Treatment Goals and Admission Criteria

The goals of opioid substitution therapy guide the development of a treatment system and form the foundation for the type, intensity, and elements of treatment services necessary to meet patient needs. The major components necessary to meet the goals of substitution therapy include either methadone or levo-alpha-acetyl methadol (LAAM), rehabilitative services, and support services. The primary goals of treatment are highly dependent on the specific population being treated; however, the general goals of opioid substitution therapy are

• To eliminate objective signs and subjective symptoms of opiate withdrawal
• To decrease craving for opioids
• To decrease or eliminate injection drug use
• To reduce inappropriate nonopioid drug use and dependence
• To improve health and encourage patient to establish a relationship with a primary care clinician
• To decrease other human immunodeficiency virus (HIV) high-risk behaviors
• To decrease or eliminate criminal activity
• To improve mental health and well-being
• To increase psychosocial supports
• To improve psychosocial functioning, including ability to gain or maintain employment.

Opioid substitution therapy is appropriate for persons with chronic opiate dependence (addiction) who have a history of repeated relapse, persons who live in environments that do not support a lifestyle free of substance use, and persons who repeatedly engage in criminal behavior related to their chronic opiate use. Criteria used to determine appropriateness include history of substance use, physical examination results, results of laboratory tests (blood and urine), Food and Drug Administration (FDA) admission criteria, and patient preference. Persons who are considered high-priority candidates for admission include

• Pregnant opioid-dependent patients
• Patients at high risk of HIV infection
• Patients with life-threatening diseases, such as tuberculosis, that are made worse by injection drug use
• Patients with serious endocarditis and septic arthritis
• Patients receiving Interferon for hepatitis C.

Many of the basic elements of matching opioid-addicted patients to opioid substitution therapy are presented in FDA guidelines, 21 C.F.R Part 291 § 291.501, § 291.505 (1993), as well as in applicable State regulations. These documents discuss minimal standards for entry into treatment, continuing care, and discharge. The regulations are reprinted in another TIP, State Methadone Treatment Guidelines.

Patient Needs

Matching patients to treatment services is critical to the successful engagement of patients in the treatment process. Not all patients need the same type or intensity of service. People in some population groups have special needs that, if not addressed, become barriers to treatment. For example, women may have gender-related and psychosocial issues such as emotional, physical, and sexual abuse that may make them uncomfortable in male-dominated treatment programs. Further, pregnant or parenting women may have needs for childcare and other services such as transportation that, if not addressed, would interfere with attending treatment. Homeless patients need housing. Patients and their families from certain ethnic and cultural backgrounds may have religious or cultural beliefs about drug and alcohol use that affect their goals and use of treatment.

Matching patients to treatment services is critical to the successful engagement of patients in the treatment process. Not all patients need the same type or intensity of service. Patients from certain ethnic and cultural backgrounds may have religious or cultural beliefs about drug and alcohol use that affect their use of treatment.

Patients with health problems and those who are at risk of exposure to life-threatening illnesses represent another group with special needs. Providing access to a full range of medical care services is critical for successful treatment outcomes. Services should address risk factors for HIV and other sexually transmitted diseases, opportunistic infections, and tuberculosis (TB). Many patients in opioid substitution therapy need assistance to gain access to social and family services. Easily accessible services for patients with physical disabilities, chronic pain, and mental illness are necessary to support successful treatment.

A large percentage of patients who are appropriate for opioid substitution therapy either abuse or are dependent on other substances, such as cocaine, alcohol, and benzodiazepines. Opioid substitution therapy programs must address these treatment needs while focusing on the patient's primary dependence on opiates. (A separate TIP in this series, Screening, Assessment, and Treatment Planning for Patients With Dual Dependency on Opioids and Stimulants, provides guidelines for treating dependence on other substances.) Outpatient and inpatient detoxification programs should allow continued methadone maintenance while patients are being detoxified from other drugs followed by referral back to the methadone program. For patients whose environments do not support their recovery, residential treatment and half-way houses can provide elements of successful treatment.

Many patients in opioid substitution therapy need educational and vocational training. Needs range from those of patients who have not completed a high school level of education and who have varying degrees of literacy and little or no licit work history, to those of patients who are college educated with a history of successful employment. Obtaining or maintaining work is an important component of the treatment process. Whether this means they need help in developing appropriate parenting skills, completing an educational program, or pursuing employment, patients entering opioid substitution therapy need structure in their lives to make the changes necessary for recovery.

It is important to perform an assessment of the patient's educational background and employment history to plan an effective treatment experience. A brief history should be taken at admission, followed by a more comprehensive assessment once the patient is stabilized in a treatment program. Resources vary in opioid substitution programs. Some programs offer vocational counseling within programs, others develop affiliation agreements with agencies that can offer these services. Regardless of the model, identifying vocational and educational needs and matching patients to the appropriate resources are important parts of the rehabilitative and habilitative process.

