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Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
Tip 40 & 43 Opiate Treatment and Buprenorphine
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Tip 40 & 43 Opiate Treatment and Buprenorphine

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NBCC, NAADAC, CAADAC, and California Board of Behavioral Sciences approved Mental Health continuing education and addictions counselor training series. Narrated versions and CEUs available at …

NBCC, NAADAC, CAADAC, and California Board of Behavioral Sciences approved Mental Health continuing education and addictions counselor training series. Narrated versions and CEUs available at http://www.allceus.com

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  • Tolerance is characterized by a decreased subjective and objective response to the same amount of opioids used over time or by the need to keep increasing the amount used to achieve the desired effect. In the case of abuse or addiction, the desired effect typically is euphoria. Physical dependence is manifested as a characteristic set of withdrawal signs and symptoms in response to reduction, cessation, or loss of the active compound at receptors (withdrawal syndrome).
  • Important Termsacute phase. Initial and usually the most symptomatic intensive-treatment phase of MAT.induction stage. The period of opioid pharmacotherapy, usually during the acute phase of treatment, in which steady-state blood levels of a medication are achieved.rehabilitative phase. Phase of MAT in which patients who are stabilized on opioid treatment medication continue to eliminate addictive substances from their lives while gaining control of other major life domains (e.g., medical problems, co-occurring disorders, vocational and educational needs, family circumstances, legal issues).tapering phase. Phase of MAT in which patients receiving medication maintenance attempt gradually to eliminate their treatment medication (e.g., methadone) while remaining abstinent from illicit substances.continuing-care phase. Optional phase of MAT in which patients who have completed medically supervised withdrawal from treatment medication and are leading socially productive lives continue to maintain regular contact with their treatment program.abstinence. Nonuse of alcohol or any illicit drugs, as well as nonabuse of medications normally obtained by prescription or over the counter. analgesic. A compound that alleviates pain without causing loss of consciousness. benzodiazepines. antianxiety, sedative, hypnotic, amnestic, anticonvulsant, and muscle-relaxing effects. buprenorphine. Partial opioid agonist approved by FDA for use in detoxification or maintenance treatment of opioid addiction comprehensive maintenance treatment. Continuous therapy with medication in conjunction with a wide range of medical, psychiatric, and psychosocial services. Compare medical maintenance.contingency contracting. Use of preestablished, mutually agreed-on privileges (e.g., take-home dosing) or consequences (e.g., loss of privileges) to motivate improvements in treatment outcomes. co-occurring disorder. In this TIP, a mental disorder, according to DSM-IV diagnosis, that is present in an individual who is admitted to an OTP.cross-tolerance. Condition in which repeated administration of a drug results in diminished effects not only for that drug but also for one or more drugs from a similar class to which the individual has not been exposed recently.dependence. State of physical adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, and/or decreasing blood level of a substance and/or administration of an antagonist. diversion control plan. Documented procedures to reduce the possibility that controlled substances are used for other than their legitimate use. Federal opioid treatment standards (42 CFR, Part 8 12(c)(2)) require a diversion control plan in an OTP as part of its quality assurance programduration of action. Length of time that a treatment medication effectively prevents withdrawal symptoms or craving. elimination half-life. Time required after administration of a substance (e.g., methadone) for one-half the dose to leave the body. iatrogenic opioid addiction. Addiction resulting from medical use of an opioid (i.e., under physician supervision), usually for pain management.interim maintenance treatment. Time-limited pharmacotherapeutic regimen in conjunction with appropriate medical services while a patient awaits transfer to an OTP that provides comprehensive maintenance treatment (42 CFR, Part 8 2).levo-alpha acetyl methadol (LAAM; trade name ORLAAM). An opioid agonist medication derived from methadone that is effective for up to 72 hours. Reports in 2000 and 2001 of potential arrhythmogenic cardiac effects of LAAM led to