# Presentation: 205159

## Welcome

**Notes:**
Show “Welcome” slide while participants are gathering.

## Training CurriculumBased on TIP 43: Phased-Treatment Approach and Duration

- Module 6: TIP Chapter 7

**Notes:**
Show “Training Curriculum” slide and welcome participants:
Welcome to the sixth module of training on TIP 43, which is devoted to Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs.

## Course Goals

- The goals of this training are to:
- Familiarize you with the content of TIP 43; and
- Increase your awareness of issues related to medication-assisted treatment of opioid addiction, especially the phased-treatment approach..

**Notes:**
Show “Course Goals” slide and explain the course goal: []
  As you will recall, the main goal of this series of courses is to familiarize you with the content of TIP 43 and...
  To increase your awareness and understanding of the issues, research and recommendations related to opioid addiction and medication-assisted treatment, especially the phased treatment approach.

## Module 6: Phases of Opioid Treatment Programs 

- During this module, you will:
- Explain the rationale for a phased-treatment approach in OTPs;
- Describe characteristics and issues of the acute phase of MAT;
- Describe characteristics and issues of the rehabilitative phase of MAT;
- Describe characteristics and issues of the supportive-care, medical maintenance, tapering and readjustment, and continuing-care phases of MAT; and
- Describe issues pertaining to transition between treatment phases in MAT and readmission to OTPs.

**Notes:**
Display “Module 6: Phases of Opioid Treatment Programs” slide and explain this module: []
Module 6 covers the seventh chapter of TIP 43. As a result of today’s training, you should be able to...
  Explain the rationale for a phased-treatment approach in OTPs; 
  Describe characteristics and issues of the acute phase of MAT; 
  Describe characteristics and issues of the rehabilitative phase of MAT;
  Describe characteristics and issues of the supportive-care, medical maintenance, tapering and readjustment, and continuing-care phases of MAT; and
  Describe issues pertaining to transition between treatment phases in MAT and readmission to OTPs.

Transition to first activity:
Let’s begin by looking at the reasoning for a phased-treatment approach in OTPs.

## Phased-Treatment Approach

- Definition:
- 	*The Phased-Treatment Approach is comprised of five or six patient-centered phases for planning and providing MAT services and evaluating treatment outcomes in an OTP, including the (1) acute, (2) rehabilitative, (3) supportive-care, (4) medical maintenance, (5) tapering (optional), and (6) continuing-care phases.*

**Notes:**
Materials: Whiteboard or flipchart and markers for discussion.
Display “Phased-Treatment Approach” slide.
Present the definition of the Phased-Treatment Approach
The Phased-Treatment Approach is comprised of five or six patient-centered phases for planning and providing MAT services and evaluating treatment outcomes in an OTP, including the (1) acute, (2) rehabilitative, (3) supportive-care, (4) medical maintenance, (5) tapering (optional), and (6) continuing-care phases.
Ask participants:
What would you consider to the be value of phased-treatment approaches in OPT?
Record participant responses on a white board or flipchart.
Thank participants for sharing their ideas.

## Rationale for Phased Treatment

- Systematic studies for effectiveness of phased-treatment are difficult.
- Phases of treatment are guidelines.
- Model is two-directional.
- Two distinct tracks: Continuing medication maintenance or medication tapering.
- Primary objective of treatment is to maintain abstinence from opioids and other substances of abuse.

**Notes:**
Talking Points: []
  Research on the effectiveness of organizing MAT into phases is limited, partly because MAT is a relatively long-term process which makes systematic studies difficult, yet it is still recommended as an effective treatment Methodology.
 Hoffman and Moolchan’s model very structured. Phases of treatment we will discuss are guidelines. 
 Model is not one directional; at any point, patients can encounter setbacks that require a return to an earlier treatment phase In terms of medication, 
 The model includes two distinct tracks, one of continuing medication maintenance and the other of medication tapering (medically supervised withdrawal). 
 Maintaining abstinence from illicit opioids and other substances of abuse, even if that requires ongoing MAT, should be the primary objective. 

