Posts Tagged ‘harm reduction’

Contingency Management

Lately I’ve been thinking about contingency management.

I listened to some sessions about contingency management (CM) during several of the national Addiction Medicine conferences this year. That reminded me our opioid treatment program had been talking about using contingency management to improve attendance at our intensive outpatient group just before COVID hit. But after COVID…*POOF* …no more groups.

Now that COVID is on the decline, it’s time to consider re-establishing our intensive outpatient group.

For those who don’t know what contingency management is, or who are a little foggy about what it means, I can tell you I had to look it up again too. I know what it is…but putting it into words is difficult.

In short, CM is a type of behavioral therapy which rewards progress towards a set goal. Patients are rewarded in some way for positive behaviors.

CM can take all kinds of shapes. For example, during one of the sessions at the American Society of Addiction Medicine conference, presenters described how they rewarded patients with small gifts as they met treatment goals. All patients got a pen and a blank journal upon admission. As patients produced negative urine drug screens, they were rewarded with draws from a fishbowl for vouchers for various prizes. The prizes ranged from positive affirmations (“You did a good job”) to polished stones with affirmations on them to gift cards for up to $25.

This program saw impressive results with these small rewards. Their patients had better attendance and more negative drug screens.

Scientific literature shows that contingency management is effective, if it is used in ways that adhere to several basic concepts. The targeted behavior should be an observable and treatment-adherent behavior. In other words, CM should target a patient behavior that is in harmony with substance use treatment goals. Then CM program should give an immediate and tangible reinforcer to the patient when the desired behavior is exhibited. If the desired behavior is not exhibited, the reinforcer is withheld.

CM is not new; at least two-hundred studies of CM techniques have shown that it works to produce desired behaviors in substance use disorder treatments. CM usually shows at least a medium effect size. This means isn’t the next great thing to fix everyone with substance use disorders, but it does provide reliable improvements for patients.

CM has been used in diverse patient populations and appears to be effective for all different socioeconomic groups.

Strangely, despite producing reliably positive results, CM hasn’t been used as much as one would think.

Some people object to the idea of contingency management. For example, an obstacle to implementing CM in substance abuse treatment cropped up last summer. The Trump administration set a cap of $75 per year per patient on CM programs. That is, whether prizes or rewards are donated by local businesses or bought by the treatment program, these programs can’t reward patients with any more than $75 per year, for fear that money would entice patients to come to one treatment program over another. The U.S. Office of the Inspector General (OIG) said such methods of paying patients to participate in treatment might violate the Anti-Kickback Statute. In other words, it’s illegal to pay patients to come to your treatment program. This could be a type of fraud, particularly if the treatment program bills Medicaid/Medicare for treatment.

Last year, the American Society of Addiction Medicine (ASAM) sent a letter to Alex Azar, the then-Secretary of Health and Human Services, asking that contingency management treatment techniques to be exempt from the Anti-Kickback Statute. The ASAM president, Dr.William Haning, pointed out in the letter that safeguards could be applied to prevent fraud, waste, or abuse when using CM techniques in counseling people with substance use disorders.

Some people feel it’s unethical to pay patients for doing what they “ought” to be doing anyway. Other people say it’s manipulative to induce patients to behave in ways decided upon by authority figures. This may be true, but patients still have the choice of participating or not participating in reward programs.

For example, let’s say a patient comes for treatment of her opioid use disorder at an opioid treatment program. That program gives CM rewards for negative urine drugs screens. Perhaps the patient wants to quit using opioids, but she doesn’t see any need to quit using cocaine. She can continue to use cocaine, and have positive drug screens, meaning she won’t get the small rewards of the CM program. She’s not out anything by her decision, and still gets treatment for opioid use disorder.

Salespeople have been using CM for decades. Many advertisers use CM to shape consumer behavior. For example, look at the BOGO sales. The sales staff want to sell more product, so they advertise “BOGO” in large letters. This means if the consumer buys one, the second one – of whatever it is – is free. The consumer is being tempted to a certain behavior – buying something – by an offer from the seller.

