drug(s) did the patient use when relapsing? What pattern of use developed after the relapses? How did the patient’s use patterns change over time with each relapse? Are there any life circumstances that would give clues to events precipitating either relapse or abstinence?
  • Has the patient ever been abstinent from all psychoactive drugs for an extended period of time? When and for how long? What has been the longest time free of opioids in the past year, the past 5 years, and lifetime? What has been the longest time free of all psychoactive substances in the past year, the past 5 years, and lifetime? Has the patient switched from one addicting substance to another over time?

Treatment History—Addiction Treatment History

  • What previous diagnoses—addiction, psychiatric, and medical—have been given to this patient?
  • Describe all past attempts at detoxification. How many times has detoxification been tried? Was detoxification medically supervised? If so, how long were the detoxification treatments? What were the complications of detoxification? What were the outcomes? How long after detoxification did the patient start using opioids again? Why?
  • If the patient has ever been treated for addiction:
    – How many times has he or she received treatment? How long was each treatment?
    – What level(s) of care were received (detoxification, inpatient, residential, outpatient, sober‐living environment, opioid maintenance therapy)? What treatments were received (group, individual, or family psychotherapy; relapse prevention; pharmacotherapy; education; cognitive‐behavioral therapy; motivational enhancement therapy; others)? Was the focus of the treatment on psychiatric symptoms or addiction problems, or did the individual receive integrated addiction and psychiatric treatment services? How long was each treatment? Did the patient complete the recommended treatments? If not, why not?
    – Has the patient received pharmacotherapy for addiction? What previous treatment was received (e.g., brief medical detoxification, opioid maintenance therapy, disulfiram, naltrexone, or other medication therapy)? Has previous treatment been medical therapy alone or medical therapy in combination with comprehensive treatment interventions?
    – Was the patient compliant with previous drug and alcohol treatment, including prior opioid treatment programs? Did he or she use drugs and alcohol while in treatment? How long did she remain completely abstinent from all nonprescribed psychoactive drugs after each treatment? Which treatment was the most successful? Which one was least successful? What factors contributed to the success or failure of treatments?
  • Has the patient had contact with Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA), or other 12‐Step recovery programs? Ask the patient to describe his or her involvement in those programs. How many meetings were attended? Did he or she ever get a sponsor and work the steps? Does he or she have a current sponsor? How frequent is meeting attendance now?
  • Has the patient been involved in support groups other than 12‐Step? If so, which ones? Ask the patient to describe the support groups and the level of his or her activities and involvement.

Psychiatric History

  • Review of symptoms: What psychiatric symptoms has the patient ever experienced? Ask about depression, anxiety, irritability, agitation, delusions, hallucinations, mood swings, suicidal thoughts or attempts, homicidal thoughts or attempts, sleep disturbance, appetite or energy disturbance, memory loss, dissociation, etc. What current psychiatric complaints or symptoms does the patient have? Are they related to current drug use or inability to stop using?
  • Were psychiatric symptoms present before, during, and/or after substance use? What effects did abstinence from other drugs and alcohol and/or compliance with maintenance treatment have on psychiatric symptoms? Has the patient ever had a substance‐induced psychotic disorder, mood disorder, anxiety disorder, persisting perceptual disorder, persisting amnestic disorder, persisting dementia, or sexual dysfunction?
  • Has the patient ever had contact with psychiatrists or psychologists? What were previous psychiatric diagnoses? What medications were provided?
  • Has the patient ever been in psychotherapy? If so, what kind and for how long? Has he or she ever been hospitalized for psychiatric treatment? If so, what precipitated hospitalization?
  • What psychotropic medications have been prescribed and what was the response to each? List current psychotropic medications, prescribers of each medication, and the patient’s clinical response.
  • Were other treatments recommended? Was the patient compliant? What has helped the most?
  • What stressors and traumas have occurred throughout life? Was the patient ever physically, emotionally, and/or sexually abused, or traumatized in other ways? If so, at what age and under what circumstances? Has the patient ever discussed such trauma with a treatment provider or received treatment for these problems?

Family History

  • Which biological relatives have a history of addiction, alcoholism, “drinking problems,” “drug problems” (including prescription drug addiction), cirrhosis or other associated medical problems, depression, anxiety, sleep problems, attempted or completed suicide or homicide, psychiatric disorders or problems, overdoses, incarceration, criminal involvement, etc.? Have any family members been in recovery from addiction?
  • What other illnesses have affected the patient’s biological relatives?

