TIPS & TOPICS
Volume 6, No.6
In this issue
— Until Next Time
Welcome to October’s TIPS and TOPICS (TNT). Occasionally I have a respected friend and colleague contribute their ideas to TNT, especially where there has been a topic of debate or controversy in the addiction and mental health fields. This is one of those months.
Gerald D. Shulman, M.A., M.A.C., FACATA has been in the design, delivery and administration of addiction services long before many of you thought about entering the field. Jerry’s years of experience on the frontline of services as well in training and consulting around the country has given him a perspective about a variety of issues that not many have a chance to match. This month in SAVVY, Jerry shares some thoughts on Medication Assisted Treatment. With his permission, I’ve edited his work; and all of the text in italics is excerpted from a larger manuscript he is preparing for future publication.
- Medication Assisted Treatment (MAT) in Addiction Services Stirs Attitudes and Practices
Early treatment for alcoholism in the USA consisted of psychosocial interventions, modeled on the philosophy of the Twelve Steps of Alcoholics Anonymous. Early clients were “rehabilitatable” (e.g., had acquired the skills to function effectively, but whose drinking interfered with the application of these skills). Later, clients referred to treatment presented with a much greater complexity and pathology, and often these clients were only “habilitatable.”)
Riding a Unicycle
The only treatments available were psychosocial, and even when evidenced-based practices were used, successful treatment outcome was considerably less than desired by providers, payers and the clients themselves. The use of psychosocial treatments alone was like riding a unicycle, very difficult to do, many falls while learning and limited to only a small number of people, and for clients, of limited effectiveness alone, especially after initial treatment.
Graduating to the Bicycle
It became clear that without environmental supports (e.g., housing, education, employment, etc.), that even the best psychosocial treatments would be limited in effectiveness. In part because of the Center for Substance Abuse Treatment’s (CSAT) Access To Recovery grants, the field then began to couple Recovery Support Services (RSS) with psychosocial treatments. The field graduated from trying to ride a unicycle to riding a bicycle, something that provided more support (two wheels instead of one) that many more people could do, rather than to ride a unicycle. But even at this point, the hoped-for outcomes for alcoholism treatment fell far short of expectations.
Moving to a Tricycle
More recently, there has been a focus on Medication Assisted Treatment (MAT), particularly the use of medications which reduce craving and therefore increase probabilities of remaining abstinent. MAT is not designed to replace, but to augment, psychosocial treatments and RSS. To complete the analogy, we have now moved to a tricycle. A cycle that can effectively be utilized by the greatest number of people including young children who have not yet acquired the skills to ride; and older adults who may still possess the skills, but need the extra support and stability of three wheels.
MAT- Welcomed or not?
While it would be assumed that practitioners would welcome MAT, in many quarters this is not the case. For many people suffering from alcohol and other substance dependence, their disorder is a chronic disease characterized by an exacerbation and remission of symptoms, in addiction, known as “relapse.” There are many chronic diseases and all of them present a range of difficulties in their management for similar reasons.
- Some are patient-related, e.g., non-adherence with lifestyle recommendations or medication.
- Other difficulties may include the client’s response to treatment- ranging from the stages of readiness to change to the effectiveness of a particular type and dose of a drug.
- Still others may be clinician characteristics, ranging from attitudes about the client and his/her condition to the clinician’s willingness and ability to engage the client in a therapeutic alliance.
Consider our attitudes about other disorders
—-> Isn’t it interesting that if a patient is hypertensive, his/her physician is likely to recommend a low salt diet, weight loss, smoking cessation, stress reduction strategies AND anti-hypertensive medication. BUT we do not refer to this as “medication assisted treatment.”
—-> Isn’t it interesting that if a patient is diabetic, his or her physician is likely to recommend lifestyle changes of losing weight, smoking cessation, a low sugar diet, regular testing of blood sugar AND an oral hypoglycemic agent or injectable insulin or other medications that increase the body’s production of insulin or make it more efficient. BUT we do not refer to this as “medication assisted treatment.”
