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Chemical Dependency

Medication Assisted Treatment

Medication-Assisted Treatment

Medication-Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful. MAT is clinically driven with a focus on individualized patient care. 

A common misconception associated with MAT is that it substitutes one drug for another. Instead, these medications relieve the withdrawal symptoms and psychological cravings that cause chemical imbalances in the body. MAT programs provide a safe and controlled level of medication to overcome the use of an abused opioid. And research has shown that when provided at the proper dose, medications used in MAT have no adverse effects on a person’s intelligence, mental capability, physical functioning, or employability.

Medications used in MAT for opioid treatment can only be dispensed through a SAMHSA-certified OTP. Some of the medications used in MAT are controlled substances due to their potential for misuse. Drugs, substances, and certain chemicals used to make drugs are classified by the Drug Enforcement Administration (DEA) into five distinct categories, or schedules, depending upon a drug’s acceptable medical use and potential for misuse. 

People who provide medication-assisted treatment (MAT) services work in a range of prevention, health care, and social service settings. They include psychiatrists, psychologists, pharmacists, nurses, social workers, counselors, marriage and family therapists, peer professionals, clergy, and many others.

Florida requires an 8-hour (4 hours online and 4 hours face-to-face) waiver training for physicians to prescribe and dispense buprenorphine for the treatment of opioid use disorders as well as the other FDA approved medications methadone and naltrexone. As a result of this training, the goal is to see a significant increase in the number of patients accessing necessary substance use disorder treatment.

 

BEHAVIORAL COMPONENT

Behavioral manifestations and complications of addiction, primarily due to impaired control, can include:
• Excessive use and/or engagement in addictive behaviors, at higher frequencies and/or quantities than the person intended, often associated
with a persistent desire for and unsuccessful attempts at behavioral control;
• Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with a
significant adverse impact on social and occupational functioning (e.g. the development of interpersonal relationship problems or the
neglect of responsibilities at home, school or work);
• Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems
which may have been caused or exacerbated by substance use and/or related addictive behaviors.

We will explore the following four approaches to assist with behavioral issues.  

  • Motivational Interviewing
  • Cognitive Behavioral Therapy
  • Acceptance and Commitment Therapy
  • Twelve-Step Facilitation

Motivational Interviewing

  • Motivational Interviewing (MI) is a goal-directed, client-centered counseling style for eliciting behavioral change by helping clients to explore and resolve ambivalence.
  • The operational assumption in MI is that ambivalent attitudes or lack of resolve is the primary obstacle to behavioral change so that the examination and resolution of ambivalence becomes its key goal.
  • MI has been applied to a wide range of problem behaviors related to alcohol and substance abuse as well as health promotion, medical treatment adherence, and mental health issues.

Processes of Motivational Interviewing include:

  • Establishing rapport with the client and listening reflectively.
  • Asking open-ended questions to explore the client’sown motivations for change.
  • Affirming the client’s change-related statements and efforts.
  • Eliciting recognition of the gap between current behavior and desired life goals.
  • Asking permission before providing information or advice.
  • Responding to ’sustain talk’ and ‘discord’ without direct confrontation. (’sustain talk’ and ‘discord’ is used as a feedback signal to the
    therapist to adjust the approach.)
  • Encouraging the client’s self-efficacy for change.
  • Developing an action plan to which the client is willing to commit

Cognitive Behavioral

  • Cognitive Behavioral Therapy (CBT) is the term used for a group of psychological treatments that are based on scientific evidence. These
    treatments have been proven to be effective in treating many psychological disorders.
  • Cognitive and behavioral therapies usually are short-term treatments (i.e., often between 6-20 sessions) that focus on teaching clients specific skills. CBT is different from many other therapy approaches by focusing on the ways that a person’s cognitions (i.e., thoughts), emotions, and behaviors are connected and affect one another.
  • Cognitive behavioral therapy (CBT) for substance use disorders has demonstrated efficacy as both a monotherapy and as part of combination treatment strategies.

