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Psychiatric Aspects of MMT: Integrating Medical Model with Recovery

Psychiatric Aspects of MMT: Integrating Medical Model with Recovery. What does it mean to “treat” addiction? Are objections to agonist therapies valid or just ignorant? Medical model and Recovery model: conflictual or complementary?

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Psychiatric Aspects of MMT: Integrating Medical Model with Recovery

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  1. Psychiatric Aspects of MMT: Integrating Medical Model with Recovery

  2. What does it mean to “treat” addiction? • Are objections to agonist therapies valid or just ignorant? • Medical model and Recovery model: conflictual or complementary? • The Kirkbride/CBH Model: Methadone-assisted rehabilitation

  3. Are Medications that reduce risk of drinking or heavy drinking, or that promote abstinence, of value in the treatment of Alcohol Dependence? • Gitlow, Willenbring: American Journal on Addictions, Jan-Feb 2008

  4. What is treatment?Medical/Psychiatric model vs. Recovery model • Responsibility/Roles of Doctor and Patient (passive vs. active) • Science or Spirituality • Alleviate symptoms vs. feel feelings, tolerate unpleasure • Stabilize and maintain vs. seek higher plane (swimming pool vs. quest)

  5. Critiques of MMT • : “It’s just being hooked on another drug, a substitute addiction” • “You’re still addicted; you’re not in recovery” • “You can never get off it” • Valid or ignorant?

  6. Critiques of MMT • Split “orphaned” treatment • You get what we offer • Implicit medical model combines with system to encourage passivity • Does MMT “treat” addiction? • Holistic vs. targeted intervention • Problems with Clinics– power, training, psychiatry, arbitrariness, drug emporia

  7. The Kirkbride/CBH Model:It Takes a Village • A new form of treatment • Collaboration with Managed Care • “Mandated” MMT– coercive? • “I want to start coming off it now” • Seeking system continuity

  8. Carl • 37 years old, heroin addiction from age 21, multiple rehabs, only sober more than 60 days while incarcerated • “I don’t want MMT, just want to be off everything– it’s just another addiction. I’ve never really wanted it before, always tried to get clean for someone else.”

  9. JOHN • “I don’t really want to be on mtd, I don’t like it , but what’s my choice really?  I get 3 months clean and get a job and start believing in myself, and then it all goes down the tubes.  At least this way maybe I can sustain something., even if I don’t really want it.”

  10. Methadone-assisted Rehab • Physician leadership • Evaluation over time, data collection (managed care), observation • Time for considered decision (Donna) • Management of co-occurring illness (Ann) • Staff feedback, observation • Challenges and resistance

  11. Donna • 20 yrs old, bright, appealing, intact family. HS grad, wants to go to college and study nursing. • Percocet age 16 >>> Oxycontin >>> heroin past 18 months.  •  Admitted for detox and rehab.  Methadone detox protocol of 30 to 0 by 5 mg/day. • Intense cravings and w/d sxs, but does not want MMT.  Extended detox 5 days at 15-10-10-5-5.  At 5 mg, same experience.  Agreed to again extend taper but no further.  Still tolerating poorly.  • "If you are as honest as you can be with yourself, what do you see happening when you leave K?"  Can't see self staying sober, agrees to MMT.

  12. Ann • 29 yo, hx childhood sexual trauma ages 4-13, • long adult psych hx depression, self-mutilation, mult hosp/rehabs, ECT, Thorazine, Paxil • heroin dependence from age 18. • Easily tolerates detox >>> rehab • Consulted 10 days after detox for impulses to self-mutilate. • Overwhelming opiate cravings, no w/d sxs. Factors: no ability to stay sober, “last chance” in marriage described as loving and highly valued. Opiates contain impulses to mutilate. • Initiation, panic, husband supports, completion

  13. Agonist Therapy: controversies • Mtd/bup as facilitator of recovery • Mtd/bup as impediment to recovery • “Is it part of your addiction or part of your recovery?” • Agonist tx as hybrid of medical model & recovery: Medical therapy within context of recovery process • Long-term: reclaim autonomy

  14. Benzos and Methadone– so happy together • “I got anxiety doc– I’ve been diagnosed” • “My nerves are bad/shot” • “I’ve been on them for years” • “I’ve tried everything– nothing else works” • “My psychiatrist says I have to take them”

  15. Benzos and Methadone– so happy together Therapeutic use of benzos? DOC in MMT patients. Problem for all programs What model? Anxiety or craving? Treatment or enabling? Symptom relief or substance abuse? Consider: “I need dope/benzo to feel normal” Increase MMT dosage? Kirkbride experience-- evolved Policies (spectrum): Individual needs vs program integrity Contrast with psychostimulants

  16. Future Directions: Why Not Buprenorphine-assisted Rehab?

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