Posts Tagged ‘qualities of good methadone clinics’

Important Factors for Successful Opioid Treatment Centers: Staff Experience

As discussed in my last blog entry, some opioid treatment centers (previously called methadone clinics) are better than others. Last time I blogged about the importance of communication between staff members. This blog is about the importance of hiring experienced, competent staff.

For an opioid treatment center, the worst counselor to hire is one who doesn’t believe in methadone. This should go without saying, but sometimes clinics hire people who are conflicted about methadone (or Suboxone), and either verbally or non-verbally communicate their uncertainty or negative attitudes about methadone. The effects on patients can be devastating. Fortunately most of these employees don’t remain at opioid treatment programs, either because they must be terminated for the welfare of patients, or because they quit on their own.

Some patients say they’d rather have a counselor who has personal experience with addiction and recovery, because he understands addiction at a deep level. Such a counselor can be valuable, but it’s not enough. A counselor also needs knowledge of counseling techniques and the skill to apply them appropriately. If recovery from addiction is the only attribute of your counselor, why pay for treatment? You can get the same thing for free at any 12-step meeting.

The factor most correlated with patient success in counseling is the relationship with their counselor. A warm and accepting, non-judgmental attitude is most successful. In short, compassion is important. While it’s true that another recovering addict can understand the pain of still-suffering addicts, non-addicts can be just as compassionate, and may have fewer preconceptions about what recovery must be.

The Substance Abuse and Mental Health Services Administration, often called SAMHSA (SAM-sah) for short, produces many publications to serve as guidelines for substance abuse and mental health treatment facilities. They’ve published “Technical Assistance Publication Series, Number 21: Addiction Counseling Competencies.” This document outlines all the necessary skills and knowledge that an addictions counselor should have to work in any drug addiction treatment program.

Counselors must understand addiction. They need to have education about drugs of abuse and how they affect the body and how withdrawal from various drugs affects the body. Counselors should know about all forms of drug addiction treatment, and know which treatment is most appropriate for their client. They should be able to apply helping strategies to best meet the needs of their clients.

Counselors need to be professionals, and conduct themselves in a capable and courteous way. One of my peeves is to hear clinic personnel refer to a urine drug screen positive for drugs as a “dirty” screen. Language matters. Counselors need to have a certain level of self-awareness with good boundaries. This prevents them from being too involved with their clients, or too distant from their clients. They need to follow the profession’s ethical standards. They need to be aware of the need for continued education and be open-minded to new information. This is a rapidly changing field, and counselors shouldn’t continue to work with dated knowledge from the 1980’s.

Once a clinic gets good counselors, they need to keep them. Patients get discouraged when they’re assigned a new counselor every few months. At one clinic where I worked several years ago, a patient told me he’d had six counselors over fifteen months. That’s not OK. Patients get tired of discussing their issues with one person and form a counseling relationship, only to have to start anew a few months later. Staff turnover discourages patients.

Of course, some turnover can’t be avoided in our mobile society, where people switch jobs frequently. But clinic owners need to try to keep good counselors (and nurses and doctors) and retain them to benefit the patients. Clinic owners should be willing to pay staff well, and provide adequate benefits.

Opioid treatment programs need to hire good nurses and doctors, too, with experience and training treating patients with addiction. Doctors should be certified in Addiction Medicine either through the American Board of Addiction Medicine, or through the American Academy of Addiction Psychiatry. And they need to go to continuing education meetings to stay current, since the field of Addiction Medicine changes so rapidly with new research and results.

When I started work at my first methadone clinic, I didn’t know much more than to start the dose low and increase slowly. In retrospect, I should have had more training. If a new doctor has no prior experience working in opioid treatment programs, I’d favor a training course similar to the  course available for doctors who want to prescribe Suboxone.

I love my present opioid treatment program, Stepping Stone of Boone. We’re a new clinic, and relatively small at around 130 patients. We opened in April of 2010, and have had no staff turnover. That’s right – none. All the staff that pioneered the clinic is still there, and all of the new people hired over the last 18 months have stayed. That’s a sign of a good clinic.

It’s a fun place to work because each of us loves what we do, and we believe in what we do. We enjoy not only our patients but also the other staff members. We feel like we are helping people.

My next blog entry will be about the importance of evidence-based dosing of methadone.

