Best Practice Models for Opioid Treatment Programs Motivated Stepped Care: An Adaptive Treatment Approach Van L. King, MD UT Health, Department of Psychiatry Grand Rounds November 15, 2016
Addiction Treatment Services Hospital-based clinic established 1972 in southeast Baltimore Comprehensive drug abuse treatment using methadone as one component of care Census of 500 primarily opioid dependent patients typical of patients in similar community-based treatment programs Long term or indefinite length of treatment
Common Problems Poor adherence to treatment services Partial and poor treatment response Fixed and limited levels of service Reliance on single elements of care Staff and patient demoralization
Solution Improve treatment adherence Use combination of evidence-based approaches Efficient use of resources using a patient - treatment matching paradigm Expose more symptomatic patients to most experienced and trained staff
Definition of Adaptive Treatment Strategy Use evidence-based treatment guidelines use empirically-based interventions integrate and combine interventions match intensity/dose of service to symptom severity Use established rules to guide treatment planning initiation of treatment services changes in intensity and type of services discharge and return to treatment Use interventions to achieve good patient adherence motivational interventions behavioral incentives available social supports
Recognize Importance of Opioid Agonist Medications One of the most effective interventions for opioid dependence (Hazelton now endorses) Use flexible dispensing schedules and doses Integrate with other interventions to improve response Ball and Ross, 1991 McLellan et al., 1993
Recognize Importance of Psychotherapies Intensifying routine drug abuse counseling can reduce drug use Adding professional psychotherapies can further reduce drug use Woody et al., 1983, 1995 McLellan et al., 1993 Kidorf et al., 1999 Brooner et al., 2004
Recognize Importance of Behavioral Reinforcement Effective behavioral incentives will enhance reductions in drug use Kidorf et al., 1993,1999 Silverman et al., 1996 Rawson et al., 2002 Brooner et al., 2004, 2007 King & Brooner, 2007 Effective behavioral incentives will enhance attendance to counseling sessions Stitzer et al., 1977 Kidorf et al., 1994,1999 Brooner et al., 2004, 2007
Use Behavioral Reinforcement to Improve Treatment Adherence Methadone dosing time restrictions Methadone dose taper in preparation for discharge Rapid methadone taper reversal and/ or clinic re-admission for treatment adherence
Motivated Stepped Care Adaptive Treatment Model Use evidence-based treatment guidelines opioid agonist treatment cognitive behavioral therapy / motivational interventions behavioral reinforcement Use established rules to guide treatment planning adaptive stepped care treatment matching utilizing ongoing treatment outcome data step rules followed by all staff and for all patients Use interventions to achieve good adherence fully integrate evidence-based treatments supervisors and doctors lead intensified group treatment use available social supports
Addiction Treatment Services Program Overview New Admissions Admission Evaluation History/Physical Admit Lab Work Infectious Diseases Other Evaluation Psychiatric Other Substance Use Psychosocial Treatment Services - On Site Medications Limited Medical Care Weekly Urine Testing Counseling Weeks 1-4 Treatment Induction and Initial Stabilization Begin Motivated Stepped Care System Week 5
Bi-directional Motivated Stepped Care (MSC) Model Medical Maintenance Schedules 13 take-home medication doses 27 take-home medication doses indefinite duration STEP 1 1 individual session wk/mo indefinite duration STEP 2 1 individual session/week 2 group sessions/week 2-4 weeks STEP 3 1-2 individual sessions/week 8 group sessions/week 4-8 weeks Methadone Taper and Discharge 30-day taper to zero dose reverse taper for 1 week attendance guaranteed readmission in 24 hours
Motivated Stepped Care (MSC) in Action STEP 1 1 individual session wk/mo indefinite duration STEP 2 1 individual session/week 2 group sessions/week 2-4 weeks Patients move from Step 1 to Step 2 after 2 consecutive weeks of: missed counseling sessions AND/OR drug positive urine specimens
Motivated Stepped Care (MSC) in Action STEP 1 1 individual session wk/mo indefinite duration STEP 2 1 individual session/week 2 group sessions/week 2-4 weeks Patients move from Step 2 back to Step 1 if during the 4 week period they: attend all counseling for 2 consecutive weeks AND are drug negative for 2 consecutive weeks
