By Alison Knopf
Counseling is a required component of an opioid treatment program (OTP) under the Substance Abuse and Mental Health Services (SAMHSA) guidelines. It’s also what differentiates the kind of medication-assisted treatment methadone patients receive in an OTP from the office-based opioid treatment (OBOT) buprenorphine patients receive.
But what is counseling? In many cases, it depends on the OTP. “The OTP landscape differs, depending on the provider,” said H. Westley Clark, MD, former director of SAMHSA’s Center for Substance Abuse Treatment (CSAT), which regulates OTPs, and a longtime OTP administrator prior to joining the federal government. “Research shows that patients benefit from psychosocial intervention, so the fundamental question is, ‘What is the nature of the intervention?’”
Not a ‘Magic Pill’
Discussions about OBOT with buprenorphine have definitely steered some of the counseling questions. The marketplace is changing, and some people say that no counseling is needed with OBOT.
But Dr. Clark disagrees. He told AT Forum that regardless of the kind of medication used, many patients do need counseling. “A lot of people in substance use disorder treatment need more than medication, and the central question is whether the providers are capable of responding to those other needs.”
Many OTP counselors learned in the late 1990s that methadone wasn’t going to work on its own, said Shirley Beckett Mikell, NCAC II, CAC II, a clinical social worker with extensive experience working in and with OTPs. “It used to be thought that methadone was a magic pill, that the doctor performed magic, and all of a sudden the patient was better,” said Ms. Mikell, a consultant with NAADAC, the Association for Addiction Professionals. “We thought that simply because you were ingesting a medication, all of your thoughts and behaviors were healed.”
The presumption was that patients were getting medications prescribed by a physician, and that counselors “were not responsible, except to encourage the patient to take the daily dose. Counselors weren’t really directing issues around trauma, said Ms. Mikell. “We had to report any child abuse or child neglect, but that is not the same as looking at issues like parenting skills.”
When staffers realized that counseling was needed, they started doing it themselves. “Fortunately, the federal government was paying for counseling services,” recalled Ms. Mikell. “And even today, counseling is being paid for through either Medicaid or block grant funding,” she said, adding that in some cases, patients do have to pay a small amount. “But these are the publicly funded OTPs,” she said. Proprietary OTPs are having more difficulty getting counseling paid for.
Charging the patient for counseling is becoming a trend, especially among for-profit OTPs. Because proprietary OTPs are trying to minimize costs, they may charge only $20 an hour for counseling, said Ms. Mikell. Or, that could be the minimum, adjusted upward on a sliding scale.
Patients in OTPs need individualized treatment, which often includes counseling of various types (see Sidebar below). “A number of OTPs pride themselves on providing counseling,” said Dr. Clark. “But not all people come in with the same needs—if you need psychological counseling, you get it; if you don’t need it, you don’t get it.”
When patients are first admitted to OTPs, what happens during the initial assessment— in addition to testing for withdrawal symptoms and for metabolites in the urine? “Patients come in with many problems, in addition to addiction, so whose responsibility is it to address those things?” asked Dr. Clark.
That’s what motivational interviewing is all about. “Someone needs to say, ‘You have other issues in your life,’” he said. Patients in early treatment are at risk of overdosing, criminal justice problems, underemployment, and more. Some are suicidal. “The counselor or case manager needs to play a bigger role,” he said. “It can’t be just ‘dose and go.’”
Issues: Initial Engagement vs. “Dose-and-Go”
The most dangerous part of OTP treatment is the first few weeks, during induction—so that is the time to engage the patient in treatment. “Use some motivational interviewing, some fidelity assessment; make sure front line people have some training,” said Dr. Clark. In many cases, because the patient is in withdrawal, methadone itself becomes the way to get the patient stabilized. Then OTP staff work on identifying any other issues, he said.
But in the “dose-and-go” model, caregivers have no responsibility beyond providing medication. This model won’t change much about many patients’ lives, said Dr. Clark.
