The consensus panel believes that opioid treatment programs (OTPs) not already offering comprehensive medication-assisted treatment (MAT) services and those lacking resources to adjust levels of care to patient needs either should augment basic opioid pharmacotherapy with services that meet the mental health, medical, and social needs of patients who are opioid addicted--at the level of care each patient needs--or should provide referrals to programs that provide such services.
Steps in Patient-Treatment Matching
Patient Assessment
Patient-treatment matching begins with a thorough assessment to determine each patient's service needs; then these needs are matched to appropriate levels of care and types of services. Assessment should include the extent, nature, and duration of patients' opioid and other substance use and their treatment histories, as well as their medical, psychiatric, and psychosocial needs and functional status. A comprehensive assessment should include a patient's gender, culture, ethnicity, language, motivation to comply with treatment, and recovery support outside the OTP.
Type and Intensity of Treatment Services Needed
Psychosocial Treatment Services
In a comprehensive MAT setting, patients often have access to a variety of psychosocial services, including individual, family, and group counseling, as well as case management. Some programs may provide psychosocial services to patients in other settings. Both residential and outpatient programs may offer intensive individual and group counseling or counseling on a periodic or as-needed basis. Ideally, service intensity should depend on the level of care required to help patients achieve and maintain successful treatment outcomes. Most patients in the acute phase of treatment need to see a counselor daily for counseling or case management, just to become stabilized, whereas others, who may be highly functioning with less severe addiction-related psychosocial problems, require fewer counseling services.
Mutual-help Programs
Although not a form of treatment, mutual-help programs (e.g., 12-Step programs, Secular Organization for Sobriety groups, Women for Sobriety groups) offer effective reinforcement and motivation for individuals during and after discontinuation of active treatment. Such programs provide social support from others who are in recovery from addiction. Many patients in MAT participate in mutual-help groups. However, patients with opioid addiction who are maintained on treatment medication can feel out of place in some group settings where continued opioid pharmacotherapy may be misunderstood. Researchers have described a variety of specialized groups and inventive strategies for mutual-help programs that meet the support needs of patients in MAT.
Matching Treatment Service Needs to Settings
After the types and intensities of serves that patients need are defined, the next crucial step in patient-treatment matching is to identify the most appropriate available setting or settings for these services. MAT has been offered primarily in a dedicated outpatient OTP. However, as the importance of treating patients' varied medical, psychological, social, and behavioral needs as part of addiction recovery has become evident, more varied programs and settings have emerged.
Throughout this Treatment Improvement Protocol (TIP), the consensus panel recommends that OTPs lacking the resources to accommodate all their patients' needs develop cooperative relationships with and refer patients to other treatment providers as appropriate. However, OTPs should coordinate these services. Based on its assessments of patients, the treatment team should collaborate with patients to determine the most appropriate treatment services, intensities of services, and settings needed to meet patient needs. This collaboration should continue throughout MAT, and patient progress should be the basis for adjustments in treatment services and intensities.
Patients' service needs may change throughout MAT. For example, one patient may need referral to an inpatient program for detoxification from alcohol or benzodiazepines and then return to the OTP setting. Another may need the environment of a residential treatment program while continuing MAT. Therefore, treatment matching in some cases can lead to multiple settings for an individual's treatment. In most cases, the originating OTP should provide case management and liaison for all treatment services.
Types of Settings and Programs Offering Opioid Addiction Treatment Services
The following are examples of treatment programs and settings that offer some or all of the comprehensive services recommended in MAT.
Outpatient OTPs
Appropriate patients for treatment in outpatient OTPs are those who meet Federal and State requirements for opioid addiction treatment, those who have done poorly in other types of programs (e.g., medically supervised withdrawal or residential treatment programs), and those who require opioid pharmacotherapy for long-term stabilization.
OTPs in hospital-based outpatient settings may provide a more enhanced continuum of care than freestanding OTPs because access to medical and psychosocial services is readily available. This availability, in turn, increases the likelihood that patients in MAT will engage in and adhere to other medical and psychosocial treatment regimens.
