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Overview of Presentation . Background informationSome general issues in treating opioid dependent patients Some treatment approaches. Opioids . Relieve painProduce and alleviate morphine-like withdrawalMorphine, heroin, methadone, codeine, hydrododone (Vicodin), oxycodone (Percodan), Darvon, Demerol.
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1. Counseling Opioid Dependent Patients Information and Treatment Approaches
for Counselors
Michael J. McCann, MA
Matrix Institute on Addictions
2. Overview of Presentation Background information
Some general issues in treating opioid dependent patients
Some treatment approaches
3. Opioids Relieve pain
Produce and alleviate morphine-like withdrawal
Morphine, heroin, methadone, codeine, hydrododone (Vicodin), oxycodone (Percodan), Darvon, Demerol
4. Opioid Dependence Repeated use results in tolerance (more is required for desired effect)
and,
Withdrawal upon cessation of use
Chills, gooseflesh, sweating, yawning
Runny nose, tearing eyes, dilated pupils,
Nausea, diarrhea,
Insomnia, anxiety, craving
5. Range of Counselor Experience Broad experience with SA dependence treatment, including opioid dependence
SA treatment experience, but not with opioid dependence
Counselors with no SA treatment experience
6. Counseling Opioid Dependent Patients: Some General Issues Recovery and pharmacotherapy
Patient orientation towards recovery
12-Step meetings
Patient management
A Cog/Behavioral approach
7. Recovery and Pharmacotherapy
Patients may have ambivalence regarding medication
The recovery community may ostracize patients taking medication
Counselors need to have accurate information
8. Recovery and Pharmacotherapy
Focus on “getting off” medication may convey taking medication is “bad”
Suggesting recovery requires cessation of medication is wrong
Support patient’s medication-taking
“Medication,” not “drug”
9. Recovery and Pharmacotherapy: Fact Methadone treatment efficacy% of sample, n=727, Hubbard et al. 1997
10. Recovery and Pharmacotherapy: Fact Methadone treatment results in a 4-fold decrease in mortality
John Caplehorn, 1996
11. “Just substituting one drug for another”
“Patients are still addicted”
But,
Medications are legal
Oral vs injected
Taken under medical supervision
Inexpensive Recovery and Pharmacotherapy: Facts and Myths
12. “Patients are getting high”
But,
Long acting, slow onset
Matches level of addiction
Recovery and Pharmacotherapy: Facts and Myths
13.
Often a narrow focus; physical relief is sufficient
Focus on not using illicit opiates vs. new behaviors
Counseling may be viewed as an unnecessary imposition Patient orientation towards recovery
14. Patient orientation towards recovery
Patient orientation, counselor response
Impatience, confrontation, “you’re not ready for treatment”
or,
Deal with patients at their stage of acceptance and readiness
15. Patient orientation towards recovery Patient orientation, counselor response
Be flexible
Don’t impose high expectations
Don’t confront
Non-judgmental acceptance
A motivational interviewing approach
16.
What is the 12-Step Program?
Benefits: peer support, widely available, social outlet, free
Meetings: speaker, discussion, Step study, Big Book readings
Self-help vs treatment 12-Step Meetings
17.
Medication and the 12-Step program
Program policy
“The AA Member: Medications and Other Drugs”
NA: “The ultimate responsibility for making medical decisions rests with each individual”
Some meetings are more accepting of medications than others
12-Step Meetings
18. Urine Testing A standard treatment component
A tool to prevent drug use
Does not reflect assumption of patient dishonesty
Ideally monitored (temperature strips)
Minimize tampering: containers, purses, backpacks, hot water, etc
Detection times
19. Urine Testing: Dealing with a positive test Re-evaluate the circumstances prior to the test
Don’t discuss validity of the result (lab error, etc.)
Don’t confront; provide an opportunity for the patient to explain
20. Urine Testing: Dealing with a positive test
Reinforce honesty
Partial confession is good enough; move on
Proceed with assumption of drug use
Communicate with physician
21. Urine Testing: Other Issues
Falsified specimens; avoiding voiding
Indicators: cold, clear, Gatorade, apple juice
Ask the patient about it
Observed test is an option
Avoidance excuses: “can’t go”; “just went”
22. Patient Management
“Manipulation”
A vestige of the drug-using lifestyle
An old survival skill
An unlikable quality in the world
A manifestation of the disorder in treatment (cardiologists don’t criticize patients having chest pains)
23. Patient Management
“Manipulation”
Counselor’s responses
Protective cynicism
Trust and openness
24. Patient Management
Pushing Boundaries
Inappropriate familiarity
Reflexive “manipulation”?
May result from past counseling experiences
25. Patient Management
Intoxication
Manage the situation, don’t counsel
Ensure patient safety
Arrange transportation
26. Patient Management
Loitering
May have been acceptable in prior treatments
Creates opportunities for dealing
Not the best use of time
Not well tolerated by neighbors
May reflect problems at home
27. Counseling Approaches Provide information and skills
Conditioning Process: you can’t “will” cravings away; modify behavior
Addiction as a brain disease
28. Counseling Approaches Information and Skills
Get rid of paraphernalia
Scheduling time
Thought-Stopping for cravings
Evaluate people and places (fools rush in)
29. Counseling Approaches Relapse Prevention
Patients need to develop new behaviors
Learn to monitor signs of vulnerability to relapse
Recovery is more than not using illicit opioids
Recovery is more than not using drugs and alcohol
30. Counseling Approaches Relapse Prevention Topics
Relapse Prevention Overview
Overview of the concept: things don't “just happen”
Using Behavior
Old behaviors need to change
Re-emergence signals relapse risk
Relapse Justification
“Stinking thinking”
Recognize and stop
31. A Good Counseling Session Patients ultimately may need to understand why they became addicted
More important early on:
Understanding the addiction disorder
Making changes in day-to-day life
A good session: the patients leaves knowing more about addiction and recovery