The Setting and Course of Treatment

Opioid substitution therapy is usually offered in a traditional outpatient model, a narcotic treatment program approved by Federal and State authorities. For the most part, patients with chronic opioid dependence and addiction receive methadone maintenance treatment in this setting. As treatment needs become clearer and the multiplicity of their medical, psychological, social, and behavioral needs becomes evident, a full continuum of care for these patients emerges as an important contributor to a positive outcome.

Some opioid substitution therapy programs are part of a continuum of substance abuse treatment programs that includes therapeutic communities, inpatient detoxification units, day treatment, and outpatient counseling programs. Others may also be part of a mental health center. Programs that are part of a continuum of substance abuse and mental health services may have a centralized intake unit that operates as the central assessment component for all the treatment programs. The central unit places the patient in more than one program according to the patient's multiple needs. For example, if a patient is eligible for opioid substitution therapy and needs the environmental containment of a therapeutic community, placement can meet both of these needs. Similarly, if a patient appropriate for substitution therapy also needs psychiatric care, both services can be accessed. Although the programs that provide such multiple placement are rare, it is important to meet the multiple needs of patients. Regardless of the model, a clear assessment of needs is the beginning of setting the course of treatment for the patient.

Patients who enter opioid substitution therapy may eventually take several different treatment courses. Some may leave methadone treatment through medically supervised withdrawal (detoxification) and then continue in drug-free treatment. Medically supervised withdrawal is accomplished in an inpatient unit or outpatient methadone treatment program, and continued therapy involves outpatient or residential treatment, with or without the use of antagonist (naltrexone) treatment. Patients who do not remain opioid free can typically reenter opioid substitution therapy with the goal of eventually becoming drug free. Some may succeed in this goal, while others will need to remain in substitution therapy.

Some patients substantially reduce their use of opioids and need continued maintenance treatment to maintain this reduction in opioid use. However, they may require the containment and support of a residential treatment environment to address alcohol and nonopioid drug use and dependence. These patients will continue on methadone during inpatient treatment for other drug and alcohol abuse. Upon completion of inpatient treatment, they can return to outpatient treatment to continue methadone treatment.

A challenge remains. As mentioned in Chapter 1, continued methadone maintenance during withdrawal from alcohol or other drugs is not always available within the addiction treatment community. Opioid substitution therapy programs must work with licensing bodies and State agencies to provide education and advocacy for these services. In some cases, treatment programs must review and revise their philosophy and policies to meet the needs of patients.

Others need continued opioid substitution therapy with an emphasis on treatment of comorbid medical and psychiatric problems. Providing opioid substitution therapy in a variety of treatment settings is necessary to meet the needs of these patients. Although some States, programs, and hospitals take a multiple-problem treatment approach, access to these additional services is not universal, and changes in the system are critical for efficacious treatment.

Continued methadone maintenance during withdrawal from alcohol or other drugs is not always available within the addiction treatment community. Opioid substitution therapy programs must work with licensing bodies and State agencies to provide education and advocacy for these services.

Medically Supervised Withdrawal From Methadone

As discussed more fully in Chapter 3, careful consideration must be given to when and how withdrawal from methadone is done and what patients are appropriate for this step. The goal of voluntary withdrawal (or tapering) from methadone should be for the patient to become drug free. A patient who is being voluntarily withdrawn from methadone and who is progressively resuming illicit drug use should be strongly discouraged from completing the withdrawal process.

Age, as well as patient preferences and beliefs about the safety and side effects of methadone treatment, should be considered in decisions to withdraw from methadone. Risk of relapse after detoxification and appropriate followup treatment should also be taken into account. Should withdrawal from methadone or LAAM be accomplished on an inpatient or outpatient basis? How quickly should it occur, and from what dose? Does the patient have other medical or psychiatric needs that would affect this decision? Is the patient pregnant? Is withdrawal voluntary or involuntary? These issues must be considered to match patients to these services. Another TIP in this series, Detoxification From Alcohol and Other Drugs (in development), addresses special issues in medically supervised withdrawal, including tapering, from methadone.

Use, Abuse, and Dependence: Evolution of Concepts and Terms

Three terms are often applied to the self-administration of abusable substances: use, abuse, and dependence. Only the latter two -- abuse and dependence -- are psychiatric disorders that justify treatment. Use in the absence of abuse or dependence is a psychosocial phenomenon that may or may not lead to abuse or dependence. Although use of abusable substances often requires attention, simple use of a substance does not qualify a person for formal treatment. However, use of substances by persons with a history of a substance use disorder may be a sign of a recurrence of the disorder.

The definitions of abuse and dependence have changed over the last 20 years, and as a result, there is often confusion about what is meant by dependence or addiction. The American Psychiatric Association publishes a manual that is widely used to diagnose mental and substance use disorders. In the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), published in 1983, dependence applied to persons with pathological patterns of abuse who also had developed tolerance and withdrawal, while abuse consisted only of a pathological pattern of use. In DSM-III, physiological dependence was the defining feature of dependence.

