Stigma is common across all levels of a practice and can be a significant barrier to individuals with substance use disorders seeking and engaging in treatment. At the beginning of implementation, all clinic or practice staff should receive training that provides an overview of opioid addiction and medication-assisted treatment (MAT) for opioid use disorder.
This training should improve staff’s understanding of addiction as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”1 It should also increase staff’s knowledge of opioid use disorder and its treatment, specifically, and prepare staff to interact with these patients. Any new staff hired after implementation begins should also receive this training.
All practice staff, including organizational leadership and administrators, understand addiction is a chronic, relapsing brain disease and have received training on the basics of treatment for opioid use disorder.
How Do You Do It?
Start With the Basics
The implementation team should hold an initial training to orient all practice or clinic staff, including nonclinical staff, to the nature of opioid addiction and MAT as a form of treatment for opioid use disorder. This training should help improve their basic understanding of the patients they will serve and the MAT process. The following items should be key components of this training:
- Explain how addiction affects one’s brain chemistry. Understanding that opioid use disorder leads to fundamental changes in the brain can help reinforce to staff that it is a disease, not a moral failing. Build an understanding of risk and protective factors and of the kinds of behaviors common in people living with addiction. Increase the understanding of withdrawal symptoms and how avoiding withdrawal is a key driver to continuing opioid use.
- Teach how to spot the signs and symptoms of opioid use disorder. Everyone should have a basic understanding of behaviors, side effects, and complications of opioid use disorder that may present in patients. Practice staff should know and understand the reasons for program policies and expectations for patient behavior while in treatment.
- Describe the core components of MAT. Educate staff about MAT as a treatment approach, emphasizing that it is a “whole-person” approach that includes both pharmacotherapy and psychosocial supports.
- Explain how each of the medications to treat opioid use disorder works. Describe the effect of these medications on the opioid receptors in the brain, known as their mechanisms of action. Use visual aids and handouts to reinforce these concepts.
- Highlight the effectiveness of MAT. Teach staff about the positive impact MAT can have on patient’s lives. Show them the research that demonstrates it can reduce opioid use, increase retention in treatment, and decrease mortality. Acknowledge that no one approach works for everyone and that it is critical to adapt the approach to the individual patient’s needs. Also, emphasize that, while recovery is an achievable goal, it will take time. As with any chronic disease, relapse is common and is not a sign of failure but rather the need to adjust the treatment plan.
- Highlight the local context. Gather local county and State data to help contextualize the opioid epidemic in your community. Use these data in training with all staff to start a discussion about the importance of offering MAT.
- Prepare staff to speak about MAT. Front desk staff and other providers may receive questions or field concerns from other patients or members of the community about MAT. Provide some tips and talking points for staff so they know how to discuss MAT and describe your practice’s approach to treatment. This approach can help create a common understanding about what you are and are not doing as a practice, while dispelling some myths about MAT and individuals with substance use disorders.
Train Staff on Patient Engagement
As policies and protocols related to patient engagement are developed during the implementation process, all staff, including front office staff, should be trained on them. During these trainings, ask staff how they would respond to hypothetical scenarios or use role play to demonstrate appropriate responses. Allow staff to ask any questions they may have and to share their concerns.
Promoting Positive Staff Interactions. As previously discussed in the section on Culture Change, negative interactions with providers and staff can deter patients from staying in treatment. It is important to understand the way our biases and stigma can affect these patients.
At a biological level, social isolation can trigger a response in the brain that increases their likelihood of continuing to use drugs. All staff should be trained how to interact with patients in a respectful and positive manner. Patients can quickly perceive judgmental attitudes or behaviors from staff, even if they are unintentional. Individuals with opioid use disorder often experience intense guilt or shame, so staff should be careful not to reinforce these feelings.
On the other hand, positive staff interactions with patients can help create a supportive practice environment and promote engagement and retention in treatment, reducing the risk of continued substance use, overdose, and death. Staff should be trained on how to assess patient needs and enhance patient motivation. Customer service techniques should embed motivational interviewing principles, such as2:
- Asking open-ended questions to discuss the situation with the client,
- Focusing on the patient’s reasons for seeking treatment,
- Expressing empathy and compassion,
- Using reflective listening to summarize what you have just heard,
- Asking patients about their preferences and any anticipated issues with maintaining scheduled appointments, and
- Giving patients an opportunity to ask questions.
Addressing Challenging Behaviors and Diversion. Staff may encounter patients with challenging behaviors, and they need to be prepared to respond. Dr. Nora Volkow, Director of the National Institute on Drug Abuse, talks about the way opioids “hijack the brain” and can lead to harmful and socially unacceptable behaviors.3 Recognizing this phenomenon, programs should work to develop and train staff on approaches that reward positive behaviors and discourage problem behaviors.
Staff should also be prepared and adequately trained on how to handle concerns about diversion. Diversion is when patients give or sell their medication to treat opioid use disorder to another individual. Patients may do so for a number of reasons. Programs should use procedures to detect and limit diversion and adequately train staff on how to implement these strategies.
Recommended strategies to handle these problem behaviors and concerns about diversion will be discussed in more detail in the section on Challenging Patient Behaviors or Concerns.
Introduce New Protocols and Workflows
The section Operational Systems and Workflows provides further detail on what will need to be developed. The implementation planning team should include representatives from all staff subgroups to help develop new protocols and workflows. This approach will ensure the protocols are feasible to implement and acceptable to staff.
After designing the program, organizations need to adequately train staff on the new or changed policies, processes, and protocols before they are implemented. Provide an initial overview and orientation to the new or changed policy, process, or protocol. Be sure to highlight the impact on the roles or responsibilities of different types of office staff. Use diagrams or flowcharts to help staff visualize these changes.
Give staff some time to digest and understand these changes on their own, and then provide an opportunity for staff to share their questions or concerns in a group setting. Remember that everyone learns differently, but active participation often helps people retain new knowledge. Demonstrate the new activity and then have staff practice it themselves. Staff who feel comfortable after being trained on the new workflows can help teach or support others in the organization.
What Not To Do
- Don’t underestimate the need to address stigma and bias related to addiction and to educate staff about the chronic, neurobiological nature of addiction.
- Don’t try to train staff on new policies, processes, and protocols all at once. Break them into logical subgroups and gradually introduce them.
- Don’t expect team members to immediately adjust to changes in workflow and to adopt new treatment models. Recognize that these adaptations take time and support.
- National Institute on Drug Abuse. Drugs, Brains, and Behavior. The Science of Addiction. NIH Pub No. 14-5605. Rockville, MD: National Institute on Drug Abuse; 2014. https://www.drugabuse.gov/sites/default/files/soa_2014.pdf. Accessed May 3, 2019.
- Strauss E, Decker D. Increasing Retention. Strengthening Treatment Access & Retention—State Implementation (STAR-SI). N.d. https://niatx.net/StarSI/Annual_Meeting07/9.45_Retention.pdf. Accessed May 3, 2019.
- Volkow N. What Does It Mean When We Call Addiction a Brain Disorder? National Institute on Drug Abuse; 2018. https://www.drugabuse.gov/about-nida/noras-blog/2018/03/what-does-it-mean-when-we-call-addiction-brain-disorder. Accessed May 3, 2019.