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13th Annual Meeting & Symposium Hyatt Lake Las Vegas Resort Las Vegas, Nevada December 12-15, 2002 PROCEEDINGS |
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WORKSHOPS
III. Second Annual International Members Workshop IV. Physician Health and Addiction V. Building a Career in Addiction Psychiatry VI. Drug Courts: Admission, Treatment, Outcome and Concerns for the Addiction Psychiatrist VII. Proximal Process and Addiction: Academic Theory or Clinical Pearl? VIII. Political Action and Building Coalitions IX. Update on Pharmacological Management of Dual Diagnosis Patients X. AIDS and Mental Illness in African American Patients XI. Management of the Difficult Opioid-Dependent Chronic Pain Patient XII. Teaching Medical Students About Addiction
Workshop I: Integrating Treatment of Adolescent Substance Use Disorders and Common Co-Morbid Disorders: Blending Research and Practice
Participants in this session learned the empirically-supported psychotherapies and pharmacotherapies for substance use disorders and co-morbid disorders in adolescents; a clinically useful and empirically based integrated treatment algorithm; and the pharmacotherapeutic and psychotherapeutic treatment principles most applicable in integrated treatment models for co-morbid adolescents with substance use disorders.
Workshop Chairs: Paula D. Riggs, MD, University of Colorado Health Sciences Center, Denver, CO, and Ramon Solhkhah, MD, St. Luke’s-Roosevelt Hospital Center, New York, NY
Workshop Presenter: Marc Fishman, MD, The Johns Hopkins University, Baltimore, MD
In a workshop sponsored by the AAAP’s Adolescent Substance Abuse Committee, Dr. Riggs presented an overview of the current state of the science in the treatment of adolescent substance use disorders (SUD) and psychiatric co-morbidity. The presentation specifically focused on the developmental relationships between adolescent SUD and co-occurring disorders as well as the clinical relevance and bi-directional treatment implications of co-morbidity. The scientific support for various treatment modalities for both SUD and co-morbid psychiatric disorders in adolescents with SUD was presented, including family-based interventions (e.g., structural-strategic; structural-functional, multisystemic); behavioral therapy based on operant principles; cognitive-behavioral therapy based on learning theory; and motivational enhancement. Research has also clearly established that the majority of adolescents with SUD also have psychiatric co-morbidity as well as significant family and psychosocial problems. Therefore, not surprisingly, it appears that comprehensive, multimodal treatment approaches that address multiple problem domains in an integrated fashion improve treatment outcomes beyond that achieved by single-modality, sequential treatment.
Yet, a variety of barriers continue to impede access to such treatment even if it is available. For example, if adolescents with current SUD are referred for psychiatric evaluation, clinicians may be uncertain of the validity of psychiatric diagnoses in adolescents who are nonabstinent from substances of abuse. Clinicians may also be reluctant to treat co-morbid disorders due to the potential for adverse interactions between drugs of abuse and psychotropic medications, resulting in referral to (or, in some cases, back to) substance treatment programs with the expectation that they successfully complete treatment and achieve a "stable" period of abstinence before pharmacotherapy is considered for treatment of a co-occurring disorder.
Yet, entering substance treatment with an untreated psychiatric illness decreases the likelihood of successful substance treatment outcomes. This clinical conundrum of sequential treatment contributes to the decreased likelihood of receiving adequate treatment for either disorder. Thus, taken together, current treatment research supports the need for comprehensive, multidimensional treatment approaches targeting multiple problem domains.
Dr. Riggs’ presentation also used current research findings to address many of the most vexing clinical questions in the field, including
By demonstrating that current research findings can offer at least preliminary answers to all of these questions, Dr. Riggs concluded that the body of research has expanded such that new integrated "practice" standards can be derived. These were then presented. Clinician attendees were specifically taught how to use a practical lifetime timeline to organize the relevant aspects of the developmental history as well as information regarding the onset and progression of both substance use and psychiatric symptoms to formulate meaningful clinical diagnoses to guide treatment. Dr. Riggs’ presentation concluded by presenting a recently published, empirically grounded algorithm for integrating the treatment of substance use disorders and co-morbid psychiatric disorders in adolescents.
Following Dr. Riggs’ presentation, Dr. Solhkhah presented a case history of a teenage girl with SUD and co-morbid attention-deficit hyperactivity disorder. The case illustrated many of the issues faced by clinicians in the course of treating co-morbid youths.
The case presentation was then used to organize an interactive discussion led by Dr. Fishman. This exercise afforded the clinician attendees the opportunity to evaluate the practical application and utilization of the lifetime timeline to formulate diagnoses and treatment goals.
Acknowledgments: Support for Dr. Riggs’ research is provided by grants from the National Institute on Drug Abuse (1K20DA00271, 1R01DA13176, 1U10DA13716).
References A comprehensive bibliography of current adolescent treatment research, including the references cited in this summary of the workshop, can be found at www.chestnut.org/li/cyt, www.drugabuse.gov and www.samhsa.gov/centers/clearinghouse/clearinghouses. 1. Riggs PD, Davies R. A clinical approach to integrating treatment for adolescent depression and substance abuse. J Am Acad Child Adolesc Psychiatry. 2002;41:1253-1255.
Workshop II: Use of Carbohydrate Deficient Transferrin (CDT) and Other Alcohol Biomarkers in Psychiatric Practice
Biomarkers can assist clinicians in identifying patients with primary alcohol problems as well as those whose drinking may exacerbate another psychiatric problem or its remediation. They can also facilitate recognition of relapse by alcoholics in recovery. This workshop focused on application of biomarkers for screening and for monitoring alcohol treatment progress.
Workshop Chair: John P. Allen, PhD, MPA, University of Maryland Baltimore Campus Department of Psychology, Baltimore, MD
Workshop Presenters: David W. Oslin, MD, University of Pennsylvania Section on Geriatric Psychiatry, Philadelphia, PA; Raymond F. Anton Jr., MD, Medical University of South Carolina, Charleston, SC; and Martin Javors, PhD, University of Texas Health Science Center at San Antonio, San Antonio, TX
As an introduction to the workshop, Dr. Allen discussed the traditional uses of biomarkers, such as screening patients in general medical practice. However, in the past decade, new uses have emerged, such as monitoring the drinking status of patients in treatment. Other emergent uses include reinstatement of driving privileges, autopsy, establishment of life insurance premiums, monitoring drinking status in liver transplant patients and occupational assessments.