—-> Isn’t it interesting that if a patient is asthmatic, his/her physician is likely to recommend the lifestyle changes of smoking cessation, avoidance of known asthma attack triggers, exercise AND either or both medication to prevent asthma attacks and medications to treat an attack once started. BUT we do not refer to this as “medication assisted treatment.”
—-> Isn’t it interesting that for patients who have a major depressive disorder, his/her physician is likely to recommend lifestyle changes of stress reduction, exercise, engaging in positive pursuits AND a combination of psychotherapy and an anti-depressant medication such as a Selective Serotonin Reuptake Inhibitor (SSRI) or a Selective Serotonin and Norepinephrine Reuptake Inhibitor (SNRI). BUT we do not refer to this as “medication assisted treatment.”
Some roots for attitude differences
There are understandable reasons for this schism between alcoholism and other chronic, relapsing diseases. In the 1960s and 1970s, because of the lack of understanding by most physicians about alcoholism, many patients were prescribed a benzodiazepine or other sedative-hypnotic drugs as a treatment for the alcoholism, which not only did not help but often resulted in an additional dependence.
In the 1950s, disulfiram (“Antabuse”), which is an aversive medication rather than one than one which directly reduces craving, began to be used in hopes of eliminating drinking because of the patient’s fear of an alcohol-Antabuse reaction. Disulfiram blocks the breakdown of acetaldehyde, a toxic substance, in the metabolism of alcohol. The results are rapid and irregular heartbeat, rapid breathing, elevated blood pressure, sweating and feelings of pressure in the chest.
In another MAT strategy, a longer-acting opioid is substituted for a shorter acting one, first methadone (methadone maintenance) and more recently buprenorphine. This approach to the management of opioid dependence engendered many concerns: chief among them is the perception that the opioid addict on methadone is “still addicted.” This is an inaccurate statement! Addiction is described as loss of control, compulsive use and continued use in spite of adverse consequences. As long as the methadone client is not abusing methadone or other psychoactive substances, this characterization does not fit. The most accurate comment is that the addict remains “physiologically dependent.”
Making the case for the tricycle
To return to alcoholism, when considering treatment, we have learned that targeting the cortex, as we do, with individual and group therapy and psychoeducation (the unicycle) is insufficient, and is not likely to alone lead to a positive treatment outcome. This is because this brain disease involves more parts of the brain than just the cortex, in this case, specifically the limbic system, the center for drive generation (e.g., hunger, thirst, sex and the drive to continue using).
- There have been a number of medications approved to reduce craving in the treatment of alcoholism: acamprosate (“Campral”), oral naltrexone (“Depade” and “Revia”) and most recently, “Vivitrol” which is naltrexone in a sustained-release (once a month) injectable formulation which bypasses the adherence problems of daily or more frequent oral dosing.
- Some clinicians, who neither embrace the use of MAT nor are outright opposed to it, ask the question, “How long does the patient need to be on the medication?” Ideally, the course of medication should be continued until the patient achieves a level of stability in their recovery where they no longer need it.
- The other answer is that it should be determined by the patient’s goals and how well the treatment approach has been working. Short of any medical contraindications that occur, there have been patients who have been maintained on disulfiram and methadone for in excess of twenty years. One way of assessing the situation is that “if it ain’t broke, don’t fix it.”
With the combination of psychosocial treatment, RSS and pharmacotherapies (MAT) we now have a tricycle available to us, a paradigm, which based on the research, is likely to increase positive treatment outcome. The question we must ask ourselves is that do we as clinicians have the right to deny our clients strategies which have proven efficacy for achieving and maintaining recovery?
Gerald D. Shulman, M.A., M.A.C., FACATA Shulman &Associates, Training and Consulting in Behavioral Health.
8658 Rolling Brook Lane Jacksonville, FL 32256 Ph.: (904) 363-0667 Fax: (904) 363-0668
Whether talking about anti-addiction medications or anti-psychotic, anti-depressant, anti-manic, or anti-anxiety medications, clients and patients will achieve no positive results IF the medication stays in the bottle or bubble pack.
In many charts, the first treatment plan goal is often “medication compliance”. But many people do not adhere to their prescribed medication regimen.
- If your client and patient is not taking his/her medication as prescribed, the first step is to assess for a variety of medication adherence issues. Then you can target for the right strategy.
