Treatment of Behavioral and Psychiatric Problems Associated With Opiate Dependence

2015

Diverse problems and challenges confront the staff members of programs/clinics intended to treat individuals with histories of opiate use and associated problems. The clinic sponsored and staffed by the Philadelphia Veterans Administration Medical Center and University of Pennsylvania provides numerous examples of the merits and problems of such treatment programs. The clinic’s patient population over the past decade has varied from two to four hundred patients. A range of services is provided along with pharmacological interventions including opiate-specific treatments such as methadone, LAAM, naltrexone, and a variety of psychotherapeutic agents administered in treatment of diverse presenting disorders. It should be noted that the clinic differs in some respects from “standard” clinics insofar as it includes numerous associated ongoing basic and applied research projects. There may therefore be more options and staff available from time to time but there may also be considerable variability uncharacteristic of other clinics. In any case the clinic appears to have many of the problems reported to prevail in other nonresearch clinics. It can therefore be used as a reference in the sorts of issues which do arise.

Patients entering standard treatment programs for opiate use often display serious behavioral and psychiatric problems both within and outside treatment programs. The successful management of these problems is of great importance for both the patient and the community. Failure on the part of a treatment program successfully to control behavioral problems of its patients has sometimes resulted in community pressure to close the program, and in some cases this pressure has achieved its intended result. Inadequate treatment of the psychological disorders of the opiate user/patient has contributed to poor treatment response and sometimes to premature termination from therapy.

Behavioral and psychiatric problems

Many of the behavioral problems demonstrated by these patients originate from drug-seeking behavior which is, of course, a normal part of the drug-using cycle. Patients may fabricate elaborate stories to obtain prescriptions for a variety of controlled substances, buy or sell illicit drugs, attempt to falsify urine samples to avoid loss of take-home methadone doses, or attempt to divert methadone at the pharmacy window.

A common problem viewed as serious by most program staff members is loitering. Its origins and rewards are diverse. The most common motive for loitering appears to be social contact (), but a considerable amount of drug dealing also takes place when patients loiter. Persistent loitering can serve as a nidus for the development of other behavioral problems such as arguments or fights. The loitering and associated behaviors can also be frightening to people who happen to be in the vicinity and who are not familiar with the personalities and lifestyles of the opiate-using patient population. Threats and disruptive behavior including fighting may occur, and when clients carry weapons, special problems are encountered.

These patients also bring with them to the clinic the full range of social and family problems. Many are unemployed, have few skills, and could likely benefit from training programs, although questions as to how best to achieve the training are numerous (e.g., see Hall et al. and Thompson et al., present volume). In addition, problems with both family of origin and current family may exist (e.g., see Todd, this volume). All of these problems may or may not be related to the addiction or to other factors such as personality disorders, psychiatric problems, or socio-environmental circumstances.

As might be expected, the range of psychiatric disorders reported in the general population has been observed in opiate-using patients. Table 1 summarizes the Research Diagnostic Criteria (RDC) diagnoses reported in a sample of 533 opiate users who were given a thorough and careful psychiatric evaluation as part of a study recently completed by Rounsaville et al. (). Depression was the most common diagnosis, with about 60% of the sample having had some form of depression at least once. The next most common, problem was alcoholism, followed by antisocial personality and anxiety disorders. Occurring with a much lower frequency were schizophrenia, other types of personality disorders, mania, and hypomania. Not included in this table but also seen regularly are acute situational reactions which involve intense but transient feelings of anger, anxiety, or depression; psychiatric disorders complicated by medical conditions such as hepatitis; and illnesses or injuries which produce chronic pain, such as pancreatitis, sickle cell anemia, or trauma resulting in nerve root irritation.

The diverse medical, behavioral, and psychiatric problems observed may be closely related to one another and interact to produce constellations of complex disorders. For example, either antisocial personality disorder or addiction itself can lead a patient to fabricate stories about psychiatric or other medical problems in attempts to obtain prescriptions for controlled substances; depression can result in chronic anger and hostile behavior; and paranoia secondary to schizophrenia or amphetamine psychosis can lead the patient to carry a weapon for “protection.”

