Oral Substitution Treatment for Opioid
Dependence: A Training in Best Practices &
Program Design for Nepal
Day 3
March 26-28, 2006
Kathmandu, Nepal
UNDP
Richard Elovich, MPH
Columbia
University Mailman School of Public Health Medical
Sociologist
Consultant, International Harm Reduction Development
International Open Society Institute
1
This Training is Adapted From:

Medication-Assisted Treatment For Opioid
Addiction in Opioid Treatment Programs
CSAT/SAMSHA (Substance Abuse and Mental Health Services
Administration Center for Substance Abuse Treatment)



2
Best Practices in Methadone Maintenance Treatment
Office of Canada’s Drug Strategy
Addiction Treatment: A Strengths Perspective
Katherine van Wormer and Diane Rae Davis
Additional Sources: Robert Newman, MD, Alex Wodak,
MD, Melinda Campopiano, M.D, Miller and Rollnick,
Prochaska, DiClemente, and Norcross, Michael Smith,
MD, Sharon Stancliff, MD, Ernest Drucker, PhD,
Adequate
Resources
Program Development
And
Design
Accessibility
3
A
Maintenance
Orientation
Training Goals

Ideally, this training will contribute to:



4
Increased knowledge, skills and best
practices among OST practitioners and
providers;
Engagement and retention of clients/patients
in the OST program in Kathmandu
Improved treatment outcomes
Six Training Modules



5
The SocioPharmacology of Opioid
Use and Dependence
Introduction and
background of oral
substitution treatment
The pharmacology of
medications used in oral
substitution treatment



Information collection
and service provision:
‘assessment-in-action’
Pharmacotherapy and
OST
Insights from the field
Learning Together
Parallel Process
6
Learning Process: Knowledge and
Skills
Acquisition of content
 Retention (store in memory)
 Application (retrieve and use)
 Proficiency (integrate and synthesize)

7
Expectations for Certification:
Training Contract



8
This is an 18 hour
training over a 3 day
period. Allowances have
been made for your work
schedules: Noon – 6 PM.
You must be present and
participate in all 18 hours
of the training to receive
certification. There can
be no exceptions.
Please stay focused. Be
on task because we have
a lot of material to cover
in 3 days.


Listening is a key to this
training. Listen to new ideas.
Listen to what’s coming up
inside you in relation to what’s
being presented. Try to put
your thoughts and feelings into
words instead of “shutting
down.”
Acknowledge and respect
differences. You can “agree to
disagree” on a contentious
point and move on. Participate
in role plays. Everyone has
permission to pass. Offer
feedback constructively not
personally. Try to receive
feedback as a gift.
Learning Environment




9
Try to be okay with
taking some learning
risks. Stretch past
your edge of what
you know and what
you are comfortable
with.
Confidentiality. Hold
the container. Don’t
be leaky.
Turn
off
phones
please.




No cross talk. Allow one
person to speak at a
time. Equal time over
time.
Start and end on time,
including breaks.
Be
alert to tendency to fudge
this.
Use “I” statements.
Can everybody agree to
this training contract? Is
there
anything
you
absolutely cannot live
with?
Now we are off.
The Counseling Relationship in
Pharmacotherapy and OST
Induction to Stabilization to
Maintenance
10
Counseling Increases
Effectiveness of OST Programs






11
Crisis intervention
Case management, incl.
referrals to and liaison
with other agencies
Individual one-on-one
counseling
Group counseling
Couples or family
counseling
Vocational counseling




Pre- and post-test HIV
counseling, and
counseling related to
other medical conditions
Health and other
education programs
Brief, supportive contacts
Long term intensive
support
Insight from the Field


12
Counseling should be as-needed, rather
than mandatory
When they are ready to do so,
client/patients should have access to
evidence-based approaches to counseling
to address issues of concern to them.
Best Practices* demonstrate:

Behavior change as it relates to drug
dependence is a set of personal and social
processes



Professional or service provider doesn’t change the
client; we providing a ‘facilitating environment that
supports their change process.
Client expectation/readiness needs to be matched to
appropriate counseling strategy
Importance of trusting relationship with warm,
inspiring, socially sanctioned counselor(s)
* Prochaska, DiClemente, Norcross Transtheoretical Model of Behavior Change
13
Role of the Clinician









