"The guiding vision of our work must be to create a city and a world in which people with a history of alcohol or drug problems, people in recovery, and people at risk for these problems are valued and treated with dignity, and where stigma, accompanying attitudes, discrimination, and other barriers to recovery are eliminated."

~ SAMHSA
 

Stigma has been defined as 'a mark of disgrace or infamy' or 'a stain or reproach on one's reputation'. Individuals with addictions, by the time they need or seek treatment, are well aware of the sting of stigma. Those whose journey to recovery includes Medication Assisted Treatment (MAT) often continue – ironically – to be stigmatized – not just for having an addiction, but for the very tools they use to combat it.

"Stigma in MAT is real and cited by many individuals and
professionals as the primary barrier to utilizing MAT."
ATTC MAT Training (1: Module 3, Slide 5).

Part 2 of this three-part series will discuss practical ways behavioral health providers can support patients who utilize MAT, including strategies for helping them deal with stigma, and ideas for helping them manage and adhere to their medications. The series will continue to draw from and highlight the new ATTC on-line training on MAT (1).

Understanding Stigma

Advancements in medicine are often met with hesitance, curiosity, and at times outright hostility, depending on social and political factors surrounding the disease or disorder. The use of MAT in substance abuse treatment is no exception, and in fact provokes a great deal of attention. The following section describes some current challenges and perspectives on MAT, and the associated stigma.

"There has been no consensus even within the recovering community about the role of 'medication-assisted recovery," concluded a panel of experts convened by the Betty Ford Institute (2):

"There appears to be essentially full agreement that formerly dependent individuals who are abstinent from all drugs of abuse but take, for example, insulin for diabetes or diuretics for hypertension, still meet contemporary views about being in recovery. There does not appear to be agreement regarding whether those whose use of alcohol has been blocked by naltrexone, acamprosate, or disulfiram are also considered to be in recovery. Finally, it appears that only few of those presently in recovery within the United States consider individuals whose illicit opioid use is blocked by buprenorphine or methadone to be in recovery." (2)

These themes were also clearly reflected in statements made by participants of focus groups held in 2011 by regional Addiction Technology Transfer Centers, in prelude to creating the new MAT curriculum (1). Themes were consistent even though the groups were conducted across the U.S. with diverse individuals – including African-Americans, Asian and Pacific Islanders, Native-Americans, as well as Hispanic and Latino Americans – and professionals working in the field.

Comments reflected a general acceptance of medications used for the treatment of chronic medical conditions – excluding addiction and psychiatric issues. Results also point toward ambivalence regarding medications used for the treatment of alcohol, albeit with a growing understanding and acceptance for some addiction and psychiatric medications. Finally focus group participants also reported patients experiencing antagonism, especially for those using methadone as treatment for opioid dependency, but also related to the use of buprenorphine.

Antagonism was clear in blunt and dismissive statements about MAT that focus group members heard from legal and healthcare professionals, peers in recovery, and family members. One theme expressed across all focus groups was the difficulty of "coming out" to family members about their use of medications. Many participants talked about having a mutual understanding that it was not to be discussed, since any open conversation resulted in criticism and/or rejection.

Additionally, physicians were often less educated about the use of medications than patients expected, and some were even antagonistic or hostile. "I had one doctor tell me that he would rather see me on heroin than methadone," said a focus group member. Stigma from physicians not only has a negative impact on addictions treatment, but also in the larger context of healthcare, as these perspectives support the myths and misperceptions about addiction, and reduce access to MAT and support for recovery.

Stigma from judges, family members, doctors and social media about MAT also have serious implications and impede recovery. One professional reported that many of her clients felt that they held a "second class" recovery status; it was good but not quite "good enough". Her concern was that this led to underutilization or premature discontinuation of medications that could support recovery. This type of experience may also create a sense of shame for clients, and influence the entire recovery experience. In summary, stigma and misperceptions related to MAT limits treatment options and opportunities for health and healing.

MAT and Myth

A main concern echoing through many antagonistic comments reported by focus group members was about replacing one drug with another drug, thus undermining the true potential of recovery. It is a common myth about MAT, and a major area in which providers can help.

Meeting myth with facts and education can be effective in combating stigma; for example, by reinforcing the difference between medications and drugs, and physical dependence versus addiction (as discussed in Part 1). Providers can also share examples of other chronic illnesses (i.e. diabetes, heart disease) that are treated with maintenance medications.
The more providers can learn about how medications work, and the research supporting their effectiveness (and the more they can help patients articulate this), the better they will be able to combat stigma and myth and support patient recovery. Patients can also be coached to talk to other professionals about what they have gone through with their addictions, and how MAT has helped them.

