Hepatitis C: education and counseling issues.

This paper examines issues and dilemmas faced by counselors and other health care providers in addressing the needs of active or recovering alcohol and drug users who test positive for HCV. The ambiguities and changing treatment prospects for these patients require education and counseling interventions, elements of which are described in the paper. Motivational enhancement issues are particularly important, to facilitate the patient's commitment to maintain a healthy life style while effective treatments are being developed. The high proportion of recovering staff in addiction treatment settings adds a level of complexity, as their concerns may mirror those of the patients being served, but are rarely addressed systematically within the program.

Conducting trials in community settings: the provider perspective.

Providers and their treatment programs are the focus of efforts to translate research into practice. In the best of partnerships, they are more than the recipients of research efforts, because they are actively involved in developing and evaluating healthy links between practice and research . This article reports on experiences in a multisite methamphetamine treatment trial funded in October of 1998 by the Center for Substance Abuse Treatment. The goal of the trial is to generate knowledge about how a comprehensive treatment protocol developed by the Matrix Center in Los Angeles can be effectively transferred to the community drug treatment system. The Matrix model provides a three-times-per-week outpatient treatment experience that combines behavioral, educational, and 12-Step counseling techniques. When complete, the study will compare outcomes of the 16-week Matrix program with the usual treatment offered by the programs at the eight participating sites. The UCLA Drug Abuse Research Center and the Matrix Institute on Addictions coordinate the trial. This article describes factors that have fostered or hindered the development of this partnership. These factors can be divided into three temporal phases, although the circumstances presented may occur at any time during the research process. The first set of factors affecting the development of a healthy research-to-practice relationship exists prior to the establishment of that relationship. A second set of circumstances occurs at the initiation of the collaborative enterprise, and the third set of factors is more involved in the development and maintenance of ongoing productive collaboration between researchers and providers.

Severely and persistently mentally ill substance abusers: clinical and policy issues.

Communities that are struggling to provide effective treatment for the challenging population of severely mentally ill clients who use alcohol and drugs have a growing research base on which to make policy decisions. Integrating outpatient treatment for mental health and addictive disorders appears to be more effective than treatment in two separate systems. Integrated treatment at a single site allows for individualizing treatment priorities without fragmenting care. Harm reduction approaches provide a low threshold entry, which can be followed by interventions to enhance motivation. Managing patient benefits to discourage drug use reduces the likelihood of their becoming homeless, hospitalized or incarcerated. Inadequate treatment capacity plays a large role in the growing number of disturbed clients who end up in the criminal justice system. Effective community treatment requires vigorous collaboration between care providers. Ultimately, professional training programs need to produce clinicians who are competent and comfortable addressing alcohol and other drug use to implement effective treatment systems.

Making residential treatment available to methadone clients.

This article addresses challenges to integrating clients on methadone into residential treatment, with the goal of promoting greater access for this population. It describes the basic administrative conditions needed for success, and discusses barriers and problems within the methadone program and the residential program. Staff communication, procedures for coordination, client and staff attitudes and understanding, and ongoing education are seen as the key to creating an environment conducive to success for the client.

The changing role of "using" dreams in addiction recovery.

The Dream Interview Method of dream interpretation can be applied to dreams depicting alcohol and drug use to elucidate the meaning of such dreams in relation to stages of recovery. This paper summarizes the method and demonstrates its application utilizing seven dreams collected from clients in psychotherapy and participants in dream workshops. The incorporation of such interpreted dreams into substance abuse treatment as well as their relationship to other life issues is discussed.

Psychiatric problems among alcohol and other drug dependent women.

This article focuses on assessment and treatment of psychiatric disorders within the alcohol and drug treatment and recovery system. Inasmuch as women are represented in all categories of psychiatric disorders, the article begins with a discussion of basic principles of assessment and treatment, examines some of the barriers to good practice, and offers recommendations for reducing them. The article then reviews in greater detail the psychiatric disorders most frequently found in women seeking help in alcohol and drug treatment settings, adding considerations relevant to those particular disorders. A brief review of key elements to facilitate planning, ongoing monitoring, and evaluation by treatment and recovery service providers is provided.

The dream interview method in addiction recovery. A treatment guide.

The Dream Interview Method is a recently developed tool for dream interpretation that can facilitate work on addiction issues at all stages of recovery. This paper describes the method in detail and discusses examples of its application in a group composed of individuals in varying stages of the recovery process. It permits the therapist to accelerate the development of insight, and once the method is learned, it can be applied in self-help formats.

Challenges in moving from a traditional therapeutic community to a women and children's TC model.

With the advent of specialized programs for addicted women and their children, some of the traditional methods used by therapeutic communities have been undergoing significant changes. This article examines the issues that are important for treatment providers to consider as they move from individual client and community orientation to a mother-child/family-centered and community approach. The major adaptations suggested are divided into three categories: structural design issues, including living arrangements and models of childcare; treatment issues, including acting-out behavior by the children; and staff and training issues, including staff composition.

Traumatic experiences and substance abuse: mapping the territory.

This article examines the relationships between various types of traumatic experiences and addictive behavior, with an eye to formulating effective treatment strategies. Interventions in the posttraumatic stress disorder (PTSD) and related fields are reviewed in an effort to understand how best to integrate them into substance abuse treatment. The recovery-oriented therapy model is used as a framework to define treatment tasks at each stage of the recovery process: how one addresses painful issues depends on the objective, given the recovery stage at hand. These tasks include making a commitment to abstinence, stopping alcohol and other drug use, consolidating abstinence and changing lifestyles, and addressing short- and long-term psychosocial issues. The article focuses on the clinical features of PTSD in an effort to enhance the practitioner's ability to address this disorder within the context of substance abuse treatment. Finally, recommendations are offered for training practitioners at varying skill levels in the addiction treatment field.