## Variations of Phased Treatment

- Types and intensity of services vary throughout treatment.
- Most patients need:
- Intensive treatment services at entry;
- Diversified services during stabilization, and fewer; and
- Less intensive services after recovery benchmarks.
- Treatment phases are on a dynamic continuum.
- Assessment of treatment should be ongoing.
- Duration of treatment is a team decision based on data and medical experience.

**Notes:**
Talking Points: []
The consensus panel recommends the following goals for initial screening. Treatment providers should: 
The types and intensity of services they need vary throughout treatment and should be determined by individual circumstances. 
 In general, most patients need more intensive treatment services at entry, more diversified services during stabilization, and fewer, less intensive services after benchmarks of recovery begin to be met.
 The consensus panel emphasizes that treatment phases should be regarded as a dynamic continuum that allows patients to progress according to individual capacity. 
 Assessment of patient readiness for a particular phase and assessment of individual needs should be ongoing.
 Decisions concerning treatment duration should be made jointly by OTP physicians, the treatment team, and patients, and should be based on accumulated data and medical experience. 

## Treatment Phases

**Notes:**
Talking Points: []
 In the Acute phase patients are admitted for detoxification. A major goal during the acute phase is to eliminate use of illicit opioids for at least 24 hours, as well as inappropriate use of other psychoactive substances. 
 The primary goal of the rehabilitative phase of treatment is to empower patients to cope with their major life problems—drug or alcohol abuse, medical problems, co-occurring disorders, vocational and educational needs, family problems, and legal issues—so that they can pursue longer term goals such as education, employment, and family reconciliation. 
 In the supportive-care phase, patients continue opioid pharmacotherapy, participate in counseling, receive medical care, and resume primary responsibility for their lives. 
 In the medical maintenance phase, stabilized patients who require continued medication for stability can have longer term (30-day) supplies of take-home medication and reductions in frequency of treatment visits, generally without the suite of services included in comprehensive MAT. 
“Tapering” and “medically supervised withdrawal” are terms commonly used to describe the gradual reduction and elimination of maintenance medication during opioid addiction treatment. 
 Continuing care treatment is comprised of ongoing medical follow-up by a primary care physician, occasional check-ins with an OTP counselor, and participation in recovery groups. 

## Instant Specialist Activity

**Work with assigned group: Acute or Rehabilitative.**
**15 minutes for group to review TIP 43 and complete assigned topic handout.**
**Each group shares their results with the class.**

**Notes:**
Materials:
Acute Phase and Rehabilitative Phase Handout for each participant.

Activity: (:25)
Objective:  Learner groups will research Acute and Rehabilitative phases of treatment and share findings with class.
Set Up:  Photocopy enough copies of Acute Phase and Rehabilitative Handout for all class members.

Display the Instant Specialist Activity slide. 
Introduce the topic.
In this activity, you will be exploring the two most involved phases of the Phased Treatment Approach:  Acute and Rehabilitative. 
Assign participants to Acute or Rehabilitative group.
Explain the activity:
Working with your group, you will have 10 minutes to review TIP 43 in order to fill in the blanks in the handout. In order to finish the research in the time allotted you will need to assign portions of the handout to a few people in your group.
Appoint one or more representatives to share with the class the group’s results.
Distribute Acute Handouts to participants in Acute group, and Rehabilitative Handouts to participants in the Rehabilitative Group.
Instruct groups to complete the handout.
When 8 minutes have lapsed, give the groups a “two minute warning” for completing the handout. Advance to the next slide.