And counseling isn’t limited to psychological problems. Just as methadone isn’t a treatment for trauma or depression, it’s not a treatment for HIV. “We need to recognize that by the time someone is knocking on our door, they have a lot of baggage with them,” said Dr. Clark.
For some patients—those who need treatment, but whose lives are still manageable, “dose-and-go” might be possible “until they figure out what to do next,” said Dr. Clark. But if no one ever assesses what they need to do next, they may not be helped.
The take-home model for OTPs kicks in only when patients are stable. The buprenorphine OBOT model is monthly visits. And now that the buprenorphine six-month implant is approved, will the model be for visits every six months?
Dr. Clark noted that up to 30 percent of SUD patients have histories of trauma. Others have psychosocial problems, or problems related to housing or other issues. Case managers, who are very important staffers in OTPs, may not have the sophistication to provide counseling with fidelity to the manual, “but they do know how to move things around in the community so the patient can get permanent housing and access to employment services,” he said.
What many counselors in OTPS are doing is actually case management, said Ms. Mikell. “In the early years, I don’t think we even realized that’s what it was. It was called patient stability. We were charged with making sure that patients came into dosing daily, and that they responded to their doses. We tracked whether they needed increases or decreases, assessed the impact of medication on their daily functioning, and reported all this to the physician or nurse,” she said. “It was also our job to make sure their other needs were met: needs for dentists, podiatrists, and, after six to eight weeks of initial stabilization, their mental health.”
For the first two months of treatment, methadone patients were educated in groups, in Ms. Mikell’s experience. “We used the term ‘medication’ instead of ‘methadone’ because we decided ‘medication’ was more essential to the patient’s understanding of the fact that they were not still in the street getting drugs,” she said.
“So the introduction to language, medication needs, the role of the physician, the full orientation toward treatment, was done in groups,” she said. “We couldn’t expect patients to focus on their issues initially. First, they got stabilized, and learned about the disease and its treatment.”
Over the years, counselors have moved away from seeing patients as drug-seeking during the initial, low-dose stage of early treatment, when patients require very close attention. Some may still be using street opioids to tide them over, something counselors and physicians are acutely aware of, said Ms. Mikell.
“We ask, ‘Are you still using? What times of day do you experience withdrawal?’” The medication dose can be adjusted, or patients can come in again in the afternoon in a split-dosing regimen.
“Some clients will play the system, we know that,” said Ms. Mikell. “But others have a reputation in the street of being a heavy user. They try to maintain that reputation, and ask for high doses even if they don’t need them.”
A Typical Early Counseling Session
Here’s a typical counselor-new patient conversation, with the counselor trying to motivate the patient (thanks to Ms. Mikell for the ‘script’):
|Counselor: Part of the program is for you to attend our individual and group counseling sessions. These will allow you to examine certain things that may have been going on in your life.
Patient: I’ve heard you’re trying to get into my head. I don’t want to look like you, I don’t want to be like you.
Counselor: I don’t want you to be like me. I want you to be the person you want to be. Let’s look at that, so you can identify who you want to be.
Patient: You sound just like my momma, every time she turns around she wants me to change.
Counselor: That’s why you’re here, right? You want to change from using street drugs to working with a physician who wants to help. Isn’t that true?
Patient: That doesn’t mean I want you to get into my head.
Counselor: I want you to do that – so you’ll be learning, and we’ll be helping you understand. We don’t want to change who you are.
Commenting on the counseling session, Ms. Mikell noted that patients typically “want to hold onto their self-identity.” And a lot of what patients hear in the street is that the counselor “gets into your head. They hear, ‘Look how she dresses, that’s how she wants you to dress, that’s how she wants you to act.’ It’s important to settle patients down.”
When patients are more comfortable on the medication, their attitudes and tone are less extreme, said Ms. Mikell. “I don’t think you can start a counseling session in an OTP on the first day.”
The bottom line: more than medication is needed for treating opioid use disorders. “If you’re running from your demons, neither methadone nor buprenorphine will help you cope,” said Dr. Clark. “Euphoria will help you cope at first, but eventually it won’t work, and the demons will show up again.”
