Clinical aspects

1. Clinical aspects Module 4

2. Steps • Assessment • Criteria for treatment • Treatment plan • Induction • Monitoring • Evaluation

3. Assessment • The aims of assessment are to: • Engage the patient in the treatment process • Ascertain valid information

4. Issues to assess • Treat emergency • Confirm patient is opiate dependent • History, physical examination, urine analysis • Degree of dependence • Previous treatment history • Identify drug related problems • Identify other medical, social and mental health problems • Identify motivation for treatment • Determine the need for substitute medication

5. Criteria • Sometimes intake criteria are adopted: ICD 10 (Europe) and DSM IV (USA) • Important is that anyone who wants to enter substitution treatment can do so • Assess and treat psychological, physiological and social aspects

6. Assessment • Psychological • Strong desire or compulsion to take the substance • Difficulty in controlling behaviour regarding onset, termination or levels of use •  Physiological • Characteristic withdrawing syndrome for substance if not taken • Evidence of tolerance and need of increased dose to achieve effect •  Social • Progressive neglect of alternative interests/pleasures and increased time necessary to obtain, take or recover from substance • Persisting with substance use despite the negative and harmful consequences

7. Treatment plan • Client goals • Current circumstances • Available recourses • Patient’s expectations of treatment • Past history and outcome • Informed consent • Evidence (safety, efficacy, effectiveness)

8. Induction • Right dose varies from person to person and from time to time • Illicit heroin varies in purity • Characteristics of the medication (methadone is a long acting opiate) • Too much medication can be fatal but too little not effective

9. Information to patient about • Delay of peak effect of the substitute drug • Fact that substitute drug can accumulate over time resulting in a greater effect • Risks of poly-drug use • Risk of overdose • Potential interaction with other medications

10. Importance of the correct dose • World wide clinical surveys validate the importance of an adequate and effective dose • Methadone between 60-120 mg • Watters and Price (1885) reviewed 44 programmes and found that dose was the single most important factor related to treatment retention • Ball and Ross (1991): • 27% (204 pts) on <45mg used heroin in 1month period • 5,4% (203 pts) on >45mg used heroin in 1month period

11. ‘Steady state’ plasma levels • Regular administration (same time each day) can avoid peaks and through providing a steady state • Reservoirs with medication can fill up in the liver and other tissues • Monitoring plasma levels can be useful to test the individual metabolism: • 150ng/ml is the lowest level that will maintain the 24 hour steady state • 400ng/ml is the optimal level

12. How much is enough? • The amount required to produce the desired response for the desired duration of time, with an allowance for a margin of effectiveness and safety (Payte & Khuri, 1992)

13. Monitoring • Engagement • Drug use • Physical and psychological health (sleep, sex, nutrition, constipation, etc) • Social functioning and life context

14. Urinalysis • Much debated • Vital part of initial medical assessment • Often used as form of control during treatment: • Information can also be obtained by asking • Expensive • Positive sample should never be a reason for discontinuing treatment • as this is the evidence of the condition patient is treated for (drug dependency)

15. Withdrawal symptoms -Itching-Rhinorrhea / lacrimation / sneezing-Yawning -Sweating (a cold film of sweat, best touchable in the neck or on the upper part of the sternum)-Pupillary dilatation-Piloerection-Muscle and bone aches, headache-„Restless legs“-Hot and cold flashes-Nausea / vomiting-Weakness , dysphoric mood, irritability, anxiety, insomnia-Abdominal discomfort, diarrhea (starting with a rumbling of the colon which may be heard by stethoscope-Increase in blood pressure, pulse, respiratoryrate and body-Fever

16. Overdose • Fatal and non-fatal OD leading cause of morbidity and mortality • Fatal OD usually follows respiratory depression which disrupts the oxygen supply to the brain and causes cardiac arrest • Likelihood increases with: • Injecting • Poly drug consumption • Substitution treatment has shown to reduce OD mortality and morbidity

17. Welcome by one member of the staff Administrative intake of personal details Check if individual meets intake criteria (if applicable)  Medical intake by doctor Assessment of opioid dependence through: personal interview, medical assessment urinalysis  Assessment of level of dependence  Treatment plan (maintenance, detoxification)  Induction and calculation of starting dose Patient kept under supervision for a few hours to check if initial dose is correct in case withdrawal symptoms reoccur, an additional dose will be given Patient given detailed information on the treatment and on the risks of using other drugs  Psycho-social intake by social worker/drug worker Assessment of problems to be addressed Liaison with relevant services In case of co-morbidity liaison with relevant medical services  Stabilisation period to establish the right dose (may take up to six weeks)  Maintenance or detoxification regimen Regular review to set new goals (depending on type of treatment)

18. Programme characteristics associated with success in MMT • Comprehensive • Integrated • Individualised • Adequate dosing policies • Sufficient and stable staff • Sufficient staff training

19. Conclusions • Accurate assessment is vital • Take individual aspects into account • Induction with care • Provide health information