Richard Elovich, MPH Columbia University Mailman School of Public Health Medical Sociologist

1. Oral Substitution Treatment for Opioid Dependence: A Training in Best Practices & Program Design for Nepal Day 1 March 26-28, 2006 Kathmandu, Nepal UNDP Richard Elovich, MPH Columbia University Mailman School of Public Health Medical Sociologist Consultant, International Harm Reduction Development International Open Society Institute

2. This Training is Adapted From: • Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs CSAT/SAMSHA (Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment) • Best Practices in Methadone Maintenance Treatment Office of Canada’s Drug Strategy • Addiction Treatment: A Strengths Perspective Katherine van Wormer and Diane Rae Davis • Additional Sources: Robert Newman, MD, Alex Wodak, MD, Melinda Campopiano, M.D, Miller and Rollnick, Prochaska, DiClemente, and Norcross, Michael Smith, MD, Sharon Stancliff, MD, Ernest Drucker, PhD,

3. Clear Program Philosophy and Treatment Goals Adequate Resources Involvement Of Wider Community Program Development And Design Focus on Engagement and Retention Client/Patient Involvement A Maintenance Orientation Integrated Comprehensive Services A Client/Patient Centered Approach Accessibility

4. Training Goals • Ideally, this training will contribute to: • Increased knowledge, skills and best practices among OST practitioners and providers; • Engagement and retention of clients/patients in the OST program in Kathmandu • Improved treatment outcomes

5. The Socio-Pharmacology of Opioid Use and Dependence Introduction and background of oral substitution treatment The pharmacology of medications used in oral substitution treatment Information collection and service provision: ‘assessment-in-action’ Pharmacotherapy and OST Insights from the field Six Training Modules

6. Learning Together Parallel Process

7. Learning Process: Knowledge and Skills • Acquisition of content • Retention (store in memory) • Application (retrieve and use) • Proficiency (integrate and synthesize)

8. This is an 18 hour training over a 3 day period. Allowances have been made for your work schedules: Noon – 6 PM. You must be present and participate in all 18 hours of the training to receive certification. There can be no exceptions. Please stay focused. Be on task because we have a lot of material to cover in 3 days. Listening is a key to this training. Listen to new ideas. Listen to what’s coming up inside you in relation to what’s being presented. Try to put your thoughts and feelings into words instead of “shutting down.” Acknowledge and respect differences. You can “agree to disagree” on a contentious point and move on. Participate in role plays. Everyone has permission to pass. Offer feedback constructively not personally. Try to receive feedback as a gift. Expectations for Certification: Training Contract

9. Try to be okay with taking some learning risks. Stretch past your edge of what you know and what you are comfortable with.  Confidentiality. Hold the container. Don’t be leaky. Turn off phones please. No cross talk. Allow one person to speak at a time. Equal time over time. Start and end on time, including breaks. Be alert to tendency to fudge this.  Use “I” statements. Can everybody agree to this training contract? Is there anything you absolutely cannot live with?  Now we are off. Learning Environment

10. I. The Socio-Pharmacology of Opioid Use and Dependence

11. Heroin/Tidigesic/’Set’ Use= Social • Heroin/opiate use, though physiological and experienced in the body, is socially mediated. • What does this mean? • Initiation– relational, social • Learning to use the drug. • Administration • The experience changes over time • Managing the experience • Contingencies • What else?

12. The production of getting “off” or getting “high”. • Brainstorm components of the production. • List names of the social actors involved in the production. • Identify social interactions. • Identify cognitive and learning processes. • Identify strategies of the heroin user or addict.

13. What is Opioid dependence?

15. “Drug Use is The Root of Their Problems” • Substance use may be an expression of a problem rather than its cause. • Rather than the cause of erratic or unhealthy behavior, substance use may be an adaptive mechanism or best solution to a range of problems including mental illness, abusive partner, homelessness, sexual abuse, poverty or other difficulties (Springer, 1991)

16. “Bad Drug Using Women” • A survey of crack-using women in New York, for example, found that nearly 1/3 had a past history of abuse and prior hospitalization for mental illness (Chavkin, 1993). • In another, women who were HIV+, were homeless in the last year, and had experienced combined physical and sexual abuse were also those most likely to report exchanging sex for drugs and money, using injection drugs in the past year, and having sex in crack houses (El Bassel et al, 2001).

17. “An Addict Stays the Same or Gets Worse.” • Addiction is cyclic and variable in intensity. While some addicts may follow the pattern, made familiar by alcoholism, of chronic, progressive illness, others may have periods of intense drug use and dysfunction followed by long periods of being drug free or vice versa (Kane, 1999). • Compare cocaine bingeing and heroin use.