By the way, there’s nothing more irritating than seeing a “BOGO” sale advertised, only to read the fine print that the deal is buy one and get some percentage off the second one. That’s not a real BOGO. That’s what I call a faux BOGO. Don’t even bother me with a faux BOGO.

But I digress.

Other contingency management sales techniques might be the reward of a free sub sandwich after you buy five regularly priced subs.

The point is, we participate in CM deals all the time, but usually the behavior desired of us is buying products or services. For treatment of substance use disorders, the desired behaviors might be attending counseling sessions or ceasing drug use to produce negative drug screens. Progress towards those goals are rewarded in some way with CM.

I’d like to start our groups again, and for every three-hour session attended, each person gets a draw from a fishbowl. The fishbowl might contain any number of rewards: gas card for $10, coupon for a sandwich at a local restaurant, a card with positive affirmations, or something similar. The possibilities are endless. Perhaps local businesses could donate goods or services in exchange for some free advertising, or just to do something nice for people who are trying to achieve recovery from substance use disorders.

Twelve-step meetings have been using a type of CM for decades: group members get chips or key tags for achieving days in recovery: they have these for one day, thirty days, sixty days, ninety days, six months, nine months, and one year and multiple of years. The chips or tags themselves are worth very little, but the value of being recognized for achievement in recovery can be important, especially when the recognition is given by people who understand how difficult recovery is.

Some of our patients don’t get the recognition they should for their achievements in recovery from friends or family. Maybe CM is a great way to acknowledge that achieving little goals is a big deal.

Buprenorphine Can Reverse Methadone Overdose

 

 

 

In the February 2020 issue of Critical Care, Zamani et al. described a trial of the use of buprenorphine to reverse methadone overdose. This was only a pilot study, with a relatively small number of subjects. The study found intravenous buprenorphine appears to be safe and effective for use in people who have had an opioid overdose.

This study randomized 85 patients with respiratory depression from methadone; 56 received buprenorphine and 29 received naloxone. One person out of each group failed to respond to the medication given.

Fewer patients had to be intubated in the buprenorphine group, and fewer had precipitated withdrawal compared to the patients randomized to naloxone. None of the patients in the buprenorphine group died or had serious complications.

This study was done in a busy emergency department of an Iranian hospital that treats up to 28,000 poisonings annually. The protocol was only for patients who had overdosed on methadone, and they had to meet certain criteria, such a low blood oxygen level and low respiratory rate.

The patients in the naloxone group received from .04mg to 2mg intravenously depending on the rate of respirations, and re-dosed at 2-3-minute intervals. Once the patient responded, they were placed on a naloxone intravenous drip.

Patients in the buprenorphine group were further randomized to two doses; one group was given 10micrograms per kilogram intravenously over 6-9 minutes, and the other group was randomized to 15micrograms per kilogram intravenously over the same rate.

For all three groups, if treatment failed to reverse the overdose, the patient was intubated, and the treatment counted as a failure.

This is a fascinating study and lends support for the use of buprenorphine for opioid overdoses.

In this study, the buprenorphine was administered intravenously, but I’ve heard patients tell me it works sublingually. Over the past five years or so I’ve had two patients tell me – and this is third hand information, but still – they know of a person who had overdosed on opioids and someone on site had sublingual buprenorphine. They placed the buprenorphine in the unconscious person’s mouth, under the tongue, and they regained consciousness some minutes later. At the time, I marveled at the creativity of whoever thought to use that buprenorphine. Of course, they also called 911.

If I had both medications available to me, I’d still use the naloxone because of its proven efficacy, but this study hints that buprenorphine could possibly be of use too.

If naloxone can’t be obtained within a few minutes, placing buprenorphine under the tongue of the overdose victim could provide some benefit, in addition to rescue breathing and calling 911.

Just as a reminder to my readers, people who inject heroin or other opioids should use harm reduction ideas to reduce risk. These include:

-Don’t use alone. Use with someone present so that they can call for help or deliver naloxone if needed.

-Alternate dosing times. Someone in the room should remain “straight” while others inject, to be available to render help.

