Oral Substitution Treatment for Opioid Dependence: A Training in Best Practices & Program Design for Nepal

1. Oral Substitution Treatment for Opioid Dependence: A Training in Best Practices & Program Design for Nepal Day 3 March 26-28, 2006 Kathmandu, Nepal UNDP Richard Elovich, MPH Columbia University Mailman School of Public Health Medical Sociologist Consultant, International Harm Reduction Development International Open Society Institute

2. This Training is Adapted From: • Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs CSAT/SAMSHA (Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment) • Best Practices in Methadone Maintenance Treatment Office of Canada’s Drug Strategy • Addiction Treatment: A Strengths Perspective Katherine van Wormer and Diane Rae Davis • Additional Sources: Robert Newman, MD, Alex Wodak, MD, Melinda Campopiano, M.D, Miller and Rollnick, Prochaska, DiClemente, and Norcross, Michael Smith, MD, Sharon Stancliff, MD, Ernest Drucker, PhD,

3. Clear Program Philosophy and Treatment Goals Adequate Resources Involvement Of Wider Community Program Development And Design Focus on Engagement and Retention Client/Patient Involvement A Maintenance Orientation Integrated Comprehensive Services A Client/Patient Centered Approach Accessibility

4. Training Goals • Ideally, this training will contribute to: • Increased knowledge, skills and best practices among OST practitioners and providers; • Engagement and retention of clients/patients in the OST program in Kathmandu • Improved treatment outcomes

5. The Socio-Pharmacology of Opioid Use and Dependence Introduction and background of oral substitution treatment The pharmacology of medications used in oral substitution treatment Information collection and service provision: ‘assessment-in-action’ Pharmacotherapy and OST Insights from the field Six Training Modules

6. Learning Together Parallel Process

7. Learning Process: Knowledge and Skills • Acquisition of content • Retention (store in memory) • Application (retrieve and use) • Proficiency (integrate and synthesize)

8. This is an 18 hour training over a 3 day period. Allowances have been made for your work schedules: Noon – 6 PM. You must be present and participate in all 18 hours of the training to receive certification. There can be no exceptions. Please stay focused. Be on task because we have a lot of material to cover in 3 days. Listening is a key to this training. Listen to new ideas. Listen to what’s coming up inside you in relation to what’s being presented. Try to put your thoughts and feelings into words instead of “shutting down.” Acknowledge and respect differences. You can “agree to disagree” on a contentious point and move on. Participate in role plays. Everyone has permission to pass. Offer feedback constructively not personally. Try to receive feedback as a gift. Expectations for Certification: Training Contract

9. Try to be okay with taking some learning risks. Stretch past your edge of what you know and what you are comfortable with.  Confidentiality. Hold the container. Don’t be leaky. Turn off phones please. No cross talk. Allow one person to speak at a time. Equal time over time. Start and end on time, including breaks. Be alert to tendency to fudge this.  Use “I” statements. Can everybody agree to this training contract? Is there anything you absolutely cannot live with?  Now we are off. Learning Environment

10. The Counseling Relationship in Pharmacotherapy and OST Induction to Stabilization to Maintenance

11. Crisis intervention Case management, incl. referrals to and liaison with other agencies Individual one-on-one counseling Group counseling Couples or family counseling Vocational counseling Pre- and post-test HIV counseling, and counseling related to other medical conditions Health and other education programs Brief, supportive contacts Long term intensive support Counseling Increases Effectiveness of OST Programs

12. Insight from the Field • Counseling should be as-needed, rather than mandatory • When they are ready to do so, client/patients should have access to evidence-based approaches to counseling to address issues of concern to them.

13. Best Practices* demonstrate: • Behavior change as it relates to drug dependence is a set of personal and social processes • Professional or service provider doesn’t change the client; we providing a ‘facilitating environment that supports their change process. • Client expectation/readiness needs to be matched to appropriate counseling strategy • Importance of trusting relationship with warm, inspiring, socially sanctioned counselor(s) * Prochaska, DiClemente, Norcross Transtheoretical Model of Behavior Change

14. Role of the Clinician • Counselor style is a powerful determinant of client resistance is a powerful determinant of client resistance and change. • Confrontation is a goal, not a style. • Argumentation is a poor method for inducing change. • When resistance is evoked, clients tend not to change. • Client motivation can be increased by a variety of counselor strategies. • Even relatively brief interventions can have a substantial impact on problem behavior. • Motivation emerges from the interpersonal interaction between client and counselor. • Ambivalence is normal, not pathological. • Helping people resolve ambivalence is a key to change.