Dr. Javors discussed the interpretation of CDT levels. He said that the perfect test would be quick, inexpensive, have a minimal risk to the patient, be easily done with minimal training, be accurate, be dependent on the amount of alcohol consumed and have a high diagnostic efficiency. He also discussed the differences between direct and indirect markers. Indirect markers are based on toxic or nontoxic effects of ethanol, while direct markers are based on direct measurement of or covalent incorporation of ethanol or acetaldehyde into proteins, lipids, etc. He then summarized major findings of the World Health Organization/International Society for Biomedical Research on Alcoholism Collaborative Project,1 which included 1,863 subjects who were 18 years of age and older. They were from community and alcohol-dependence treatment centers. Patients were excluded from the study if they had major medical or psychiatric disorders, if they were IV drug users or if they had other drug dependence.
The patients were balanced across five countries and were balanced across age groups. The study found that CDT, gamma glutamyltranspeptidase (GGT) and aspartate aminotransferase (AST) have limited performance in the detection of intermediate- or high-risk drinking. CDT performed better than GGT for men, but not for women with high-risk drinking. No differences were found between CDT and GGT in women regardless of the level of drinking. The authors concluded that biological markers do not, in general, provide effective early detection of hazardous alcohol use, particularly in women, but tend to become elevated with sustained heavy consumption.
Dr. Oslin discussed alcohol biomarkers for screening and treatment engagement. Screening purposes include
Screening tools for alcohol problems include clinician-administered questionnaires, self-administered questionnaires, clinical exam, patient self-identification and biomarkers.
Dr. Oslin said that biomarkers are not likely to replace clinical questionnaires for mass screening. However, they are extremely useful for selected screening or as a motivational tool. They can be used as objective evidence that alcohol has negatively affected health.
Dr. Anton discussed the use of CDT in monitoring abstinence and relapse during treatment. Biological markers are useful for monitoring treatment outcome because many patients will not accurately report their drinking. In addition, these markers provide objective feedback about success, and they allow for discussion about alternative or more intensive treatments. They can be used to evaluate why underlying diseases such as depression, schizophrenia, insomnia or hypertension are not responding. They can also provide objective proof for family members, insurers or employers about the success of treatment or the need for more treatment.
Reference 1. Conigrave K, Degenhardt L, Whitfield J, et al. WHO/ISBRA Collaborative Project. Alcoholism: Clinical and Experimental Research. 2002;26:332.
Workshop III: Second Annual International Members Workshop
How addiction psychiatry is practiced internationally depends on the unique political, social and public circumstances of that practitioner’s country. At this workshop, clinicians discussed their experiences and summarized current research from the international community.
Workshop Chair: David Crockford, MD, FRCPC, DABPN, Foothills Hospital, Calgary, Alberta, Canada
Workshop Presenters: Robert P. Milin, MD, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada, and Ben J. M. van de Wetering, MD, PhD, Boumanhuis Addiction Care, Rotterdam, The Netherlands
Dr. Ben van de Wetering presented "Addiction Care in the Netherlands: A Dutch Treat?" which contrasted drug policy in the Netherlands with that in North America. The foundation of the policy in the Netherlands involves an emphasis on harm reduction both on an individual and on a societal level. This emanated from the origin of addiction treatment being directed by social institutions rather than medical ones. While the disease model is upheld, policy focuses on means to reduce access to harder drugs, minimization of harm in persistent users and limiting public nuisance. This is done by localizing use to defined areas, making access to softer drugs permissible under legally defined circumstances and providing medical prescription of substances (including heroin) for refractory cases. Possession of all drugs remains illegal, but only if defined quantities are exceeded. Use of drugs is not viewed as criminal per se. Punishment is differentially higher for defined harder drugs, especially in the cases of production and distribution. The policy has resulted in reductions in the morbidity and mortality of opiate users, but has not been without its problems. With a change in the recent political landscape of the Netherlands, public policy now is focusing more on the problems of prior policy with medical involvement in addiction care and elements emphasizing abstinence being increasingly advocated for.
Dr. Crockford presented "Functional Magnetic Resonance Imaging of Pathological Gamblers – A Pilot Study," which focused on the work being done by his group at the University of Calgary where pathological gamblers are being studied using functional magnetic resonance imaging (fMRI). The premise of the study was to determine if functional brain abnormalities at least contribute to the development and persistence of pathological gambling. A literature review of prior findings of neuropsychological abnormalities in pathological gamblers and their overlap with those seen with the substance use disorders and obsessive compulsive disorder was initially presented suggesting that abnormalities most likely would be found on fMRI, involving the frontal lobes and striatolimbic regions of the brain. In the pilot study, 10 male pathological gamblers and 10 matched control subjects underwent 3T fMRI while exposed to an audiovisual stimulus, which would alternate between a nature video and a video to induce cravings for gambling and then a nature video alternating with real-time interactive gaming on a slot machine. Preliminary findings of increased activity in the anterior dorsal cingulate and decreased activity in the ventrolateral prefrontal and orbitofrontal cortexes were present. Abnormalities expected in the dopamine reward pathway regions were not prominent. The findings may suggest abnormalities in cognitive strategy development to risk situations are more important to pathological gambling than emotional rewards. This could suggest that cognitive restructuring and cue exposure might be better for treatment than physiologic modifications of reward or avoidance strategies in some pathological gamblers. Heterogeneity in findings may relate to severity and duration of gambling addiction, duration of abstinence, chosen game exposure and functional limitations of fMRI paradigms and technology.
Dr. Milin presented "Adolescent Substance Use Disorders and Co-morbidity: Treatment Implications." Adolescence is a period of major risk for the onset of substance abuse. The disruption of developmental tasks, education, employment and family role responsibilities are well-established negative consequences of adolescent substance abuse. There is a great deal of co-morbidity associated with substance use disorders in adolescents. The most common co-morbid disorders include conduct and major depressive disorders. The relationship between adolescent substance use disorders and the following psychiatric disorders was described: conduct disorder, mood disorders, attention-deficit hyperactivity disorders (ADHD) and schizophrenia spectrum disorders. Substance use disorders are prevalent in adolescent psychiatric patients.
The marked prevalence and significance of co-morbid psychopathology demonstrated by adolescent substance abusers makes it imperative that adequate evaluation of other psychiatric disorders occurs in adolescent substance abusers to assist with more specific and comprehensive treatment. This workshop gave an overview of some essential ingredients for conducting a comprehensive, multi-dimensional assessment of substance use in adolescents. The Wagner and Kassel (1995) guidelines for developing a substance abuse intervention program for adolescents were described. Components included focus on the individual, consideration of the unique developmental characteristics of adolescence and identification of mechanisms of promoting positive behavioral changes.
