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MILESTONE  REHABILITATION PROGRAM
DRUG AND ALCOHOL PRINCIPLES OF EFFECTIVE TREATMENT

Background

Milestone Rehabilitation Program is licensed by the Department of Health's Division of Drug and Alcohol Program and provides alcohol and other drug abuse and dependency treatment services, and ensures that minimum standards are being maintained to protect the health, safety and welfare of the client.​

Philosophy

Substance abuse and dependence are primary diseases, not symptoms of other underlying conditions. Substance use disorders can be diagnosed, are responsive to treatment and are complex behavioral disabilities usually having chronic medical, social and psychological components, which result in multiple negative consequences. Substance abuse and dependence related problems affect not only the dependent individual, but other family members, particularly children. Denial is a central characteristic or symptom of substance abuse and dependence that complicates an individuals ability to acknowledge a problem.

Principles
a

Treatment needs to be readily available. Because individuals who are addicted to drugs may be uncertain about entering treatment, taking advantage of opportunities when they are ready for treatment is crucial. Potential treatment applicants can be lost if treatment is not immediately available or is not readily accessible.

c

Effective treatment attends to multiple needs of the individual, not just his or her drug use. To be effective, treatment must not only address the individual's drug use but any associated medical, psychological, social, vocational, and legal problems.

e

Treatment should be client specific and guided by an individualized treatment plan based upon a face-to-face comprehensive biopsychosocial evaluation of the patient and when possible, a comprehensive evaluation of the family as well.

g

Self-help groups such as Alcoholics Anonymous, Narcotics Anonymous and Double Trouble are essential adjuncts to the treatment process. Attendance should be encouraged when appropriate.

i

Treatment programs should provide assessment for HIV/AIDS, Hepatitis B and C, Tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection. Counseling can help patients avoid high-risk behavior. Counseling also can help people who are already infected manage their illness.

k

Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term abstinence and fully restored functioning. Participation in self-help support programs during and following treatment often is helpful in maintaining long-term abstinence.

m

Persons recovering from alcoholism or other drug dependencies are viewed as important resources in the statewide service system. As representatives of the recovering community, persons in recovery serve as an inspiration to the addicted client. As a practicing professional they provide an empathetic and knowledgeable approach to treatment philosophy, offer valuable input into the recovering community network, and serve as a voice for patient advocacy.

b

No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each individual's particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.

d

Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. Because addictive disorders and mental disorders often occur in the same individual, patients presenting for either condition should be assessed and treated for the co-occurrence of the other type of disorder.

f

Counseling (individual and group) and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address issues of motivation, build skills to resist drug use, replace drug-using activities with constructive and rewarding nondrug-using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships and the individual's ability to function in the family and community.

h

Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone and Burpenorphine are very effective in helping individuals addicted to heroin or other opiates stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some opiate addicts and some patients with co-occurring alcohol dependence. For persons addicted to nicotine, a nicotine replacement product (such as patches or gum) or an oral medication (such as bupropion) can be an effective component of treatment. For patients with mental disorders, both behavioral treatments and medications can be critically important.

j

Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The appropriate duration for an individual depends on his or her problems and needs. Research indicates that for most patients, the threshold of significant improvement is reached at about 3 months in treatment. Treatment may include Residential care followed by Intensive Outpatient care or Partial treatment followed by Outpatient care, or any movement through the level of care continuum. After this threshold is reached, additional treatment can produce further progress toward recovery. Because people often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.

l

Treatment does not need to be voluntary to be effective. Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting, or criminal justice system can increase significantly both treatment entry and retention rates and the success of drug treatment interventions.

Milestone Rehabilitation Program (MRP)
provides the following services:

  1. Level 1: Outpatient D & A Services and
     

  2. Level 1-WM: Ambulatory Withdrawal Management without Extended On-Site Monitoring.

Mission or purpose statement for the service:

1.

MRP will develop addiction services in a manner that reflects the Philadelphia system emphasis on recovery transformation and population health and has a strong focus on the use of evidence-based practices (EBPs).

2.