## Instant Specialist: Acute Phase

**Acute Phase**
**Detoxification.**
**Comprehensive maintenance.**
**Goals.**
**Other substance abuse and co-occurring disorders.**
**Medical/dental problems.**
**Legal problems.**
**Basic needs.**
**Therapeutic relationships. **
**Motivation, patient readiness.**
**Transition.**

**Notes:**
After 10 minutes, display the Instant Specialist: Acute Phase slide.
Distribute blank Rehabilitative Phase handouts to each participant in the Acute group and Acute Phase handouts to each participant in the Rehabilitative group.
Invite the representative(s) for the Acute group to share with the class the group’s results from the handout. 

## Instant Specialist: Rehabilitative Phase

**Rehabilitative Phase****        **
**Co-occurring disorders.**** **
**Comprehensive maintenance.**
**Ongoing health concerns.**
**Pain management****.**
**Employment and related issues.**
**Family/social issues.**
**Legal problems.**

**Notes:**
Display the Instant Specialist: Rehabilitative Specialist slide.
Invite the representative(s) for the Acute group to share with the class the group’s results from the handout. 

## Treatment Phases

**Notes:**
Display the Treatment Phases slide.
Tell participants that you will now cover the remaining four phases.
Display the slides relating to the remaining four phases and address the Talking Points for each:
Supportive-Care Phase
Medical Maintenance Phase
Tapering and Readjustment
Continuing Care

## Supportive-Care Phase

- Treatment Issues:
- Alcohol and drug abuse.
- Medical and mental health concerns.
- Vocational and educational needs.
- Family issues.
- Legal issues.

**Notes:**
Talking Points:
In the supportive-care phase patients continue opioid pharmacotherapy, participate in counseling, receive medical care, and resume primary responsibility for their lives. Take-home medication for longer periods and be permitted to make fewer OTP visits, depending on regulations. Let’s look at the strategies and appropriate transition to the next phase of treatment for the following treatment issues in the Supportive-care phase.
Treatment issues occur with:
Alcohol and drug abuse
Medical and mental health concerns.
Vocational and educational needs.
Family issues.
Legal issues.

## Supportive-Care Phase (cont’d)

- Alcohol and Drug Abuse Strategies
- Monitoring.
- Drug Testing.

**Notes:**
Talking Points:
Regarding Alcohol and Drug Abuse, patients should have discontinued alcohol and prescription drug abuse and all illicit-drug use, as well as any involvement in criminal activities, before entering the supportive-care phase. Heavy or problem substance use should result in patients’ return to the acute phase. 
Strategies: Use monitoring and 
Continued drug screening. Patients should have discontinued alcohol and prescription drug abuse and all illicit-drug use prior to entering the Supportive-care phase. Heavy problem substance abuse could send patients back to the Acute phase.

## Supportive-Care Phase (cont’d)

- Medical and Mental Health Concerns Strategies:
- Monitor compliance with medical/psychiatric regimens.
- Maintain communication with patients’ health care and mental health care providers.

**Notes:**
Talking Points:
Medical and Mental Health Concerns Strategies include:
Monitoring compliance with medical/psychiatric regimens to ensure that the patients are physically healthy and recovered from the physical aspects of opiate addiction and mentally able to cope with life issues. 
Maintaining communication with patients’ health care and mental health care providers ensures that patients are progressing as they should in order to move to the next stage of treatment.

## Supportive-Care Phase (cont’d)

- Vocational and Educational Strategies:
- Monitor vocational status and progress toward educational goals.
- Assist in addressing workplace problems.

**Notes:**
Talking Points:
Regarding Vocational and Educational strategies, patients in supportive care should be employed, actively seeking employment, or involved in other productive activities, and they should have legal, stable incomes. 
Patients’ vocational status and progress toward educational goals should be monitored to ensure their success in becoming financially stable and independent.
Patients may need assistance in addressing workplace problems. 

## Supportive-Care Phase (cont’d)

- Family Issues:
- Monitor family stability and relationships.
- Refer for family therapy as needed.

**Notes:**
Talking Points: []
For family issues, patients’ progress in coping with their life domains should be assessed at least quarterly to determine whether patients are eligible and ready for transition from supportive care to either the medical maintenance or tapering phase.  
Strategies: Monitor family stability and relationships and 
Refer patients for family therapy as needed.

