Methadone and Drug FreeMethadone and Drug Free
Therapeutic CommunitiesTherapeutic Communities
Limitations and OutcomesLimitations and Outcomes
Moscow, 4 December 2015Moscow, 4 December 2015
Martien Kooyman Martien Kooyman M.D., Ph.D.M.D., Ph.D.
orientation
methadone detox day centre
project 4T.C.
EmiliehoeveT.C.
MistralT.C.
Triple-Ex
re-entry
““PPerhaps the limitations of medical erhaps the limitations of medical treatment for complex medical-social treatment for complex medical-social problems were not sufficiently problems were not sufficiently stressed. No medicine can stressed. No medicine can rehabilitate persons. But to succeed rehabilitate persons. But to succeed in bringing disadvantaged addicts to a in bringing disadvantaged addicts to a productive way of life, a treatment productive way of life, a treatment program must enable its patients to program must enable its patients to feel pride and hope in accepting feel pride and hope in accepting responsabilityresponsability””
Dole & Nyswander, 1976Dole & Nyswander, 1976
Heroin addiction is a symptom of an underlying psychological and/or social problem.Substitution with methadone does not solve these underlying problems
Definition of addictionDefinition of addiction
Addiction is a self-continuing harmfulAddiction is a self-continuing harmfulprocess resulting from the loss ofprocess resulting from the loss of
control over adaptive behaviour whichcontrol over adaptive behaviour whichthen itself becomes a problemthen itself becomes a problem
Definition of addiction
Addiction is a dependency disorder from which
recovery is possible
Calling addiction a chronic relapsing disease
gives practicioners an excuse for failing treatment
and creates a lack of motivation among addicts
and primary care physicians
50% of heroin addicts were involved in criminal behaviour
before they used their first drug
Because heroin use is illegal, serious secondary problems exist.It is questionable if prohibition solves more problems than it produces
Drug addicts are aDrug addicts are a
nuisance to others, so nuisance to others, so
- force them to give up drugs- force them to give up drugs
- lock them up- lock them up
- supply free drugs- supply free drugs
- shoot them- shoot them
All addicts should be reached by treatment
All addicts should be given methadone
Profits from methadone and crime
Drug Related Deaths in Scotland Linked to Methadone
year Total Number of Addict Deaths
Total Number of Methadone Related Deaths
% of Total Deaths linked to Methadone
2004 356 80 22
2005 336 72 21
2006 421 97 23
2007 455 114 26
2008 54 169 29
2009 545 173 32
2010 485 174 35
2011 584 275 47
2012 581 237 40www.drugmisuseresearch.org Centre for Drug
Misuse Research
2007 National Treatment Agency Client Survey England n=12,398
Drug Happy with Use Like to Reduce Use
Like to Stop Using
Heroin 11.4 8.1 80.5
Methadone 36.5 12.9 50.7
Crack Cocaine 16.3 10.5 73.2
Amphetamines 27.5 11.4 61.0
Cannabis 64.2 14.7 21.1
Alcohol 53.6 21.2 25.2
Benzodiazepines 50.4 12.7 36.9
Centre for Drug Misuse Research Scotland
Only methadone substitution programmes with sanctions regarding illegal drug use have positive effects on criminality
Qualities of methadone programs Qualities of methadone programs
- Methadone maintenance makes clients Methadone maintenance makes clients no longer dependent on black marketno longer dependent on black market
- Structured methadone programs can Structured methadone programs can improve re-socializationimprove re-socialization
- Methadone can be a first step towards Methadone can be a first step towards further treatmentfurther treatment
- Structured methadone programs are cost-Structured methadone programs are cost-effectiveeffective
Limitations of methadone programsLimitations of methadone programs
- Methadone can only be used for heroin Methadone can only be used for heroin addictsaddicts
- Availability of methadone postpones the Availability of methadone postpones the decision to stop using and entering a drug decision to stop using and entering a drug free programfree program
- Harm reduction programs without further Harm reduction programs without further rehabilitation are expensive rehabilitation are expensive
Unintended harm caused by methadoneUnintended harm caused by methadone
- Deaths in combination with alcoholDeaths in combination with alcohol
- Sudden deaths through heart arrhytmias Sudden deaths through heart arrhytmias (doses higher than 100 mg) (doses higher than 100 mg)
- Availability of methadone postpones the Availability of methadone postpones the decision to stop using and entering a drug decision to stop using and entering a drug free programfree program
