Ask the PCSS Expert: Counseling Requirements in Addiction Treatment?

A physician wrote the PCSS mentor network seeking advice on what type of counseling (group/individual/AA, NA/therapist) is typically required as part of addiction treatment. The inquiry asked for some ways to verify that patients are going to their counseling meetings, and how often patients were required to go to engage in counseling or similar therapies. Finally, the doctor wanted to know if there was a temporal end point to buprenorphine therapy or is it appropriate to treat indefinitely.

Answer:

There is no “one size fits all” answer to these questions. Each patient and their counseling needs are different. That being said, there is research to date that shows that, for some patients, additional counseling does not add much if any benefit beyond what high quality medical management and buprenorphine treatment already provide.

However, many addiction medicine physicians feel that optimal management of the disease of addiction includes some level of formal therapy/counseling. ASAM’s definition describes addiction as a disease with biopsychosocial parameters, meaning that ideal management requires attention to the multifaceted needs of patients. Formal therapy or counseling is furthermore often required by insurers when physicians prescribe medication for addiction, and engaging a patient in therapy or counseling is also a requirement of DATA 2000.

With that in mind, some recommend that some level of counseling focusing on behavior change be done by the prescribing physician. For example, early on there needs to be an emphasis on careful and safe storage of medications. The invariable questions asked (sometimes by the patient) should also be addressed (eg. whether taking a prescribed medication is simply “substituting one addiction for another,” optimal dosing, how to handle taking a medication while participating in a 12-step program, questions asked about concurrent use of alcohol and/or marijuana, duration of treatment, etc).

While answering these basic questions and developing a therapeutic working relationship with a patient often helps clinicians be able to address the full spectrum of patient need, it is at the same time understood that many prescribers are not trained as psychiatrists, and furthermore that time in follow up sessions may be limited. If effective behavior change is not occurring or if prescribers are uncomfortable or limited in the counseling they can provide, it would then be best if a therapist experienced with addiction treatment worked closely with the prescribing physician and periodically discussed the patient's progress and goals.

Requiring a patient to attend 12-step mutual support meetings on a regular basis is also a good way to engage patients in most cases, especially patients who are reluctant to participate in formal counseling. Attendance can be verified by getting meeting slips signed at the 12-step meeting. For patients receiving formal counseling or therapy, prescribers can also ask patients to sign a release form allowing them to talk to the counselor/therapist about the patient and verify attendance.

To address the temporal question; an end point should at least be discussed with the patient at some point during treatment with a medication. Doctors, counselors and patients must balance the risk of relapse with the potential for sustained recovery without a medication. Tapering for many patients is an option if the risk of relapse is low, and doctors should investigate this option with their patients, while encouraging them to participate in other recovery maintenance treatment services.

The risk of relapse when tapering medication can be mitigated when doctors, counselors and patients have in place a comprehensive plan for continued recovery. Relapse indicates a failure of treatment, not a failure of the patient. Some doctors do feel it is appropriate to treat with buprenorphine long-term or indefinitely. There is also research that shows that relapse rates are high and overdose mortality increases short term when patients with opioid use disorder discontinue medications for this condition. As these are complex treatment questions the right approach for each patient may vary.

For further resources on opioid maintenance therapy in general check out these links to PCSS-MAT, the APA and ASAM:

• http://pcssmat.org/mentoring/frequently-asked-questions/
• http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/national-practice-guideline.pdf
• http://www.psychiatry.org/practice/professional-interests/addiction-psychiatry/opioid-maintenance-terminable-or-interminable

For more information about the Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT) visit www.pcssmat.org.

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