This workshop also discussed the recent advances in psychosocial and pharmacotherapy treatment of adolescent substance abuse and co-morbid disorders, including Minnesota treatment model (12 step), Motivational Enhancement Therapy, Cognitive Behavioural Therapy, Interactional Therapy, Multidimensional Family Therapy and preliminary results of the Cannabis Youth Treatment study. Some evidence of successful pharmacotherapy using pemoline for those with co-morbid ADHD and fluoxetine, buproprion and sertraline for those with co-morbid major depressive disorder was presented.
Workshop IV: Physician Health and Addiction
This workshop educated participants on the various aspects of physician health programs. Participants were updated on recent developments in the treatment, research and monitoring of physicians with addiction and mental health problems.
Workshop Chair: Anne Linton, MD, Betty Ford Center, Rancho Mirage, CA
Workshop Presenters: Deborah Uchalik, PhD, Betty Ford Center, Rancho Mirage, CA; Penelope P. Ziegler, MD, The William J. Farley Center, Williamsburg, VA; and Peter A. Mansky, MD, New York State Physician Health Program, Slingerlands, NY
Dr. Uchalik presented a case of an alcohol- and fentanyl-dependent physician whose history included dysthymia, anxiety and panic as well as family- and occupation-linked trauma experiences. In light of the contribution of re-ignited trauma reactions to relapse on alcohol and re-emergence of depressive symptoms, eye movement desensitization and reprocessing (EMDR) was used as an adjunctive modality. A positive impact on post-traumatic stress symptomatology, personal and professional identity integration and emotional expression has been noted beyond 1 year of sobriety. The importance of integrating evaluation and treatment of unresolved trauma reactions into substance abuse treatment for physicians was emphasized.
Dr. Ziegler presented information about the diversion of opioids by health care professionals. By far the majority of this diversion is for personal use by physicians, nurses, dentists, pharmacists, veterinarians and other licensed professionals who are addicted to the drugs. Often, the addictive disorder begins in the context of self-medication for a painful condition, with the professional harboring the erroneous and dangerous belief that knowledge of and experience with the medication will prevent the development of addiction. Hydrocodone is the most common pharmaceutical agent reported in these cases. Another pattern, seen especially in anesthesiologists, is experimentation provoked by curiosity about patients’ intense euphoric responses to ultra-short-acting anesthetic opioids such as fentanyl. Professionals addicted to opioids have an excellent prognosis for recovery provided they receive adequate primary treatment followed by continuing care and monitoring. They should not return to immediate direct contact with opioid drugs following short-term primary treatment, but rather need to demonstrate their ability to maintain abstinence in an outpatient setting. Naltrexone can be a valuable adjunctive tool, but compliance must be monitored.
Dr. Mansky spoke about suicide in physicians. Physicians have higher suicide rates than the general population. A review of 14 international studies of physicians’ suicides from 1963 to 1991 indicates relative risks of 1.1 to 3.4 for men compared to 2.5 to 5.7 for women. In the general population, the male suicide rate is reported as four times the female rate. Physicians have a higher ratio of suicide completions perhaps related to greater knowledge of toxicology and access to lethal drugs with the most common methods in physicians being overdoses and firearms. Physician health programs (PHPs) address physicians with psychiatric illnesses, primarily substance use disorders (SUD). SUD and depression are psychiatric illnesses associated with suicide. Surprisingly, the suicide rates for physicians participating in PHPs tend to be low. Anesthesiologists suffering from SUD were noted to have a high suicidal rate that was dramatically decreased while participating in PHPs. Unpublished preliminary data from six PHPs over 10 years indicated a total rate of 13 suicides out of 2,500 participants.
Stress can be related to life change units as well as the workplace requirements of physicians, including the demands of vigorous training, multiple critical decisions, interpersonal professional relationships, long work hours including on-call time with attendant decreased time for self-care while mostly caring for others. Social support mediates the effect of stress but the time required for professional activities tends to isolate physicians from their social support system. Physicians start with better physical and mental health, but the high stress of the profession without the mitigation of adequate social support may equalize their risk for developing an SUD or other illness. PHPs provide support for physicians who are less likely to seek routine or preventive health care than other professionals. Medical professions tend to attract people who value altruism and caregiving. These same values are frequently present in families that have at least one parent suffering from SUD. The values lead to career choice while genetic and stress factors lead to the development of SUD in physicians.
Workshop V: Building a Career in Addiction Psychiatry
This workshop focused on the practical aspects of career building for the early career addiction psychiatrist. Topics addressed included research, private practice, hospital practice, forensics and rehabilitation centers. The workshop also addressed administrative and political issues.
Workshop Chair: Laurence M. Westreich, MD, New York University School of Medicine, New York, NY
Workshop Presenters: Roger D. Weiss, MD, McLean Hospital, Belmont, MA; Carol J. Weiss, MD, New York, NY; Petros Levounis, MD, Columbia University College of Physicians and Surgeons, New York, NY; Penelope Ziegler, MD, William J. Farley Center, Williamsburg, VA; and Marianne T. Guschwan, MD, New York University School of Medicine, New York, NY
This workshop focused on practical aspects of career building for the early career addiction psychiatrist. The speakers addressed their own specific branches of addiction psychiatry, with an emphasis on the knowledge, skills and attitudes necessary for successful practice. After the brief talks noted below, the audience participated in a lively question-and-answer session on the pragmatic issues in building a career in addiction psychiatry.
Dr. Roger Weiss discussed constructing a research career, giving various models for financial support, institutional interactions and collaboration with peers. He pointed out the necessity of strong mentorship in navigating the intellectual and political currents of a research career.
Dr. Carol Weiss reviewed the benefits and pitfalls of a traditional private practice model. Her own experience with constructing a practice with a workable patient mix included advice on continuing academic involvement, as well as the practicalities of working on one’s own.
Dr. Levounis gave an outline of his hospital practice at Bellevue Hospital and Smithers Center. He reported on his work in building a sense of teamwork in each institution and the necessity for finding a branch of psychiatry that fits with the practitioner’s own personality. He emphasized the necessity for understanding the goals of the overall institution in promoting addiction education.
Dr. Ziegler described her work in a rehabilitation center and the special issues involved in treating impaired physicians. By tracing her own career path, Dr. Ziegler was able to give a clear picture of the twists and turns that can lead to opportunities and success within addiction psychiatry.
Dr. Westreich talked about his work in forensic psychiatry, especially with addicted individuals. In reporting on forensic cases involving criminal acts, disability actions and impaired physicians, Dr. Westreich emphasized the importance being comfortable with the adversarial nature of forensic psychiatry.
Dr. Guschwan elaborated on her own career within administrative psychiatry and the halls of the American Psychiatric Association (APA). In encouraging others to become involved in the administrative side of addiction psychiatry, Dr. Guschwan accentuated the growing need for well-trained addiction psychiatrists to advocate for sensible policies in addiction training, treatment and reimbursement.
