As previously noted, counseling and behavioral therapies that address the psychological and social needs of individuals with opioid use disorder are embedded in the definition of medication-assisted treatment (MAT). Behavioral health services can help address the underlying causes of opioid use disorders, co-occurring substance use disorders, and other comorbid mental health conditions. Learn more in Co-Occurring Behavioral Health Conditions.
Providers should tailor the type and intensity of psychosocial support to the patient’s needs and preferences. All practices and organizations implementing MAT should establish systematic policies, processes, and protocols that address how they will collaborate with internal or external providers for behavioral health services.
Practices ensure that patients who are willing to engage in some form of behavioral health services are connected with internal or external providers to address their current issues or needs. Ongoing communication, information sharing, and care coordination take place between medical and behavioral health providers.
How Do You Do It?
Understand the Role of Behavioral Health Services
The types of behavioral health services and psychosocial support in MAT vary widely depending on patient needs, setting, providers, treatment model, and availability of services. A range of methods to deliver psychosocial support may be used:
- Individual counseling
- Group therapy
- Self-help groups
- Family therapy
- Peer services
- Case management
The Substance Abuse and Mental Health Services Administration Treatment Improvement Protocol (TIP) 63 expert panel notes that “counseling and ancillary services should target patients’ needs and shouldn’t be arbitrarily required as a condition for receiving opioid use disorder medication.”1 They further clarify that the law requires buprenorphine prescribers to have the ability to refer MAT patients to counseling and other adjunctive services. Providers can meet this requirement by providing counseling to patients themselves or by maintaining a list of potential referrals.1 However, it does not require providers to guarantee patients are actively engaging in counseling or psychosocial support.
The first question providers should ask is whether patients have current problems or concerns that they think any kind of counseling, coaching, or support might help with.2 Questions using motivational interviewing techniques may help the patient recognize areas in which behavior change could be beneficial.
Patients may be reluctant to explore the possibility of or engage in counseling and psychosocial support, particularly in the beginning stages of treatment. If so, providers should return to the conversation about referrals to behavioral health services after they have stabilized on the medication.
In particular, individuals with a history of trauma may be reluctant to participate in counseling, especially in group settings. Providers should recognize that trauma is extremely common, especially among individuals with opioid and other substance use disorders, and that a history of trauma may affect how they seek or engage in care. Learn more about how to incorporate evidence-based treatment approaches such as trauma-informed care.
If patients indicate an interest or willingness to engage in behavioral health services, providers should identify their unique needs, preferences, and challenges before making the referral.2 Not every patient will need intensive, adjunctive behavioral health services, but such services may help address the underlying causes of the addiction and promote positive behavior change, particularly among those struggling to meet their treatment goals. Some patients may need or prefer community-based recovery support services that help them achieve stability and success in life and recovery.
Coordinate With Internal Behavioral Health Services
Some organizations or practices may already have counseling or behavioral therapies integrated in their service model or may be interested in adding these services to complement the MAT program. One advantage of integrated behavioral health care is the ability to provide patients with quick and convenient access to these services.
The following discussion highlights some key considerations for organizations offering internal behavioral health services for patients with opioid use disorder. For a more thorough, detailed guide to integrating behavioral health in primary care, refer to the AHRQ Academy’s Integration Playbook.
Leverage Existing Service Models. Behavioral health services may be integrated into primary care through a variety of models. Examples include:
- Collaborative Care: In this model, primary care treatment for patients with one or more behavioral health disorders is enhanced by adding care management for monitoring patients between visits and regular review of patients, using a registry, by a psychiatrist or other appropriate behavioral health clinician. Care management and consulting psychiatry can be provided either onsite or remotely. Extensive evidence shows the effectiveness of this model, and it can be very cost-effective as it stretches scarce behavioral health staffing resources.
- Behavioral Health Consultant: This model, sometimes also called the Primary Care Behavioral Health (PCBH) model, includes a licensed clinician, typically onsite, who works as part of the care team with the medical staff and is available for warm handoffs and huddles.
When leveraging existing internal behavioral health models, providers should consider that internal barriers may limit these efforts. Stigma against treating patients with opioid use disorder, or using MAT, may exist and need to be identified and worked through. Additional training may be needed for providers to learn about supporting MAT and how to use their existing skill set to help those with substance use disorders.
In the case of the Collaborative Care model, the consulting psychiatrist may not have the expertise to consult on substance use disorder issues. Additional addiction expertise may need to be sought in those situations or in-house local expertise developed. Finally, capacity issues can surface when expanding a service model’s scope. It is important to think through how internal services fit along the spectrum of care and which patients to refer elsewhere.
Refer Patients to Internal Behavioral Health Services. MAT programs should develop or adapt a process to connect patients receiving medications for opioid use disorders to behavioral health services, and vice versa. Practices should establish clear workflows for communications, information sharing, and care coordination.
