Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs. A Treatment Improvement Protocol TIP

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1 Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs A Treatment Improvement Protocol TIP 43 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment MEDICATION- ASSISTED TREATMENT

2 Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs Steven L. Batki, M.D. Consensus Panel Chair Janice F. Kauffman, R.N., M.P.H., LADC, CAS Consensus Panel Co-Chair Ira Marion, M.A. Consensus Panel Co-Chair Mark W. Parrino, M.P.A. Consensus Panel Co-Chair George E. Woody, M.D. Consensus Panel Co-Chair A Treatment Improvement Protocol TIP 43 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857

3 Acknowledgments Numerous people contributed to the development of this Treatment Improvement Protocol (see pp. xi and xiii as well as Appendixes E and F). This publication was produced by Johnson, Bassin & Shaw, Inc. (JBS), under the Knowledge Application Program (KAP) contract numbers and with the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS). Christina Currier served as the Center for Substance Abuse Treatment (CSAT) Government Project Officer, and Andrea Kopstein, Ph.D., M.P.H., served as Deputy Government Project Officer. Robert Lubran, M.S., M.P.A., and Alan Trachtenberg, M.D., served as CSAT technical experts. Lynne McArthur, M.A., A.M.L.S., served as the JBS KAP Executive Project Co-Director. Barbara Fink, R.N., M.P.H., served as the JBS KAP Managing Project Co-Director. Other JBS KAP personnel included Dennis Burke, M.S., M.A., Deputy Director for Product Development; Wendy Caron, Editorial Quality Assurance Manager; Frances Nebesky, M.A., Quality Assurance Editor; Leah Bogdan, Junior Editor; Emily Tinkler, Junior Writer; and Pamela Frazier, Document Production Specialist. Catalina Vallejos Bartlett, M.A., Margaret Brooks, J.D., Jonathan Max Gilbert, M.A., Randi Henderson, and Deborah J. Shuman were writers. Disclaimer The opinions expressed herein are the views of the consensus panel members and do not necessarily reflect the official position of CSAT, SAMHSA, or DHHS. No official support of or endorsement by CSAT, SAMHSA, or DHHS for these opinions or for particular instruments, software, or resources described in this document is intended or should be inferred. The guidelines in this document should not be considered substitutes for individualized client care and treatment decisions. Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA/ CSAT or the authors. Do not reproduce or distribute this publication for a fee without specific, written authorization from SAMHSAís Office of Communications. Electronic Access and Copies of Publication Copies may be obtained free of charge from SAMHSAís National Clearinghouse for Alcohol and Drug Information (NCADI), (800) or (301) ; TDD (for hearing impaired), (800) ; or electronically through the following Internet World Wide Web site: Recommended Citation Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Originating Office Practice Improvement Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD DHHS Publication No. (SMA) Printed 2005

4 Contents What Is a TIP?...ix Consensus Panel...xi KAP Expert Panel and Federal Government Participants...xiii Foreword...xv Executive Summary...xvii Chapter 1óIntroduction...1 Purpose of This TIP...1 Key Definitions...2 Audience for This TIP...2 A Decade of Change...2 Remaining Challenges...6 The Future of MAT...10 Chapter 2óHistory of Medication-Assisted Treatment for Opioid Addiction...11 Emergence of Opioid Addiction as a Significant Problem and the Roots of Controversy...11 Origins of Opioid Maintenance Therapy...17 Regulatory History...21 Chapter 3óPharmacology of Medications Used To Treat Opioid Addiction...25 Pharmacology and Pharmacotherapy...28 Dosage Forms...31 Efficacy...32 Side Effects...33 Interactions With Other Therapeutic Medications...36 Safety...42 Chapter 4óInitial Screening, Admission Procedures, and Assessment Techniques...43 Initial Screening...43 Admission Procedures and Initial Evaluation...46 Medical Assessment...49 Induction Assessment...53 Comprehensive Assessment...53 Appendix 4-A. Example of Standard Consent to Opioid Maintenance Treatment...61 iii