- Life longe Methadone programs without Life longe Methadone programs without further rehabilitation are expensive further rehabilitation are expensive
- Selling of methadone to othersSelling of methadone to others
Contra indications for methadone Contra indications for methadone prescription prescription
- Heavy alcohol useHeavy alcohol use
- Below 21 yearsBelow 21 years
- Continuing use of opiods or other non Continuing use of opiods or other non prescribed drugsprescribed drugs
- No prior detoxification attemptNo prior detoxification attempt
СамопомощьСамопомощь
ВзаимопомощьВзаимопомощь
Ответственное отношениеОтветственное отношение
Self HelpSelf Help
Mutual Help Mutual Help
Responsible ConcernResponsible Concern
Значимость ролевых поведенческих моделей, Значимость ролевых поведенческих моделей,
реализуемых более старшими резидентами и реализуемых более старшими резидентами и
штатными сотрудниками, штатными сотрудниками,
имеющими опыт аддиктивности в прошлом имеющими опыт аддиктивности в прошлом
The importance of role models of older residentsThe importance of role models of older residents
and ex addicts in the staffand ex addicts in the staff
Только ТЫ САМ можешь сделать это,Только ТЫ САМ можешь сделать это,
но ты не сможешь сделать это ОДИН, без но ты не сможешь сделать это ОДИН, без
поддержкиподдержки
You alone can do itYou alone can do it
but you can not do it alonebut you can not do it alone
Медицинская модельМедицинская модель
Medical ModelMedical Model
врачврачdoctordoctor
пациент пациент patientpatient
Врач несет ответственность за лечениеВрач несет ответственность за лечение
The doctor is responsible for the treatmentThe doctor is responsible for the treatment
Пациент не отвечает за свое заболеваниеПациент не отвечает за свое заболевание
The patient is not responsible for the diseaseThe patient is not responsible for the disease
George De Leon
Собственность Наш дом
Ownership Our House
Все виды деятельности, которые выполняются Все виды деятельности, которые выполняются
в Терапевтическом Сообществе, включая в Терапевтическом Сообществе, включая уборку, уборку,
приготовление пищи, приготовление пищи,
организационные вопросы – являются терапиейорганизационные вопросы – являются терапией
AAll T.C. activities includingll T.C. activities including
cleaning, cooking andcleaning, cooking and
administration are administration are
therapytherapy
Обучение умению помогать самому себе
с помощью других людей
learning to help yourself
with the help of others
ГОВОРИ О ТОМ,ЧТО ЧУВСТВУЕШЬ, И
ПРОЧУВСТВУЙ ТО, О ЧЕМ ГОВОРИШЬ
say what you feel
and feel what you say
«Группы столкновений»Encounter groups
Отношение к гневуюмор
angry concern
humor
В Терапевтическом Сообществе В Терапевтическом Сообществе участникиучастники
могут обрестимогут обрести самоощущение, самоощущение, благодаря которому получают возможность благодаря которому получают возможность использовать свои использовать свои
собственные внутренниесобственные внутренние ресурсы, ресурсы, находясь при этом находясь при этом
в безопасной и стимулирующей среде в безопасной и стимулирующей среде и следуя здоровому образу жизнии следуя здоровому образу жизни
In the therapeutic communityIn the therapeutic community
residents can find a sense of self from which they can use their own residents can find a sense of self from which they can use their own
power in a safe and stimulating environment promoting a heathy lifepower in a safe and stimulating environment promoting a heathy life
Терапевтическое Сообщество дает людям с разрушенной Терапевтическое Сообщество дает людям с разрушенной идентичностьюидентичностью
шанс на преодоление своего страхашанс на преодоление своего страхаблизких контактов и отверженностиблизких контактов и отверженности посредством коррекции посредством коррекции состояния эмоциональной сферы и повышения самооценки, состояния эмоциональной сферы и повышения самооценки, делая их способными делая их способными выстраивать стабильные отношения выстраивать стабильные отношения
The therapeutic community gives people wth a failure identityThe therapeutic community gives people wth a failure identity
a possibility to overcome their fear a possibility to overcome their fear
of closeness and rejection through corrective emotional experiences and increase their self of closeness and rejection through corrective emotional experiences and increase their self
esteem enabeling them to have stable relationshipsesteem enabeling them to have stable relationships
Терапевтическое сообществоТерапевтическое сообщество является является терапевтическим по сути.терапевтическим по сути.
Сообщество – это метод.Сообщество – это метод.