14
Counselor style is a powerful determinant of client resistance is a
powerful determinant of client resistance and change.
Confrontation is a goal, not a style.
Argumentation is a poor method for inducing change.
When resistance is evoked, clients tend not to change.
Client motivation can be increased by a variety of counselor
strategies.
Even relatively brief interventions can have a substantial impact on
problem behavior.
Motivation emerges from the interpersonal interaction between
client and counselor.
Ambivalence is normal, not pathological.
Helping people resolve ambivalence is a key to change.
Action = Abstinence?

15
Many professionals are trained to help
people who are in the action stage of
change, and programs are geared to
action. “Action” is synonymous with
readiness and commitment to abstinence.
Stages of Changing Behavior (Prochaska et al)
16
Characteristics of SOC



17
Change is a process and happens in
stages; it is not linear.
Each stage of readiness for change has its
own cognitive and behavioral
characteristics.
Counseling interventions need to be
appropriately matched or tailored to the
stage of readiness.
Characteristics of SOC



18
Relapse is a normal part of the process of
stage, not outside.
Thinking happens at every stage; it
doesn’t start with action or preaction. It
can be engaged as ambivalence.
Goals look different and evolve through
stages.
Operationalizing Health Promotion
Objectives



19
Just because someone learns to parrot a
message doesn’t mean they are committed to
changing their behavior or practices
Just because someone is committed to
changing does not mean this translates into
what they actually do when they are confronted
in their local worlds with competing variables
The role of the intravention, collective
empowerment
Stages of Changing Behavior (Prochaska et al)
20
PROCESS
21
GOALS
Emotional Arousal
Experiencing and
expressing feelings
about one’s
ambivalence, problems,
and solutions
Self-reevaluation
Assessing feelings
and thoughts about
self with respect to
problem
TECHNIQUES
PROCESS GOALS
Commitment Choosing and
committing to act,
or belief in ability
to change
Countering
22
Consciously
substituting
alternative strategies
for problem
behaviors
TECHNIQUES
PROCESS
Identifying
and
controlling
environmental
effects
Reward
23
GOALS
Avoiding stimuli
(people, places,
things) that elicit
problem behaviors
Rewarding self, or
being rewarded by
others, for ‘showing up’,
experiencing
alternatives, making
changes.
TECHNIQUES
Environmental
restructuring, avoiding
high-risk cues/triggers,
“book-ending” with peer
support in stressful
situations, assertiveness
PROCESS
Helping
relationships
Increasing
social capital
GOALS
Enlisting the help of
someone who cares
Joining social networks which
provide personal, interpersonal,
community resources that can
enhance individual’s social
functioning, development and
access to social and material
resources. Entails obligation and
expectation. Social control, norms,
and relationships valuable to
personal development.
24
TECHNIQUES
Outreach



25
Outreach: In order to increase access to OST,
programs should consider proactive measures
to reach out to potential clients/patients who are
not likely to access treatment without
encouragement and support.
Outreach is an area in which peer-based
strategies and linkages and partnerships with
NGOs working at the front-line or “street” level
are particularly important.
Outreach workers can benefit from motivational
interviewing (MI) training
Advocacy

26
The role of a client/patient advocate
includes providing clients/patients with
information about the program and their
rights and responsibilities, as well as
intervening on clients’/patients’ behalf to
help access services and support.
Client/Patient Involvement
OST programs need to value, seek out, encourage and
support client/patient involvement.
 Feedback mechanisms
 Client/patient
for clients/patients, such
participation on
as suggestion boxes,
community advisory
surveys, and focus
boards
groups
 Client/patient
 Outreach programming
participation on decision Providing peer
making bodies
counseling and support
 Client /patient
involvement in evaluating  Clients/patients training
to become counselors
the program
27
Self-efficacy

