Office of National Drug Control Policy. Medication Assisted Treatment for Opioid Addiction. Healthcare Brief ONDCP. 2012. Available at: https://www.whitehouse.gov/sites/default/files/ondcp/recovery/medication_assisted_treatment_9-21-20121.pdf Accessed on: 2016-11-30.
SAMHSA. Medication and Counseling Treatment. Medication Assisted Treatment. 2015; 9/28/15: . Available at: http://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat Accessed on: 2016-11-30.
What is Medication-Assisted Treatment?

Individuals who are physically dependent may benefit from medication-assisted treatment in support of abstienence, and in some cases, detoxification. Medication assisted treatment needs to be combined with psychosocial treatment in order to be effective. Medication-assisted treatment may be used at multiple treatment level. The FDA has approved five medications for use in medication-assisted treatment (MAT) for alcohol and opioid use disorders:

  • buprenorphine, with or without naloxone (opioid use disorder)
  • methadone (opioid use disorder)
  • naltrexone (alcohol and opioid use disorder)
  • acamporosate (alcohol use disorder)
  • disulfiram (alcohol use disorder)

Buprenorphine and Methadone. The first two medications, buprenorphine and methadone, can be used for the initial process of quitting opioids (first stage of treatment - detoxification) and help reduce the need for in-patient care at this stage (ASAM, 2015; SAMHSA, 2015; SAMHSA, 2016). Buprenorphine and methadone also help in managing the worst of the period of withdrawal from opioids by relieving withdrawal symptoms and psychological cravings. Buprenorphine and methadone work via the opioid receptors; the same ones responsible for problematic dependence on opioids (ONDCP, 2012). They have weaker effects and/or have slower onset, so the individual does not feel "high" from taking them.

Naltrexone has a different mechanism, as it acts by blocking the receptors where opioids were having their effects (antagonist). By blocking the opioid receptors, the pleasant effects of opioids and alcohol are blocked (USDHHS, 2016). Naltrexone is used to block alcohol cravings, but may not be effective at reducing opioid cravings.

Naltrexone is supplied as tablets to be taken daily or as an extended release injection (USDHHS, 2016). The injection is more effective and can be given by an individual licensed and authorized to prescribe it by the state.

Acamprosate is used for alcohol maintenance (USDHHS, 2016). It acts by normalizing the brain neurochemistry, reducing cravings.

Acamprosate is given as a delayed-release tablet, provided by prescription and is not a scheduled substance. It can be given by an individual licensed and authorized to prescribe it by the state

Disulfiram is used for alcohol maintenance (USDHHS, 2016). It acts by creating metabolic products that cause a negative reaction and nausea, thus motivating the individual not to drink to avoid having this experience.

Disulfiram is given as a tablet and is not a scheduled substance.

These medications can be used to support long-term maintenance of being free from dependence on opioids (other than those being used in treatment) as they can be taken safely for years. Additionally, MAT has a higher rate of success than medication-free treatment. Whether or not medication-assisted treatment is chosen, however, psychosocial treatment is an important component of treatment and should be integrated into the overall treatment plan for your patients.

How Is the Treatment Chosen?

The provider and patient work together to select the best treatment considering:

  • Whether the patient is open to taking a medication to assist with treatment, including an understanding of the physical dependence they will have on methadone or buprenorphine
  • Efficacy, requirements/costs, side effects, and risks of each medication
  • Patient preference among the choices
  • Past experience with treatment
View ReferencesHide References
American Society of Addiction Medicine (ASAM). The ASAM National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use. . June 1, 2015. Available at: https://www.asam.org/quality-practice/guidelines-and-consensus-documents/npg Accessed on: 2015-10-06.
Office of National Drug Control Policy. Medication Assisted Treatment for Opioid Addiction. Healthcare Brief ONDCP. 2012. Available at: https://www.whitehouse.gov/sites/default/files/ondcp/recovery/medication_assisted_treatment_9-21-20121.pdf Accessed on: 2016-11-30.
SAMHSA. Medication and Counseling Treatment. Medication Assisted Treatment. 2015; 9/28/15: . Available at: http://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat Accessed on: 2016-11-30.
Substance Abuse and Mental Health Services Administration. Sublingual and Transmucosal Buprenorphine for Opioid Use Disorder: Review and Update. Advisory. Winter 2016; 15 (1): . Available at: http://store.samhsa.gov/shin/content//SMA16-4938/SMA16-4938.pdf Accessed on: 2016-03-05.
National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide. Rockville, Md: National Institute on Drug Abuse. 2012; December: . Available at: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment Accessed on: 2016-11-30.
Family Therapies

