What Not To Do

As you work toward implementation, it is important to keep in mind paths and obstacles to avoid. Awareness of what not to do will help your organization succeed in implementing medication-assisted treatment (MAT) and ultimately enhance patient care and health outcomes. Below is a list of things not to do while implementing MAT in your setting organized by section of the Playbook.

Offline Version
An abbreviated version of this list is available for download. You may wish to print several copies of the infographic for providers and staff to reference.

Plan To Integrate Medication-Assisted Treatment for Opioid Use Disorder in Your Ambulatory Care Setting

  • Don’t decide not to prescribe medications to treat opioid use disorder because you have limited access to behavioral health services.
  • Don’t take a “one-size-fits-all” approach to patient care. Patients will have different needs and preferences depending on the complexity and severity of their disease as well as other lifestyle factors.
  • Don’t dismiss providers’ and staff’s concerns about treating patients with opioid use disorder. Listen to and acknowledge their concerns, as they may have had negative experiences with individuals with substance use disorders, but brainstorm ways to address them.
  • Don’t take a top-down approach. You will need to involve staff across the organization to achieve buy-in.
  • Don’t expect change overnight. Organizational culture change takes time and messages need to be continuously reinforced.
  • Don’t include only senior leadership in the implementation planning process. Stakeholders from all levels of practice staff should be involved.

Initial Training

  • 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.
  • Don’t start prescribing buprenorphine until you complete the required amount of training, obtain your waiver, and develop a thorough understanding of proper treatment practices.
  • Don’t use a “one-size fits all” approach to evidence-based behavioral health counseling techniques. Adapt your strategies to the patient’s needs and preferences.
  • Don’t assume that behavioral health techniques should only be used by dedicated behavioral health providers. Strategies to help patients achieve behavior change are useful across provider types and disciplines.
  • Don’t assume every person with opioid use disorder will benefit from behavioral health techniques or require them for recovery.

Ongoing Training & Support

  • Don’t fail to take advantage of available resources such as mentoring and Project ECHO that can help you become comfortable managing more complex patients.
  • Don’t underemphasize the need for ongoing monitoring and supervision to avoid drift from the practices and models your program is implementing.

Principles of Substance Use Treatment

  • 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.

Operational System & Workflows

  • Don’t delay treatment due to requirements to complete paperwork that can wait.  
  • Don’t treat workflows as static processes. Re-evaluate workflows to identify points where patients are failing to initiate treatment or are being lost to followup, and adjust as needed to promote retention and engagement.
  • Don’t fail to recognize that every patient faces a distinct set of challenges that may interfere in engagement or retention in treatment. Tailor treatment approaches and services to their needs.
  • Don’t underestimate the importance of empathetic communication, listening, and relationship building to engage and retain patients in treatment.
  • Don’t unilaterally decide which medication to prescribe for the patient. The patient should have input into this decision through a shared decisionmaking process between patient and provider.
  • Don’t set an arbitrary limit on patients’ length of time in treatment or discontinue medications against their will.
  • Don’t terminate treatment on the basis of urine screens that show continued substance use; instead consider the appropriateness of more intensive treatment.
  • 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.
  • Don’t kick a patient out of the program for poor behavior, unless it poses a distinct risk to the safety of staff and other patients. If he or she can no longer be seen at your practice, do your best to connect the patient with another source of treatment.
  • Don’t forget that challenging and difficult behaviors are often a normal part of the illness, even though they still need to be addressed safely in the clinic.
  • Don’t assume patients diverting their medication have no interest in getting better. Some patients diverting or misusing their medication may be sharing their medications with a family member or friend who does not have access to treatment or selling medications because financial problems are challenging their ability to secure stable housing, food, and other necessities.   
  • Don’t take it personally when patients behave in a way that seems disrespectful of the program or you. Recognize that you may be seeing the results of an addiction that has “taken over” their brain and that engagement in treatment and recovery may still be possible in time.
  • Don’t send a paper or electronic referral to another provider and assume that will result in a successful care transition. Most referrals fail, and patients often don’t follow up. It’s essential to take a more active and coordinated approach in dealing with referrals and care transitions.
  • Don’t assume that the patient remembers why the transition or referral is taking place—how it will help them and how it fits their overall care. Don’t assume that the referral paper will be meaningful to the patient.
  • Don’t use privacy regulations as an excuse for not sharing information across the care team. Instead, develop patient consent forms that allow sharing of essential information that will keep patients safe, and train staff to help patients understand the value of information sharing.
  • Don’t focus only on your role in addressing a patient’s complex care needs. View yourself and your practice as part of an extended care team. Share information and contribute resources as you can.
  • Don’t forget your responsibility to be aware of the State and Federal privacy and confidentiality regulations and to comply with them.
  • Don’t let privacy and confidentiality regulations stand in the way of sharing critical information across the care team. Use appropriate patient consent forms and processes that authorize such sharing of information as a standard procedure.
  • Don’t forget to develop an understanding of DEA requirements and establish procedures to ensure you comply with them.
  • Don’t fail to consider using telehealth strategies to address problems of provider shortage or maldistribution.
  • Don’t rely on clinician impressions, outside referrals, or patient disclosure as your only methods for identifying patients who could benefit from MAT.
  • Don’t assume that one treatment model is appropriate for all patients. Recognize that each patient has unique strengths and challenges and that differing levels of care may be appropriate depending on those factors and the patient’s stage in the treatment process.