In other cases the behavioral and psychiatric problems appear to be unrelated. Examples include anxiety attacks or schizophrenic hallucinations which result in psychiatrically correlated behavioral problems which are not characteristic of the typical opiate user.

As seen from this brief overview, many combinations of behavioral and psychiatric problems can occur in a methadone treatment program. Comments throughout the remainder of the paper review some thoughts on management and treatment of these problems. They derive from the perspective of persons who are responsible for directing a clinic very much invested in methadone maintenance but with the adjuncts previously mentioned. In any case the comments have a strong practical orientation,

General approaches

The staff members of the treatment clinic have spent many hours deliberating about and experimenting with various general and specific approaches to management and treatment of patients’ behavioral and psychiatric problems. The strategy that has emerged is one which uses external environmental controls combined with procedures designed to change internal processes and affective states. The external measures are primarily behavioral-psychological, while the internal ones are mainly pharmacological. The external interventions aim primarily to punish certain behaviors and to reinforce others. These in turn affect attitudes, or reduce the intensity of the affects and impulses which are part of the problematic behaviors and psychiatric disturbances demonstrated by the patients.

Clinic patients are similar in many ways, but dissimilar in others. In this combined approach it is essential to diagnose the problem correctly in order to make the appropriate response. For example, a primary focus on behavioral controls and limit-setting can be destructive for patients who are primarily depressed, but it can be constructive for patients who are displaying only sociopathic behavior. Thus the needed strategies and arrangements to maximize reinforcement must be individualized as well as being established for the clinic as a whole.

The first treatment priority is often control of the behavioral problems because they can be detrimental to the entire program, including staff. The techniques used focus on three potentially problematic target behaviors: (1) loitering, (2) drug dealing or other forms of drug-seeking behavior, and (3) disruptive or aggressive behavior. Many drug treatment programs implement specific techniques that are aimed to modify these behaviors, and the techniques are usually implemented from specific behavioral guidelines presented in the form of general program rules.

Treatment occurs within the program milieu, and it is necessary to consider certain aspects of it that contribute importantly to the success or failure of the specific techniques used. The milieu includes the physical location, appearance, and design of the program facilities, as well as the attitudes, hierarchies, and power structures that exist within the staff.

The physical layout of programs can vary tremendously and may include storefront clinics, medical offices in separate buildings, and offices in both general and psychiatric hospitals. Drug treatment programs can be located in urban or rural areas and their level of maintenance can vary from exceptionally clean to extremely insanitary. The formal and informal power structures within the staff, and the way patients and staff interact, form another important part of the milieu. In combination, these factors determine the success of treatment.

A view of clinic administration

From the onset, the administrative structure that will be used to run the program must be clearly established and made known. This step may sound trivial, but it is extremely important. Drug abuse programs typically have both professional and paraprofessional staff who work together to solve many complicated problems, and competition or role diffusion often occurs. Similarly, the contributions to general policies and to program rules that can appropriately be made by patients and staff members are sometimes unclear, especially concerning issues of the degree of authority and administrative latitude accorded to the group.

The administrative structure that has been found to be effective in the Philadelphia VA Medical Center clinic is fairly standard. It is a hierarchical organization which involves differing levels of power and responsibility for various categories of people within the program. Examples of these levels are a service chief, senior program staff member, nurse, counselor, and patient. Patients should have input into the formation of rules and policies, but the program staff must retain the authority to-make final decisions. The hierarchy of responsibility and authority should begin with one person who is clearly identified as being in charge and given the authority to act accordingly and is also the one held responsible if problems occur. Job descriptions and delegations of authority must be clearly specified. Regular staff meetings must be held in which management and clinical issues are discussed and comment from all staff members can be used in making decisions and in setting policies. These meetings serve to unify and coordinate program activities.

