As providers, you may find yourself needing to advocate for your patients and their treatment needs. This can mean many different things and may happen within your own clinic among staff, at administrative levels, or at the policy level. You can find out more about how to advocate for your patients and utilizing MOUD at the websites below.
Sederer, L. I., & Marino, L. A. (2018). Ending the Opioid Epidemic by Changing the Culture. The Psychiatric Quarterly, 89(4), 891–895. https://doi.org/10.1007/s11126-018-9589-0
Substance use disorders, including opioid use disorder, are chronic diseases that improve with proper medical treatment and support. The language we use to talk about substance use can cause further harm. By using non-stigmatizing language, we can focus on proper treatment and providing much-needed support for those who need it most.
Ashford, R. D., Brown, A. M., Ashford, A., & Curtis, B. (2019). Recovery dialects: A pilot study of stigmatizing and nonstigmatizing label use by individuals in recovery from substance use disorders. Experimental and Clinical Psychopharmacology. https://doi.org/10.1037/pha0000286
Ashford, R. D., Brown, A. M., McDaniel, J., & Curtis, B. (2019). Biased labels: An experimental study of language and stigma among individuals in recovery and health professionals. Substance Use & Misuse, 54(8), 1376–1384. https://doi.org/10.1080/10826084.2019.1581221
Wakeman, S. E. (2017). Medications for Addiction Treatment: Changing Language to Improve Care. Journal of Addiction Medicine, 11(1), 1–2. https://doi.org/10.1097/ADM.0000000000000275
Opioid use disorder (OUD) is a chronic brain disorder that can be successfully managed when properly diagnosed and treated.
Screening - Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a common screening tool for substance use and mental/behavioral health disorders.
Clinical Decision Tool: SBIRT Tool
Diagnostic Information for OUD: Here are 11 diagnostic criteria for OUD (DSM-5). A diagnosis of OUD requires at least 2 of the DSM-5 criteria. However, tolerance and withdrawal alone are not enough for a diagnosis because this occurs for anyone who uses a sufficient daily dosage, even when taken as prescribed. Opioids are often taken in larger amounts or over a longer period than was intended.
Clinical Decision Tool: ASAM DSM-5 OUD Criteria Checklist
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Wu, L.-T., Payne, E. H., Roseman, K., Kingsbury, C., Case, A., Nelson, C., & Lindblad, R. (2019). Clinical Workflow and Substance Use Screening, Brief Intervention, and Referral to Treatment Data in the Electronic Health Records: A National Drug Abuse Treatment Clinical Trials Network Study. EGEMs, 7(1). https://doi.org/10.5334/egems.293
Special populations that require more complex treatment plans include pregnant women, individuals with co-occurring disorders, individuals with PTSD or a history of trauma, and adolescents.
Pregnant Women & Infants
Neonatal Abstinence Syndrome (NAS) occurs in babies whose mothers used opioids during pregnancy. Both mothers and their babies can be successfully treated using MOUD treatment during and after pregnancy.
CLINICAL DECISION TOOL: A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders
Fetal Alcohol Spectrum Disorders (FASD) includes a range of disorders that result in babies whose mothers drank alcohol while pregnant.
CLINICAL DECISION TOOL: CDC FASD Treatment Guide
When treating OUD, it is important to take into consideration co-occurring disorders and how MOUD may impact the treatment of other disorders. “Co-occurring disorders” usually refers to other psychiatric disorders, but patients may have additional substance use disorders or other medical problems that complicate their OUD treatment course.
Medication with a potential for abuse should be avoided. For example, certain medication combinations, such as opioids and benzodiazepines, pose a greater risk when used together.
CLINICAL DECISION TOOL RESOURCE: Co-Occurring Disorders Toolkit
Co-Occurring Psychiatric and Substance Abuse Disorders (COPSD)
Substance Use & Trauma
Individuals with substance use disorders commonly have a history of trauma in their life. When treating substance use, including opioid use disorder, it is important to also address trauma as part of treatment.
Patients may directly associate traumatic events to their substance use or describe their substance use as a way of coping with trauma. Traumatic experiences may influence medication regimes and will likely be key aspects of the psychological therapy involved in treatment and the recovery path.
CLINICAL DECISION TOOL: SAMHSA Guidelines for Treating PTSD and OUD
Seeking Safety is an evidence-based counseling model that helps people achieve safety from trauma and substance use while being mindful not to focus on trauma narratives. This model can be used with individuals and groups.
