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06/01/2007 10:24 7753542378 LESYMAE F'PGE 06 Ysychiatric'I'imes !?qqe 4 0}•6 rehabilitation. In other words, harm reduction is palliative care a:; ap F i t::1 to drug addiction. Because of the intensity of the nnti::n el dobate, however, harm reduction is a term that i.; :r;ul, c { with symbolic meanings. To those unhaDDY with curre:nl i policy, harm reduction is either prohibition in disguise a ~ a sign of progress. To defenders of current policy, harry reduction is seen as a first step toward legalizatic r . ~ rn currant practice, methadone maintenance Is tl hr: known harm reduction approach. Maintenance trFzd,r•ucr t with along-acing opioltl such as methadone, LA,f,hl lrr, c cr i acetyl-mcthadol) or buprenorphine (Buprenex) is h•. icu CI•u: most effective treatment for Opioid addiction (Nations) Institutes of Health, 1997). Although ongoing use of medication is generally required, it leads to substantai reductions in illicit drug use, associated crime anc.i h ea L t erd social problems. currently, oplold maintenance can :-i :s: prescribed through a licensed program, but office f prescription of methadone under the auspices of a lin:a:.~a~a program by Dsvchiatrists and other physicians is like^y 1, a I:r_ approved in the future. When combined with naloxea<! (Norton), sublingual buprenorphine Is as eMeetlve as methadone, but has much less abuse Or diverslar :w C::r t ;n. j When it is aDProved for this indication, it also will br ' available. These developments are Likely to result in Incrcasod access to treatment for a substantial numtr.• of j addicts not now receiving it. The best-known integrated treatment for co-occum np mental and addictive disorders is based upon assertiv community treatment (RachBeisel et al., 1999). "h'l: is ; i hamt reduction model that stresses pragmatic fle < al z I methods, long-term Supportive management and yl:rl~.l progress toward goals. Relapses and exacerbatior•s arc: j expected to occur, but proponents of this model zrf: r~cq: a t`ul that they can be reduced. However, this type of pr:~l,re r i is only appropriate for patients with severe and per=is'ent mental illnesses. Furthermore, rc is not widely aveu5iblr:;, Frrr., a high degree of fidelity to the program model is ,i~a~ass a•y to achieve good outwmes (McHugo et al., 1999). I Consequent{y, psychiatrists treat many patients v.i•:I•r ~;nai~~~e psychiatric and co-existing substance use disorde a nr. t has not been very clear how best to manage then i. 'Y:: ti;:~is: In this area, new tllnlcal practice guidelines for the management of substance use disorders are being rlcr~e c ord by [he U.S. Department of veterans affairs, whrr_r It outlined a Systematic approach, In the guideline, th•> approach is called care management, a term mcr: descriptive than harm reduction. Care management (Takla 2) is a harm reduction z,fgsrc::h t:a atldlctlve dlsortlers that can be appued In a varlet! of settings, including psychiatric care, Uke other pallia•tivF; approaches, it emphasizes pragmatism, compass!Snatr:• :a •e and gradual progress toward goals (which may hE l¢ss: t can ideal, especially initially). Care management is not the a•n~: as case management, where the focus is on coorcina; ar ~ rf j care. Care management will often include some cosy: management, and some models heavily depend of is ~ Evidence for the effectiveness of care management is ur?alca~r http:/lwww.psychiattictimes.com/p000255.htm1 SC3::12007