Patients often request a democracy, or accuse the administration of being dictatorial when administrative decisions are made unilaterally. However, a “democracy” can pose very difficult problems in a methadone program. One of these is that the drug-seeking behaviors among the patients are often so intense that there is a strong tendency to attempt to use “democracy” to manipulate the system in order to obtain extra supplies of drugs or whatever other tangible rewards are be available in a manner that subverts the prevailing rules or contingencies. Other serious problems can occur in situations where rules must be enforced and patients disciplined. Attempts to implement democratic forms of government within this population have been numerous. For example, a committee (the “Judicial Committee”) was established that consisted of patients and staff members whose purpose was to hear the comments of all interested parties in situations where program rules had allegedly been violated. It was never clear that the committee was very effective. Rarely did the committee agree on whether rule infractions had occurred. The deliberations often took hours and required large amounts of staff time, and meaningful punishment (such as suspension from the program) almost never occurred. After trying very hard to make this committee work for almost 2 years, it was disbanded and a much more authoritarian approach to problems was taken. It resulted in more penalties and more success in controlling behavioral problems.

There must be written program rules which consist of explicit guidelines for conduct with specific penalties for violations. The rules should be carefully formulated by the combined efforts of staff with comment from patients. Penalties should, of course, be graduated according to the severity of the offense. The rules are helpful to both patients and staff, because they provide a consistency and uniformity of consequences for behavioral problems. The rules should be explained to all patients when they are admitted to the program, and patients should sign a copy which is then placed in their chart. The rules should also be conspicuously posted in the clinic. Program rules can be modified if necessary, but only after a similar thoughtful and deliberate process.

Many of the specific rules used by programs will vary depending on the local situation. For example, the program discussed herein is in a separate building remote from the main hospital. One of the results of reducing loitering in the clinic and in the immediate vicinity was that patients spent considerable time and caused some difficulty in the cafeteria of the main hospital. Therefore specific rules were developed governing appropriate and inappropriate use of the cafeteria. Many programs such as those located in storefront clinics rather than general medical centers have no need for such rules.

As noted earlier there must be a clear line of authority that is consistent and readily understandable to both patients and staff if the established rules and policies of the clinic are to be meaningful. It must be expected that patients will “test the limits” of the system and this will result in “going to the top,” especially when serious problems develop, including cases involving suspension. Good communication among staff members and clear policies for review of patient requests to speak with people at higher levels of authority are necessary in these situations.

As in any treatment setting, all aspects of activity including infractions of rules that occur must be documented clearly. In publicly funded facilities, legislative or congressional inquiries about response to specific incidents may occur and accurate documentation is essential. In addition some patients in drug treatment programs are expert “jailhouse lawyers,” experienced at casting a reasonable doubt upon any evidence of illicit behavior on their part. In some cases they may have been through similar procedures on repeated occasions during appearances in court. Thus, it is not uncommon for patients frankly and adamantly to deny engaging in a problematic behavior that has been witnessed by reliable staff people. On the other hand, many patients have been subjected to arbitrary, discriminatory, and unfair treatment by people in authority, and it is essential that this pattern not be repeated by the program. Thus, all alleged infractions of program rules must be examined thoroughly so that a fair and appropriate decision concerning consequences may be made.

The chief administrator and the administrative system must, of course, maintain staff morale. Actions that successfully deal with problematic patient behaviors build and maintain morale, while lack of control of behavioral problems has the opposite effect. Morale is strengthened by providing staff regular opportunities to contribute to decisions, by encouraging discussion at the regular staff meetings where clinic policies, rules, and management problems are reviewed.

In-service training sessions can make an important contribution to morale by providing the staff members with opportunities to develop professionally. This can be done in a variety of ways, the most direct one being a weekly presentation of topics related to the problems that are treated by the program. These can include sessions about family therapy, high- vs. low-dose methadone treatment, jobs programs, how to use psychotropic medicines, current issues in the criminal justice system, and many other topics.

It is essential that the administrators spend time working on the procedures that are necessary for program operations, such as scheduling hours, secretarial coverage, treatment manuals, and directives that the staff use in their daily work. These measures can be very helpful to staff morale via their organizing and supporting effects.

Finally, it is helpful to develop a clinic manual that defines and describes counseling duties. This manual should include guidelines for making treatment plans, making clinical notes, procedures for using ancillary medicines and for implementing clinic take-home policies. These written guidelines provide a framework that the counseling staff can use in formulating a unified approach to patient management.