A related myth is that medications are not part of addiction treatment. Medications can and are an accepted and effective part of treatment of many chronic mental and physical conditions, and addictions medications work with bio-chemistry just as other medications do, and are vetted and approved by the FDA.

Peer-Support Groups

Another pervasive myth is that the most common and accepted peer support groups ¬¬– Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) – do not support the use of medications. Much of the objection from 12-step members is founded in a fear that members will use medications inappropriately and undermine their own recovery, as sometimes happens. Many members have also relapsed while using prescribed medication, and for many the safest path to sustained recovery becomes "just say no" to all medications. For others, the use of medications is necessary to support their sobriety.

Counselors can and should proactively prepare patients to address resistance by peer-support group members. One approach is to use examples from peer-group program literature to underscore the importance of distinguishing the stance of a program from the opinions of its members. For instance, consider the following quotation from The AA Member – Medications and Other Drugs:

"Some alcohol dependent clients require medication: It becomes clear that just as it's wrong to enable or support any alcoholic to become re-addicted to any drug, it's equally wrong to deprive any alcoholic of medication which can alleviate or control other disabling physical and/or emotional problems." (3)

Importantly, the Big Book of AA, itself, says that the world is full of "fine doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such persons. Most of them give freely of themselves, that their fellows may enjoy sound minds and bodies.... we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward." [Chapter 9, p. 133]

The avenue to partnership with primary care is paved with acceptance and knowledge, just as the recovery communities acceptance of MAT was also paved long ago. However, despite the overall support of AA and NA for MAT, some written material – such as a 1996 NA bulletin about methadone (http://www.na.org/?ID=bulletins-bull29) – seems to indicate that people who are taking methadone and attend NA meetings should not speak and cannot lead meetings. Some NA groups are even hostile to individuals who are receiving methadone as part of their course of treatment. Here, providers and peer recovery coaches and sponsors can assist by being prepared to identify the most accepting and appropriate support groups and sponsors.

MAT and Discrimination

Providers can also help patients using MAT to address discrimination, particularly in regard to use of addictions medications for opioid treatment. Per SAMHSA: "This discrimination is largely due to lack of knowledge about MAT's value, effectiveness, and safety; and a lack of knowledge about the anti-discrimination laws that protect people who are using MAT. Discrimination is also common because people in MAT frequently do not have the tools necessary to educate employers, landlords, courts, and others about MAT and relevant legal protections." (4)

Providers can share accurate information and resources with patients. An example is a free publication by SAMHSA (4), which covers issues and laws related to housing; government benefits and services, and private educational, health care, and other facilities. The publication aims to reduce discrimination by giving patients and advocates basic information necessary to exercise their rights; or, at a minimum, to know where to find help. It also aims to educate those who might discriminate about both the laws and MAT, itself.

The Legal Action Committee (www.lac.org) is another reliable source for useful publications, including one covering the legal rights related to child welfare and/or the criminal justice system (5).

Medication Support

If the patient is equipped with comprehensive information regarding the importance of taking their medications regularly, avoiding potential interactions, keeping to a schedule, etc., he/she will experience a greater sense of control, and will know what to expect. Also, as described in the ATTC Network MAT training, supporting patients in continuing to take prescribed medications properly can significantly improve treatment outcomes, as well as treatment for other co-morbid medical conditions, such as HIV or hepatitis C, or hypertension OR psychiatric conditions such as bipolar disorder, or anxiety (1: Module 2, Slide 86).

There are several strategies providers can employ regarding medication management and adherence, and these can be effective whether the medication is designed to treat a mental health, medical, or substance use disorders. When discussing mediations it is important to keep in mind that medical decisions must be made by trained and licensed providers, and although substance abuse treatment providers cannot make specific recommendations, they can encourage patients to talk to their prescribing provider and they can support the patients use of MAT as one tool in their recovery process.

Talking About Medications

For patients using MAT, behavioral health providers should plan to devote about five to ten minutes every few counseling sessions to discuss medication usage and the importance of following their treatment plan. These open discusisons help patients experience conversations about adherence as routine, and it builds rapport by demonstrating support for the physical, mental, and emotional well being of patients.

An important initial step is the development of a game plan for how to regularly introduce the topic of medication use. You might begin a discussion by reminding patients that taking medications as prescribed can help prevent relapse, and that the more informed a patient can be about their medications the greater chance they will follow their treatment plan. Or, as part of "normalizing" the discussion, patients should be encouraged to talk about their use of medications for any chronic condition, such as high blood pressure or insulin for type 2 diabetes.

