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These individuals also may be in physical distress, for example, suffering from a cocaine crash or heroin withdrawal (Gold 1992). They may have HIV and/or AIDS, TB, STDs, or other infectious diseases.
Need for PrivacyThe program's physical surroundings should be attractive and welcoming and allow for privacy during the screening interview (Langrod 1993). Privacy is especially important because questions raised during the screening process (and later on during the admission and assessment processes) may evoke feelings of shame or guilt, cause fears of possible legal consequences, or cause other emotions best managed by both the patient and the interviewer in a private setting (Senay 1992). Determining Patient Eligibility for TreatmentDrug users who are primarily regular users of cocaine and not physiologically dependent on opioids are generally neither therapeutically nor legally appropriate for admission to MTPs. (Exceptions are individuals physically addicted to opioids but not currently using due to enforced abstinence, for example, because of incarceration.) They should be referred to treatment centers that treat primary cocaine problems. Patient eligibility for a methadone treatment program must comply with Federal and State requirements (21 CFR, § 291.505). (Please refer to the State Methadone Treatment Guidelines [CSAT 1993b] for Federal and State requirements not discussed in the following pages.) It is important to remember that Federal regula- tions on eligibility represent the minimum criteria for admission. Many States develop and implement criteria more stringent than those required by the Federal Government. Providers need to be aware of their respective States' regulations.
Preliminary Assessment and Treatment PlanIf treatment staff have collected screening data and determined that an applicant is eligible for treatment, they should make an initial assessment and recommend the applicant for admission. (If the applicant is not eligible, staff should provide a referral to a more appropriate program.) If the applicant accepts admission, an initial assessment and preliminary treatment plan should be developed. The plan should briefly state the patient's primary problem, the immediate goal, and the action plan to begin treatment services. AdmissionThe admission process includes a medical evaluation. Because MTPs are an important provider of initial medical services to heroin addicts, Kosten and coworkers (1987b) suggest that careful medical evaluations on admission are necessary and that the development of primary medical care facilities within or closely associated with drug treatment programs is justified. A substance abuse history should also be completed during the admission process. A medical evaluation is especially important for narcotic addicts and multidrug users since these patients may have many medical problems. While a medical history may be completed by any staff person trained in the medical aspects of addiction, a physician must decide whether to admit a patient to a narcotic treatment program, and only a physician can order medications. Medical HistoryA complete medical history typically examines current information to determine whether the patient has any chronic or acute medical conditions such as diabetes, renal diseases, hepatitis, HIV, TB, STDs and other infectious diseases, sickle-cell trait or anemia, chronic cardiopulmonary disease, or pregnancy. The history should document any treatments that the patient has had or is currently receiving for any medical condition, including any medications the patient may currently be taking. For women, the history should include documentation of any previous pregnancies, types of delivery, pregnancy complications, and current involvement with prenatal care. The history should document alcohol and drug use during and prior to any pregnancies and any incidence of sudden infant death syndrome (SIDS). A family health history should be obtained.