tightening of guidelines, including recommendations that LAAM no longer be used for first-line therapy but only for treatment of patients who already have used it successfully or do not show an acceptable response to other addiction treatments. At this writing, LAAM's future availability for opioid pharmacotherapy is doubtful. maintenance dosage. Amount of medication that is adequate to achieve desired therapeutic effects for 24 hours or more, with allowance for day-to-day fluctuations.maintenance medication. Medication used for ongoing treatment of opioid addiction.maintenance treatment. Dispensing of an opioid addiction medication at stable dosage levels for a period in excess of 21 days in the supervised treatment of an individual for opioid addiction (42 CFR, Part 8 2).medically supervised withdrawal. Dispensing of a maintenance medication in gradually decreasing doses to alleviate adverse physical or psychological effects incident to withdrawal from the continuous or sustained use of opioid drugs. The purpose of medically supervised withdrawal is to bring a patient maintained on maintenance medication to a medication-free state within a target period.medication-assisted treatment for opioid addiction (MAT). Type of addiction treatment, usually provided in a certified, licensed OTP or a physician's office-based treatment setting, that provides maintenance pharmacotherapy using an opioid agonist, a partial agonist, or an antagonist medication, which may be combined with other comprehensive treatment services, including medical and psychosocial services.methadone. The most frequently used opioid agonist medication. Methadone is a synthetic opioid that binds to mu opiate receptors and produces a range of mu agonist effects similar to those of short-acting opioids such as morphine and heroin.methadone maintenance treatment. Dispensing of methadone at stable dosage levels for more than 21 days in the supervised treatment of an individual for opioid addiction (42 CFR, Part 8 2).naloxone. Short-acting opioid antagonist. Because of its higher affinity than that of opioids for mu opiate receptors, naloxone displaces opioids from these receptors and can precipitate withdrawal, but it does not activate the mu receptors, nor does it cause the euphoria and other effects associated with opioid drugs. Naloxone is not FDA approved for long-term therapy for opioid addiction, except in the combination buprenorphine-naloxone tablet. Some programs use naloxone to evaluate an individual's level of opioid dependence. See naloxone challenge test.naloxone challenge test. Test in which naloxone is administered to verify an applicant's current opioid dependence and eligibility for admission to an OTP. Withdrawal symptoms evoked by naloxone's antagonist interaction with opioids confirm an individual's current dependence.naltrexone. Derivative of naloxone and the only opioid antagonist approved for use alone in long-term treatment of people with opioid addiction. Naltrexone is used primarily after medically supervised withdrawal from opioids to prevent drug relapse in selected, well-motivated patients.opioid. Natural derivative of opium or synthetic psychoactive substance that has effects similar to morphine or is capable of conversion into a drug having such effects. One effect of opioid drugs is their addiction-forming or addiction-sustaining liability.opioid agonist. Drug that has an affinity for and stimulates physiologic activity at cell receptors in the central nervous system normally stimulated by opioids. Methadone and LAAM are opioid agonists.opioid antagonist. Drug that binds to cell receptors in the central nervous system that normally are bound by opioid psychoactive substances and that blocks the activity of opioids at these receptors without producing the physiologic activity produced by opioid agonists. Naltrexone is an opioid antagonist.opioid partial agonist. Drug that binds to, but incompletely activates, opiate receptors in the central nervous system, producing effects similar to those of a full opioid agonist but, at increasing doses, does not produce as great an agonist effect as do increased doses of a full agonist. Buprenorphine is a partial opioid agonist.opioid treatment program (OTP). SAMHSA-certified program, usually comprising a facility, staff, administration, patients, and services, that engages in supervised assessment and treatment, using methadone, buprenorphine, LAAM, or naltrexone, of individuals who are addicted to opioids. An OTP can exist in a number of settings, including, but not limited to, intensive outpatient, residential, and hospital settings. Services may include medically supervised withdrawal and/or maintenance treatment, along with various levels of medical, psychiatric, psychosocial, and other types of supportive care.