Overall Communication Tips

There are three overarching communication tips to keep in mind whenever a discussion about medications occurs. First, be prepared to provide patients with information regarding potential medication interactions – such as interactions with food, alcohol or other drugs, other medications, and/or pregnancy considerations. Second, be aware that some medications may require a routine blood test to monitor for side effects like liver toxicity or blood pressure; while this is something a physician would initiate and monitor, it is a process you can collaboratively support. Lastly, be prepared to discuss the positive outcomes related to consistent medication compliance as well as potential side effects from the medications themselves.

Medication Adherence

Several specific prompts or questions are important to can keep in mind when discussing medication adherence with patients:

• How many doses have you missed?
• Have you felt or acted different on days when you missed your medication?
• Was missing a scheduled dose of medication related to any substance use relapse?
• Why did you miss the medication? Did you forget, or did you choose not to take it at that time?

Leading into a discussion about adherence, providers might ask how many doses patients missed during a specified time period, rather than asking if they missed doses. This implies acceptance that missing doses is a real possibility and may prompt a more open discussion. This open communication between provider and patient generates a chance to assess potential patterns of non-compliance, or to assses specific circumstances that may contribute to missed doses. It is possible that missed doses may be a sign of future substance use relapse, which would be critical information to learn. It's important to refrain from asking questions about adherence in a judgmental or confrontational way. Body language may also influence the message and communicatino while interacting with your patients on this potentially sensitive topic. The purpose of this type of discussion is to help your patients stay on a path that will hopefully lead to better overall health.

Medication Adherence: Common Reasons for Missing Doses

Patients may cite a myriad of reasons for why they miss medication doses, whether frequently or sporadically, and this always presents an opportunity to acknowledge that many people miss taking their medication at times. Then, once a patient provides a specific reason for missing a dose (or doses), it is critical to help them identify one or more concrete strategies to lessen barriers to ongoing medication adherence. Additionally, you might need to consult with the prescriber, informing them about the frequency of missed doses and asking about related medical consequences. The prescriber may also be involved in developing strategies for medication adherence.

The following are a few of the more common reasons given for missing doses, and suggestions for how to respond (1):

"I don't need to take medications anymore,
because I am cured."

Sometimes, when patients first start taking medications, they feel better than they have in a long time, and consider themselves to be suddenly healed or cured. Because of this, they may be inclined to cease the use of medications or taper the prescribed dose. It may be important to remind patients that for many medications, they need to take the medications everyday at the precribed dose so that a therapeutic level builds in the body.

"I don't like the side effects."

All types of medications, including those approved for treating chronic medical conditions, psychiatric conditions, and those used in the treatment of alcohol or opioid addiction, have at least some negative side effects. It is likely the case, however, that the minor side effects experienced when taking prescribed medications under a physician's supervision are much less severe than the negative effects associated with harmful use of alcohol and illicit drugs, or the misuse or abuse of prescription medications. Behavioral health providers can help the client bring the side effects back to their doctor, as many of these can be managed through dose adjustments, supportive medications, or just a better understanding that the effects will diminish with time.

"I don't want to hear objections or ridicule
from friends and family members."

As discussed previously, a pervasive myth is the notion that individuals who are taking a medication for their opioid or alcohol addiction (and, to a lesser extent, a medication for a psychiatric condition) are not in recovery, and that they are replacing one drug for another. Again, it is critical to help arm patients with information about the physiology and biochemistry of addiction to combat this stigma. Friends or family members who ridicule a patient receiving MAT may also be in need of education or information, including how MAT works and evidence supporting its effectiveness as a treatment tool.

The ATTC MAT curriculum (1) includes other common reasons given for missing doses, along with strategies for discussing them and ideas for helping patients avoid missed doses in the first place (e.g., using an alarm, a pill box, and/or placing medications near commonly used objects); it also covers crucial information about responding to patients who admit to purposefully deciding not to take doses (1: Module 2, Slides 86-108).

Mat in the Context of Recovery

It is critical that individuals are able to access and be supported in using the tools that are relevant to their recovery, whether they utilize a medication, a form of unforced outpatient treatment, support from a recovering peer group, or some alternative lifestyle. The tools that individuals, families and communities use are just that – tools; they do not define or undermine the quality of this recovery.

As more medications become available for the treatment of addiction, how can individuals, family, community, and the healthcare profession begin to define and understand MAT in the context of recovery? Additionally, how can the definition of recovery be understood and be inclusive of medications as a legitimate and effective tool for pursuing recovery?

These questions were considered in National Summit on Recovery Conference, convened by the Substance Abuse and Mental Health Services Administration in 2005. The report it generated (7) articulated a number of principles key to understanding recovery, including the role medications can play as a supportive tool. For example, the report's first principle states that recovery has many pathways, and the report emphasizes the need to transcend shame and stigma and to define and evaluate recovery by its "condition", not the method by which one attains it. In this context, recovery is defined as "a process of change through which individuals work to improve their own health and well-being, live a self-directed life, and strive to achieve their full potential."