Compare self-esteem and self-efficacy. The transition
from I think I can to I know I can. Becoming to being.
1.
Awareness of a problem or discrepancy/dissonance.
If I do it, there will be a benefit for me and things will
be better.
I have the capacity to do that. I have the skills to do
that. I can see myself doing that. I have what it takes.
That is who I am. The person who does that.
2.
3.
If someone doesn’t believe they can change, why should
they look at it as a problem?
28
Counseling and ‘Self-Talk’ : A
Strengths Perspective








29
Informal Learning and the Notion of ‘scaffolding’
Collective empowerment and the dynamics of
group work
Accurate Empathy
Attention to Stage of Readiness for Change
Engaging Ambivalence: Motivational
Interviewing
Alternative social and physical activities
Mutual Self-Help Groups
Peer Driven Activities and Volunteering
Change is a Social Process




30
It is important to recognize from the start that change in
drug practices is a complicated social process
Individual change including being exposed to drugs and
having the opportunities to use drugs to initiating drug
use to modifying drug practices happens in social
situations and proximal environments
Behavior change is a consequence of social change
Too often, health workers focus exclusively on the
individual as the way to realize health objectives
Working with Drug Using Youth and Young
Adults: A Strengths Based Approach





31
Ambivalence among youth is common
Developing autonomy and individuation
means pushing back against authority,
institutions, and norms
There is an interest in values, identities,
roles, relationships
Peer groups are important
Curiosity and openness to philosophical
questions
Capacity Building in Brazil*


32
The key is to not to treat population as if they
are empty bank accounts to be filled by our
expertise.
How to we facilitate a process that will
collectively empower them to be more
competent in their everyday world by enlisting
them to: describe “scenes” in their own wordscoding; analyze operative scripts and structures
that condition their practices- decoding. *
Paiva, 2000
Capacity Building II

33
This involves decoding and
consciousness raising; they identify
problem areas from their point of
view, e.g. acting out a skit or tableau,
in which they have an opportunity to
generate and practice new choices
and solutions for each other.
Capacity Building III

34
The process of “conscientization”* is
useful for marginalized or stigmatized
people where they are able to see
themselves and each other as responsible
subjects capable of self-regulation and
making change rather than passive
objects acted upon. *Freire, as cited in Paiva, 2000
Capacity Building

On-going experience of conscious practice, like strengthening a muscle, as
an alternative to passivity or falling into something or in with what other
people do.

New experiences mean new experiences of themselves. When they reflect
back on a new experience: ‘I can do this. I did this, I can do it again. That
was really me,’ they are integrating or internalizing new experiences, into a
new idea about themselves and their capacity, e.g. self regulation,
persistence, achieving competence in their every day life.

Transformation of understanding of self from a person ‘things happen to’ to
an active subject acting relationally in the world to take better care of
themselves. Treatment that focuses on building self-efficacy, and
ego
strengthening is in plain words, building up the ‘executive manager’ within
oneself, i.e., the person who ‘gets things done.’ Think, for example, of the
manager of his or her own business.

Group work can help develop language and communication skills that build
an individual’s confidence to have a conversation, to self manage the
impression they leave on others with whom they are interacting.
35
Group Work in OST Provides:


36
A mirroring process where individuals can
observe or experience similarities or contrasts
in their thoughts, feelings, actions;
An opportunity to experience oneself in the
presence of others, breaking isolation,
uniqueness, fear, shame;
Group Work in OST Provides:

A social arena to witness and model a peer
transformational process:







37
Learning by analogy (other’s behavior).
Learning by identification.
Learn through trial and error.
Learn by modeling.
Amplification of positive change.
Collective empowerment
Clear parameters or limits for interpersonal
interaction
Group Work in OST Provides:

38
Support for the development of alternative
social networks that reinforce the process of
transformation
Example: First Group Session
Closing
Introductions
Check
Out by participants
Summary
Ground rules
Centering
Reasons for coming to
The group and concerns
What
Is not
So Good
injecting
39
What
is good
about
injecting
Second Group Session
Summarizing
Check
out and
closing
Welcome
Centering
Ambivalence about
relationships,
values and
behaviors
Values
40
Check in and Review of
Second session
Map of my relationships
Third Group Session
Summarizing
Check
out and
closing
Welcome
Centering
Ambivalence about
change
Building Discrepancy
41
Check in and Review of
Third session
Reasons for wanting
And not wanting to make
a particular change
What are the norms within your drug using relationships
or informal groups?
+
42
?
-
A Basic Counseling Exercise

What is something pleasurable to me,
important or valuable? Describe in detail.

