The Federal Government views women, pregnant
women, children and adolescents, and/or
individuals with a dual diagnosis to be
designated as special populations. These
special populations receive particular attention
in the accreditation standards manual. Services
to pregnant clients are offered to maximize
the health outcomes for both the mother
and the child.
Accreditation Requirement(s)
To conform to these standards, the organization
must show evidence of the following:
Adolescents
When admitting adolescents (under age
18) to maintenance treatment, the program
documents two unsuccessful attempts at
short-term detoxification or two unsuccessful
attempts at drug-free treatment within
a 12-month time period.
Written consent is obtained from the
parent/legal guardian or responsible adult,
and the physician documents physical dependence
on an opioid in the medical record.
Assessments and all other services
are developmentally appropriate. Family
counseling is facilitated, necessary referrals
are made, and the safety of the adolescent
is protected, including the reporting
of any abuse or neglect to the proper
authorities per applicable laws.
HIV Positive/Hepatitis B &
C
There are no specific CARF standards
in the Opioid Treatment Programs Standards
Manual for Re-Surveys regarding infectious
diseases.
Women
All women receiving services are provided
counseling regarding general health issues,
domestic violence, sexual abuse, and reproductive
health. Staff is assigned based on the
needs of the women.
Pregnant Women
Priority admission is given to pregnant
women seeking treatment, and the reasons
for denying admission are clearly documented.
The program provides education on medically
supervised withdrawal (MSW) and its impact
on the welfare of unborn children, access
to referrals for prenatal care or prenatal
instruction provided on site, pregnancy/parenting
education, and postpartum follow-up. If
these services are declined, it should
be documented in the medical record that
they were offered but refused by the client.
Opioid treatment is initiated on a
priority basis for pregnant women, and
to accepted medical practices for adequate
dosing are followed. If a woman becomes
pregnant while on methadone, she is maintained
on her pre-pregnancy dosage, if effective.
Since pregnancy may change a person's
metabolism, determining proper dosage
is important and taken into consideration.
The dosing strategy reflects the same
effective dosing protocols used for all
clientele. Split dosing is considered
if the woman is experiencing withdrawal
symptoms sooner than 24 hours after the
last dose. The methadone is monitored
carefully during the third trimester.
If a pregnant woman decides to withdraw
from methadone, a physician with experience
in addiction medicine supervises the withdrawal
process, and conducts regular fetal assessments.
Withdrawal does not begin before 14 weeks
or after 32 weeks of gestation.
If withdrawal symptoms cannot be eliminated
during MSW, a pregnant woman is referred
to an inpatient medical program.
Consultation with an OB/GYN or family
physician on related medical issues occurs
as needed.
Breastfeeding is encouraged unless
client is medically contraindicated, such
as in carrying an HIV-positive infection.
The program also provides (or makes referrals) for parenting skills and reproductive health services to all clients.
Dual Diagnosis
If a person has a co-occurring health
and/or psychosocial issue, then appropriate
services should be provided either directly
by the program or referrals should be
made to external sources.
Co-occurring health and psychosocial
needs may include infectious/sexually
transmitted diseases, mental health/other
addiction diagnoses, medical problems,
pregnancy, vocational/employment issues,
and/or legal services.
If possible, co-morbidities are managed
as part of the program, including multiple
drug use and psychiatric and medical disorders.
Programs should seek to hire staff members
who have training/expertise in addictions
and mental health issues.
If prenatal care is not available on
site or by referral, then it should be
offered as part of the counseling/education
curriculum (maternity, physical, and dietary
care). Prenatal education includes information
regarding the fetal development and the
effects of drug use on the fetus, breastfeeding,
nutritional practices, caring for a newborn,
etc.
Many clinics have partnered with local
hospitals and health departments to provide
services to pregnant women.
Dosing practices for pregnant women
should follow the usual and customary
dosing procedures of the program, with
careful monitoring in the last trimester
of the pregnancy. Programs that are part
of a hospital often have access to the
dietician on staff for nutritional counseling.
