Approach for treating methadone patients created
Challenging patients are paired with experienced staff
The professionals in the addiction treatment services team at Johns Hopkins Bayview Medical Center in Baltimore have created an approach for treating methadone patients, called the motivated stepped care (MSC) model, which has decreased positive urine tests from 74% to 54% and increased group counseling attendance from 14% to 65%.
The model, which won the facility a coveted Codman award, features a patient/provider matching protocol that puts the most severely affected patients under the care of the most experienced and highly trained staff, along with behavioral contingency plans to reinforce adherence to recommended treatments.
"We had noticed at the methadone treatment clinic that patients were not attending scheduled counseling sessions at anywhere near the rates that we needed; research shows the more they attend and the longer they attend the better the results," notes Van King, MD, associate professor, department of psychology and behavioral Science at Johns Hopkins. "The problem was, how to get them motivated to attend these important meetings."
'Carrot and stick'
The team came up with what King calls a "behavioral motivating" approach: They required the patients to come to meetings in order to have access to methadone. "In order to come and get the methadone, which in and of itself is helpful, they had to participate more completely in group and therapy sessions," King explains. "Ultimately, availability is based on whether you come to treatment."
Often, he notes, there is no rehabilitation if a patient just comes for meds and other treatment. But doesn't denying a patient medication that makes them feel better raise ethical questions? "The fact of the matter is that anytime physicians agree to treat a patient it's based on a collaborative approach," says King. "You don't just hand out drugs to people if you do not think they will ultimately benefit from them."
Based on the team's observations, he continues, "handing out [methadone] can be helpful, but it's not unusual for people to continue to deteriorate. Maybe they will take the methadone but [without counseling they will still] use alcohol or cocaine; their relationships will continue to deteriorate, and so on. The idea here is that by patients coming to more complete treatment and maintaining abstinence for a longer time they can actually start to rehab in a very significant and meaningful way."
And how do patients react to this 'either-or' proposition? "This gets the patient's attention," King observes.
The second aspect of the program, which makes it not only successful but "efficient and economical," in King's words, is that it tries to match the intensity of treatment to the severity of the problem. "When the patient first comes in, they get a basic level of care — educational group sessions one or two hours a week," says King. "If they continue to use, in a step-rated fashion they are assigned to more counseling to address those problems."
Currently, the program has four steps of care. "If they come in at 'two' and do great, they step down," notes King. He explains that level three includes additional group counseling sessions, and four "is like an intensive outpatient level of care — and they stay there until they get some initial control of their drug use problem." When they are somewhat stabilized, they are reduced in care again and continue to be monitored with urine tests.
The more severe cases also are matched with more experienced staff. "One thing we noticed is that a lot of these patients who do poorly may have other psychological disorders, and tend to be more disordered in general," says King. "What we have done is for group therapy sessions we have the most experienced staff; they can tend to more complicated issues that counselors may not be equipped to deal with."
What's more, says King, "Patients can be disruptive or disgruntled and often it takes a more experienced person to help direct them in a more positive way." In addition, he notes, there is a lot of turnover among counselors, "And it's a long-term treatment process; we expect these patients to stay with us for years."
Staff develop plans
The entire staff were involved in program development from the start, notes King.
"One of our supervisors developed computerized data tracking sessions, and the staff had input into how we ended up implementing it," he says. "The group sessions we took from standardized cognitive behavioral manuals."
Another key to success, he says, was the overall approach. "What we do is use therapy in a thoughtful and consistent fashion," he says. "Patients are told about the requirements right up front." Initially, he says, there were complaints about the group sessions because "nobody likes them at first" — but he adds that "we never hear that now; they are a valued part of our treatment."
Because patients are motivated to see the staff more often, he explains, "we are often better able to improve their engagement and relationships. A lot of them are demoralized when they show up and do not believe they can stop using."
This model, he asserts, can easily be replicated by other facilities. "The nice thing about it is that you can use the same basic principles, but not necessarily use the exact same protocols we do," he says. "You may not have the staff to do so many groups, for example."
[For more information, contact:
Van King, MD, Johns Hopkins Bayview Medical Center, Baltimore, MD. Phone: (410) 550-0100.]
The professionals in the addiction treatment services team at Johns Hopkins Bayview Medical Center in Baltimore have created an approach for treating methadone patients, called the motivated stepped care (MSC) model, which has decreased positive urine tests from 74% to 54% and increased group counseling attendance from 14% to 65%.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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