Person-Centered Treatment Considerations

SAMHSA defines trauma as resulting “from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being.”¹

The link between trauma and substance use is well documented, with high rates of comorbidity between post-traumatic stress disorder and SUDs.² A history of trauma can also increase the risk of early treatment dropout.³ To support retention and recovery, it is critical to integrate trauma-informed approaches into care delivery.

When treating patients with OUD, it is helpful to assume a trauma history is likely. Integrate trauma-informed care across all aspects of treatment. SAMHSA describes a trauma-informed program as one that:¹

• Realizes the impact of trauma and knows ways to promote recovery;
• Recognizes the signs and symptoms of trauma in clients, families, staff, and others;
• Responds by integrating knowledge about trauma into policies, procedures, and practices; and
• Resists re-traumatization of those who have experienced trauma.

Pregnancy can offer a critical window to engage women in treatment for OUD. Even women who were not previously interested in treatment are often open to it during pregnancy. Beginning MOUD treatment with buprenorphine or methadone is the standard of care and increases the likelihood of healthy pregnancy outcomes.^4,5 Treatment with buprenorphine or methadone is generally preferred over naltrexone, medically supervised withdrawal, or abstinence during pregnancy.⁶ All three medications are safe to use while breastfeeding.⁷ Of note, discontinuation of MOUD during pregnancy is not advised due to risks to the fetus.^6,8

Continue buprenorphine throughout the prenatal period, delivery, and postpartum period. You may need to increase the buprenorphine dose as the pregnancy progresses.⁶ Discuss a plan for pain management during delivery well in advance of the anticipated date.

Patients and their family are concerned about the effects of MOUD on the fetus. This presents an opportunity to provide education on the safety and benefits of treatment. For example, medications for OUD offer consistent dosing and medication, making them safer than non-prescribed opioids or street drugs of unknown potency and composition. Because medications for OUD are taken on a regular schedule, they also help avoid repeated withdrawal episodes in both the patient and the fetus, and reduce the risks associated with drug seeking behaviors and drug use. Finally, women receiving MOUD are more likely to obtain prenatal care. See the Resources section for patient education materials regarding using medications for OUD during pregnancy.

Pregnant women and their families may be concerned that the baby will be born “addicted”. This is an educational opportunity to differentiate between physiological dependence and addiction. That is, the newborn is not addicted even though they may experience physiological symptoms of withdrawal, known as neonatal opioid withdrawal syndrome (NOWS, formerly neonatal abstinence syndrome or NAS). The severity of NOWS symptoms varies, symptoms abate within days, and it is medically easy to keep the baby comfortable while the symptoms subside.

Once the patient delivers her baby, the mother will be at elevated risk for recurrence of use ¹¹ and overdose. She may experience diminished peer support for recovery, she may be faced with the stress and guilt of an infant with NOWS, or she may face child protective service or other legal involvement.

Mandatory reporting of prescribed MOUD depends on state laws. The federal Child Abuse Prevention and Treatment Act (CAPTA) requires the delivery of substance-exposed (including MOUD) newborns to be reported to child protective services (CPS). However, the report does not need to be one of suspected abuse or neglect, and it can exclude patient-identifying information. Therefore, the determination is based on state laws.

State laws dictate whether perinatal substance use detected at delivery, including prescribed MOUD, must be reported to child protective services (CPS). State laws vary from mandatory reporting to reporting only if there is child maltreatment to no specific requirements. Some states use this information to direct pregnant women toward treatment, but others involve child protective services, which can affect parental rights and custody. Know the laws in your state¹² and share with pregnant women prior to screening them for substance use.

In 2023, 316,000 adolescents aged 12 to 17 and nearly 396,000 young adults ages 18 to 25 in the United States had an OUD.¹³ Also in 2023, 708 adolescents died from overdose, mostly due to fentanyl (76%).¹⁴ Despite the need for treatment, medications for OUD are underused in this population.¹¹⁸ Youth are clearly an important population to address.

In 2016, the American Academy of Pediatricians (AAP) released a policy statement that advocated for pediatricians to provide medications for severe OUD.¹⁶ Only buprenorphine is FDA approved to treat youth, and that is limited to ages 16 and older, although it is sometimes prescribed off-label for adolescents under age 16 with severe OUD.¹⁷ Methadone and LAI naltrexone are only approved for treating adults.

Consider adjusting patient care approaches and treatment plans throughout the course of treatment. They also need to know the common risk factors for prescription drug misuse among adolescents and use screening tools specialized for adolescent substance use.

During medication management or counseling, also consider the unique psychosocial needs and developmental stage of this age group. For example, consider addressing common life stressors from school, social relationships, and family. Family can play a key role in the treatment of youth. Family members need education about OUD, treatment options, and preventing and responding to overdose. Keep in mind that family members may have an SUD or OUD as well, which may affect the youth's and family's treatment engagement and adherence.

Parents can play a supportive role in treatment by encouraging their children to take their medications, helping them attend appointments, and providing emotional support.¹⁹ In addition, work with patients and parents to plan “structured time” to encourage participation in healthy activities and social environments.²⁰

The relationship between parent and child may be complicated. Further, family members may not understand that addiction is a chronic, recurring brain disease, and they may hold negative attitudes toward the idea of using medications to treat addiction. Family therapy can be particularly effective with adolescents and may be key to getting family members to support the patient's use of medications for OUD.²⁵

Treating adolescents may present additional issues related to patient confidentiality. Be aware of relevant state and federal laws and regulations depending on patient age or emancipation status. All patients, including minors, must sign a consent form for the release of information to a parent or guardian.²² If an adolescent under 18 years of age requests confidentiality, providers may be obligated to adhere to certain clinical or legal responsibilities.²³ If patients are over 18, they will need to sign releases of information if they want providers to share information with family members.