Ideally the physical setting should be one that permits reliable provision of treatment and makes it easy to enforce rules. For example, it is sometimes difficult to have a methadone treatment program located in the main traffic area of a general hospital. This may, depending on the characteristics of the drug patient population, lead to difficult interactions between addicts and other patients or hospital staff. Some feel that the ideal location for a drug treatment program is in a separate building which patients can enter without having to pass through other office or clinic areas. If this situation does exist, the building should have a waiting area that is comfortable yet highly visible. Patient access to treatment areas should be easily controlled by a clinic secretary or other staff via locks with buzzers or other appropriate traffic control devices. This type of physical design will facilitate control of patient traffic within the building, and this decreases the chances for behavioral problems within the clinic. On the other hand, it must be recognized that while a separate facility may have fewer obvious problems, it may simply be the case that the problems such as loitering are being displaced to other locations. It is most helpful to have a staffing pattern which includes people trained to manage the different behavioral and psychiatric problems that may occur. This includes counselors, medical personnel, secretaries, and depending again on the nature of the facility and patients, police. In general the important issue is that the clinic have well trained personnel for all the services it provides. If, for example, the clinic does not have professional job counselors, it should refer clients elsewhere for this service. Excellence in available services rather then diversity of services is probably important in reassuring patients concerning treatment.

Finally, it may at times be necessary to use legal sanctions, in addition to the program rules, for the more serious problems such as threats, weapons offenses, thefts, or fights. Since methadone programs are under Federal control, it can be valuable to work out an informal liaison with the Federal criminal justice system so that formal charges can be filed in situations where serious behavioral problems have occurred. Thus, in addition to suspension from the program, patients can be fined or may actually go to jail for certain offenses. When patients know that this process exists and that it will be used, problems occur less often.

Implementation of these clear guidelines has decreased problems in the vicinity of the clinic, although success in eliminating some problems is not as clear. In some instances, the behaviors are suppressed in the clinic area but transferred to another location. For example, some of the patients stopped loitering around the hospital but moved to a fast food restaurant located nearby. This shift of problems from one locale to another may limit their occurrence, but it indicates that these measures are far short of being curative. Nevertheless, they can have the positive effect of maintaining a therapeutic milieu within the immediate vicinity of the treatment program, and in developing positive regard for the program in the community.

Applying behavioral controls to specific individuals

Careful thought should be given to application of behavioral control techniques, especially when dealing with “problem behaviors” as opposed to development of adaptive behaviors leading to positive consequences. Patients who are often angry must be approached in ways that will maximize the chances of their benefitting from the sanctions to be applied, and minimize the chances for destructive acting out of their anger. Some of the patients are truly dangerous, and their potential for aggressive acting out should always be kept in mind. HOW the patient is approached is an extremely important factor for the safe and effective management of these situations. Several therapeutic guidelines may be helpful in these cases.

First, it is important to be open and nonjudgmental when discussing the specific infraction with the patient/violator. This should be done in a matter-of-fact, nonhostile manner, and he should be given the opportunity to express his point of view about the situation. This approach will minimize the chances for aggressive acting out by the patient. The patient may complain, but the complaints should not cause serious problems when things are consistent, open, and direct, and when he feels that sincere and honest efforts have been made to assess the situation accurately and to treat him fairly and in accordance with the program rules.

Thus one communicates a sense of firm and consistent limits, combined with the feeling of underlying support and some degree of flexibility about the exact timing of his expulsion from the program. The message that seems important to communicate when problem behaviors arise is, “We are very concerned with you and your treatment, but you must understand that certain behaviors are unacceptable and cannot be tolerated.” Support is very important for this population. Many people have written about the necessity to provide support for drug-dependent individuals, and this clinic’s experience is consistent with these observations.

Many details have been omitted in the above discussion, such, as comments about collecting urine specimens, pharmacy dispensing procedures, and specific techniques for control of patient traffic flow in the clinic area. Guidelines for these aspects of program management are also important, and many of them are specified in FDA or DEA regulations or are found in clinic treatment manuals or regulations used by the hospital police force.