## Supportive-Care Phase (cont’d)

- Legal Issues:
- Monitor ongoing legal issues.
- Provide needed support.

**Notes:**
Talking Points: []
Regarding legal issues the following strategies:
Strategies: Ongoing legal issues should be monitored, and
Service providers should provide support to patients dealing with these issues.

## Supportive-Care Phase Transition

- Discontinued alcohol and drug abuse.
- Stable medical and mental health.
- Stable source of income.
- Stable family situation and relationships.
- Resolved legal issues.

**Notes:**
Talking Points:
Patients should have discontinued alcohol and prescription drug abuse and all illicit-drug use before entering the supportive-care phase. Heavy or problem substance use should result in patients’ return to the acute phase. Opinions vary on the length of time patients should be free from illicit-drug use and abuse of prescription drugs before being allowed to move to the next phase. However, to receive the maximum 30-day supply of take-home medication, a patient must be demonstrably free from illicit substances for at least 2 years of continuous treatment.
Even though all treatment plans and patients’ progress should be assessed individually, if any requirements largely are unmet, counselors should consider returning these patients to the rehabilitative phase to address areas of renewed concern rather than advancing them to the medical maintenance or tapering phase.
Patients should be employed, actively seeking employment, or involved in other productive activities, and they should have legal, stable incomes. 
Patients’ progress in coping with their life domains should be assessed at least quarterly to determine whether patients are eligible and ready for transition from supportive care to either the medical maintenance or tapering phase.
Legal issues should be resolved before patients move to the next phase.

## Medical Maintenance Phase

- Two years continuous treatment.
- Abstinence from illicit drugs and prescription drug abuse for the period indicated by Federal and State regulations.
- No alcohol use problem.
- Stable living conditions in environment free of substance use.
- Stable and legal source of income.
- Productive via employment, school, or volunteer work.
- No criminal/legal issues for at least three years and no current parole or probation status.
- Adequate social support system and absence of significant unstabilized co-occurring disorder.

**Notes:**
Talking Points: [] In the medical maintenance phase, stabilized patients who continue to require medication to remain stable are allowed longer term (up to 30-day) supplies of take-home medication and further reductions in the frequency of treatment visits The consensus panel recommends the following criteria to determine a patient’s 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 (at least 2 years for a full 30-day maintenance dosage)
 No alcohol use problem
 Stable living conditions in an environment free of substance use
 Stable and legal source of income
 Involvement in productive activities (e.g., employment, school, volunteer work)
 No criminal or legal involvement for at least 3 years and no current parole or probation status
 Adequate social support system and absence of significant unstabilized co-occurring disorders. 

## Medical Maintenance Phase Strategies

- Monitor drug and alcohol usage and test for drug usage.
- Monitor and maintain communication regarding medical and mental health issues.
- Monitor vocational/education progress and be available for workplace problems.
- Monitor family stability and refer to therapy as needed.
- Monitor and provide support for ongoing legal issues.

**Notes:**
Talking Points: []
 During the medical maintenance phase, OTPs that provide only limited health care services should integrate their services with those of other health care providers.
 The consensus panel recommends random drug testing and callbacks of medication. Positive drug test results should be addressed without delay, and patients should be returned to the rehabilitative phase when appropriate.
 Although patients in medical maintenance may not require psychological services, they may need occasional dosage adjustments based on their use of other prescription medication or on such factors as a change in metabolism of methadone. 
 Evaluation of life domains including vocational and educational needs, family circumstances, and legal issues should continue during the medical maintenance phase, regardless of the setting.
 Patients in medical maintenance should be monitored for risk of relapse. The consensus panel recommends that, as part of the diversion control plan required for all OTPs by SAMHSA, evidence of medication diversion by a patient in medical maintenance result in reclassification of that patient to the most appropriate previous phase of treatment and in adjustment of treatment, other services, and privileges. Reinstatement into medical maintenance should occur only after the phase-regressed patient is observed over a reasonable period (at least 3 to 6 months) and has demonstrated required progress. 

