The rewards for LPNs working at one of the three sites of Brandywine Counseling Inc. in Delaware can be very satisfying. The job also can be frustrating at times.

When things go right, and they see evidence of their drug-rehabilitation program working, the LPNs and their RN associates get a lot of satisfaction in knowing they are helping provide a much-needed therapy for people whose drug use has made life unmanageable. On the other hand, however, frustration comes in knowing the therapy does not work for all of their clients.

The therapy is a combination of.regulated dispensing of methadone (Dolophine^®, Roxane Laboratories) to aid in withdrawal from addiction to heroin or other opiates, such as morphine, and individual and group counseling. Antiabuse^® (tetraethylthiuram Wyeth-Ayerst Laboratories) to help keep alcoholics sober also is dispensed to a lesser degree. LPNs contribute in large measure to the ongoing success of the program.

For Marcia Blancato, LPN, CD, who has been with the program since 1979, the realization of knowing she has helped someone wean off of an addicting drug is very gratifying indeed. She is nursing supervisor of the counseling center's Lancaster Avenue site in Wilmington, where a staff of six LPNs currently handles a caseload of approximately 420 methadone clients daily. The "Riverfront" site, also in Wilmington, is staffed by one LPN, who is the nursing supervisor, and two RNs. They have approximately 200 clients. A recently opened third clinic in Newark, DE, which handles about 140 clients daily, is staffed by one RN and two LPNs, one of whom is the nursing supervisor.

Kay Malone, MHS, RN, CD, who is director of the medical department for all three sites, noted that expansion of the program has been necessitated in recent years by the concern over acquiring deadly viruses such as HIV through shared needles.

"We're now seeing an increase in the number of young people coming in for treatment," she said. She attributed this to the fact that "dope on the street is cheaper now, and much purer, so they become addicted faster." While the average age of clients used to be 29-40, it is now 23-35, she added.

METHADONE MAINTENANCE
Methadone, a synthetic narcotic that is itself addictive, was determined in the mid-'60s to be a viable treatment for opiate addiction. While addictive, Blancato explained, it is relatively inexpensive and the effects of one dose last 24-36 hours, so it only needs to be taken once a day (the effects of heroin, by comparison, last 4-5 hours).

"Our job is to help people become drug-free," Blancato said. "The time- frame for total treatment varies. They could be off all meds in 1 year or 18 months, but some will be on methadone their whole life. They have to accept the concept that addiction is a disease and it is a long-term process for recovery. Counseling is very important."

The frustration for clinic staffers, she added, is in seeing some people back time and again to be detoxed. "Some have been in the clinic 20 years off and on, and are no better than 10 years ago." Unfortunately, adding to the overall problem is the fact that most of the clients are poly-substance abusers.

The drug rehab program has been in existence since 1968, when it was affiliated with the Delaware Division Hospital in Wilmington. "In 1984 we became a private, non-profit agency and have increased our client numbers from 70 to 1,500 since its inception," said Malone.

Brandywine Counseling's clientele includes patients with opiate or other drug addictions, drug-free clients and alcoholics. They range from 18 years of age to 70, and come from all facets of society ? "from Yale to jail," as one associate commented. Clients' participation in the program is kept confidential as required by law unless the client signs a release for a specific person, reason and length of time.

While some people find methadone objectionable as a treatment because it is itself addictive, Blancato and her associates at the clinics point to statistics indicating that with methadone treatment, crime rates and the number of HIV and other sexually transmitted diseases are lower, and job participation by those on methadone are higher.

A DAILY DOSE REQUIRED
The staff at this JCAHO-certified facility generally gets to know clients very well, since the treatment initially requires clients to come to the clinic daily for their methadone dose. The clinics open at 5 a.m. so that clients can get their treatment before work. "And more than half are employed full time," which is encouraging, Blancato said. When accurately ordered by a physician, methadone prevents clients from going through addiction withdrawal and enables them to hold a job, go to school, care for their family and otherwise function in a totally acceptable manner, she added.

Because of the potential for problems in handling a controlled substance, security at the clinics is a big concern, and the LPNs in charge of distribution work behind a secure window. Security personnel also patrol areas adjacent to the clinic. Problem clients are not frequent, however, Blancato said.

"Some days you can get cussed out, and wonder why you put up with it. You can go to work and laugh, cry and hug clients, but we've had very few times when we had to call the police or push the panic button" ? a silent alarm that rings directly into the local police station ? "because someone was threatening or fighting."

The LPNs at Brandywine Counseling's clinics have some typical nursing responsibilities, such as distributing meds, but they also assist certified drug and alcohol counselors and do a host of other things unique to their training. For one, they observe all urine screens, which are randomly selected at least one time a month by a computer at the center. Clients may also be ordered by the physician or counseler to provide a urine screen.

LPNs also work with the doctors in giving physicals required to enter the treatment program, making appointments, performing medical assessments and referrals for other facilities, and sitting in on treatment planning meetings with the counselor and supervisor to determine the most appropriate plan for the client.

