Understanding the Components of Medication-Assisted Treatment

It is important to determine available support, both internally within your organization and externally within the local community. The types of support accessible to patients and providers may influence your decisions about the MAT components your organization can provide.

For example, some organizations, such as federally qualified health centers, may have behavioral health providers who can offer counseling or other behavioral health services onsite. Practices with no access to internal behavioral health services may need to leverage local providers and community-based organizations for patients as needed. These services may include drug and alcohol counseling providers, support groups (e.g., Alcoholics Anonymous, Narcotics Anonymous, Self-Management and Recovery Training [SMART] Recovery, etc.), and peer providers (e.g., certified peer specialists, peer support specialists, recovery coaches).

If local services are not available, providers can also explore options for telehealth services, mobile applications, or web-based platforms. Learn more in the Playbook section on telehealth.

Providers and staff will also need support from internal and external resources. Doctors, nurse practitioners, and physician assistants will first need to be trained and receive their Drug Enforcement Administration (DEA) DATA 2000 waiver to allow them to prescribe. Continuing education and ongoing clinical decision-making support are also available. For example, other more experienced local providers may be willing to mentor or provide consultations on challenging cases.

Many States have launched their own initiatives to support providers and expand treatment capacity through grant programs funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), including the State Targeted Response to the Opioid Crisis (Opioid-STR) and State Opioid Response (SOR) Grants. Providers can also participate at the State or national level in a teleECHO clinic or the Providers Clinical Support System (PCSS) Clinical Mentoring Program, both of which are free of charge. Learn more in the section on Obtain Training and Support.

Opioid use can cause serious health effects, including death, so reducing risk and harm should be part of the strategy with your patients. Harm reduction approaches aim to lessen the negative outcomes of drug use, such as infectious disease transmission and overdose. Many individuals seeking treatment may continue to use substances, particularly early in treatment or during relapse. When patients perceive negative attitudes or disdain from providers and practice staff, they may be less likely to engage in treatment.

Harm reduction strategies and interventions can provide valuable tools and resources to patients while also building trust between patient and provider. Providers can educate patients on:

• Transmission, symptoms and treatment of infectious disease, particularly HIV and hepatitis;
• Wound care to prevent infection;
• Phlebotomy skills to avoid accessing arteries;
• Safe disposal of syringes;
• Sexual health to reduce risk of sexually transmitted diseases and unplanned pregnancies; and
• Overdose prevention and intervention.

In particular, harm reduction strategies related to opioid-involved overdoses are critical as they can save lives. Naloxone (common brand names Narcan^®, Evzio^®) is an overdose-reversing drug that can be prescribed to those at risk of an overdose or those likely to witness an overdose. Learn more about the treatment of overdoses in the later section Recovery Plans for Recurrence of Use.

If providers are not comfortable offering harm reduction interventions themselves, they can refer patients to local harm reduction programs, such as needle exchanges.

When setting up a MAT program, providers should decide which medications and formulations they plan to prescribe. The Food and Drug Administration has approved three medications to treat opioid use disorder: methadone, buprenorphine, and naltrexone.

Methadone may only be prescribed in certified opioid treatment programs (OTPs), so it will not be discussed in great detail within this Playbook. However, providers should understand the benefits of methadone as they may need to refer patients to this treatment modality based on the complexity of their disorders.

The table below compares the different pharmacotherapy options for MAT. SAMHSA provides more information about buprenorphine and naltrexone including how they are used to treat opioid use disorders, their side effects, and recommended safety precautions. 

Each medication and formulation has pros and cons, and individual patients may have different needs or preferences. In general, providers should consider offering a range of medications to their patients and provide information on the costs, benefits, and risks associated with each. Providers should tailor patients’ treatment plans to their circumstances and preferences. For example, some patients may prefer a daily tablet or film, while others may like extended-release injectable formulations. Costs and insurance coverage of medications may be important factors. Other considerations include required visit frequency and risk of diversion.

Providers offering office-based buprenorphine treatment also need to decide whether they will provide services to patients during all three phases of treatment:

• Induction: Induction refers to the first phase of treatment in which providers begin administering buprenorphine to a person who is experiencing mild to moderate withdrawal symptoms. While home-based inductions are becoming the standard of care, in the past inductions have usually been performed in the office and monitored by medical personnel to reduce the risk of precipitated withdrawal (i.e. a rapid, intense onset of withdrawal symptoms).
• Stabilization: Patients in this second phase of treatment have stopped or significantly decreased their opioid use. The goal of this phase is to treat patients with the smallest dose of medication needed to minimize side effects, while eliminating cravings and withdrawal symptoms. Patients in this phase should be seen for frequent medication management visits (multiple times per week, to weekly, to every other week) to discuss how they are doing and to determine if they are being prescribed the right dosage. Depending on patient progress, providers may be able to change the dosing schedule and begin to decrease the frequency of office visits during this stage. However, State Medicaid regulations may dictate the frequency of visits.
• Maintenance: Individuals in this phase of treatment have been progressing well on a steady dose of buprenorphine. The maintenance phase has no standard length. Some patients will be in maintenance for several years before tapering off buprenorphine, while others may be in this phase indefinitely.