## Medical Maintenance Phase Transition

- Non-abuse of drugs and alcohol for two years.
- Stability in the areas of:
- Medical and mental health;
- Vocation and education;
- Family issues; and
- Legal issues.

**Notes:**
Talking Points: []
To be considered for transition to the next phase of treatment, patients must not have abused drugs and alcohol for two years.
 Patients should also demonstrate stability in the areas of medical and mental health, vocation and education and family and legal issues.

## Tapering Phase

- Tapering is gradual reduction of maintenance medication during treatment.
- Decision to taper should be made with careful consideration of the patient’s situation.
- As medication is tapered, services should intensify.

**Notes:**
Talking Points: []
“ Tapering” and “medically supervised withdrawal” are terms commonly used to describe the gradual reduction and elimination of maintenance medication during treatment. 
 Decision to taper from opioid treatment medication should be made without coercion and include careful consideration of a patient’s wishes and preferences, level of motivation, length of addiction, results of previous attempts at tapering, family involvement and stability, and disengagement from activities with others who use substances.
 As medication is being tapered, intensified services should be provided. 

## Tapering Phase Strategies

- Monitor drug and alcohol use, continue drug testing and add counseling support.
- Monitor compliance with health and mental health regimens, maintain communication with healthcare providers and continue education.
- Monitor vocational and educational issues and be available for workplace issues.
- Monitor family stability and refer to counseling as required.
- Monitor ongoing legal issues and provide support as needed.

**Notes:**
Talking Points: []
 Drug and alcohol abuse monitoring should continue.
 As medication is being tapered, intensified services should be provided, including counseling and monitoring of patients’ behavioral and emotional conditions. 
 Service providers should continue to monitor vocational and educational issues and be available to deal with workplace issues.
 Family stability should be monitored and referrals to counselors made when required.
 Service providers should continue to monitor ongoing legal issues and provide support as needed.

## Reasons for Tapering

- Hardships of OTP and stigma.
- OTPs should identify situational motives to ensure that withdrawal from MAT is driven by legitimate concerns.

**Notes:**
Talking Points: []
 Sometimes decisions to taper are motivated by the hardships of OTP attendance and other requirements or by the stigma often associated with MAT. 
 The consensus panel urges OTPs to identify such situational motives and ensure that patients who choose medically supervised withdrawal from MAT are motivated instead by legitimate concerns about health and relapse.

## Relapse After Tapering

- Risk of relapse due to physical and emotional stress of attempting to discontinue medication.
- Patients should discuss difficulties with tapering and readjustment in order to avoid relapse.
- Educate patients regarding how to reenter MAT if relapse is imminent.

**Notes:**
Talking Points: []
 The risk of relapse during and after tapering is significant because of the physical and emotional stress of attempting to discontinue medication (Magura and Rosenblum 2001). 
 The consensus panel recommends that patients be encouraged to discuss any difficulties they experience with tapering and readjustment so that appropriate action can be taken to avoid relapse. 
 Patients should be educated about how to reenter MAT if they believe that relapse is imminent.

## Readjustment After Tapering

- Continued support required.
- Reinforce relapse prevention skills.
- Initiate Naltrexone therapy after tapering complete.
- Problem-solving counseling, positive behavior reinforcement, open-door policy, strengthen patients’ support systems, relapse prevention plan.

**Notes:**
Talking Points: []
 Many patients who complete tapering need support and assistance during the first 3 to 12 months. 
 During this period, treatment providers should focus on reinforcing patients’ coping and relapse prevention skills. 
 Initiate naltrexone well after tapering is completed to avoid precipitating withdrawal symptoms. 
 Additional recommended strategies include problem solving counseling approaches, reinforcement of positive behaviors and attitudes, an open-door policy to maximize availability of counselors and providers, steps to strengthen patients’ own support systems, and development of a relapse prevention plan, including how to return to MAT if necessary.

