Providers should understand that each patient has unique needs and circumstances and that they will change and evolve over the course of recovery. This section describes considerations for treatment approaches and how care plans may need to be adjusted based on the specialized needs of some patient populations. Depending on the practice’s capacity to treat complex issues and the providers’ comfort level, other common issues (such as co-occurring behavioral health disorders, infectious diseases, or chronic pain and increased risk for suicidality) may be important to consider when designing a treatment plan and will be discussed in greater detail later in the Playbook.
Care plans incorporate effective treatment approaches and are tailored to the unique needs and preferences of each patient. Research evidence and practice-based measurement are used to identify the most appropriate treatment approaches for the setting and the patients served.
How Do You Do It?
Use Effective Treatment Approaches
Practices need to consider the treatment models or tools that are appropriate to implement in their setting and that have been shown to be effective with their patient populations. These may be approaches for which systematic research shows effectiveness with similar patients. It is important to use approaches that meet the individual patient’s needs.
Measuring treatment outcomes is essential to confirm that treatment approaches are effective in the specific practice setting and with the patients the program serves. Practices should identify which behavioral therapy models may be effective and fit in their MAT program during patient engagement, medication management, or counseling sessions.
While medical providers may focus on their role in the pharmacotherapy component of MAT, learning techniques and principles of these treatment approaches can be very helpful to support positive behavior change in patients with opioid use disorder, as well as those receiving treatment for a range of chronic medical conditions. Examples include:
- Motivational Interviewing (MI): This series of techniques or brief intervention aims to help individuals resolve ambivalence toward making behavior changes. MI requires providers to be supportive and empathetic to help patients build confidence and optimism in their ability to change. Learn more about MI.
- Cognitive Behavioral Therapy (CBT): This method is one of the most commonly used evidence-based approaches in behavioral 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. Learn more about CBT (PDF—5.27 MB).
- 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 social determinants of health (e.g., employment, housing). Family-based approaches can also be particularly important when treating youth or adolescents. A number of specific family therapy models exist, including family behavior therapy, functional family therapy, multidimensional family therapy, brief strategic family therapy, and behavioral couples therapy. Learn more about family therapy.
- Contingency Management (CM): This evidence-based approach involves programs providing patients rewards to reinforce positive behaviors such as abstinence and treatment engagement. Rewards may be delivered through vouchers with monetary value or prize incentives. While research has supported the use of CM strategies in the treatment of opioid use disorder, it may be less common in practice because it can require additional financial resources. In addition, some providers express resistance to providing incentives. However, some internet-based or mobile apps, such as Reset-O, WeConnect, and DynamiCare, can be useful tools that incorporate CM strategies.
- Matrix Model: This approach may be useful for providers offering treatment to individuals with co-occurring opioid use disorders and stimulant use disorders, such as methamphetamine or cocaine. Learn more about the Matrix Model.
Integrate Trauma-Informed Care
All practices implementing MAT services should incorporate trauma-informed approaches to their care. The Substance Abuse and Mental Health Services Administration (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 exposure to trauma and substance use is well established, and comorbidity is high between post-traumatic stress disorder and substance use disorders.2 A history of trauma may increase the patient’s risk of dropping out of treatment early.3
Providers should operate under the assumption that their patients with substance use disorders are more likely than not to have a history of trauma. Therefore, trauma-informed care should be integrated across all aspects of treatment. Learn more about Why Trauma Matters in Primary Care.
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 retraumatization of those who have experienced trauma.
These resources can help practices implement trauma-informed care:
- Resource Guide to Trauma-Informed Human Services: A series of resources from the Administration for Children and Families on key concepts related to trauma
- Trauma-Informed Care Implementation Resource Center: A website that provides information and resources for health care providers and other stakeholders implementing trauma-informed care
- Center for Evidence-Based Practices: A list of tools, trainings, and other resources for trauma-informed care
- Treatment Improvement Protocol 57—Trauma-Informed Care in Behavioral Health Services: A manual for behavioral health professionals to understand to the impact of trauma and how to support recovery
- Conversation Guide for Delivering a Trauma-Informed Brief Intervention (PDF—1.59 MB): A guide that provides examples to help providers start the conversation and highlights other important considerations
- Seeking Safety: An evidence-based counseling model to help individuals with a history of trauma and/or substance use disorders
- Pharmacologic Guidelines for Treating Individuals With Post-Traumatic Stress Disorder and Co-Occurring Opioid Use Disorders (PDF—580 KB): A set of guidelines for delivering MAT services to individuals with post-traumatic stress disorder
Consider Needs of Pregnant and Postpartum Women
Treatment of pregnant and postpartum women with opioid use disorder requires careful planning and clinical decision making. Methadone treatment is the standard of care during pregnancy, although buprenorphine monoproduct is a “reasonable and recommended alternative.”4
Providers should seek training on the clinical challenges of opioid dependence in pregnancy to understand the risks to the mother and developing baby, as well as treatment options. Then they should follow clinical guidance regarding the treatment and care of pregnant and postpartum women with opioid use disorders, including:
- Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants (SAMHSA)
- Opioid Use and Opioid Use Disorder in Pregnancy (American College of Obstetricians and Gynecologists)
Providers also need to educate these women on what to expect during pregnancy (PDF—207 KB), as well as childbirth, infant care, and breastfeeding (PDF—199 KB). In addition, SAMHSA has developed four Healthy Pregnancy Healthy Baby Fact Sheets that emphasize the importance of continuing a mother's treatment for opioid use disorder throughout pregnancy.