5 Chapter 5óClinical Pharmacotherapy...63 Contraindications to Opioid Pharmacotherapy...64 Stages of Pharmacotherapy...65 Medically Supervised Withdrawal...78 Take-Home Medications...81 Office-Based Opioid Therapy...85 Chapter 6óPatientñTreatment Matching: Types of Services and Levels of Care...87 Steps in PatientñTreatment Matching...88 Patients With Special Needs...91 Treatment Planning...95 Chapter 7óPhases of Treatment Rationale for a Phased-Treatment Approach and Duration Phases of MAT Transition Between Treatment Phases in MAT Readmission to the OTP Chapter 8óApproaches to Providing Comprehensive Care and Maximizing Patient Retention Core Services Retaining Patients in MAT Counseling and Case Management, Behavioral Treatments, and Psychotherapy Benefits of Family Involvement Integrative Approaches Relapse Prevention Referral to Social Services Involuntary Discharge From MAT Patient Advocacy Chapter 9óDrug Testing as a Tool Purposes of Drug Testing in OTPs Benefits and Limitations of Drug Tests Drug-Testing Components and Methods Development of Written Procedures Other Considerations in Drug-Testing Procedures Interpreting and Using Drug Test Results Reliability, Validity, and Accuracy of Drug Test Results iv Contents

6 Chapter 10óAssociated Medical Problems in Patients Who Are Opioid Addicted Integrated Versus Referral Services Routine Testing and Followup for Medical Problems Acute, Life-Threatening Infections Infectious Diseases Patients With Disabilities Pain Management Hospitalization of Patients in MAT General Medical Conditions and MAT Chapter 11óTreatment of Multiple Substance Use Prevalence of Multiple Substance Use in MAT Common Drug Combinations Used by Patients in MAT Effects of Other Substance Use Management of Multiple Substance Use in MAT Inpatient Detoxification and Short-Term Stabilization Chapter 12óTreatment of Co-Occurring Disorders Prevalence of Co-Occurring Disorders Motivation for Treatment and Co-Occurring Disorders Etiology of Co-Occurring Disorders Screening for Co-Occurring Disorders Making and Confirming a Psychiatric Diagnosis Prognosis for Patients With Co-Occurring Disorders Treatment Issues Appendix 12-A. Internet Resources for Accessing Psychiatric Instruments Chapter 13óMedication-Assisted Treatment for Opioid Addiction During Pregnancy Acceptance of Methadone Maintenance as the Standard of Care Diagnosing Opioid Addiction in Pregnant Patients Medical and Obstetrical Concerns and Complications Methadone Dosage and Management Postpartum Treatment of Mothers in MAT Breast-Feeding Effects on Neonatal Outcome Use of Buprenorphine During Pregnancy Importance of Integrated, Comprehensive Services Nutrition Assessment, Counseling, and Assistance Contents v

7 Chapter 14óAdministrative Considerations Staffing Medication Diversion Control Plans The Community Effort OTPs and National Community Education Initiatives Evaluating Program and Staff Performance Appendix AóBibliography Appendix BóAbbreviations and Acronyms Appendix CóGlossary Appendix DóEthical Considerations in MAT Fundamental Ethical Principles Ethics in Practice Ethics: Conclusion Appendix EóResource Panel Appendix FóField Reviewers Index CSAT TIPs and Publications Based on TIPs vi Contents

