Methadone Maintenance Treatment, Specific Guidelines for

Section F: Substance Abuse Intervention

See also Appendix H: Qualifications of MMT Substance Abuse Program Providers.

See also description of role for Institutional Correctional Programs Officer and for Community Correctional Programs Officer in Section C: Specific Responsibilities of CSC's MIT Members.

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Background

Quality substance abuse intervention is a critical element for a successful methadone maintenance treatment program. The purpose of Substance Abuse Intervention in relation to Methadone Maintenance Treatment (MMT) is to assist the inmate in addressing problem areas in his/her various life areas, which was not possible when he/she was actively using heroin or other opioids. With the inmate's physical requirements being met through the proper titration of methadone, these intervention sessions are designed to address the psychological and environment needs of the inmate so he/she may learn to cope with life without the use of heroin and other opioids.

Once the inmate has been accepted into MMT, he/she meets with the correctional programs officer to establish a specific Methadone Maintenance Substance Abuse Treatment Plan (CSC/SCC 1260-01). This plan will identify specific areas the inmate will address through his/her substance abuse intervention sessions and must be maintained throughout.

It must be noted that the inmate may require a period of stabilization (possibly several months) prior to commencing substance abuse programs. During this time, the correctional programs officer should maintain contact with the inmate.

As well, the inmate is expected to participate in regular substance abuse intervention. This intervention may take the form of one of the following.

• group maintenance sessions
• individual appointments
• a combination of the two

The following guidelines articulate the content and process of the CSC's MMT Substance Abuse Intervention and offer guidance in creating and following the Methadone Maintenance Substance Abuse Treatment Plan (CSC/SCC 1260-01).

Table 11: Notes on MMT Substance Abuse Intervention

Goals of Intervention

To assist the inmate in maintaining compliance with the Methadone Maintenance Treatment Agreement (CSC/SCC 1260-05) and to encourage and support offenders to lead a drug free life.
To increase the likelihood of success by providing the inmate with the required skills and knowledge to address his/her areas of need.

Focus of Intervention

The focus of the intervention will be on addressing the immediate and long-term needs of the inmate in order to become stable in each of his/her life areas.

Although the intention of the intervention is not necessarily to work toward moving the inmate to a point where he/she is voluntary weaned from MMT, the correctional programs officer should be ready to deal with this issue should it arise.

Group Size for Sessions

Consistent with other core program standards, maximum group size is 10.

If the number of inmates on MMT reaches beyond 10, it is recommended that the site conduct more than one group session per week to accommodate the maximum number of participants.

Sites without sufficient numbers to conduct groups (e.g., less than 4 MMT inmates), are encouraged to participate in OSAPP or Choices maintenance sessions, if they meet the criteria of those groups. However, they would require supplemental sessions, as required, to focus on specific methadone concerns. An alternative to group sessions for sites with few inmates on MMT would be to conduct individual sessions.

One on one Intervention Sessions

These may be conducted with inmates if they are warranted, as follows.

• Sessions are required in addition to weekly sessions.
• Immediate issues arise that can't wait for the next group session.
• The site does not have a sufficient number of MMT inmates to conduct group sessions.

However:

• One-to-one sessions do not replace weekly group sessions.
• One-to-one sessions should follow the same process and content guidelines provided earlier in this document.
• It is recommended to employ group sessions whenever possible, and minimize the use of one to one sessions.

Frequency of Sessions

See "Frequency of Substance Abuse Intervention Sessions" below

See also "CSC 'Stable' and 'Non-Stable' Monitoring Guidelines" in Section B. of these guidelines.

Content of Sessions

The MMT sessions can take a wider scope than those of other maintenance sessions (OSAPP/Choices).

Facilitator's approach

The facilitator is required to tailor the content and approach of the sessions according to the participant's level of expertise and previous programming experiences.

The key is to satisfy the specific needs of the inmates in their initial and on-going stabilization on MMT, to focus on improving each of their life areas and assist them in their reintegration.

Recommended topics of skills for sessions

The following are recommended topics/skills to be considered by the correctional programs officer when preparing the structured segment of each intervention session.

• Education regarding methadone and the common side-effects
• 'Myths' of methadone
• The 'stigma' of being on methadone
• Current challenges of being on MMT
• Specific risk situations (current and future)
• Problem solving strategies (use current, real life scenarios)
• Cognitive coping skills (identify destructive thinking patterns and employ coping by thinking techniques), as well as .
• Behavioural coping skills to enhance the inmate's ability to effectively cope with unpleasant emotions, physical discomfort, pleasant emotions, personal urges and temptations, conflict with others, pressure from others to use and good times with others
• The inmate's crime cycle and its relation to substance use
• Slips versus relapse
• Relapse prevention strategies
• Relapse management strategies
• Aftercare
• Life area planning (e.g., substance use, work/school, relationships, health and fitness, leisure)
• Pain management strategies
• Relaxation and stress management

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Format of Individual or Group Maintenance Sessions

The intervention sessions follow a similar format to that of the OSAPP and Choices maintenance sessions. Each intervention session is to be conducted in an interesting and interactive manner.