Medical History

  • Perform a detailed review of systems. What medical problems or complaints does the patient have now? Which ones are or could be related to drug or alcohol use?
  • Past medical history: Ask about delirium tremens (DTs), withdrawal complications, or overdoses; tuberculosis or positive purified protein derivative (PPD) skin test, HIV infection, viral hepatitis (hepatitis A, B, C, D), syphilis, gonorrhea, pelvic inflammatory disease, or other sexually transmitted diseases (STDs); menstrual abnormalities, pregnancy or obstetric complications, spontaneous abortion; diabetes, thyroid disease, or other endocrine problem; cancer; hypertension, endocarditis, pericarditis, cardiomyopathy, congestive heart failure, ischemic heart disease, arrhythmia, heart murmur, mycotic aneurysm, thrombophlebitis; gastritis, ulcers, pancreatitis, hepatomegaly, hepatitis, or cirrhosis; pulmonary edema, chronic cough, pneumonia, lung abscess, chronic obstructive pulmonary disease; renal failure, renal calculi; sexual dysfunction; anemia, thrombocytopenia, neutropenia, lymphocytosis, or other blood disorders; lymphadenopathy; aseptic necrosis; osteoporosis; cellulitis, septic arthritis, osteomyelitis; brain, epidural, or subdural abscess; fungal meningitis; other infections; headaches, seizures, stroke, neuropathy, or other neurologic problems; physical trauma, accidents, and hospitalizations; any other medical complications of addiction. See figure 3-11 for a listing of selected medical disorders related to drug and alcohol use.
  • For any female patient, is it possible that she is pregnant? When was her last menstrual period? Is she sexually active with men? What method of birth control does she use? Does she desire to become pregnant in the near future?
  • Obtain the names and addresses of all other physicians currently providing care to the patient and obtain written consent to contact all treatment providers. Does the patient have a designated primary care physician? Is he or she being treated by a number of physicians? (See chapter 6 for a discussion of privacy and confidentiality laws and regulations pertaining to substance abuse treatment information.)
  • What medications is the patient taking now, and for what reason? Who prescribed the current medications? What has been the response to medication? Ask the patient to list all current medications and complementary or alternative therapies, such as vitamins, minerals, herbs, and supplements.
  • Explore the use, past and present, of addicting prescription drugs. What was the pattern of use of prescription drugs? Did the patient take the medications as prescribed, or more than prescribed, or in combination with alcohol or other drugs? Has the patient received prescriptions from several physicians? Has the patient ever “lost” prescriptions in order to obtain new ones, forged or phoned in prescriptions, stolen prescription pads, split prescriptions with others, or otherwise misused prescription medications?
  • Does the patient have pain problems? What pain treatments have been tried or recommended? Have opioid medications been prescribed? What was the response to various pain treatments? What is the level of pain now?

Sexual History

  • Is the patient sexually active? How many sexual partners does the patient have? How long has he or she been involved with his or her current partner(s)? Quantify the number and gender of sexual partners over the patient’s lifetime. Has the patient had sex with multiple partners or strangers? Has the patient had sex with males, females, or both?
  • What specific sexual activities has the patient engaged in? Does he or she ever have sex without a condom or other barrier protection? Has he or she traded sex for money or drugs?
  • Has the patient or any of his or her partners ever had or been treated for an STD? If so, which ones (syphilis, gonorrhea, HIV, chlamydia, or others)? How long ago were these treatments? How many times has the patient been treated for an STD?
  • Does the patient have any current symptoms of an STD, such as genital discharge, pain, itching, sores, or lumps?
  • Has the patient ever been hurt or abused by a sexual partner? Has he or she ever been sexually abused, molested, raped, or assaulted?
  • Is sex satisfying for the patient? Does he or she have any problems with or concerns about his or her sexual activities or function?

Cost/Consequences of Drug Use

  • What is the patient’s current level of functioning in social, family or relationship, educational, occupational, legal, physical health, and mental health arenas?
  • Has functioning been affected by drug use? If so, how? What financial, familial, social, emotional, occupational, legal, medical, or spiritual problems have occurred while the patient has been using drugs or as a result of having used drugs? Has the patient experienced legal problems, arrests, been charged with driving while intoxicated, had multiple divorces, marital discord, bankruptcy, fights, injuries, family violence, or suicidal thoughts? Describe specific problems and consequences.
  • Has there been hazardous or impairing substance use? If so, describe specifics.
  • Has a great deal of time been spent in activities necessary to obtain the substance, use the substance, or recover from its effects? Have important social, occupational, or recreational activities been given up or reduced because of substance use?
  • Has there been continued use despite adverse physical and social consequences? Has the substance use continued despite knowledge of having persistent problems that are likely to have been caused or worsened by the substance? If so, give examples.

Compulsivity or Craving

  • Does the patient report drug craving and/or urges to use? How does the patient deal with them?
  • Does the patient obsess about using drugs? Is there a compulsive pattern to the drug use?

Control

  • Has loss of consistent control over drug use occurred? Does the patient feel he or she has ever lost control over use, even one time? When did this first occur? What was the situation? What happened? Has the patient often taken a substance in larger amounts or over a longer period than was intended? Describe the evidence for loss of consistent control over use.
  • If the patient does not think control has ever been lost, do others (family, friends, employers, physicians, or others) think differently?