  • Ellis identified 12 irrational idea which can trigger and prolong neurosis.  They are:  (1) The idea that it is a dire necessity for adults to be loved by significant others for almost everything they do.  (2) The idea that certain acts are awful or wicked, and that people who perform such acts should be severely damned.  (3) The idea that it is horrible when things are not the way we like them to be.  (4) The idea that human misery is invariably externally caused and is forced on us by outside people and events.  (5) The idea that if something is or may be dangerous or fearsome we should be terribly upset and endlessly obsess about it.  (6) The idea that it is easier to avoid than to face life difficulties and self-responsibilities.  (7) The idea that we absolutely need something other or stronger or greater than our self on which to rely.  (8) The idea that we should be thoroughly competent, intelligent, and achieving in all possible respects.  (9) The idea that because something once strongly affected our life, it should definitely affect it.  (10) The idea that we must have certain and perfect control over things.  (11) The idea that human happiness can be achieved by inertia and inaction.  (12) The idea that we have virtually no control over our emotions and that we cannot help feeling disturbed about things (Ellis, 1994. p. 2-3). These 12 irrational ideas were developed and defined by Albert Ellis and are contributing factors to individuals who exhibit neurotic behaviors. Many cognitive distortions are also logical fallacies; related links are suggested in parentheses.All-or-nothing thinking - Thinking of things in absolute terms, like \"always\", \"every\" or \"never\". Few aspects of human behavior are so absolute. (See false dilemma.) Overgeneralization - Taking isolated cases and using them to make wide generalizations. (See hasty generalization.) Mental filter - Focusing exclusively on certain, usually negative or upsetting, aspects of something while ignoring the rest, like a tiny imperfection in a piece of clothing. (See misleading vividness.) Disqualifying the positive - Continually \"shooting down\" positive experiences for arbitrary, ad hoc reasons. (See special pleading.) Jumping to conclusions - Assuming something negative where there is no evidence to support it. Two specific subtypes are also identified: Mind reading - Assuming the intentions of others. Fortune telling - Predicting how things will turn before they happen. (See slippery slope.) Magnification and Minimization - Inappropriately understating or exaggerating the way people or situations truly are. Often the positive characteristics of other people are exaggerated and negative characteristics are understated. There is one subtype of magnification: Catastrophizing - Focusing on the worst possible outcome, however unlikely, or thinking that a situation is unbearable or impossible when it is really just uncomfortable. Emotional reasoning - Making decisions and arguments based on how you feel rather than objective reality. (See appeal to consequences.) Making should statements - Concentrating on what you think \"should\" or ought to be rather than the actual situation you are faced with, or having rigid rules which you think should always apply no matter what the circumstances are. Albert Ellis termed this \"Musturbation\". (See wishful thinking.) Labeling and Mislabeling - Explaining behaviors or events, merely by naming them; related to overgeneralization. Rather than describing the specific behavior, you assign a label to someone or yourself that puts them in absolute and unalterable terms. Mislabeling involves describing an event with language that is highly colored and emotionally loaded. Personalization (or attribution) - Assuming you or others directly caused things when that may not have been the case. (See illusion of control.) When applied to others, blame is an example.