Here is a comprehensive, but not exhaustive, list of:
- *What to check out about a person’s medication non-adherence – not in any particular order- +
- *Some possible things to do.
1. Check for bad side effects in client’s current medication. Or has the client felt medications have not worked before and so won’t take them anymore?
To do: Treat the fear of side effects. Change doses or types of medication, and/or address the lack of confidence in medication.
2. Check Readiness to change issues. Perhaps your client is not ready to accept medication as necessary for an illness which s/he may accept, or about which is still ambivalent?
To do: Try motivational enhancement, stages of change work
3. Check if client wants to use natural substances rather than psychotropic medication.
To do: Try what the client wants, if not convinced by your explanations about medication. Track results and continue what works; and change what is not.
4. Check for Cultural issues. Perhaps the client believes the medication is dangerous from his/her cultural perspective (ethnic or religious cultural reasons).
To do: Explore to understand the concern; when necessary, see if you can find a person of the same cultural background who is more accepting of medication to influence the client.
5. Check for unconscious non-adherence. Client has somatic complaints; takes on a sick role; has characterological problems; the more the therapist is involved, the more it reinforces and rewards the sick role.
To do: For this person, for example, avoid Assertive Community Treatment (ACT) because the more you go to their home to count pills, the more they are non-compliant to keep you coming back.
6. Check for drug addiction, or swapping meds with others at Pharm Parties; overusing pills due to a prescription dependence on benzodiazepines or narcotic medication; or wants to drink or drug so stops their Antabuse or naltrexone.
To do: Address whatever stage of change the client has slipped back to.
7. Check if client is psychotic, delusional, believes they are being poisoned.
To do: Maintain the relationship and don’t struggle over the diagnosis. ACT is appropriate in such situations to proactively avoid deterioration and rehospitalization.
8. Check if there’s malingering with external ‘rewards’ for this behavior e.g., client stays sick to keep getting workers compensation.
To do: Set the limit
9. Check out if there are Recovery Environment problems. Do they have insufficient funds to pay for medication and/or transportation and/or childcare to keep appointments for medication monitoring?
To do: Address whatever obstacle stands in the way.
10. Check if client feels better, and therefore stops taking medication. Or if now stabilized from a manic episode, they may actually feel that they are depressed, would rather be hypomanic, and stops taking their medication.
To do: “It’s great that you’re feeling better. But how are you going to avoid a relapse with all the bad things that happened before, if you stop the very medication that helped you improve now?”
11. Check for the reasons someone is missing follow-up appointments for medication monitoring.
To do: Explore and address any logistical or attitudinal obstacles; involve family and significant others.
12. Check if pride and self-defeating will-power exists that says “I don’t need meds. I can get better by myself.”
To do: You may have to ‘Roll with Resistance’ and try the “I can do it myself; no medication” treatment plan to see if it works.
13. Check if client gets busy and forgets to take medication.
To do: Use reminders and pill containers that set out the medications for that day or that week. Tie pill-taking to some specific daily activity like tooth-brushing which may help your client to remember a routine of medication.
14. Check out if client is embarrassed or afraid of what others will think – stigma issues: “What if people know I am taking antidepressants? They might think I’m weak or a psycho.” “What if my sponsor gets onto me for seeing a psychiatrist and says I am chewing my booze and shouldn’t be taking pills?”
To do: Empathize and educate about mental illness and addiction, neurotransmitters and brain disease. For those in AA, refer to the AA pamphlet at the following link, “The AA Member – Medications and Other Drugs.”
15. Check for poor therapeutic alliance and trust issues; mistrusts the therapist or physician
To do: Work on empathy and alliance building. Explore negative attitudes in a patient-centered manner and address knowledge, attitudinal or misconception issues.
16. Check if the client wants specific medication that the physician disagrees about.
To do: Patiently explain the rationale for the physician’s preference. Take a collaborative approach rather than an authoritarian role. If the patient’s preferred medication is not dangerous, try out their preferences and continue if the outcome is good. If outcome is not good, this is a motivational strategy to gain client ‘buy-in’ to try the physician’s preference.
You can probably come up with ten more reasons your clients don’t take their medication.