Qualities of Good Opioid Treatment Programs

Not all opioid treatment programs are created equal, meaning some are better than others. Over the years, studies have shown which clinic factors are associated with better patient outcomes. Over the next week or so, my blog postings will elaborate on each of the following factors:

  • Good communication between medical, counseling, and administration portions of the clinic
  • Experienced staff with adequate training and low turn-over
  • Low patient to counselor ratios
  • Program follows evidence-based guidelines for dosing
  • Opioid treatment program provide more care than just methadone treatment (also provide primary care, vocational rehabilitation, etc)

Today I’ll blog about communication between staff members. Communication is a good quality in any business, allowing it to run more smoothly. But it’s even more important in healthcare, where patients’ lives and well-being are affected.

In opioid treatment programs, communication happens in many ways, but case staffing is the most formal and efficient. Case staffing is when multiple members of the treatment team gather in one place, usually at a set time, to discuss what’s going on with patients. The treatment team usually includes all of the counselors, the nurses, the doctor, and the program manager. Besides communicating information about patients, case staffing also helps generate creative solutions to problems, and checks for negative emotions among staff. This can also be a forum where concerns about clinic protocols can be raised by staff.

At the program where I work, once or twice per week, after we finish seeing the day’s patients, the nurses, the counselors, nurses, program director and program manager sit in our lobby and discuss patients. First we talk about the new admissions. I tell the staff of any medical concerns I found on my intake assessment. For example, if a patient was found to have an enlarged liver on my exam, I ask the counselor to follow up with the patient later in the week to make sure the patient makes an appointment with his primary care doctor. The counselors raise concerns about new patients. Perhaps one of the counselors noticed symptoms of depression and we decide I should check that patient again the next week, when opioid withdrawal isn’t as severe.

Then we discuss established patients, and try to problem-solve. For example, maybe a patient needs to travel out of town for work, and there’s no opioid treatment program nearby where he can guest dose. We talk about the patient’s progress and whether it’s appropriate to ask the state methadone authority for extra take-home doses. We have some leeway to decide about Sunday and holiday take home doses, and discuss who is ready for these take homes.

Counselors may ask about how to approach ongoing drug use. The approach is different for different types of drugs. If a patient has had repeated relapses to opioids, maybe the methadone dose needs to be increased. If benzos are a problem, we must discuss if it’s safe to continue to dose that patient with methadone. For marijuana and cocaine, more intense counseling is indicated, and we discuss the best approaches.

Case staffing also helps us watch each other for negative attitudes. Patients with addiction sometimes behave badly. In active addiction, some addicts have had to lie and deceive to survive, and these tendencies don’t disappear overnight. The whole staff of an opioid treatment program needs to watch each other for negative or pessimistic attitudes developing toward patients.

For example, recently I was in a case staffing where we were talking about the repeated relapses of a patient. I made a comment which was more negative than the situation warranted, and this patient’s counselor appropriately challenged my comment. I’m no different than any other human and can take a skeptical view of a patient when it’s not reasonable. This counselor made me re-consider my opinion, and she was right to do so.

We talk about clinic policies that may need to be changed. For example, when patients can’t pay for treatment, how long do I have to taper their methadone dose? I’ve worked in clinics where if you didn’t have money for that day’s dose, you didn’t get a dose. They had no policy in place to allow a taper. I’ve worked in clinics where the dose was tapered over 4 days. At my present clinic, the dose is tapered over ten days. That’s still too short, and I’d prefer to keep everybody in treatment for free, but that’s not possible. The program would fold. I’ve had the unpleasant experience of working for a methadone program that closed because it ran out of money to operate. So it’s important to include the clinic administrators in some aspects of case staffing.

The best part of case staffing is talking about patient successes. Counselors talk about patients who are participating in counseling, who’ve had negative drug screens, and qualify for take home levels. Unless any staff member has concerns, I sign a form to make it official. We talk about patients who have recently gone through difficult situations without using drugs. We even have an unofficial “patient of the week,” a term for the patient who has worked hard on recovery and had a recent success. Sometimes it’s a patient who got a job promotion. Sometimes it’s a patient who has started going to 12-step meetings. Sometimes it’s a patient who has a negative drug screen for marijuana because he’s stopped smoking pot for the first time in his entire adult life.

Talking about this good stuff is so important for staff. We get to feel like we are at least some small part of the positive changes happening in the lives of our patients. Fortunately, there’s much to celebrate at every case staffing. As I’ve said before, I never saw the kind of positive changes when I worked in primary care that I see working in addiction medicine.