While discussions of MAT often focus on the medications to treat opioid use disorder, behavioral health services are an important component of treatment. Medications primarily help with the physical symptoms of addiction, including cravings and withdrawal. However, many patients with an opioid use disorder have other underlying psychological, behavioral, and social factors that should be addressed as well.

Ideally, providers should tailor the type and intensity of psychosocial support to the patient’s needs and preferences across the phases of treatment. Behavioral health services within MAT can take many forms, including individual counseling, group therapy, support groups, family therapy, and peer services. These services can also be delivered by a wide range of providers, such as social workers, counselors, peer recovery support specialists, outreach workers, physicians, nurses, and advanced practice professionals. They may be offered onsite, through integrated or collaborative care models, via telehealth, or by referral with systematic followup.

Providers often report a lack of behavioral health services as one of the biggest barriers to delivering MAT, particularly in rural communities. Given the dangerous public health threat the opioid epidemic poses, some experts in the field argue it is important to increase access to medications to treat opioid use disorder even when availability of behavioral health services is limited.

For example, at a minimum, providers can deliver enhanced medication management during routine visits that addresses the patient’s continued use of substances (if applicable) and overall progress. They may provide education about the health impact of opioid use disorders, while promoting treatment adherence. As they do with many other chronic diseases, providers should discuss the patient’s functioning or any life stressors they may be experiencing and encourage lifestyle changes as appropriate.

While thinking about what services to offer, it is important to understand that different approaches to MAT are available. Ultimately, MAT implementation depends on an organization’s and patients’ needs, preferences, and available resources. What works for one organization may not work for another.

Below are some examples of innovative models of MAT that may be useful in rural, primary care settings. The Hub and Spoke and Project ECHO models serve as examples of system-level models that may not be available in every State. The Office-Based Opioid Treatment with Buprenorphine (OBOT-B) Collaborative Care model does not require State-level support and may be implemented in individual practices.

The Hub and Spoke Model. This model was developed in Vermont and includes two levels of care: regional OTPs that serve as the "hubs" and community clinics that function as the "spokes." The OTPs that serve as the hubs also provide methadone and typically have extensive experience in the treatment of opioid use disorders. The community clinics, or spokes, have waivered providers who can prescribe medications to treat opioid use disorder (typically buprenorphine/naloxone) and connect patients with some level of counseling and psychosocial services. The model emphasizes care coordination and features a "care connector" such as a registered nurse or clinician case manager at spoke clinics.

Patients who need a higher level of care may be referred to the hub, while patients who have less complex treatment needs may only receive care in office-based clinic settings. Hub staff serve as consultants to the spoke clinic team, and responsibility for patient care may shift back and forth between hub and spoke as needed. For example, initial treatment induction might be conducted by the hub OTP, and then the patient could be transferred to the spoke clinic for ongoing management. Learn more about the Hub and Spoke Model.

The Project ECHO Model. The Project Extension for Community Healthcare Outcomes (ECHO) model aims to leverage the knowledge and skills of experts to expand treatment capacity. Since its initial development at the University of New Mexico, this model has been widely adopted throughout the United States. Using videoconferencing platforms, teleECHO clinics create a knowledge-sharing network and conduct "grand rounds" style, case-based presentations to educate, consult, and mentor providers on addiction medicine.

In addition to building knowledge and skills, participation in an ECHO program can decrease feelings of professional isolation, which often plague rural providers. Learn more about Opioid and Pain Related ECHOs.

The OBOT-B Collaborative Care Model. The OBOT-B Collaborative Care model, also known as the Massachusetts Model, was created at the Boston Medical Center in 2003. Nurse care managers (NCMs) play a key role by providing support to and acting as a liaison between patients and waivered providers. This model has four treatment stages in which the NCM (or physician, as needed):

1. Conducts an initial screening and assessment of the patient's appropriateness for OBOT-B,
2. Supervises medication induction,
3. Monitors stabilization and provides support to the patient with frequent visits or telephone communication, and
4. Holds followup visits with the patient, as appropriate, for maintenance.

Often, physicians may hesitate to provide MAT services because they have many competing priorities and lack adequate support to manage these patients. However, with the OBOT-B Collaborative Care Model, NCMs take on the responsibilities of complex care management while communicating with the physician primarily through documentation in the electronic medical record and regular team meetings. This approach benefits patients as well because NCMs are more accessible than physicians, so they can quickly address patient issues and concerns. Learn more about the OBOT-B Collaborative Care Model.