There is also an emerging national consensus supporting recovery as a non-linear process, a chronic condition that may involve relapse and other setbacks, but is based on continual growth and improved functioning (2,6,7). Of relevance is whether a person in the process of building or rebuilding what they have lost, or never had, due to their condition and its consequences. Are their relationships and quality of their life improving? Are they obtaining education, employment, housing, and/or increasingly become involved in constructive roles in the community? Evaluating recovery in this context – rather than judging the journey's tools – makes much more sense.

Conclusion

Clearly, there are numerous, specific strategies clinicians can employ to help patients succeed when using MAT and, ultimately, in their overall treatment and recovery approaches. Acquiring and sharing accurate information and facts that run counter to stigmatizing myths is key, as is supporting medication management and adherence.

Another crucial area is communicating and collaborating with physicians, as we'll discuss in Part 3, along with issues related to increasing and improving access for patients to MAT.

For more information, please consider exploring the resources listed below, or contact your regional ATTC: www.attcnetwork.org.

Series Author: Lynn McIntosh is a Technology Transfer Specialist for the Northwest Frontier ATTC and the Alcohol and Drug Abuse Institute at the University of Washington in Seattle.

Series Editor: Traci Rieckmann, PhD, NFATTC Principal Investigator, is editing this series.
The Addiction Messenger's monthly article is a publication from Northwest Frontier ATTC that communicates tips and information on best practices in a brief format.

Northwest Frontier Addiction Technology Transfer Center

3181 Sam Jackson Park Rd. CB669
Portland, OR 97239
Phone: (503) 494-9611
FAX: (503) 494-0183

A project of OHSU Department of Public Health & Preventive Medicine.

References | Download PDF Version

Part 1: Setting the Context

"When you love someone who suffers from the disease of addiction you await the phone call. There will be a phone call. The sincere hope is that the call will be from the addict themselves, telling you they've had enough, that they're ready to stop, ready to try something new. Of course though, you fear the other call, the sad nocturnal chime from a friend or relative telling you it's too late, she's gone."

~ Russell Brand, 2011

(Resource 1: Module 3, Slide 2)

Although there is an increasing understanding that addiction is a chronic disease, ongoing stigma and shame often make seeking treatment difficult. Those who do engage in treatment deserve every opportunity available to help them pursue recovery. For some, Medication-Assisted Treatment (MAT) is the key they need to help them enter or stay in recovery.

An article by Carlo C. DiClemente (Resource 2, below), tells the stories of four women whose ongoing struggles with addictions are finally addressed through the use of medications. One of the women, Nikki, began drinking alcohol and using marijuana when she was 11, and by age 20 was also using heroin and crack cocaine. At age 27 – having been through inpatient treatment, and entered and left eight different detoxification centers and halfway homes – oral naltrexone was recommended as part of psycho-social treatment.

"Naltrexone did not cure my addiction or alcoholism, but it helped with the strength for me to begin the lifelong process," Nikki says. "When the cravings were curbed, I was able to focus on myself and the core of my addiction – and the treatment program." (2)

To assist treatment providers with preparing for and offering MAT in their treatment programs, the Addiction Technology Transfer Center Network has produced a new on-line training: Medication-Assisted Treatment with Special Populations. The new ATTC training includes tracks for both primary care and substance abuse treatment providers, and each track includes three general modules and four modules about providing outreach and treatment to specific populations, namely Asian and Pacific Islanders; African Americans; Hispanics and Latinos; and Native Americans and Alaska Natives (1).

This series, focused on MAT, will draw from and highlight information from the ATTC training modules for treatment providers, and will include introductory information; a discussion of the challenges and benefits involved in using and implementing MAT; and also issues related to outreach, access, and ethnicity/culture.

Defining MAT

According to the Treatment Improvement Protocol #42 (Substance Abuse Treatment for Persons With Co-Occurring Disorders), published by the Substance Abuse and Mental Health Services Administration, MAT is any alcohol or opioid addiction treatment that includes an FDA-approved medication for the detoxification or maintenance treatment of alcohol or opioid addiction.

MAT may be provided in an opioid treatment program (OTP), a medication unit affiliated with an outpatient or residential treatment, a physician's office, a community-based treatment program which integrates medical providers, or in other health care settings, such as community health centers. It includes comprehensive maintenance, medical maintenance, interim maintenance, detoxification, and medically supervised withdrawal.