What is the risk? Describe in detail.

How can I reduce the risk or cost but hold
on to what is pleasurable or find a new
alternative?
43
Incremental Change





44
Process of getting stuck or dependent and the process
of getting unstuck
Autonomy- Staff or helpers are on the sidelines. How
do you help without encouraging dependency
Capacity for Flexibility—adjust strategies: “I had a math
teacher. I didn’t understand the problem. She explained
it again the same way.”
Progress not perfection or single outcome
Set own goals and move at own pace. Goals evolve.
Motivational Interviewing


45
Uncertainty or ambivalence about change is at
the heart of the difficulties many clients
experience in treatment. This is also the
challenge narcologists experience with clients
who have addictive problems.
The question for us is how can we provide the
client with an opportunity to articulate,
explore and resolve this ambivalence for
him/herself?
AMBIVALENCE AND
DECISIONAL BALANCE
46
What is Motivation?

47
“Motivation” can be defined as the
probability that a person will enter into,
continue, and adhere to a specific change
strategy.
Motivation



48
Motivational interviewing assumes that the state
of motivation may fluctuate from one time or
situation to another (Miller & Rollnick, 1991).
Therefore, this “state” can be influenced.
By providing a safe, nonconfrontational
environment, eliciting hope, helping clients
clarify ambivalence about their drug use and
about making change, counselors can be helpful
in ‘tipping the scales’ in favor of readiness to
make a positive change.
Spirit of Motivational Interviewing





49
Developing a collaborative partnership
Counselor facilitates rather than coerces
ambivalence and change
Client is assumed to have resources and
motivation for change
Ambivalence is enhanced by drawing on
client’s own perceptions, goals and values
Counselor supports client’s capacity for
self-directed change
Review: 7 Early Strategies







50
Ask open-ended questions
Listen reflectively.
Elicit ambivalence.
Do not project your ideas onto the client.
Affirm. Focus on eliciting strengths not on
pathologies or what is wrong with the person.
Foster a sense of collaboration with the person.
Summarize at key intervals and ask for their
comments
A Working definition




51
We can define motivational interviewing as “a
client-centered , directive method for enhancing
intrinsic motivation to change by expressing,
exploring, and resolving about problematic
behaviors and behavioral change.”
It is “a way of being with people”.
It is directive in terms of the process and techniques of
addressing ambivalence, not directive about the
outcome of the counseling.
It is client centered because all the benefits and
consequences of making a change are elicited from the
client.
Engagement of People who are
highly ambivalent



The largest group of people who are using
and are at risk are outside the action
stage, yet majority of services are directed
to action.
Passive recruitment
Proactive recruitment

52
use of ambivalence and identification, avoid
labeling, be positive and tangible
Stages of Changing Behavior (Prochaska et al)
53
‘Sanjar’: On the One Hand:






54
His use provides excitement, a change in feeling and
thinking, relief
Finding ways to obtain and afford the drug provides him
with adventure and achievement
Preparing and administering may provide a sense of
competence and even looking out for others in his group
Interpersonal reinforcement as he negotiates
successfully various networks in which he interacts to
obtain money, acquire the drug, share the drug, play a
role, earn respect and recognition.
Using is a reward for successfully completing the
‘mission’.
Euphoric properties add to positive feelings
‘Sanjar’: On the Other Hand






55
Once he is down, he feels shame that he has
neglected his familial obligations
He sees himself in how neighbors look at him or
avert their eyes
He may feel used/depleted from the social
interactions involved in the ‘mission’.
He may feel he has let himself down and others
He may hate needing his need for the drug
He may feel wasted, depressed, low energy
Best Practices* demonstrate:

Behavior change as it relates to drug
dependence is a set of personal and social
processes