–> Send me any that are not listed and what you have found works. We’ll add those in a future edition of TNT.
My morning jog took me through the park where the 10 & 11 year old boys’ soccer team was at half-time. The coach was earnestly pep-talking the huddle of sweaty, tired-looking boys who were obviously losing at this point.
“OK, guys, let’s stay focused. You’ve got to run and work as hard as you can. We win this game and we’re in the playoffs. If we don’t, it’s not a big deal; you just go home and watch some football. But which would you rather do? Be in the playoffs; or watch football on TV?” The answer was obvious.
“So you’ve really got to work hard right now and focus. Joey, look at me. You’re—–” Even with my jog (now a walk) I had passed the team by now and didn’t get to hear what Joey needed to do to improve. I started thinking that lots of kids don’t think they have a choice. In lots of things, either way it is not life and death to win or lose. Naturally it’s more fun at the moment to win, but there’s a lot to be learned from the losses too.
- Mandated clients don’t think they have a choice. You only feed into their victim view by reinforcing that they have to be here, so “suck it up” and “see what you can get from treatment.”
- Disgruntled employees feel they have no choice and are victims of a dissatisfying job and a tyrant of a boss. Even if they can’t storm out and quit for fear of defaulting on their mortgage or letting the family down, they do have choices. They can choose to be perpetually negative and poison the work environment. Or they can take responsibility for staying; and use the current experience to help design the next kind of new opportunity.
- Cash-strapped and unemployed, a person may feel they are a victim of the crazy economy and greedy Wall Street traders and tycoons. It’s true- there are not going to be many gifts under the tree and there may not even be a tree. But we could choose to make all the gifts from materials around the house; or have gifts only of original poems, short stories; or handmade, handwritten cards; or choose names out of a hat with one gift per person.
- Burdened with sickness, you can fume over the frailties of failing health. Or you can embrace what faculties and abilities you still have and develop those to your fullest capacity. (What must it be like for all the athletes in the Special Olympics?)
It always easier to point out the choices others have when our backs are not the ones against the wall. But it is true that when you are looking at a problem with the “page” one inch from your eyes, the perspective is all out of whack. Hard to focus at one inch. That’s where a coach comes in handy—-or a trusted ally, therapist, counselor, spiritual mentor.
Whether you get a “coach” or not, the choices are yours.
What is that quote? Pain is inevitable. Suffering is optional. Or my version: Adversity is mandatory. Suffering is optional.
Until Next Time
Thanks for reading. See you in November after the Election.
Volume 5, No.9 | January 2008
In this issue
SAVVY | SKILLS | SOUL
David Mee-Lee M.D.
Happy New Year and may 2008 be a successful and productive year for you and your team.
January’s edition takes a fresh look at the Mission, Vision & Values of both your agency and your personal work. Similarly I also am taking a fresh look at my Mission, Vision & Values and -my website, www.DMLMD.com.
I am evaluating the website – what works, what doesn’t, what’s relevant, outdated, helpful, useless, unfriendly, missing, time-saving, cumbersome, easy, difficult. You name it —- the good and the bad! I want my website to be really useful to all the people I serve, including you, the readers of TIPS & TOPICS.
Many of you have given me helpful feedback about TNT. Now I’d like to harness your feedback to help me revamp the website. I want it to serve you better, and build on the community of TNT readers. So I’d like to meet you where you’re at: I need your opinion.
Look for a second email where you can express your opinions. There just might be some prizes for three randomly selected responders. We all love free stuff!
It seems there are hardly any cities, counties, states and health care systems NOT thinking about, planning for, or actively working on integrating services for people with co-occurring substance use and mental health problems. Administrators may decide to re- define their mission to better serve people with multiple needs. That doesn’t mean every frontline worker is ready and willing to suddenly shift focus. I have consulted with systems on this, and here are a few steps I suggest:
- Assemble team members to take a fresh look at the Mission, Vision and Values of the agency or system involved in the change process.
Addiction counselors may not be interested in working with those “crazy” psychiatric patients, and mental health clinicians in working with “those people – those out of control alcoholics and addicts”. In fact these sentiments partly explain why clinicians may have chosen their ‘specialty’ in the first place. Suddenly they are now expected to work with clients with both problems (not that they weren’t actually working with them already.) The juices for working with co-occurring disorders don’t just automatically flow simply because administration declares a new direction.