8 Exhibits 1-1 NIDA Comprehensive Care-Related Principles of Effective Drug Addiction Treatment Pharmacotherapeutic Medications for Opioid Addiction Treatment Requirements for Physiciansí Waivers To Dispense or Prescribe Buprenorphine and Buprenorphine-Naloxone to Patients Who Are Opioid Addicted Intrinsic Activity of Full Agonist (Methadone), Partial Agonist (Buprenorphine), and Antagonist (Naloxone) Therapy Possible Side Effects of Opioid Agonist and Partial Agonist Therapy Reported Drug Interactions With Methadone Other Inducers and Inhibitors of CYP450 and CYP3A Suicide Risk Factors Recommended Responses to Indicators of Suicidality Recommended Procedures for Identifying and Addressing Domestic Violence Using Signs and Symptoms To Determine Optimal Methadone Levels Induction SimulationóModerate to High Tolerance Heroin Use in Preceding 30 Days (407 Methadone-Maintained Patients by Current Methadone Dose) Methadone Dose/Mean Plasma Levels Blood Plasma Levels Over 4 and 24 Hours With an Adequate and Inadequate Methadone Dose SMLs After Single and Split Methadone Dosing in a Fast Metabolizer Types of Detoxification From Illicit Opioids Case Study: PatientñTreatment Planning in MAT Acute Phase of MAT Rehabilitative Phase of MAT Supportive-Care Phase of MAT Medical Maintenance Phase of MAT Tapering Phase of MAT Resource Materials for Psychoeducational, Skill-Building, and Group Counseling Sessions Strategy for Contingency Management in MAT Common Strategies for Psychotherapy in MAT Strategies for Psychoeducation in MAT Patient Goals in Building Relapse Prevention Skills Typical Testing and Confirmation Cutoff Concentrations and Detection Times for Various Substances of Abuse Common Immunoassays Sample OTP Guidelines for Monitoring Urine Drug Test Specimen Collection Examples of Onsite Analytical Methods for Drug Tests Classification of TB Hepatitis C Evaluation Flowchart Contents vii

9 10-3 Nonpharmacologic Approaches to Managing Chronic Nonmalignant Pain Reported Use of Other Substances by Patients Admitted to OTPs Current Substance Use Disorders in Patients Dependent on Another Substance While Addicted to Opioids and Admitted to OTPs, With and Without Co-Occurring Disorders (N=716) Drug Combinations and Common Reasons for Use Common Co-Occurring Disorders in Patients Who Are Opioid Addicted DSM-IV-TR Classification of Diagnoses Associated With Different Classes of Substances Mutual-Help Groups for People With Co-Occurring Disorders Topics for Psychoeducational Groups for People With Co-Occurring Disorders Interactions of Some Medications for Depression and Bipolar Disorder With Methadone and Recommended Treatment Response in MAT Common Medical Complications Among Pregnant Women Who Are Opioid Addicted Laboratory Tests for Pregnant Women Who Are Opioid Addicted Common Obstetrical Complications Among Women Addicted to Opioids D-1 Case Example D-2 AATOD Canon of Ethics D-3 Ethical Codes of Selected Treatment-Oriented Organizations and Their Web Sites viii Contents

10 What Is a TIP? Treatment Improvement Protocols (TIPs), developed by the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA), within the U.S. Department of Health and Human Services (DHHS), are best-practice guidelines for the treatment of substance use disorders. CSAT draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private treatment facilities to include practitioners in mental health, criminal justice, primary care, and other health care and social service settings. CSATís Knowledge Application Program (KAP) expert panel, a distinguished group of experts on substance use disorders and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Drug Abuse Directors to generate topics for the TIPs. Topics are based on the fieldís current needs for information and guidance. After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to be members of a resource panel that recommends specific areas of focus as well as resources that should be considered in developing the content for the TIP. These recommendations are communicated to a consensus panel composed of experts on the topic who have been nominated by their peers. This consensus panel participates in a series of discussions. The information and recommendations on which they reach consensus form the foundation of the TIP. The members of each consensus panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A panel chair (or co-chairs) ensures that the contents of the TIP mirror the results of the groupís collaboration. A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and on line. TIPs can be accessed via the Internet at The ix

11 online TIPs are consistently updated and provide the field with state-of-the-art information. Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey ìfront-lineî information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either panelistsí clinical experience or the literature. If research supports a particular approach, citations are provided. This TIP, Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs, incorporates the many changes in medication-assisted treatment for opioid addiction (MAT) that have occurred over the most active decade of change since the inception of this treatment modality approximately 40 years ago. The TIP describes the nature and dimensions of opioid use disorders and their treatment in the United States, including basic principles of MAT and historical and regulatory developments. It presents consensus panel recommendations and evidence-based best practices for treatment of opioid addiction in opioid treatment programs (OTPs). It also examines related medical, psychiatric, sociological, and substance use disorders and their treatment as part of a comprehensive maintenance treatment program. The TIP includes a discussion of the ethical considerations that arise in most OTPs, and it provides a useful summary of areas for emphasis in successfully administering MAT in OTPs. x What Is a TIP?