-Use tester doses. This means use a tiny amount of the material before preparing a usual shot. If the drug has more fentanyl than usual, the tester shot may warn the user that it is very potent.

-Don’t mix drugs. Sedatives like alcohol and benzodiazepines can suppress respirations and lead to overdose in people who are also using opioids of any kind, including heroin.

-Use new needles and clean equipment when injecting. Many more sources for free new needles are now available.

-Get a naloxone kit and use if needed. If you can’t get one from a pharmacy, contact your state’s harm reduction coalition.

-Consider enrolling in medication-assisted treatment for opioid use disorder.

 

  1. https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-2740-y#Sec1

Harm Reduction and the Clothing Police

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“Oh I know that’s not a marijuana leaf on your cap!”

I had just ushered a young lady into my office. She entered treatment the week before, and I wanted to check on how she was feeling. When I called her from the waiting room, I noticed a rhinestone design on her cap with one part of my brain. I like bright sparkly things, so it caught my eye. But by the time we walked the short distance to my office, it dawned on me what the design was, and I confronted her about it.

“What? Yeah, it’s marijuana. Sorry. I didn’t even think about it.”

“What part of you thought it would be OK to wear clothing promoting drug use to your drug addiction treatment program?” I continued.

Usually I’m more complacent about clothing our patients wear. Some programs have minimal dress codes: no pajamas, nothing too revealing, must wear shoes, no obscene tee shirts… I’ve never gotten too worked up about clothing, thinking that as long as they came into the building, it was a victory.

But for some reason, on that day, I went a little nuts. What can I say, I have bad days too.

My patient was apologetic, but said it was the only cap she had. I told her she could turn it inside out, which she did without hesitation.

Before you are tempted to write in about how marijuana is really a medication and will be legal someday, let me tell you this: I don’t care. I’d feel the same way if I saw a large, legal, liquor bottle outlined in sequins, or a big sequined Opana pill on a shirt. It’s a symbol of drug-using culture.

Today, I’m conflicted. One part of me still thinks it’s not OK to wear clothing promoting any kind of drug use, and this includes alcohol. After all, we are treating patients in whom drug use has caused significant problems. Some of them could be triggered by symbols of drug culture. Is it too much to ask our patients to think about the message they send with their clothing?

Other addiction treatment professionals endorse similar ideas. If our patients are to return to mainstream society, don’t we have an obligation to educate them about traits that may still associate them with active drug use?

For example, is it possible my patient wasn’t aware of the message she sends with her bedazzled marijuana cap? If my patient wanted to go for a job interview, for example, would wearing this cap work against her? Maybe it depends on the job, but overall I would say the cap would hurt her chances of being hired.

On the other hand, if we view the situation with a harm reduction eye, isn’t it good enough at this point that my patient is getting treatment for her addiction? If a patient wants to get help for some aspect of addiction, isn’t that good enough? Maybe it’s unreasonable to expect a patient in treatment for a short time to start viewing her wardrobe with a recovery-oriented eye. Maybe such issues can be addressed later, in counseling, or maybe not, but perhaps I should concentrate on more important issues. Like helping her get through the day without illicit opioids.

A harm-reduction model would recommend meeting that person where she is now, in her THC-wearing mindset. Harm reduction is an idea that says any change that reduces the risk of drug use is success, and that we need to accept her as she is. We should respect our patient’s choices and help in any way she is willing. Any reduction around the risk of her addiction is an acceptable goal, even if it doesn’t conform to what I may view as “real” recovery.

The question is, or course, where do we draw the line? If it’s OK to wear clothing glamorizing drug use, is it OK to allow patients to tell glamorized stories of drug use in the waiting room?  Is it OK for patients to use drugs on the premises? What about dealing drugs?

I endorse harm reduction principles, but have come to realize I have limits. The longer I’ve been doing this job, the more enthusiastically I approve of harm reduction principles. However, I still draw the line when one patient’s behavior affects the other patients. That’s why I won’t tolerate drug dealing on the premises, patient violence (against other patients or staff), or drug use on OTP grounds. But that’s a hard call to make, and it’s a decision best made at case staffing with input from other staff.

