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1. Introduction

1.1. Rationale for Medical Management (MM) Treatment

 

This manual serves as a standardized guide for delivering Medical Management (MM) treatment to patients with alcohol abuse and dependence. MM treatment was designed to be used in conjunction with prescribed medication and to be easily implemented by medically trained practitioners in nonspecialty settings in keeping with the national trend toward integrating substance abuse treatment into medical practice.

 

Patients who do not take prescribed medication are a common problem, regardless of their disorder. One focus of MM treatment is to help clinicians provide education, support, and strategies to ensure that their alcohol-dependent patients are medication compliant. Medication compliant means taking medications as prescribed. As the medical practitioner, it is important that you familiarize yourself with common reasons why patients skip doses or stop taking their medications (see Chapter 4, “Medication Compliance and Attendance”). This understanding will keep you vigilant in monitoring medication compliance and will assist you in helping patients overcome barriers to correctly following medication instructions.

 

MM treatment was developed as part of the NIAAA-supported COMBINE study to provide a basic form of clinical intervention supporting effective pharmacotherapy. Thus, medication information in this manual is specific to naltrexone and acamprosate, the two medications provided to patients in COMBINE. The treatment approach is generic, however, so it is possible to use it and substitute other medications and related information.

 

One of the central questions examined by researchers in the COMBINE study was to compare the effectiveness of pharmacotherapy, delivered in the context of a supportive intervention, such as MM treatment, to pharmacotherapy delivered with MM treatment that has been partnered with an intensive behavioral treatment—Combined Behavioral Intervention (CBI), which includes motivational interviewing, skill building, and detailed discussions of 12-step concepts. If MM treatment were to be delivered in another research or clinical context, modifications to MM treatment to incorporate more intensive techniques could be appropriate and should be considered.

 

For those interested in more details about COMBINE, see the COMBINE Study Fact Sheet (Form A–16) included in “Appendix A: Clinician Packet.”

REFERENCE
Form A–16: COMBINE Study Fact Sheet

1.2. Treatment Overview

The goal of the MM intervention is to promote the patient’s recovery from alcohol dependence. You can help your patients meet this goal in the following four ways:

  • Provide patients strategies for taking their medications and staying in treatment.

  • Provide educational materials about alcohol dependence and pharmacotherapy.

  • Support their efforts to change drinking habits.

  • Make direct recommendations for changing drinking behaviors.

Follow your patients throughout treatment, providing expert assessment, support, and direct advice in their efforts to achieve recovery from alcohol dependence. When talking with your patients, appeal to their reason and common sense, particularly in relation to the overall goal of preserving or restoring their health. In expressing concern for your patients, it is important to be nonjudgmental. Always be friendly, supportive, and optimistic about their recovery.

Your initial MM session occurs after your patient has been evaluated and should last from 40 to 60 minutes. In this session, cover the following points:

  • Review the results from his/her evaluation and address any medical concerns.

  • Use the results from the evaluation to support the diagnosis of alcohol dependence, provide basic information about the disorder (including prognosis), and advise abstinence.

  • Provide a rationale for and information about pharmacotherapy.

  • Provide a rationale for evaluating medication compliance at each session.

  • Use the patient’s history of taking medication to establish an individualized plan that will ensure medication compliance.

  • Encourage participation in mutual-support groups (e.g., AA, SMART Recovery).

  • Provide pamphlets on alcohol dependence, medications, and mutual-support groups.

  • Answer any questions or concerns about treatment.

In followup sessions, follow the procedures below:

  • Perform a medical check on the patient’s general functioning.

  • Take a reading of the blood alcohol concentration (BAC).

  • Take the patient’s vital signs, and weigh the patient.

  • Ask about medication side effects and concurrent medications.

  • Perform a brief assessment of the patient’s drinking.

  • Monitor his/her medication compliance.

  • Make recommendations for the patient to follow until the next visit.

These visits typically last about 15 to 25 minutes, though they can be as long as 30 minutes, depending on each patient’s medical status, progress in maintaining recovery, and medication compliance between visits.

The treatment adherence checklists to use in the initial and followup sessions are in Appendix B, “Medical Management Training and Session Adherence Checklists.” You can also use these checklists when you deliver MM or if you are monitoring adherence by listening to audiotapes of the MM sessions.