12 Consensus Panel Chair Steven L. Batki, M.D. Professor and Director of Research Department of Psychiatry SUNY Upstate Medical University Syracuse, New York Co-Chairs Janice F. Kauffman, R.N., M.P.H., LADC, CAS Vice President Addiction Treatment Services North Charles Foundation, Inc. Cambridge, Massachusetts; Director Addiction Psychiatry Service Department of Psychiatry Brigham and Womenís Hospital Boston, Massachusetts; and Assistant Professor of Psychiatry Harvard Medical School Boston, Massachusetts Ira Marion, M.A. Executive Director Division of Substance Abuse Albert Einstein College of Medicine Bronx, New York Mark W. Parrino, M.P.A. President American Association for the Treatment of Opioid Dependence New York, New York George E. Woody, M.D. Treatment Research Institute University of Pennsylvania/ MIRECC Philadelphia VAMC Philadelphia, Pennsylvania Editorial Advisory Board John D. Crowley Crowley Associates Elgin, South Carolina Herbert D. Kleber, M.D. Professor of Psychiatry Columbia University College of Physicians & Surgeons New York, New York Stewart B. Leavitt, Ph.D. Leavitt Medical Communications Glenview, Illinois Jocelyn Sue Woods, M.A. President National Alliance of Methadone Advocates New York, New York Joan Zweben, Ph.D. Executive Director 14th Street Clinic & Medical Group, Inc. East Bay Community Recovery Project Berkeley, California Consensus Panelists Patrick Abbott, M.D. Medical Director Center on Alcoholism, Substance Abuse, and Addictions University of New Mexico Albuquerque, New Mexico Leslie Amass, Ph.D. Principal Investigator Friends Research Institute, Inc. Los Angeles, California Hector D. Barreto, M.D., M.P.H. Medical Director Center for Drug-Free Living Orlando, Florida xi

13 Michael D. Couty Director Division of Alcohol and Drug Abuse Missouri Department of Mental Health Jefferson City, Missouri Vashti Jude Forbes, R.N., BC., M.S.N., LCDC Associate Director Substance Abuse and Specialized Services Austin Travis County Mental Health and Mental Retardation Center Austin, Texas Ron Jackson, M.S.W. Executive Director Evergreen Treatment Services Seattle, Washington Karol A. Kaltenbach, Ph.D. Director Maternal Addiction Treatment Education and Research Jefferson Medical College Thomas Jefferson University Philadelphia, Pennsylvania Judith Martin, M.D., FASAM Medical Director 14th Street Clinic & Medical Group, Inc. Oakland, California J. Thomas Payte, M.D. Medical Director Drug Dependence Associates San Antonio, Texas Norma J. Reppucci, R.N. Director Operations for Eastern MA and NH Community Substance Abuse Centers Malden, Massachusetts Yong S. Song, Ph.D. Assistant Clinical Professor and Program Director Opiate Treatment Outpatient Program University of California, San Francisco San Francisco, California Jo L. Sotheran, Ph.D. Associate Research Scientist Mailman School of Public Health Columbia University New York, New York Trusandra Taylor, M.D. Physician Advisor Parkside Recovery Methadone Maintenance Philadelphia, Pennsylvania Violanda T. NuÒez, M.S.W. Executive Director Ayudantes, Inc. Santa Fe, New Mexico xii Consensus Panel