  • Transcript

    • 1. TIPS 40 AND 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs (40 HOURS) Dr. Dawn-Elise Snipes, PhD, LMHC, CRC, NCC  Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 2. Methadone Maintenance Facts Methadone does not produce  euphoric, tranquilizing, or analgesic effects like morphine or heroin Therapeutic doses of methadone reduce or block  euphoric and tranquilizing effects of all opioid drugs Over time, usually no changes were noted in  tolerance levels for methadone Methadone is effective when administered orally  Methadone relieved opioid craving  Methadone caused minimal side effects  Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 3. California Drug and Alcohol Treatment Assessment's Findings Treatment was cost beneficial averaging $7  returned for every dollar invested Methadone treatment yields savings of $3 to  $4 for every dollar spent Patients in MAT showed the greatest  reduction in intensity of heroin use Decreased healthcare use  Number of days of hospitalization, down  more than half during MAT Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 4. Pharmacology 5 Topics  1) Receptors 2) Function of opioids at receptors 3) Consequences of repeated administration and withdrawal of opioids 4) The affinity, intrinsic activity and dissociation of opioids from receptors 5) General characteristics of abused opioids Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 5. Receptors Different types in the brain   Mu receptor is most relevant to opioid treatment  Activation of the mu receptor allows opioids to exert their analgesic, euphorigenic and addictive effects Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 6. Functions of Opioids at Receptors Full Agonists   Activate receptors in the brain  Bind to receptors and turn them  Increasing doses of full agonists produce increasing effects, until the receptor is fully activated  Opioids with the greatest abuse potential are full agonists ○ Examples of full agonists are morphine, heroin, methadone, oxycodone and hydromorphone Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 7. Functions of Opioids at Receptors cont… Antagonists   Bind to opioid receptors, but instead of activating receptors, they effectively block them  Prevent receptors from being activated by agonist compounds  Like a key that fits in a lock but does not open it and prevents another key from being inserted ○ Examples of opioid antagonists are naltrexone and naloxone Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 8. Functions of Opioids at Receptors cont… Partial Agonists   Partial agonists possess some of the properties of both antagonists and full agonists  Bind to receptors and activate them but not to the same degree as full agonists  Increasing effects of partial agonists reach maximum levels and do not increase further, even if doses continue to rise—the ceiling effect  As higher doses are reached, partial agonists can act like antagonists by occupying receptors but not activating them and blocking full agonists from receptors ○ Buprenorphine is an example of a mu opioid partial agonist Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 9. Consequences of Repeated Administration and Withdrawal Repeated administration of a mu opioid agonist  results in tolerance and dose-dependent physical dependence Withdrawal symptoms are similar to flu  Spontaneous withdrawal   begins 6–12 hours after the last dose  peaks in intensity 36–72  lasts approximately 5 days Precipitated withdrawal occurs when an  individual physically dependent on opioids is administered an opioid antagonist or partial agonist Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 10. Affinity, Intrinsic Activity, and Dissociation Affinity: strength with which a drug binds to  its receptor  Intrinsic activity: degree to which a drug activates its receptors  Dissociation: measure of the disengagement of the drug from the receptor Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 11. Characteristics of Abused Drugs Rate of onset of the pharmacological effects  of a drug, and its abuse potential, is determined by:  the drug's route of administration  its half-life  its lipophilicity which determines how fast the drug reaches the brain Abuse Potential is related to:   ease of administration  cost of the drug  how fast the user experiences the desired results Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 12. Naltrexone Antagonist   Naltrexone may decrease the likelihood of relapse to drinking  Can precipitate an opioid withdrawal syndrome in buprenorphine-maintained patients  Should not be prescribed for patients being treated with buprenorphine for opioid addiction Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 13. Buprenorphine Typical analgesic dose of buprenorphine is  0.3–0.6 mg (IM/IV), lasting about 6 hours Because it is a partial agonist, higher doses of  have fewer adverse effects High affinity prevents displacement  Slow dissociation rate (half life)  Daily dosing is not necessarily required  Abuse of buprenorphine primarily via  diverting sublingual tablets to the injection route Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 14. Buprenorphine cont… Lower abuse/overdose potential than full agonists  due to ceiling  