Hospital-based MAT programs are appropriate for some patients who also are medically ill and require coordinated services or care by special teams. In addition, because hospitals can provide a one-stop-shopping model of care by incorporating some primary care services with MAT, some patients with histories of poor treatment compliance may be more likely to adhere to medical treatment.
Residential Treatment Programs
A residential treatment setting is indicated for patients who require residential placement to support treatment and ensure their physical or psychological safety and who are unlikely to continue MAT otherwise. Such patients generally exhibit high relapse potential, evidenced by an inability to control substance use despite active participation in less intensive outpatient programs. On completion of treatment in these settings, patients should return to an outpatient setting to continue MAT.
Mobile Treatment Units
Appropriate patients for treatment in mobile treatment units are those in locations where fixed-site programs are unavailable, those with ambulatory disabilities, and those initially stabilized in an OTP and then transferred to a mobile unit for continued treatment. Mobile units not staffed on weekends are appropriate only for patients who meet State and Federal regulations for weekend take-home medications.
Office-Based Opioid Treatment Settings
After achieving biomedical and psychosocial stabilization in an OTP, some patients might be eligible for referral to less intensive physician's office-based opioid treatment (OBOT) for medical maintenance. In these settings, patients receive the same level of monitoring and intervention as patients receiving other types of health care.
Criminal Justice Settings
At this writing, relatively few jails or prisons offer comprehensive MAT or selected MAT services, but these numbers are likely to increase (for information about substance abuse treatment in criminal justice settings, see TIP 44, Substance Abuse Treatment of Adults in the Criminal Justice System). As a result, MAT services are often interrupted or discontinued when patients are incarcerated. Rikers Island, New York City's central jail facility, is an example of a model program that provides comprehensive MAT for this patient group. Patients who receive MAT there are guaranteed a slot at a community-based program in New York City after their incarceration. Other corrections facilities provide rapid medically supervised withdrawal from maintenance medication to patients. When this withdrawal is the only option, OTPs should work with criminal justice institutions to ensure that appropriate dose-tapering procedures are followed. Patients released from a criminal justice setting should be offered referral to an OTP when referral is desirable and feasible.
Other Treatment Settings
Numerous other settings and specialized programs offer some services and levels of care needed by patients who are opioid addicted. Any of these programs can be sources of referral by OTPs or can function as satellite OTPs to ensure that patients receive services and levels of care they need.
Choice of Medications
The consensus panel recommends that OTPs offer a variety of treatment medications.
Patients With Special Needs
Effective treatment for opioid addiction should address the unique needs of each patient. Culturally competent and creative treatment planning, implementation, and referrals should address the distinct needs of patients from different backgrounds.
Patients With Serious Medical Disorders
If a serious medical condition is discovered during medical evaluation or patient assessment, the patient should receive appropriate medical treatment either on site or by referral to a medical center. OTPs should develop and maintain referral networks for patients who present for MAT and have other medical conditions. Moreover, OTP staff should coordinate referrals and follow up as needed to ensure compliance with medical treatments and to act as consultants about MAT and medication interactions.
Patients With Serious Co-Occurring Disorders
The existence of co-occurring disorders should not prevent patients' admission to an OTP; however, diagnosis of these disorders is critical to match patients with appropriate services and settings. Therefore, OTPs should include professional staff trained to screen for the presence of co-occurring disorders, develop appropriate referrals to services (e.g., psychopharmacology or psychotherapy) for these disorders, and provide coordination of care. Most staff members can be trained to recognize and flag major symptoms of co-occurring disorders. The OTP should maintain communication and follow-up with referral resources.