Social and Recovery Environment

  • What is the quality of recovery environment for this patient (supportive, nonsupportive, or toxic)? What has been the response of family, significant others, friends, employer, and others to the patient’s problems? What is the existing problem as the spouse, partner, or significant other sees it? Have any of these individuals suggested that the patient may have an alcohol or drug problem? When did they first suggest this? What do others object to about the patient’s drinking or drug use? What are their concerns or complaints?
  • Is the patient’s neighborhood, job, or profession a factor that does not support recovery?
  • What is or has been the patient’s support system? Have supportive individuals been involved in Al‐Anon, Nar‐Anon, or similar programs? Are they supportive of the patient’s getting help? Who has been alienated?
  • How many friends, family, or associates are partners in drinking or using? Are alcohol or other drugs present or used in the house where the patient lives? Who is drinking or using drugs in the patient’s home? What addicting drugs, either prescribed or nonprescribed, are still at home now?

Insight, Motivation, Readiness to Change

  • What is the patient’s understanding of his or her problem? What does the patient understand about the disease of addiction?
  • What Stage of Change is the patient in now: Precontemplation, Contemplation, Preparation, Action, Maintenance, Relapse? (See appendix G.) What stages has he or she passed through in the past? How responsive is he or she to motivational enhancement therapy?

Why Now?

  • Why did the patient seek treatment or help at this time?
  • Is treatment coerced or voluntary? What are the consequences if the patient does not seek help or complete treatment? How does the patient feel about these consequences?

Detection of Drugs in Urine and Other Samples

Physicians should become familiar with their laboratory’s collection procedures, sample testing methodology, quality control and assurance procedures, and adulterant testing methodology. They must understand laboratory report forms and procedures, the drugs screened in a routine panel, other drug tests performed at the laboratory, sensitivity of tests, and cutoff levels for reporting positive or negative test results. A comprehensive discussion of urine drug testing in the primary care setting can be found in Urine Testing in Primary Care: Dispelling the Myths & Designing Strategies (Gourlay et al. 2002). It is advisable that physicians become acquainted with the laboratory director and other personnel who can answer questions and provide other useful information.

Initial screening typically utilizes an enzyme multiplied immunoassay test (EMIT), a radio‐immunoassay (RIA), or a florescent polarization immunoassay (FPIA) test; each is based on antigen‐antibody interactions and is highly sensitive for specific drugs. Gas chromatography with mass spectrometry (GC/MS) is a highly sensitive and specific test that is labor intensive and costly, and is generally used to confirm the results of screening tests.

Detection of a drug depends on usage factors (e.g., dose used, frequency of use, proximity of last use) and characteristics of the specific drug. Most common drugs of abuse (e.g., cocaine, methamphetamine, heroin, marijuana) or their metabolites are readily detectable in the urine. Recent alcohol use is detectable in saliva, breath, blood, and urine samples.

Morphine (the metabolite of heroin) is detected by commercially available urine testing; however, methadone will not be detected as an opiate on some drug tests, unless a methadone assay is specifically requested. Oxycodone will cross‐react only at high concentrations. Buprenorphine does not cross‐react with the detection procedures for methadone or heroin. Although buprenorphine and its metabolite are excreted in urine, routine screening for the presence of buprenorphine is not feasible until testing kits become commercially available; none were available at the time this document was prepared.

Low‐potency benzodiazepines (e.g., diazepam and chlordiazepoxide) are readily detected in routine urine drug screens. However, clonazepam, flunitrazepam, alprazolam, and several other benzodiazepines may be undetected in urine samples. Since the combination of buprenorphine and benzodiazepines can be lethal (Reynaud et al. 1998a ,b; Tracqui et al. 1998), it is essential to screen effectively for the recent use of benzodiazepines. It may be necessary to specifically request that a sample be evaluated for benzodiazepines that are not detected on routine drug screens.

Figure E–1 FRAMES: Elements of Brief Interventions

  • FEEDBACK of personal risk or impairment. Most successful brief interventions provide clients with some form of feedback of the results of their assessment of alcohol and other drugs.
  • Emphasis on personal RESPONSIBILITY for change. Many brief interventions advise patients that drinking is their own responsibility and choice. The implicit or explicit message is that “What you do about your drinking is up to you.” Perceived control has been recognized as an element of motivation for behavior change and maintenance (Miller 1985).
  • Clear ADVICE to change. Effective brief interventions contain explicit verbal or written advice to reduce or stop drinking. In fact, advice has been described as the essence of the brief intervention (Edwards et al. 1977).
  • A MENU of alternative change options. Effective brief interventions seldom advise a single approach, but rather a general goal or a range of options. Presumably, this broad approach increases the likelihood that an individual will find an approach appropriate to his or her situation.
  • Therapeutic EMPATHY as a counseling style. Successful interventions have emphasized a warm, reflective, empathic, and understanding approach. No reports of effective brief counseling contain aggressive, authoritarian, or coercive elements.
  • Enhancement of client SELF‐EFFICACY or optimism. It is common in brief interventions to encourage self‐efficacy for change, rather than emphasizing helplessness or powerlessness. Optimism regarding the possibility of change is often embedded in effective motivational counseling.
  • Ongoing followup. In addition to these six elements, effective use of brief intervention often includes repeated followup visits. At least two studies have found that a reduction in drinking occurs after the first followup visit (Elvy et al. 1988; Heather et al. 1987). However, even without the benefit of repeated followup, studies consistently document the occurrence of marked behavior change immediately following the brief intervention.

Source: Adapted from Miller and Sanchez 1994.

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