Physical ExaminationA complete physical examination conducted by medical staff ordinarily includes examination of all major systems. As required by Federal regulation (21 CFR, § 291.505 (d)(3)(i)), narcotic treatment programs must document physical examination of organ systems for possibilities of infectious disease; pulmonary, liver, and cardiac abnormalities; dermatologic sequelae of addiction; vital signs; general appearance-head, ears, nose, throat, chest, abdomen, extremities, and skin; evidence of physical drug dependence; and the physician's clinical judgment of physical dependence. Patients should be examined for symptoms of active TB, including cough, fever, night sweats, weight loss, and fatigue. Psychiatric EvaluationThe physical examination can be useful in understanding psychiatric symptomatology (e.g., psychiatric symptomatology related to a diagnosis of AIDS). An initial psychiatric evaluation should be completed, beginning with a determination of the potential risk of suicide or violence or the presence of psychosis. A full evaluation should then proceed only after acute withdrawal and lingering withdrawal effects have passed (Dackis and Gold 1992). Another evaluation should occur 6 months later. When applicable, patients should be told that their mental state may be the result of cocaine or other drug use. Staff should also assess risk factors for women who may be subject to past or current physical or emotional abuse. Laboratory TestsFederal regulation requires narcotic treatment programs to conduct a drug screening test or analysis, a serological test for syphilis, and a tuberculin skin test (21 CFR, § 291.505 (d)(3)(i)). Given the fact that some drugs are extensively metabolized and quickly excreted from the body, it is important to use analytic procedures that give the highest level of specificity when screening for the presence of drugs. For patients concurrently dependent on opioids and cocaine, enzyme immunoassay or radioimmunoassay urine screening techniques have been found to be effective because they have high sensitivity levels (Verebey 1992). Detecting cocaine can be particularly difficult because the half-life of cocaine is only about 1 hour, and unchanged cocaine is detectable in urine for only 12-18 hours after use. Screening for cocaine is therefore most effective when conducted within hours of use or if the patient is suspected to be under the influence of cocaine at the time of the sample collection. Given cocaine's short half-life, medical staff should routinely test for the presence of benzoylecgonine, a metabolite of cocaine that may be detected in the urine for at least 24-48 hours after the last use. Since cocaine use can go undetected on admission, patients should be screened frequently during the assessment process. TB TestingThe Centers for Disease Control and Prevention recommends the use of the Mantoux TB test on admission and annually thereafter unless the patient is known to be purified protein derivative (PPD) positive (10-millimeter induration or more for HIV-negative persons and 5-millimeter induration for HIV-positive persons or those at risk of HIV infection). Some HIV-positive patients may have a false negative reading on a PPD test because immunocompromised persons are frequently anergic. For such cases, anergy testing can be used to screen out false negative PPD tests. All patients with a positive PPD test should receive a chest x-ray. Care should be taken to assist patients placed on isoniazid (INH) prophylaxis, in complying with daily doses. (See appendix D for a sample TB/PPD testing form and supplementary questions.)
Hepatitis TestingHepatitis is one of many possible medical complications that can result from injecting heroin or cocaine. Many injecting drug users can have acute hepatitis infection without serologic evidence of hepatitis A or B. Recent data demonstrate that rates of hepatitis C are high among injecting drug users. Hepatitis C is described as having a chronic indolent course (Donahue et al. 1991). A simple blood test for antibodies against hepatitis C is now available. However, a positive result does not indicate that the patient is currently infected with the virus. It shows only that antibodies have been developed as a result of previous or current exposure. Interferon is being investigated as a promising treatment for hepatitis C, but it can have significant side effects and is very expensive. HIV TestingBecause of the high rate of HIV risk behaviors associated with opioid addiction, it is especially important for the physician to talk with applicants about safer sex and needle use practices. Given the increasing impact of AIDS on narcotic-dependent patients, medical staff should carefully consider counseling and testing patients for HIV. It is recommended that the physician discuss medical aspects of HIV infections and ask the patient the following questions:
In addition, the physician should ask the patient for a complete history of any HIV testing that has been performed. All staff providing HIV testing and counseling services should be educated about HIV/AIDS and able to provide pretest and posttest counseling (see chapter 4) and perform a risk assessment of the patients who enter the treatment center. Determining Current DependenceA patient's current dependence on opioids or stimulants or both can be determined by medical staff through a history, an examination, and urine screening. The history should determine the length of time the patient has been dependent on narcotics or stimulants. A sample form for taking this history is shown in figure 1. The physical examination should include examination for the presence of clinical signs of addiction such as needle marks, constricted or dilated pupils, and a state of sedation. Medical staff should check for reported and observable withdrawal symptoms such as yawning, rhinorrhea, lacrimation, chills, restlessness, irritability, perspiration, piloerection, nausea, and diarrhea. If the physician is not certain of the applicant's medical eligibility for admission to an MTP (that is, whether the patient is physiologically dependent on opioids), it is sometimes appropriate to implement a Narcan challenge. This test induces symptoms of withdrawal and is often controversial. To give a Narcan challenge, the following criteria should be met:
Narcan may be administered using the following method (Ling and Wesson 1990):
Determining current dependence on cocaine can be more difficult because clearly defined withdrawal symptoms may not be present. In fact, the presence of a cocaine abstinence syndrome has been debated. Gawin and Kleber (1986) described a three-phase process in outpatients lasting 1-10 weeks. The phases include "crash," withdrawal, and extinction. During phase 1, the patient experiences exhaustion, intense depression, agitation, anxiety, hypersomnolence, hyperphagia, and craving for cocaine. In phase 2, the patient has no craving, but the craving may reemerge, bringing on symptoms of anhedonia, anergia, and anxiety. During phase 3, which can last indefinitely, the patient's mood returns to normal but the patient experiences recurrent craving, typically in response to cues. Inpatient studies have not found such clearly defined phases of withdrawal. Instead, symptoms were found to be very acute in the first 24 hours and associated with intense depression. Mood state, cravings, and sleep problems gradually returned to normal in approximately 4 weeks (Weddington 1991). The difference between these findings may relate to the effects of cocaine availability on craving, such availability and cues being much greater for outpatients. Treatment Eligibility and Treatment OptionsThe admitting physician is responsible for recommending the treatment disposition and determining admission. The physician should make a clinical judgment about the appropriate level of care on the basis of the patient's individual needs. For narcotic treatment services, the physician must document current dependence on opioids and a 1-year history of physiological dependence prior to admission (21 CFR, § 291.505 (d)(1)(i)(A)). Langrod (1993) recommends that medical staff fully explain available treatment options to the patient, including alternatives for less intensive and restrictive treatment, the chances for success or failure, the benefits and the risks of treatment, and the treatment process. Such an explanation should be based on the results of the medical evaluation, and medical staff should ensure that the best possible treatment option is being recommended. The physician is also responsible for explaining the pharmacological properties of any medication to be used for treatment or maintenance. The Consensus Panel recognizes that some communities may not have extensive resources. However, if there are no facilities elsewhere in the community, the MTP itself should consider developing programs to meet the needs of patients who need alternative treatment. Program administrators should consult with appropriate State regulatory agencies, financing agencies, and community groups before opening a new service. AssessmentThe assessment process may be conceptualized as taking place in three stages. First, the initial screening provides an opportunity to establish eligibility and, perhaps more importantly, to assist the applicant with concomitant psychosocial crises. This kind of help facilitates a working alliance. Second, indepth evaluation is based on subsequent interviews once the patient has entered treatment. More detailed information is collected over a 3-4-week period. This information permits clinicians to formulate a comprehensive treatment plan. Third, an ongoing evaluation process measures patient progress, updates the treatment plan, and signals the need for relapse prevention. Initial Screening and Crisis InterventionAlthough initial screening interviews are often devoted to collecting eligibility data for methadone treatment, it is important not to overlook this initial contact as an opportunity to negotiate and establish an effective treatment alliance. Actively assisting the patient with the psychosocial crisis at hand makes the treatment system appear more helpful and less bureaucratic. Many patients who do not qualify for methadone maintenance nonetheless have life crises that require prompt assistance. Indepth EvaluationA conscientious and individualized assessment guides treatment planning decisions toward effectively matching the patient to the most appropriate treatment interventions (Wallace 1992). The assessment process should go over details not covered in the initial screening interview. Many treatment centers are increasingly turning to the use of standardized diagnostic assessment instruments such as the Addiction Severity Index (ASI). Such instruments can be used periodically throughout treatment to measure patient progress and to assist in matching specific treatment interventions to specific kinds of problems. Indepth interviews elicit greater detail about salient patient characteristics revealed during the initial interview and are