Patients With Housing, Family, or Social Problems
The following psychosocial problems should be addressed during or directly after admission to increase the likelihood that patients will engage successfully in treatment:
- Lack of stable housing
- Broken ties with family members; nonexistent or dysfunctional family relationships
- Poor social skills and lack of a supportive social network
- Unemployment; lack of employable skills
Once these needs are identified during assessment, referrals can be made. Although some OTPs have social workers on site to manage the assessment and referral processes, most OTPs rely on counselors to assume this role. Case management duties should include arrangements for provision of psychosocial care when indicated. Family members need education about MAT, including information on how to support a partner or loved one in recovery, self-care of family members, signs and symptoms of active addiction, and support and assistance from family members willing to participate in family counseling. Programs can offer monthly classes to patients, their families, and the community, which can reduce the stigma connected with MAT.
Patients With Disabilities
OTPs should try to provide access for patients with physical disabilities. Treatment interventions for these patients usually include vocational rehabilitation, physical therapy, and social services that help procure prosthetic limbs, wheelchairs, and other assistive devices. Alternative approaches in MAT, specifically those that reduce OTP visits, include take-home dosing and requests for medical exceptions through visiting-nurse services to provide equal access to treatment for persons with disabilities.
Mobile medication units and office-based or home-nursing services may offer viable treatment options for patients with disabilities. OTP staff should address these challenges with patients so that barriers to treatment are overcome.
The consensus panel recommends that OTPs engage in discussions with their Federal and State agencies to develop solutions for treating patients with disabilities. Such discussions should balance the medical needs of these patients and the safety issues involved in providing take-home medications for patients with disabilities who continue to engage in substance abuse or create a risk of medication diversion.
Adolescents and Young Adults
Treatment for adolescents and young adults should integrate knowledge of their specific developmental and psychosocial concerns and needs. Some needs are related to identity formation and peer group preoccupation (e.g., the strong desire to be viewed as fearless or to feel invincible), legal complications regarding consent for treatment, and, often, factors leading them to run away from their homes.
The interaction of developmental and psychosocial factors affects the ability of adolescents and young adults to engage in MAT and therefore complicates the recovery process. OTPs should provide psychosocial services that address the unique needs of this age group, especially those needs that affect their substance use and recovery, or they should establish referrals and links to youth-oriented psychosocial counseling services.
Buprenorphine may be a particularly satisfactory treatment for some adolescents. Because buprenorphine can be administered in an OBOT setting, it should become more widely available and offer more privacy and less stigma for young patients.
Women
Pregnancy
The special needs of women who are opioid addicted and pregnant should be assessed thoroughly through a comprehensive medical evaluation. Treatment matching for pregnant patients in MAT should provide optimal, comprehensive, and intensive services related to pregnancy and birth including prenatal care, maternal nutrition, and psychosocial rehabilitation, along with MAT.
OTPs are required by regulation or accreditation standards to test for pregnancy, but the provision of prenatal care and ancillary services for pregnant women varies depending on the treatment setting. Hospital-based programs may be better suited for pregnant women in some cases because hospitals offer easy access to referrals and links to specialty care (on or off site).
Sexual or Physical Abuse
Patients' risks of ongoing abuse in their current relationships should be addressed, and appropriate plans or referrals made. Co-occurring disorders such as posttraumatic stress disorder can occur among both women and men who have experienced sexual or physical abuse. The best treatment settings to address women's needs in these cases include OTPs with onsite care provided by psychiatrists, psychologists, licensed social workers, or mental health professionals with special training in this area. In lieu of onsite services, OTPs should establish referral links to programs offering such services.
Complex Medical Problems
The complex medical problems commonly diagnosed in women in MAT include gynecological infections, amenorrhea, hypertension, and pneumonia. It is optimal to provide primary care services on site; hospital-based programs and OTPs with formalized medical referral systems are best equipped to deliver such services.
Parents
The consensus panel recommends that OTPs seek opportunities and funding for onsite childcare where appropriate and feasible to help patients with children engage successfully in psychosocial services. Where childcare is unavailable, program staff should offer referrals to community daycare agencies.
