Today s Topics. Session 2: Introduction to Drug Treatment. Treatment matching. Guidelines: where should a client go for treatment?

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1 Session 2: Introduction to Drug Treatment Today s Topics Level of care determination How to know when treatment works What does treatment include Description of treatment modalities Naomi Weinstein, MPH Director, Center on Addiction and the Family (COAF) Phoenix House nweinstein@phoenixhouse.org Guidelines: where should a client go for treatment? Person in need of chemical dependency services should be in the least restrictive, most clinically appropriate level of care available. Requires treatment matching (including Level of care determination) Treatment matching the science and art of placing people in the appropriate level of care, with consideration to the person s specific needs, issues, and concerns (i.e., geography or family issues) Services can be stepped up (when there is no improvement and all interventions have failed) or stepped down, given progress Level of care determination NYS ASAM (American Society of Addiction Medicine) Patient Placement Criteria LOCADTR Level of Care for Alcohol and Drug Treatment Referral (NYS) 1

2 ASAM Patient Placement Criteria Acute intoxication and/or withdrawal potential Biomedical conditions and complications Emotional/Behavioral conditions and complications Treatment acceptance/resistance Relapse potential Recovery environment LOCADTR New York State system for treatment matching Decision tree Must be completed, and documented Qualified Health Professional (QHP) in a OASAS facility New York State says Level of care determination is a clinical procedure provided by an OASAS licensed treatment provider All patients must have a chemical dependency or chemical abuse diagnosis to be admitted to services. Treatment today More emphasis on the science Developments in understanding pharmacology Pressure from insurance and other payers Increase in research NIDA TIPS, manualized approaches, etc. Future of treatment Research/evidence-based treatment Use of medications (craving, withdrawal) Multiple needs mental health, physical health, spirituality, case management Treatment protocols 2

3 Objectives of drug treatment Elimination of drug/alcohol misuse Desire for and appreciation of healthy lifestyle Learn skills to participate in recovery Learn skills to avoid relapse Put new skills into practice in supportive environment Ensuring a supportive environment Principles of effective drug treatment (NIDA) No one-size-fits all Needs to be readily available Multiple needs Regular update treatment/service plan Minimum three months Counseling and other behavioral therapies are critical Medications can be important Treat co-occurring in integrated way Detox is only first stage Can by mandated to be successful Ongoing monitoring of drug use Need to assess for HIV/AIDS, Hep B and C, TB Recovery is long-term and may require several treatment episodes Components of comprehensive treatment Counseling and other behavioral therapies Replace drug using activities Drug resistance skills Motivation Problem solving skills Interpersonal relationships Self-help and drug addiction treatment Complements and extends treatment efforts Most commonly used models include 12-step (AA, NA), and Smart Recovery Most treatment programs encourage self-help participation during/after treatment Groups as treatment tool Mutual support Reduce isolation Rebuild social skills Identify with others Learn not alone with problem Recognize ability to contribute 3

4 When treatment works Clean urinalysis Resolve legal problems Reconnect with family/friends Positive social network Not isolate Healthy recreation Improved health Improved parenting and coping skills Productive member of society Mismatch Goal appropriate level of care within the least restrictive setting Undertreatment Relapse Critical issues unaddressed Overtreatment Relapse may leave treatment if too intense OASAS audit Medicaid disallowances Cost inefficient When treatment level is not appropriate Failure to comply with tx plan (i.e., non-participation) Continued use Continued legal issues Health problems related to use Family discord and stress No healthy social networks Continuing breaking of rules/illegal behavior Toxicology reports Details needed May be taking medications (i.e., anxiety) Marijuana can stay in blood stream for up to 30 days May take a while for methadone dosage to be stabilized Need to look at pattern, not individual events UA results don t indicate safety Types of treatment Typical treatment services Detox (precursor to treatment) Outpatient Residential Replacement therapy (methadone) Special programs MICA Parent/child Crisis intervention Education Group work Individual counseling Medication management and detoxification Medical, psychiatric, dental consultation Recreation Vocation/education training Housing assistance Case management Family work multisystemic: structure, support, education Special services (i.e., child care, acupuncture) Life skills 4