Goals and Bio-Psycho-Social Context

Medication-assisted treatment can be used to reduce acute or long-term withdrawal symptoms, prevent cravings, and/or block the effects of illicit substances. In brief, the goals in using addiction medications are to:

• Reduce symptoms and signs of withdrawal;
• Reduce or eliminate craving;
• Block the effects of alcohol or illicit opioids;
• Restore normal physiology; and,
• Promote psychosocial recovery, including a non-drug lifestyle.

Medications can help address the physical and biological ramifications of alcohol or opioid use, by specifically targeting affects on the brain. However, FDA labeling on all medications for alcohol and opioid addictions recommends that MAT should be used in conjunction with behavioral therapies. Evidence-based behavioral treatments – such as cognitive behavioral therapy (CBT), motivational engagement therapy (MET), or Person-Centered Therapy (PCT) – increase the likelihood of success. (More information about these and other behavioral therapies can be found on the Addiction Technology Transfer Center Network's website: www.attcnetwork.org.) Additionally, research on behavioral treatment indicates that treatment should address the multifaceted needs of the individual (Resource 1: Module 2, Section 2, Slide 79).

When offering MAT as a treatment strategy it is important to remember that comprehensive, quality care is holistic, integrated, and multifaceted, taking into account the physical, behavioral, and spiritual wellbeing (bio-psycho-social needs) of individuals. To give patients the best chance at success, medication should be part of a comprehensive treatment plan, including thorough evaluation and diagnosis.

Side effects, drug interactions, and contraindications exist to varying degrees for all medications, and it is the responsibility of primary care providers to prescribe medications and to educate and monitor patients. The best outcomes, however, will be achieved only if treatment providers are educated – and open-minded – enough to offer and support MAT as an option. Obviously not all strategies will be effective for everyone, so it is critical that patients work with SUD treatment providers and private physicians to determine the course of action that is best for their individual circumstances.

Dependency versus Addiction

In considering MAT, it is also critical to understand the difference between addiction, and physical dependence on a substance. Anyone who takes certain kinds of medications (opioids, certain blood pressure meds, etc.) for an extended period of time will most likely become physically dependent on the medication. This means that they will have withdrawal symptoms if they suddenly stop taking the medication. Addiction, however, is defined as a collection of symptoms that may include physical dependence, but requires other behavioral symptoms indicating loss of control over use, exacerbation of problems because of use, and continued use despite negative consequences.

Drug Use versus Medication Use

Another critical distinction is the difference in terminology between drugs and medications. Drugs are typically used to alter or enhance reality. Medications are intended to help an individual participate in reality or life - not to escape it. The Influence of prescription medications (controlled substances) on an individual's recovery status is best evaluated, not in terms of its presence, but in terms of the motivations for medication use and its effects. For example, using this principle, the same dose of a drug could constitute relapse for one person (e.g., the use of unprescribed methadone for purposes of intoxication) and a recovery adjunct for another patient (i.e., the same amount mg of methadone prescribed for metabolic stabilization).

Many providers already understand the two crucial points above, but explaining them to others can go far in helping them understand what is meant by MAT in the context of recovery.

FDA-Approved Medications

There are several FDA-approved medications available for treating addiction. In summary, the FDA-approved medications for opioid addiction are methadone, buprenorphine (Subutex®), buprenorphine-naloxone (Suboxone®), and naltrexone (ReVia®, Vivitrol®, Depade®). The approved medications for alcohol addiction are naltrexone (ReVia®, Vivitrol®, Depade®), Disulfiram (Antabuse®), and Acamprosate Calcium (Campral®).

There are no other FDA-approved medications for treating other stimulant addictions, although strides have been made in developing effective psychosocial treatments. Given the high personal and societal costs related to stimulant addiction – and the chronic, relapsing nature of recovery from stimulants – developing effective medications is an ongoing priority area for the National Institute of Drug Abuse. Focusing mainly on cocaine and methamphetamine, researchers are actively identifying and testing medications that might assist with detoxification, relapse prevention, and acute toxic emergencies related to stimulant abuse and addiction.

Medications – Resources for More Information

Whether a provider is new to MAT, or already provides support to patients utilizing MAT, there are excellent resources for use as quick reference guides or more comprehensive, on-going education. Rather than providing cursory summaries of the main medications listed above, this article offers the following resources, which are readily available, free, and already offer excellent summaries:

The new on-line ATTC training Medication Assisted Treatment for Special Populations (1) includes a thorough overview of medications in Module 2, including summaries of supporting research, current costs, and many other important factors.

A key resource – Pyschotherapeutic Medications 2011: What Every Counselor Should Know (3) – provides information about medications organized as a quick desktop reference guide. (Note: All modules of the new ATTC MAT training [1] conclude with self-directed learning activities; Module 2 features an interactive activity to help providers gain familiarity with this resource, as well as reviewing it in Section 3, slides 81-86).