## Reversion to MAT

- Reversion to MAT is not failure, rather an indicator that medical maintenance is more appropriate for treatment.

**Notes:**
Talking Points:
The consensus panel recommends that all patients attempting tapering be counseled that a return to medication and a previous phase does not represent failure but simply that medical maintenance is more appropriate for some patients in general and for others at particular times in their lives.  

## Indicators for Transition

- Discontinuation of medication.
- Positive self-image.
- Socially productive lifestyle.
- No signs of abuse or dependence.

**Notes:**
Talking Points: []
Successful transition from the tapering phase to the continuing-care phase requires the following.
 Successful discontinuation of medication is a key indicator for transition from the tapering phase to the continuing-care phase. 
 Another key indicator is a positive self-image as someone who feels and functions well without medication. 
 Having a socially productive lifestyle without involvement with substances of abuse also is critical to completing this phase and to continued recovery. 
 No signs and symptoms of abuse or dependence, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.

## Continuing-Care Phase

- Ongoing medical follow-up.
- Patients should have socially productive lifestyle.
- Appointments should be scheduled every one to three months.

**Notes:**
Talking Points: []
 Continuing care is the phase that follows successful tapering and readjustment. Treatment at this stage comprises ongoing medical followup by a primary care physician, occasional check-ins with an OTP counselor, and participation in recovery groups. 
 Patients in continuing care should have a socially productive lifestyle, no involvement with drugs or problem involvement with alcohol, and improved coping skills demonstrated over at least 1 year. Significant co-occurring disorders should be well under control. 
 Appointments with the OTP continue to be scheduled every 1 to 3 months.

## Transition and Readmission

- Transition according to patient’s progress and circumstances.
- Relapse could indicate more counseling or dosage adjustment.
- Relapse requires quick action.
- Imminent relapse or relapse: remain in treatment and return to pharmacotherapy.
- Negative feelings should not inhibit patients reentering treatment.

**Notes:**
Talking Points: []
Regarding Transition:
 The criteria for transition between phases are not intended to be rigidly interpreted or enforced. The treatment system should be flexible enough to allow for transition according to a patient’s progress and circumstances. The program should modify treatment based on the best interests of patients, rather than infractions of program rules.
 Occasional relapses to drug use might not require that a patient return to the acute phase but instead that he or she receive intensified counseling, lose take-home privileges, or receive a dosage adjustment. 
 If a patient is in the medical maintenance phase or the tapering and readjustment phase, a relapse often requires a rapid response and change of phase. In these cases, the patient might be reclassified into the rehabilitative phase. After providing evidence that problems are under control, the patient might be able to return to the supportive-care or medical maintenance phase.  
Regarding Readmission:
   Patients almost always should be encouraged to remain in treatment at some level and that pharmacotherapy should be reinstituted unreservedly for most previously discharged patients if and when relapse occurs or seems likely. 
 Feelings of shame, disappointment, and relapse-related guilt, especially for rehabilitated patients who have close relationships with staff members, should not be allowed to inhibit patients from seeking reentry to treatment. The consensus panel recommends that all patients be informed at entry to the OTP that subsequent reentry is common and can be accomplished more quickly than initial intake because regulations waive documentation of past addiction for returning patients. 

## Training CurriculumBased on TIP 43: Phased-Treatment Approach and Duration

- Module 6: TIP Chapter 7

**Notes:**
Materials:
None.

Activity: (:01)
Objective:  N/A.

Show “Training Curriculum” slide and offer a closing statement:
During this module we have explored phased-treatment for opioid addiction, including strategies and indicators for transition to the next phase. 
Thank learners for their participation, and remind learners of next training session.
Thank you for your attention during this training session. Our next session will be...