Treatment of psychiatric problems

The psychiatric problems experienced by addicts are important contributors to overall treatment outcome; thus psychiatric treatments can make important contributions to a program’s effectiveness. Some psychiatric problems appear closely related to drug dependence, and in these cases one problem cannot be brought under good control without effective treatment of the other (). In general, the psychiatric problems of drug-dependent patients are treated in the same way similar problems are treated in non-drug-using psychiatric patients. This view and approach are empirical and do not derive from experimental evidence but do seem reasonable. Commonly observed psychiatric conditions are considered below.

Anxiety is one problem commonly observed, particularly in patients who have recently undergone withdrawal. The condition may have a different physiological basis from that observed in other patients with an anxiety disorder. However, post-detoxification anxiety is usually treated with a combination of supportive counseling or psychotherapy and psychotropic medications, much as it is treated in general psychiatric patients. Anxiety may also occur during the course of maintenance treatment and can be treated with psychotherapy, counseling, family therapy, biofeedback or relaxation exercises, or with anti-anxiety medications. These treatments can be used separately or in combination. Anti-anxiety medications are usually monitored very closely with these patients because there is a much higher risk of improper use or abuse than is seen among general psychiatric patients. The anti-anxiety medications that appear to be most effective are the benzodiazepines. Diazepam (Valium), however, appears to have high abuse potential in this population, and thus it is used under very specific conditions or not used at all. Examples might be patients being maintained on very low doses of methadone who are in regular contact with their counselors and who have consistently drug-free urines; or patients who are detoxified and keeping regular clinic appointments; or patients who are being treated with a narcotic antagonist such as naltrexone. Oxazepam (Serax) is a frequently used benzodiazepine which appears to be effective and which does not seem to be abused or misused to any significant degree.

Depression in its various forms appears to be even more common than anxiety disorder in drug-dependent and post-drug-dependent patients. These include major, minor, and intermittent depressive disorders. Depressive illnesses seen in drug-dependent patients are often precipitated by disruptive life events, and they commonly have a significant anxiety component. Depression in these patients is usually not as severe as that seen on general psychiatric inpatient units, and it appears to respond to counseling, psychotherapy, or antidepressant medications. Favorable results have been obtained with administration of doxepin, a sedative type antidepressant, when used in combination with counseling and psychotherapy (). Doxepin appears to help control the symptoms of anxiety and depression that are so often found in these patients, and it also appears not to have any significant abuse potential. It is unclear whether the apparent positive effect of doxepin with this population is due primarily to its anti-anxiety or to its antidepressant effects; however, it seems to be a useful drug.

Sociopathic behavior is another common and serious problem, and our best treatment for it is to control and structure the milieu via clear and consistent rules. Treatment contracts emphasizing aversive control are sometimes used for patients demonstrating sociopathic behavior or for selected patients without sociopathy who appear to be doing poorly in spite of our best efforts to help them through traditional psychotherapeutic strategies. These contracts call for the patient to engage in certain behaviors within a specific time period or face suspension. Patients who fail to comply with the conditions of the negative reinforcement-based treatment contracts have the option of detoxification or transfer to another program. About 50% of patients given a treatment contract fulfill its conditions.

Alcoholism is another common problem in this population, and it is one which we have not been able to treat very effectively. Counseling combined with regular verification of nondrinking, using breath testing and sometimes disulfiram (Antabuse) is typically used with these patients. Treatment contracts are also used with alcoholics, and those patients who fail their contracts are usually advised to enter an inpatient alcohol treatment facility. These patients are also encouraged to attend meetings of Alcoholics Anonymous or engage in other therapeutic activities.

Schizophrenia is observed only infrequently in this population but it can be quite disruptive not only for the patient but for other patients and staff members’ efforts to maintain the clinic as a therapeutic environment for others. Almost every case of schizophrenia we have seen has been of the paranoid type. Patients with this disorder are usually treated with phenothiazines, often in the liquid form which can be mixed with . The daily dose of methadone. It is important to mention that methadone itself has some antipsychotic effects; it appears to have a sufficiently positive psychotropic effect in some schizophrenic patients to make other medications unnecessary.

