Action and maintenance phase
The primary focus of the action and maintenance phase of the methadone maintenance treatment (MMT) is to help the client adjust to life without substance use. Clients make lifestyle changes, such as improving relationships with family and friends, getting stable housing, developing financial security and finding work. At this stage, any chronic physical or mental health issues need to be addressed.
It is common for clients to relapse after a period of success during the action and maintenance phase. For that reason, counsellors should regularly assess clients' changing needs.
A variety of considerations emerge during the action and maintenance phase, as follows.
Avoiding the "complacency trap"
Once clients reach an optimal dose of methadone and have taken major steps toward resolving acute socioeconomic problems (e.g., housing), they may either begin to think that the crisis and hard work are over and become complacent about treatment or they may make fundamental lifestyle changes that increase the likelihood of long-term treatment success.
Counsellors should be aware of the potential to build on clients' initial successes but also be alert to complacency, both in clients and in themselves.
Renegotiating the treatment plan
Through acknowledging their client's progress, counsellors can motivate them to begin work on other issues in his or her life (e.g., improving family relationships, addressing chronic physical or mental health concerns, beginning vocational counselling).
Strengthening the therapeutic alliance
Once clients reach the action and maintenance phase and the treatment goals expand, the counsellor-client therapeutic alliance undergoes a subtle shift. At this point, counsellors need to balance their supportive, empathic approach with one that challenges clients to explore other difficult areas in their lives.
Counselling during the action and maintenance phase of treatment concentrates on helping clients readjust to their lifestyle changes. Adjustments may include developing new social networks and supports that do not involve using, coping with stress, structuring leisure time, planning for the future (e.g., returning to work or school), resuming prior roles without using (e.g., parenting, working) and developing positive self-care strategies (e.g., nutrition, exercise).
During this phase, clients are often involved with a variety of service providers, which makes case co-ordination an important, but challenging, consideration. Challenges may include working with agencies that are reluctant to take referrals from MMT programs because they have misconceptions about MMT and about MMT clients.
Consolidating gains made during the stabilization phase
As the client becomes more stable, the focus of counselling can turn to long-term lifestyle changes. A key part of this work is helping the client devise strategies in advance to cope with triggers to recurrence that they may come to face.
Discussing substance use
Clients may continue to use substances during this phase. They may fear loss of privileges (e.g., take-home doses) if they are open about their continued substance use. They may also be afraid of disappointing their counsellor. Nonetheless, continued use is a key concern, and the counsellor should encourage clients to discuss it openly.
Some clients, however, may also be required to report to other agencies (e.g., probation or Children's Aid), with whom disclosure of substance use and a positive urine sample might have severe consequences (e.g., incarceration, losing custody of children). In these circumstances, the counsellor should, therefore, early in treatment clarify the possible implications of openness to the client. For example, the counsellor and all MMT team members must explain their relationship with external agencies, the limits of confidentiality, their obligation to report, as well as the MMT team's role as an advocate to other agencies on the client's behalf.
Increasing treatment flexibility when the client is clinically stable
If the MMT team feels that a client is stable, he or she may not be required to attend as many medical appointments or take part in urine drug screening. Greater flexibility in treatment tends to positively reinforce the client's progress.
Clinical stability is a key concept in MMT. The Methadone Maintenance Guidelines established by the College of Physicians and Surgeons of Ontario (CPSO) provides an accepted definition of clinical stability:
Patients are clinically stable when they demonstrate the social, cognitive and emotional stability necessary to assume responsibility for the care and safeguarding of methadone and use it only as prescribed. Clinical stability can be shown when the following criteria have been considered:
- Elimination of sustained problematic drug or alcohol use and demonstration of mostly negative urine drug screens.
- The patient's methadone dose is stable and the patient is emotionally stable.
- Housing, employment and/or a stable support system is in place.
- Adherence to the methadone treatment agreement, and program requirements (CPSO, 2005, p. 31).
However, even if clinical stability is reached and greater flexibility is provided, clients should always:
- have no more than six carries per week (note: occasional exceptions can be made to accommodate vacations and similar circumstances), and take at least one dose of methadone weekly under pharmacist observation, to allow the dose safety to be monitored
- have an annual medical assessment
- have an annual psychosocial assessment (note: this can be performed by the doctor during the medical assessment using the Addiction Severity Index [ASI], or other standard interview questions about substance use issues) (Martin et al., 2003).
For a more in-depth discussion of maintenance in the context of MMT, see Chapter 9 of Methadone Maintenance: A Counsellor's Guide to Treatment (PDF).