Can precipitate an opioid withdrawal syndrome  Buprenorphine treatment should not be combined with opioid antagonists (e.g., naltrexone)  Buprenorphine is metabolized by the cytochrome P450 3A4 enzyme system  Other medications that interact with this enzyme system should be used with caution  Plasma concentrations of these drugs increase when they are administered with newer antidepressants  Buprenorphine's partial mu agonist properties make it mildly reinforcing thus encouraging patient compliance with regular administration Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 15. Buprenorphine/Naloxone Combination Developed for the U.S. market to decrease the  potential for abuse  When taken as directed  buprenorphine effect  When dissolved and injected  naloxone (antagonist) effect Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 16. MAT Comprehensive Care Effective treatment addresses:   Mental Health  Substance Abuse  Employment/Finances  Housing  Social Skills and Support  Relationship Skills  Parenting Skills Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 17. Good Treatment Candidates Are interested in treatment for opioid  addiction Have no contraindications  Can be expected to be reasonably compliant  with such treatment Understand the benefits and risks  Are willing to follow safety precautions  Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 18. Poor Treatment Candidates Co-morbid dependence on high doses of  benzodiazepines or other central nervous system depressants (including alcohol) Significant untreated psychiatric co-morbidity  Active or chronic suicidal or homicidal  ideation/attempts Multiple previous treatments for drug abuse  with frequent relapses Poor response to previous treatment attempts  with buprenorphine or methadone Significant medical complications  Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 19. Services Counseling   Group and/or individual  Strengths-based  Motivational approaches  Cognitive behavioral approaches  Addresses SA and MH concurrently  Realizes the interaction between SA, MH and other issues Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 20. Services cont… Psychoeducation   Fundamentals of addiction  Communication skills  Coping skills  Relapse prevention  Employment/interview skills  Relationship skills  Stinkin’ Thinkin’ (Cognitive distortions and Irrational Thoughts) Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 21. Services cont… Medications   Mental health  Substance abuse (Methadone, Antabuse)  Pain Pro-social Activities   To address “down time”  Provide support and acceptance from pro-social peers  Help people learn how to have fun while sober Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 22. Services cont… Wrap-around   Child care  Transportation  Food  Medical and dental care Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 23. Possible Side Effects of Opioid Agonist and Partial Agonist Therapy Weakness, loss of Dry mouth   energy (asthenia) Nausea, vomiting, abdo  Back pain, chills minal pain  Hot flashes, sweating  Joint and/or muscle  pain (arthralgia) Flu syndrome and  malaise: Abnormal dreams  cough, rhinitis, headach  Anxiety, depression e Sexual side effects  Weight gain or loss  Euphoria  Constipation  Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 24. Possible Side Effects of Opioid Agonist and Partial Agonist Therapy cont… Decreased sensitivity Postural hypotension   to tactile stimulation Abnormal liver  (hypoesthesia) function tests Insomnia Hyperprolactinemia   Somnolence Absence of menstrual   Yawning periods (amenorrhea)  Electrocardiogram Rash   changes, decreased Blurred vision  heart rate (bradycardia) Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 25. Risks of Drug Interaction During any agonist-based pharmacotherapy, abusing  respiratory depressants (e.g., alcohol, other opioid agonists, benzodiazepines) may be fatal.  Current or potential cardiovascular risk factors may be aggravated by opioid agonist pharmacotherapy.  Other drugs often interact with opioid agonist medications.  Patients should know the symptoms of arrhythmia:  palpitations, dizziness, lightheadedness, syncope or seizures  seek immediate medical attention Maintaining and not exceeding dosage  schedules, amounts and other medication regimens are important to avoid adverse drug interactions. Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 26. *Discussion Forum* Think of your experience from working with  patients who are on an opioid agonist or partial agonist therapy.  How would you generalize results of the therapy in relation to side effects, interaction with any other drugs, effect on co-morbid disorders, and patient’s ability to successfully avoid substance abuse?  What is your professional stance on furthering the area of agonist-type therapies (further pharmaceutical research and availability; increased usage of these medications)? Please take a moment to share your responses in  our professional’s discussion forum. Thank you. Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 27. The Consensus Panel Recommends the Following Goals for Initial Screening Crisis intervention 1) Eligibility verification 2) Clarification of the treatment alliance 3) Explanation of patient and program 4) responsibilities Education 5) Communication of essential information about 6) MAT and OTP operations and discussion of the benefits and drawbacks of MAT Identification of treatment barriers 7) Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 28. Behavioral and Circumstantial Indicators of Suicide Risk Talk about committing suicide  Trouble eating or sleeping  Drastic changes in behavior  Withdrawal from friends or social activities  Loss of interest in hobbies, work, or school  Preparations for death, such as making a will  or final arrangements Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 29. Behavioral and Circumstantial Indicators of Suicide Risk cont… Giving away prized possessions  History of suicide attempts  Unnecessary risk taking  Recent severe losses  Preoccupation with death and dying  Loss of interest in personal appearance  Increased use of alcohol or drugs  Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 30. Expressed Emotions that May Indicate Suicide Risk Can't stop the pain Can't make the   sadness go away Can't think clearly  Can't see a future Can't make decisions   without pain Can’t see any  Can't see oneself as solutions  worthwhile Can't sleep, eat, or  Can't get someone's work  attention Can't get out of  Can't seem to get depression  control Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 31. Recommended Responses to Indicators of Suicidality Be direct. Talk openly and matter-of-factly  about suicide. Be willing to listen.  Don’t debate whether suicide is right or  wrong. Get involved. Become available.  Don't dare an individual to do it.  Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 32. Recommended Responses to Indicators of Suicidality cont… Don't act shocked.  Don't be sworn to secrecy.  Offer hope but not glib reassurances.  Take action. Remove means, such as guns or  stockpiled pills. Get help from persons or agencies  specializing in crisis intervention and suicide prevention. Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 33. Recommended Procedures for Identifying and Addressing Domestic Violence Look for physical injuries   Pay attention to other indicators:  history of relapse or treatment noncompliance  inconsistent explanations for injuries and evasiveness  complications in pregnancy  possible stress- and anxiety-related illnesses and conditions Fulfill legal obligations to report suspected  abuse Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 34. Recommended Procedures for Identifying and Addressing Domestic Violence cont… Get the patient’s permission before  discussing their case  Understand which types of subpoenas and warrants require records be turned over to authorities  Convey there is no justification for battering  Contact domestic violence experts when battery is confirmed Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 35. Psychosocial Problems that Decrease Patient Success Lack of stable housing   Nonexistent or dysfunctional family relationships  Poor social skills and lack of a supportive social network  Unemployment; lack of employable skills Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 36. Working with Elderly Patients Monitor the increased risk for drug interactions  Differentiate between co-occurring disorders and  symptoms and disorders associated with aging Differentiate between depression and dementia  Screen for and treat physical and sexual abuse  Develop referral sources for elderly patients  Be sensitive to the elderly patient population  Provide treatment for age-associated stressors  Assess and adjust dosage levels of medication for  the slowed metabolism of many elderly patients Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 37. 6 Patient-Centered Phases for MAT Services Acute 1) Rehabilitative 2) Supportive-care 3) Medical maintenance 4) Tapering 5) Continuing-care phases 6) Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 38. Acute Phase Elimination of Illicit Opioids for at Least 24 Hours   Initially prescribe a medication dosage that minimizes sedation and negative side effects  Assess the safety and adequacy of each dose after administration  Rapidly but safely increase dosage to suppress withdrawal symptoms and cravings and discourage patients from self-medicating Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 39. Acute Phase cont… Provide or refer clients for services to lessen  the intensity of other biopsychosocial disorders  Help patients identify high-risk situations and develop alternative strategies for coping Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 40. Goals of the Acute Phase Elimination of symptoms of 1) withdrawal, discomfort, or craving for opioids and stabilization Express feelings of comfort and wellness 2) throughout the day Abstinence from illicit opioids and abuse of 3) opioids normally obtained by prescription, as per drug tests Engagement with treatment staff in assessment 4) of medical, mental health, and psychosocial issues Satisfaction of basic needs for food, shelter, and 5) safety Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 41. Transition From the Acute to the Rehabilitative Phase Amelioration of signs of opioid withdrawal  Decrease in physical drug craving  Elimination of illicit-opioid