18. “It’s Their Choice; it’s Their Own Fault.” • Ongoing substance use is rarely a simple question of choice. • Much as with people in abusive relationships or those with compulsive disorders, “choice” for substance users is shaped by perceptions of self-efficacy, mental health status, and social conditions.

19. “They stopped growing. They are not themselves. They are addicted.” • How do we know they stop growing? • Who defines when people are themselves? • How do we define these terms? Societal or cultural norms? • How does the “planet heroin” story lead us to the disappearance of the person into the drug? • How are heroin users accounts of themselves ignored or marginalized when we make these assumptions based on the label addict?

20. “They are manipulative. They lie.” • Once a person is labeled a heroin addict, what assumptions do we make about them? • How are they treated by health providers? • Imagine yourself at your last job interview.

21. “Whose Fault is it Anyway?” • Addiction– like hypertension, asthma, or diabetes– is chronic, relapsing condition whose etiology frequently includes a combination of behavioral, genetic, and environmental factors. • As with substance users, only a minority of diabetics or hypertensives successfully abstain from the behaviors contributive to these conditions, yet these patients are not stigmatized, blamed for their condition, or denied health services (McLellelan et al, 1995)

22. 1. How Do Drugs Work? • Drug Action: Interconnection between neurology, the science of the nervous system, and chemistry • Drug Effects represents broader phenomena than drug and living tissue association. • Drug Factors, which originate outside the laboratory, in real life practice that shapes effects.

23. Drug Action I • In passing through the brain, a given drug (the “key”) will be attracted to, and will bind to a specific site in the brain (the lock). • The sites in the brain that control certain organs are rich in receptors into which specific drugs “fit” much like a key into a lock; these same sites may lack receptors for other drugs.

24. Drug Action II • For instance, after heroin turns into morphine in the body, morphine “fits into” the receptors in the brain that control breathing and heartbeat rate, and hence, a sufficiently large dose of this drug can shut down these two functions and cause death by overdose.

25. Opiates: Duration of action • Methadone 24 hours • Oxycontin 12 hours • Heroin 6-8 hours • Dilaudid 4-6 hours • Codeine 3-4 hours • Demerol 2-4 hours • Fentanyl 1-2 hours

26. Heroin In The Brain

27. Short-term Effects Of Heroin Use • Soon after injection (or inhalation), heroin crosses the blood-brain barrier. • In the brain, heroin is converted to morphine and binds rapidly to opioid receptors. • Abusers typically report feeling a surge of pleasurable sensation, a "rush."

28. Short-term Effects Of Heroin Use • The intensity of the rush is a function of how much drug is taken and how rapidly the drug enters the brain and binds to the natural opioid receptors. • Heroin is particularly addictive because it enters the brain so rapidly.

29. Short-term Effects Of Heroin Use • With heroin, the rush is usually accompanied by • A warm flushing of the skin, • Dry mouth, and • A heavy feeling in the extremities, • The rush may also be accompanied by • Nausea, • Vomiting, and • Severe itching.

30. Short-term Effects Of Heroin Use • After initial effects, drowsy for several hours. • Mental function clouded by effect on CNS. • Cardiac function slows. • Breathing severely slowed, sometimes to the point of death. • Overdose is a particular risk on the street, where the amount and purity of the drug cannot be accurately known.

31. Short-term Effects Of Heroin Use • “Rush” • Depressed Respiration • Clouded Mental Functioning • Nausea and Vomiting • Suppression of pain • Spontaneous abortion

32. Heroin Intoxication • Pupil size (pinned pupils) • Voice (slower, lower in tone) • Conversations (talkative) • Being high (feeling warm, euphoric, content) • Scratching • Droopy eyes • Itchiness? • Blood spots (needle marks bleed) • Expansive mood • Nodding out (sleep-like state)

33. Drug Action and Drug Effects • It is crucial to make a distinction between the specific pharmacological action of a drug, which is the product of a biological and chemical process, and drug effects.

34. Drug Effects • Drug effects is far more than the chemistry of a drug placed in the setting of living tissue. They represent the nonspecific factors that influence drug effects. • Six more or less pharmacological dimensions: (1) identity and half-life in the body; (2) dose; (3) potency and purity; (4) drug mixing; (5) route of administration; (6) habituation.