Professional or service provider doesn’t change the
client; we providing a ‘facilitating environment that
supports their change process.
Client expectation/readiness needs to be matched to
appropriate counseling strategy
Importance of trusting relationship with warm,
inspiring, socially sanctioned counselor(s)
* Prochaska, DiClemente, Norcross Transtheoretical Model of Behavior Change
56
Benefits and Costs
Short term things that are good,
okay or acceptable to me
Long term things that are good,
okay or acceptable to me
57
Short term things that are not so
good, okay or acceptable to me
Long term things that are not so
good, okay or acceptable to me
Benefits and Costs


58
Use Motivational Interviewing approach,
which aims to decrease the participant’s
perception about the costs of changing.
Change here depends on the pros (of change)
outweighing the cons. Individuals can see that
the cons of changing are different short and
long-term, just as there are not many long-term
benefits to continuing a problematic behavior.
Let’s Come Up With Situations or Dilemmas Adapted to Real
Life Among Drug Users In Our Regions
59
Agenda Setting

An outreach worker to an active drug user(s) in
a ‘natural’ setting:
“As you know, there are a number of things that
we could discuss today– HIV, preventing
overdoses, injecting practices and relations with
others, any concerns you have generally about
drug use– but what are you most concerned
about? What would you like to talk about today?
Perhaps there is something especially important
or something that is immediate?”
60
Is It an Open or Closed Question









61
What do you like about injecting?
Where did you grow up?
Would you tell me what was good and maybe not so
good about your first experience injecting?
Isn’t it important that you have the respect of your
family?
Have you ever had an overdose or witnessed someone
overdosing?
Are you willing to meet with me again?
What happens with an overdose?
What brings you here today?
Do you want to stay in this relationship?
Is it an Open or Closed Question?





62
Have you ever thought about getting work?
What do you want to do about your overdoses: not inject
alone, test the dose first, stop injecting, or just do what
you are doing?
In the past, how have you overcome an important
obstacle in your life?
Will you try for a week to avoid talking about injecting
with non-injectors, not injecting in front of non-injectors,
and not giving people their first hit?
What are the most important reasons for avoiding talking
about injecting with non-injectors, not injecting in front of
non-injectors, and not giving people their first hit?
Empathy




63
The principle of empathy is acceptance.
Through respectful reflective listening the counselor
seeks to understand the client’s perspective without
judging, criticizing or blaming.
Acceptance is not the same thing as approval or
agreement.
Ironically, this kind of acceptance of people as they are
seems to free them to change, whereas insistent
nonacceptance tends to immobilize the change process.
The person focuses on defending, arguing, winning the
argument or the counselor’s acceptance, rather than
self- reflection and self-assessment.
Summary of Accurate Empathy



64
Express empathy, which helps create the
safe and non-judgmental setting for the
participant, regardless of the setting
Skillful reflective listening is a fundamental
tool of motivational interviewing
Ambivalence is accepted as a normal part
of human experience and change, rather
than a pathology or sign of incapability or
defensiveness or resistance.
Reflective Listening


65
The fundamental tool of motivational
interviewing
“What people really need is a good
listening to.” Mary Casey
Listen Reflectively



66
Overview: You all know it but it is an art. We’re going to open it
open for examination over the next exercises. It’s not one note but
scales. Repeating, rephrasing, paraphrasing, identifying underlying
feeling.
Referring back to what we discussed yesterday about reflective
listening— when a client listens to you reflect back on what s/he
just said, s/he is now listening to see:
 if you are really paying attention
 if it’s accurate
 if s/he hears something new about him/herself
 How it feels to hear his/her own thoughts expressed by
another
In these exercises try to self observe how you feel about limits. Try
to find your authenticity within structure of each form.
Exercise

What is ambivalence or feeling two ways
about something? What do you associate
with it?

What is reflective listening?
67
Consciousness Raising

68
It begins with how I treat a client, the
assumptions I make, the conversation we have.
Needs Improvement:


Lack of Drug Dependence Training of
Physicians, Psychiatrists, Nurses, and Social
Workers
Lack of willing providers




Cost


69
Lack of awareness in Primary Care
Professional turf issues
Fear of regulation
Medication
Profiteering
Capacity Building

70
Expanding the team to address drugs and drug
practices appropriately:
 The client can identify a drug issue with me
 The client can talk about drug use within our
services
 The client can get supportive services to stay
healthy
 The OST can respond more effectively to drug
related health issues.
Medically Supervised Withdrawal

When stable client/patients in the maintenance
stage ask for dosage reductions, it is important
to explore their reasons.