The World Health Organization also publishes a diagnostic and classification manual of diseases and disorders, the International Classification of Diseases (ICD). In recent years, the World Health Organization and the American Psychiatric Association have made a serious effort to make their criteria, including those for identifying substance use disorders, as similar as possible. One of the problems that arose as a consequence of the emphasis that the DSM-III placed on tolerance and withdrawal was that persons who had become physiologically dependent on a substance through the course of legitimate medical treatment (for example, taking opioids as prescribed for treatment of chronic pain) were classified as drug dependent. Many persons saw this classification as misplaced, primarily because the type of dependence seen in medical and surgical patients is usually different from that of persons who seek out and compulsively use substances for nonmedical reasons.

Additionally, in DSM-III there was significant overlap between the criteria for dependence and abuse. The only clear distinction between these two disorders was the presence or absence of tolerance or withdrawal. Based on the criteria, it was unclear whether abuse was a less severe form of dependence or if it represented a different disorder with a different course and prognosis.

With the revised version of the DSM-III, published in 1987 and referred to as the DSM-III-R, the definition of dependence was significantly changed. This definition reflected changes in views that had already been incorporated in the ICD-9 (ninth edition), published in 1977. The DSM-III-R criteria indicated a shift away from the physiological to the behavioral elements of dependence. Behavioral components indicating compulsive use and loss of control over use were emphasized. In DSM-III-R, tolerance and withdrawal continued to be important features of dependence, but they were not the defining features and were not necessary for making a diagnosis of dependence. Persons could be diagnosed with substance dependence if three or more of the nine criteria could be applied. Only three of the criteria related to tolerance or withdrawal. Abuse was a residual category, defined as a maladaptive pattern of problematic use in which compulsive use, tolerance, and withdrawal were not prominent.

The shift in focus toward behavioral elements of dependence reflected growing recognition of a definable and independent syndrome that could result after an organism learned to self-administer abusable substances. This syndrome was not dependent upon the ability of the substance to produce tolerance and withdrawal, but rather on its positive reinforcing effects. Thus, the DSM-III-R clarified the distinction between prescribed drug use by medical, surgical, or psychiatric patients that is accompanied by tolerance or withdrawal and dependence. It also developed criteria that applied to dependence on cocaine and other substances that do not always cause prominent withdrawal. In doing so, DSM-III-R significantly broadened the definition of dependence and increased the number of persons with this diagnosis.

The most recent version of the manual, DSM-IV (American Psychiatric Association, 1994), continues the emphasis on compulsive use and loss of control as the defining features of dependence (see Exhibit 2-1). The criteria items were modified slightly, and the number of criteria describing dependence was reduced from nine to seven. One of the criteria continues to be tolerance and another withdrawal. Dependence is diagnosed if three or more criteria can be applied to a patient; dependence is subtyped as being with or without physiological features, depending upon whether tolerance, withdrawal, or both are present.

Table

Exhibit 2-1 DSM-IV Diagnostic Criteria for Substance Dependence.

The major change in DSM-IV was in the definition of abuse. Criteria for abuse were clearly separated from those for dependence. This change was accomplished by identifying as abuse only items that signify problematic or hazardous use. Items that signify compulsive use, tolerance, or withdrawal are criteria of dependence.

ICD-10, the latest version, published in 1992, no longer separates drug and alcohol dependence; they are merged into a single dependence syndrome that is applied to all substances. ICD-10 has six criteria for dependence Exhibit 2-2 As in DSM-IV, a person must meet three or more to be diagnosed as dependent. ICD-10 does not have a category called "abuse." Instead, the category of "hazardous use" described in ICD-9 was changed to "harmful use." Harmful use is defined as a pattern of psychoactive substance use that causes damage to health. The damage may be physical (for example, hepatitis resulting from injection drug use) or mental (for example, episodes of depressive disorder secondary to heavy consumption of alcohol).

Table

Exhibit 2-2 ICD-10 Criteria for Substance Use Dependence.

In this TIP, the term addiction is frequently used to describe patients with opioid dependence who are appropriate candidates for substitution therapy. Although these individuals generally meet the criteria for opioid dependence as described in DSM-III-R or DSM-IV, the term addiction, rather than dependence, is often used in this TIP because it is commonly used in the field. In DSM-III-R or DSM-IV terms, addiction as used here describes someone who meets three or more of the items for dependence, including criterion item 1 (tolerance) and item 2 (withdrawal). Thus, in DSM-IV terms, someone with addiction is classified as having dependence, with physiological features.

Persons who have developed physiological adaptation to chronic opioid use as a consequence of pain treatment -- even though they exhibit tolerance and withdrawal -- are to be distinguished from opioid-addicted persons as the term is used here, unless they also develop signs and symptoms of compulsive use and loss of control. They typically do not need the structure and drug-focused therapy that are part of an opioid substitution treatment program and should not be confused with persons who have an addiction simply because they share some of the symptoms.

The Need for Emergency Care

Any patient who has an acute or severe medical problem, who is suicidal or psychotic, or who exhibits other symptoms that jeopardize his or her safety or that of others must be referred immediately for inpatient medical or psychiatric care. Persons doing the initial assessment should rule out such conditions before referral for outpatient substitution therapy.