Consider Needs of Youth and Young Adults
In 2017, more than 100,000 adolescents ages 12 to 17 and nearly 450,000 young adults ages 18 to 25 in the United States had an opioid use disorder.5 Although adolescents need treatment for opioid use disorder, MAT is underused in this population.6 In 2016, the American Academy of Pediatricians (AAP) released a policy statement (PDF—688 KB) advocating for improved access to MAT for adolescents and young adults, specifically within primary care, and to developmentally appropriate substance use disorder counseling in community settings.
Providers offering MAT services to youth should 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 (PDF—1.5 MB) among adolescents and use screening tools specialized for adolescent substance use. These include the National Institute on Drug Abuse’s (NIDA’s) two brief online screening tools.
During medication management or counseling, providers should also consider the unique psychosocial needs and developmental stage of this age group. For example, providers should consider addressing common life stressors from school, social relationships, and family. In particular, family can play a key role in the treatment of youth and adolescents. Family members need education about opioid use disorders, treatment options, and preventing and responding to overdose.
Parents can play a supportive role in treatment by encouraging their children to take their medications, helping them attend appointments, and providing emotional support.7 In addition, providers should work with patients and parents to plan “structured time” to encourage participation in healthy activities and social environments.7
The relationship between parent and child may be complicated. Further, some family members may not understand that addiction is a relapsing brain disease, or 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 MAT.3
Treating adolescents may present additional issues related to patient confidentiality. Providers should be aware of relevant Federal and State laws and regulations depending on patient age or emancipation status. If Federal substance abuse confidentiality regulations apply to a program (i.e., 42 CFR Part 2), all patients, including minors, must sign a consent form for the release of information to a parent or guardian.7
If an adolescent under 18 years of age requests confidentiality, providers may be obligated to adhere to certain clinical or legal responsibilities.4 If patients are over 18, they will need to sign releases of information so that providers can share 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.7
Additional resources for the treatment of youth and adolescents include:
- Demystifying Buprenorphine Prescribing for Youth With Opioid Use Disorders (Providers Clinical Support System [PCSS]).
- Substance Use Screening and Intervention Implementation Guide (AAP).
- Treatment Improvement Protocol 31: Screening and Assessing Adolescents for Substance Use Disorders (SAMHSA).
- Principles of Adolescent Substance Use Disorder Treatment: A Research Based Guide (NIDA).
Consider Needs of Individuals With Chronic Pain
Individuals with chronic noncancer pain treated with opioids are at higher risk of developing an opioid use disorder. Often, the narrative focuses more on their pain and may minimize or cover up the development of an opioid use disorder. Providers need to acknowledge their pain and their addiction and reassure them that they will continue to work on addressing both.
The ASAM National Practice Guideline Supplement (PDF—1.0 MB) provides recommendations for three situations in which patients with opioid use disorder may be treated for pain:
- Pain in patients with an untreated opioid use disorder;
- Pain in patients engaged in opioid use disorder treatment with opioid agonists (i.e., methadone or buprenorphine); or
- Pain in patients engaged in opioid use disorder treatment with opioid antagonists (i.e., naltrexone).
In all three of these situations, providers should first determine the cause of the pain and identify an appropriate treatment approach. Nonpharmacological treatments, such as physical therapy, may be effective.
If pharmacologic treatment is indicated, non-narcotic medications such as acetaminophen or nonsteroidal anti-inflammatory drugs should be used first.4 The Centers for Disease Control and Prevention offers a training module on Treating Chronic Pain Without Opioids and a factsheet for Nonopioid Treatments for Chronic Pain (PDF—1.53 MB).
SAMHSA’s guide to Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders (PDF—228 KB) highlights key components for clinicians, including:
- Elements of a comprehensive patient assessment,
- An algorithm for managing chronic pain in patients with substance use disorders,
- Options for nonopioid analgesics,
- Steps to take if opioid therapy is indicated,
- An addiction behavior checklist, and
- How to discontinue opioid therapy.
