Residential Treatment: What’s Methadone Got To Do With It? Siara Andrews, Psy.D. 1 Yong S. Song, Ph.D. 1 Steve Myers 2 University of California at San Francisco 1 Walden House, Inc. 2 Presentation at American Association for the Treatment of Opioid Dependence October 16-20, 2004

Acknowledgements  Support from NIDA: R01DA14922  Staff of Walden House  Staff of Methadone Programs: SFGH, BAART, Westside  Co-investigators & Consultants on the Project  Research Staff

Preview  Objectives  Methadone Clinic-Overview  Therapeutic Community-Overview  Research to Practice: Methadone-Enhanced Recovery in the Therapeutic Community  Improving collaboration between methadone clinic and residential treatment  Discussion, Q & A

Objectives: What you can expect to learn today  How the TC is adapted to integrate methadone treatment.  How methadone clinics work with other treatment providers.  Review of identified challenges and how to overcome these challenges to integrating methadone into residential treatment.

Opiate Treatment Outpatient Program San Francisco General Hospital

OTOP Methadone Clinic  History of OTOP MMT –Opened in 1972 –County Hospital based program –Serves medically indigent population –HIV epidemic in 1980s  Components of treatment –Methadone maintenance –Psychiatric Care –HIV Primary Care –Nursing Services –Social Services

OTOP Methadone Clinic  Patient population –Licensed capacity of 750 –Provider of last resort in SF –Medically & psychiatrically severe –Many homeless  Demand surpassing Capacity –15,000 to 17,000 IDU heroin users in SF –SF top 4 in heroin-related hospital admissions –Approximately 3500 methadone treatment slots –Long waits for access to MMT

OTOP and Walden House  Expansion of treatment –Mobile Methadone Program –Expansion of 150 additional treatment slots –Cooperative agreement with WH –Transfer of WH patients from other methadone programs to Mobile program at WH –Receipt of medical services at main clinic –Methadone counselor onsite at WH

Walden House, Inc.

Walden House  History of the TC – First methadone clients in Walden House, clients had to be on 30mgs or less to get into treatment. –1997 – 30mg requirement was dismissed and client’s doses are now and have been accepted on an individual basis with no dose limit requirements. –Clients must be on methadone when entering treatment as Walden House does not put anyone on while in treatment. –Clients must sign a treatment agreement before entering treatment.

Research to Practice: MERIT 1. Determine the effectiveness of treating ORT patients in a TC. 2. Investigate challenges to the acceptance of ORT in the TC environment. 3. Develop a manual for integrating ORT into TC’s.

MERIT: Design & Methods Follow two groups of residents entering a TC, comparing: 1. Residents receiving ORT (n=125) 2. Residents with heroin history but NOT receiving ORT (n=125)

Medication Use in the TC?  Evolutionary perspective: To survive, we change, but also maintain the essential elements of the TC.  Historically: Use of medications is incompatible with TC perspective.  TC Policy is changing to allow –HIV medications: non-psychoactive –Psychiatric medications: Mood stabilizing –Maintenance medications: Methadone, buprenorphine –Pain medications: vicodin, oxycontin *De Leon, George (2000).

Use of Medications in USA TCs Uniform Facilities Data Set (1998) Very few residential programs provide medication (26%). Almost no residential programs provide ORT (2%).

TC staff familiarity with substance abuse pharmacotherapies MedicationNo extent Very great extent Methadone7% 37% of staff Buprenorphine38% 4% ( Univ. of Georgia, NIDA R01-DA-14976, from Paul Roman)

TC Staff Use of Methadone  Ever use methadone? 11%  Using methadone now? 7% (n=21)  Provide methadone in own clinic? N=6 TC’s

Investigating Challenges: Stigma about Methadone among TC Staff  I nvestigated TC staff beliefs & knowledge of methadone  Surveyed staff (N=87)in the 4 SF WH programs  Administered Surveys: –Abstinence Orientation Scale 1 –Methadone Knowledge Scale 2 1Caplehorn, et al. (1996). 2Caplehorn, et al. (1998).

Stigma Study: Results  Higher abstinence orientation than among methadone clinic staff in NYC and Australia  Greater methadone knowledge among TC staff who had been in drug/alcohol treatment  Especially among staff who had been in MMT  Taking methadone sensitivity training was correlated with lower abstinence orientation and greater methadone knowledge.

Investigating Challenges: TC client beliefs about methadone  Focus Groups conducted separately with clients on methadone and clients not on methadone –Clients from both groups expressed jealousy toward the other –Clients from both groups had similar suggestions for improving the integration of treatment: Add client and staff education about methadone Make methadone more accessible at the TC

Challenges to integrating methadone and residential treatment  Differences in structure  Difference in staff  Differences in treatment philosophy model

Differences in Structure  Time: –Methadone clinic: 1 hour/day or less, depending on counseling required, take-home doses –Residential treatment: 24 hours/day  Interaction with other clients: –Methadone clinic: limited to groups –Residential TC: relationships in the community serve as treatment  Intensity –Methadone - outpatient - use motivation –TC - inpatient - use behavioral intervention with structure  Confidentiality and rapport-building

Differences in Staff  Methadone Clinic –Greater medical focus –Some staff in recovery –University based program –Smaller staff  Therapeutic Community –Less medical focus –Most WH staff in recovery –Most staff are certified counselors

Differences in Treatment Philosophy (1) Client Centered Approach vs. Consensus Model (2) Abstinence vs. Harm Reduction Model –Abstinence philosophy: historically actively discouraged use of most mood altering drugs including prescription medications. –Harm reduction: the reduction, even to a small degree, of the harm caused by the use of drugs (Parry, 1989). (3) Biopsychosocial model vs. Social Rehabilitation Model

Challenges  Staff have differing ideas of what treatment goals are  Clients may get mixed messages from different programs  Some behaviors are tolerated in one environment, but not another (relapse, nodding, dose increase)  Opportunity for staff splitting

Recommendations to Improve Collaboration  Training/Inservices –Tours  Policy –Fast Track Admissions to Methadone  Communication –Collaborative work groups

Suggested Accommodations in TC  Modifications for Residents –Methadone Group (Separate groups for clients tapering vs. maintaining –Alternative Therapies (e.g., acupuncture) –Medical Support while tapering –Coordination of medication issues with methadone clinic staff –Education for non-ORT residents –Include methadone goals in treatment plans  Modifications for Staff –Methadone sensitivity training –Policies regarding residents on ORT

Suggested Accommodations for Methadone Clinics  Modifications for Clinic Clients –Flexibility in psychosocial treatment requirements –Ease of access: Mobile Program/Take home doses –Coordination of medication issues with TC Staff  Modifications for Clinic Staff –Policies regarding residents in TC Take homes, etc. –Training on TC ’ s, facility tour –Focused supervision with counselors Common treatment goals, cultural integration, communication –Active role in education & bridging relationships

Discussion/Questions ???

Therapeutic Community as Treatment 1. In the TC, the relationship is the treatment. 2. The TC is community-centered, not client-centered. 3. The TC goal is always to get patients off all Opioid Replacement Therapies. 4. TCs do not use a harm-reduction approach. 5. Use of medication is incompatible with TC policies. 6. In the TC, confrontation is a necessary part of treatment.