Documentation in the common medical record is key to integration and care coordination. For example, it should detail the diagnosis, type of treatment to be provided, patient’s engagement in treatment, progress, and any other treatment or care coordination needs.
Whenever possible, providers should do a “warm handoff” between medical and behavior health staff, in which one provider directly introduces the patient to the other provider. Warm handoffs can help facilitate communication between providers, build relationships, and ensure referrals are not lost to followup. Relationships are fundamental to quality care. The goal is for the patient to see behavioral health services as one integrated dimension of their overall care for opioid use disorder, not as a separate and parallel health problem or treatment regimen.
Programs should aim to maximize opportunities for informal and formal interactions between medical and behavioral health staff to promote coordinated care. This approach includes team “huddles” during which providers can help plan patient care and share observations. The whole integrated care team should be involved in coordinating care, tracking patient outcomes, and monitoring patient progress. For more information, refer to Referrals and Care Coordination.
Connect the Patient to External Behavioral Health Services
Identify Programs and Providers. As programs begin implementing MAT, they should develop a list of resources for external behavioral health and community support.3 This list should be revised on an ongoing basis and should include substance use, mental health, and medical providers or programs across levels of care and treatment settings. If possible, the program should establish a formal working relationship with the external provider that specifically addresses areas such as communication, information sharing, and care coordination. This template of a Memorandum of Understanding (Word—22 KB) between primary care and substance use treatment providers provides general guidelines regarding what to include.
It is also important to identify locally available community-based services and recovery support. Some patients may hesitate to follow up on working with external substance use treatment counselors, but may be open to peer recovery support groups such as Alcoholics Anonymous, Narcotics Anonymous, or Self-Management and Recovery Training.3 Learn more about Community-Based and Recovery Supports. It is important to be aware that some recovery support groups may have negative attitudes toward MAT, and patients may want to avoid those groups.
Some communities, particularly rural areas, may have a shortage of behavioral health providers or recovery support groups. In these situations, practices should explore telehealth options or phone or web-based apps.
Connect Patients to External Providers. When connecting a patient to an external behavioral health clinician, providers should3:
- Obtain patient consent to share information;
- Consider patient needs and preferences (e.g., program availability, eligibility, and affordability);
- Actively connect patients with external providers (e.g., calling the program on behalf of the patient to make a connection as opposed to providing a phone number to follow up with); and
- Follow up to determine if the patient connected with and worked with the external provider.
Ongoing care coordination will be key to successful patient outcomes when working with external behavioral health providers. Practices should create processes to work with external providers to coordinate care. Upon referring a patient, providers should reach out to the external provider for an initial conversation about the patient’s needs and progress. This step can go a long way to help build a relationship with the external provider. Rather than relying on written progress notes or shared records, the whole care team of internal and external providers should have direct communication, or even meetings or “huddles” if feasible, to discuss the appropriateness of the treatment plan and make adjustments as needed. For more information, refer to Referrals and Care Coordination.
Practices also often report experiencing challenges related to the sharing of records with external providers because of restrictions set forth by the Code of Federal Regulations Title 42 Part 2. It is important that staff understand the limits on sharing information and requirements for patient consent without being unnecessarily strict. Learn more about privacy regulations and information sharing in General Operations.
What Not To Do
- Don’t withhold medication if a patient is not ready to engage in counseling or other psychosocial support.
- Don’t insist that all patients participate in the same type of psychosocial support activities or require them to engage on the same schedule.
- Don’t avoid leveraging internal behavioral health services.
- Don’t make referrals to external providers without building some connection. Establish ground rules about information sharing and care coordination, if possible.
Treatment Improvement Protocol (TIP) 63. Part 4: Partnering Addiction Treatment Counselors With Clients and Healthcare Professionals
- Substance Abuse and Mental Health Services Administration. Treatment Improvement Protocol 63: Medications for Opioid Use Disorder. Part 4: Partnering Addiction Treatment Counselors With Clients and Healthcare Professionals. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018. Publication No. SMA18-5063PT4. https://store.samhsa.gov/system/files/sma18-5063pt4.pdf. Accessed May 21, 2019.
- Substance Abuse and Mental Health Services Administration. Treatment Improvement Protocol 63: Medications for Opioid Use Disorder. Part 2: Addressing Opioid Use Disorder in General Medical Settings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018. Publication No. SMA18-5063PT2. https://store.samhsa.gov/system/files/sma18-5063pt2.pdf. Accessed May 20, 2019.
- Substance Abuse and Mental Health Services Administration. Treatment Improvement Protocol (TIP) 63: Medications for Opioid Use Disorder. Part 3: Pharmacotherapy for Opioid Use Disorder. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018. Publication No. SMA18-5063PT3. https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Pharmacotherapy-for-Opioid-Use-Disorder-Part-3-of-5-/SMA18-5063PT3. Accessed May 20, 2019.