Substance use and child welfare by the National Center for Substance Abuse and Child Welfare -- Tutorial 1: understanding child welfare and the dependency court
Edge, R., & Butcher, R. (2019). Buprenorphine for Opioid Use Disorders During Pregnancy: A Review of Comparative Clinical Effectiveness, Safety, Cost-Effectiveness, and Guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK545816/
Roper, V., & Cox, K. J. (2017). Opioid Use Disorder in Pregnancy. Journal of Midwifery & Women’s Health, 62(3), 329–340. https://doi.org/10.1111/jmwh.12619
Wachman, E. M., Schiff, D. M., & Silverstein, M. (2018). Neonatal Abstinence Syndrome: Advances in Diagnosis and Treatment. JAMA, 319(13), 1362–1374. https://doi.org/10.1001/jama.2018.2640
Griggs, C., Wyatt, S., Wally, M. K., Runyon, M., Hsu, J. R., Seymour, R. B., … PRIMUM Group. (2019). Prescribing of Opioids and Benzodiazepines Among Patients with History of Overdose. Journal of Addiction Medicine, 13(5), 396–402. https://doi.org/10.1097/ADM.0000000000000513
Keyser-Marcus, L., Alvanzo, A., Rieckmann, T., Thacker, L., Sepulveda, A., Forcehimes, A., … Svikis, D. S. (2015). Trauma, gender, and mental health symptoms in individuals with substance use disorders. Journal of Interpersonal Violence, 30(1), 3–24. https://doi.org/10.1177/0886260514532523
Rasmussen, I. S., Arefjord, K., Winje, D., & Dovran, A. (2018). Childhood maltreatment trauma: a comparison between patients in treatment for substance use disorders and patients in mental health treatment. European Journal of Psychotraumatology, 9(1), 1492835. https://doi.org/10.1080/20008198.2018.1492835
Lenz, A. S., Henesy, R., & Callender, K. (2016). Effectiveness of Seeking Safety for Co-Occurring Posttraumatic Stress Disorder and Substance Use. Journal of Counseling & Development, 94(1), 51–61. https://doi.org/10.1002/jcad.12061
Opioid use disorder can be successfully treated with a combination of pharmacotherapy and cognitive behavioral therapy. There are currently 3 medications that are approved by the FDA to treat OUD: buprenorphine, naltrexone, and methadone. Each medication has a different pharmacologic mechanism, binding to opioid receptors in different ways. Medication for Opioid Use Disorder (MOUD) is also called Medication-Assisted Treatment (MAT).
Clinical Decision Tool: Pharmacotherapy for OUD Guide (SAMHSA)
Clinical Decision Tool: Texas HHS Medication Guidelines
Kampman, Kyle MD; Jarvis, Margaret MD, FASAM. American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. Journal of Addiction Medicine: September/October 2015 - Volume 9 - Issue 5 - p 358-367 https://doi.org/10.1097/ADM.0000000000000166
Bell, J., & Strang, J. (2019). Medication Treatment of Opioid Use Disorder. Biological Psychiatry. https://doi.org/10.1016/j.biopsych.2019.06.020
Oesterle, T. S., Thusius, N. J., Rummans, T. A., & Gold, M. S. (2019). Medication-Assisted Treatment for Opioid-Use Disorder. Mayo Clinic Proceedings, 94(10), 2072–2086. https://doi.org/10.1016/j.mayocp.2019.03.029
We’ve compiled a list of helpful, patient-friendly resources that you can distribute to your patients and/or put in your waiting room areas.
When treating any patient who is taking opioids, it is important to have a conversation about harm reduction and overdose prevention. Naloxone (Brand name: Narcan) is a life-saving overdose reversal medication that can be prescribed to patients who are taking opioids. Loved ones may also wish to carry naloxone so they can administer it if an overdose occurs.
Clinical Decision Tool: How to use Naloxone
Clinical Decision Tool: Healthcare Professional Resources - Naloxone Nasal Spray
Clinical Decision Tool: Guide to Developing Overdose Prevention and Take-Home Naloxone Kits
Naumann, R. B., Durrance, C. P., Ranapurwala, S. I., Austin, A. E., Proescholdbell, S., Childs, R., … Shanahan, M. E. (2019). Impact of a community-based naloxone distribution program on opioid overdose death rates. Drug and Alcohol Dependence, 204, 107536. https://doi.org/10.1016/j.drugalcdep.2019.06.038
Chimbar, L., & Moleta, Y. (2018). Naloxone Effectiveness: A Systematic Review. Journal of Addictions Nursing, 29(3), 167–171. https://doi.org/10.1097/JAN.0000000000000230
Han, J. K., Hill, L. G., Koenig, M. E., & Das, N. (2017). Naloxone Counseling for Harm Reduction and Patient Engagement. Family Medicine, 49(9), 730–733.
