Making Treatment Work
by Kana Enomoto and Dr. Kimberly A. Johnson
Addiction is a chronic, neurobiological condition with the potential for recovery and relapse. We know that recovery is possible and that treatment works best if it is multi-dimensional, evidence-based, and addresses both the physiological and psychological elements of substance use disorders. When coupled with appropriate psychosocial supports, medication-assisted treatment can provide one of the best paths to long-term recovery.
Medication-assisted treatment, also known as MAT, is one of the most powerful tools in the behavioral health toolbox for responding to heroin and opioid use disorders. Methadone, buprenorphine and extended-release injectable naltrexone all reduce opioid use, opioid use disorder-related symptoms, risk of infectious disease and crime, according to The American Society of Addiction Medicine’s 2003 report, Advancing Access to Addiction Medications.
Substance use disorders are often chronic, so medications may need to be administered for a long period of time, possibly for a lifetime. However, particularly in the early stages of recovery, medication alone is not considered best practice in treating opioid use disorders. Buprenorphine, methadone and naltrexone reduce physical cravings but do not address the psychosocial aspects of substance use disorders.
Too few people who are diagnosed with an opioid use disorder have received appropriate treatment for their condition. Therefore, expanding access to MAT is a primary focus for the Substance Abuse and Mental Health Services Administration, or SAMHSA. As part of a comprehensive effort to improve access to treatment, SAMHSA is proposing a change to the Drug Addiction Treatment Act of 2000 regulation to increase the number of patients that providers can treat for opioid use disorders. Currently, physicians can be approved to prescribe buprenorphine to 30 patients or, after a year of treating 30 or fewer patients, may apply for a waiver to treat up to 100 patients. SAMHSA has proposed regulations that would increase the waiver limit to 200 after additional requirements have been met. Realizing the urgency of the opioid public health crisis, we expedited the timeline for the rulemaking.
While the increased limit is intended to make MAT available to more people, it cannot ensure that treatment is accessible to all who need it. Many areas, particularly rural and underserved populations, have little or no access to treatment in general, and MAT in particular. To address this need, SAMHSA has identified states with the highest increase per capita in primary treatment admissions for opioids and heroin and is offering funding to help them improve access to medication-assisted treatment. These Targeted Capacity Expansion: Medication-Assisted Treatment—Prescription Drug and Opioid Addiction grants provide funding and technical assistance to states for use in identified communities of greatest need.
While improving access to medication is key to successful outcomes, as stated earlier, psychosocial interventions are necessary to help patients alter their lifestyle and improve their quality of life. The most effective psychosocial interventions are comprehensive, flexible, culturally aware and address the needs of the individual patient. Rather than a “one size fits all” approach, providers should have a toolbox of treatment approaches that can be utilized and integrated into a treatment plan as appropriate.
There are many evidence-based pyschosocial interventions that can be found on SAMHSA’s interactive database, National Registry of Evidence Based Programs. With the increased emphasis that the Affordable Care Act has placed on utilizing evidence-based practices, addiction specialty providers will need to identify the best programs for the patients with whom they work.
Unfortunately, states have reported challenges in finding physicians willing to offer office-based opioid treatment; therefore, locating opiate treatment programs is an ongoing issue. Patients may be reluctant to use antagonists such as extended-release injectable naltrexone because of withdrawal fears, and physicians lack experience with treating withdrawal symptoms in non-specialty care settings. States also express frustration with the slow pace of uptake of evidence-based practices by specialty-care programs. Programs have a hard time incorporating more than one of the rather complex evidence-based practices. Some of these issues can be addressed via technical assistance that SAMHSA can provide to states and their providers. Others, such as the complexity of the available evidence-based practices, require a longer-term solution that involves working with researchers to conduct studies that identify the essential elements of effective practices and programs and to conduct systemic reviews to identify the common elements that cut across specific evidence-based practices that can be incorporated into psychosocial interventions.
People for whom substance use disorders are chronic will need long-term care, which may include peer supports as well as medication and psychosocial interventions by trained professionals. Peer support workers fill in gaps in the treatment continuum and offer the particular perspective of a person who has been through the disease and is coping effectively. In addition to their support role, peer support staff can serve as a resource to link patients to needed social supports such as housing, job seeking or training programs, family supports, and other essential services. SAMHSA has grants available to states to help them enhance their peer support efforts.
With its grants programs and training/technical assistance services, SAMHSA is working with states to move the treatment of substance use disorders from a short-term counseling model to a model of treatment that includes the use of medications, counseling and peer supports over an extended period of time for some patients, as well as being able to address the needs of people who have a diagnosis of mild substance use disorders—in accordance with the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition—who may need shorter-term, less intense interventions.
About the Authors
Kana Enomoto serves as principal deputy administrator for the Substance Abuse and Mental Health Services Administration, or SAMHSA, where she has been delegated the functions, duties and authorities of the administrator to oversee an agency with four centers, four offices, over 600 employees and a budget of $3.7 billion. Through data, policy, public education and grants, Ms. Enomoto and the SAMHSA team advance the agency’s mission to reduce the impact of substance abuse and mental illness on America’s communities.
Dr. Kimberly A. Johnson, director of the Center for Substance Abuse Treatment, has an extensive career in behavioral health that has earned her numerous awards, including the federal Department of Health and Human Services Commissioner’s Award for Child Welfare Efforts and the National Association of State Alcohol and Drug Abuse Directors’ Recognition for Service to the field of Substance Abuse Treatment and Prevention.