Delivering Effective, Low Barrier Treatment

Practices and organizations implementing medication-assisted treatment (MAT) must recognize that addiction is a complex illness—a fact that should inform every aspect of their approach to treatment. No “one-size-fits all” approach is available. Patient-centered care, which will be discussed in great detail later in this Playbook, is a key theme in chronic disease management and can help empower patients to make better decisions about their treatment.

A number of organizations have developed principles or strategies for effective substance use treatment, including the National Institute on Drug Abuse Principles of Effective Treatment, the Shatterproof National Principles of Care, and NIATx Promising Practices.

For the purposes of this Playbook, we have summarized and synthesized these ideas to develop the following set of principles for substance use treatment integrated in ambulatory care settings. While practices and organizations may have limited resources and capacity to treat complex patients, these themes will inform the approach taken throughout this Playbook and should be kept in mind as programs begin to implement MAT.

North Star

Practices and organizations adopt models of care that are flexible enough to tailor treatment to the patient’s individual circumstances and needs. Patients have access to medications to treat opioid use disorder as soon as clinically appropriate, and shared decision making is a standard of practice.

How Do You Do It?

Principle #1: Implement Routine Screening To Identify Individuals With or at Risk for Substance Use Disorders

Universal screening for substance use disorders should be integrated into routine care in primary care and other ambulatory care settings. Screening can help identify and prevent substance misuse and substance use disorders, including opioid use disorder. Individuals with symptoms of a substance use disorder should undergo a diagnostic assessment and be connected with treatment as soon as possible.1

Principle #2: Facilitate Fast Access to Treatment

Treatment needs to be readily available and accessible to those who need it.2 Addiction can alter one’s brain chemistry, which can affect motivation, inhibition, and stress tolerance. When patients are motivated or ready to engage in treatment for their substance use disorder, it is important to seize this moment and connect them with appropriate treatment as soon as possible.1

Starting patients on medications on the same day they are first seen by providers improves retention in treatment.3 Originally, clinical recommendations for the use of buprenorphine to treat opioid use disorder were heavily influenced by strict methadone regulations. These cautious practices have inadvertently created barriers to accessing and continuing care. Over time, new evidence has emerged that that these “common, widespread, and outdated practices have the paradoxical effect of potentially harming patients.”4

For example, inductions do not always need to be performed in medical settings. Home inductions with adequate education, support, and communication can be safe and effective.4 Similarly, providers have traditionally withheld buprenorphine if a patient was taking benzodiazepines or other substances. However, the potential harms of an untreated opioid use disorder outweighs the risks of using both medications.4

Principle #3: Take a Patient-Centered Approach to Service Models and Care Plans

No single treatment approach is best for everyone.2 Treatment for substance use disorders should consider each patient’s unique social, mental, biological, and environmental needs1 and tailor the types and intensity of services offered to patients accordingly.3 Treatment plans should be regularly assessed and modified to meet the patient’s changing needs.2 For example, someone in the early stages of treatment may want help meeting basic needs (e.g., housing and food stability) before engaging in regular counseling appointments.3

Practices should consider how to incorporate patient-centered care principles as they design their service models and approach. Programs should also develop strategies to identify patients who may be at risk for leaving treatment. Staff should work to address patients’ unique barriers to care and try to keep them engaged in the program.3 Patient needs and preferences should help inform how to develop operational systems and workflows. For example, practices should consider offering hours dedicated to a walk-in clinic or during the evening or weekends to accommodate patients’ schedules.3

Principle #4: Recognize That Addiction is a Chronic, Relapsing Brain Disease

Addiction is a complex, yet treatable, disease that affects the brain.2 Providers should recognize that recurrence of use is a common part of a chronic, relapsing disease such as addiction. It does not mean these patients are inappropriate for or “failing” treatment, but rather require more support and potentially adjustments to their treatment plan.4 Practices should use the results of drug testing as a tool to indicate patient progress toward treatment goals rather than a method of punishment or a reason to remove a patient from buprenorphine treatment.4

Polysubstance use is very common among individuals with opioid use disorder. Different substances may require different treatment strategies or clinical approaches. Continued use of other substances should not be viewed as an indicator that MAT is not successful; rather, the patient may need adjunctive services. Providers should consider taking harm reduction approaches related to the use of other substances and maintaining these patients in treatment.4

Principle #5: Address the Holistic Needs of the Patient To Support Recovery

Effective substance use disorder treatment addresses holistic needs of the individual, not just his or her substance use.2 Individuals with substance use disorders, including opioid use disorders, often have complex needs and can benefit from treatment that goes beyond what medication provides.

Ideally, treatment of the substance use disorder and other co-occurring conditions would be delivered in a fully integrated health care system or through carefully coordinated care across different providers.1 Most individuals who enter treatment for a substance use disorder also have a co-occurring mental health or medical disorder.

For example, individuals with substance use disorders often present with physical health problems such as chronic pain, sleep disorders, infectious diseases, diabetes, or hypertension.1 Treatment programs should test patients for the presence of infectious diseases and provide targeted risk-reduction counseling, linking patients to treatment if necessary.2

Behavioral therapies are the most commonly used form of substance use disorder treatment and can be effectively combined with medication to address patients’ unique needs.2 Many individuals with substance use disorders have co-occurring mental health conditions,2 such as depression, anxiety, and post-traumatic stress disorder.1 Behavioral therapies can not only teach patients coping strategies and promote behavior change related to addiction, but also help address the patients’ other mental health needs.

However, not all patients will need traditional counseling to achieve recovery or treatment goals. Patients have different needs and preferences related to behavioral therapies and recovery supports. They may also differ in the types or intensity of psychosocial supports needed, depending on the phase of treatment.4

Sustained recovery may require practical and emotional support from family, friends, and the community.1It may be difficult for patients to maintain their recovery unless they have positive relationships, a stable living situation, and their basic needs met. While providers may not be able to directly address these issues, they should consider these needs when developing treatment plans.

MAT programs should connect patients with nonmedical recovery support services in the community,1 such as peer services, self-help groups, supported education or employment services, and housing.

Principle #6: Support Long-Term Retention in Treatment

Staying in treatment for enough time is critical to the patient’s long-term success and sustained recovery.2 MAT has no standard length, and prematurely discontinuing treatment can pose great risks to the patient, including overdose death. Patients should be allowed to continue to receive buprenorphine treatment as long as it is benefiting them, and any decisions to discontinue treatment should be a shared process between patient and provider.4

Long-term outpatient, community-based care with ongoing monitoring is key to recovery. As patients’ needs change over time, the nature and intensity of care should be adjusted accordingly.1

What Not To Do

  • Don’t have a single fixed program design that every patient is expected to fit within.
  • Don’t forget to identify what is important to patients and use motivational interviewing principles to encourage them to begin and remain in treatment.
  • Don’t expect all patients to progress at the same rate or treat them disrespectfully if they stumble and return to substance use.

Resources

References

  1. Shatterproof. National Principles of Care for Substance User Disorder Treatment. New York: Shatterproof; 2018. https://www.shatterproof.org/shatterproof-national-principles-care. Accessed June 4, 2019.
  2. National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). Bethesda, MD: National Institute on Drug Abuse; 2018. https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/preface. Accessed June 4, 2019.
  3. NIATx. Promising Practices. Madison, WI: NIATx; 2019. https://niatx.net/promisingpractices/Search.aspx?SPNID=19. Accessed June 4, 2019.
  4. Martin SA, Chiodo LM, Bosse JD, et al. The next stage of buprenorphine care for opioid use disorder. Ann Intern Med 2018;169(9):628-35.