15. Action = Abstinence? • Many professionals are trained to help people who are in the action stage of change, and programs are geared to action. “Action” is synonymous with readiness and commitment to abstinence.

16. Stages of Changing Behavior (Prochaska et al)

17. Characteristics of SOC • Change is a process and happens in stages; it is not linear. • Each stage of readiness for change has its own cognitive and behavioral characteristics. • Counseling interventions need to be appropriately matched or tailored to the stage of readiness.

18. Characteristics of SOC • Relapse is a normal part of the process of stage, not outside. • Thinking happens at every stage; it doesn’t start with action or preaction. It can be engaged as ambivalence. • Goals look different and evolve through stages.

19. Operationalizing Health Promotion Objectives • Just because someone learns to parrot a message doesn’t mean they are committed to changing their behavior or practices • Just because someone is committed to changing does not mean this translates into what they actually do when they are confronted in their local worlds with competing variables • The role of the intravention, collective empowerment

20. Stages of Changing Behavior (Prochaska et al)

21. PROCESS GOALS TECHNIQUES

22. PROCESS GOALS TECHNIQUES

23. PROCESS GOALS TECHNIQUES

24. PROCESS GOALS TECHNIQUES

25. Outreach • Outreach: In order to increase access to OST, programs should consider proactive measures to reach out to potential clients/patients who are not likely to access treatment without encouragement and support. • Outreach is an area in which peer-based strategies and linkages and partnerships with NGOs working at the front-line or “street” level are particularly important. • Outreach workers can benefit from motivational interviewing (MI) training

26. Advocacy • The role of a client/patient advocate includes providing clients/patients with information about the program and their rights and responsibilities, as well as intervening on clients’/patients’ behalf to help access services and support.

27. Client/patient participation on community advisory boards Client/patient participation on decision-making bodies Client /patient involvement in evaluating the program Feedback mechanisms for clients/patients, such as suggestion boxes, surveys, and focus groups Outreach programming Providing peer counseling and support Clients/patients training to become counselors Client/Patient Involvement OST programs need to value, seek out, encourage and support client/patient involvement.

28. Self-efficacy • Compare self-esteem and self-efficacy. The transition from I think I can to I know I can. Becoming to being. • Awareness of a problem or discrepancy/dissonance. • If I do it, there will be a benefit for me and things will be better. • I have the capacity to do that. I have the skills to do that. I can see myself doing that. I have what it takes. That is who I am. The person who does that. If someone doesn’t believe they can change, why should they look at it as a problem?

29. Counseling and ‘Self-Talk’ : A Strengths Perspective • Informal Learning and the Notion of ‘scaffolding’ • Collective empowerment and the dynamics of group work • Accurate Empathy • Attention to Stage of Readiness for Change • Engaging Ambivalence: Motivational Interviewing • Alternative social and physical activities • Mutual Self-Help Groups • Peer Driven Activities and Volunteering

30. Change is a Social Process • It is important to recognize from the start that change in drug practices is a complicated social process • Individual change including being exposed to drugs and having the opportunities to use drugs to initiating drug use to modifying drug practices happens in social situations and proximal environments • Behavior change is a consequence of social change • Too often, health workers focus exclusively on the individual as the way to realize health objectives

31. Working with Drug Using Youth and Young Adults: A Strengths Based Approach • Ambivalence among youth is common • Developing autonomy and individuation means pushing back against authority, institutions, and norms • There is an interest in values, identities, roles, relationships • Peer groups are important • Curiosity and openness to philosophical questions

32. Capacity Building in Brazil* • The key is to not to treat population as if they are empty bank accountsto be filled by our expertise. • How to we facilitate a process that will collectively empower them to be more competent in their everyday world by enlisting them to: describe “scenes” in their own words-coding; analyze operative scripts and structures that condition their practices- decoding. * Paiva, 2000

33. Capacity Building II • This involves decoding and consciousness raising; they identify problem areas from their point of view, e.g. acting out a skit or tableau, in which they have an opportunity to generate and practice new choices and solutions for each other.