Process of Cognitive Behavioral:

  • The therapist and client work together with a mutual understanding that the therapist has theoretical and technical expertise, but the client is the expert on him or herself.
  • The therapist seeks to help the client discover that he/she is powerful and capable of choosing positive thoughts and behaviors.
  • Treatment is often short-term. Clients actively participate in treatment in and out of session. Homework assignments often are included in therapy. The skills that are taught in these therapies require practice
  • Treatment is goal-oriented to resolve present-day problems. Therapy involves working step-by-step to achieve goals.
  • The therapist and client develop goals for therapy together and track progress toward goals throughout the course of treatment.

Common Cognitive Distortions:

  • All-Or-Nothing Thinking – You see things in black-and-white categories. If your performance falls short of perfect, you see yourself as a total failure.
  • Overgeneralization – You see a single negative event as a never-ending pattern of defeat.
  • Mental Filter – You pick out a single negative defeat and dwell on it exclusively so that your vision of reality becomes darkened, like the drop of ink that colors the entire beaker of water.
  • Disqualifying the positive – You dismiss positive experiences by insisting they “don’t count” for some reason
    or other. In this way, you can maintain a negative belief that is contradicted by your everyday experiences.
  • Jumping to conclusions – You make a negative interpretation even though there are no definite facts that convincingly support
    your conclusion.
  • Mind reading. You arbitrarily conclude that someone is reacting negatively to you, and you don’t bother to check this
    out.
  • The fortune-teller error. You anticipate that things will turn out badly, and you feel convinced that your prediction is an
    already-established fact.
  •  Magnification (Catastrophizing) or Minimization- You exaggerate the importance of things (such as your goof-up or
    someone else’s achievement), or you inappropriately shrink things until they appear tiny (your own desirable qualities or the other fellow’s imperfections). This is also called the “binocular trick.”
  • Emotional Reasoning – You assume that your negative emotions necessarily reflect the way things
    really are: “I feel it, therefore it must be true.”
  • Should Statements – You try to motivate yourself with“shoulds” and “shouldn’t,” as if you had to be whipped and punished before you could be expected to do anything. “Musts” and “oughts” are also offenders. The emotional consequence is guilt. When you direct “should” statements toward others, you feel anger, frustration, and resentment.
  • Labeling and Mislabeling – This is an extreme form of overgeneralization. Instead of describing your error, you attach a negative label to yourself: “I’m a loser.” When someone else’s behavior rubs you the wrong way, you attach a negative label to him: “He’s a louse.” Mislabeling involves describing an event with language that is highly colored and emotionally loaded.
    • Personalization – You see yourself as the cause of some negative external event for which, in fact, you were not
    primarily responsible.

Acceptance and Commitment Therapy ACT

• Acceptance and Commitment Therapy (ACT) is a contextually focused form of cognitive-behavioral psychotherapy that uses mindfulness and behavioral activation to increase clients’ psychological flexibility–their ability to engage in values-based, positive behaviors while experiencing difficult thoughts, emotions, or sensations.
• ACT has been shown to increase effective action; reduce dysfunctional thoughts, feelings, and behaviors; and alleviate psychological distress for individuals with a broad range of mental health issues (including DSM-5 diagnoses, coping with chronic illness, and workplace stress).

Processes of ACT:

ACT establishes psychological flexibility by focusing on six core processes:
• Acceptance of private experiences (i.e., willingness to experience odd or uncomfortable thoughts, feelings, or physical sensations in the
service of response flexibility)
• Cognitive diffusion or emotional separation/distancing (i.e., observing one’s own uncomfortable thoughts without automatically taking them
literally or attaching any particular value to them)
• Being present (i.e., being able to direct attention flexibly and voluntarily to present external and internal events ratherthan
automatically focusing on the past orfuture)
• A perspective-taking sense of self (i.e., being in touch with a sense of ongoing awareness)
• Identification of values that are personally important
• Commitment to action for achieving the personal values identified

Ten Steps to Trying on a Value:

  • Choose a Value. Choose valued directions that you are willing to try on for at least a week. This should be a value that you can enact and a
    a value that you care about. This is not a time to try to change others or manipulate them into changing.
  • Notice Reactions. Notice anything that comes up about whether or not this is a good value, or whether or not you really care about this value.  Just notice all thoughts for what they are. Remember that your mind’s job is to create thoughts. Let your mind do that and you stay on the exercise.
  • Make a List. Take a moment to list a few behaviors that one might say are related to the chosen value.
  • Choose a Behavior. From this list, choose one behavior or set of behaviors you can commit to between now and next session or the
    next few sessions.
  • Notice Judgments. Notice anything that comes up about whether or not that is a good behavior, whether or not you will enjoy it, or whether
    you can actually do that to which you are committing yourself.
  • Make a Plan. Write down how you will go about enacting this value in the very near future (today, tomorrow, this coming weekend, at the next meeting with your supervisor). Consider anything you will need to plan or get in order (e.g., call another person, clean the house, make an appointment, etc.). Choose when to do that – the sooner the better.
  • Just Behave. Even if this value involves other people, do not tell them what you are doing. See what you can notice if you just enact this value without telling them it is an ‘experiment’.
  • Keep a Daily Diary of Your Reactions. Things to look for are others’ reactions to you, any thoughts feelings or body sensations that occur before, during and after the behavior, and how you feel doing it for the second (or fifth, or tenth, or hundredth) time.  Watch for evaluations that indicate whether this activity, value, or valued direction was ‘good’ or ‘bad’ or judgments about others, or yourself in relation to living this value.  Gently thank your mind for those thoughts, and see if you can choose not to buy into the judgments it makes about the activity.
  • Commit. Every day. Notice anything that shows up as you do so.
  • Reflect. Please bring your Daily Reactions Diary back to session on XX/XX/XXXX.

 

Twelve-Step Facilitation Therapy (TSF)

  • Twelve-Step Facilitation Therapy (TSF) is a brief, structured, and manual-driven approach to facilitating early recovery from
    alcohol abuse, alcoholism, and other drug abuse and addiction problems.
  • TSF is implemented with individual clients or groups over 12-15 sessions.
  • The intervention is based on the behavioral, spiritual, and cognitive principles of 12-step fellowships such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).
  • These principles include acknowledging that willpower alone cannot achieve sustained sobriety, that reaching out to others must replace self-centeredness and that long-term recovery consists of a process of spiritual renewal.

Processes of TSF:

  • Therapy focuses on two general goals:
    1. acceptance of the need for abstinence from alcohol and other
    drug use
    2. surrender, or the willingness to participate actively in12-step fellowships as a means of sustaining sobriety.
  • The TSF counselor assesses the client’s alcohol or drug use, advocates abstinence, explains the basic 12-step concepts, and actively supports and facilitates initial involvement and ongoing participation in AA.
  • The counselor also discusses specific readings from the AA/NA literature with the client, aids the client in usingAA/NA resources in crisis times, and presents more advanced concepts such as moral inventories.

Twelve Steps of Alcoholics Anonymous
www.aa.org Copyright A.A. World Services, Inc.
1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or
10. Continued to take personal inventory, and when we were wrong, promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him,
praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and
to practice these principles in all our affairs.

• A.A., N.A., C.A.
• Group format
• Anonymous
• No cost
• No affiliations 

 

MEDICATION COMPONENT

FDA has approved several different medications to treat opioid addiction and alcohol dependence.

Opioid Dependency Medications

Methadone, buprenorphine, and naltrexone are used to treat opioid dependence and addiction to short-acting opioids such as heroin, morphine, and codeine, as well as semi-synthetic opioids like oxycodone and hydrocodone. People may safely take medications used in MAT for months, years, several years, or even a lifetime. Plans to stop a medication must always be discussed with a doctor.

Methadone

Methadone tricks the brain into thinking it’s still getting the abused drug. In fact, the person is not getting high from it and feels normal, so withdrawal doesn’t occur. Learn more about methadone.

Pregnant or breastfeeding women must inform their treatment provider before taking methadone. It is the only drug used in MAT approved for women who are pregnant or breastfeeding. Learn more about pregnant or breastfeeding women and methadone.   

Buprenorphine

Like methadone, buprenorphine suppresses and reduces cravings for the abused drug. It can come in a pill form or sublingual tablet that is placed under the tongue. Learn more about buprenorphine.

Naltrexone

Naltrexone works differently than methadone and buprenorphine in the treatment of opioid dependency. If a person using naltrexone relapses and uses the abused drug, naltrexone blocks the euphoric and sedative effects of the abused drug and prevents feelings of euphoria. Learn more about naltrexone.

