Counseling opioid dependent patients
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Counseling Opioid Dependent Patients. Information and Treatment Approaches for Counselors Michael J. McCann, MA Matrix Institute on Addictions. Overview of Presentation . Background information Some general issues in treating opioid dependent patients Some treatment approaches. Opioids .

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Counseling opioid dependent patients

Counseling Opioid Dependent Patients

Information and Treatment Approaches

for Counselors

Michael J. McCann, MA

Matrix Institute on Addictions


Overview of presentation

Overview of Presentation

  • Background information

  • Some general issues in treating opioid dependent patients

  • Some treatment approaches


Opioids

Opioids

  • Relieve pain

  • Produce and alleviate morphine-like withdrawal

  • Morphine, heroin, methadone, codeine, hydrododone (Vicodin), oxycodone (Percodan), Darvon, Demerol


Opioid dependence

Opioid 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 experience

    Range 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 patients some general issues

    Counseling Opioid Dependent Patients: Some General Issues

    • Recovery and pharmacotherapy

    • Patient orientation towards recovery

    • 12-Step meetings

    • Patient management

    • A Cog/Behavioral approach


    Recovery and pharmacotherapy

    Recovery and Pharmacotherapy

    • Patients may have ambivalence regarding medication

    • The recovery community may ostracize patients taking medication

    • Counselors need to have accurate information


    Recovery and pharmacotherapy1

    Recovery 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 fact methadone treatment efficacy of sample n 727 hubbard et al 1997

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


    Recovery and pharmacotherapy fact

    Recovery and Pharmacotherapy: Fact

    • Methadone treatment results in a 4-fold decrease in mortality

      • John Caplehorn, 1996


    Recovery and pharmacotherapy facts and myths

    Recovery and Pharmacotherapy: Facts and Myths

    • “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 facts and myths1

    Recovery and Pharmacotherapy: Facts and Myths

    • “Patients are getting high”

    • But,

      • Long acting, slow onset

      • Matches level of addiction


    Patient orientation towards recovery

    Patient orientation towards recovery

    • 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 recovery1

    Patient 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 recovery2

    Patient orientation towards recovery

    • Patient orientation, counselor response

      • Be flexible

      • Don’t impose high expectations

      • Don’t confront

      • Non-judgmental acceptance

      • A motivational interviewing approach


    12 step meetings

    12-Step Meetings

    • What is the 12-Step Program?

    • Benefits: peer support, widely available, social outlet, free

    • Meetings: speaker, discussion, Step study, Big Book readings

    • Self-help vs treatment


    12 step meetings1

    12-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


    Urine testing

    Urine 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 positive test

    Urine Testing: Dealing with a 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 positive test1

    Urine Testing: Dealing with a positive test

    • Reinforce honesty

    • Partial confession is good enough; move on

    • Proceed with assumption of drug use

    • Communicate with physician


    Urine testing other issues

    Urine 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 management

    Patient 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 management1

    Patient Management

    • “Manipulation”

      • Counselor’s responses

        • Protective cynicism

        • Trust and openness


    Patient management2

    Patient Management

    • Pushing Boundaries

      • Inappropriate familiarity

      • Reflexive “manipulation”?

      • May result from past counseling experiences


    Patient management3

    Patient Management

    • Intoxication

      • Manage the situation, don’t counsel

      • Ensure patient safety

      • Arrange transportation


    Patient management4

    Patient 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 approaches

    Counseling Approaches

    • Provide information and skills

      • Conditioning Process: you can’t “will” cravings away; modify behavior

      • Addiction as a brain disease


    Counseling approaches1

    Counseling Approaches

    • Information and Skills

      • Get rid of paraphernalia

      • Scheduling time

      • Thought-Stopping for cravings

      • Evaluate people and places (fools rush in)


    Counseling approaches2

    Counseling 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 approaches3

    Counseling 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 session

    A 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


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