14 KAP Expert Panel and Federal Government Participants Barry S. Brown, Ph.D. Adjunct Professor University of North Carolina at Wilmington Carolina Beach, North Carolina Jacqueline Butler, M.S.W., LISW, LPCC, CCDC III, CJS Professor of Clinical Psychiatry College of Medicine University of Cincinnati Cincinnati, Ohio Deion Cash Executive Director Community Treatment and Correction Center, Inc. Canton, Ohio Debra A. Claymore, M.Ed.Adm. Owner/Chief Executive Officer WC Consulting, LLC Loveland, Colorado Carlo C. Di Clemente, Ph.D. Chair Department of Psychology University of Maryland Baltimore County Baltimore, Maryland Catherine E. Dube, Ed.D. Independent Consultant Brown University Providence, Rhode Island Jerry P. Flanzer, D.S.W., LCSW, CAC Chief, Services Division of Clinical and Services Research National Institute on Drug Abuse Bethesda, Maryland Michael Galer, D.B.A., M.B.A., M.F.A. Chairman of the Graduate School of Business University of PhoenixóGreater Boston Campus Braintree, Massachusetts Renata J. Henry, M.Ed. Director Division of Alcoholism, Drug Abuse, and Mental Health Delaware Department of Health and Social Services New Castle, Delaware Joel Hochberg, M.A. President Asher & Partners Los Angeles, California Jack Hollis, Ph.D. Associate Director Center for Health Research Kaiser Permanente Portland, Oregon Mary Beth Johnson, M.S.W. Director Addiction Technology Transfer Center University of MissourióKansas City Kansas City, Missouri Eduardo Lopez Executive Producer EVS Communications Washington, D.C. Holly A. Massett, Ph.D. Academy for Educational Development Washington, D.C. Diane Miller Chief Scientific Communications Branch National Institute on Alcohol Abuse and Alcoholism Bethesda, Maryland Harry B. Montoya, M.A. President/Chief Executive Officer Hands Across Cultures Espanola, New Mexico xiii

15 Richard K. Ries, M.D. Director/Professor Outpatient Mental Health Services Dual Disorder Programs Seattle, Washington Gloria M. Rodriguez, D.S.W. Research Scientist Division of Addiction Services New Jersey Department of Health and Senior Services Trenton, New Jersey Everett Rogers, Ph.D. Center for Communications Programs Johns Hopkins University Baltimore, Maryland Jean R. Slutsky, P.A., M.S.P.H. Senior Health Policy Analyst Agency for Healthcare Research & Quality Rockville, Maryland Nedra Klein Weinreich, M.S. President Weinreich Communications Canoga Park, California Clarissa Wittenberg Director Office of Communications and Public Liaison National Institute of Mental Health Bethesda, Maryland Consulting Members to the KAP Expert Panel Paul Purnell, M.A. Social Solutions, L.L.C. Potomac, Maryland Scott Ratzan, M.D., M.P.A., M.A. Academy for Educational Development Washington, D.C. Thomas W. Valente, Ph.D. Director, Master of Public Health Program Department of Preventive Medicine School of Medicine University of Southern California Alhambra, California Patricia A. Wright, Ed.D. Independent Consultant Baltimore, Maryland xiv KAP Expert Panel and Federal Government Participants

16 Foreword The Treatment Improvement Protocol (TIP) series supports SAMHSAís mission of building resilience and facilitating recovery for people with or at risk for mental or substance use disorders by providing best-practices guidance to clinicians, program administrators, and payers to improve the quality and effectiveness of service delivery and thereby promote recovery. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-federal clinical researchers, clinicians, program administrators, and client advocates debates and discusses its particular areas of expertise until it reaches a consensus on best practices. This panelís work is then reviewed and critiqued by field reviewers. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of practicing clinicians and administrators who serve, in the most current and effective ways, people who abuse substances. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field. Charles G. Curie, M.A., A.C.S.W. Administrator Substance Abuse and Mental Health Services Administration H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration xv