Patients with manic depressive illness (Bipolar I or II) are seen infrequently. They are usually treated with lithium or with combinations of phenothiazines and antidepressants, as are nonaddicted manic-depressives (). Special attention must be given to monitoring compliance if the patient is treated with lithium because of the narrow margin between the therapeutic and toxic dose. Patients taking it must thoroughly understand its dangers and how important it is to take it exactly as prescribed. Compliance with the regimen is probably encouraged if patients know that lithium cannot produce euphoria and that extra doses will only lead to severe adverse reactions. Drug dependence generated by administration of analgesics for medical problems involving pain is seen occasionally. Patients with chronic pain often have significant depression and can be treated with an antidepressant plus psychotherapy and relaxation. Amitriptyline HCl (Elavil) may be especially helpful for these patients, since it appears to have a mild analgesic effect; however, it has some degree of abuse potential, and compliance should be monitored carefully.

One serious problem seen occasionally is persistent opiate drug use in patients who appear to be maintained on doses of methadone that are more than sufficient to suppress withdrawal symptoms and which also provide some degree of narcotic blockade. In these cases we will often raise the dose to the highest allowable levels (80-100 mg/day). Sometimes this process is also combined with a treatment contract.

Research in clinical settings

An important situation that is worthy of comment is the interface between research and clinical work when both are performed in the same setting. The coordination of research projects with the clinical work is extremely important in these situations. Competition between clinical and research staff can occur if this interface is not monitored and cultivated. Lack of coordination between research and clinical programs can cause treatment or research staff to feel resentful, and both programs can suffer. A problem from the therapeutic perspective is that clinicians may have trouble dealing with the unknowns, e.g., placebos, that are part of many research projects. Clinical staff feel most comfortable doing something that will provide known, direct and tangible benefits. They may also feel uncomfortable with the basic supposition of research, which is that the most effective treatment is not known, that several therapeutic approaches will be examined and that these results will then be evaluated to delineate an improved treatment. These problems can usually be managed by explaining to clinical staff placebo effects, the purposes of research, how there is always a degree of experimentation in medical practice, what the purposes of the specific study in question are, and especially how it may improve treatment. Conversely, research staff may have trouble understanding or appreciating the interpersonal and unpredictable aspects of clinical practice which in fact arise from the same source; that is that diverse aspects of traditional therapeutic strategies are poorly understood. Regular meetings of the research and the clinical staffs will usually resolve problems that arise in this clinical/research interface. The benefits that may result from integrating research into a busy clinical program are considerable, and careful attention to these potential problems is well worth the effort.

Summary

Many difficult and complex behavioral and psychiatric problems can occur in a methadone treatment program. Some behavioral problems are very serious, and it is essential that the program place a high priority on controlling them. This is best done by structuring the treatment milieu via program rules. Careful attention must be paid to consistent, fair, and accurate enforcement of these rules. A proper staffing pattern is essential; this should include counselors along with medical, administrative, and pharmacy personnel, and police. Written policies explaining clinic procedures such as treatment plans, use of ancillary medications, and take-home policies are most helpful. They provide structure for the staff and increase the chances that work will be done in an organized and consistent manner. The physical facility may have features which either enhance or interfere with treatment and must be taken into account when planning. Attention should be paid to accurate diagnosis and treatment of the patients’ psychiatric, behavioral, and social problems, and staff morale must be maintained. The best general ingredients for good patient management appear to be a combination of structure and support, applied in a systematic and coordinated way by a well-trained staff. Finally, integration of research and clinical efforts may present unique problems but has considerable benefit in most programs.

 

Selections from the book: “Behavioral Intervention Techniques in Drug Abuse Treatment”. John Grabowski, Ph.D.; Maxine L. Stitzer, Ph.D., and Jack E. Henningfield, Ph.D., eds. Reports on behavioral contingency management procedures used in research/treatment environments. National Institute on Drug Abuse Research Monograph 46, 1984.