Financial Sustainability

  • Don’t start implementing MAT without considering the need for long-term financial stability. Developing a sustainability plan should be an early component of your MAT work.
  • Don’t fail to explore alternative payment models (APMs) that may be available from the payers in your patient mix. APMs that reflect clinical requirements can sometimes be negotiated to better support MAT.
  • Don’t miss the opportunity to be innovative in your clinical and staffing approach, building on the evidence base on what works for the kinds of patients you treat.
  • Don’t forget to document the essential information in the medical record that will support clinical decisions made and help address utilization management requirements.
  • Don’t forget to develop organized workflows for billing and to respond to utilization management requirements for each payer.
  • Don’t hesitate to advocate with payers to develop more enlightened and evidence-based practices to support treatment of people with opioid use disorder, including use of APMs that cover the full range of required services at sustainable rates.

Patient-Centered Care

  • Don’t ignore the impact of social determinants of health on patient behaviors and outcomes.
  • Don’t forget there are many paths to recovery. Everyone is unique, and what works for one person may not work for another.
  • Don’t expect patients or their families to have well-formed or accurate information about substance use disorders or their treatment. Providing education grounded in evidence and experience is important.
  • Don’t fail to appreciate cultural and linguistic differences in patients and their families and the need to adapt communication styles to be effective with your audience.
  • Don’t underestimate the central importance of building and sustaining relationships to the process of recovery.
  • Don’t allow comprehensive screening and assessments upon intake to delay patients’ access to medications.
  • Don’t assume patient needs will stay the same throughout the course of treatment. Conduct periodic assessments to help inform adjustments and updates to the treatment plan.
  • Don’t develop a care plan and consider the process complete. The shared care plan should function as a living document that members of the care team refer to and update on an ongoing basis.
  • Don’t develop a care plan without input from the patient.
  • Don’t develop treatment plans without giving full consideration to the unique needs and characteristics of the individual patient you are working with.

Other Common Issues Among Individuals With OUD

  • Don’t think of mental health and substance use disorders as separate conditions that require separate treatment. It’s important to remember that they may drive one another or impede a patient’s long-term success if untreated.
  • Don’t withhold diagnosis or treatment of patients’ mental health disorder until they have stopped using opioids. Sometimes, both will need to be addressed at the same time to help a person stop using opioids. 
  • Don’t think that suicide risk is fixed. Risk of suicide may fluctuate over time depending on life stressors, so it is important to frequently rescreen or assess patients.
  • Don’t screen for suicidality without a plan for how to respond if the results indicate a patient is at risk for suicide.
  • Don’t think there’s nothing you can do for patients at risk for suicide if you’re not trained as a mental health practitioner. Screening tools and effective interventions are available that can be implemented in primary care or other health care settings.
  • Don’t assume that screening is the only way to identify patients at risk for suicide. Be alert to other warning signs or cues you may encounter.
  • Don’t forget to assess patients’ risk for infectious disease at the beginning of treatment or throughout treatment, especially if a person is still using illicit drugs.
  • Don’t wait for a person to have stopped using substances before connecting them with care for infectious diseases.
  • Don’t treat pain as an experience as simple as 0 to 10 on a numeric scale. Conduct a complete assessment to fully understand the patient’s dimensions of pain.
  • Don’t forget that pain can be mysterious and scary for patients. Educate them on the biopsychosocial model of pain and reassure them that there is a difference between hurt and harm.

Monitor Patient & Program Progress

  • Don’t create barriers to access to naloxone.

Patient Progress Assessment

  • Don’t discharge or “fire” a patient who is not making progress. Patients who are struggling need more help, not less.
  • Don’t forget to consider a patient’s personal definition of “success” as a critical outcome. 

Recovery Plans for Recurrence of Use

  • Don’t assume that a prevention plan will stay the same throughout the course of treatment. The risks of returning to substance use change over the course of recovery and a patient’s stressors, coping strategies, and needs will similarly evolve.
  • Don’t respond to recurrence of use by punishing or involuntarily discharging a patient.
  • Don’t feel disappointed in the patient if he or she returns to using substances. Setbacks should be expected. The most important thing is how you respond and what you do when they occur.

Collecting & Using Data for Quality Improvement

  • Don’t forget that quality improvement is an ongoing process, not a singular initiative.
  • Don’t jump right in and make a change. Collect baseline data first so you can see if the change has a measurable effect.