In most States, OTPs are mandated reporters of child abuse and neglect. When children are at imminent risk of harm or appear neglected, OTPs are required to notify local children's protective services (CPS) agencies so that an investigation can be conducted. This requirement can create conflict between an OTP and a patient, and the OTP should try to address this issue in a supportive way. Programs and treatment providers should not discriminate against patients because they have entered into pretreatment agreements or have difficulties with CPS agencies.
Lesbian, Gay, and Bisexual Patients
Just as important as sensitivity to cultural differences based on race or ethnicity is providing a treatment climate that is available and sensitive to lesbian, gay, or bisexual (LGB) patients by openly acknowledging their heterogeneity and variations in sexual orientation and treating these individuals with dignity and respect. OTP staff should be prepared to assist LGB patients in coping with problems related to their sexual orientation and the need for human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and sexually transmitted disease (STD) risk avoidance. Providers should help patients obtain appropriate medical care and secure their safety if, for example, they are threatened. OTPs also should acknowledge the unique social support structures of LGB patients, which can provide a way to counteract isolation and separation from community, peers, and immediate and extended family members. Finally, the consensus panel recommends that OTPs identify and refer LGB patients to community counseling, support, and spiritual and religious organizations that are sensitive to these groups and address any sexual- or gender-orientation concerns these patients have that could affect treatment.
Aging Patients
MAT treatment planners should consider the stressors common to the aging patient, such as loss of family, retirement, loneliness, and boredom, which can contribute to high risk of self-overmedication and addiction to alcohol and medications. The consensus panel recommends that OTPs focus on the following areas when working with elderly patients:
- Monitoring the increased risk for dangerous drug interactions; elderly patients often are prescribed multiple medications.
- Differentiating between co-occurring disorders and symptoms and disorders associated with aging (including dementia).
- Differentiating between depression and dementia.
- Screening for and treating physical and sexual abuse.
- Developing referral sources that meet the needs of elderly patients. Relationships with skilled nursing facilities and nursing homes are particularly important.
- Training staff to be sensitive to the elderly patient population.
- Providing psychosocial treatment for age-associated stressors and medical screening and referral for common medical conditions affected by the aging process.
- Assessing and adjusting dosage levels of medication for the slowed metabolism of many elderly patients.
Patients With Pain
MAT providers should evaluate patient treatment needs for pain management and assist patients directly in obtaining optimal pain treatment. Medical providers in MAT should work collaboratively with primary care providers and pain and palliative-care clinicians to ensure establishment of appropriate pain interventions for patients in MAT. Providers need education about maintaining current opioid levels while adding sufficient immediate-release treatment agents to manage acute or chronic pain. More frequent dosing and short-term increased demand for pain treatment medication should be expected. Referrals to specialty pain clinics often provide patients a full spectrum of pain care, including pharmacological and psychological or behavioral treatments to alleviate pain symptoms. These services most often are accessible through hospital-based programs or referral linkages. Most patients can be maintained on their MAT dosage while taking short-acting opioids for pain relief; however, individualized pain treatment is usually necessary.
Treatment Planning
After patients' individual needs are assessed and the best available treatment services and most appropriate levels of care are determined, a treatment plan should be developed with the patient, as required by accreditation guidelines.
Developing a Treatment Plan
Treatment planning for MAT should involve a multidisciplinary team, including physicians, counselors, nurses, case managers, social workers, and patients. Based on a thorough patient history and assessment, a treatment plan should be realistic and tailored to each patient's needs, strengths, goals, and objectives. Good treatment plans contain both short- and long-term goals and specify the actions needed to reach each goal. Treatment plans should indicate which goals and objectives require referral to and follow-up with outside resources and which are provided by the OTP itself. Treatment plans should contain specific, measurable treatment objectives that can be evaluated for degree of accomplishment.