1. Warm-up (check in, re-establish rapport).
2. Current Issues: Explore how the inmates have been coping since the previous session, as well as to identify issues that have emerged. The correctional programs officer must be ready to deal with any and all issues that are identified. In most cases, a decisional balance, problem solving and motivational interviewing techniques will be necessary to assist the inmate address his/her immediate concerns and those issues which may affect his/her success or compliance with the MMT Agreement (CSC/SCC 1260-05).
3. Prepared Lesson Plan/Exercise: Based on the inmates' identified need areas and the progress to date, a specific lesson or exercise is prepared by the correctional programs officer in advance (see "Content of Sessions" in Table 11: Notes on MMT Substance Abuse Intervention above).
4. Explore anticipated issues that may be encountered by the inmates between now and the next session, and if required, assist in developing action plans.
5. Establish specific objectives and/or tasks for the inmate/s to work on through to the next session.
6. Wrap-up.

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Frequency of Substance Abuse Intervention Sessions

Not all inmates on methadone are the same - some will require frequent intervention and close supervision, while others will not. These differences may be based on a number of variables such as the length of time on MMT, level of stability, urine drug screen results, his/her engagement in the correctional plan and progress made toward addressing his/her problem areas.

Consistent with the principle of matching need with appropriate intervention, the following guidelines are designed to maximize the service provided to each inmate, as well assist the correctional programs officer in deciding which inmates are in the highest need of intervention. This approach takes a three-tiered 'cascading approach' with MMT inmates requiring High, Moderate or Low frequency. This design should maximize the program's effectiveness and efficiency for both inmates and correctional programs officers.

Changes of Frequency
It is imperative that all staff closely monitor each inmate. Based on his/her attitude, behaviour and circumstances, the inmate's required frequency will fluctuate. For example, an inmate in the moderate category may be required to attend intervention sessions more frequently if his/her behaviour warrants it. However, as the inmate's monitored behaviour stabilizes, then his/her required frequency would again be reduced. The inmate's required frequency should be revisited at each MIT meeting.

High Frequency:
Minimum Attendance of Once per Week

Inmates categorized as requiring High Frequency

• Are starting on MMT and have not yet reached their stabilized dosage.
• Have been on MMT for less than 3 months.
• Are displaying risky and/or deteriorating behaviour (positive urinalysis tests, not abiding by MMT agreement, disruptive).
• Are only interested in 'warehousing on methadone' and not interested in addressing their Correctional Plan;
• Have limited information about methadone, its purpose and its side-effects.
• Display a clear need to address skills deficits.

Moderate Frequency:
Minimum Attendance of Once every Two Weeks

Inmates categorized as requiring Moderate Frequency

• Have been on MMT for more than 3 months.
• Have achieved a stabilized dosage.
• Are displaying few symptoms of risky or deteriorating behaviour.
• Are still slightly resistant to intervention sessions.

Low Frequency:
Minimum Attendance of Once per Month

Inmates categorized as requiring Low Frequency

• Have been on MMT for a minimum of 6 months.
• Have minimal or no symptoms of risky or deteriorating behaviour.
• Are attending to their Correctional Plan.
• Are demonstrating progress in their life areas.
• Are classified as "Stable" by the MIT and is monitored under the Stable Monitoring Guidelines in these guidelines.

Table 12: Notes on the Methadone Maintenance Substance Abuse Treatment Plan (CSC/SCC 1260-01)

Notes for the Correctional Programs Officer on
The Methadone Maintenance Substance Abuse Treatment Plan (CSC/SCC 1260-01)
(referred to in this table as the "Treatment Plan")

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Purpose

The Treatment Plan provides the inmate with a treatment focus and assists the correctional programs officer in determining the content to prepare and deliver for each intervention session.
The Treatment Plan is dynamic and changes with the needs of the inmate.

Formulating the Treatment Plan

Following the Initial Case Conference, the inmate and correctional programs officer review the inmate's needs, as identified from the substance abuse assessment process as well as the options listed on the Treatment Plan.
Each option listed in the form represents a key life area, a specific risk situation, or a combination of the two, and are based on the risk categories identified by the Inventory of Drug Taking Situations.
Each option requires the development of "coping by thinking" or "coping by doing" skills. These skills are compatible with those found in the "Content of Sessions" segment of Table 11: Notes on MMT Substance Abuse Intervention.

Section A(pages 1-2)

Inmate identifies specific areas he/she is interested in working on. Then based on these choices, he/she selects the top 3 areas he/she wishes to work on first, rates his/her current coping ability and details the steps he/she will take to improve the area.
The inmate and correctional programs officer sign the completed form at the beginning of the assessment period.

Section B (page 3)

The "Summary of Participant's Needs" identifies the inmate's top three need areas from his/her Treatment Plan and details the skills required to further improve the inmate's coping ability.
This will help identify the focus for the intervention sessions that will be conducted over this assessment period.
The correctional programs officer completes this section at the beginning of the assessment period.

Section C (page 4)

The "Post-assessment Summary" summarizes the inmate's progress made in the specific areas that were identified at the beginning of this assessment period.
The correctional programs officer completes this section at the end of the assessment period (e.g., 6 months later).

Reassessing the inmate and Revising the Treatment Plan

Periodically, but at least every 6 months, the correctional programs officer revisits the inmate's Treatment Plan.

• The inmate and correctional programs officer repeat the initial process for formulating the plan and identifying the inmate's three most pertinent areas to work on.
• The correctional programs officer also completes the "Post-assessment Summary", rating the inmate's progress since the previous assessment (e.g., attendance, participation, attitude).
• Share this information with the other MIT members to contribute to the overall management of the inmate's MMT. Summarize inmate's progress at each MIT meeting.

Maintaining a Record

After each revision of the Treatment Plan, the correctional programs officer must provide a copy of the Treatment Plan to the nurse for filing on the inmate's Medical Record. This file, containing historical revisions, is necessary for audit purposes, and will assist in monitoring the inmate's progress.