Family Therapies engage family members and friends to help support the patient's recovery and long-term abstinence. Different kinds of family therapies meet a variety of patient needs. Family Behavior Therapy (FBT) and Behavioral Couples Therapy (BCT) are most often used by adult patients (NIDA, 2012; USDHHS, 2016).

  • Family Behavior Therapy (FBT) looks at not only the substance use but also surrounding family issues that may contribute, such as conflicts in the home or mental disorders in the family (NIDA, 2012; USDHHS, 2016). FBT helps the patient set goals, develop skills, eliminate or change factors that might prevent treatment success, and prepare both the patient and their social support system for treatment. Therapy can last up to 20 sessions (NIDA, 2012; USDHHS, 2016).
  • Behavioral Couples Therapy (BCT) involves both patient and their spouse. It includes the patient making a "daily sobriety contract" and the spouse supporting this commitment, giving the patient some accountability (NIDA, 2012; USDHHS, 2016). The couple also learns effective communication and how to become involved in positive social activities that are substance-free (NIDA, 2012; USDHHS, 2016).
Twelve-Step Facilitation Therapy

Twelve-Step Facilitation Therapy (TSF) uses individual therapy sessions to support becoming involved in a 12-step program (NIDA, 2012; USDHHS, 2016). It includes milestones of acceptance, surrender, and active involvement, similar to 12 step programs.

The Matrix Model

The Matrix Model combines multiple evidence-based practices (family and group therapy, relapse prevention, self-help, reduction of other risky behaviors, and drug education) in a coordinated, sequential approach (NIDA, 2012; USDHHS, 2016). The treatment centers around group therapy (3 times a week for 16 weeks) which promotes social support, individual counseling, cognitive behavior therapy, family education, and urine drug testing in order to achieve the patient's overall goal of abstinence (NIDA, 2012; USDHHS, 2016).

View ReferencesHide References
National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide. Rockville, Md: National Institute on Drug Abuse. 2012; December: . Available at: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment Accessed on: 2016-11-30.
USDHHS. Facing Addiction in America. The Surgeon General's Report on Alcohol, Drugs, and Health. Surgeon General Reports. 2016. Available at: https://addiction.surgeongeneral.gov/ Accessed on: 2016-11-17.

Counseling is typically a part of any treatment program. A number of evidence-based treatment types have been shown to be effective for substance use disorders and may be a part of the treatment program to which you refer a patient. Alternatively, you may refer a patient who does not need that level of care directly for such counseling:

Cognitive-Behavioral Therapy

Cognitive-Behavioral Therapy (CBT) is grounded in the theory that certain patterns of behavior and thoughts can contribute to the development and maintenance of substance use disorders (NIDA, 2012; USDHHS, 2016). Weekly individual sessions (usually lasting 12-24 weeks) teach patients to identify thought and behavior patterns through self-monitoring and to cope with them as they arise in order to decrease substance use (NIDA, 2012; USDHHS, 2016). CBT has been shown to increase the rate of long-term treatment success and improve mental health outcomes for those with co-occurring mental health disorders (NIDA, 2012; USDHHS 2016).