Motivated Stepped Care (MSC) in Action STEP 2 1 individual session/week 2 group sessions/week 2-4 weeks STEP 3 1 individual session/week 8 group sessions/week 4-8 weeks Patients move from Step 2 to Step 3 if during the 4 week period they produce 2 weeks of: missed counseling sessions AND/OR drug positive urine specimens
Motivated Stepped Care (MSC) in Action STEP 1 1 individual session wk/mo indefinite duration STEP 3 1 individual session/week 8 group sessions/week 4-8 weeks Patients move back from Step 3 to Step 1 if during the 8 week period they: attend all counseling sessions in 4 consecutive weeks AND have drug negative urines in 4 consecutive weeks
Motivated Stepped Care (MSC) in Action STEP 3 1 individual session/week 8 group sessions/week 4-8 weeks Patients move from Step 3 to a medication taper and possible discharge if they do not produce over 8 weeks: Methadone Taper and Discharge 30-day taper to zero dose reverse taper for 1 week adherence guaranteed readmission in 24 hours 4 consecutive weeks of full counseling attendance AND 4 consecutive weeks of drug negative urine specimens
Motivated Stepped Care (MSC) in Action Medication taper reversed and restart Step 3 by: attending all counseling for 1 week AND submitting single drug negative urine STEP 3 1 individual session/week 8 group sessions/week 4-8 weeks Methadone Taper and Discharge 30-day taper to zero dose reverse taper for 1 week adherence guaranteed readmission in 24-hours
Motivated Stepped Care (MSC) in Action STEP 3 1 individual sessions/week 8 group sessions/week 4-8 weeks Readmission after taper in 1 to 7 days with agreement to: restart care in Step 3 AND work towards Step 1 Methadone Taper and Discharge 30-day taper to zero dose reverse taper for 1 week adherence guaranteed rapid readmission
Randomized and Controlled Clinical Trial Enrolled new admissions (n=144/160) Methadone induction. Completed 1 month baseline (n=127) Motivated Stepped Care (MSC) Randomized to: -or- Standard Stepped Care (SSC) STEP 1 (New Admits) N=65 STEP 1 (New Admits) N=62 STEP 2 (2-4 Weeks) STEP 2 (2-4 Weeks) STEP 3 (4-8 Weeks) Discharge STEP 3 (4-8 Weeks) Discharge Rapid Readmission Rapid Readmission Participants compared on: 90 day retention, counseling adherence/attendance, weekly drug positive urine
Demographic Characteristics of Sample Variable MSC SSC p Age (yrs) 38.0 38.4 ns Education (yrs) 11.1 11.7 ns Female 57% 52% ns Minority 60% 66% ns
% Completing 90 Days Randomized Care Treatment Retention
Weekly Counseling Adherence % Sessions Attended * * MSC SSC
Weekly Urinalysis Results % Positive Urine Samples * MSC SSC
Post-Trial Therapeutic Transfer of Controls Rescue of poor responders Pre-defined partial/poor responding Transfer to MSC treatment (35/62 = 60%) Within-subject crossover design
Counseling Adherence: Pre & Post Transfer (n=35) % Sessions Attended * Pre-90 days Post-90 days *
Urinalysis Results: Pre & Post Transfer (n=35) % Positive Urine Samples * Pre-90 days Post-90 days *
MSC is Powerful and Versatile Reduces cannabis use Kidorf et al., 2007 Improves involvement of family and other community supports Kidorf et al., 1997; 2007 Improves rates of employment and other productive activity Kidorf et al., 1998; 2004 As effective as voucher based protocols in decreasing drug use Brooner et al., 2007
Conclusions/Summary Single service and restricted care models are not adequate to treat the range of needs Severe, long-term problems benefit from adaptive, long-term treatment solutions MSC is an efficient and clinically effective approach to match the amount of treatment to objective ongoing indicators of symptom severity and treatment response
Be Well Clinic, UT Health Structured, multiple levels of service intensity. Can accommodate short-term and long-term treatment needs. Behaviorally integrate medication and counseling services. Utilize buprenorphine or naltrexone for opioid use. Utilize naltrexone and other medications for other drug use disorders. Utilize other reinforcers such as family, social support and legal status to assist in process of rehabilitation and recovery.
Thank you 4 3 2 1
Continuous Performance Improvement Collection and tracking of counseling attendance and urine testing data using a computer-based platform All data monitored weekly by executive staff Data monitored weekly in clinical rounds for Step 3 patients Data monitored monthly/ quarterly for reduced care patients