Opioid Overdose Prevention Medication

FDA approved naloxone, an injectable drug used to prevent an opioid overdose.  According to the World Health Organization (WHO), naloxone is one of several medications considered essential to a functioning health care system

Alcohol Use Disorder Medications

Disulfiram, acamprosate, and naltrexone are the most common drugs used to treat alcohol use disorder. None of these drugs provide a cure for the disorder, but they are most effective in people who participate in a MAT program. Learn more about the impact of alcohol misuse.

Disulfiram

Disulfiram is a medication that treats chronic alcoholism. It is most effective in people who have already gone through detoxification or are in the initial stage of abstinence. This drug is offered in a tablet form and is taken once a day. Disulfiram should never be taken while intoxicated and it should not be taken for at least 12 hours after drinking alcohol. Unpleasant side effects (nausea, headache, vomiting, chest pains, difficulty breathing) can occur as soon as ten minutes after drinking even a small amount of alcohol and can last for an hour or more.

Acamprosate

Acamprosate is a medication for people in recovery who have already stopped drinking alcohol and want to avoid drinking. It works to prevent people from drinking alcohol, but it does not prevent withdrawal symptoms after people drink alcohol. It has not been shown to work in people who continue drinking alcohol, consumes illicit drugs, and/or engage in prescription drug misuse and abuse. The use of acamprosate typically begins on the fifth day of abstinence, reaching full effectiveness in five to eight days. It is offered in tablet form and taken three times a day, preferably at the same time every day. The medication’s side effects may include diarrhea, upset stomach, appetite loss, anxiety, dizziness, and difficulty sleeping.

Naltrexone

When used as a treatment for alcohol dependence, naltrexone blocks the euphoric effects and feelings of intoxication. This allows people with alcohol addiction to reduce their drinking behaviors enough to remain motivated to stay in treatment, avoid relapses, and take medications. Learn more about how naltrexone is to treat alcohol dependency.

MAT Medications and Child Safety

It’s important to remember that if medications can be kept at home, they must be locked in a safe place away from children. Methadone in its liquid form is colored and is sometimes mistaken for a soft drink. Children who take medications used in MAT may overdose and die.

The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act affords practitioners greater flexibility in the provision of medication-assisted treatment (MAT)

The SUPPORT Act extends the privilege of prescribing buprenorphine in office-based settings to Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and Certified Nurse-Midwives (CNSs, CRNAs, and CNMs)* until October 1, 2023.

* NPs, PAs, CNSs, CRNAs, and CNMs are also referred to as “qualifying other practitioners.”

The SUPPORT Act expands the ability of certain physicians and qualifying other practitioners to treat up to 100 patients in the first year of waiver receipt if they satisfy one of the following two conditions:

  1. The physician holds a board certification in addiction medicine or addiction psychiatry by the American Board of Preventive Medicine or the American Board of Psychiatry and Neurology; or
  2. The practitioner provides medication-assisted treatment (MAT) in a “qualified practice setting.” A qualified practice setting is a practice setting that:
    1. provides professional coverage for patient medical emergencies during hours when the practitioner’s practice is closed;
    2. provides access to case-management services for patients including referral and follow-up services for programs that provide, or financially support, the provision of services such as medical, behavioral, social, housing, employment, educational, or other related services;
    3. uses health information technology systems such as electronic health records;
    4. is registered for their State prescription drug monitoring program (PDMP) were operational and in accordance with Federal and State law; and
    5. accepts third-party payment for costs in providing health services, including written billing, credit, and collection policies and procedures, or Federal health benefits.

After one year at the 100-patient limit, physicians and qualifying other practitioners who meet the above criteria can apply to increase their patient limit to 275.

MAT for opioid addiction is subject to federal legislation, regulations, and guidelines, including DATA 2000 and federal regulation 42 CFR 8.

More must be done to facilitate treatment options and the development of therapies to address OUD as a chronic disease with long-lasting effects. This means helping more people secure MAT, which requires us to break the stigma often associated with some of the medications used to treat OUD. It also requires us to find new and more effective ways to advance the use of medical therapy for the treatment of opioid use disorders.