Workshop VI: Drug Courts: Admission, Treatment, Outcome and Concerns for the Addiction Psychiatrist
Participants in this workshop considered the treatment issues, responsibilities and limitations of treating a client mandated to addiction treatment. Presenters discussed the interface between the court and the treating psychiatrist. Additionally, they described how decisions for specific psychiatric and addiction treatments are made by the court.
Workshop Chair: Beth K. Boyarsky, MD, Albert Einstein College of Medicine, Bronx, NY
Workshop Presenters: Edgar P. Nace, MD, University of Texas, Southwestern Medical School, Dallas, TX; David W. Preven, MD, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY; Judith Rosenthal, EdM, Rockland County Drug Court, White Plains, NY; and Joseph J. Westermeyer, MD, PhD, Minneapolis VA Medical Center, Minneapolis, MN
According to Dr. Boyarsky, admission criteria to the drug court results in diversion from prosecution for those perpetrators of crimes in which substance use plays a major role. Nonviolent offenders who accept the offer of mandated treatment may receive a reduction or elimination of their sentence. Admission criteria, screening and evaluation for DSM-IV criteria for a substance use disorder were discussed. Matching participants to specific types of available drug treatment, the timeline for treatment and monthly status hearings are a part of court-mandated treatment, which provides incentives and sanctions to modify behavior toward the goal of successful drug and alcohol treatment.
The court treatment team often also mandates completion of high school education and medical and psychiatric care. Additionally, the team works with the client on social issues that might affect recovery, such as housing and job training.
Ms. Rosenthal said that outcome studies of court-ordered treatment suggest that mandated treatment is very successful, not only in decreasing re-arrests, but in promoting abstinence in the population who accepts the treatment plan decided by the court treatment team. Issues discussed included the striking co-morbidity of psychiatric illness with substance abuse and dependence, the advantage of control in therapy and the progression of the individual through treatment during the 12- to 18-month treatment course. The role of the judge as decision-maker in the treatment process was addressed.
Dr. Preven discussed the addiction psychiatrist’s multiple roles in court-mandated treatment. There can be confusion over who enforces mandated treatment; e.g., the statutes and court orders governing the referral. To whom is the treating psychiatrist responsible ultimately? Who determines what circumstances result in a referral to treatment? Who determines the patient’s obligation in treatment? How will the court impact on the therapeutic relationship and the issues brought to therapy?
Important issues also are the court’s expectations for the psychiatrist and the treatment team regarding treatment planning, monitoring of drug and alcohol use, the writing of reports and providing testimonies. Moreover, the court and court-related employees such as the prosecutor and probation officer may differ regarding confidentiality including such topics as access to the client’s and families’ evaluation and treatment records.
The psychiatrist must be aware of the legal leverage the team may use to maximize compliance and the time frame that constitutes failure to comply with treatment. What are the consequences of treatment noncompliance, and under what circumstances will a termination occur? Can termination occur without court approval? Finally, the psychiatrist must have guidelines as to what constitutes successful treatment and the consequences of successful treatment.
Dr. Westermeyer discussed cultural issues in coercive treatment of addicted people. He explained the lay and professional definitions of "alcoholic" and "drug addict." Communication and political differences surface when professionals, families and patients use the terms "alcoholic" and "addict" as though they were synonymous. Cases of "family over-diagnosis" — lay people using more narrow or restrictive definitions than professionals — were used as examples of families’ definition of any alcohol use as abusive. Cases of "family under-diagnosis" may be encountered more frequently, depending on the beliefs, mores, knowledge and acculturation of the family (i.e., "earning" the right to drink by virtue of working hard and supporting the family).
He also discussed families’ reluctance to commit as a function of culture. Hispanic and Celtic cultures, for example, hold the individual to be autonomous, a law unto himself or herself, for example. As long as the individual does not pose a risk to others, family members and community peers must respect and accept the self-destructive behaviors chosen freely by the group member. As in all cultural values, however, the "autonomy value" contains a fallacy. Leaving the alcoholic or addict to his or her own destiny is not a "no-fault" exercise. Another fallacy of the "autonomy value" is the notion that the self-destructive individual can make a free, unencumbered choice, which others must then respect.
Then, he addressed the populist movement to lower commitment threshold. Although cultures tend to remain stable over time, numerous factors can instigate change within a culture. For example, several factors contributed to raising the threshold to commit psychiatric and addicted patients to treatment. These included mass media (such as the film "One Flew Over the Cuckoo’s Nest"), the popular civil rights movement, as well as improved treatment of psychiatric disorders so that many formerly disabled patients were able to return to and function in society.
He also focused on leverage points as a function of sociocultural factors. In most early cases of substance use disorder, one or more factors can be identified to motivate the addicted person to attempt recovery. These factors vary with culture, with socioeconomic factors and with the individual. If possible, more than one factor may be applied to strengthen the urge toward recovery.
Dr. Nace discussed encouraging the development of prosocial ideas and conscience. He argued that coercion must be seen as a starting point for change — an opportunity to move individual development forward from antisocial to prosocial behaviors. Tapping into the human agency of "conscience" is put forth as a possible therapeutic strategy compatible with the latter objective. Conscience can be thought of as a "capacity" analogous to the capacity of humans to develop language. Just as language development requires favorable biological, psychological and social substrates, the same might be inferred for conscience — that it can be underdeveloped, ignored or compromised by psychopathology.
Conscience is a vector of intentionality; that is, it has both magnitude and direction. It discerns what is right versus wrong, good versus bad, "ought to" versus "ought not." The so-called "moral emotions" — empathy, sympathy, guilt and shame — are not the conscience per se but are "fuel" for the intentionality of conscience. The functional nature of conscience is an intention toward what ought to be rather than what is immediately desired. Elucidation or development of the conscience can be expected to lead to
Workshop VII: Proximal Process and Addiction: Academic Theory or Clinical Pearl?
This workshop explored the relevance of proximal process theory for the addiction psychiatrist. Clinical examples of interactive processes that contribute to behavior and addiction problems were presented from child, adolescent and adult or parental perspectives.
Workshop Chair: Jeffrey J. Wilson, MD, Columbia University College of Physicians and Surgeons, New York, NY
Workshop Presenters: Edward V. Nunes, MD and Stephen J. Donovan, MD, Columbia University College of Physicians and Surgeons, New York, NY
This interactive workshop focused on the role of proximal processes in the treatment of adults and adolescents with addiction, considering as well their impact on children of addicted parents. Family processes that may maintain addictive behaviors are commonly observed during addiction treatment. Proximal process theory suggests coercive or aggressive interactions promote the development of antisocial and possibly addictive behaviors. Treatment of these maladaptive interactions at various stages of the addictive process may inhibit the further development of psychopathology or addiction. For the addiction psychiatrist, proximal (vs. more distal) processes offer a critical point of systemic intervention, which may be overlooked when relying on an individual perspective.