The therapeutic community isThe therapeutic community is
therapeutic in itselftherapeutic in itself
The community is the methodThe community is the method
Criteria for success Criteria for success
- no use of hard drugs- no use of hard drugs
- no alcohol problems- no alcohol problems
- less than once a week cannabis,- less than once a week cannabis,
tranquillizerstranquillizers or sleeping pills usedor sleeping pills used
- no drug related arrests or convictions- no drug related arrests or convictions
- no treatment for addiction- no treatment for addiction
- no admission to a psychiatric hospital- no admission to a psychiatric hospital
EH N= 172
ES N= 47
NA N= 62
N Success
85 20 10
% 49,4 42,6 16,1
Success half year before interview ofSuccess half year before interview of
all clients two years out of program all clients two years out of program
with follow-upwith follow-up
Вовлеченность родителей в работу (ВР) позволяет
добиться более продолжительного пребывания на
программе (БПП) и делает ее более
результативной и успешной (РУ)
Parent participation (PP) is related to longer time in the
programme (TIP) and gives therefore more successful
outcome (SO)
ВР PP
БППlonger TIP РУ
more SO
Triple Ex Triple Ex
- ex-addict- ex-addict
- ex-unemployed- ex-unemployed
- ex-prisoner- ex-prisoner
Relapse after Triple-Ex(FU of 116 ex-clients (76%) after average 2 years)
No relapse: 41%
< 1 month: 3%
1-3 months: 7%
3-6 months: 4%
> 6 months: 45%
period of drug useperiod of drug useafter Triple-Exafter Triple-Ex
91% received after care
Social integration after Triple-ExSocial integration after Triple-Ex(FU of 116 ex-clients (76%) after average 2 years)
Dominant social situationDominant social situation
- study- study 7% 7%- job (part/full-time)job (part/full-time) 47%47%- unemployedunemployed 31%31%- disabillity allowancedisabillity allowance 4% 4%- residential treatmentresidential treatment or prisonor prison 11%11%
Social integration after Triple-ExSocial integration after Triple-Ex(FU of 116 ex-clients (76%) after average 2 years)
Crime after dischargeCrime after discharge
Arrests after dischargeArrests after discharge (before admission)(before admission)
dealing drugsdealing drugs 8% 8% (55%) (55%)stealingstealing 36% 36% (92%) (92%)violenceviolence 14% 14% (49%) (49%)
Month before interviewMonth before interview
illegal activitiesillegal activities 17% 17%detention, prison 19%detention, prison 19%
5 year follow-up Donovan PrisonProgram - Amity TC California
0
10
20
30
40
50
60
70
80
90
% Gearresteerd
8386
42
Contr gr Gev. TG Gev. TG+ nazorg TG
(Prendergast, c.s., 2004)
EHN= costs benefits
a year 1,500,000after care 300,000in-/out 60in treatment 30 1,200,000success yr 1 20 800,000success yr 2 18 720,000success yr 3 16 640,000success yr 4 12 480,000long success 12 1,440,000
total 1,800,000 5,280,000C-B ratio 2.9
total before 50,000after 10,000 (success)
long = 7 yr
Cost-Benefit Ratio Emiliehoeve TCCost-Benefit Ratio Emiliehoeve TC
Benefits each per yearBenefits each per year
EmiliehoeveEmiliehoeve 3,5 million Euro3,5 million Euro
Triple-ExTriple-Ex 3,5 million Euro3,5 million Euro
Longer term success4 year follow-
up of Treatment
Leavers2005/06
(n= 41,475)
NDTMSCJS:
Prison & Commun
ity
Drug Test
Did notre-
present
54%
46%
What constitutes successful treatment? (present)
Contra indication for Therapeutic Contra indication for Therapeutic communitiescommunities
- Non drug related psychosisNon drug related psychosis
- (Need double diagnosis TC or psychiatric (Need double diagnosis TC or psychiatric clinic)clinic)
Qualities of drug free T.C.’sQualities of drug free T.C.’s
- T.C.’s can treat clients addicted to any drugsT.C.’s can treat clients addicted to any drugs- 30% of all admissions have a successful long term 30% of all admissions have a successful long term
outcome outcome - Longer time spent in the program improves Longer time spent in the program improves
outcome successoutcome success- Parent participation improves successful outcomeParent participation improves successful outcome- Treatment in a T.C. can be an alternative for prisonTreatment in a T.C. can be an alternative for prison- Treatment in a T.C. is cost-effective Treatment in a T.C. is cost-effective
Limitations of drug free T.C.’sLimitations of drug free T.C.’s
- Highly structured programs are not Highly structured programs are not popular with the addicts and helperspopular with the addicts and helpers
- High drop-out rate in first monthsHigh drop-out rate in first months- Not all addicts can sustain the pressure of Not all addicts can sustain the pressure of
a T.C. a T.C.
Minimun Standards of drug free T.C.’sMinimun Standards of drug free T.C.’s- Basic rules:Basic rules:
No Drugs No Alcohol No Violence or Threat of Violence No Drugs No Alcohol No Violence or Threat of Violence Breaking can lead to dischargeBreaking can lead to discharge
- - A job structure A job structure
- - Groups on behavior here and nowGroups on behavior here and now
- Consequences for negative behaviorConsequences for negative behavior
- Clear procedures for admission and Clear procedures for admission and discharge discharge - Meetings for parents and relativesMeetings for parents and relatives- Develop a staement on the philosophy of the programDevelop a staement on the philosophy of the program
- Protection from negative use of powerProtection from negative use of power
Best Practices of drug free T.C.’sBest Practices of drug free T.C.’s- Specific groups: (, extended groups (marathons, thematic Specific groups: (, extended groups (marathons, thematic
groups, separate groups for females and males, groups, separate groups for females and males, mindfulness, peer groups, (dynamic) meditations, mindfulness, peer groups, (dynamic) meditations, psychodrama, bonding groupspsychodrama, bonding groups
- Family therapyFamily therapy
- Sport, outward bound activitiesSport, outward bound activities
- Education classesEducation classes
- Creativity Creativity
- Separate re-entry program and after care - Separate re-entry program and after care - Training and adequate supervision for staff Training and adequate supervision for staff
- Accountability to an external or community boardAccountability to an external or community board
- Evaluation of the programEvaluation of the program
- AA and NA meetings - AA and NA meetings
Harm reduction is not treatment.
Treatment is harm reduction
Treatment in any form will never solve
the total drug problem
Treatment is cost effective and
part of the solutoion
Thank you
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