Presence of Opioid Dependence

Federal guidelines restrict entry into methadone programs to individuals who have been dependent on opioids for the better part of the year prior to application for admission and who manifest symptoms of physical dependence on opioids. Pregnant women who are opiate dependent and persons released from an institutional environment who are on the verge of relapse are exempted from the rule regarding 1-year duration of opioid dependence (see details in FDA regulations reprinted in the TIP State Methadone Treatment Guidelines). Criteria for diagnosing psychoactive substance dependence, such as those set forth in the DSM-IV or the ICD-10, should be used to assess the presence of opioid dependence. It should be noted that, although such criteria are useful, Federal regulations do not specify a DSM-IV or ICD-10 diagnosis of opioid dependence for admission to opioid substitution therapy, although such a diagnosis is required de facto, according to the way the regulations are written.

When applying criteria during the preliminary assessment of a person who uses opioids, the clinician must give special attention to several areas. Individuals who use opioids only occasionally, who can control their use, and who are not physically dependent are not appropriate candidates for opioid substitution therapy unless they meet the special conditions defined below (Zinberg and Harding, 1982; Zinberg et al., 1981). Given the wide variations in patterns of heroin and other opioid use, it is helpful to begin the preliminary assessment by reviewing these broad distinctions.

To determine whether a prospective patient meets Federal requirements, one must secure a complete history of the patient's drug use, focusing on the length of time that opioids have been used, the quantity and type of drugs used, the route of administration, and physical signs and symptoms of dependence. Application of diagnostic criteria will elicit information on intensity, duration, and pattern of use that is needed to establish the presence of dependence. Pattern of use is especially important because it is a subtler and potentially more revealing indicator of problems than duration or intensity of use alone. Determination of opioid dependence is discussed in more detail in the section in this chapter on The Medical Assessment.

If the patient's reported drug history and physical examination are inadequate to substantiate a diagnosis of chronic opioid dependence, it may be necessary to gather data from outpatient observation, with a more extended assessment, or from material submitted by other medical and healthcare professionals, family members, a legal guardian, or a significant other.

A patient may insist he or she is addicted, but the clinician may remain uncertain. In these cases, it is appropriate to administer a naloxone (Narcan) challenge test. The patient is administered slowly .4 or .8 mg of naloxone intramuscularly or intravenously. If physical dependence on opioids is present, the patient will develop opioid withdrawal symptoms within 30 to 60 seconds if naloxone is given intravenously, or within 2 to 5 minutes if it is given intramuscularly. If withdrawal does not occur, the person is not physically dependent and probably does not qualify for opioid substitution therapy. If the naloxone test is positive, withdrawal symptoms can be marked; however, since naloxone is a short-acting drug, they disappear within 30 to 60 minutes. The Narcan challenge is inappropriate for certain individuals; it should not be used with pregnant women or who persons who have heart disease.

Adolescents

The majority of adolescents drink alcohol, but the use of marijuana, cocaine, and crack, as well as tranquilizers and sedatives, is also prevalent and varies with geographic location. Opiate use is less common. In a 1983 national survey, only 6 percent of senior high school students reported ever using opioids; opioid use, when it occurs, usually comes later in the use progression (Johnson et al., 1984). For the most part, adolescents who come to treatment programs are heavily involved in substance use and may use alcohol or drugs daily. They tend to have started drug use at an early age, have endured many negative experiences within a brief span of time, and have problems functioning at home and in school.

Although assessment is similar in many ways for adolescents and adults, an adolescent's age, psychosocial development, environment, and family supports are critical factors in assessing opioid dependence.

Adolescence marks a time of great physical, social, cognitive, psychological, and emotional changes. Struggling to cope with these changes can stir up feelings of powerlessness, alienation, and rebellion. Adolescents often assess their emotions and behaviors by the reaction of their peers and are highly vulnerable to the influence of their peer group. Therefore, experimentation and recreational use of drugs are common, often associated with pleasure and euphoria, and not perceived as bad or dangerous (Dusenbury et al., 1992).

Although assessment is similar in many ways for adolescents and adults, an adolescent's age, psychosocial development, environment, and family supports are critical factors in assessing opioid dependence. (Another TIP in this series, Screening and Assessment of Alcohol- and Other Drug-Abusing Adolescents, addresses issues unique to adolescents.) Most adolescents who use opioids sniff or snort heroin; few inject. Some have access to opioids from physicians for treatment of menstrual pain or migraine headaches. These issues should all be considered in the assessment process.

A range and variety of drug treatment programs are available for adolescents. Opioid substitution therapy may be considered for adolescents, but admission depends on the patient's having tried and failed two prior treatment interventions before he or she is eligible for admission. Most methadone treatment programs do not accept patients unless they are over 18 years old, but admission is possible for patients under 18 with parental consent. When exploring the option of opioid substitution therapy for an adolescent, careful consideration should be given to referral to programs that specialize in the treatment of heroin addiction in this age group. The Adolescent Development Program in New York City has developed such a program, which could serve as a model for others (Millman et al., 1978).