35. Five additional factors that originate outside the laboratory setting in real life practice • Set • Setting • Script • Schedule(раскумарчтвся or morning shot) • Structure

36. Need for increased amounts of the drug to achieve desired effect Markedly diminished effect with continued use of the same amount of the drug Withdrawal Characteristic withdrawal syndrome The same (or closely related) drug is taken to relieve or avoid withdrawal symptoms The drug is taken in larger amounts or over a longer period than was intended There is a persistent desire or unsuccessful efforts to cut down or control drug use A great deal of time is spent in activities necessary to obtain the drug Important social, occupational or recreational activities are given up or reduced Drug use is continued despite knowledge of having a persistent or recurrent problem that is likely to have been caused or exacerbated by the drug use Tolerance

37. What is Substance Dependence • As the DSM IV explains, the term “addiction” is no longer widespread in the medical community, and has been widely replaced by the term “drug {or substance} dependence. They also note that the term “drug {or substance abuse} abuse” is: • “a highly complex, value-laden and often excessively vague term that does not lend itself completely to any single definition.” • Furthermore, because the term has different meanings for different groups of people– and their definition of the term reflects their different perspectives– there is often difficulty in drawing a line between use of substances and abuse of substances (Brands et al., 1998, 45).

38. Dependence Syndrome • Dependence syndrome consists of the particular behavioral, cognitive and physiological effects that may arise through repeated substance use. • Psychological characteristics include a strong desire to take the drug (craving), impaired control over its use, persistent use despite harmful consequences, and the prioritization of drug use over other activities and obligations. • Physical dependence comprises increased tolerance and a physical withdrawal reaction that occurs when drug use is discontinued (WHO 1984)

39. The DSM-IV* Specifies Criteria for Opioid Dependence: “A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring any time in the same 12-month period: • tolerance, as defined by either of the following: • A need for markedly increased amounts of the substance to achieve intoxication or desired effect • Markedly diminished effect with continued use of the same amount of the substance. *American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorder (DSM-IV)

40. The DSM-IV Specifies Criteria for Opioid Dependence: • Withdrawal, as manifested by either of the following: • The characteristic withdrawal syndrome for the substance • The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms • The substance is often taken in larger amounts or over a longer period than was intended • There is a persistent desire or unsuccessful efforts to cut down or control substance use

41. The DSM-IV Specifies Criteria for Opioid Dependence: • A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects • Important social, occupational, or recreational activities are given up or reduced because of substance use • The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

42. Perspectives on Drug Dependence • The unfolding nature of heroin dependence • Different types of dependencies and patterns of practices. Drug dependence is complex and variable but literature speaks in absolutes • Fluid phenomenon: movable famine • Drug users are thinking, strategizing • Range of different therapies/services for multiple and incremental outcomes

43. Tolerance and Habituation • When a person uses heroin regularly, they develop a tolerance– they have to use more heroin to get the same effects. The greater the amount and frequency of their use, the faster they become tolerant. • Some people try to “chip” or use only occasionally, avoiding two days in a row. • Others try to “manage their habits” by using a little less for a day or two to lower their tolerance, allowing them to decrease the amount needed to get high-- or well.

44. Overdose • Overdose is a serious health risk for heroin users. • Heroin slows down the heart rate and breathing; someone who overdoses may eventually stop breathing altogether. • Mixing heroin with other drugs (valium, alcohol, cocaine) significantly increases risk of overdosing, especially alcohol.

45. Active Drug users can be approached about overdosing: • Avoid mixing heroin with other drugs, especially “benzos” (Xanax, Clonopin, Ativan, Valium), other “downs” (Seconal, Elavil, Placidyl) or alcohol. • Many drug users overdose after coming out of jail because their tolerance has fallen. Users should do a tester shot if it is from a new source or they have not used in a while.

46. Overdose are very serious but do not have to be fatal: • Drug users should talk with using partners and make a plan for dealing with ODs. If they have thought it through, they are less likely to panic or freeze up in the event of an actual OD. • Drug users should know about Naloxone, what paramedics use, and can call 1 866 STOP ODS for more information. • Drug users can learn rescue (mouth to mouth) breathing, which is the most important thing they can do to help someone survive an overdose.

47. Heroin Withdrawal (1 of 2) • Elevated Blood Pressure & Pulse • Insomnia (can last for days or weeks) • Restlessness • Anxiety (confusion, exaggerated startle reflex) • Irritability • Body aches • Lacrimation • Sneezing

48. Heroin Withdrawal (2 of 2) • Runny nose • Piloerection (body hair stands up) • Nausea and vomiting (can lead to dehydration) • Sweating • Diarrhea • Deep muscle twitch • Spontaneous erection or ejaculation (due to hypersensitivity) • Pupil dilation (enlarged pupils)

49. Long-term Effects Of Heroin Use • Dependence • Infectious Diseases: HIV/AIDS, Hepatitis B & C • Collapsed veins • Bacterial Infections • Abscesses • Infection of heart lining and valves • Arthritis and other rheumatologic problems

50. Long-term Effects Of Heroin Use • Physical dependence develops with higher doses of the drug. • The body adapts to the presence of the drug and withdrawal symptoms occur if use is reduced abruptly. • Withdrawal may occur within a few hours after the last time the drug is taken.