Maintenance Phase
Judith Martin, MD
Medical Director,
The 14th Street Clinic,
Oakland
Clinical tasks of maintenance
phase:
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Stable medication as a platform
Monitoring progress in treatment
Managing threats to stability
Referrals for higher level of care
rapport
engagement
attendance
support
RETENTION IN TREATMENT
stability stability
stability
Groundwork
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Initial agreement with patient
Initial questionnaires
Initial problem list and assessment
Stabilized dose schedule
Home meeting/counseling
Examples of Patient agreements:
• to take the medication only as
prescribed
• to notify the clinic immediately in
case of lost or stolen medication
• to comply with the required pill
counts and urine tests.
Integrating care:
Examples from Patient
Intake Questionnaire
How do you achieve peace of mind?
What are your sources of inner strength?
What are your best qualities?
INTEGRATING CARE:
PATIENT QUESTIONNAIRE
ABOUT RELAPSE
• What ‘triggers’ do you know which put
you in danger of relapse to drug abuse?
• What coping methods have you
developed to deal with these triggers to
relapse?
Adjustment to chronic disease
Grief process
Hope for cure or mild case
Life changes needed
Specifics of addiction:
social milieu dangerous
supports burned out
coping by drug a pattern
Periodic monitoring
• Protocol for random testing
• Periodic observed dosing
• Relapse prevention/ongoing
behavior change
• Periodic physical examination/labs
MONITORING
Urine toxicology screens: On -Site at each visit
Send -away initial and yearly
Random call twice a year
Pill counts at each visit
Breathalyzer: initial, then individualized
Physical exam: initial, annual and individualized
Labs: initial, then individualized, some annual
Physical comfort at dose
Monitoring Treatment Progress
• Drug use must be a primary measure of
treatment progress
• How to measure?
–Self-report?
–Report of spouse or other concerned party?
–Drug Testing: urine? sweat? hair?
–Changes in drug associated behaviors?
Stealing, drug-dealing
Urine Testing
• Develop Standard Collection
procedures for in office or off site
testing
– Observed vs. not observed
Reasonable alternative to
watching
• Urine collection container
with temperature strip
Reasonable alternative to
watching
• Urine collection container
with temperature strip
Treatment Outcome Data:
Methadone Maintenance
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8-10 fold reduction in death rate
reduction of drug use
reduction of criminal activity
engagement in socially productive roles
reduced spread of HIV
THREATS TO STABILITY
Other drug abuse or positive screens
Medical problems
Life changes: moves, divorce, new job
RED FLAGS CHECKLIST
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Missing appointments
Running out of medication too soon
Taking medication off schedule
Not responding to phone calls
Refusing urine or breath testing
Neglecting to mention new medications or
outside treatment
RED FLAGS CHECKILST,cont.
• Appearing intoxicated or disheveled in
person or on the phone
• Frequent or urgent inappropriate phone calls
• Neglecting to mention change in address,
work, or home situation
• Inappropriate outbursts of anger
• Lost or stolen medication
RED FLAGS CHECKLIST,cont.
• Frequent physical injuries or accidents
• Non-payment of visit bills
RESPONSE TO RED FLAGS
Address with patient as soon as noticed
Ask for self-evaluation
Ask for patient-generated plan
Formalize plan within office limits
Written contract may be needed
HAS TO MAKE SENSE FOR THIS PATIENT
STAGES OF CHANGE:
MAINTENANCE
• Solidify gains of the active phase
• Work to prevent relapse
• Consistently engage in new
behavior
RELAPSE
-Regress to earlier “stage of
change”
-Relapse and recycling is the rule, not the
exception.
-Most relapse is to
contemplation.
-Some people benefit from
recycling.
MONITORING:
META-MESSAGES
Stability allows progress
Progress in treatment is expected and encouraged
Relapse does not necessarily mean complete failure
It’s important to have people who ‘watch out for you’
Addiction treatment is not just a pill
Structure varies depending on progress
MONITORING: SUMMARY
Regular follow-up visits
Regular and random testing and pill counts
Address red flag behavior promptly
Adjust structure and contracts
according to progress
What you are doing should make sense
Referral and discontinuation
• Higher level of care needed
• Immediate dismissal for behavior
• Taper for administrative noncompliance
• (clear guidelines important)