1.3. Pitfalls to Avoid When Using MM Treatment in a Research Context

1.3a. Non–MM Treatment Therapeutic Strategies. Many professional therapies, such as those listed below, use techniques and strategies that extend beyond the scope of MM treatment:

  • Confrontational sessions

  • Skills training approaches

  • Client-centered counseling

  • Family therapy.

Although these methods might complement MM treatment in a clinical setting, they are not part of the MM intervention per se, and most medical staff will not have training to deliver these methods. These approaches were not used by MM clinicians during the COMBINE project (see section 1.1, “Rationale”).

1.3b. Nonabstinent Goals. Typically, you should encourage your patients to be abstinent throughout MM treatment if possible. This was also the case in the COMBINE project. Do not tell patients things such as, “Expect slips—they are a natural part of recovery,” or “Some reduction in the amount you are drinking is an acceptable goal.” However, when patients do drink during treatment, avoid expressing disapproval or disappointment. Praise any improvements or steps they make toward achieving recovery. If a patient does slip, reassure him/her that slips are common and are not signals he/she will not attain recovery.

1.4. Materials

“Appendix A: Clinician Packet” has forms that help you deliver MM treatment; “Appendix B: Medical Management Training and Session Adherence Checklists” has treatment adherence checklists for each session; and “Appendix C: Patient Packet” includes information for the patient to take home and review as necessary. The forms included in each appendix are listed below.

1.4a. Appendix A: Clinician Packet

To Be Used at the Initial MM Session

Form

A–1 Clinician Report

A–2 Vital Signs and BAC

A–3 Concurrent Medications

A–4 Naltrexone Information Sheet: Clinician Version

A–5 Acamprosate Information Sheet: Clinician Version

A–6 Medication Instructions Summary

A–7 Modified SAFTEE

A–8 SAFTEE Guidelines: Part 1

A–9 SAFTEE Guidelines for Rating Severity of Adverse Events: Part 2

A–10 Menstrual Calendar

A–11 Serious Adverse Event Report

A–12 Serious Adverse Event Followup Report

A–13 Medication Compliance Plan

A–14 Pill Count

A–15 Day 3 Clinician Phone Contact

To Be Used at All MM Followup Sessions

Form

A–2 Vital Signs and BAC  

A–3 Concurrent Medications

A–7 Modified SAFTEE

A–8 SAFTEE Guidelines: Part 1

A–9 SAFTEE Guidelines for Rating Severity of Adverse Events: Part 2

A–10 Menstrual Calendar

A–14 Pill Count

To Be Used as Needed

Form

A–11 Serious Adverse Event Report

A–12 Serious Adverse Event Followup Report

A–16 COMBINE Study Fact Sheet

1.4b Appendix B: Medical Management Training and Session Adherence Checklists

Form

B–1 MM Practitioner Qualifications, Training, and Supervision

Adherence Checklists To Be Used at the MM Initial Session

Form

B–2 Instructions for Use of MM Treatment Adherence Checklists

B–3 MM Initial Session, Advance Preparation (Review Clinician Report Form Information Checklist and Prepare Chart Material Checklist)

B–4 MM Initial Session: Introduction and Feedback Checklists

B–5 MM Initial Session: Medication Compliance Checklist

B–6 MM Initial Session: Wrap-Up Checklist

B–7 Brief Checklist for MM Initial Session

Adherence Checklists To Be Used at MM Followup Sessions

Form

B–8 MM Followup Sessions: Part 1 Checklist

Checklists To Be Used Depending on Patient Status

Form

B–9 Abstinent and Medication Compliant

B–10 Nonabstinent and Medication Compliant

B–11 Abstinent and Medication Noncompliant

B–12 Nonabstinent and Medication Noncompliant

B–13 Brief Checklist for MM Followup Sessions

B–14 Brief Checklist for Medical Attention Visits

1.4c Appendix C: Patient Packet Medication Education

Form

C–1 Naltrexone Information Sheet: Patient Version

C–2 Acamprosate Information Sheet: Patient Version

C–3 Medication Instructions Summary

C–4 Quick Reference Medication Information Grid

C–5 Patient Instructions for Managing Side Effects

C–6 Sample Medical Emergency Card

Alcohol Education/Mutual-Support Groups

Form

C–7 Name and Location of AA Pamphlet Relevant to Pharmacotherapy

C–8 Listing of Local Mutual-Support Groups