fundamental in developing a comprehensive treatment plan. This workup commonly includes a detailed substance abuse history, a detailed psychosocial history, and a thorough psychiatric history. The patient also should be asked if he or she has been tested for HIV. Additional elements to be included may depend on the patient's background (e.g., education, employment, legal involvement, general health) and the particular treatment modality and target population. In assessing the level of a patient's concurrent dependence on opioids and cocaine, it is important to conduct frequent urine screens for cocaine. Cocaine and cocaine metabolites are cleared from the bloodstream more rapidly than most opioids. Resources permitting, urine screens should occur two times per week. A functional analysis of cocaine use should be done to identify the circumstances of use (where, when, with whom, and relapse triggers). It is important to involve family members and other significant relations of the patient in the evaluation to help diminish defensive behaviors such as denial, isolation, and compartmentalization (Beeder and Millman 1992). The clinician should also determine whether the patient's family and friends also use drugs. All seven domains of the problem areas identified by the ASI (described in the section on diagnostic assessment instruments later in this chapter) should be addressed:
Since opioid abusers are at risk for abusing cocaine and cocaine abusers are at high risk for abusing opioids, the temporal relationship of the other drug use (whether heroin or cocaine is the primary drug of choice) should be identified (Barthwell and Gastfriend 1993). Primary cocaine addicts will tend to use cocaine first and then heroin to relieve the adverse agitation or "crash" effects. Primary heroin addicts tend not to use cocaine prior to a heroin fix because the cocaine agitation may be confused with opioid withdrawal. In complex cases with psychiatric disorders, it is important to try to assess whether substance abuse preceded or followed psychiatric symptoms, although this distinction is admittedly difficult to make in many cases. Substance abuse may mimic psychiatric disorders and in some cases provoke them. Depression, for example, is a very common outcome of alcoholism, sedative abuse, and stimulant abuse. Paranoia may be provoked by the use of amphetamine or cocaine. Conversely, patients with distressing psychiatric symptoms often seek to self-medicate. This experience appears to be especially true for individuals with attention deficit disorder or manic symptoms. Depressed individuals often seek out a variety of drugs, which they hope will ameliorate their dysphoria. The following section gives an overview of pertinent elements to include in the substance abuse history, psychiatric examination, and psychosocial history to ensure that the indepth interviews and assessments are comprehensive. Substance Abuse HistoryThe substance abuse history should include information about the following areas:
If the patient's use of various drugs from major drug classes has not been addressed during the screening process, this topic should be reviewed while taking the history. The commonly recognized major drug categories include alcohol and other depressants, cannabis, opioids, stimulants, hallucinogens, phencyclidine (PCP), inhalants, nicotine, caffeine, and certain over-the-counter drugs with sedative effects. This core set may need to be supplemented by local fad drugs. The period of heaviest lifetime use may provide clues to the patient's motivation for use (Senay 1992). In the case of opioids and cocaine, it is important to learn the patient's drug use pattern during the past month because, without recent drug use, the possibility of physical drug withdrawal is unlikely. While not lethal, withdrawal from opioids and cocaine may be marked by depression or anxiety. Psychosocial HistoryThe psychosocial history should describe the relevant dynamics of the patient's functioning prior to the onset of illness (e.g., depression or anxiety). Make a point of identifying and supporting the patient's specific strengths (a good job, strong family ties, sensitivity, etc.) to provide the basis for a focused, individualized, and effective treatment plan. Information gained from the psychosocial history is important because addiction-related problems may be uncovered in psychosocial areas. The following elements may be explored to obtain a psychosocial history:
Psychiatric ExaminationThe purpose of the psychiatric examination is to look for threshold criteria of disorders requiring emergency intervention or referral to a specialist. This evaluation should occur in three stages analogous to the previously described stages of substance abuse assessment:
During the psychiatric examination, the following points are important to consider: (1) The psychiatric disorder may be a consequence of the addiction, (2) substances may be used for self-medication of underlying psychiatric symptoms, and (3) addiction and psychiatric illness may develop independently and later impact on each other (Meyer 1986; Senay 1992). The prognosis, course of treatment, and clinical approach will differ depending on which of these categories the patient falls into (Dackis and Gold 1992). The patient's presenting complaints should guide the order of the interviewer's questions about drug abuse symptoms versus DSM-IV disorders. What is essential, however, is that both spheres are equally and adequately explored (Senay 1992). Indicators of psychopathology can also be sought in the specific pattern of reported drug use, choice of drug(s), and positive and negative effects of the drug(s) on the patient. For instance, a borderline patient may describe drug taking as a disorganized, chaotic pattern while an obsessive-compulsive patient may take the drug(s) of choice in a carefully prescribed pattern (Beeder and Millman 1992). Psychiatric symptoms may be the result of agonist effects of drugs and, therefore, may not be a true psychiatric comorbidity. However, psychiatric symptoms occurring following at least a 2-3-week period of abstinence are reliable indicators of psychiatric comorbidity (Beeder and Millman 1992; Dackis and Gold 1992). While antisocial personality disorder is often present among substance abusers, the diagnosis should be made with caution. Care should be taken that antisocial personality disorder, which requires a history of problems before the age of 15, is not confused with adult antisocial behavior, a disorder that frequently develops as a result of substance abuse (American Psychiatric Association 1987). Substance abusers often have great difficulty identifying and naming feelings. This inability to identify feelings (alexithymia) can make the assessment of anxiety, depression, and sadness more difficult (Dackis and Gold 1992). Krystal and Raskin (1970) have described these patients as "concrete" and "flat." They may appear depressed or unimaginative. They may be subject to internal experiences that are primitive, poorly differentiated, and difficult to articulate. It is important to learn whether these dysphoric experiences lead to relapse. If so, relapse prevention work may include helping these patients to identify, differentiate, and verbalize poorly understood feelings. Baseline sexual behavior, with an emphasis on changes secondary to cocaine use, should be explored. To elicit a patient's sexual history, the AIDS Initial Assessment Questionnaire (AIA) can be consulted to help formulate questions that should be asked. Typical questions suggested by the AIA include the following:
The AIA questionnaire also includes questions for patients with multiple sex partners and questions about specific acts that may occur in male-female, male-male, and female-female relationships. Diagnostic Assessment InstrumentsIn addition to the psychiatric examination, diagnostic assessment instruments can be useful in gathering data (Beeder and Millman 1992). Although questionnaires and diagnostic instruments are not essential for an accurate diagnosis and effective treatment planning, some clinicians use such tools to supplement interview information. Instruments used alone are detrimental because some instruments assess for only one drug class and may miss local fads, and the patient may not experience the interviewer as interested and responsive to his or her needs (Senay 1992). The following is a brief description of some of the more widely recognized and used instruments. (Refer to appendix F for information on ordering these instruments.) Comprehensive Assessment ToolsAddiction Severity Index (ASI)The ASI is a research instrument widely used to evaluate the overall severity of a patient's addiction disorder and the extent to which patients exhibit significant change over time. It is designed to evaluate seven key areas of problem severity. These domains are rated on 9-point scales, with the higher numbers signifying greater severity. The ASI is highly regarded and extremely well established as the most important addiction assessment available. It must be administered to the patient by a trained staff person and takes approximately 45 minutes. Structured Clinical Interview (SCID)This clinical interview is used to assess psychiatric and substance abuse-related disorders. It guides an experienced mental health clinician through all of the major mood, anxiety, psychotic, and substance use disorders. An advantage of SCID is that the interview is modular. It can be shortened by focusing only on the diagnoses of interest. The interview provides very reliable DSM-IV-R diagnoses, which, along with Research Diagnostic Criteria (RDC), can be considered the "gold standard" for psychiatric diagnosis. The SCID takes an hour or more to administer and requires a highly skilled interviewer with prior mental health specialty training. It is primarily for use in clinical research settings that have sufficient resources to support indepth testing. Diagnostic Interview Schedule (DIS)The DIS is a structured interview that has been used in numerous clinical and research settings to support DSM-III-R diagnoses and is also available for DSM-IV. It must be administered by a trained interviewer and takes a minimum of 45-60 minutes to administer. The DIS is helpful in documenting psychiatric diagnostic information. It is not specifically geared to drug- or alcohol-dependent patients, and it is not a measure of change to be used in preoutcome or postoutcome studies. Brief Assessment ToolsBeck Depression Inventory (BDI)The BDI is a well-established, brief questionnaire easily used to assess symptoms of depression. The BDI is self-administered and easily scored, and the results are widely recognized. In the field of addiction treatment, the BDI can be used to measure one dimension of patient functioning-the level of depressive symptoms. However, the BDI is not a comprehensive or multidimensional instrument since it does not measure attributes other than depression. Like other self-rating depression instruments (the Zung Depression Scale and the Hamilton Depression