Methadone Detox - The Stages of Change

Transcription

1 Community Detoxification Progression Routes 2008 Dr Austin O Carroll Acknowledgement Fiona O Reilly

2 Drug Usage North Inner City

3 Participating GP s

4 North Inner City Methadone Maintenance 1244 people living North Inner Central area receive methadone maintenance (1.16% of pop). Compares to 2.2% NE Inner City and 1.6% NW Inner City.

5 Methadone Treatment in General Practice. In % of patients on methadone were being treated in General Practice in the Eastern Region.

6 So why Detox?

7 Their communities want it!

8 Their families want it!

9 They want it!

10 Methadone maintenance treatment is often experienced as a hostile and/or arbitrary forum for social control and enforced dependency among street addicts. It seeps into the fabric of one s most intimate relationships, distorting respectful interaction with children, wives, intellectual friends. Bourgois 2000.

11 We re People Too Participants expressed the desire to be free from drugs and seemed less than satisfied to continue on methadone without a long term plan asking So what s the plan are we to be hobbling in here to get methadone when we re 65?

12 We re People Too They felt there were not enough opportunities for detoxification. I am asking them eight months to get me in to the hospital. I am after having problems with me kids and I am asking them for help to get me into hospital. I am on a 120mls of phy. They tell me to see counsellors, to see my doctor and I ve done that and there s still no help. I am still going nowhere fast there s nothing happening.

13 We re People Too They felt that the treatment centre could do more to help people come down off methadone They should encourage people to detox off their methadone, people who are doin well on their methadone they should encourage them to get off it. Try to bring them on...

14 Mountjoy Street Family Practice Survey Long term Goals: 80% want to be off methadone "I'd like to be drug free "At the end of the day I'd like to get off. I hate the stuff. I hate having to come in for it" "I don't want to be on methadone for the rest of my life or years like some people"

15 Have you long term goals re methadone? 60.0% 50.0% 40.0% Percent 30.0% 58.5% 20.0% 10.0% 22.0% 17.1% 0.0% To get off To get off eventually Continue methadone maintainance 2.4% Other

16 Is this service helping you achieve your long term goals? - Yes 34 Stability "It keeps you away from the street and other elements and to spend more time with the family... and if you want you can hold down a job" Encouragement to come off drugs "I would have been on heroin if I wasn't here. It does push you now and again... Since I'm getting stable now I'll start to come off soon

17 So are we offering methadone detox?

18 Detox 22 clients were offered vs 19 never offered a detox of whom 14 said they would think about detox if this was offered 7 clients requested a detox which they did not receive. 9 clients had detox 4 completed detox "It was great. I was off for two years" "It was successful at the time, but things got the better of me and I went back on" 5 did not complete detox "It was pointless with all the methadone on the street" "It was too fast"

19 Methadone Detox works.

20 The Stages of Change

21 The Stages of Change

22 The Spiral of Change

23 Two Types Detox. Long term (Community) Detox Short term (Inpatient Detox)

24 Factors that would indicate that long-term detox may be a successful treatment option Client determination to become drugfree with a recognition that other factors (physical, social, psychological) need working on as a pre-condition to successful outcome of the detox Failure of short-term detox: particularly if withdrawal symptoms precipitate relapse Client request for long-term detox Desire to address psychological issues during the detox period Social support system in place or that can be rebuilt by the end of the detox Need and desire to stop injecting behaviour in addition to detoxing Support available from a specialist and/or counselling drug service Factors that would indicate that long-term detox may not be a successful intervention Client requests to become drug-free without recognition of the factors which may cause relapse Long-standing chaotic, drug-using lifestyle Little m otivation to becom e drug-free No desire to address psychological issues that may contribute to relapse No prospect of a social support network developing during the detox Desire to use injected drugs in a controlled way following detox No support available from a specialist drug and/or counselling service

25 Factors that would indicate that short-term d eto x m ay b e a successful treatm ent option Strong m otivation to becom e drugfree Strong social support network Short history of opiate use Low daily opiate us e High degree of control in opiate use No other drugs being used Client requesting this treatm ent option of their own free will Client has a clear vision of what they are aim ing for and of the benefits of being drug-free A vailab ility of in-p atient d eto x facility D etox is part of a c are plan w hich includes residential rehabilitation C lie n t is s m o k in g ra th er th a n in jec tin g opiates Factors that would indicate that short-term detox may not be a successful intervention Little m otivation to b ec om e drug -free Poor social support network Long history of continuous opiate use H ig h d aily opiate us e Low degree of control in opiate use Poly drug use e.g. opiates, alcohol, benzodiazepines, etc. Pressure from others to undergo treatm ent despite reluctance and anxiety C lient only w ants to be 'off opiates' and has not considered how to stay off Early or late pregnancy U n availab ility of in-p atien t d eto x facility C om pulsory detox following breach of prescribing contract

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27 Benzo s

28 The Bad Doctor Hypothesis 11.6% of the GMS pts on benzo s in % of medical card patients taking bzds on a long-term basis.

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31 So why benzo detox?

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33 Does Benzo Detox Work 22 patients offered a slow tapering reduction in benzodiazepine medication. 4 refused tapering course 12 patients completed detox successfully. No long term data available McDuff et al, J Sat 1993, 10:

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35 Common Symptoms Withdrawal

36 Suitability for Detox