use and  reduction in other substance use Completion of medical and mental health  assessment Development of a treatment plan to address  psychosocial issues Satisfaction of basic needs for  food, clothing, shelter, and safety Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 42. Eligibility for the Medical Maintenance Phase of Treatment 2 years of continuous treatment  Abstinence from illicit drugs and from abuse  of prescription drugs for the period indicated by Federal and State regulations No alcohol use problem  Stable living, safe conditions  Stable and legal source of income  Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 43. Eligibility for the Medical Maintenance Phase of Treatment cont… Involvement in productive activities   No criminal or legal involvement for at least 3 years and no current parole or probation status  Adequate social support system  Absence of significant unstabilized co- occurring disorders Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 44. OTP Required Services Comprehensive psychosocial assessment   Mental Health  Substance Abuse  Physical Health  Psychosocial Issues Initial and yearly medical assessment   Medication dispensing  Drug tests  Identification of co-occurring disorders Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 45. OTP Required Services cont… Treatment planning  Case Management  Co-Occurring disorders counseling  Evaluation of and interventions to address  family problems HIV and Hepatitis C virus (HCV)  testing, education, counseling, and referral Referral for additional services as needed  Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 46. Improve Patient Retention Individualize medication dosages  Clarify program goals and treatment plans  Simplify the entry process  Attend to patients' financial needs  Reduce the attendance burden  Provide useful treatment services as soon as  possible Enhance staff-patient interactions  Improve staff knowledge and attitudes about  MAT Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 47. Counseling in MAT Provide support and guidance  Monitor other problematic behaviors  Help patients comply with OTP rules  Identify problems that need extended  services and referral Identify and remove barriers to full  treatment participation and retention Provide motivational enhancement for  positive changes in lifestyle Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 48. The Standard Components of Substance Abuse Counseling Assistance in locating and joining mutual-help/  peer support Education about addiction and the effects of  substances of abuse Education about relapse prevention strategies  Identification of unexpected problems needing  attention Assistance in complying with program rules  and regulations Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 49. The Standard Components of Substance Abuse Counseling cont… Information about stress- and time-  management techniques  Assistance in developing a healthy lifestyle  Assistance in joining socially constructive groups  Continuing education on health issues Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 50. Format of Individual Counseling Sessions Review how patient feels, coping with cravings, or  changing his or her lifestyle Review drug test results and what they mean  Identify emergencies and decide how to address  them Review the treatment plan  Identify measurable goals and reasonable time  frames Review progress in achieving goals, including  abstinence Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 51. Format of Individual Counseling Sessions cont… Discuss dosage and take-home medications  Discuss legal concerns  Discuss family concerns  Provide liaison services  Address routine issues  (e.g., transportation, childcare) Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 52. Strategy for Contingency Management in MAT Pick a target behavior that can be measured  easily  Provide non-monetary incentives for accomplishing the desired behavior  such as non-refundable movie passes Specify link between the targeted behavior and  the reward  Put the contract in writing; specify its duration and any changes over time in contingencies  shaping Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 53. Strategies for Psychotherapy in MAT Devote part of each session   addressing patient’s most recent successes and failures regarding their substance use Adopt a more active therapist role   Strengthen patient’s resolve to stop substance use  Teach patient to recognize  relapse warning signs and develop coping skills Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 54. Strategies for Psychotherapy in MAT cont… Assist in rearranging priorities   reduce preoccupation with substance use Assist patient in managing painful affects   Help patient enhance social functioning and supports  Use psychotherapy only after a strong therapeutic alliance has developed or other supportive structures are in place  guard against relapse Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 55. Strategies for Psychoeducation Psychoeducation serves as an orientation to both  OTP operational and recovery processes.  Involve family members and selected friends, with consent Adapt educational strategies and materials to the  patient's culture and family Discuss methadone and other medications; dispel myths  Discuss the implications of continuing substance abuse  Discuss sexual behaviors that may affect relapse  Discuss the power of triggers with patients and families  Incorporate special groups to discuss  parenting, childcare, women's issues and coping with HIV/AIDS and Copyright 2008-2012 AllCEUs.com, a subsidiary of HCV CDS Ventures, LLC
