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

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Overview of Presentation

• Background information
• Some general issues in treating opioid dependent
  patients
• Some treatment approaches

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Opioids

• Relieve pain
• Produce and alleviate morphine-like withdrawal
• Morphine, heroin, methadone, codeine, hydrododone
  (Vicodin), oxycodone (Percodan), Darvon, Demerol

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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

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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

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Counseling Opioid Dependent Patients Some
General Issues

• Recovery and pharmacotherapy
• Patient orientation towards recovery
• 12-Step meetings
• Patient management
• A Cog/Behavioral approach

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Recovery and Pharmacotherapy

• Patients may have ambivalence regarding
  medication
• The recovery community may ostracize patients
  taking medication
• Counselors need to have accurate information

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Recovery and Pharmacotherapy

• Focus on getting off medication may convey
  taking medication is bad
• Suggesting recovery requires cessation of
  medication is wrong
• Support patients medication-taking
• Medication, not drug

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Recovery and Pharmacotherapy Fact Methadone
treatment efficacy of sample, n727, Hubbard et
al. 1997
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Recovery and Pharmacotherapy Fact

• Methadone treatment results in a 4-fold decrease
  in mortality
• John Caplehorn, 1996

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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

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Recovery and Pharmacotherapy Facts and Myths

• Patients are getting high
• But,
• Long acting, slow onset
• Matches level of addiction

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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

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Patient orientation towards recovery

• Patient orientation, counselor response
• Impatience, confrontation, youre not ready for
  treatment
• or,
• Deal with patients at their stage of acceptance
  and readiness

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Patient orientation towards recovery

• Patient orientation, counselor response
• Be flexible
• Dont impose high expectations
• Dont confront
• Non-judgmental acceptance
• A motivational interviewing approach

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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

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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

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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

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Urine Testing Dealing with a positive test

• Re-evaluate the circumstances prior to the test
• Dont discuss validity of the result (lab error,
  etc.)
• Dont confront provide an opportunity for the
  patient to explain

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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

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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 cant go just went

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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 dont criticize patients having
  chest pains)

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Patient Management

• Manipulation
• Counselors responses
• Protective cynicism
• Trust and openness

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Patient Management

• Pushing Boundaries
• Inappropriate familiarity
• Reflexive manipulation?
• May result from past counseling experiences

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Patient Management

• Intoxication
• Manage the situation, dont counsel
• Ensure patient safety
• Arrange transportation

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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

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Counseling Approaches

• Provide information and skills
• Conditioning Process you cant will cravings
  away modify behavior
• Addiction as a brain disease

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Counseling Approaches

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

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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

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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

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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