Extent of AOD Use

From 30 to 70 percent of opioid-dependent patients use other drugs. The most common AOD use disorders among opioid users involve cocaine, benzodiazepines, and alcohol. A recent study estimated that up to 75 percent of persons being treated in methadone programs might be abusing cocaine (Avants et al., 1994). Nicotine dependence is also extremely prevalent. Marijuana use is common, and some patients seek treatment for marijuana abuse or dependence. Abuse of alcohol and drugs other than opioids creates major life problems among patients in methadone treatment. A urine toxicological screening test is very helpful in documenting current opioid use and identifying other substances being used. It is critical to note that, unlike withdrawal from opioids, withdrawal from alcohol and sedatives can be life threatening.

The most common AOD use disorders among opioid users involve cocaine, benzodiazepines, and alcohol. A recent study estimated that up to 75 percent of persons being treated in methadone programs might be abusing cocaine.

Results of urine, breath, or blood tests are only one consideration for determining appropriateness for opioid substitution therapy. No patient should automatically be excluded from substitution therapy because he or she has a positive test for (or uses) other drugs. One essential purpose of the preliminary assessment is to identify individuals whose AOD use is so out of control that they are physically dependent. Another purpose is to determine if they need detoxification from other drugs or other inpatient treatments before opioid substitution therapy may begin. For example, a patient who uses benzodiazepines but is otherwise stable may enter opioid substitution therapy immediately. However, an individual whose use of benzodiazepines cannot be controlled may have to be detoxified from benzodiazepines before admission to an opioid substitution therapy program. Hospitalization may not be available in some cases, and it should not be required for entry into an opioid substitution therapy program. For programs with adequate medical staff, medically supervised outpatient detoxification from benzodiazepines is an option.

Comorbid Conditions

Housing, Family, and Social Problems

Substance abuse and alcoholism are found in 30 to 40 percent of the homeless population; severe mental illness affects about 30 percent. Heroin, cocaine, and crack use are major causes of homelessness for 10 to 20 percent of the homeless population nationwide. The incidence of AIDS among the homeless is significantly higher than in the general population (Wright, 1990). Health conditions such as vascular disease, trauma, hypertension, poor dental health, gastrointestinal disorders, liver disease, neurological and seizure disorders, arthritis, tuberculosis, and syphilis are also more prevalent. In addition, homeless patients are usually undereducated and in need of vocational assessments and services (Joseph, 1992).

Many patients entering opioid substitution therapy programs are homeless. Addressing their needs at the time of admission is a high priority. If these needs are not addressed, such patients are unlikely to engage successfully in treatment. Patients living with other addicted individuals or in buildings or neighborhoods where the use of drugs is commonplace require special support services or help to secure more appropriate living arrangements. Programs should screen for these problems and must establish referral relationships with housing agencies or other programs that address the special needs of the homeless.

Many patients entering opioid substitution therapy programs are homeless. Addressing their needs for housing at the time of admission is a high priority. If these needs are not addressed, such patients are unlikely to engage successfully in treatment.

Family conflict secondary to drug abuse and to many other problems should be expected for all patients entering treatment. The preliminary assessment should include questions about family relationships and problems (including domestic violence); whenever possible, relatives and sexual partners should be included in the assessment process. Program staff must also be sensitive to special issues related to atypical family arrangements. For example, programs with significant numbers of single parents should consider establishing childcare programs onsite to facilitate treatment participation by the parents. Because family problems are so common, every opioid substitution therapy program should have at least one staff member skilled in family evaluation and family therapy.

Review of Treatment Options

Once the initial assessment has been completed in the areas indicated above, treatment options should be developed and reviewed with the patient. In most cases, these options include

• Opioid substitution therapy
• Therapeutic community
• Inpatient or outpatient detoxification programs
• Inpatient or outpatient psychiatric treatment
• Rehabilitative day hospital treatment
• Outpatient drug-free counseling programs, often with the use of naltrexone
• Acupuncture (see Chapter 4).

The interviewer should begin by familiarizing the patient with the range of treatment possibilities. The ensuing negotiations should focus on five questions:

• What is the most appropriate option?
• What is realistic?
• What is available?
• What does the patient want?
• What will the patient accept?

Responses to each of these questions will narrow the range of options. If, for example, a female candidate for treatment is pregnant, a program that offers comprehensive resources for pregnant and postpartum women should be recommended. Other factors that should be incorporated into decisionmaking include the patient's living arrangements, family and peer support systems, sexual orientation, and employment and legal history.

As stated earlier, treatment modalities may be combined. For some patients, residential treatment or day treatment and opioid substitution therapy may be appropriate if available. A patient addicted to opioids and alcohol, benzodiazepines, or cocaine may need inpatient detoxification from these substances in a facility that can initiate or maintain opioid substitution therapy prior to discharge to an opioid substitution therapy program. Some patients may elect to combine substitution therapy with acupuncture.

Final Determination of Eligibility for Opioid Substibution Therapy

The Primary Assessment Instrument

Patient status should be assessed with a comprehensive and reliable instrument. The National Institute on Drug Abuse has published a useful resource book -- the Diagnostic Source Book on Drug Abuse Research and Treatment -- to assist substance abuse treatment personnel in choosing appropriate instruments. The book describes and evaluates a variety of tools for assessing patients' needs in many areas.