The 2010 Addiction Messenger Series 37: Medication-Assisted Treatment (4) features three issues on each of the primary medication groups, including medications used for the treatment of alcohol and opioid addictions (along with supporting research). Additionally, the third issue provides a review of medications used for treating nicotine addiction, and also discusses the ongoing research into promising medications that may one day be approved for use with other stimulant addictions.

Other key resources that provide more comprehensive information about MAT are listed in "Resources" below.

MAT Treatment Settings

The following is basic information about where MAT is generally used.

Opioid Treatment Programs (OTP):

• Methadone prescribed for addiction treatment must be delivered by a SAMHSA-certified "OTP".
• OTPs are regulated by SAMHSA, and are also required to meet DEA requirements.
• Buprenorphine may be delivered by an OTP, in which case the same regulations apply: i.e., if an individual receives buprenorphine at an OTP they will be required to follow OTP regulations and restrictions, including take home medication schedules.
• OTPs often provide intensive supervision and support – for example, specific medication schedules, psychosocial treatment, and other supportive services.

Office-Based Settings – Links to Primary Care:

• All other medications besides methadone may be accessed through a physician and regulations are less stringent.
• A physician waiver (including mandated training) is required to prescribe buprenorphine.

MAT as aides for treating both opioid and alcohol addictions are becoming increasing available through doctors and healthcare clinics, which is one of the reasons it is even more important for treatment providers to have tools and resources to support patients receiving MAT.

Methadone is the most studied and understood addiction medication, and scientific evidence is strong for its effectiveness; (Resource 1: Module 2, Section 2, Slides 40-50); buprenorphine has been much more recently approved by the FDA, but is also backed up by decades of research with positive results (Slides 51-78). Both medications increase the likelihood for cessation of illicit opioid use or of prescription opioid abuse.

While buprenorphine (nicknamed "bupe") may not be as appropriate for clients who benefit from higher levels of methadone medication (i.e., who have higher levels of opioid tolerance), is an excellent addition to opioid treatment, in part because it has brought opioid treatment into mainstream medicine. Opioid treatment can now be accessed in primary care settings through prescriptions, and also provides the further convenience of less frequent dosing. (On the down-side, buprenorphine is much more expensive than methadone; the ATTC on-line MAT training provides a section to help providers troubleshoot this and other access issues [Resource #1: Module 3, Section 4 – Implementation Barriers and Strategies, Slides 48-71)).

Putting MAT in Context – Teamwork is Essential!

The last Addiction Messenger series, entitled "Integrated Care", discussed the importance of treatment providers finding ways to engage with emerging systems of integrated care, if they are to thrive, and, in some cases, even survive. Given that addiction professionals already have the training and experience that enable them to assist primary care and mental health providers to recognize and treat substance abuse issues, it behooves them to be on the look-out for avenues of intersection through which to connect and partner with primary care and mental health providers and systems.

MAT provides one such avenue, because prescribers and behavioral health workers must work together if MAT treatment is to be optimized to give patients the best chance of success. Addiction is a chronic illness, with ramifications for physical and mental health, and crucial for those with addictions seeking help in integrated healthcare systems will be the inclusion of – or strong linkages to – substance abuse treatment providers.

MAT in the Context of Psychosocial Treatment

Part 2 will discuss practical ways treatment providers can support (and promote) MAT. Here, to help set the stage for understanding MAT in the context of substance abuse treatment, we'll consider how the use of medications can be guided by Prochaska's "stages of change".

Beginning in the 1970s, James Prochaska and colleagues developed the transtheoretical model based on an analysis of different treatment theories. The model identifies five independent stages of behavior and thinking that patients experience when making changes. In the model, change is a process involving progress through a series of stages, which represent ordered categories along a continuum of motivational readiness to change a problem behavior, such as alcohol or opioid use. By identifying where the person is in terms of their readiness to change, providers can tailor interventions (including the use of medicines) specifically to that person.

The five stages of change are pre-contemplation, contemplation, determination (also called preparation for action), action, and maintenance. Also, in recurrence (otherwise called relapse), an individual may return to an earlier stage of change, meaning they might return to use, or simply begin to contemplate returning to old behaviors.

The new ATTC on-line training on MAT (1) includes a "Stages of Change Intervention Matching Guide" (Module 1, Section 1, Slide 8) with both general treatment activities and more information about how medications may be useful for each stage. For example, someone in pre-contemplation may be helped by a provider offering factual information in order to raise awareness about the nature of the problem they face; while the individual in pre-contemplation may not be ready to take medications – even if MAT may be appropriate – providing information about MAT at this stage may spark an interest in treatment and offer additional hope that change is possible. Continuing the example, MAT may help someone in determination support their commitment to engaging in recovery activities, and help them initiate abstinence. In the maintenance phase, medications can help prevent relapse to illicit substance use and reduce cravings that can make continued abstinence difficult.