Where does a system start in the change process? Team members will be challenged on their attitudes, perspectives and comfort zone of work competence. Include all important stakeholders to fashion the Mission. This meeting sets the context, and establishes the process of collaboration with all involved parties. It gives each person the opportunity to take responsibility for re-committing to his/her job. It is a time (if they are honest in their heart) when some may decide/declare they are not interested in, or committed to the new Mission.
When you arrive at discussing Values, the team identifies principles before policies, procedures and personalities. This discussion usually provokes the inevitable disagreements over “what to do” in a variety of clinical situations. What do we do if a client shows up to treatment having used alcohol or some other drug on the way? What do we do when a client refuses to take medication? What do we do when a client wants to stop methamphetamine or heroin, but keep drinking alcohol or smoking marijuana? When we discuss and name Values before a concrete clinical situation arises, this creates an anchor, a solid reference point to guide what to do in the heat of the moment.
–> For example, suppose your team agreed on this Value:
“Any relapse -whether in addiction or mental health – will be addressed as a crisis in a client’s treatment. This requires evaluation of the crisis and a revision of the service plan. We will not suspend, discharge from treatment, or have zero tolerance for relapse with any client – whether a substance use or mental health crisis.”
–> When the Value is discussed as a group, all team members have the chance to air their various points of view.
- Develop individualized agency development plans and individualized staff development plans that recognize all agencies, program sites and team members are likely to be at different levels of preparedness to integrate co- occurring services.
Most clinicians are familiar with Stages of Change, and understand that clients seek help at different “stages of readiness.” Agencies (or program sites within an agency) are no different, just a larger organism. Staff also may be at different “stages” on being ready to adopt more integrated services. However, all would be expected to develop a formal plan that begins where they are comfortable, but also requires that they progress toward better integrated services.
–> Change leaders, technical assistance (TA) staff or consultants guide each agency/service site in the development of an “individualized agency development plan” matched to the stage of change and readiness for integrated services of that unit or provider.
–> They then monitor the progress of the individualized plans inside each agency in their service network.
–> Similarly each team member fashions an “individualized staff development plan.” This is done in collaboration with their supervisor, Change leader or TA consultant. The plan should honor each team member’s stage of readiness. It provides for training to increase awareness of the need for integrated services, as well as the skills to engage and treat people with co-occurring disorders.
–> Change leaders are personnel who have embraced the mission for integrated services. They are committed to improving services to the co- occurring population. To give Change leaders time to meaningfully participate in this mission, administrators and supervisors may need to adjust caseloads, job descriptions or duties.
It is fairly easy to stage training workshops, write up elaborate strategic plans and sketch out impressive timelines for goals/tasks to integrate services. The more challenging task is actually making change happen, the type of change which ends up making a difference on a daily basis to the people we serve in the trenches.
- Develop specific implications for each Value raised in discussions of the new Mission and Vision.
Nearly every agency and company has a Mission Statement which very few team members can recall, let alone articulate, or explain concrete implications of the Mission.
–> Test yourself. Can you recite right now your agency’s Mission Statement without looking it up?
–> Have you always thought of it as being so generically lofty, “motherhood and apple pie,” so broad as to be of little practical use in the dilemmas and pressures of daily life on the job?
A good next step is to comprehensively explore and list all the implications for each Value you created. Let’s work with the example Value above.
It states: “Any relapse -whether in addiction or mental health – will be addressed as a crisis in a client’s treatment. This requires evaluation of the crisis and a revision of the service plan. We will not suspend, discharge from treatment, or have zero tolerance for relapse with any client – whether a substance use or mental health crisis.”
What would be the implications of such a Value? The list could include:
–> If a crisis of substance use, suicidal, violent or self-mutilation behavior, psychosis, mood instability should occur, all clients will receive timely assessment to address any immediate needs. We will revise the treatment plan to improve the client’s progress and outcome.
–>If a client’s relapse triggers reactions in other clients, this provides the opportunity to assist both the relapsing client, as well as helping other clients learn from their reactions to the relapse and crisis.
