Chapter 4 - Treatment PlanningIn planning treatment for patients receiving levo-alpha-acetyl-methadol (LAAM) therapy, clinicians must address several unique considerations. First, the initial 30 days of treatment are of critical importance. Some patients find that adjusting to LAAM is more difficult than adjusting to methadone, because of its delayed onset of action and prolonged effect. Although persons who are being transferred from methadone to LAAM therapy generally do not have as many difficulties as those entering LAAM treatment directly, problems can occur in both groups. To support patients during this transition, treatment staff need special training in the pharmacodynamics of the drug. Flexibility and involvement of all staff members are also important. If all staff express support for the treatment regimen, patients will experience less anxiety and make better progress. This chapter presents valuable guidelines for engaging and retaining patients in LAAM treatment. The importance of patient education is reviewed, and suggestions for issues to address in education sessions are provided. A discussion is included of typical issues that may arise in counseling sessions, such as adapting to dosing schedules and structuring increased time away from the clinic. Reinforcing treatment progress may be a challenge for counselors who are used to working with patients maintained on methadone; with methadone, patients often receive take-home medications in recognition of their progress in treatment. However, no take-home LAAM is permitted. This chapter presents some suggestions for reinforcing treatment progress. Other clinical issues, such as relapse, urinalysis, and discharge planning are also briefly addressed. For more detailed discussions of clinical issues related to treatment planning, the reader is referred to two other Treatment Improvement Protocols (TIPs) in this series, State Methadone Treatment Guidelines and Matching Treatment to Patient Needs in Opioid Substitution Therapy. The Center for Substance Abuse Treatment (CSAT) has also prepared a valuable handbook Treatment of Opiate Addiction With Methadone: A Counselor Manual, which is part of its Technical Assistance Publication (TAP) series. The manual includes patient questionnaires that help focus counselor-patient discussions of important treatment issues, such as recognizing stress, staying busy, developing healthy eating and exercise habits, and preventing relapse. These questionnaires can be used with both methadone- and LAAM-maintained patients. Patient EducationPatient education is essential to successful outcomes for patients in LAAM therapy. A comprehensive education plan that takes into account the patient's educational background, ethnicity, and culture is an integral part of the treatment plan. Patient education should be initiated early in the treatment process and should be ongoing. Information should be presented, clarified, and reinforced at every opportunity. Patient education is essential to a successful outcome for patients in LAAM therapy. A comprehensive education plan that takes into account the patient's educational background, ethnicity, and culture is an integral part of the treatment plan. Although certain principles of patient education apply to all persons being treated for a chronic disease, individuals undergoing treatment for opiate addiction have additional requirements. Patients may be divided into two categories:
While all patients need basic information about opioid substitution therapy, the focus of education differs for each group. It should be noted here that clinical trials with LAAM have clearly shown that when program staff do not accept LAAM therapy as a potential alternative to methadone treatment or are not properly informed about counseling and casework issues, patients also tend not to accept LAAM treatment. Therefore, even the best efforts to educate patients can be undermined by staff with negative attitudes about LAAM. As discussed in Chapter 5, every effort should be made to provide staff members with appropriate training about LAAM therapy and to ensure that their questions or fears about its use are addressed. Although this chapter focuses primarily on patient education about LAAM therapy, the need for patient education in numerous areas, such as human immunodeficiency virus (HIV) risk reduction, alcohol and other drug (AOD) abuse, nutrition, health care, parenting, and so forth should not be overlooked. The TIP Matching Treatment to Patient Needs in Opioid Substitution Therapy provides several recommendations for patient education. In addition, patients' families and significant others also benefit greatly from education about LAAM therapy. Patients Newly Admitted to Opioid Substitution TherapyPatients who have not previously participated in an opioid substitution therapy program need to understand the treatment options that are available and how they differ from one another. Staff should describe treatment alternatives and explain the differences between LAAM and methadone. The nature and goals of opioid substitution therapy should be presented. An effort should also be made to allay patients' concerns about the social stigma associated with this type of therapy. Staff should also be prepared to counter the prevailing idea that the sole objective of treatment is to become drug free, an idea which tends to alienate those who need and want continuous maintenance treatment. Patients should be helped to view LAAM as medicine and not as a drug. Issues specific to the individual program, especially those relating to clinic management, services, hours of operation, and administrative matters, should be thoroughly discussed. Policies governing involuntary withdrawal from treatment should also be explained. The program's policies should be posted in public areas throughout the facility. All information should be continually reinforced in individual sessions with the patient. New patients should be given a copy of the program's policies and rules. Ample opportunity should be allowed for patients' questions. When available, programs should provide patients with a patient handbook that includes all relevant program-specific information necessary for patient compliance. The handbook should be written so that all patients can understand the expectations and the rules. The handbook should be available in the patient's first language, where applicable. Patients Newly Admitted to LAAM TherapyPatients who have received or are currently receiving treatment for opiate addiction and who are being inducted onto LAAM therapy also need to be educated about the unique aspects of LAAM and how it differs from methadone. For these patients, the first issue to be addressed is the action of LAAM, particularly with regard to its delayed onset and duration of effect. It is of utmost importance to warn patients about the dangers of using other drugs while waiting for the onset of action of LAAM. The change from daily dosing to every-other-day or Monday-Wednesday-Friday dosing has broad implications for patients. Many patients may be initially unaware of how the schedule change will affect them. Counselors should help patients explore in detail the lifestyle changes that will accompany the LAAM dosing schedule. Patients will have more unstructured time and less clinic contact; they may need support in finding ways to deal with this new situation. The involvement of the patient's family and significant others, although not essential, should be encouraged, if appropriate. In addition, the issue of LAAM dosing during vacations, emergencies, and other unanticipated interruptions in treatment should also be explored. (See Chapter 3 for approaches to handling planned and unplanned interruptions in treatment.)
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