Addressing treatment needs of Southeast Asian Mien opium users in California.

This report describes efforts in progress to meet the needs of opium smoking Mien immigrants in Oakland, California. Translating concepts of addiction and recovery into terms that are culturally relevant constitutes the basis for efforts to assist the Mien to adjust to an opium-free lifestyle. The acceptability and utility of clonidine, acupuncture, methadone, counseling, support groups, and other medical services are discussed.

Psychotic conditions and substance use: prescribing guidelines and other treatment issues.

This article examines several circumstances in which psychotic symptoms coexist with substance abuse. It reviews psychotic states that may occur as a result of alcohol and other drug use, including intoxication, overdose and withdrawal, offering medication guidelines for managing these situations. It also examines psychiatric disturbances in which psychotic symptoms are recurrent features, exploring patients' self-medication practices and some strategies to address them, as well as difficulties commonly encountered with prescription medications. It briefly discusses other psychosocial interventions that play a significant role in the treatment of the dual diagnosis patient.

Methadone maintenance treatment: a primer for physicians.

The doctor-patient interaction in the methadone maintenance treatment clinic is qualitatively different from general medical settings. The patient presents with a specific request for treatment of opioid dependence, most often having already selected the methadone treatment modality, and the initial contact is centered around obtaining methadone. Addiction and needle use increase susceptibility to life-threatening illnesses, such as syphilis, endocarditis, tuberculosis, and AIDS. The physician is working with counselors, nurses, therapists and 12-Step programs, incorporating the best of the medical, psychodynamic, behavioral, and recovery models into treatment. Federal and state governments also control and regulate methadone treatment. Given this complex picture, the basic techniques of methadone maintenance treatment are reviewed, including the intake examination, the annual examination, dose adjustment, withdrawal from methadone maintenance, management of pregnant patients, dual diagnosis patients, and severely ill or medically disabled patients.

Counseling issues in methadone maintenance treatment.

This article reviews some of the issues and dilemmas faced by methadone maintenance treatment (MMT) programs counselors. The context in which MMT occurs sets the tone and constraints within which clinicians must find ways to be effective; negative attitudes and tensions with regulatory agencies have a strong impact. Coexisting disorders, particularly depression and thought disorders, are discussed and special medication considerations are noted. Counselor collaboration on medical issues, and dosing policies and practices are explored, as well as the clinical approach to tapering off methadone. The article examines helpful clinical strategies when clients continue to use heroin or other drugs, and explores psychological issues that frequently occur, women's issues, and problems that may arise when patients have human immunodeficiency virus-spectrum disease. It also reconsiders the role of family therapy. Several innovative and promising psychoeducational approaches are described and the potential integration of MMT with 12-Step programs is addressed. Recommendations are offered for training and supervision.

Methadone maintenance in the treatment of opioid dependence. A current perspective.

We describe the historical underpinnings of negative attitudes towards methadone and how these affect medical decisions. Current developments have increased the understanding of the origins of opioid addiction, such as how receptor system dysfunction may affect the ability to remain abstinent once out of treatment. Specialized topics include the pregnant addict, the role of methadone maintenance in limiting the spread of the acquired immunodeficiency syndrome, and patients with a dual diagnosis. We also describe issues that arise when methadone is used in conjunction with prescribed or abused drugs, noting pharmacologic alternatives and adjuncts to methadone treatment. Finally, we comment on treatment issues such as methadone patients in 12-step programs and the growing legitimacy of this treatment method.

Unrecognized substance misuse: clinical hazards and legal vulnerabilities.

This paper explores clinical psychologists' relative lack of attention to alcohol and other drug problems, and examines clinical consequences as well as legal vulnerabilities. The ease with which manifestations of substance abuse readily imitate every other entity seen in clinical practice allows both use and abuse to influence treatment in ways which remain often unrecognized. Borderline personality disorder is a common example. Failure to assess and appropriately treat or refer places the psychologist in an increasingly untenable position, especially as sophistication about alcohol and drug problems increases among other professionals and the lay public. The paper outlines sources of legal vulnerabilities, such as negligence and deviation from the standard of care, as they could be arise in substance abuse cases.

Legal vulnerabilities in the treatment of chemically dependent dual diagnosis patients.

Substance abusing patients with significant psychiatric disorders can present unique legal vulnerabilities for treatment professionals. The tendency within the chemical dependency community to treat patients uniformly can militate against the individualized treatment planning that satisfies legal obligations to act in the best interest of the patient. The failure to adequately consider both the psychiatric disorder and substance abuse problem may create legal vulnerabilities that issue from the failure to refer a patient in need of medication or the failure to prevent the suicide of a patient in a situation where suicide is preventable. Patients suffering harm from acts of commission or omission of a chemical dependency treatment specialist have recourse through laws regarding negligence. Variations in the backgrounds and training of care providers create problems for the harmed patient in establishing a standard of care for the treatment of chemical dependence. However, the psychological symptoms of the dual diagnosis patient make it easier to establish a standard of care that may be legally cognizable. The chemical dependency specialist--of whatever discipline--has a duty to patients that requires sound assessment and disposition.

Considerations in using psychotropic medication with dual diagnosis patients in recovery.

This article addresses some of the issues that arise when chemically dependent patients with coexisting psychiatric disorders require medication. A history of chemical dependence may alter prescribing practices, as certain medications may have a higher abuse potential or may enhance the danger of relapse to the primary drug of abuse. Recovering patients have complex attitudes and feelings toward medications that need to be explored, particularly as they affect compliance with prescribed regimens. Issues arising in the treatment of anxiety disorders, depression, and attention deficit disorders are discussed. Guidelines are provided for therapists working with prescribing physicians, and for handling problems that may arise in conjunction with 12-Step program participation.