Conclusion

Medication-assisted treatment can help alcohol and opioid dependent individuals lead healthy, productive lives. The medications themselves can help address the changes caused in the user's brain, which can facilitate the process of recovery.

The over-arching goal of MAT is to help the individual to function normally, and thereby promote ongoing recovery and a healthy productive life.

It is important to always remember that – consistent with the research on many chronic diseases – MAT should be incorporated into a comprehensive, patient-centered treatment strategy.

Coming Up... Part 2 of this three-part series will discuss ideas and practical approaches for supporting clients who are considering or receiving MAT, including talking with treatment clients, supporting adherence, and ideas and tools for collaborating with physicians. Stay tuned!

Series Author: Lynn McIntosh is a Technology Transfer Specialist for the Northwest Frontier ATTC and the Alcohol and Drug Abuse Institute at the University of Washington in Seattle.

Series Editor: Traci Rieckmann, PhD, NFATTC Principal Investigator, is editing this series.
The Addiction Messenger's monthly article is a publication from Northwest Frontier ATTC that communicates tips and information on best practices in a brief format.

Northwest Frontier Addiction Technology Transfer Center

3181 Sam Jackson Park Rd. CB669
Portland, OR 97239
Phone: (503) 494-9611
FAX: (503) 494-0183

A project of OHSU Department of Public Health & Preventive Medicine.

References | Download PDF Version

> Back to Focus on Stimulants Page
 

The ATTC Network proudly presents a core curriculum training package to provide information about central nervous system stimulants and their impact on brain, body, and behavior. Prepared by members of the Addiction Technology Transfer Center Network, Stimulant Workgroup, the training covers (1) the scope of stimulant use in the United States and beyond; (2) stimulants and the brain and impact of use on cognition; (3) stimulant use and psychosis; (4) short- and long-term physical and mental health consequences of stimulant use and considerations for specific populations; (5) the intersection of stimulant use and HIV risk; and (6) effective evidence-based behavioral treatment interventions and recovery supports for people with a stimulant use disorder.

The national core curriculum includes two modalities:
 

Face-to-Face Curriculum: Daylong introductory level training of Stimulants and their Impact on Brain and Behavior – Best Practices and Approaches for Effective Treatment and Recovery
 

Live Virtual Three-Hour Condensed Curriculum: Three-part overview of Stimulants and their Impact on Brain and Behavior – Best Practices and Approaches for Effective Treatment and Recovery

Daylong Curriculum Learning objectives:
At the end of the daylong Stimulant 101 training, participants will be able to:

• Identify three specific national patterns and trends in stimulant use.
• Recall at least three short-term and three long-term physical or psychological effects of stimulant use.
• Specify two examples of the cognitive impact of stimulant use.
• Catalog the differential patterns of stimulant use in at least three populations.
• Interpret at least three links between stimulant use and the behaviors that may put a person at increased risk of becoming infected with HIV or other sexually transmitted infections.
• Apply at least two specific behavioral treatment interventions and two recovery approaches that have been proven effective in treating people with a stimulant use disorder.

Three-Hour Virtual Overview
Core Curriculum content provided in three 1-hour sessions:

    Part 1: Stimulants -What are they and who uses them?
    Part 2: Impact of Stimulant Use on the Brain and Body
    Part 3: Effective Treatment Approaches and Recovery Supports

Training materials for the full day and three-part virtual training are only available to those trainers who have been trained by an ATTC. However, anyone can download the reference list used in the curriculum. If you would like to learn more or request a training, click on the button below that fits your need.

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Considerations For Families in the Child Welfare System Affected by Stimulant Use

https://player.vimeo.com/video/668296132?h=32af2562ba&badge=0&autopause=0&player_id=0&app_id=58479

Considerations For Families in the Child Welfare System Affected by Stimulant Use from ATTC Network on Vimeo

Learning Objectives:

The goal of this training is to provide an overview of the effects of stimulant use on parents and their children. Participants will be able to assess how stimulant use may affect the safety of children, risk and the well-being of the whole family. 

At the end of this module, participants will be able to understand:

• The effects of parental stimulant use on parents and their children
• Trauma-informed and family-centered care approaches
• Evidence-based and practice-informed parent engagement strategies and case planning with families
• The importance of collaboration with other service providers

Considerations For Families in the Child Welfare System Affected by Stimulant Use Reference List

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Gender Differences and Stimulant Use

Gender Differences and Stimulant Use from ATTC Network on Vimeo.