This workshop explored the relevance of proximal process theory for the addiction psychiatrist. Following an introduction to coercion theory, this theory was applied to an example of an adult (with a child) in addiction treatment. Clinical examples of interactive processes that contribute to behavior and addiction problems were then presented from child, adolescent and adult (parental) perspectives. The interactive influences of child behaviors on parents, and parental behavior on children, were evaluated. The special circumstances of active parental or adolescent addiction, as well as the parent or adolescent in recovery were examined. The audience considered several different cases in this context, and the clinical complexity of addiction was reviewed from a systemic, interactive perspective. Through presenting their own clinical experiences, they were encouraged to consider the relevance of proximal theory to their own practice of addiction psychiatry. Many participants found this theory directly relevant to their practices.
References 1. Brook JS, Whiteman M, Nomura C, Gordon AS, Cohen P. Personality, family and ecological influences on adolescent drug use: a developmental analysis. J Chem Depend Treat. 1988;1:123-161. 2. Brown S, Lewis V. The Alcoholic Family in Recovery. New York: Guilford; 1999. 3. Dishion TJ, Kavanagh K, Kiesner J. Prevention of early adolescent substance abuse among high-risk youth: a multiple gating approach to parent intervention. National Institute of Drug Abuse: Research Monograph Series. 1998;177:208-228. 4. Nunes EV, Weissman MM, Goldstein RB, et al. Psychopathology in children of parents with opiate dependence and/or major depression. J Am Acad Child Adolesc Psych. 1998;37:1142-1151. 5. Patterson G. Coercive Family Process. Eugene, OR: Castalia; 1982. 6. Tarter RE, Hegedus AM, Goldstein G, Shelly D, Alterman AI. Adolescent sons of alcoholics: neuropsychological and personality characteristics. Alcohol: Clin Exp Res. 1994;8:216-221 7. Tsuang MT, Lyons MJ, Eisen SA, Goldberg J, True W, Meyer JM, Eaves LJ. Genetic influences on DSM-III-R drug abuse and dependence: A study of 3,372 twin pairs. Am J Med Genet. 1996;67(5):473-477. 8. Wilson JJ, Nunes EV, Greenwald S, Weissman M (In Press). Linguistic deficits and disruptive behavior disorders among children of opiate dependent parents. Am J Addict.
Workshop VIII: Political Action and Building Coalitions
This workshop reviewed the resources of the AAAP and its Public Policy Committee. Strategies were discussed for mobilizing local membership and organizations and for impacting the legislative process.
Workshop Presenters: John T. Pichot, MD, University of Texas Health Science Center at San Antonio, South Texas Veterans Healthcare Systems, San Antonio, TX; John A. Renner Jr., MD, Boston University, Boston VA Healthcare System, Boston, MA; Joseph G. Liberto, MD, University of Maryland, VA Maryland Healthcare System, Baltimore, MD; and Jeanne G. Trumble-Hejduk, MSW, Director, Public Policy and Government Relations, American Academy of Addiction Psychiatry, Prairie Village, KS
Dr. Pichot presented an overview of the American Academy of Addiction Psychiatry Public Policy Section. He reviewed the history and mission statement of AAAP. The AAAP Public Policy Section includes the Public Information Committee and the Public Policy Committee. The Public Policy Committee works to "educate the public to influence public policy regarding addictive illness."
The committee is responsible for developing and revising Public Policy Statements for AAAP. AAAP currently has 15 Public Policy Statements that address such issues as organ transplantation, treatment parity and confidentiality. The committee is currently developing new Public Policy Statements. Policy statement development takes approximately 1 to 1½ years. The process includes topic suggestion, formation of a work group to work on a policy addressing the topic, development and review of policy drafts and approval by the Board of Directors. The policy is then published on the AAAP Web site at www.aaap.org/policies/policystatements.html and is sent to members through the AAAP News or E-News. A news release is also developed and is sent to various media outlets and other organizations about the new Policy Statement.
The Public Policy Committee is also developing a new online publication, Public Policy Update, which is designed to enhance participation in the Public Policy Section by committee members. The publication is available at www.aaap.org/policies/policy.html and will be published to coincide with the December and May AAAP Board of Directors meetings.
Dr. Liberto spoke about political action and coalitions at the national level. He reviewed negotiation considerations for building alliances with other organizations including having willingness to compromise and used AAAP’s experience with Parity and Office-Based Opioid Treatment initiatives as two practical examples. He discussed the importance of identifying priorities for the organization, getting membership input, understanding the most important players on the issue and using the media. Citing a document from the Physicians Leadership on National Drug Policy (PLNDP), he emphasized that individuals can get involved in political action by writing letters to lawmakers, meeting with policymakers, forming or serving on a policy committee for medical organizations, using their influence in academia to explore enhancements in substance abuse training and becoming involved in community-based partnerships. Individuals can also use the media by writing letters to the editor, offering themselves as a resource and coming prepared for interviews.1
Ms. Trumble-Hejduk underscored the critical need for advocacy activities on behalf of addiction psychiatry and its patients. Educational efforts need to take place with the executive and legislative branches at both the state and federal levels as well as with the media. Each person has a role to play; these activities cannot be isolated from the mainstream of a professional organization’s work nor from the activities of an individual practitioner, researcher or administrator. Advocacy and education must be integrated into our everyday responsibilities.
How do we get "inside" to make a difference? The most effective way is to offer a solution to a problem or dilemma that is being faced by a public employee, member of Congress or state legislator. Another way is to be perceived as a potential threat that could interfere with someone accomplishing his or her agenda. There are many ways to communicate with members of the legislative and executive branches of government. Face-to-face meetings are by far the most effective; formal letters (especially to those in higher authority) can be very effective in establishing a paper trail and ensuring a response. E-mail is effective only if part of a mass e-mail campaign on a particular issue. Otherwise, they will get lost in the hundreds or thousands of e-mails received daily by government officials. Phone calls can be effective if the caller knows the person he or she is contacting; the major disadvantage is that there is no paper trail or other documentation of the conversation.
It is important to get to know your legislators. Surprisingly to some, many physicians are members of state legislatures; 30 state legislatures had physicians in office in the 2002 term of office.2
The Web is an excellent source of information; for example, you can download documents; find sample letters; and track the status of legislation. The AAAP Web site contains a list of helpful Web sites for public policy advocacy at the state and federal levels (Go to the public policy activities area of the public policy section at www.aaap.org/policies/policyactivities.html).
