The M.A.R.S. Peers Model at Work in Medication-Assisted Treatment for Opioid Addiction

couselingThe M.A.R.S. Project is the only federally funded program that provides peer recovery support to patients in medication-assisted treatment (MAT) for opioid addiction. Funded by the Substance Abuse and Mental Health Services Administration, M.A.R.S. is conducted in collaboration with the substance abuse division of the Albert Einstein College of Medicine in New York City, Yeshiva University, and the National Alliance for Medication-Assisted (NAMA) Recovery.

Walter Ginter, CMA, M.A.R.S. project director, talked with AT Forum recently about how peers can help patients in MAT. First of all, MAT peers can help new patients understand that recovery is a long-term commitment. “All of us come into treatment with the idea that we’re just visiting,” said Mr. Ginter. By the time most patients enter an opioid treatment program (OTP), they have already been through “a couple of detoxes, a therapeutic community,” he said. Patients are usually older than 35, and have already been told that being on methadone means “still using.” Other programs tell people with opioid addiction to go to detoxification and go to meetings, which doesn’t help—at least 80 percent of people who go through detoxification only relapse.

So when they finally get to an OTP, they’re desperate, he said. But they still don’t think they should stay, because being on methadone isn’t “real recovery.” Peers—other patients on methadone—can communicate the facts: They can say, “’I’m not using, I’m taking a medication for a brain disorder,’” and model the appropriate recovery response. This was an unexpected bonus for M.A.R.S., he said.

Trusting Peers More Than Counselors

Why do you need peers? Of course, counselors can say the same thing—that methadone is a medication for a brain disease, and does mean being in recovery. “But when they hear that from the counselor, they wonder about the motivation, because the counselor is paid to say it,” said Mr. Ginter.  The real problem is that patients haven’t learned to trust their counselors, not that counselors are giving misinformation. The same phenomenon occurs in other conditions; for example, patients who are overweight can get better nutrition support from peer groups than from doctors, who they may feel patronized by and disconnected from.

Support is key. Recovery in general has been based on mutual support, he said. “Why do people go to 12-step meetings—for support.”

Mental health peers are part of community mental health centers, and are much more allied with treatment than MAT peers, he said. Insurance companies are starting to reimburse some peers in substance use disorders, but not in MAT. At a recent meeting of mental health peers, Mr. Ginter got the clear impression that insurance companies don’t like the idea of maintenance medication. “They’re concerned about paying for methadone treatment for the rest of someone’s life,” he said.

Mr. Ginter’s M.A.R.S. program is the only one like it in the country, but some other peers have been trained there. Cheryl Blankenship Kupras, a Licensed Clinical Social Worker, worked for an OTP for 12 years in Santa Clara County, California. The OTP, a Beyond M.A.R.S. grantee, sent Ms. Blankenship Kupras, a manager, to peer training, along with two long-standing patients.

‘By the Patients and For the Patients’

It’s essential that any peer group be “by the patients and for the patients,” said Ms. Blankenship Kupras. “It can’t be an arm of the clinic,” because then patients don’t trust the peers.”

The peer who was most involved in the program “really wanted to break down the us-versus-them mentality,” she said. “Whatever was said in M.A.R.S. stayed in M.A.R.S.”

The clinic does control medication, but beyond that, the peers make sure that patients have a place to go for support that is different than mandated counseling, said Ms. Blankenship Kupras. This is particularly important because many OTP patients don’t feel welcome at 12-step meetings. “Just having another option for support is important,” she said. It’s important for the OTP to give the peers a place to meet in the building, as well.

Peer groups can also provide education to dispel myths. “Everybody was hearing rumors,” Ms. Blankenship Kupras said. “So they asked a physician from the program to come in and make a presentation.” Originally, the doctor was reluctant to do this, because she was afraid patients would ask questions about their personal treatment. As it turned out, that didn’t happen. She saw the patients in a different light, and more importantly, they saw her in a different light as well. “The presentation helped them to make a connection with the doctor in a way they hadn’t before,” she said.

Walter Ginter on the Importance of Peers in Recovery With Medication-Assisted Treatment

walterStigma is a common theme among people seeking recovery from the disease of opioid addiction, but it’s particularly poignant for people in medication-assisted treatment (MAT), because stigma can itself prevent recovery from taking place. People who don’t understand MAT—and that’s a big group, including many employers, politicians, and even friends and family members—don’t believe methadone or buprenorphine treatment means being in recovery. But it does. And that’s the message that Walter Ginter, CMA, project director of Medication- Assisted Recovery Services (MARS), and the country’s foremost patient advocate, brings to patients. On December 9, he brought this message to the first White House drug policy conference.