Since the late 1970s, methadone has
been accepted for treating opioid addiction
during pregnancy. In 1997, a National
Institutes of Health (NIH) consensus panel
recommended methadone maintenance as the
standard of care for pregnant women with
opioid dependence (NIH, 1997; see Clinical
Practice Guideline module). Methadone
is currently the only opioid-agonist medication
approved by the U.S. Food and Drug Administration
(FDA) for medication-assisted treatment
for opioid addiction (MAT) with pregnant
clients.
Pregnant women with a history of injection
drug use are at high risk for HCV infection
and should be screened for the anti-HCV
antibody.
As pregnancy progresses, the same dose
of methadone will produce lower blood
methadone levels. Women who are on methadone
maintenance frequently experience signs
and symptoms of withdrawal in later stages
of pregnancy and require dose elevations
to maintain the same blood level and remain
withdrawal free. The daily dose can be
increased and administered singly or split
to a twice-daily schedule.
Methadone withdrawal, or MSW, is not
recommended for pregnant women. When withdrawal
is being considered, it is important that
a thorough assessment be conducted to
determine whether a woman is an appropriate
candidate for medical withdrawal because
there is a high rate of relapse to heroin
use after withdrawal.
Methadone-maintained mothers can breastfeed
as long as they are not HIV positive,
are not abusing drugs, or do not have
another disease or infection in which
breastfeeding is contraindicated. Hepatitis
C is no longer considered a contraindication
for breastfeeding.
Increase in research and clinical attention
has focused on persons who have a co-occurring
substance use and psychiatric disorder.
Clients who have co-occurring disorders
often exhibit behaviors or have feelings
such as depression, anxiety, aggression,
suicidal thoughts or plans, or psychotic
ideation that interfere with treatment.
These symptoms can indicate underlying
psychiatric disorders that would be present
regardless of opioid dependence, psychiatric
disorders caused by opioid and other drug
use, or combinations of both. Refer to
the Report to Congress on the Prevention
and Treatment of Co-occurring Substance
Abuse Disorders and Mental Disorders
(Substance Abuse and Mental Health Services,
2002); and Strategies for Developing
Treatment Programs for People With Co-occurring
Substance Abuse and Mental Disorders
(Substance Abuse and Mental Health Services,
2003) for information on co-occurring
psychiatric disorders among people with
substance use disorders. Both of these
reports are available in the Clinical
Practice Guideline module.
Vocational services can usually be
obtained from any given state's Department
of Rehabilitative Services. Methadone
programs that are part of a larger organization
may have ready access to a vocational
counselor.
Some opioid treatment programs have
scheduled classes and groups that clients
in various phases of treatment are required
to take. Examples of these classes/groups
include relapse intervention, risk and
health, vocational, chronic illness, cocaine
group, women's group, anger management,
stress management, acupuncture, basic
drug education, prenatal education, etc.
HIV prevention/early intervention services
are often provided directly by specially
designated program staff to educate clients
regarding risk reduction and the prevention
of infection and transmission, to detect
the presence of the virus, and to offer
referral to treatment where indicated.
Some programs offer groups for HIV-positive
clients for support purposes and to encourage
healthy lifestyles.
Referrals for pregnant women can be
made to private OB-GYNs, the local health
department, family practitioners, university-based
programs, community parenting classes,
or a free community health clinic/cooperative.
Oftentimes opioid programs have signed
cooperative agreements with the above
listed entities. There are also many videos
available the program could purchase that
address pregnancy, parenting, and family
planning. Refer to Appendix
D of the Treatment of Opiate Addiction
With Methadone: A Counselor Manual (TIP
7), published by the U.S.
Department of Health and Human Services.
Note that programs that serve adolescents
must also adhere to CARF's standards for
assessment and treatment planning that
pertain to clinician's being responsive
to a person's age and developmental status
(see section 3 of the Standards Manual).