Dr. Renner presented information on political action at the local level. Tactics include identifying allies such as provider organizations, patients and families (i.e., NAMI) and professional groups; linking with existing lobbying forces such as state medical societies and state psychiatric societies; providing technical data and mobilizing AAAP members. Dr. Renner finished his presentation with his experience fighting Massachusetts' budget cuts when the House voted to eliminate Medicaid funding for methadone.
References 1. Physician Leadership on National Drug Policy. A Physician’s Guide on How to Advocate for More Effective National and State Drug Policies. 2. Physicians Making Policy in State Legislatures. Clinical Psychiatry News. October 2002; vol. 30, no. 10. 3. Lewis DC. Ten Rules for Influencing Policy. Brown University Digest of Addiction Theory and Application. 2001:8.
Workshop IX: Update on Pharmacological Management of Dual Diagnosis Patients
This workshop familiarized participants with the latest pharmacological treatment strategies for dual diagnosis patients.
Workshop Chair: Timothy W. Fong, MD, University of California-Los Angeles Neuropsychiatric Institute, Los Angeles, CA
Workshop Presenter: John Tsuang, MD, University of California-Los Angeles Neuropsychiatric Institute, Los Angeles, CA
According to the 1990 ECA study, 50% of general psychiatric patients suffer from a substance abuse disorder. These patients, so-called dual diagnosis patients, are extremely difficult to treat and are often high utilizers of public health services. Clinical presentations can be confusing, and practitioners are often unsure of what and when to treat first — the psychiatric symptoms or the substance abuse problem.
Dr. Tsuang reviewed the epidemiology of dual diagnosis. First, he highlighted the parallels between psychiatric disorders and addictions. Both are biological illnesses explained partially by genetic contributions, but also by early life experiences and social situations. Both are chronic conditions but are treatable with the appropriate treatment and will progress in terms of severity if left without treatment.
In terms of prevalence, the ECA study demonstrates that the lifetime prevalence rates for any type of addictive disorders is 29%.1 The following list demonstrates how frequently substance use disorders co-exist with the psychiatric disorder:
Dr. Fong then reviewed diagnostic strategies that can be used to differentiate psychiatric vs. substance-induced symptoms. Emphasis is placed on establishing a clear history with attention paid to periods of sobriety and assessing whether symptoms were present or absent. A premature diagnosis of substance-induced disorder will lead to undermedication, which leads to continued suffering, disability and a potential for symptoms to become more treatment-resistant. A premature diagnosis of a psychiatric condition will lead to overmedication with the possibility of unnecessary exposure to medication, further confusion in making the diagnosis and overlooking other diagnoses. Finally, the most important strategy in differentiating diagnoses is to follow the patient prospectively and to recognize that diagnostic uncertainty may be present for a long time.2
Dr. Fong reported on work by Compton who showed that a psychiatric diagnosis was more likely than a substance-induced diagnosis if the patient presented with antisocial personality disorder or with phobias.3 On the other hand, a psychiatric diagnosis is more likely to be secondary if the diagnosis is generalized anxiety disorder. Meanwhile, diagnoses of depression, dysthymia or alcohol dependence are equally likely to appear before or after substance abuse.3
Dr. Tsuang then provided an overview of treatment approaches to dual diagnosis that are used at UCLA. First, understanding the stages of change model as developed by Prochaska is critical in assessing what type of intervention is appropriate for the patient.4 Furthermore, evidence is accumulating that an integrated treatment approach (that is one that has outpatient/inpatient services as well as case management and relapse prevention strategies) is more effective than traditional models.5 A review of the phases of recovery was also reviewed, highlighting the importance of understanding where the patient is in recovery. Finally, Dr. Tsuang compared the approaches of harm reduction versus the abstinence approach that can be used in dual diagnosis programs.
Dr. Fong reviewed important principles of medication treatment:
Most practitioners may wait for 1 month of sobriety before starting medications, but it may be more helpful to start right away if symptoms are severe (suicidality, aggression) or if the patient has a history of responding to medications.
Dr. Tsuang described treatment approaches with psychotic dually-diagnosed patients.
For typical antipsychotics, depot forms are an advantage for noncompliant patients. These agents are associated with increased EPS, increased rates of smoking and continued substance use, and do not appear to reduce the amount of substances used.
For atypical antipsychotics, there are emerging case reports of Clozaril, risperidone and olanzapine6 being used in dually-diagnosed patients, but there have been no double-blind trials yet.
In the pharmacological management of dual diagnosis patients with affective symptoms, one principle to keep in mind is that depressive symptoms from alcohol and sedatives may take longer to pass than from stimulants.
With depression and cocaine, many agents were studied, principally TCAs and fluoxetine. Schmitz reports negative results with fluoxetine compared to placebo in cocaine-dependent and depressed patients.7
For depression and alcoholism, four placebo-controlled studies in the 1990s all showed reduced depressive symptoms with medications but no sustained abstinence from alcohol.7
Other major classes of agents and relevant clinical pearls were discussed including
Dr. Fong reviewed the common forms of anxiety that dual diagnosis patients present with including co-morbid anxiety disorders (panic disorder, generalized anxiety and social anxiety), anxiety from acute and chronic withdrawal states and situational anxiety (legal problems, unemployment, financial concerns).
Main agents to treat anxiety in dual diagnosis patients were discussed, and clinical pearls from the audience were shared:
References 1. Regier DA, Farmer ME, Rae DS, et al. Co-morbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA. 1990;264(19):2511-2518. 2. Shaner A, Roberts LJ, Eckman TA, et al. Sources of diagnostic uncertainty for chronically psychotic cocaine abusers. Psychiatr Serv. 1998;49(5):684-690. 3. Compton WM 3rd, Cottler LB, Phelps DL, Ben Abdallah A, Spitznagel EL. Psychiatric disorders among drug dependent subjects: are they primary or secondary? Am J Addict. 2000;9(2):126-134. 4. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. Am Psychol. 1992;47(9):1102-1114. 5. Cuffel BJ, Regier D. The relationship between treatment access and spending in a managed behavioral health organization. Psychiatr Serv. 2001;52(7):949-952. 6. Buckley PF. Novel antipsychotic medications and the treatment of co-morbid substance abuse in schizophrenia. J Subst Abuse Treat. 1998;15(2):113-116. 7. Schmitz JM, Averill P, Stotts AL, Moeller FG,
Rhoades HM, Grabowski J. Fluoxetine treatment of cocaine-dependent
patients with major depressive disorder. 8. Randall CL, Johnson MR, Thevos AK, et al. Paroxetine for social anxiety and alcohol use in dual-diagnosed patients. Depress Anxiety. 2001;14(4):255-262.