MRP is based on the Recovery Model.  The method of care delivery will use as its foundation self-determination, the concept of hope and the belief that all individuals are capable of living their own lives.  Through the concept of empowerment, MRP will utilize treatment partnerships and community-based opportunities for those individuals struggling with addiction.  MRP provides a collaborative approach to treatment with the MRP staff and consumer as equal partners in the consumer’s recovery.  MRP is committed to the belief that each individual is in charge of his/her own life with expectations of symptom control, respectful and supportive psychotherapy, medication management and positive community interactions.

3.

MRP offers group and individual therapies (specialized and generalized), medication assisted therapy, family education, vocational and skills development, resource information and case management.  Groups and activities are categorized into mandatory sessions and elective choices; the consumer and assigned staff work collaboratively to identify treatment strategies that support the consumer’s goal and empowerment objectives.

4.

In additional to individual and group therapy techniques, MRP will offer medication assisted therapy (MAT) to those consumers struggling with opioid addiction.  MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful. MAT is clinically driven with a focus on individualized patient care.

5.

MRP will use MAT based on the most recent research that shows that medications are useful at different states of treatment for handling withdrawal symptoms including depression, anxiety and sleeplessness.  Medications stay in a person’s system to ward off drug cravings and also have a calming effect on the body, which helps consumers focus on counseling. They also interfere with relapse triggers that help sustain recovery. It has been long noted that opiate addicted consumers who come for treatment often find it difficult to remain engaged in treatment, detoxification and primary counseling, because the withdrawal is very uncomfortable and the craving or compulsion to use, is too great to overcome without pharmacotherapy. Based on this, MRPwill use buprenorphine as the medication assisted treatment.  Studies and randomized clinical trials have shown that buprenorphine is an efficacious and safe medication for opioid addiction treatment.  A study published by the Center for Substance Abuse Treatment reported that 60% of people taking buprenorphine were abstinent from all drugs after 30 days of treatment, while 59% were abstinent from all drugs after 6 months in treatment.  Buprenorphine, in the form of Suboxone and Subutex, was approved by the FDA in October 2002 for the treatment of opiate dependence, medical maintenance and medically supervised detoxification.  It has been used successfully since in outpatient settings.

Specific Benefits

  1. Medication Assisted Therapy is the most effective treatment for opiate addiction. Compared to the other major drug treatment modalities -drug-free outpatient, therapeutic communities, and chemical dependency treatment – medication assisted therapy is the most rigorously studied and has yielded the best results.
     

  2. Medication Assisted Therapy (MAT) is effective HIV/AIDS prevention. MAT reduces the frequency of injecting and of needle sharing. Medication Assisted Therapy is also an important point of contact with service providers and supplies an opportunity to teach drug users harm reduction techniques such as how to prevent HIV/AIDS, hepatitis and other health problems that endanger drug users.
     

  3. Medication Assisted Therapy reduces criminal behavior. Drug-offence arrests decline because MAT consumers reduce or stop buying and using illegal drugs. Arrests for predatory crimes decline because MAT consumers no longer need to finance a costly opiate addiction, and because treatment allows many consumers to stabilize their lives and obtain legitimate employment.
     

  4. Medication Assisted Therapy drastically reduces, and often eliminates, opiate use among addicts. Treatment Outcome Prospective Study (TOPS) – the largest contemporary controlled study of drug treatment – found that consumers drastically reduced their opiate use while in treatment, with less than 10% using opiate weekly or daily after just three months in treatment. After two or more years, heroin use among MAT consumers declines, on average, to 15% of pre-treatment levels. Often, use of other drugs – including cocaine, sedatives and even alcohol – also declines when an opiate addict enters medication assisted treatment, even though the medication used by MRP, buprenorphine has no direct pharmacological effect on non-opiate drug craving.
     

  5. Medication Assisted Therapy works, specifically the use of buprenorphine. Studies and randomized clinical trials have shown that buprenorphine is an efficacious and safe medication for opioid addiction treatment. A study published by the Center for Substance Abuse Treatment reported that 60% of people taking buprenorphine were abstinent from all drugs after 30 days of treatment, while 59% were abstinent from all drugs after 6 months in treatment.
     