Many factors affect decisions on which information to share with family members. For example, if an adolescent's behavior puts him or her in danger, providers may want to communicate their concerns to the parents and teach them how to effectively monitor and support their child's recovery. On the other hand, building trust and rapport between provider and patient will be extremely important, so providers need to avoid sharing details not directly relevant to treatment.²²

Rural communities have been hit hard by the opioid epidemic, with high rates of OUD and opioid-related overdoses.²⁴ Practices providing medications for OUD in rural communities face particular challenges that may affect treatment planning. For example, the following factors contribute to high rates of SUDs in rural areas:²⁵

• Social isolation;
• Poverty;
• Low educational attainment; and
• High-risk behaviors.

The same issues that increase an individual's risk of developing an OUD can also complicate its treatment. For example, individuals living in poverty may have unstable or dangerous living arrangements that expose them to ongoing substance use, or they may struggle to pay for their medications and other treatment services. Individuals in rural areas may feel isolated and struggle to form connections with others. Social support and positive relationships can be key to helping individuals achieve and maintain recovery.

Rural areas of the United States also often lack resources to prevent and treat OUD. Specifically, specialty substance use treatment, including OTPs, intensive outpatient, and residential treatment, may be scarce.²⁵ Workforce shortages of behavioral health providers can limit access to needed services. On the one hand, the lack of these services reinforces the necessity of integrating medications for OUD into primary care to increase access to these life-saving services. On the other hand, lack of services may pose a challenge for primary care providers when they determine a patient has complex needs that would be better suited for a higher level of care.

Even if individuals with OUD can connect with these services, they may need to travel long distances to attend appointments. Depending on their access to transportation, staying in treatment may not be possible. Public transportation is often woefully inadequate in rural areas, so patients may rely on family or friends for rides if they do not have a personal vehicle, unless the clinic or the state Medicaid program can provide transportation. Explore options to provide travel vouchers or Medicaid-subsidized transportation in their state. If group sessions are part of the practice or organization's service model, encourage patients to coordinate transportation with each other to attend sessions.

If office-based treatment is not logistically possible, or if patients prefer telehealth as a more private source of treatment, determine whether using telehealth is a feasible option. Logistical issues that could interfere with telehealth are phone availability, access to a private place to talk or videochat, and adequate Internet service. See more on telehealth in the General Operations section.

Stigma can also pose more strain on patients with OUD in smaller communities. Speak with your patients about the stigma or judgment they feel and provide educational materials, talking points, or strategies for the patient to use with others when discussing their condition or treatment. Smaller communities can also mean patients know providers, pharmacists and others personally which may make it more difficult to ensure privacy in their treatment. Consider posting or sharing private telehealth MOUD services for all your patients to allow them to access care in a manner they feel is more confidential.

Homelessness is a spectrum, from visible, unsheltered homelessness (e.g., living in the street) to temporary living situations (e.g., couch surfing) to being housing insecure (e.g., facing eviction, unsafe housing). Not all these categories are included in homelessness data.

Treating Unsheltered Homeless People with MOUD: It is unlikely that you will treat many unsheltered patients with MOUD in your primary care practice, unless you work in an outreach or mobile program or other program that focuses on this population. You may be more likely to engage and retain unsheltered people in treatment if you offer some of the following whole-person care components:²⁶

• LAI buprenorphine, which may be particularly effective with unhoused patients as it overcomes challenges such as storing buprenorphine or traveling to an OTP for methadone.²⁶ LAI naltrexone would be equally convenient, but it is a more difficult medication to start (without precipitated withdrawal) and treatment retention tends to be shorter than with buprenorphine.²⁷
• Case management to help them procure housing, food, and other health-related social needs (Read about health-related social needs in Assess Individualized Needs);
• Flexible hours and flexible rules if they miss appointments or come at the wrong time;
• Flexibility regarding continued substance use. The substance use may be the reason they cannot stay in a shelter;
• Treatment for infectious diseases;²⁶
• Access to psychiatric medications; and
• Fostering relationships in the community for housing supports for people with OUD.

Given the right circumstances, there is evidence that unhoused people respond well to MOUD.²⁶

More Information on Unsheltered People with OUD: Unhoused people are more likely to misuse opioids than housed people^28,29 and are 12 times more likely to die from a drug overdose than the general U.S. population.³⁰ The following factors contribute to high rates of SUDs among unhoused individuals:

• Poverty;³¹
• Mental health issues;³²
• Food insecurity;³² and
• Incarceration.²⁶

Based on a literature review,²⁶ compared to housed people with OUD, unhoused people are:

• More likely to receive OUD care in emergency department and inpatient settings such as detoxification;
• More likely to receive LAI naltrexone (reviewed studies were published before LAI buprenorphine became available); and
• Less likely to receive outpatient buprenorphine or methadone.

There have been some promising results from programs that lower barriers to access such as mobile clinics³³, street-outreach clinics, shelter-based programs, and even telemedicine.²⁶