Contingency Management and Community Reinforcement Approach

Contingency Management centers around tangible positive reinforcement for positive behavior change (NIDA, 2012; USDHHS, 2016). Positive behavior, such as participation in therapy sessions or having a negative urine drug test, is rewarded with vouchers that can be exchanged for desired objects, goods, or activities. Having a goal to work towards along with a tangible reward has been shown to be more effective than traditional treatment approaches in terms of longer abstinence and active engagement in treatment.

Community Reinforcement Approach (CRA) Plus Vouchers is an outpatient program that furthers the positive reinforcement approach by combining the voucher system with group therapy (NIDA, 2012; USDHHS, 2016). Group counseling sessions focus on how to reduce substance use and build support systems for long-term abstinence (NIDA, 2012; USDHHS, 2016).

Motivational Enhancement Therapy

Motivational Enhancement Therapy (MET) utilizes motivational interviewing techniques to support patients having uncertainty about ceasing substance use (NIDA, 2012; USDHHS, 2016). Patients develop awareness of how their actions and goals are misaligned, which often increases motivation to change their behaviors to meet their goals. MET uses empathy and support rather than confrontational tactics in order to promote change, which leads to self-efficacy in the patient and better long-term outcomes.

View ReferencesHide References
National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide. Rockville, Md: National Institute on Drug Abuse. 2012; December: . Available at: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment Accessed on: 2016-11-30.
USDHHS. Facing Addiction in America. The Surgeon General's Report on Alcohol, Drugs, and Health. Surgeon General Reports. 2016. Available at: https://addiction.surgeongeneral.gov/ Accessed on: 2016-11-17.
Treatment Technology

Emerging technologies have made it possible to support patient treatment inside the office and expand the exchange of information outside of office visits:

  • Telehealth delivery systems, such as electronic health records (EHR), allow for the exchange of patient information between providers, creating a more coordinated care approach for total health.
  • Patient portals allow for web-based delivery of information.
  • Mobile apps that can be used for patient education are readily available wherever the patient uses a mobile device and can be used to provide patient education.
  • Telemedicine provides remote clinical services to patients through the use of two-way, real-time interactions, such as through video conference calling. It allows patients to receive diagnosis and care for a number of ailments when they are unable to physically get to the medical office.

(USDHHS, 2016)

Assessments

Electronic assessments can help aid in early intervention for substance abuse, and also help your patients with their overall addiction treatment needs. Studies show that patients are more likely to disclose substance use within an online/digital setting rather than in face-to-face assessments (USDHHS, 2016). Studies have also shown that web-based, evidence-based assessments are effective in determining levels of substance use and identifying those who may benefit from treatment (USDHHS, 2016). These types of assessments can be utilized for early interventions, which will, in turn, improve treatment outcomes for those who need addiction support. NIDA has developed one such online screening tool. See the resources on this page or at the end of this module.

Interventions

Electronic interventions can be utilized to support and extend care outside the office setting. Ongoing electronic interventions, such as automatic motivational calls to patients with substance use issues, may help them to decrease their substance use over time and be more encouraged to work towards continued overall abstinence (USDHHS, 2016).

To find one of the many apps available that support recovery, direct patients to search their mobile app store for terms such as "substance abuse recovery apps" or "addiction apps".

View ReferencesHide References
USDHHS. Facing Addiction in America. The Surgeon General's Report on Alcohol, Drugs, and Health. Surgeon General Reports. 2016. Available at: https://addiction.surgeongeneral.gov/ Accessed on: 2016-11-17.
USDHHS. Facing Addiction in America. The Surgeon General's Report on Alcohol, Drugs, and Health. Surgeon General Reports. 2016. Available at: https://addiction.surgeongeneral.gov/ Accessed on: 2016-11-17.

Please be sure to always access the activity through the activity homepage, to ensure being able to progress through the modules correctly (Please do not "bookmark" pages directly). Once you enter through the activity homepage, you should get normal navigation.

Read More

Pages

Subscribe to SBIRT Training RSS