  6. For Practitioners involved in treatment delivery, medication assisted therapy is an opportunity to:
     

  • Provide an important component of medical and public health care;

  • Develop partnerships and linkages with other service providers and provide consumers/families with a range of service and supports;

  • Establish positive, supportive therapeutic relationships with, and learn from people who are dependent on opioids;

  • Contribute to an educational and therapeutic process that can lead people who are dependent on opioids to gain a new perspective on themselves and their use of drugs, and make changes in their lives.

Specific design of the service

  1. MRP is an organized, non-residential treatment service in which the consumer resides outside the facility. The initial goal of the program is to support consumers through the detoxification process.  Until a consumer is physically stabilized through detoxification, they are not physically or psychologically prepared to participate in treatment services. MRP will offer MAT to assist consumers through this process. Once detoxification has been completed, the consumer then enters the recovery phase of the program. MRPprovides structured psychotherapy and consumer stability through increased periods of staff intervention. These services are provided according to a planned regimen consisting of regularly scheduled treatment sessions at least 3 days per week for at least 5 hours (but less than 10).  MRP will offer the following services:
     

    • Integrated Clinical Need Assessment

    • Biopsychosocial Assessment

    • Specialized professional medical consultation, and tests such as a physical examination, psychiatric evaluation, HIV and TB testing, and other laboratory work, as needed

    • Individualized treatment planning, with reviews at least every 60 days or more as clinically indicated

    • Psychotherapy, including individual, group, and family (per clinical evaluation)

    • Random drug testing

    • Aftercare planning and follow-up

    • Development of discharge plan and plan for referral into continuum of care

    • Psychoeducational seminars

    • Structured positive social activities available within non-program hours, including evenings and weekends

    • Access to more intensive levels of care, as clinically indicated

    • Emergency telephone line available when program is not in session

    • Collaboration between the treatment team and various agencies for the coordinated provision of services

    • Occupational and vocational counseling

    • Case management and social services that allow the staff to assist with attendance monitoring, child care, transportation to treatment services, and the provision of stable shelter and other basic care needs
       

  2. When a consumer requires medication-assisted treatment, the first step is to meet with a doctor or other medical staff member. During this meeting, the consumer learns about treatment choices, rules that must be followed to stay in treatment, and what to expect next. A physical exam also is part of this assessment. This exam provides critical information about the consumer’s general health. It checks for diseases that are common to people who have been abusing drugs. The exam will include a drug test. After the assessment, the doctor clinician discuss treatment choices with the consumer, who may choose to include family or friends in the discussion.
     

  3. The consumer works with the treatment team to develop a treatment plan that includes:
    ​

    • The goals for treatment

    • The decision on which medication to use and the dose level to start

    • The schedule for visits to the treatment center

    • The plan for counseling

    • Other steps to take, such as attending a support group

    • How success toward goals will be measured.

    • How to handle relapse
       

  4. Once a treatment plan is agreed to and signed, medication is introduced carefully. Buprenorphine will only be administered once withdrawal has begun as taking it too soon can make withdrawal worse. Medical staff members meet with the consumer a few hours after the first dose is taken and regularly for a week or two. These meetings are to make sure the medication is working, that side effects are not too uncomfortable, and that the person is taking medication exactly as told.
     

  5. If a lack of sober-living housing is preventing a consumer from taking part in MRP program staff will manage and implement a transition from full treatment to a sober living environment. Sober living housing provides a safe, structured, alcohol and drug free setting. This is crucial in providing individuals opportunities to put the principles of recovery into practice, and an important way to become immersed in the recovering community.

Expected outcomes and goals:

  1. Services are assessed on a regular basis using validated outcomes tools including the Maudsley Addiction Profile (MAP) and the Addiction Severity Index.
     

  2. The goals of MRP for each consumer are to:
    ​

    • Withdrawal from the problem opioid or other drug in a medically approved and safe manner.

    • Develop a plan for recovery using both individual and group counseling opportunities, program supports and community-based resources.

    • Stay in recovery reducing intensity of services as needed while increasing positive living skills and informal supports.

    • Live addiction free.

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