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

2. What does it mean to “treat” addiction? What does it mean to “treat” addiction? Are objections to agonist therapies valid or just ignorant? Are objections to agonist therapies valid or just ignorant? Medical model and Recovery model: conflictual or complementary? Medical model and Recovery model: conflictual or complementary? The Kirkbride/CBH Model: Methadone-assisted rehabilitation 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 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) Responsibility/Roles of Doctor and Patient (passive vs. active) Science or Spirituality Science or Spirituality Alleviate symptoms vs. feel feelings, tolerate unpleasure Alleviate symptoms vs. feel feelings, tolerate unpleasure Stabilize and maintain vs. seek higher plane (swimming pool vs. quest) 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” : “It’s just being hooked on another drug, a substitute addiction” “You’re still addicted; you’re not in recovery” “You’re still addicted; you’re not in recovery” “You can never get off it” “You can never get off it” Valid or ignorant? Valid or ignorant?

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

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

8. Carl 37 years old, heroin addiction from age 21, multiple rehabs, only sober more than 60 days while incarcerated 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.” “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.” “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 Physician leadership Evaluation over time, data collection (managed care), observation Evaluation over time, data collection (managed care), observation Time for considered decision (Donna) Time for considered decision (Donna) Management of co-occurring illness (Ann) Management of co-occurring illness (Ann) Staff feedback, observation Staff feedback, observation Challenges and resistance Challenges and resistance

11. Donna 20 yrs old, bright, appealing, intact family. HS grad, wants to go to college and study nursing. 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. Percocet age 16 >>> Oxycontin >>> heroin past 18 months. Admitted for detox and rehab. Methadone detox protocol of 30 to 0 by 5 mg/day. 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. 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. "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, 29 yo, hx childhood sexual trauma ages 4-13, long adult psych hx depression, self-mutilation, mult hosp/rehabs, ECT, Thorazine, Paxil long adult psych hx depression, self-mutilation, mult hosp/rehabs, ECT, Thorazine, Paxil heroin dependence from age 18. heroin dependence from age 18. Easily tolerates detox >>> rehab Easily tolerates detox >>> rehab Consulted 10 days after detox for impulses to self-mutilate. 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. 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 Initiation, panic, husband supports, completion

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

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

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

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