Workshop X: AIDS and Mental Illness in African American Patients
This workshop addressed AIDS as an issue for the mentally ill in an academic medical center with 95% African American patients. Issues involving diagnoses and treatment were addressed for patients in an AIDS clinic referred for mental health services, for HIV-positive severely mentally ill on an inpatient unit and for HIV-positive patients in an outpatient clinic.
Workshop Chair: William B. Lawson, MD, PhD, Howard University Department of Psychiatry, Washington, DC
Workshop Presenters: Janice Hutchinson, MD, Dianne Reynolds, MD and Tony Gore, MD, Howard University Hospital Department of Psychiatry, Washington, DC
Dr. Lawson discussed AIDS and mental illness in African Americans. He said that African Americans and Latinos are at greater risk of becoming infected with AIDS than Caucasians. Ethnicity is important in understanding prevention, education, diagnosis and access to treatment. Socioeconomics can play a role in these patients being diagnosed and receiving treatment. Forty percent of African American children are raised in poverty. African Americans are more likely to lack health insurance and are more likely to pay out of pocket. The annual direct costs of mental disorders may exceed the median income of African Americans. In addition, African Americans with insurance are less likely to receive care than Caucasians with insurance.
Despite symptoms of distress or major depression in African Americans, treatment is often not sought, is delayed or is sought from nonmedical health professionals. African Americans are more likely than Caucasians to be admitted to inpatient care, to be referred to the correctional system, to be involuntarily committed and to leave treatment against medical advice. He stressed that, when treating AIDS and mental illness, culture does matter.
Dr. Hutchinson said that in 2000, 47% of all AIDS cases were African Americans, 63% of all women with AIDS were African Americans and 65% of all children with AIDS were African Americans.
There is less tolerance in the African American community for homosexuality. It is considered a weakness and a vulnerability. Some homosexual African American men have sex with both men and women so they can say they’re heterosexual. These men can be an HIV bridge to women. They often have unprotected sex because they perceive that as more masculine than having sex while wearing a condom. She said that they are on the "down low" because they fear rejection for being homosexual. Their sexual preferences are a source of shame.
In a recent survey, 80% of Caucasian women with bisexual partners knew that their partners were bisexual, while only 20% of African American women with bisexual partners knew that their partners were bisexual.
For the treatment of AIDS, Caucasian men rely on doctors, while African American men rely on prayer. African American men often delay seeking treatment. By the time African American men present for treatment, 48% are symptomatic compared with 27% of Caucasian men.
African American men often distrust medical professionals. They fear discrimination, and there are communication barriers. She said that physicians need to be sensitive to the stigma of homosexuality in these patients.
Dr. Reynolds discussed how HIV impacts the brain and the mind. HIV affects the central nervous system. HIV is associated with a loss of blood-brain integrity. In addition, patients may experience metabolic/endocrine dysfunction. Psychiatric complications associated with HIV and AIDS include increased risk of depression, mania, psychosis and substance abuse. Mania is observed in both early and late HIV patients. The risk of suicide is increased in HIV-positive patients.
Additionally, she discussed the psychiatric effects of medication. For example, steroids can cause mania or depression. Interferon can cause neurasthenia, fatigue and depression. Interleukin-2 can cause depression, disorientation, confusion and coma. HAART can cause myelopathy, neuropathy, changes in cognition, dementia, mania and depression. In addition, it can complicate schizophrenia and substance abuse and dependence.
Dr. Gore discussed some case studies he has encountered on the inpatient psychiatric unit at Howard University Hospital. Most of these patients were admitted through the emergency room.
Workshop XI: Management of the Difficult Opioid-Dependent Chronic Pain Patient
These difficult patients are increasingly common and involve a disproportionate share of health costs, yet existing pain management guidelines are often insufficient. Participants at this workshop learned about management strategies for several specific problem areas.
Workshop Chair: Jon Streltzer, MD, University of Hawaii, Honolulu, HI
Workshop Presenters: Penelope P. Ziegler, MD, The William J. Farley Center, Williamsburg, VA; Michael M. Scimeca, MD, Mount Sinai Medical School, New York, NY; Larry M. Nahmias, MD, New Dimensions Day Hospital, Houston, TX; Brian Johnson, MD, Boston Psychoanalytic Society, Harvard Division on Addiction, Boston, MA; and Carl Rollynn Sullivan, MD, West Virginia University, Morgantown, WV
Dr. Sullivan presented an overview of the problem of chronic, nonmalignant pain and addiction. Nationally, it is estimated that somewhere between 30 and 50 million people suffer with chronic pain. This is juxtaposed against the lifetime prevalence of addiction in the United States, which is about 15%. A smaller but more controversial issue involves the risk of iatrogenic addiction in chronic pain patients to prescription pain medicines. In West Virginia, this has been a particularly hot issue involving litigation against Purdue Pharma (maker of OxyContin) regarding wrongful deaths. Politically, this has been tied to West Virginia’s dubious distinction of having the worst record at getting injured workers back on the job and the skyrocketing costs of prescription pain medicines associated with chronic pain.
Dr. Streltzer presented a treatment model for the problematic opioid-dependent chronic pain patient:
This model was demonstrated by role-playing the patient-doctor interaction (Dr. Blanca Diez played the role of the dramatic, somatizing patient) and was discussed by Dr. Nahmias.
Dr. Johnson presented the case of a 60-year-old woman with a 50-year history of pain who was treated with the approach described above, explaining that chronic opiates were increasing her pain sensitivity and suggesting nonopiate treatments. She had a denial system about her (addictive) need for opiates, which was attenuated via interpretation and a family meeting.
Her revised problem list was food addiction, opiate addiction and chronic pain (back, knees), which was strongly influenced by morbid obesity. Treatment centered on the need to be active in Overeaters Anonymous, and she was prescribed naltrexone, which decreased her craving both for opiates and for food.
Dr. Ziegler spoke about the issues involved when a physician is experiencing acute or chronic pain. These included self-treatment without monitoring by a treating physician; failure to recognize the developing signs of physical dependence and addiction; changes in behavior and practice as addiction progresses, which can lead to impairment; and problems that can result when a physician needs management of ongoing chronic pain in terms of licensing board attitudes, malpractice issues and possible cognitive and motor impairment.