By Barbara Goodheart, ELS
Federal Requirements for OTPs
SAMHSA makes its position on psychosocial intervention very clear—considering it an essential part of treatment for opioid use disorder, and specifying the requirements for psychosocial intervention in the 2015 Federal Guidelines. To summarize: opioid treatment programs (OTPs) must provide adequate medical, counseling, vocational, educational, and other assessment and treatment services at its primary facility, unless the program has made—and documented—other arrangements, spelled out in the Guidelines. (43 CFR 8.12 (f). http://store.samhsa.gov/shin/content/PEP15-FEDGUIDEOTP/PEP15-FEDGUIDEOTP.pdf.
SAMHSA also requires OTPs to provide adequate substance abuse counseling, as necessary, and lists the qualifications counselors and OTPs must meet. Further, the OTP must provide counseling related to HIV exposure, and, when requested or deemed appropriate, provide, directly or by referral, vocational rehabilitation, education, and employment services. (43 CFR 8.12 (f) (5).
Psychosocial Interventions at OTPs
The following table ranks counseling interventions at OTPs by frequency of use, in 2013.
|Intervention or Treatment||% of OTPs Using
Always or Often
|Cognitive Behavioral Therapy||71|
|Contingency Management / Motivational||26|
(Data are from Table 4.10 of a 2013 N-SSATS survey: http://www.samhsa.gov/data/sites/default/files/2013_N-SSATS/2013_N-SSATS_National_Survey_of_Substance_Abuse_Treatment_Services.pdf (complete citation below, under References).
Substance Abuse and Mental Health Services Administration. Federal Guidelines for Opioid Treatment Programs. HHS Publication No. (SMA) PEP15-FEDGUIDEOTP. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015. http://store.samhsa.gov/shin/content/PEP15-FEDGUIDEOTP/PEP15-FEDGUIDEOTP.pdf.
Substance Abuse and Mental Health Services Administration, National Survey of Substance Abuse Treatment Services (N-SSATS): 2013. Data on Substance Abuse Treatment Facilities. BHSIS Series S-73, HHS Publication No. (SMA) 14-489. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. http://www.samhsa.gov/data/sites/default/files/2013_N-SSATS/2013_N-SSATS_National_Survey_of_Substance_Abuse_Treatment_Services.pdf.
(Because psychosocial intervention is a topic we haven’t been covering to any extent, we’re including additional references for those of you who are interested in further reading.)
Behavioral Health Treatments and Services: Treatments for Substance Use Disorders Behavioral Health Treatments and Services: Treatments for Substance Use Disorders. http://www.samhsa.gov/treatment/substance-use-disorders.
Dugosh K, Abraham A, Seymour B, McLoyd K, Chalk M, Festinger D. A systematic review on the use of psychosocial interventions in conjunction with medications for the treatment of opioid addiction. J Addict Med. 2016;Mar-Apr;10(2):91-101. doi:10.1097/ADM.0000000000000193. PMID:26808307. PMC4795974 [available 2017-03-01]. http://www.ncbi.nlm.nih.gov/pubmed/26808307.
Substance Abuse and Mental Health Services Administration. Recovery and Recovery Support. Updated: 10/05/2015. http://www.samhsa.gov/recovery.
Substance Abuse and Mental Health Services Administration. Cognitive Behavioral Therapy. Part 1 – An Overview. http://www.integration.samhsa.gov/clinical-practice/sbirt/CBT_Overview_Part_1.pdf.
Substance Abuse and Mental Health Services Administration. Cognitive Behavioral Therapy. Part 2 – Strategies and Methods. http://www.integration.samhsa.gov/clinical-practice/sbirt/CBT_sbirt,_part_2.pdf.
Substance Abuse Treatment. What are Peer Recovery Support Services? HHS Publication No. (SMA) 09-4454. Rockville, MD: Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 2009. https://store.samhsa.gov/shin/content/SMA09-4454/SMA09-4454.pdf