71
They may believe they can get by on less medication
or may be responding to external pressures.
Client/patients on lower dosages may consciously or
unconsciously be perceived as “better patients”.
Counseling and education is key to exploring the
short and long term benefits and costs of current
dosage and then of dosage reduction.
Voluntary Tapering and Dosage
Reduction


72
Some studies indicate high relapse rates, often
80% or more, for client/patients who attempt
cessation of maintenance medication, including
those judged to be rehabilitated before tapering
(e.g., Magura and Rosenblum, 2001).
However, likelihood of successful tapering also
depends on individual factors such as
motivation, family support, and other ‘social
protections’ such as employment, etc.
Clients/patients may consider leaving
treatment for a variety of reasons including:





73
Unrealistic expectations for
recovery
Pressure from family members
and others, including program
team members
The social stigma associated
with methadone
Program team members’
beliefs about the desirability of
abstinence from methadone as
a goal of treatment
The inconvenience of regular
attendance to obtain
methadone and other program
requirements




Financial reasons (cost of
treatment)
Demands of work
Travel restrictions
To find out if they can manage
without methadone or not, e.g.
for individuals who have
become stabilized on
methadone, and have not used
opioids in a long time, a
decision to attempt tapering
may be wise and appropriate.
Voluntary Tapering and Dosage
Reduction



74
As part of informed consent process, the
possibility of relapse should be discussed with
client/patients, especially those who are not
stable on their current dosage.
They and their families should be aware of risk
factors for relapse during and after tapering.
Client/patients who choose tapering should be
monitored closely and have access to individual
and group relapse prevention counseling,
education, and support that accompanies and
extends beyond period of tapering.
Voluntary Tapering and Dosage
Reduction

If relapse occurs or is likely, additional
therapeutic measures can be taken, including
rapid resumption of OST when appropriate
(American Society of Addiction Medicine 1997).

75
Clients/Patients being tapered off methadone
should have access to an increased dose– to
get through a “rough patch”– without having to
go through a program re-entry process.
Methadone Dosage Reduction


76
A common practice of graded methadone
reduction is to reduce daily does in roughly 5-to10 percent increments with 1 to 2 weeks
between reductions, adjusting as needed for
client/patient conditions.
Because reductions become smaller but
intervals remain about the same, many months
may be spent in such graded reductions.
Methadone Dosage Reduction


77
A slow withdrawal gives client/patients time to
stop the tapering or resume maintenance based
on individual client/patient response, especially
if relapse seems likely.
Regardless of rate of tapering, a point usually is
reached at which steady-state occupancy of
opiate receptors is no longer complete, and
discomfort, often with drug hunger and craving,
desperate feelings or panic, emerges.
Methadone Dosage Reduction




78
This point may occur at any dosage but is more common
with methadone when the dosage is below 40 mg per
day.
Highly motivated client/patients with good support
systems can continue withdrawal despite these
symptoms by tightly embracing structural supports as
dose decreases.
Some client/patients appear to have specific thresholds
at which further dosage reductions become difficult.
Blind dosage reduction is appropriate only if requested
by the client/patient, discussed and agreed upon before
it is implemented.
Methadone Dosage Reduction

79
SAMHSA’s Treatment Improvement
Protocol (TIP) 43 strongly recommends
that OST staff always disclose dosing
information unless individual
client/patients have given specific
informed consent and have requested that
providers not tell them their exact
dosages.
Methadone Detoxification

For client/patients who prefer detoxification to
maintenance, there are two kinds of detoxification:




80
Short-term treatment of less than 30 days
Long-term treatment of 30 to 180 days
Patients who fail two detoxification attempts in 12
months should be evaluated for different treatment or
mode of treatment.
Two factors should be considered in short-term detox:
the brief duration of initial dose may preclude
achievement of steady state; tapering may be too steep
if it begins at a dose greater than 40 mg.
Involuntary Tapering or Dosage
Reduction




