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A behavioral health practitioner reflects on Medication Assisted Treatment and Medications for Opioid Use Disorder

Monday, October 19, 2020
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By:  Dan Mullin

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This summer a fellow behavioral health professional reached out to a listserv in which we participate for some insights into working as a behavioral health practitioner in a clinic focused on Medication Assisted Treatment and Medications for Opioid Use Disorder (MAT/MOUD).  My clinical work is as a BHP in a rural clinic that has a substantial population of individuals and families impacted by substance use.  Most of our medical providers have their DATA waiver and can prescribe buprenorphine or naltrexone. And I have collaborated with some of those providers in presenting to groups about MOUD and harm reduction as well as delivering and developing DATA waiver training.

Here are my thoughts.

Intervention Skills

Behavioral health services should be optional not required for patients receiving MOUD (buprenorphine or naltrexone).  Motivational Interviewing is a critical skill for engaging these patients in care.  Though many providers have been exposed to MI, very few are skilled enough to provide MI consistent interventions - additional training in this area would be helpful.  Role plays and practice to build MI skills are ideal approaches to training, unfortunately, lectures alone will not build MI skills. 

Patients will also need to develop skills in psychoeducation and relapse prevention-based interventions.  Behavioral activation and cognitive behavioral therapy (CBT) are helpful for addressing the co-morbid anxiety and mood disorders experienced by many patients with OUD.  The ability to help couples and families adjust to and process recovery from active substance use is important. 

Assessment Skills

The best assessment questions are future-oriented “What do you want your life to look like in one year?” the least helpful assessment questions are history-focused “At what age did you first use opioids?”  A detailed history of a patient’s substance use will not change your approach to treatment.  While specialists focus on collecting exhaustive histories of their patients, primary care team members should spend less of their time collecting data that does not inform the treatment option.  There are also strategic problems with asking patients to recount all of their “failures” or “poor choices” at the same time you are trying to engage them in treatment.   It is far more helpful to focus on their goals for the future and helping them to identify their own motivations for change. 

The rates of violence against women with Opioid Use Disorder (OUD) are extremely high - 60-90% by some estimates.  Clinicians should consider a universal precautions approach and assume all these patients would benefit from trauma-informed care.  You don’t need to screen for trauma, it’s probably there, assume it’s there, and when patients trust you, they will disclose.  Do not force these patients to talk about trauma unless they want to, and even then, in many cases it is best to get stable on MOUD before launching deeply into trauma work. 

You will encounter many patients with symptoms of panic disorder that will be hard to treat without medications, this work is tricky.  Be patient.  These patients tend to be locked into using substances to manage their arousal, they rarely believe that non-pharmacological interventions can help.  And sometimes they are right to be skeptical about the value of breathing techniques, mindfulness training, or relaxation training.  Nevertheless, be patient and continue to offer but not insist on offering behavioral strategies for management of panic symptoms.  This work takes patience on the part of the clinician and the patient. 

You will encounter many patients with mood disorders and OUD.  When the patient is clearly struggling with Major Depressive Disorder (MDD) they can be treated with usual meds and behavioral activation or CBT.  Many of these patients will have a diagnosis of bipolar disorder in their chart.  If the diagnosis was made during the time they were using substances, consider delaying treatment if you can safely get them to 30-60 days of not using opioids while you try to understand if they actually have bipolar depression before launching into meds for bipolar.  You will need collateral family information and a better history to make this assessment.  Be sure you know how to get timely consultations from a psychiatrist who understands buprenorphine but use these referrals sparingly, for patients with real concerns about self-harm or especially serious symptoms. 

I would suggest BH providers participate in training.  My team at the Center for Integrated Primary Care delivers this training and would be happy to discuss it with you.  You also need to train non-clinical staff and help them understand that this work is not “trading one addiction for another.”  If you don’t give your staff the opportunity to participate in discussions about MOUD then you will find they develop their own attitudes about the work, and often these attitudes are not helpful. 

Providers need to be literate in harm reduction and Motivational Interviewing.  It is important that they understand the enormous stigma and misinformation about SUD and SUD treatment in our society.  Much of this misinformation has been internalized by providers, including BH providers.  They need to understand the similarities and differences between treating OUD and alcohol use disorder.  The typical eight-hour required buprenorphine training for providers is unhelpful in addressing these issues, so you will need supplementary training focused on this topic. 

Buprenorphine is a controlled substance.  But providers should throw out all of their preconceptions about how this controlled substance compares to other controlled substances.  Buprenorphine is safe and almost always improves the functioning of patients who take it.  It also greatly reduces the risk of death.  This makes buprenorphine different from full agonist opioids, stimulants, and benzodiazepines - which are clearly helpful for some patients and clearly harmful for other patients.  The risk/benefit equation is completely different.