Counseling Opioid Dependent PatientsCounseling Opioid Dependent Patients

Information and Treatment Approaches for Counselors

Michael J. McCann, MAMatrix Institute on Addictions

Overview of Presentation Overview of Presentation

Background informationSome general issues in treating

opioid dependent patients Some treatment approaches

Opioids Opioids

Relieve painProduce and alleviate morphine-like

withdrawalMorphine, heroin, methadone,

codeine, hydrododone (Vicodin), oxycodone (Percodan), Darvon, Demerol

Opioid DependenceOpioid Dependence

Repeated use results in tolerance (more is required for desired effect)

• and,

Withdrawal upon cessation of use– Chills, gooseflesh, sweating, yawning– Runny nose, tearing eyes, dilated pupils,– Nausea, diarrhea, – Insomnia, anxiety, craving

Range of Counselor ExperienceRange of Counselor Experience

Broad experience with SA dependence treatment, including opioid dependence

SA treatment experience, but not with opioid dependence

Counselors with no SA treatment experience

Counseling Opioid Dependent Counseling Opioid Dependent Patients: Some General Issues Patients: Some General Issues

1. Recovery and pharmacotherapy

2. Patient orientation towards recovery

3. 12-Step meetings

4. Patient management

5. A Cog/Behavioral approach

Recovery and PharmacotherapyRecovery and Pharmacotherapy

Patients may have ambivalence regarding medication

The recovery community may ostracize patients taking medication

Counselors need to have accurate information

Recovery and PharmacotherapyRecovery and Pharmacotherapy

Focus on “getting off” medication may convey taking medication is “bad”

Suggesting recovery requires cessation of medication is wrong

Support patient’s medication-taking “Medication,” not “drug”

Recovery and Pharmacotherapy: FactRecovery and Pharmacotherapy: Fact Methadone treatment efficacyMethadone treatment efficacy% of sample, n=727, Hubbard et al. 1997% of sample, n=727, Hubbard et al. 1997

89%

28%

42%

22%29%

14%

0%10%20%30%40%50%60%70%80%90%

100%

Heroin use(weekly)

Cocaine use(weekly)

I llegalactivities

PretreatmentPosttreatment

Recovery and Pharmacotherapy: FactRecovery and Pharmacotherapy: Fact

Methadone treatment results in a 4-fold decrease in mortality

– John Caplehorn, 1996

“Just substituting one drug for another”

“Patients are still addicted”But, –Medications are legal– Oral vs injected– Taken under medical supervision– Inexpensive

Recovery and Pharmacotherapy: Recovery and Pharmacotherapy: Facts and MythsFacts and Myths

“Patients are getting high”But,– Long acting, slow onset–Matches level of addiction

Recovery and Pharmacotherapy: Recovery and Pharmacotherapy: Facts and MythsFacts and Myths

Often a narrow focus; physical relief is sufficient

Focus on not using illicit opiates vs. new behaviors

Counseling may be viewed as an unnecessary imposition

Patient orientation towards Patient orientation towards recoveryrecovery

Patient orientation towards recoveryPatient orientation towards recovery

Patient orientation, counselor response– Impatience, confrontation, “you’re not

ready for treatment”

or,– Deal with patients at their stage of

acceptance and readiness

Patient orientation towards Patient orientation towards recoveryrecovery

Patient orientation, counselor response– Be flexible– Don’t impose high expectations– Don’t confront– Non-judgmental acceptance– A motivational interviewing approach

What is the 12-Step Program?Benefits: peer support, widely

available, social outlet, freeMeetings: speaker, discussion, Step

study, Big Book readingsSelf-help vs treatment

12-Step Meetings12-Step Meetings

Medication and the 12-Step program– Program policy

• “The AA Member: Medications and Other Drugs”• NA: “The ultimate responsibility for making medical

decisions rests with each individual”

Some meetings are more accepting of medications than others

12-Step Meetings12-Step Meetings

Urine TestingUrine Testing

A standard treatment component A tool to prevent drug use Does not reflect assumption of patient

dishonesty Ideally monitored (temperature strips) Minimize tampering: containers, purses,

backpacks, hot water, etc Detection times

Urine Testing: Dealing with a Urine Testing: Dealing with a positive test positive test

Re-evaluate the circumstances prior to the test

Don’t discuss validity of the result (lab error, etc.)

Don’t confront; provide an opportunity for the patient to explain

Urine Testing: Dealing with a Urine Testing: Dealing with a positive test positive test

Reinforce honesty Partial confession is good enough; move

onProceed with assumption of drug useCommunicate with physician

Urine Testing: Other IssuesUrine Testing: Other Issues

Falsified specimens; avoiding voiding– Indicators: cold, clear, Gatorade, apple juice– Ask the patient about it– Observed test is an option– Avoidance excuses: “can’t go”; “just went”

Patient ManagementPatient Management

“Manipulation”– A vestige of the drug-using lifestyle– An old survival skill– An unlikable quality in the world – A manifestation of the disorder in

treatment (cardiologists don’t criticize patients having chest pains)

Patient ManagementPatient Management

“Manipulation”– Counselor’s responses• Protective cynicism• Trust and openness

Patient ManagementPatient Management

Pushing Boundaries– Inappropriate familiarity– Reflexive “manipulation”?–May result from past counseling

experiences

Patient ManagementPatient Management

Intoxication– Manage the situation, don’t counsel– Ensure patient safety– Arrange transportation

Patient ManagementPatient Management

Loitering– May have been acceptable in prior

treatments– Creates opportunities for dealing– Not the best use of time– Not well tolerated by neighbors– May reflect problems at home

Counseling ApproachesCounseling Approaches

Provide information and skills– Conditioning Process: you can’t “will”

cravings away; modify behavior– Addiction as a brain disease

Counseling ApproachesCounseling Approaches

Information and Skills– Get rid of paraphernalia– Scheduling time– Thought-Stopping for cravings– Evaluate people and places (fools rush

in)

Counseling ApproachesCounseling Approaches

Relapse Prevention– Patients need to develop new

behaviors– Learn to monitor signs of vulnerability

to relapse– Recovery is more than not using illicit

opioids– Recovery is more than not using drugs

and alcohol

Counseling ApproachesCounseling Approaches

Relapse Prevention Topics– Relapse Prevention Overview

• Overview of the concept: things don't “just happen”

– Using Behavior• Old behaviors need to change• Re-emergence signals relapse risk

– Relapse Justification• “Stinking thinking”• Recognize and stop

A Good Counseling SessionA Good Counseling Session

Patients ultimately may need to understand why they became addicted

More important early on:– Understanding the addiction disorder– Making changes in day-to-day life

A good session: the patients leaves knowing more about addiction and recovery