81
When clients/patients violate program rules or no longer
meet treatment criteria, involuntary tapering should be
avoided if at all possible.
Treatment decisions should be made in the
client/patients best interest rather than as punitive
measure.
Many days of dosing missed, client progress is
unsatisfactory, unwillingness to comply with treatment
contract, nonpayment of fees are some reasons for a
change in strategy.
Continued maintenance at an adjusted rate along with
increased and focused counseling and support is
recommended.
Impact of discharge
Deaths following involuntary discharge or
drop outs from methadone treatment: 1 year
follow- up
In treatment Discharged
Deaths
4/397
9/110
(%)
(1%)
(8.2%)
Zanis, 1998
82
Involuntary Tapering or Dosage
Reduction
 “Efforts
should be made to retain
these at-risk clients/patients in
methadone treatment even
though their treatment response
may be suboptimal.”

83
Zanis 1998
Take-Home Medications:
Unsupervised Doses





84
Absence of recent drug
and alcohol abuse
Regular OST attendance
Absence of behavior
problems at OST
Absence of recent
criminal activities outside
OST
Stable home environment
and social relationships



Acceptable length of time
in comprehensive
maintenance treatment
Assurance of safe
storage of take-home
medication
Determination that
rehabilitative benefits of
decreased OST
attendance outweigh the
potential risk of diversion
Take-Home Medications: Once
Clinical Criteria (Above) are Met




85
First 90 days: 1 takehome per week
Second 90 days: 2 takehome per week
Third 90 days: 3 takehome per week
Fourth 90 days: 6 days’
supply of take-home
doses per week


After 1 year of continuous
treatment: 2 weeks’
supply of take-home
medication
After 2 years of
continuous treatment: 1
month’s supply of takehome medication, but
monthly visits to OST are
still required.
5. Best Practices in MMT- Program
Policies and Reducing the Barriers












86
Open Admission Procedures
Timely Assessment and First Medication
Immediate Crisis Management
Initial Assessment
Informed Consent
Ongoing Assessment-in Action
Comprehensive Assessment
Adequate Individualized Dosage
Unlimited Duration of Treatment
Clear Criteria for Involuntary Discharge
Non-Punitive Use of Urine Toxicology Screening
Client/Patient-Centered Tapering
OST Goal: Engagement





87
Distinguish between response to illicit drugs and
response to people who use illicit drugs
Drugs trafficked across borders and circulated locally
are objects
There is tendency to objectify people using those
drugs, dehumanize them, deprive them of rights to
treatment and assistance
We distance ourselves from people who use these
drugs and forget that they are part of families,
communities, societies
Most People who need treatment stay away
Maslow Needs/Values Pyramid
Self-actualization,
Creation,
transcendence of
identity barriers
Achievement, knowledge,
understanding, psychology
Acceptance by others, sense of belonging,
receipt of attention, approval, praise
Sustenance of biological needs, protection and safety from
pain or danger, facilitation of pleasure
88
Engagement of People who are
highly ambivalent



The largest group of people who are using
and are at risk are outside the action
stage, yet majority of services are directed
to action.
Passive recruitment
Proactive recruitment

89
use of ambivalence and identification, avoid
labeling, be positive and tangible
Reducing Barriers






90
Program location inaccessible to or remote from
target group or community
Fear of or perception of ‘registration’, stigma,
professionals
Lack of availability of treatment
Lack of confidence in treatment effectiveness
Financial Costs
Requirement that abstinence be the exclusive
goal of treatment
Reducing Barriers:


“Low threshold” access to services where the
requirement of abstinence is not a precondition
for receiving treatment.
Recruit, train and hire members of target group
(users and former users) to do communitybased outreach:

91
“They have insider access to drug-using (networks),
they know the rules governing the social systems of
the streets, and they are able to develop trusting
relationships with the target population of active drug
users” (Booth et al, 1998)
Meeting Drug Users on Their
Own Ground






92
The labeling of clients is avoided
Clients provide the definition of the situation as they see
it
Clients who wish it are given advice on how to reduce
the harms associated with their drug use
Counselor and client collaborate on a broad range of
solutions to the client-defined problem
Resources are gathered or located to meet the individual
needs of the client
Change can be incremental and clients are viewed as
amenable to change, if abstinence is not the only option.
WHAT IS A STRENGTHS-BASED
APPROACH?