Sponsored by the Office of National Drug Control Policy (ONDCP), the conference included a panel that focused on stigma and drug addiction. Michael Botticelli, deputy director of the ONDCP, and himself in recovery, invited Mr. Ginter to participate. “He called me himself to ask me to be on that panel, and afterwards I got a nice handwritten note from him thanking me for participating,” said Mr. Ginter.  Mr. Botticelli, formerly the official in charge of substance use disorder services for Massachusetts, is a strong supporter of MAT. “This direction and focus that we are seeing from the Obama Administration is encouraging,” continued Mr. Ginter “It would strengthen that effort to see Mr. Botticelli promoted and the recovery community is hopeful that he will fill the opening as director of the ONDCP.”

 Stigma Impedes Recovery

The main stigma patients face in terms of methadone comes from believing what people who know nothing about MAT tell them. They learn to believe the myth that methadone is a substitute drug, and that they aren’t really in recovery. What peer recovery support services can do for patients is to help them eliminate feelings of stigma by helping them understand that they are in treatment with a medication, just like someone with any other disease. “If people come into treatment with the idea that methadone is just substituting one addiction for another,” said Mr. Ginter, “that attitude makes them feel as if recovery isn’t an option, for them. This discouraging prospect sets the stage for a less than optimal outcome. They ask themselves what difference does it make if they use a little benzodiazepines or smoke a little pot, if recovery isn’t an option anyway? That is how stigma stops patients from achieving recovery.”

 Peers Believe Peers

Peers—other people who are in MAT—can help support patients’ recovery in a way that nobody else—not a physician and not other people who are not taking methadone—can. “In the recovery community, you always hear people say they ‘support all pathways to recovery,’” said Mr. Ginter, “but often this is just lip service and not really an endorsement, with too many anti-MAT people weighing in and adding to the stigma. A lot of people support it and understand it’s evidence based practice, but still they don’t accept it as a legitimate pathway.”

At the MARS project, patients learn from peers that methadone and buprenorphine are “not substitute drugs, they’re medications,” said Mr. Ginter. “And suddenly, that person is a candidate for recovery. Before that, they never had a choice.”

When people are given the option of being in recovery, they choose it. Once they realize that taking methadone or buprenorphine is not the same as using, they stop using other drugs and alcohol. Yes, they were in treatment, but neither the opioid treatment program nor the physician could convince them that they were in recovery—it took another person in MAT to do that. “Peers believe things from other peers that they would not believe from anyone else,” said Mr. Ginter.

 Feeling Good

One of the magical things about erasing stigma is this: Once people start to feel good about themselves, the community starts to look at them differently. That’s why one exercise patients can use is to write down three nice things that happen each day.“ At the end of a few weeks, people start to feel better,” said Mr. Ginter. “For us to do well in recovery, we have to feel good about ourselves.”

Calling addiction a brain disease—which it is—takes away a lot of guilt, said Mr. Ginter. That internal feeling of guilt is magnified by stigma coming from the outside world.

In some ways, stigma from the outside world isn’t getting any better. “There are these nice dissertations out there about your rights, but if you’re in jail because you got picked up outside your methadone clinic, you can’t tell the cop he’s wrong,” said Mr. Ginter. It would help if drug courts and parole officers saw more patients for whom treatment is working, and not just those for whom it isn’t, he added.

Finally, fear of stigma keeps people from even saying that they are on buprenorphine or methadone. Thousands of people are doing well in treatment—not just the few, like Mr. Ginter, who publicly identify themselves.

As an anecdote illustrating this, Mr. Ginter related that visitors from overseas at the MARS booth at the AATOD conference last fall were amazed that two of the people working at their display booth were patients. “They couldn’t believe that peer recovery support services were provided by ‘real’ methadone patients,” he said.

 Other Participants

The ONDCP half-day meeting also featured panels on public health approaches to drug policy, being “smart on crime” instead of “tough on crime,” with an emphasis on drug courts using MAT, and a screening of The Anonymous People. Mr. Ginter related that the drug court speaker, magistrate Alby Zweig from Denver, was shocked to hear that many of his colleagues require participants to stop using methadone or buprenorphine before they can be admitted.