The Addiction Severity Index (ASI) (McLellan et al., 1980; 1990) or the Intake Form developed under the Drug Abuse Treatment for AIDS-Risk Reduction (DATAR) Project at Texas Christian University (Rounsaville et al., 1993; Simpson, 1992) are among the comprehensive instruments used ¹ .

A valid assessment tool must contain quantifiable indicators used to measure progress in specific domains and to track the patient through treatment. The instrument also should be useful to program managers who wish to assess program effectiveness.

The ASI assesses seven domains: drug use, alcohol use, medical needs, psychiatric needs, family and social support systems, legal needs, and vocational needs. Patients are asked specific questions within each domain, and scores indicating the need for treatment or intervention are then formulated. Persons administering the ASI must receive training in its use; refresher training and reevaluation must be conducted periodically.

Principal areas included in the DATAR Intake Form are sociodemographic background, family background, peer relations, criminal history, health and psychological status, drug history, and acquired immunodeficiency syndrome (AIDS) risk. The form provides a comprehensive assessment of these areas but does not include standardized scoring procedures or clinical norms.

The area of AIDS risk, which is not separately covered in the ASI, is an essential part of the assessment. Questions about needle use and sexual practices that increase the risk of HIV infection, as well as questions about domestic violence and sexual abuse history, must be asked of all candidates for opioid substitution therapy.

The panel recommends that whatever assessment tools are used cover at least the following areas

• Drug use (injection and noninjection)
• Alcohol use
• Medical history and status
• HIV serostatus or risk
• Psychiatric history and mental status
• Family relations and supports
• History of domestic violence and sexual abuse
• Community and peer relations and supports
• Housing status
• Criminal history and legal status
• Educational history
• Employment history and status
• Military or other service history.

An assessment of the patient's treatment history, a cultural assessment, and a determination of the patient's expectations and motivation are also key elements of the biopsychosocial assessment and are described in this chapter.

When selecting an assessment tool, program staff should be reminded of the difficulty in developing a reliable and comprehensive assessment instrument. Existing instruments should be used or tailored, when necessary, to a specific population or program.

Secondary Assessment Instruments

The initial assessment often reveals the need for a more focused evaluation in one or more domains. Clinical staff should be familiar with diagnostic instruments available in each of the assessment areas. They may then select the instrument(s) that best meet the patient's needs. The Diagnostic Source Book on Drug Abuse Research and Treatment (Rounsaville et al., 1993) also contains descriptions of recommended secondary instruments or measures to use in six areas:

1. Demographic characteristics, employment history, and legal history
2. Alcohol and drug use history
3. Medical history and medical consequences of AOD abuse
4. Psychiatric diagnosis
5. Family functioning
6. Social adjustment and social supports.

Need for Quantitative Data

Assessment data traditionally have been recorded in narrative form. While use of clinical treatment notes will undoubtedly continue, program staff should ensure that data also are recorded in quantitative form. Collecting data on specific dimensions can provide valuable information about a program's patient population and can assist clinicians in matching patient needs to program services. For example, collecting data about patient health status on admission and at specific intervals throughout treatment can provide valuable information to the program about the health status of the patients served and their progress or changing needs throughout treatment.

Quantitative data can assist clinicians in program planning, advocating for funds, and developing relationships with affiliated agencies. Monitoring program operations and treatment outcomes is increasingly important in an era of scarce resources and managed care. (The TIP Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment provides guidelines for gathering useful data.)

Evaluation of Earlier Treatment Experiences

The patient's treatment history is a useful indicator of future treatment needs. For this reason, the clinician should solicit as much information as possible concerning this subject. To supplement the patient's self-reports, summaries and records should be requested from programs in which the patient previously has been enrolled. This information will give the clinical team an understanding of approaches that have and have not worked well for the patient.

Of particular importance is information about psychiatric symptomatology during periods of abstinence, which may help the clinician differentiate symptoms induced by drugs from primary psychopathology. An exploration of past periods of abstinence also may reveal important clues to effective management approaches. An awareness of the patient's response to mandatory abstinence (for example, during periods of incarceration) may provide valuable insight into character structure and coping skills.

Physical and Sexual Abuse

Some information important in treatment planning is not easily accessible using a specific assessment tool. For example, some patients may have significant histories of physical and sexual abuse, which they may deny during the interview process or in responding to a question on an assessment tool. Gathering this kind of information is a delicate process, and extreme care must be taken when pursuing this line of questioning. For example, a battered woman may deny being abused even when questioned about a visible injury. The patient may not be ready to address the problem, or may be concerned that revealing this information will put her at further risk.

Creating a safe atmosphere is important, and respecting the patient's hesitancy to reveal information is critical. An important initial step is for the clinician to let the patient know that he or she is aware that a problem might exist and that the clinician is available to discuss it. As the therapeutic relationship develops, the patient may be more willing to reveal and discuss abuse issues. Making resources such as shelters and support groups available to the patient is also helpful.