Scale), the Beck overrates the true incidence of DSM-III depression, but it is a good screening tool to use prior to administering more complex depression assessments. It is also useful for monitoring the progress of the patient in treatment. Michigan Alcoholism Screening Test (MAST)MAST is a brief, self-administered questionnaire that assesses the extent of a person's problem with alcohol. Although MAST has been widely used as a screening instrument, some question its accuracy as a measure of change over time. Therefore, it may be useful to gain a quick assessment of alcohol-related problems, but not as a treatment outcome instrument. Another limitation is that the instrument assesses problems related only to alcohol use and not to all substances of abuse. Drug Addiction Severity Test (DAST)DAST is an instrument parallel to MAST; it is used to assess the level of drug-related problems and is used less widely than MAST. DAST's use is limited to screening programs, and it is not used to measure change over time. CAGE (Cut Down, Annoyed, Guilty, Eye-Opener)CAGE is a quick indicator of alcohol-related problems and can be self-administered. It may be useful as part of the routine medical screening process. It asks the following four questions (Ewing 1984):
These questions are not intended for use in measuring changes in behavior and do not provide any information regarding drug use. Ongoing AssessmentWhile assessment serves as a beginning phase of treatment, it also must be an ongoing process used to measure patient progress, update the treatment plan, and aid in relapse prevention. In this sense, assessment is a dynamic process that creates a feedback loop from treatment intervention and disposition of patient progress to continued treatment planning. The frequency of ongoing assessments will vary from case to case. Patients at risk for suicide, for example, should be assessed more often than those concentrating on long-term goals. Ongoing assessment can be accomplished by using the instruments described above, consulting with patients to review progress as measured by treatment plan goals, and doing followup studies of patients that measure abstinence at different intervals of treatment (e.g., 6 months or 1 year or both). Of particular importance in the ongoing assessment of MTPs is the evidence that many methadone-maintained patients initiate, continue, or increase cocaine use after the onset of treatment to experience the euphoric state no longer attainable with heroin (Condelli et al. 1991; Dunteman et al. 1992). Ongoing assessment also serves as a relapse prevention strategy by identifying early warning signs of relapse (see the Relapse Prevention section of chapter 4). Diagnosis and Confirmatory ProceduresAssessment allows the clinician to form an accurate diagnosis and build an appropriate and realistic treatment plan. Two diagnostic classification systems are currently in use: The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the International Classification of Disease, 10th revision (ICD-10), soon to be used by the World Health Organization. Although the two systems are organized differently, they are conceptually similar (Woody and Cacciola 1992). However, the DSM-IV classification system is more widely used in substance abuse treatment programs. Disorders related to psychoactive substance use, most commonly dependence and abuse, are covered in the Substance-Related Disorders section of the DSM-IV. In DSM-IV, Axis I disorders such as depression, when accompanied by psychoactive substance use within 30 days, may be categorized as secondary or due to psychoactive substance use. A total of 11 categories of abuse and dependence are specified: alcohol; amphetamines or similarly acting sympathomimetics; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opioids; PCP; and sedatives, hypnotics, or anxiolytics. Other DSM-IV categories include polysubstance dependence (meeting criteria for at least three categories of dependence as a group), psychoactive substance dependence not otherwise specified, and psychoactive substance abuse not otherwise specified (see appendix G, DSM-IV Diagnostic Criteria for Substance Abuse). Preparing the Treatment PlanAfter completing a thorough assessment and preliminary diagnosis of the patient, a treatment plan specific to the patient's identified needs should be prepared. A formalized treatment plan is required by Federal methadone regulations (21 CFR, § 291.505 (d)(3)(iv)), the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), and the Commission on Accreditation of Rehabilitation Facilities (CARF). Formulation of a comprehensive, individualized, attainable treatment plan is based on patient strengths and the application of an appropriate mix of available programs or external resources. Often this plan concretely addresses the steps an individual must take to attain each goal. A quality treatment plan addressing short- and long-range goals is developed within a 90-day period through a series of progressive action plans. It is a much expanded version of the initial treatment plan identified earlier in this chapter. This plan is critical for ensuring that treatment is delivered in an organized fashion, and it serves as a continuous reference point for the clinician. The patient should participate in preparing the treatment plan and should sign and receive a copy so that patient and program work toward the same goals. The case study in the following section introduces an example of an appropriate treatment plan and what it might entail.