Note: MARS is a project of the National Alliance of Medication-Assisted (NAMA) Recovery. NAMA chapters are small groups of individuals who organize around advocacy to teach patients about their rights and to support them in their rights. Patient advocates are not the same as peer recovery support.

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Two Kinds of Roles for OTP Peers under the Affordable Care Act

flag and stetPeers—patients in medication-assisted treatment (MAT) who are in recovery—are gradually being enlisted into the workforce, thanks to the Affordable Care Act (ACA). Two kinds of roles are surfacing: recovery coaches, and “navigators” who help enroll uninsured people in private insurance through health insurance exchanges. The recovery coaching idea is not new, but the navigator one is—especially at the level of actually enrolling patients.

Community-based organizations in New York City have already signed up to be navigators, and the National Alliance for Medication Assisted Recovery (NAMA) hopes to be a part of this, says Joycelyn Woods, executive director.

Ms. Woods, like many observers, thinks there are going to be many glitches in getting people enrolled, and doubts that everyone who isn’t insured will be by next January. NAMA received a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) for educating patients and training navigators. “What SAMHSA is trying to do is to educate people,” explains Ms. Woods.

Recovery coaches will be a great asset to opioid treatment programs (OTPs), because they will make the programs more like the early ones in which “half the staff were patients,” says Ms. Woods. “They would hire patients and social workers and pair them together. The social worker would teach the patient about the academic part, and the patient would teach the social worker about the other part.” The “other part” is the experience of being a patient, a person with addiction, a person in a program.


Training is based on the Connecticut Community for Addiction Recovery (CCAR) protocol. As it is being used in the FOR-NY Recovery Coach Academy, the training consists of 30 hours. CCAR includes regular follow-up telephone calls—that probably won’t happen with Medicaid, which requires face-to-face contact, says Ms. Woods. But in New York City, which is not rural like Connecticut, it’s likely that face-to-face counseling can be done.

There are also issues with the payment structure for the peers doing coaching, and the state is still working on those.

Some methadone counselors have already participated in training, because they want the recovery coach credential, says Ms. Woods. Although recovery coaching spans all addiction, including alcohol, in New York State anyone doing recovery coaching in a methadone program must also have four hours of training in MAT. This is essential, says Ms. Woods. “Can you imagine people from abstinence-based programs doing recovery coaching in an OTP?”

The NYCB recovery coach credential which requires 60 total hours of training requires 4 hours of MAT training for all coaches wanting the credential, explains Mr. Ginter. The NYCB is the only certification board currently requiring this for their recovery coach credential.

Navigator vs Peercoaching

There’s a subtle difference between what a navigator does, and what the peer acting as a navigator does, says Tom Hill, director of programs at Faces and Voices of Recovery, which has been a major guiding light in the peer recovery coaching movement. “The peer assister or navigator does outreach and pulls people in to walk through the insurance enrollment process,” says Mr. Hill. “There’s one port of entry, and depending on the income, the person would be routed to Medicaid or the exchanges.”

The enrollment process for Medicaid has always been cumbersome, but the Center for Medicare and Medicaid Services (CMS) says it has simplified that process, notes Mr. Hill. “An organization that is able to conduct outreach and get someone to a computer can walk them through the process and get them enrolled.” The Centers for Medicare and Medicaid Services (CMS) is soon to issue a request for applications for navigator grants, says Mr. Hill.

The SAMHSA grants are small: only $25,000 for and there were only eight awarded, says Mr. Hill. “They’re not very detailed because there’s only so much you can do with that amount,” he says. “Some of the grants deal directly with developing enrollment strategies—but others are more generally focused on educating the community,” he says.

There’s a lot of pressure to enroll uninsured people by October 1, says Mr. Hill. “We’ve been pretty clear that the folks we have on the ground in addiction recovery communities are capable of doing the assisting and the navigating,” he says. “Now it’s just a matter of everything falling into place.”

New York City is a good litmus test for the navigator grants, says Mr. Hill, noting that the NAMA grant is good model.

The NAMA contract is to educate MAT patients about the ACA, says Walter Ginter, project director of the Medication Assisted Recovery Support (MARS) project at NAMA. “We’re going to contact all the doctors, and through focus groups and webinars, provide the education about the exchanges,” he says. But he is concerned that the education isn’t going to go far enough, and that actually enrolling people in insurance is a task that has not been well thought out.

“There’s a lot going on at breakneck speed right now,” he says. “It’s exciting and scary and terrifying.”

Site last updated July 17, 2014 @ 5:55 pm