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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

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Oral Substitution Treatment for Opioid Dependence: A Training in Best Practices & Program Design for Nepal

Day 3

March 26-28, 2006 Kathmandu, Nepal


Richard Elovich, MPH

Columbia University Mailman School of Public Health Medical Sociologist

Consultant, International Harm Reduction Development International Open Society Institute

this training is adapted from
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)

  • 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,

Clear Program

Philosophy and

Treatment Goals







Program Development



Focus on












A Client/Patient




training goals
Training Goals
  • Ideally, this training will contribute to:
    • 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
The Socio-Pharmacology 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

Six Training Modules
learning together

Learning Together

Parallel Process

learning process knowledge and skills
Learning Process: Knowledge and Skills
  • Acquisition of content
  • Retention (store in memory)
  • Application (retrieve and use)
  • Proficiency (integrate and synthesize)
expectations for certification training contract
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.

Expectations for Certification: Training Contract
learning environment
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.

Learning Environment
the counseling relationship in pharmacotherapy and ost

The Counseling Relationship in Pharmacotherapy and OST

Induction to Stabilization to Maintenance

counseling increases effectiveness of ost programs
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

Counseling Increases Effectiveness of OST Programs
insight from the field
Insight from the Field
  • 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
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

role of the clinician
Role of the Clinician
  • 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
Action = Abstinence?
  • 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.
characteristics of soc
Characteristics of SOC
  • 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 soc18
Characteristics of SOC
  • 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
Operationalizing Health Promotion Objectives
  • 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
  • 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
  • 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
Client/patient participation on community advisory boards

Client/patient participation on decision-making bodies

Client /patient involvement in evaluating the program

Feedback mechanisms for clients/patients, such as suggestion boxes, surveys, and focus groups

Outreach programming

Providing peer counseling and support

Clients/patients training to become counselors

Client/Patient Involvement

OST programs need to value, seek out, encourage and support client/patient involvement.

self efficacy
  • Compare self-esteem and self-efficacy. The transition from I think I can to I know I can. Becoming to being.
  • 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.

If someone doesn’t believe they can change, why should they look at it as a problem?

counseling and self talk a strengths perspective
Counseling and ‘Self-Talk’ : A Strengths Perspective
  • 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
Change is a Social Process
  • 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
Working with Drug Using Youth and Young Adults: A Strengths Based Approach
  • 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
Capacity Building in Brazil*
  • The key is to not to treat population as if they are empty bank accountsto 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 words-coding; analyze operative scripts and structures that condition their practices- decoding. * Paiva, 2000
capacity building ii
Capacity Building II
  • 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
Capacity Building III
  • 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
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.
group work in ost provides
Group Work in OST Provides:
  • 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 provides37
Group Work in OST Provides:
  • A social arena to witness and model a peer transformational process:
      • 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 provides38
Group Work in OST Provides:
  • Support for the development of alternative social networks that reinforce the process of transformation
example first group session
Example: First Group Session




Out by participants


Ground rules


Reasons for coming to

The group and concerns


is good




Is not

So Good


second group session
Second Group Session

Check out and





Ambivalence about relationships, values and behaviors

Check in and Review of

Second session


Map of my relationships

third group session
Third Group Session

Check out and





Ambivalence about change

Check in and Review of

Third session

Building Discrepancy

Reasons for wanting

And not wanting to make

a particular change

a basic counseling exercise
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?
incremental change
Incremental Change
  • 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
Motivational Interviewing
  • 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?
what is motivation
What is Motivation?
  • “Motivation” can be defined as the probability that a person will enter into, continue, and adhere to a specific change strategy.
  • 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
Spirit of Motivational Interviewing
  • 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
Review: 7 Early Strategies
  • 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
A Working definition
  • 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
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
    • use of ambivalence and identification, avoid labeling, be positive and tangible
sanjar on the one hand
‘Sanjar’: On the One Hand:
  • 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
‘Sanjar’: On the Other Hand
  • 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 demonstrate56
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


Benefits and Costs

Short term things that are not so good, okay or acceptable to me

Short term things that are good, okay or acceptable to me

Long term things that are good, okay or acceptable to me

Long term things that are not so good, okay or acceptable to me

benefits and costs
Benefits and Costs
  • 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.
agenda setting
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?”

is it an open or closed question
Is It an Open or Closed Question
  • 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 question62
Is it an Open or Closed Question?
  • 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?
  • 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
Summary of Accurate Empathy
  • 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
Reflective Listening
  • The fundamental tool of motivational interviewing
  • “What people really need is a good listening to.” Mary Casey
listen reflectively
Listen Reflectively
  • 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.
  • What is ambivalence or feeling two ways about something? What do you associate with it?
  • What is reflective listening?
consciousness raising
Consciousness Raising
  • It begins with how I treat a client, the assumptions I make, the conversation we have.
needs improvement
Needs Improvement:
  • Lack of Drug Dependence Training of Physicians, Psychiatrists, Nurses, and Social Workers
  • Lack of willing providers
    • Lack of awareness in Primary Care
    • Professional turf issues
    • Fear of regulation
  • Cost
    • Medication
    • Profiteering
capacity building70
Capacity Building
  • 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
Medically Supervised Withdrawal
  • When stable client/patients in the maintenance stage ask for dosage reductions, it is important to explore their reasons.
    • 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
Voluntary Tapering and Dosage Reduction
  • 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
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.

Clients/patients may consider leaving treatment for a variety of reasons including:
voluntary tapering and dosage reduction74
Voluntary Tapering and Dosage Reduction
  • 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 reduction75
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).
  • 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
Methadone Dosage Reduction
  • A common practice of graded methadone reduction is to reduce daily does in roughly 5-to-10 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 reduction77
Methadone Dosage Reduction
  • 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 reduction78
Methadone Dosage Reduction
  • 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 reduction79
Methadone Dosage Reduction
  • 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
Methadone Detoxification
  • For client/patients who prefer detoxification to maintenance, there are two kinds of detoxification:
    • 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
Involuntary Tapering or Dosage Reduction
  • 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
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

involuntary tapering or dosage reduction83
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.”
  • Zanis 1998
take home medications unsupervised doses
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: Unsupervised Doses
take home medications once clinical criteria above are met
First 90 days: 1 take-home per week

Second 90 days: 2 take-home per week

Third 90 days: 3 take-home 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 take-home medication, but monthly visits to OST are still required.

Take-Home Medications: Once Clinical Criteria (Above) are Met
5 best practices in mmt program policies and reducing the barriers
5. Best Practices in MMT- Program Policies and Reducing the Barriers
  • 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
OST Goal: Engagement
  • 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
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

engagement of people who are highly ambivalent89
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
    • use of ambivalence and identification, avoid labeling, be positive and tangible
reducing barriers
Reducing Barriers
  • 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 barriers91
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 community-based outreach:
    • “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
Meeting Drug Users on Their Own Ground
  • 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:
    • 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
  • 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
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

best practices in mmt program development and design
Best Practices in MMT- Program Development and Design
  • 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
Setting Realistic Treatment Goals
  • 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
Treatment Readiness
  • 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
drug substitution therapy in kyrgyzstan
  • 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
  • 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
Research and Evaluation
  • 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





Ongoing Client/patient

Input into











Dosage during



Approach to

Drug Use




Duration of


Clear Criteria

For Involuntary


Summarizing Best Practices in OST