Short-Term Objectives1. Evaluate depression and suicidal ideation Objective: To determine the patient's needs for psychotropic medication, inpatient care, or weekly counseling Action: Obtain an assessment, diagnosis, and treatment plan from the psychiatrist Target date: Within 1 month Responsible persons: Social worker, case- worker, psychiatrist 2. Obtain housing Objective: To obtain a stable residence for the patient Action: Contact Section 8 (an assisted- housing program), speak to Department of Social Services housing representative, check classified ads, contact realty agencies Target date: Immediately Responsible persons: Patient, caseworker, social worker, case aide Criteria: Copy of lease, patient self-report, or both 3. Obtain followup HIV care Objective: To obtain immediate medical attention for the patient, including possible medication with AZT, to delay the progress of the virus, and to reduce the patient's risk of transmitting the virus Action: Refer to health care practitioners for medical history and comprehensive HIV physical examination. Target date: 2 weeks Responsible persons: Patient, caseworker, health care coordinator, medical staff Criteria: Patient self-report and verification of medical results 4. Address cocaine abuse Objective: To educate the patient on the psychological and physiological effects of cocaine abuse Action: Arrange for weekly meeting with caseworker, refer to a cocaine group, or to self-help groups such as Narcotics Anonymous (NA) or Cocaine Anonymous (CA). Target date: Within 1 month Responsible persons: Patient, caseworker, group worker, medical staff Criteria: Patient attendance at meetings with the caseworker and group(s) Long-Term Objectives1. Abstain from cocaine use Objective: To be free from cocaine abuse, regain custody of children, help resolve criminal court case, prevent physical deterioration due to HIV status Action: Treatment through inpatient detoxification if outpatient approach has not worked; aftercare, such as cocaine continuing recovery groups; relapse prevention groups, NA, or CA meetings; or weekly meetings with the caseworker Target date: 6 months Responsible persons: Patient, caseworker, social worker, medical staff, group workers Criteria: Toxicology reports, patient self-report, and patient's observed behavior at the treatment program 2. Regain custody of the children Objective: To reconcile the family unit Action: Refer to family and child welfare services; cooperate with the child welfare agency; and encourage the patient to become involved in treatment, maintain abstinence, obtain housing, etc. Target date: 1 year Responsible persons: Patient, caseworker, social worker, COSA (children of substance abusers) worker Criteria: Patient self-report and Family and Children Welfare Services report 3. Continue HIV medical care Objective: To provide ongoing HIV education, treatment, and assessment Action: Continue with primary care unit and attendance at support group meetings for HIV-positive individuals Target date: Ongoing Responsible persons: Patient, medical staff, primary care worker, social worker, caseworker, group worker Criteria: Patient's self-report, primary care unit reports, and group leader reports 4. Obtain GED Objective: To enhance patient's employability and self-esteem Action: Refer to an educational therapist for testing, and have patient attend GED classes Target date: 2 years Responsible persons: Patient and educational therapist Criteria: Patient's self-report and diploma 5. Obtain employment Objective: To have the patient support herself and her children, and to enhance her self-esteem Action: Refer to a vocational counselor for testing and determine an appropriate career goal, attend life skills group, consult classified advertisements, and refer to the National Association for Drug Abuse Problems (NADAP) or Vocational Educational Services for Individuals with Disabilities (VESID) Target date: 2 years Responsible persons: Patient and vocational counselor Criteria: Employment verification and patient's self-report In developing the treatment plan, the clinician should focus the discussion on the problem areas identified by the ASI or a similar instrument, giving special consideration initially to areas critical to survival (eating, sleeping, housing). The treatment plan should evolve as the patient's circumstances change.