    • 56. Common Topics in Patient Education Sessions Physical and psychological effects of opioid and  other substance abuse Health education information  Effects of drug use on family and other relations  Introduction to mutual-help groups such as NA  Effects and side effects of addiction treatment  medications and interactions with other drugs Symptoms of co-occurring disorders  Compulsive behaviors besides substance abuse  Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 57. Patient Goals in Building Relapse Prevention Skills Understand relapse as a process, not an event.  Develop new coping skills for high-risk situations.  Make lifestyle changes to decrease the need for  drugs. Increase participation in healthy activities.  Understand and address social pressures to use  substances. Develop a supportive relapse prevention network.  Develop methods of coping with negative  emotional states. Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 58. Patient Goals in Building Relapse Prevention Skills cont… Learn methods of coping with cognitive  distortions. Recognize relapse warning signs and triggers.  Combat memories of drug abuse-associated  euphoria. Reinforce recollections of negative aspects of  drug use. Avoid people, places, and things that might  trigger drug use. Develop pleasurable and rewarding alternatives  to drug use. Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 59. First Responses to a Behavioral Problem Identify it   Review the treatment plan  Discuss plan with the patient  Modify or intensify treatment to match the patient's treatment status Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 60. Remedial Approaches Reevaluate medication dosage, plasma levels, and  metabolic responses; adjust dosage for adequacy and patient comfort Assess co-occurring disorders; provide  psychotherapy and pharmacotherapy as needed Intensify counseling or add ancillary services  Treat medical or other associated problems  Consider alternative medications  Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 61. Remedial Approaches cont… Provide inpatient detoxification from  substances of abuse, and continue opioid pharmacotherapy  Change counselors if indicated  Reschedule dosing to times when more staff are available  Provide family intervention Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 62. Physical Interventions to Managing Chronic Nonmalignant Pain Cold and heat   Ultrasound  Counterstimulation  TENS* Massage and manipulation   Stretching and strengthening  Orthotics, splints and braces  Positioning aids  pillows, supports Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 63. Psychological Interventions to Managing Chronic Nonmalignant Pain Deep relaxation  Biofeedback  Guided imagery  Cognitive behavioral therapy  Mood disorder treatment  Posttraumatic stress disorder treatment  Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 64. Summary MAT uses a phased approach   Patients are provided integrated, holistic treatment  MAT provides a viable means for many people to end their addiction to opiate based drugs. Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 65. Common Drug Combinations and Effects Heroin + alcohol   Enhance a high; create euphoria or sedation Heroin followed by alcohol   Medicate opioid withdrawal; medicate cocaine overstimulation (e.g., anxiety, paranoia) Heroin + cocaine (“speedball”)   Enhance or alter cocaine euphoria Heroin followed by cocaine   Medicate opioid withdrawal Cocaine + alcohol   Enhance high; reduce cocaine overstimulation (e.g., anxiety, paranoia) Cocaine followed by heroin   Reduce cocaine overstimulation (e.g., anxiety, paranoia); modulate the cocaine crash Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 66. Common Drug Combinations and Effects cont… Methadone plus alcohol   Create a high; sedate Methadone plus cocaine   Reduce cocaine overstimulation (e.g., anxiety, paranoia); moderate the cocaine “crash” Methadone plus benzodiazepines   Create a high; sedate Any opioid plus any nonbenzodiazepine sedative   Create a high; sedate Any opioid followed by any nonbenzodiazepine  sedative  Medicate opioid withdrawal Any opioid plus amphetamine   Create a high Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC
    • 67. Drug Descriptions to Know Methadone  Sublingual tablet   Partial mu opioid agonist  Oral solution, liquid concentrate, tablet/disket  Schedule III te, and powder Buprenorphine-   Full mu opioid agonist naloxone  Never formally approved  Sublingual tablet by FDA  Partial mu opioid  Schedule II agonist/mu antagonist LAAM   Schedule III  Oral solution Naltrexone   Full mu opioid agonist  Oral tablet  Schedule II  Mu opioid antagonist  Not Scheduled Buprenorphine  Copyright 2008-2012 AllCEUs.com, a subsidiary of CDS Ventures, LLC

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