Harm reduction is a difficult idea for many of us. What one person sees as harm reduction, another sees as enabling. Here are some other quotes I’ve heard from other people. I’d like to give credit, but my memory’s not that great.

“Don’t allow the perfect to be the enemy of the good.”

“The enemy of the best is the good.”

“It’s OK to meet a person where they are, but it’s not OK to leave them there.”

“I don’t promote drug use. I don’t promote car accidents either, but I still think seatbelts are a good idea.”

“Dead addicts don’t recover.”

Readers, any thoughts?

 

Harm Reduction

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In the interest of harm reduction, I’m going to describe precautions that addicts, still in active addiction, can take to reduce the risk of overdose death. This information can be accessed at: http://harmreduction.org/wp-content/uploads/2011/12/getting-off-right.pdf

1. Don’t use alone. Use a buddy system, to have someone who can call 911 in case you stop breathing. Do the same for another addict. Obviously you shouldn’t inject at the same time. Stagger your injection times.
Many states now have Good Samaritan laws that protect the overdose victim and the person calling 911 for help, so that police don’t give criminal charges to people who do the right thing by calling for help for an overdose.
Take a class on how to give CPR so that you can revive a friend or acquaintance with an overdose while you wait on EMS to arrive.

2. Get a naloxone kit. I’ve blogged about how one patient saved his sister with a naloxone kit. These are easy to use and very effective. You can read more about these kits at the Project Lazarus website: http://projectlazarus.org/

3. Use new equipment. Many pharmacies sell needles and syringes without asking questions. Your addict friends probably can tell you which pharmacies are the most understanding.
Don’t use a needle and syringe more than once. Repeated use dulls the needle’s point and causes more damage to the vein and surrounding tissue. Don’t try to re-sharpen on a matchbook – frequently this can cause burrs on the needle point which can cause even more tissue damage.

4. Don’t share any equipment. Many people who wouldn’t think of sharing a needle still share cottons, cookers, or spoons, but hepatitis C and HIV can be transmitted by sharing any of this other equipment. If you have to share or re-use equipment, wash needle and syringe with cold water several times, then do the same again with bleach. Finally, wash out the bleach with cold water. This reduces the risk of transmitting HIV and Hepatitis C, but isn’t foolproof.

5. Use a tester shot. Since heroin varies widely in its potency, use small amount of the drug to assess its potency. You can always use more, but once it’s been injected you can’t use less. The New England overdose deaths described by SAMHSA may have been avoided if the addicts had used smaller tester shots instead of shooting up the usual amount.

6. Use clean cotton to filter the drug. Use cotton from a Q-tip or cotton ball; cigarette filters are not as safe because they contain glass particles.

7. Wash your hands thoroughly before preparing your shot, and clean the injection site with an alcohol wipe if possible. Don’t use lemon juice to help dissolve heroin, as it carries a contaminant that can cause a serous fungal infection.

8. Opioid overdoses are much more likely to occur in an addict who hasn’t used or has used less than usual for a few days, weeks, or longer. Overdose risks are much higher in people just getting out of jail and just getting out of a detox. Patients who have recently stopped using Suboxone or Subutex may be more likely to overdose if they resume their usual amount of IV opioids.

9. Don’t mix drugs. Many opioid overdoses occur with combinations of opioids and alcohol or benzodiazepines, though overdose can certainly occur with opioids alone.

10. Don’t inject an overdosed person with salt water, ice water, or a stimulant such as cocaine or crystal methamphetamine – these don’t work and may cause harm. Don’t put the person in an ice bath and don’t leave them alone. Call for help, and give mouth-to-mouth resuscitation if you can.

To people who believe I’m giving addicts permission to use, I’d like to remind them that addicts don’t care if someone gives them permission or not. If an addict wants to use, what other people think matters little. But giving people information about how to inject more safely may help keep the addict alive until she wants to get help.

The Harm Reduction Coalition has excellent information on its website: http://harmreduction.org