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 1. Recovery and pharmacotherapy 2. Patient orientation towards recovery 3. 12-Step meetings 4. Patient management 5. 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, 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