Recognizes and supports incremental
change: sees possibility of change in
everyone
Allows choices:




93
the goal of the helping relationship (harm reduction,
substitution therapy, treatment readiness, abstinence)
informed choice about a variety of treatment contexts
(same gender group, outpatient, inpatient, mutual
help groups)
Informed choice about treatment methods
Pays attention to client’s expectations and
stage of readiness for change
VARIETIES OF MT CAN BE
CLIENT-CENTERED(WHO, 1990)




94
Short-term detoxification decreasing doses
during one month or more
Prolonged detoxification decreasing doses
while more than one month
Short-term maintenance treatment: stable
prescription methadone during a six month or
less period
Long-term maintenance therapy using
methadone in the time frame of longer than one
year and possibly ongoing
Harm Reduction in Practice
Meet them where they’re at

Work on what’s bothering them rather than
what’s bothering me
Have low threshold access

Same day and walk-in appointments
If at first you don’t succeed, redefine
success
Dana Davis, Allegheny General Hospital Positive Health Center,
Pittsburgh, PA
95
Best Practices in MMT- Program
Development and Design









96
Clear Program Philosophy and Treatment Goals
Focus on Engagement, Retention, and Improved
functionality and fitness
A Maintenance Orientation
A Client/Patient-Centered Approach
Accessibility
Integrated Comprehensive Services
Client/Patient Involvement
Involvement of Wider Community
Adequate Resources
Setting Realistic Treatment Goals



97
Retention is important because research has
affirmed that again and again, the longer opiate
users stay in treatment, the better the outcomes
The goal of drug treatment can be increased
quality and quantity of life, functionality and
fitness, as they describe those, rather than
abstinence
Both individual and societal benefit is achieved
in maintenance even if abstinence is not an
outcome
Treatment Readiness






98
Brings Treatment to Where People Are
“Stepped” Approach to Treatment
Abstinence is Not the Exclusive Outcome
Avoids Labeling
Recognizes Stages of Change
Uses Motivational Interviewing,
Acupuncture, Individual and Group
Counseling
Recognize success
•Success in medical treatment
•Obtaining employment
•Recognition of all life improvements
•Family relationships
99
DRUG- SUBSTITUTION THERAPY
IN KYRGYZSTAN




100
In the MMTP in Bishkek, patients interacted comfortably
with staff who treated them with respect; they took
individual and group counseling, and family members
also had an opportunity to be involved throughout
treatment process.
Family members of methadone clients reported that they
had ‘returned’ to themselves, they looked, spoke and
acted differently and were able to resume their roles
within the family.
Drug users talked animatedly about the impact the
methadone treatment experience on their lives with
families and their work
It was apparent that this form of substitution therapy,
provided within this context, from the perspective of the
users and the family members was treatment.
INTEGRATION WITH OTHER
APPROACHES

101
Nearby the narcological dispensary in
Kyrgyzstan, where MMTP was offered, NGO
“Sotsium,” run by another narcologist, provided
an array of services including syringe exchange,
medical services, a hot line, volunteer and
training opportunities, a variety of self-run 12
step meetings open to the community, and a
pilot inpatient treatment and rehabilitation
program
Research and Evaluation






102
Increase the understanding, acceptance of and
level of support for OST in Nepal
Refine Program Delivery on an Ongoing Basis
Identify the Most Effective Ways to Address the
Needs of Diverse Client/Patient Groups
Improve Treatment Outcomes
Reduce the Harms Associated with Opiate
Dependence
Expanding OST in Nepal and Adapting OST to
Other Settings Across Nepal
Open
Admission
Program
Policies
Methadone
Dosage during
Pregnancy
Clear Criteria
For Involuntary
Discharge
Summarizing Best Practices in OST
103
12. Next Steps
104