34. Capacity Building III • The process of “conscientization”* is useful for marginalized or stigmatized people where they are able to see themselves and each other as responsible subjects capable of self-regulation and making change rather than passive objects acted upon. *Freire, as cited in Paiva, 2000

35. Capacity Building • On-going experience of conscious practice, like strengthening a muscle, as an alternative to passivity or falling into something or in with what other people do. • New experiences mean new experiences of themselves. When they reflect back on a new experience: ‘I can do this. I did this, I can do it again. That was really me,’ they are integrating or internalizing new experiences, into a new idea about themselves and their capacity, e.g. self regulation, persistence, achieving competence in their every day life. • Transformation of understanding of self from a person ‘things happen to’ to an active subject acting relationally in the world to take better care of themselves. Treatment that focuses on building self-efficacy, and ego strengthening is in plain words, building up the ‘executive manager’ within oneself, i.e., the person who ‘gets things done.’ Think, for example, of the manager of his or her own business. • Group work can help develop language and communication skills that build an individual’s confidence to have a conversation, to self manage the impression they leave on others with whom they are interacting.

36. Group Work in OST Provides: • A mirroring process where individuals can observe or experience similarities or contrasts in their thoughts, feelings, actions; • An opportunity to experience oneself in the presence of others, breaking isolation, uniqueness, fear, shame;

37. Group Work in OST Provides: • A social arena to witness and model a peer transformational process: • Learning by analogy (other’s behavior). • Learning by identification. • Learn through trial and error. • Learn by modeling. • Amplification of positive change. • Collective empowerment • Clear parameters or limits for interpersonal interaction

38. Group Work in OST Provides: • Support for the development of alternative social networks that reinforce the process of transformation

39. Example: First Group Session Closing Introductions Check Out by participants Summary Ground rules Centering Reasons for coming to The group and concerns What is good about injecting What Is not So Good injecting

40. Second Group Session Check out and closing Welcome Summarizing Centering Ambivalence about relationships, values and behaviors Check in and Review of Second session Values Map of my relationships

41. Third Group Session Check out and closing Welcome Summarizing Centering Ambivalence about change Check in and Review of Third session Building Discrepancy Reasons for wanting And not wanting to make a particular change

42. What are the norms within your drug using relationships or informal groups? ? + -

43. A Basic Counseling Exercise • What is something pleasurable to me, important or valuable? Describe in detail. • What is the risk? Describe in detail. • How can I reduce the risk or cost but hold on to what is pleasurable or find a new alternative?

44. Incremental Change • Process of getting stuck or dependent and the process of getting unstuck • Autonomy- Staff or helpers are on the sidelines. How do you help without encouraging dependency • Capacity for Flexibility—adjust strategies: “I had a math teacher. I didn’t understand the problem. She explained it again the same way.” • Progress not perfection or single outcome • Set own goals and move at own pace. Goals evolve.

45. Motivational Interviewing • Uncertainty or ambivalence about change is at the heart of the difficulties many clients experience in treatment. This is also the challenge narcologists experience with clients who have addictive problems.  • The question for us is how can we provide the client with an opportunity to articulate, explore and resolve this ambivalence for him/herself?

46. AMBIVALENCE AND DECISIONAL BALANCE

47. What is Motivation? • “Motivation” can be defined as the probability that a person will enter into, continue, and adhere to a specific change strategy.

48. Motivation • Motivational interviewing assumes that the state of motivation may fluctuate from one time or situation to another (Miller & Rollnick, 1991). • Therefore, this “state” can be influenced. • By providing a safe, nonconfrontational environment, eliciting hope, helping clients clarify ambivalence about their drug use and about making change, counselors can be helpful in ‘tipping the scales’ in favor of readiness to make a positive change.

49. Spirit of Motivational Interviewing • Developing a collaborative partnership • Counselor facilitates rather than coerces ambivalence and change • Client is assumed to have resources and motivation for change • Ambivalence is enhanced by drawing on client’s own perceptions, goals and values • Counselor supports client’s capacity for self-directed change

50. Review: 7 Early Strategies • Ask open-ended questions • Listen reflectively. • Elicit ambivalence. • Do not project your ideas onto the client. • Affirm. Focus on eliciting strengths not on pathologies or what is wrong with the person. • Foster a sense of collaboration with the person. • Summarize at key intervals and ask for their comments