Cultural Assessment

A key part of a biopsychosocial assessment is a cultural assessment, that looks at cultural values and assumptions of various populations. For example, some Native Americans, Asian Americans, and new immigrants have strong traditional and religious ties. Other members of these groups may have been assimilated into the "mainstream" American culture. Knowledge of how different cultural groups define a family unit or work through problems is important to providing services to multicultural and ethnic groups. For example, a desire to confine knowledge about problems just to family members may be part of a patient's culture and may result in resistance to counseling or family therapy, even when obvious personal or family problems are contributing to AOD use. Some patients who will not confide in treatment providers may, however, seek counseling from someone at their church. Cultural and ethnic considerations should inform the design of programs and individual patient treatment plans.

Gathering information about domestic violence and sexual abuse is a delicate process, and extreme care must be taken when pursuing this line of questioning. Creating a safe atmosphere is important, and respecting the patient's hesitancy to reveal information is critical.

Limited knowledge of the cultural context of substance use disorders has resulted in treatment approaches that sometimes seem irrelevant or conflictive to specific populations. It is important to understand that how a minority cultural group views illness and treatment may have an influence on group members' entering treatment and using services. For example, an awareness that one is addicted may be unacceptable to some Asian patients. Asian Americans may enter treatment late because personal loss of control runs against the norm of many Asian cultures. Many ethnic healing traditions are focused on brief, magical cures with consultation from many healers. Such a belief system may make it difficult for some individuals to accept the long-term focus of opioid substitution therapy.

A Hispanic-American patient may view compulsory urine testing as indicative of the program's mistrust of the patient's word; testing may offend his or her sense of dignity, a highly relevant and strongly defended principle among many members of this ethnic group. The prospect of long-term substitution is seen as a modern form of "slavery" by some African Americans. Some Puerto Rican patients who have been forced to assimilate into the Anglo culture suffer from an identity crisis. They often feel that their culture is devalued, that they have been fragmented from their extended family networks and polarized between generations. These issues, along with language barriers, should be considered in the assessment and treatment planning process (Ruiz et al.).

A shared staff-patient cultural identity is more attractive to some patients entering treatment. To the extent possible, staffing should reflect the population being served by the program. Use of bilingual educational materials and display of materials in the program waiting room can be helpful in making patients feel comfortable when English is not the primary language.

Determination of Patient Expectations and Motivation

Because effective matching must take into account patient preferences, the clinician should carefully explore the patient's wishes and expectations from opioid substitution therapy. During this process, the patient should be treated with dignity and respect. Clinician-patient interchanges should take the form of negotiations between two parties working toward a mutual goal.

Limited knowledge of the cultural context of substance use disorders has resulted in treatment approaches that seem irrelevant or conflictive to specific populations. It is important to understand that how a minority cultural group views illness and treatment may have an impact on group members' entering treatment and using services.

The role of patient motivation, readiness, and suitability for treatment cannot be overemphasized. Poor motivation has been found to be a predictor of early dropout from AOD abuse treatment (De Leon and Jainchill, 1986; Simpson and Joe, 1993). Clinicians should be able to assess the patient's motivation and readiness for change (De Leon and Jainchill, 1986); mastery of the techniques of motivational interviewing is an invaluable clinical skill (Miller and Rollnick, 1991).

The Process of Change

The clinical team can benefit from an understanding of the stages of change and their impact on patient progress. Building on the work of Cashdan (1973), and Egan (1975), and Horn and Waingrow (1966), Prochaska and colleagues (1982; 1986; 1992) formulated a model that explained how people change. Applying their model to the treatment of addictive behavior, these authors proposed five stages of change:

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance.

Change begins as a cognitive process and moves incrementally toward the behavioral domain. Movement through these changes is similar to the process of recovery; a period of progress may be followed by a retrenchment. Just as a majority of patients will relapse one or more times before recovery from AOD dependence, most patients will return to a previous stage before moving definitively to the next stage.

A treatment intervention may be appropriate or inappropriate, depending on the patient's position on the change continuum. Interventions that are appropriate to the patient's current stage of change enhance the possibility of positive treatment outcomes; in other words, one must do the right thing at the right time. Patients in the contemplative stage of change, for example, are usually ambivalent about stopping AOD use; consequently, a nondirective, client-centered technique designed to help the patient resolve such ambivalence may be helpful. A patient in the active stage of change, by contrast, is generally amenable to a directive intervention that may include recommendations for specific therapeutic activities.

Finally, assessment of motivation requires that the clinician know when to encourage the patient and when to realize that limits have been reached. While movement toward recovery remains the foremost goal, the clinician also must realize that progress must come at a pace with which the patient is comfortable.

Example 1: Mr. G

Mr. G, who is 38 years old, is applying for admission to a methadone maintenance program. He reports that he has experienced hopelessness and loss of interest in everything. He spends most of the day in bed except for buying and using heroin to prevent withdrawal. He recently lost his job because of poor attendance. He reports that since his early teens he has experienced pervasive anxiety, periods of depression, and trouble concentrating. These conditions predate his drug use. In fact, he believes that drugs have helped him feel less anxious and more focused so he can work. However, he reports that drugs no longer have this effect. He has made two serious suicide attempts (a deliberate overdose and crashing his car into a tree). He has transient thoughts of suicide now but no specific plan. He has used antidepressants in the past, but had to discontinue use because he couldn't afford the medication.