Providers should be sure to educate patients on how to manage chronic pain while seeking treatment for an opioid use disorder with patient-oriented informational materials, such as You Can Manage Your Chronic Pain To Live a Good Life: A Guide for People in Recovery From Mental Illness or Addiction (PDF—2.85 MB).
Consider Needs of Individuals in Rural Areas
Rural communities have been hit hard by the opioid epidemic in recent years, with high rates of opioid use disorders and opioid-related overdoses. Practices providing MAT services to patients in rural communities face additional challenges that may affect treatment planning.
The following factors contribute to high rates of substance use disorders in these areas:8
- Social isolation,
- Low educational attainment, and
- High-risk behaviors.
The same issues that increase an individual’s risk of developing a substance use disorder can also challenge its treatment. For example, individuals living in poverty may have unstable or dangerous housing situations in which they are exposed to ongoing substance use, or they may struggle to pay for their medications and other treatment services. Similarly, 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 substance use disorders. Specifically, specialty substance use treatment, including detoxification, day treatment, and long-term residential treatment, may be scarce.8 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 MAT into primary care to increase access to these life-saving services. On the other hand, it may pose a challenge for providers when they determine a patient has complex needs that would be better suited for a higher level of care.
Providers will need to consider whether it is more important to continue treating an individual in office-based treatment if it is the only option available. Practices should also explore the feasibility of telehealth models in their rural settings.
Even if individuals with opioid use disorders 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.
Practices should 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, providers should encourage patients to coordinate transportation with each other to attend sessions.
Recurrence of use is a common and expected feature of this chronic, relapsing disease. Decreased tolerance to opioids while in treatment can increase patients’ risk of overdose if they return to using opioids. All individuals with opioid use disorder face this risk, but patients in rural areas are at increased risk during these times because first responders or emergency services may be spread over large geographic areas. Thus, they may be delayed in responding to an overdose or getting an individual experiencing an overdose the care her or she needs.8
Because of the potential delays in care, providers in rural areas should consider spending more time educating patients and their family and friends on how to respond to overdoses, including dispensing naloxone kits to reverse the effects. Learn more in Recovery Plans for Recurrence of Use
Stigma can also pose more strain on individuals with substance use disorders in small communities. Providers should speak with their 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.
Polysubstance use may also be common in rural areas. Recently, the rates of methamphetamine use in rural areas have increased, with the rate of methamphetamine use by young rural adults ages 18 to 25 being six times that of young urban adults.9 Learn more about addressing polysubstance use.
The following resources may provide additional ideas, strategies, and guidance for providers implementing MAT in rural areas:
- Rural Prevention and Treatment of Substance Use Disorders Toolkit (Rural Health Information Hub)
- Rural Opioid Educational Resources (National Organization of State Offices of Rural Health)
What Not To Do
- Don’t develop treatment plans without giving full consideration to the unique needs and characteristics of the individual patient you are working with.
Treatment Improvement Protocol (TIP) 63: Medications for Opioid Use Disorders. Part 2: Addressing Opioid Use Disorder in General Medical Settings
National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use
- Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. Publication No. SMA14-4884.pdf. https://store.samhsa.gov/system/files/sma14-4884.pdf. Accessed June 6, 2019.
- Khoury L, Tang YL, Bradley B, et al. Substance use, childhood traumatic experience, and posttraumatic stress disorder in an urban civilian population. Depress Anxiety 2010;27(12):1077-86. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051362/. Accessed June 6, 2019.
- Substance Abuse and Mental Health Services Administration. Treatment Improvement Protocol 63: Medications for Opioid Use Disorder. Part 4: Partnering Addiction Treatment Counselors With Clients and Healthcare Professionals. Publication No. SMA18-5063PT4. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018. https://store.samhsa.gov/product/SMA18-5063PT4. Accessed June 6, 2019.
- American Society of Addiction Medicine. National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. Rockville, MD: American Society of Addiction Medicine; 2015. https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf. Accessed June 6, 2019.
- Substance Abuse and Mental Health Services Administration. 2017 NSDUH Annual National Report. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018. https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report. Accessed June 6, 2019.
- Saloner B, Feder KA, Krawczyk N. Closing the medication-assisted treatment gap for youth with opioid use disorder. JAMA Pediatr. 2018;171(8):739-31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6007012/. Accessed June 6, 2019.
- Subramaniam GA. Demystifying Buprenorphin Prescribing for Youth With Opioid Use Disorders; 2017. Webinar slides. https://www.aap.org/en-us/Documents/cosup_pcsso_webinar_5_slides.pdf. Accessed June 6, 2019.
- Rural Health Information Hub. Substance Abuse in Rural Areas; 2018. https://www.ruralhealthinfo.org/topics/substance-abuse. Accessed June 6, 2019.
- Center for Behavioral Health Statistics and Quality. 2016 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD; 2017. https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf. Accessed June 6, 2019.