–> No client will be excluded from treatment because symptoms recur. But if a client deliberately undermines treatment by enticing others to use substances or violates boundaries with violence or impulsive behavior, we will likely discharge a client who is not interested in accountable treatment.
When you actually put pen to paper and write out the implications, this generates open discussion of often disparate ideologies and attitudes. When implications are made explicit -before confronting a “live” relapse crisis- this minimizes the inevitable conflicts which arise amongst people of different disciplines, personalities and life experiences. Remember, conflict is normal. There are policies and procedures that can make resolution more likely. See the February 2007 edition of TIPS and TOPICS for one example.
- Work with team members in the same way you would with a client: i.e. challenge/ support one another in adhering to each team member’s development plan.
When a client presents for services, what drives the treatment planning process should be an alliance around what the client wants, and why they chose to walk in the door.
Here is the parallel process on the agency level. When a new Mission is written, it requires team members to re-commit to work in that agency. So each team member can ponder the following steps. Supervisors and Change leaders can facilitate the team member’s personal exploration by ensuring a strong, supportive, safe work environment:
–> What do you want that makes you choose to work here, especially with the new Mission? For example: being honest, do you just want a paycheck especially if you are close to retirement? Or are you getting ready to go to graduate school and want to be on the cutting edge of new directions? Or are you wanting a paycheck and not wanting to change what you are doing- in which case, your plan may be to transition out of the system if you are taking responsibility for your personal sanity and self-care.
–> Where are you at as regards the new directions the Mission promotes? What is your attitude, stage of change, comfort level and competence level? For example, if you see no reason to change the Mission, your personal development plan will require attention to some consciousness-raising. What information do I need to convince me of the need for change, before I am ready to focus on actually expanding knowledge and skills? If you are eager to be on the cutting edge of new technologies and methods, your development plan might have you lead the team in a journal club; or plan the in-service training curriculum; or be the local change agent champion.
–> How best would you acquire new skills necessary to promote the new Mission? Do you learn best by observation, trial and error, didactic presentations, individual supervision, group peer supervision, discussion of case examples, viewing videos, on the job coaching etc.? Your personal plan would include whatever methods will quickly and efficiently expand your knowledge and skills.
I have not gotten on the Harry Potter bandwagon of incredibly successful books and spin-off films and merchandise. It’s not because I approve or disapprove; I just haven’t read JK Rowling’s works. Her fans may gasp at this point. What I do admire about her is how she pressed ahead when hardly anyone believed in what she had to offer.
In an interview recorded in TIME Magazine’s December 31, 2007 – January 7, 2008 edition, she was asked about her beginning fame. “It happened very, very quickly. I had written a book that I was told repeatedly was uncommercial, overlong, wouldn’t sell. So when it happened, it really was a profound shock.” That prediction about her book is right up there with “Who would want a computer in every house?” What successful author, musician, artist, entrepreneur, politician or athlete has not faced repeated failure, before eventually finding themselves contributing in a way they had set their sights on? And it is not just those professions. This is true for just about anything worth achieving.
Most of us are involved in work, leisure and community activities which do not require the kind of commitment and energy that it takes to run for the Presidency of the United States or to compete in the Super Bowl with a perfect win record of 18 straight games. But when you show up for work everyday, have you chosen to be there? Or are you just going through the motions? How cynical, burnt-out, compassion-fatigued, frustrated are you? When a flight gets cancelled due to weather, and I have to drive seven hours in freezing rain and snow to make sure the workshop goes on the next morning, the experience of frustrated, burnt- out and fatigued come to mind. All that melts though, when participants leave having gained a lot to help them in their work—and appreciatively feed that back to me.
Here’s what JK Rowling also said: “I hope my work sends the message that self-worth is about finding out what you do best and working hard at it.”
This won’t necessarily translate into instant fame and fortune. Who wants the paparazzi anyway? But it is a great formula for a meaningful way of being and contributing; and a potent antidote if you find yourself cynical, burnt-out, compassion-fatigued, and frustrated.
Until Next Time
Thanks for joining us for this first edition of 2008. See you in late February.