At the end of the module, participants will be able to:

• Identify differences in use of stimulants between genders
• List differences risk factors and motivations to use stimulants between genders
• Describe evidence-based and promising practices related to treating substance use disorders

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Polysubstance Use Among Stimulant Users

Polysubstance among stimulant users: Course, complications and the clinical pictures from ATTC Network on Vimeo.

At the end of this module, participants will be able to:

• Distinguish aspects of stimulant use that occurs alone vs. that which occurs with co-use of other substances
• Recognize patterns of use, risk factors, and clinical challenges faced by individuals who co-use stimulants and other substances, specifically alcohol and opioids
• Understand the available evidence-based treatment options for individuals with co-occurring stimulant and other substance use disorders

Polysubstance Use Among Stimulant Users Reference List

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Overview of Recovery and Recovery Supports

At the end of this module, participants will be able to:

• Define the concept of recovery and its guiding principles
• Describe how Recovery Peer Specialists support people with substance use disorders along the continuum of recovery
• Recognize how long-term stimulant use uniquely impacts a person’s recovery journey

Overview of Recovery and Recovery Supports

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Stimulant Use Among African Americans

At the end of this module, participants will be able to:

• Identify factors related to stimulant use in the African American (AA) and gay community.
• List and describe risk factors and motivations to use stimulants.
• Describe evidence-based treatment specific to AA communities.

Stimulant Use Among African Americans

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Stimulant Use in Rural and Remote Areas

At the end of this module, participants will be able to:

• Identify the Scope of:
  • Substance Use Disorders, Mental Health Disorders, and Co-Occurring Disorders
  • Illicit Drug Use
  • Cocaine & Methamphetamine Use
  • Increases in Stimulant Use in the US
• Recite the Definitions for Rural and Frontier Areas
• Highlight the Importance of Rural/Frontier as a Diversity/Cultural Issue
• Identify Two Differences regarding Substance Use in Rural Areas versus Urban Areas
• Describe 3 out 5 Recommendations for Providing SUD Treatment and Recovery Services in Rural/Frontier Areas

Stimulant Use in Rural and Remote Areas

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Stimulants and HIV

Stimulants and HIV from ATTC Network on Vimeo.

Keynote Learning Objectives: At the end of this keynote presentation, participants  will  be able to:

• Distinguish at least two (2) ways that cocaine influences the progression of HIV in the human body.
• Identify at least two (2) effects of methamphetamine on HIV transmission and progression.

Stimulants and HIV Supplemental Module Reference List

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Stimulant Use Among the Latinx Population

Stimulant Use Among the Latinx Population from ATTC Network on Vimeo.

Keynote Learning Objectives: At the end of this keynote presentation, participants  will  be able to:

• Learn about current trends in Latino demographics
• Recognize differences in stimulant use when compared to other demographic groups
• Learn about risk and protective factors for Latino communities
• Acknowledge the need for more research in trends of use and successful treatment options

Stimulant Use Among the Latinx Population Reference List

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Stimulant Use among the American Indian/Alaska Native Population

Stimulant Use among the American Indian/Alaska Native Population from ATTC Network on Vimeo.

Keynote Learning Objectives: At the end of this keynote presentation, participants  will  be able to:

• Learn about current trends in Native American demographics
• Recognize differences in stimulant use when compared to other demographic groups
• Learn about protective factors for Native communities
• Acknowledge trends of use and successful treatment options for Native populations

Stimulant Use Among the American Indian/Alaska Native Population Reference List

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Training Materials to Supplement the Stimulant 101 National Core Curriculum:

Conference Keynote Presentation: Stimulant Use: Current Trends, Impact on the Brain and Body, and Implications for Treatment

Stimulant Use: Current Trends, Impact on the Brain and Body, and Implications for Treatment from ATTC Network on Vimeo.

Keynote Learning Objectives: At the end of this keynote presentation, participants  will  be able to:

• Identify  three specific  national  patterns and trends in stimulant  use.
• Recall  at least  three short-term  and three long-term physical  or psychological  effects  of stimulant  use.
• Apply at least  two specific  behavioral  treatment interventions  and two recovery  approaches that have been proven effective  in treating  people with a stimulant  use disorder.

Helping those in recovery and facing substance use disorders, the Addiction Technology Transfer Center Network (ATTC) plays a pivotal role. Since 1993, ATTC has been a leading expert in this domain, providing professionals with free training, tools, and support. These services include evidence-informed education, technical assistance, and custom resources aimed at strengthening the skills of practitioners. By listening to the needs of local, regional, and national partners, ATTC ensures it stays relevant and effective, working to empower professionals and foster a thriving, recovery-oriented system of care.