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

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

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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

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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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16. MAT Comprehensive Care
Effective treatment addresses:

 Mental Health
 Substance Abuse
 Employment/Finances
 Housing
 Social Skills and Support
 Relationship Skills
 Parenting Skills
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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

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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

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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
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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)
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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
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22. Services cont…
Wrap-around

 Child care
 Transportation
 Food
 Medical and dental care
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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

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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)
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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.
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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.
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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)
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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
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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

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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
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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.

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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.
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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
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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
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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
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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
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37. 6 Patient-Centered Phases for MAT Services
Acute
1)
Rehabilitative
2)
Supportive-care
3)
Medical maintenance
4)
Tapering
5)
Continuing-care phases
6)
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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
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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
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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
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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
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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

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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
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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
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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

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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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

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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.
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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.
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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
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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

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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
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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
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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

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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.
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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
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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
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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

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CDS Ventures, LLC