Role of the Counselor in Plan Formulation
Counselors should ensure that treatment plans incorporate strategies to develop therapeutic relationships with patients, based on respect for patients' autonomy and dignity, while motivating patients to become willing partners in the change process. This role, which places great responsibility on the counselor, usually incorporates cognitive behavioral approaches in which providers strive to enhance patient motivation for change by focusing on patient strengths and respecting patient decisions. To engage patients in the process of treatment planning, counselors should encourage the inclusion of motivational enhancement strategies that highlight appropriate, realistic treatment goals.
Role of the Patient in Plan Formulation
A patient in MAT should be an integral member of the treatment team with his or her needs and expectations considered respectfully and incorporated into the treatment plan. Patients who agree with the treatment rationale or therapeutic approach tend to experience increased determination to improve. A patient's participation in treatment planning can enhance motivation to adhere to change strategies, leading to positive treatment outcomes such as higher rates of abstinence and better social adjustment. When possible, the treatment plan should be written in a patient's own words to describe his or her unique strengths, needs, abilities, and preferences as well as his or her challenges and problems. The plan also should contain mutually approved goals that reflect awareness of and sensitivity to a patient's informed choices, cultural background, age, and medical status or disability.
Other Factors in Plan Formulation
Treatment plans should incorporate an assessment of linguistic and cultural factors that might affect treatment and recovery either positively or negatively. Treatment providers should work collaboratively with patients to identify health-related cultural beliefs, values, and practices and to decide how to address these factors in the treatment.
Motivation for Treatment
Patient motivational strategies should be incorporated throughout the treatment plan. As part of this process, the treatment team can benefit from an understanding of stages of change and their effects on patient progress.
Patients and treatment providers ideally should develop recommended treatment options in the plan based on each patient's readiness for treatment, which can be determined by identifying the patient's stage-of-change readiness.
Elements of a Treatment Plan
Because some patients require assistance in many functional areas, treatment plans should address measurable, achievable goals relevant to the patient's current situation. Short-term goals, such as vocational rehabilitation assessment or computer training, can evolve from a long-term goal, such as full-time employment. However, treatment plans should be simple and not so comprehensive that they overpower a patient with the tasks that must be achieved. Although both short- and long-term goals should be considered, the patient's involvement in defining measurable, achievable goals is important. Treatment plans should be modified periodically when progress can be assessed. Most OTPs have forms to use for treatment planning, many of which were developed to meet regulatory and accreditation requirements, specifying goals, actions, responsible parties, and measurable outcomes. The panel urges that these forms not be overly complex or overwhelming to the patient. Patients should receive a copy of the plan. Exhibit 6-1 in the original guideline document provides a case study and an example of a treatment plan.
The Multidisciplinary Team Approach
The complexities of treatment planning for patients who receive MAT require a multidisciplinary treatment team, the composition of which varies with OTP resources and the population being treated. The consensus panel recommends that the treatment team consist of the following:
- A physician trained in addiction psychiatry, who provides leadership, health care, and medical stabilization; conducts detailed evaluations of the patient; monitors medications; and provides needed substance abuse interventions when indicated
- Nonphysician medical staff members (e.g., registered nurse, nurse practitioner, physician's assistant), who administer medications, assist in medical evaluations, maintain records, and facilitate referrals for medical and psychiatric treatments
- A pharmacist or pharmacy assistant, who dispenses (and sometimes administers) medications, orders controlled substances, maintains records, and consults with program staff on all aspects of patient care, particularly drug interactions
- Nonmedical professional staff members (e.g., case coordinator, social worker, psychologist, vocational and educational specialist), who provide a range of psychosocial services, including counseling and case management, psychotherapy and family therapy, psychological testing and evaluation, health education, and vocational skills assessment and training
- A certified or licensed addiction specialist or drug counselor
- Nontreatment and administrative staff members (e.g., office manager, clerical staff, receptionist, secretary), who often provide information to treatment teams and whose responsibilities include operational management, billing, receipt of payments, review of records, observation of patient interactions, and telephone coverage
- Security personnel, who ensure the safety and well-being of patients and staff on site