The ASI (or a comparable assessment tool) is administered upon admission to assess, among other indicators, Mr. G's psychological status. He scores higher than 5 on the psychiatric scale. Identifying specific indicators for depression is an important part of this patient's initial assessment. The counselor could further investigate Mr. G's psychiatric complaints and should refer the patient for a more comprehensive psychiatric evaluation. If the evaluation reveals a specific condition, such as major depression, Mr. G should be referred to a psychiatrist, who can determine whether antidepressant medication, psychotherapy, or a combination of these treatments is appropriate. Identification and treatment of the patient's comorbid condition could be a critical factor in retaining Mr. G in the opioid substitution therapy program.

Assessment of motivation requires that the clinician know when to encourage the patient and when to realize that limits have been reached. While movement toward recovery remains the foremost goal, the clinician also must realize that progress must come at a pace with which the patient is comfortable.

Example 2: Ms. J

Ms. J is a 45-year-old divorced mother of two (a 10-year-old son and a 5-year-old daughter), who has been in methadone maintenance treatment for 10 months. Her children are currently living with a relative. Ms. J is receiving 85 mg of methadone and has stopped using heroin. In the last 2 months, her urine test results have been positive for cocaine, and she reports that her current partner deals and uses cocaine. Upon admission, her liver function tests are elevated and she tests positive for hepatitis B and C. Although she had not shared needles in the last 18 months, she has done so with her partner a few times in recent weeks. She has not been HIV tested because she is afraid to learn her status.

Ms. J attends counseling on a regular basis but is hesitant to attend community support groups such as Narcotics Anonymous. She recognizes the severity of her opioid addiction and minimizes her cocaine use. She has learned to recognize some of her relapse triggers, but she does not have sufficient coping skills to interrupt cravings or impulsive use at this time.

According to the Massachusetts Methadone Treatment Criteria, Ms. J demonstrates the need for continued care in all of the outlined dimensions for methadone maintenance. For example, she needs ongoing medical monitoring for her hepatitis and medical problems, while demonstrating her ability to make use of the treatment environment. She has biomedical complications, specifically for her liver problems and hepatitis, and is at risk of HIV infection. Her episodic use of cocaine is also a problem. Once her biomedical needs have been identified, Ms. J should be referred to a primary care physician for blood work and continued medical followup. A counselor should attempt to explore her resistance to HIV testing and describe pre- and posttest counseling that may help motivate, support, and provide further education about HIV risk factors.

Indicators of emotional-behavioral conditions provide evidence that Ms. J has responded to treatment and has made some life-change progress, but she continues to manifest risk behaviors such as needle sharing. She recognizes the severity of her addiction to heroin but demonstrates minimal understanding of her cocaine use and its relationship to her risk of relapse to heroin use. Ms. J requires continued treatment to begin to address her AOD use. She recognizes some relapse triggers for heroin use but has not developed sufficient skills to resist AOD use. In addition, Ms. J's living environment is not conducive to recovery, and she has not developed the socialization skills to establish a supportive network.

Groups focusing on cocaine use, identifying risk factors, and exploring ambivalence to change might be helpful. Further discussion and understanding of her relationships with her partner and her children, of her home environment, and of her goals for change may help identify the specific services that can assist her in this effort.

Identifying the issues for Ms. J according to the dimensions in the Massachusetts criteria can be helpful in identifying specific areas for treatment planning and recognizing and documenting progress in treatment. Uniform documentation, whether using the ASI, the Massachusetts criteria, or other assessment tools, can help quantify progress and identify specific needs for further assessment and continued treatment.

Clearly Defining Initial Treatment Goals

Patient progress can be assessed only after treatment goals have been clearly articulated, shared with the patient, and jointly accepted. The treatment plan should balance program requirements and patient needs. It should define short- and long-term goals and set forth information on the level, duration, and frequency of counseling and other services. Pertinent information related to treatment goals must be clearly reflected in the assessment forms.

Patient progress cannot be assessed effectively if treatment goals have not been articulated clearly, shared with the patient, and jointly accepted.

Assessing Patient Progress and Services Received

Interpreting Patient Progress

Any significant change in patient status revealed by the assessment, whether positive or negative, should be viewed as an opportunity to reassess the treatment plan and determine whether the mix and intensity of services are appropriate. As described in Chapter 3, services may need to be more intensive during times of crisis and decreased when sufficient progress is made. For example, increased counseling services provided to a patient after the death of a partner, family member, or friend may provide the support needed to prevent relapse. Requiring attendance at a specialized group for those struggling with cocaine use can help a patient attain the skills and support to control or stop use. Responding to a positive urinalysis by developing a more responsive treatment plan can work to ensure good treatment outcomes. Providing positive feedback, readjusting counseling services, and increasing privileges can demonstrate to the patient that progress has been made and less monitoring is needed. Programs should be ready to increase services in response to acute crises, even for patients who have been stable for a long time.