17

18 Executive Summary Research supports the perspective that opioid addiction is a medical disorder that can be treated effectively with medications when they are administered under conditions consistent with their pharmacological efficacy and when treatment includes necessary supportive services such as psychosocial counseling, treatment for co-occurring disorders, medical services, and vocational rehabilitation. Medication-assisted treatment for opioid addiction (MAT) has been effective in facilitating recovery from opioid addiction for many patients. This TIP provides a detailed description of MAT, especially in opioid treatment programs (OTPs). MAT includes optional approaches such as comprehensive maintenance treatment, medical maintenance treatment, detoxification, and medically supervised withdrawal. Some or all of these approaches can be provided in OTPs or other settings. With the approval of buprenorphine for physicianís office-based opioid treatment, MAT availability is expected to increase. Growing understanding and acceptance of opioid addiction as a treatable medical disorder have facilitated advances in MAT. The effectiveness of MAT advanced significantly with the development of methadone maintenance treatment in the 1960s and the creation and expansion of publicly funded treatment programs in the 1970s. The first official Federal use of the term ìmaintenance treatmentî (referring to opioid addiction treatment) occurred in the Narcotic Addict Treatment Act of Perhaps the most important development in MAT during the 1990s was publication of recommendations by a National Institutes of Health consensus panel on Effective Medical Treatment of Opiate Addiction. The panel concluded that opioid addiction is a treatable medical disorder and explicitly rejected notions that addiction is self-induced or a failure of willpower. The panel called for a commitment to providing effective treatment for opioid addiction and for Federal and State efforts to reduce the stigma attached to MAT and to expand MAT through increased funding and less restrictive regulation. The implementation of an accreditation system for OTPs further serves to standardize and improve MAT. xvii

19 Accompanying these improvements in opioid addiction treatment is an increasing emphasis on the concomitant treatment of diseases such as HIV/AIDS, hepatitis, and tuberculosis, all of which occur at higher rates among people who inject drugs than in the general population. This TIP addresses a variety of issues and challenges in MAT, including ï Drug testing for screening and assessmentó how and when (chapters 4 and 9) ï Administrative dischargeóissues of safety and noncompliance (chapter 8) ï Use of other substances with opioids and resulting complications for MAT (chapter 11) ï Co-occurring mental disorders and their complications for MAT (chapter 12) ï Administration of staffs and procedures (chapter 14). The following paragraphs summarize chapters in this TIP. Chapter 1, Introduction, introduces MAT and provides important concepts for understanding this TIP. It describes opioid addiction as a medical disorder with similarities to other disorders. It outlines the main options for MAT, such as choices of medication and optional services. The chapter concludes by summarizing the greatest challenges facing OTPs and offering a vision of the future. Chapter 2, History of Medication-Assisted Treatment for Opioid Addiction, provides the historical context for MAT. It details the history of the use of opioids in the United States; the political, legal, and regulatory responses to opioid abuse; treatment trends (including logistics and strategies); and development of modern medications available in MAT. Chapter 3, Pharmacology of Medications Used To Treat Opioid Addiction, reviews the pharmacology and clinical applications of the medications used for treating opioid addiction. It focuses on the metabolic activity, dosage forms, efficacy, side effects, drug interactions, safety considerations, and current availability and restrictions for methadone, levo-alpha acetyl methadol (LAAM), buprenorphine, and naltrexone. The information will enable treatment providers to compare the benefits and limitations of available opioid addiction treatment medications. Chapter 4, Initial Screening, Admission Procedures, and Assessment Techniques, describes screening and assessment procedures used with applicants for admission to treatment and with patients in MAT. The chapter describes components of the screening (or intake) process that provides a foundation for treatment and procedures used during the admissions process to ensure thorough, efficient data collection and to gather information for ongoing treatment intervention. Components of substance use, medical, medication induction, and comprehensive psychosocial assessments are used to determine MAT eligibility, individualize treatment plans, and monitor changes in patient status. The chapter also provides information on managing emergency situations during admission and treatment. Chapter 5, Clinical Pharmacotherapy, explains opioid pharmacotherapy, focusing on the clinical use of methadone, buprenorphine, LAAM, and naltrexone. It details the discrete stages of opioid pharmacotherapy, each of which requires unique clinical considerations. It discusses factors that may affect individual responses to treatment medications and key considerations in determining individual dosages. For patients who must leave MAT, either voluntarily or involuntarily, the chapter explains methods of withdrawal from treatment medications. It also discusses important considerations in administering take-home medication. Chapter 6, PatientñTreatment Matching: Types of Services and Levels of Care, describes a multidimensional, clinically driven strategy for matching patients in MAT with the types of treatment services and levels of care that optimize treatment outcomes, within or in xviii Executive Summary