Hawk, K. F., Vaca, F. E., & D’Onofrio, G. (2015). Reducing Fatal Opioid Overdose: Prevention, Treatment and Harm Reduction Strategies. The Yale Journal of Biology and Medicine, 88(3), 235–245.
Lewis, C. R., Vo, H. T., & Fishman, M. (2017). Intranasal naloxone and related strategies for opioid overdose intervention by nonmedical personnel: a review. Substance Abuse and Rehabilitation, 8, 79–95. https://doi.org/10.2147/SAR.S101700
Medication for opioid use disorder (MOUD) treatment includes both medication and cognitive behavioral therapy. The therapy/counseling component of treatment helps providers and patients to address other factors that relate to substance use and potentially affect receptibility and adherence to medication treatment.
Motivational Interviewing (MI) & Motivational Enhancement Therapy (MET)
MI is a way of interviewing and communicating with patients to strengthen their motivation to make changes and achieve a specific goal. MET is similar to MI but focuses on motivating patients that are less motivated initially.
Clinical Decision Tool: Medication-Assisted Treatment (MAT)
Cognitive Behavioral Therapy (CBT)
CBT is a type of therapy that focuses on addressing and changing behavior to improve decision-making. Goals for CBT are short-term and practical.
Contingency Management (CM)
CM is a behavioral therapy that uses motivational incentives and tangible rewards to help patients become abstinent from drugs and alcohol.
CLINICAL DECISION TOOL: CM Summary + 7 Principles to Guide Tx
DiClemente, C. C., Corno, C. M., Graydon, M. M., Wiprovnick, A. E., & Knoblach, D. J. (2017). Motivational interviewing, enhancement, and brief interventions over the last decade: A review of reviews of efficacy and effectiveness. Psychology of Addictive Behaviors: Journal of the Society of Psychologists in Addictive Behaviors, 31(8), 862–887. https://doi.org/10.1037/adb0000318
Shi, J. M., Henry, S. P., Dwy, S. L., Orazietti, S. A., & Carroll, K. M. (2019). Randomized pilot trial of Web-based cognitive-behavioral therapy adapted for use in office-based buprenorphine maintenance. Substance Abuse, 40(2), 132–135. https://doi.org/10.1080/08897077.2019.1569192
Barrett, K., & Chang, Y.-P. (2016). Behavioral Interventions Targeting Chronic Pain, Depression, and Substance Use Disorder in Primary Care. Journal of Nursing Scholarship: An Official Publication of Sigma Theta Tau International Honor Society of Nursing, 48(4), 345–353. https://doi.org/10.1111/jnu.12213
Walter, K. N., & Petry, N. M. (2016). Motivation and Contingency Management Treatments for Substance Use Disorders. Current Topics in Behavioral Neurosciences, 27, 569–581. https://doi.org/10.1007/7854_2015_374
Practicing cultural humility with all patients allows providers to be mindful of cultural differences that can be important when deciding on a treatment plan. Being respectful and asking questions when unsure of patient preferences are key first steps to practicing medicine in a culturally competent manner.
Clinical Decision Tool: A Treatment Improvement Protocol: Improving Cultural Competence (SAMHSA)
Gainsbury, S. (2016). Cultural competence in the treatment of addictions: Theory, practice and
evidence. Clinical Psychology & Psychotherapy. http://dx.doi.org/10.1002/cpp.2062
Steinka-Fry, K. T., Tanner-Smith, E. E., Dakof, G. A., & Henderson, C. (2017). Culturally sensitive substance use treatment for racial/ethnic minority youth: A meta-analytic review. Journal of Substance Abuse Treatment, 75, 22–37. https://doi.org/10.1016/j.jsat.2017.01.006
If providing state-funded OUD treatment in Texas, providers are required to utilize the CMBHS system. Information regarding CMBHS provider training and other information can be found here.
CMBHS Helpdesk #: 1-866-806-7806