Patient-Treatment MatchingPatient-treatment matching requires further research. A variety of conclusions have been drawn by researchers about how to match patients to treatment modalities, but the type of treatment that works best for a particular patient at a particular time remains unclear. These are some areas that are under investigation:
Patients with psychiatric comorbidity should be carefully matched to treatment modalities because their success varies in different types of programs (McLellan et al. 1984). In a study that measured treatment improvement of patients in both therapeutic communities and methadone maintenance programs, it was found that those in the residential therapeutic community with high psychiatric severity actually worsened the longer they were retained. However, high-severity patients in the methadone programs slightly improved. Although high-severity patients may improve marginally in a therapeutic community, their chances may be better in a methadone maintenance program (McLellan et al. 1984). The American Society of Addiction Medicine (ASAM) has developed criteria for assessing the level of care appropriate for substance abuse patients (Hoffman et al. 1991). The criteria are defined for four levels of care using the following categories:
(See appendix B for a more extensive discussion of the ASAM placement criteria and levels of care.) The Multidisciplinary TeamThe complexities of treating patients concurrently dependent on opioids and cocaine require a multidisciplinary treatment team ideally involving general physicians, psychiatrists, psychologists, nurses, and counseling and social work staff (Barthwell and Gastfriend 1993). The actual composition of the treatment team will vary with the resources of the treatment program and the population treated by the program. Recovering staff often have important insights and can make significant contributions to the multidisciplinary team. RolesThe general physician or psychiatrist has the primary medical responsibility on the treatment team. He or she should actively provide direction in the medical care of the patient. Not only should the physician be involved in decisions about medication and dosing levels for methadone patients, but he or she should also have an active role in treatment assessment, diagnosis, and planning in case conferences with the team. The physician should also provide supervision and training to other team members and play an active role in treatment planning. Preferably, the physician will have been trained in addiction medicine. Ideally, program quality assurance plans should incorporate a peer review process. Physicians are usually involved in doing indepth evaluations of the patient, monitoring all medications, and providing needed substance abuse interventions when indicated. Physicians can also provide help with specialty care and consultation on substance abuse treatment. While trained counseling staff can complete historical information on concurrent opioid and cocaine addicts, only a physician can make the final decision on admitting them to methadone maintenance treatment. Medical staff in a methadone maintenance treatment program are required to determine current dependence, document medical and family history, determine treatment eligibility, and explain the treatment process and the treatment options (Langrod 1993). An additional role for the psychiatrist is to evaluate the patient and provide a psychological profile as well as administer standard psychological instruments, help the team articulate patient strengths and weaknesses, provide primary therapy when indicated, and consult with and train the treatment team. A psychologist may also perform these tasks. Nursing staff see patients most often and routinely dispense medication; therefore, they can assess acute changes in appearance or demeanor that may indicate drug impairment or withdrawal and monitor all pharmaceutical medication taken by the patient as well as potential drug-drug interactions. Nurses may also be involved in conducting health education, HIV and TB counseling and education, HIV and TB testing, and TB prophylaxis and treatment. The counselor or social worker or both work directly with the patient to develop and follow the treatment plan. In programs that do not have social work staff, counselors are often involved in case management services, sometimes supervised by social workers. The case manager on the treatment team helps the patient acquire a healthy living environment, education, employment, or new job skills; negotiate with social, criminal justice, and other systems in which the patient must interact; and address other areas of focus relevant to meeting primary living needs and psychosocial adjustment. Sometimes the social worker also functions as the counselor.
Multidisciplinary Team MeetingsMultidisciplinary treatment planning and ongoing assessment of the patient by professional staff is most beneficial for an effective treatment strategy and ensures that members of all disciplines work together on the same plan, each from a unique perspective. During these meetings, staff contribute their perspectives on the patient's progress and reach consensus on a treatment course. Team members must base clinical decisions on the patient's readiness for treatment, which can be determined by identifying the patient's stage of change. For a patient not yet ready to change, for example, the clinician should seek ways to develop motivation. Miller and Rollnick (1991) describe the stages-of-change model developed by Prochaska and DiClemente (1982). This model can be viewed as a wheel divided into five stages of readiness, with a sixth stage (Precontemplation) positioned outside the wheel. Once the patient enters the wheel, he or she can move through the stages of change. The clinician should recommend treatment appropriate for the patient's particular stage. The six stages are described below:
These stages of change and corresponding counseling responsibilities are outlined in the text box.
TrainingIn addition to specific knowledge about methadone medication (e.g., its pharmacology), all staff should have specialized training in working with patients who may be addicted to cocaine. Staff should receive cross-training and continuing medical education from multidisciplinary team members so that each understands the different roles on the team. This training should include information about HIV and TB, including infection control; counseling concurrently dependent patients; psychiatric comorbidity; domestic violence; and cocaine-specific pharmacology and associated medical complications. A helpful resource in staff training is the State Methadone Treatment Guidelines (CSAT 1993b). |
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