20 conjunction with OTPs. Patientñtreatment matching involves individualizing the choice and application of treatment resources to each patientís needs, abilities, and preferences. The chapter describes alternative types of treatment programs and settings for identified types of patients and recommends elements that should be included in patientñtreatment matching, including ways to accommodate patients with special needs. The chapter describes elements of a treatment plan and the planning process, including the roles of counselor and patient, the importance of cultural and linguistic competence, motivation for treatment, and the need for a multidisciplinary team. Chapter 7, Phases of Treatment, describes phases of treatment for patients in MAT. These phases are conceptualized as parts of a dynamic continuum of patient progress toward intended treatment outcomes. Each patient progresses according to his or her capacity and needs. After an orientation to introduce patients to the program, successive treatment phases include (1) the acute phase, during which patients attempt to eliminate illicit-opioid use and lessen the intensity of other problems associated with their addiction, (2) the rehabilitative phase, during which patients continue to address addiction while gaining control of other major life domains, (3) the supportive-care phase, during which patients maintain their abstinence while receiving other interventions when needed, (4) the medical-maintenance phase, during which patients are committed to continuing pharmacotherapy for the foreseeable future but no longer rely on other OTP services, (5) the tapering and readjustment phase, an optional phase in which patients gradually reduce and eliminate opioid treatment medication, and (6) the continuing-care phase, in which patients who have tapered from treatment medication continue regular contact with their treatment program. Phases of treatment address the therapeutic relationship, motivation, patientsí use of alcohol and illicit drugs, their mental and medical disorders, legal problems, and basic needs (including housing, education, and vocational training). Most patients need more frequent, intensive services in the acute phase, careful monitoring and diversified services during rehabilitative and supportive-care phases, and less frequent services in subsequent phases. Chapter 8, Approaches to Providing Comprehensive Care and Maximizing Patient Retention, describes the core- and extendedcare services essential to MAT effectiveness in OTPs. It explains how a comprehensive treatment program improves patient retention in treatment and the likelihood of positive treatment outcomes. Patients who receive regular, frequent, integrated psychosocial and medical services along with opioid pharmacotherapy often realize better outcomes than those who receive only limited services. Counseling services are integral to comprehensive maintenance treatment and can be behavioral, psychotherapeutic, or family oriented. Strategies that target relapse prevention also should be part of any comprehensive treatment program. The chapter describes ways to increase patient retention and avoid administrative discharge. Administrative discharge usually results in rapid relapse and may lead to incarceration or death. Clear communication and awareness on the part of both patients and staff members help avoid administrative discharge. Chapter 9, Drug Testing as a Tool, presents an overview of drug testing in OTPs. Drug testing provides an objective measure of treatment efficacy and a tool to monitor patient progress, as well as information for quality assurance, program planning, and accreditation. OTPs must ensure the clinical utility of test results and protect patientsí privacy. Several drugtesting methodologies are available or in development, including tests of urine, oral fluid, blood, sweat, and hair. The chapter describes the benefits and limitations of these tests. Most often, OTPs use urine drug testing by immunoassay or thin-layer chromatography because these methods are the least costly and best validated of all options, but the Center for Substance Abuse Treatment has indicated that Executive Summary xix

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