Counseling and Other Psychosocial Supports

As described in Screening and Diagnosis, screen patients for co-occurring psychiatric disorders common among people with OUD (or re-screen them if time has passed since the initial screening). Screening for anxiety and depression is recommended by the U.S. Preventive Services Taskforce,⁵ and can be more informative than simply asking the patient. Common co-occurring disorders with SUD with screening tools are as follows:

• Depression:
  • Data Element: Patient Health Questionnaire 9 item (PHQ-9) total score [Reported] (2001) - 9-item questionnaire with a suicide risk screening, or
  • Form: Patient Health Questionnaire-2 (PHQ-2) (2015) - 2-item questionnaire without a suicide risk screening;
• Anxiety: Generalized Anxiety Disorder 2-item (GAD-2) - Mental Health Screening - National HIV Curriculum, or Generalized Anxiety Disorder 7-item (GAD-7) scale; and
• Post-Traumatic Stress Disorder (PTSD): Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) - PTSD: National Center for PTSD (2015).

For patients who screen positive for mental health symptoms, consider referring for counseling and other psychosocial supports and, if indicated, prescribing psychiatric medications. Even if a patient does not meet criteria for a psychiatric disorder, they may benefit from counseling and other supports.

In addition, ask your patients whether they have current problems or concerns that they think counseling or extra support might help.²⁵ If they indicate an interest or willingness to engage in mental health services or other supports, refer the patient based on their unique needs, preferences, challenges,¹⁵⁶ affordability, and availability of services. If your practice has made progress toward integrating behavioral health services you may already have relevant professionals as part of the care team, either internally or through well-established collaboration. Note also that there are digital therapeutics available that have been found to be effective in symptom reduction, either on their own or in combination with in-person or virtual therapies.⁸ Not every patient will need intensive mental 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.

One patient with OUD shared,

Common categories of support include:

• Mental health therapy or counseling, which can include individual, group, or family sessions;
• Substance use counseling, which can also include individual, group, or family sessions;
• Peer support services and self-help groups, such as Alcoholics Anonymous, SMART Recovery, and Narcotics Anonymous (These meetings are typically free or request an optional, discretionary contribution. Prescreening is suggested as some programs staunchly disapprove of the use of medications for OUD, so they would not be appropriate. Note that virtual self-help groups are also becoming more widely available); and
• Case or care management, which is particularly helpful for patients with health-related social needs such as safe housing, food assistance, education/employment, transportation, childcare, and so forth.

• Motivational Interviewing (MI): This evidence-based series of techniques or brief intervention aims to help individuals resolve ambivalence toward making behavior changes. MI requires providers to be supportive and empathic to help patients build confidence and optimism in their ability to change. To learn more, see Resources.
• Cognitive Behavioral Therapy (CBT): This method is one of the most used evidence-based approaches in mental health treatment. CBT helps patients identify their problem behaviors and triggers for substance misuse and teaches them skills and coping strategies to manage cravings and high-risk situations.
• Contingency Management (CM): This evidence-based approach involves programs providing patients with rewards (e.g., cash voucher or prize) to reinforce positive behaviors such as abstinence and treatment engagement.
• Family Therapy: Support from and healthy relationships with family members as well as a safe, stable living environment can be key to an individual's recovery. Family therapy can help address not only the individual's substance use, but also other underlying issues with co-occurring mental health disorders; family conflict; and other health-related social needs such as employment and housing. Family-based approaches can also be particularly important when treating adolescents.
• Mobile Apps: Internet-based or mobile apps, such as Reset-O, DynamiCare, WEconnect, and OARS incorporate CM and CBT strategies to support recovery. Other apps, such as CHESS Health, have a more comprehensive array of supports such as CBT, coaching, peer groups, and education. See the Integration Academy Topic Brief on Behavioral Health Apps in Primary Care for a discussion of the use of apps, including pros and cons. Note that there is some recent evidence that these tools can improve treatment outcomes.¹⁰
• Recovery Supports: People with OUD are more likely to have experienced a trauma, with rates exceeding 80%.¹¹ Sex differences have been observed in the types of traumas experienced, response to trauma, rates of PTSD, and treatment response.^12,13 Patients' experience with trauma may affect how they engage in care. See the Integrate Trauma-informed Care section for more information. There has been a growing use of peer recovery specialists, who can play a crucial role in treatment for OUD by providing support and guidance based on their own lived experiences with recovery. They offer emotional support and mentorship, serving as positive role models and sharing their recovery journeys to inspire hope and demonstrate that recovery is possible.¹⁴ Additionally, they educate individuals about medications for OUD, dispelling myths and misconceptions, and advocate for patients' needs within the healthcare system.¹⁵ While there is a need for additional research on the impact peer recovery specialists on medication adherence for OUD, incorporating peer support services into primary care treatment is an accessible and increasingly utilized way to engage and retain patients in recovery support.^16,17

Mental 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 comorbid mental health disorders is enhanced by adding care management to monitor patients between visits and regular review of patient progress by a mental 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 mental health staffing resources.¹⁹
• Mental 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.²⁰

Note that the consulting psychiatrist or mental health clinician may not have the expertise to consult on issues related to opioid and other SUDs. You may need to supplement with additional addictions expertise or develop in-house expertise. Finally, capacity issues can surface when expanding a service model's scope. Consider where the practice and its internal service capacity fits along the continuum of OUD care to determine which patients to refer elsewhere.