Dr. Scimeca spoke about the treatment of pain in patients on methadone maintenance. He reviewed the basic principles of methadone maintenance, including the need for a sufficiently high blockade dose to achieve the purpose of not getting high on further abuse of opiates. He emphasized that methadone for maintenance, given once daily, is not analgesic and that the half-life for analgesic methadone is relatively short (4-6 hours). Therefore, methadone for analgesia must be prescribed several times a day. He also emphasized the need to understand that the respiratory tolerance to opiates is established early and makes it relatively safer to prescribe opiates as analgesics. He urged the appropriate use of short-acting opioid analgesics to relieve the pain of methadone maintenance patients.
Workshop XII: Teaching Medical Students About Addiction
This workshop examined ways of addressing the teaching of knowledge and skills to medical students at various stages in their training. It also addressed ways of attempting to influence student attitudes toward patients with substance use disorders.
Workshop Chairs: Christopher J. Welsh, MD, University of Maryland School of Medicine, Baltimore, MD, Jonathan I. Ritvo, MD, University of Colorado Health Sciences, Denver, CO
Workshop Presenters: Walter Hiott, MD, Medical University of South Carolina, Charleston, SC; Martin Leamon, MD, University of California-Davis, Sacramento, CA; Anisha Patel, DO, California Pacific Medical Center, San Francisco, CA; and Marcia Verduin, MD, Medical University of South Carolina, Charleston, SC
Dr. Welsh introduced the topic of medical student education in substance use disorders, highlighting the obvious importance as well as some of the challenges often faced by educators.
Dr. Leamon gave an overview of the concept of "attitudes." He discussed the need to address the various components that make up an attitude: affects, behaviors and cognitions. He then discussed the literature pertaining to attitude change in general as well as the rather limited literature specific to medical student education in addiction. Finally, he provided some recommendations for attempting to influence medical students’ attitudes about addiction.
Drs. Hiott and Verduin discussed the topic of teaching medical students about addiction through various clinical rotations. They provided examples of programs from several medical schools that have appeared to be useful in educating students. They also discussed some of the limitations and challenges that must be addressed in the successful implementation of these programs. Dr. Hiott then provided an overview of the addiction component of the psychiatry clerkship that he facilitates at the Medical University of South Carolina.
Dr. Welsh discussed various resources available for medical educators in addiction. This included Internet sites that provide prepared lectures (such as www.alcoholmedicalscholars.com) as well as experiential programs (such as the Betty Ford Clinic). The use of fictional literature and Hollywood films to both provide information and enhance interest in addiction was also discussed. Clips were shown from two different educational videos: Wearing Masks (which is a poignant account of addiction in a physician) and The Emergency Physician and the Problem Drinker: Motivating Patients for Change (which demonstrates strategies for motivational interviewing).
Dr. Patel, a first-year psychiatry resident, gave an overview of her experience as a medical student with regard to her education in addictions. She discussed both the positive and negative aspects and offered some insights as to how educators might try to address these.
Dr. Ritvo discussed a proposal for minimal competencies to be expected from all medical students with regard to training in addiction. Specific categories for knowledge, skills and attitudes were outlined. The entire group discussed this issue and the difficulties faced by educators due to the lack of any uniformity across medical schools.
Workshop XIII: Effective Integration of a Methadone Medical Maintenance Intervention Into a Step Care System of Methadone Maintenance Treatment Delivery
This workshop reported the results of a 12-month, randomized, controlled trial of methadone medical maintenance (MMM). The practical aspects of effective integration of a MMM intervention into a routine Step Care system of methadone maintenance were described.
Workshop Chair: Van L. King Jr., MD, The Johns Hopkins University School of Medicine, Baltimore, MD
Workshop Presenters: Van L. King Jr., MD, Kenneth B. Stoller, PhD and Robert K. Brooner, PhD, The Johns Hopkins University School of Medicine, Baltimore, MD
Methadone medical maintenance (MMM) was conceptualized as a method for clinically matching the intensity of treatment services with medically-necessary care.1 Patients clinically appropriate for MMM reduce the frequency of clinic visits for medication dispensing to once per month, with counseling only provided as needed. While some limitations on the amount of methadone given for take-home dosing are appropriate for many unstable patients, most are inordinately restrictive for high-functioning patients with sustained abstinence from heroin and other drugs. Requiring this subgroup of patients to continue with weekly or more frequent clinic visits essentially mandates the continued delivery of medically-unnecessary services and impedes maximal rehabilitation by disrupting employment, family, social and recreational activities.2-4
Several important concerns have restrained the implementation of MMM as a routine intervention. One major impediment is continuing apprehension that widespread use of the intervention will clinically destabilize patients, leading to relapse and increased diversion of methadone into the community. Several studies have evaluated this risk and have reached the conclusion that MMM is both safe and effective for patients with several years of abstinence from heroin and other drugs.4-6 While these studies have collectively lessened concern about MMM provoking drug use and possible medication misuse among formerly-abstinent patients, they typically included infrequent urine testing and monitoring of possible medication misuse. Further studies with more intensive monitoring could help address these concerns.
The prior studies also fail to address at least two basic service delivery issues intimately related to expanding the availability of MMM. The first challenge involves developing and testing methods for implementing MMM as a seamless extension of the current service delivery continuum. Prior work has primarily evaluated MMM as a stand-alone treatment, as opposed to an intervention placed within a dynamic therapeutic continuum of care. Using MMM to expand the therapeutic continuum can greatly facilitate treatment matching, such that patients who relapse to drug use are rapidly provided more intensive services and returned to MMM following stabilization.
To respond to this challenge, the present study uses a unique stepped-care system of service delivery to both deliver MMM and to respond to possible episodes of clinical instability. A stepped-care system of service delivery that also used behavioral reinforcement to maximize participation in treatment has been used at Addiction Treatment Services at Hopkins Bayview for more than 9 years. Controlled studies of the treatment delivery system have been conducted and were recently summarized by Kidorf et al.7 Overall, the service delivery system has consistently been associated with excellent attendance to counseling sessions and low rates of drug use, both achieved without sacrificing retention in treatment.7,8 Stepped-care treatment approaches are also receiving increased recognition in the field. Several treatment experts have argued that a "step system" of care, using progressively higher intensities of service only for those who demonstrate a need for the intervention, is a responsible and effective method for matching patients to the least invasive/intensive and least costly intervention necessary to maintain good clinical response.2,3 Stepped-care treatment approaches are also frequently used by other health care practitioners in other medical specialties (e.g., treatment of other psychiatric disorders and other chronic medical disorders).
The stepped-care approach fits well into the structure of a comprehensive and dynamic substance abuse treatment service delivery system, and incorporation of MMM into this continuum enhances the approach. In fact, this service delivery model can improve implementation and long-term therapeutic response to MMM. It is important to remember that even abstinent patie |