They also sit in on appeal meetings, held when the client is in jeopardy of removal from the program because of not adhering to the requirements. And if clients have become incarcerated, the LPNs may travel to the prison to medicate them for a limited amount of time. They also go to clients' homes to medicate when the individuals are on bedrest or incapacitated with an end-stage illness.

Although much of the training for their unique roles is obtained on the job, the state of Delaware offers seminars in treating alcohol and drug abuse as well. All told, they are required to earn 30 hours of continuing education bi-annually to both maintain their LPN license and meet their clinical dependency certification issued through the National Consortium of Chemical Dependency Nurses.

Blancato, an LPN with previous hospital nursing experience, said that 23 years ago when she first saw a classified ad for someone to work in a methadone clinic, she not only had "no clue as to what it was, I didn't like the idea of working with drug addicts. But I decided to give it a shot, and have been here ever since. I realized that most of society is addicted to something ? coffee, cigarettes, sleeping pills ? but we don't look at that population as having a problem. So there is a lot of legal drug addiction that people don't realize until they're in the field and see over a period of time."

MOST COME IN VOLUNTARILY
About 70 percent of Brandywine Counseling's clients "walk in off the street seeking treatment," according to Blancato, and the remainder are referred by the justice system.

The first order of busines for LPNs, she explained, is to assess potential clients for their last use of heroin or other opiate, how long they've been using it over their lifetime, how long they've been using it daily, if they have any other medical problems and if they've been in any type of previous treatment program.

"Then they obtain the vital signs, get a urine specimen (and pregnancy test on all females) and send the client to the intake department for a complete history. The necessary paperwork is prepared and the client is given a physical by the attending doctor."

DIFFERENT STROKES
New clients generally remain under the intake department's care for 30 days while being evaluated on their specific needs. Then they are placed in one of several different treatment programs conducted by the clinic. For example, the prenatal program provides specific methadone treatment for pregnant addicted women. "Pregnant women should stay on methadone until giving birth," Blancato noted. "Otherwise, they could abort during withdrawal. Babies actually are healthier when born to mothers who have been on methadone than if they have been on the street doing other drugs."

Detoxing newborns, which takes between 2-6 weeks, is done using opium, she added.

Other clinic components include a bridge program for young mothers with children up to 7 years old, and an assertive treatment team for chronic drug users who have the dual qualifier of multiple medical problems and previous unsuccessful attempts to get clean. A special program called Aegis is set up for Hispanics and other minority populations who are at high risk, such as HIV clients and others previously unable to get clean.

The counseling center's Drug Diversion component, which handles the largest volume of clients, treats individuals who are ordered by the court to undergo urine screens and counseling because of drug possession or driving under the influence when arrested. If they sign up for the Drug Diversion program and their urine continues to be clean over a 6-month period, Blancato explained, their criminal charges will be dismissed.

The Core department, with the second largest volume, handles those being treated with methadone who are not in a special category.

Then there is the COAP (Community Outreach AIDS Prevention) department, which is a service for people not coming in on their own for help. It is staffed by people comfortable with the high-risk environment of the inner city whose job it is to try to convince addicts to enter a treatment program. "A lot of addicts are snorters whose mentality is that if they snort [rather than use needles] they won't get AIDS" and therefore don't need treatment," Blancato commented. "But this is not true, because sharing straws for snorting also can pass on the virus."

Another therapy, offered to people who have only been using drugs less than a year is naltrexone (ReVia^®, DuPont Pharma.), which is a non-addictive opiate drug blocker. It works by covering receptor sites in the brain where any type of opiate would go, Blancato explained, so if the person would take an opiate-based pain pill, for instance, naltrexone blocks the opiate from activating, thus preventing them from going through withdrawal. This therapy often helps reduce the individual's total treatment time.

VIP STATUS A GOAL
While clients must understand their commitment to the treatment regimen involves daily visits to the clinic for their meds ? at $4 per ? plus random urine screens, counseling, group therapy and doctor's appointments, Brandywine Counseling offers some incentives to help them look ahead. These include "take home" privileges when they have met all the requirements (urines remain clean, fees are paid up and all appointments are kept, etc.). When they have met these conditions for 3 months, they can take two doses of meds home Friday for the weekend, so they don't have to come in Saturday or Sunday. After an additional 3 months, the same criteria will earn them another day of meds to take home. They lose that privilege, of course, if they are caught selling the methadone, or their urines are dirty, or they are chronically missing appointments, Blancato explained. After 2 years "in good standing," they only have to come in twice a week to pick up their medications.

About one-fourth of all the clinics' clients currently are on take-home status and thus "doing well," she reported.

Noting that there has been much success with the drug treatment program overall, Blancato said the clinic administrators are "constantly instituting new programs and changing policies and procedures to increase the standards of care and accommodate clients' needs." For instance, she added, "Encouragement and suggestions by the staff assist clients in their struggle to become drug-free."

While methadone does not work for everyone, over the years the clinic has helped many people, Malone added. Some have become totally detoxed from the program, while others may be on methadone for the rest of their lives, living rewarding and socially acceptable lifestyles.

Bette Mooney is a freelance writer and retired editor of ADVANCE Newsmagazines.