5 Detox programs Purpose medical supervision during detox Manage withdrawal symptoms Engage in idea of treatment Length 3 7 days (avg.) Often leave detox still in active withdrawal Target population alcohol, benzodiazepines, opiates Next steps go to treatment Problems use of detox as treatment, with revolving door mentality Detox: typical day Detox is not Monitor vital signs treatment! Given medications to manage: Withdrawal symptoms (ie: prevent seizures) Cope with cravings Meals Ideal program: Educational seminars Group counseling Individual counseling On-site NA/AA meetings Morning/Evening meetings Outpatient programs Attend program but live at home Clients: more stable home environment, lower relapse potential, family support Time commitment: depends on intensity Frequent, random drug testing Can be step-down after residential Typical components: outpatient 1 2 visits per week Groups Process groups (how are things going) Special topics (family violence, relationships, relapse prevention) Education Referrals Family services Individual counseling (min 1x/month) Outpatient: intensive outpatient (IOP) and day treatment Clients: less stable home environment, moderate relapse potential, willing to show up Time commitment: IOP hours/week, day treatment 15+ hours Highly structured Need more habilitation services Typical Components: IOP/day treatment Meals (breakfast and lunch) Morning meeting Recreational therapy Individual counseling Educational seminars Group work (process and educational) Family work Special services (i.e., child care, Reiki) 5

6 Pharmacological approaches Goals: Relief from withdrawal symptoms Prevent drugs from working Reduce cravings Aversive reactions Some medication options Methadone opiates, reduces cravings, withdrawal symptoms Buprenorphine opiates, like methadone Acamposate alcohol, reduces cravings Antabuse adverse reaction to alcohol Naltrexone stops opiates from using, changes alcohol action for some Neurontin helps with insomnia in early recovery Clonidine reduce withdrawal, cravings Baclofen reduction in cocaine cravings Replacement therapy (methadone and suboxone) Methadone or Buprenorphine (suboxone) For opiate addicts who have used for 1+ years When other treatment options don t work Purpose: eliminate withdrawal symptoms, reduce opiate craving, and allow normalization of the body's function (dose dependent) Some get long-term prescriptions (i.e., 28 days between appointments) Political issue Dosage Is it acceptable drug treatment Long-term nature (replacement therapy) Service Components: replacement therapy Methadone programs offer: Health care Crisis intervention Case management Social and human services Mental health services Voc/Ed Services Family support and education HIV/AIDS casework Buprenorphine fewer services Residential options Short-term (inpatient rehab) Long-term (intensive rehab) Therapeutic communities Halfway house (Community residence) Supportive living Life skills Relapse prevention Residential treatment: short-term (inpatient rehab) Duration: up to 30 days typically Similar to day treatment Very structured Many aligned with 12-step programs 6

7 Residential components: short term (inpatient rehab) Room and board House meetings evening and morning Education and process groups Individual counseling Recreational therapy Homework independent work Special events Family program Residential treatment: Longterm/therapeutic community Clients: Need habilitation Minimal home support Long-term drug users Few economic or other resources Often alternative to incarceration Special features: Highly structured, rules Community as method Job functions Every interaction is a clinical tool Long-term (up to 2 yrs) Residential components: therapeutic community House meetings Job responsibilities Structure and rules Encounter groups Recreational therapy Life skills Educational seminars Vocational/Education Services Medical, psychiatric and dental services Family services Individual and group counseling Adolescents: Add on formal school attendance, intensified family component Special programs: MICA/Mental Health Can be outpatient or residential Mental illness (primary or secondary diagnosis, contributor or sequelae) More severe mental illness Difficulty in everyday functioning Special groups focused on mental health Medication management Rehabilitation programming Special Programs: parent/child Usually residential Usually for mothers Typical: 1 parent/1 child, 0-3 yrs Parenting education General have beds available More sensitive to gender and parenting issues Child development focus Close links with child welfare, kinship care, etc. Continuing care At least 90 days post-graduation On-going check-ins Components: Employment and education guidance Housing referrals/sober living Family relationships Relapse prevention 7

8 Effectiveness of treatment Goal of treatment to return to productive functioning Treatment reduced drug use by 40-60% Treatment reduces crime 40-60% Treatment increases employment prospects by 40% Drug treatment is as successful as treatment of diabetes, asthma, and hypertension 8

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