TOXICOLOGY ASSOCIATES

STAFFING OF A METHADONE PROGRAM

PROGRAM COUNSELOR:

PATIENT INTAKE PROCEDURES:

Pre-admission screening is the responsibility of the intake counselor. Individuals presenting by telephone or in person meet the counselor as their first professional contact. Many patients have a long history of adverse responses from the medical community, so a counselor with a positive attitude and confidence in the treatment modality leads to a constructive interaction with the patient at the time of his entry into the Methadone maintenance program.

The counselor must have a functional understanding of the merits and limitations of Methadone and convey these to the patient (see Understanding Opiate Tolerance).

The guide to pre-admission evaluation presents six questions that should determine whether intake procedures are appropriate, and suggests alternative sources if Methadone maintenance is inappropriate for the patient.

Admission procedures are outlined in the package of intake forms which are completed jointly with the patient (see Intake Package). The information in these forms provides the database necessary to formulate appropriate clinical management and meet the statutory requirements for admission to Methadone treatment.

Upon completion of the intake evaluation, a pre-medication admission urine specimen must be collected for a drug screen and routine urinalysis. Blood should be collected for routine admission studies including complete blood count, serology and liver tests. The TB skin test is administered by the nurse, and vital signs are recorded by the nurse. The intake physical examination is scheduled. After the medical evaluation and after a diagnosis of opiate dependence is confirmed by the physician, the records are turned over to the nurse for initial Methadone administration and initiation of the titration procedure (see Titration discussion).

Provide the patient with treatment program policies and retain a signed confirmation that they have been reviewed and understood by the patient. EACH PAGE SHOULD BE INITIALED BY THE PATIENT.

The patient must be provided a map showing the location of all of the Toxicology Associates locations, and allow the patient to decide which is the most convenient.

EMERGENCY COMMUNICATION:

Discuss with the patient with the need for valid emergency contact information should any situation arise which might interrupt clinic services or change dispensing schedules, e.g. threat of a hurricane, when the patient may have to be contacted for emergency takeout medication. If flooding occurs, notification of an alternative medication site may be required. Should emergency contact numbers be used, any message left will not identify the call as originating from a Methadone program. As an alternative, the patient may use the Toxicology Associates website, which has maps showing the clinic locations. Emergency messages will also be posted on the website (see Emergency Communications Protocol).

TITRATION:

Review with the patient the titration procedures used for induction to Methadone treatment. Explain that some initial withdrawal discomfort may occur during the first few days but dose adjustments will be made as they are required. Caution the patient that supplementation with other drugs during the titration period will delay finding the appropriate dose of Methadone.

The counselor will see the patient each day while titration is in process and record the patient’s response to the medication received on the preceding day. The daily contact with the patient provides an opportunity for further understanding of the patient and development of a rational treatment program in addition to recording information which will assist the nurse in making appropriate dose changes as provided in the standing orders for titration. Daily visits will continue until stable.

Prepare an initial treatment plan pursuant to identified problems.

A long term treatment plan should also be developed.

FREQUENCY OF PATIENT CONTACT:

The frequency and content of counseling sessions shall be in keeping with the needs of the patient. The counselor will also evaluate the patient when the following situations occur:

When requested by the nurse of observed unusual behavior in the patient;

When urine is positive for illicit or non-prescribed drugs, or negative for Methadone or metabolites;

On patient’s return to the clinic after unexcused absences.

Counseling sessions should occur at least once per month for stable patients.

OTHER COUNSELING ACTIVITIES:

Although the nurse has the most frequent contact with the patient and therefore is more likely to discover problems not volunteered by the patient, the counselor is the staff person with the most in-depth contact with the patient. The counselor is the primary interface with assistance available from other providers.

Primary emphasis should be on crisis intervention and pharmacotherapy rather than psychotherapy.

The counselor should maintain an inventory of community resources available to assist the patient, and to provide appropriate referrals for legal, occupational, educational, medical, psychiatric, financial planning, housing, etc.

The counselor should perform quarterly evaluation of treatment plans during the first year, then every six months during subsequent years (see 26TexReg5587).

All treatment plans prepared by counselor interns must be countersigned by the supervising counselor.

Schedule collection of monthly urines from all patients.

PATIENT DISCHARGES:

Patients shall not be discharged solely for positive urines.

Patient shall not be discharged for cause without a direct order from the program physician or the medical director, and only after appropriate consultation and provision of referral or detoxification schedule.

If patients are found to be enrolled in two programs, only one may discharge the patient.

Immediate discharge is a last resort procedure and should occur only for behavior that endangers the safety of the staff or other patients, or the program operations. Sale of drugs or known diversion of drugs are examples of immediate discharge.

Patients may be discharged at their own request. If leaving the program is non-therapeutic in the opinion of the program physician, discharge against medical advice should be recorded (see 26TexReg5589).

A patient who leaves the program after detoxification should be advised that readmission to the program is available for up to two years upon request without recurrent drug use.