Overview and Context

Scope of the Problem

Opioid misuse has caused a growing nationwide epidemic of OUD and unintentional overdose deaths.¹ This epidemic affects people in all regions, of all ages, and from all walks of life. Opioid misuse devastates families, burdens emergency departments and first responders, fuels increases in hospital admissions, and strains criminal justice and child welfare systems.

Counselors can play an integral role in addressing this crisis. Counseling helps people with OUD and other substance use disorders (SUDs) change how they think, cope, react, and acquire the skills and confidence necessary for recovery. Counseling can provide support for people who take medication to treat their OUD. Patients may get counseling from prescribers or other staff members in the prescribers' practices or by referral to counselors at specialty addiction treatment programs or in private practice.

Counselors and peer recovery support specialists can work with patients who take OUD medication and refer patients with active OUD to healthcare professionals for an assessment for treatment with medication.

Figure

Part 4 uses “counselor” to refer to the range of professionals—including recovery coaches and other peer recovery support services specialists—who may counsel, coach, or mentor people who take OUD medication, although their titles, credentials, and range of responsibilities vary. At times, Part 4 refers to individuals as “clients.” For other key terms, see Exhibit 4.1. Part 5 of this TIP provides a full glossary and other resources related to the treatment of OUD.

Box

EXHIBIT 4.1. Key Terms.

Counseling clients who take OUD medication requires understanding:

•

Basic information about OUD.

•

The role and function of OUD medications.

•

Ways to create a supportive environment that helps clients work toward recovery.

•

Counseling's role within a system of whole-person, recovery-oriented OUD care.

Setting the Stage

Since the 1990s, dramatic increases in controlled medication prescriptions—particularly opioid pain relievers—have coincided with increases in their misuse.¹⁰ Since the mid-2000s, heroin^11,12 and fentanyl (mainly illicit formulations)¹³ consumption has also sharply increased. People who turn to illicit drugs after misusing opioid medications have driven greater use of heroin and fentanyl, which are cheaper and easier to obtain.

Approximately 1,500 OTPs currently dispense methadone, buprenorphine, or both.¹⁴ They may also offer naltrexone. Historically, OTPs were the only source of OUD medication and offered only methadone.

Buprenorphine is increasingly available in general medical settings. Physicians, nurse practitioners, and physician assistants (whether or not they're addiction specialists) can get a federal waiver to prescribe buprenorphine. These healthcare professionals can also prescribe and administer naltrexone, which does not require a waiver or OTP program certification. Until October 1, 2023, qualified clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives also can obtain a waiver to prescribe and administer buprenorphine in office-based settings.

People with OUD should have access to the medication most appropriate for them. Medication helps establish and maintain OUD remission. By controlling withdrawal and cravings and blocking the euphoric effects of illicit opioids, OUD medication helps patients stop illicit opioid use and resolve OUD's psychosocial problems. For some people, OUD medication may be lifesaving. Ideally, patients with OUD should have access to all three FDA-approved pharmacotherapies. (See the “Quick Guide to Medications” section for an overview of each medication.)

Many patients taking OUD medication benefit from counseling as part of their treatment. Counseling helps people with OUD change how they think, cope, react, and acquire the skills and confidence needed for recovery. Patients may get counseling from medication prescribers or staff members in prescribers' practices or by referral to counselors at specialty addiction treatment programs or in private practice. Exhibit 4.2 discusses recommending versus requiring counseling as part of medication treatment for OUD.

Box

EXHIBIT 4.2. Recommending Versus Requiring Counseling.

The counselor's role with clients who take OUD medication is the same as it is with all clients who have SUDs: Help them achieve recovery by addressing addiction's challenges and consequences.

Understanding the Benefits of Medication for OUD

Medication is an effective treatment for OUD.^18,19,20 People with OUD should be referred for an assessment for medication unless they decline.²¹ To be supportive and effective when counseling clients who could benefit from or who take medication for OUD, know that:

•

Treatment with methadone and buprenorphine is associated with lower likelihood of overdose death compared with not taking these medications. ^{22,23,24,25,26}

•

Medication helps people reduce or stop opioid misuse.^27,28,29,30 As Jessica's story in Exhibit 4.3 shows, even if people return to opioid use during treatment or don't achieve abstinence in the short term, medication lessens misuse and its health risks (e.g., overdose, injection-related infections).³¹

•

Patients taking FDA-approved medication used to treat OUD can join residential or outpatient treatment. Decades of clinical experience in OTPs, which must provide counseling, suggest that patients taking OUD medication can fully participate in group and individual counseling, both cognitively and emotionally. Patients with concurrent SUDs (involving stimulants or alcohol) can benefit from residential treatment while continuing to take their OUD medication.

•

Randomized clinical trials indicate that OUD medication improves treatment retention and reduces illicit opioid use.^32,33,34 Retention in treatment increases the opportunity to provide counseling and supportive services that can help patients stabilize their lives and maintain recovery.

•

The longer patients take medication, the less likely they are to return to opioid use, whereas short-term medically supervised withdrawal rarely prevents return to use:^{35,36,37,38,39}

-

Conducting short-term medically supervised withdrawal may increase the risk of unintentional fatal overdose because of decreased tolerance after withdrawal completion.^40,41

-

Providing short-term medical treatment for OUD is the same as treating a heart attack without managing the underlying coronary disease.

-

Providing longer courses of medication that extend beyond withdrawal can allow patients to stabilize.

-

Getting stabilized, which may take months or even years, allows patients to focus on building and maintaining a healthy lifestyle.

•

Patients taking OUD medication can achieve long-term recovery. People who continue to take medication can be in remission from OUD and live healthy, productive lives.⁴²

Box

EXHIBIT 4.3. Jessica's Story About Medication.

Reviewing the Evidence on Counseling in Support of Medication To Treat OUD

Dedicated counseling can help clients address the challenges of extended recovery. For clients who seek a self-directed, purposeful life, counseling can help them:

•

Improve problem-solving and interpersonal skills.

•

Find incentives for reduced use and abstinence.

•

Build a set of techniques to resist drug use.

•

Replace drug use with constructive, rewarding activities.

Moreover, evidence shows that counseling can be a useful part of OUD treatment for people who take OUD medication. Impact studies of counseling for people with SUDs show that:

•

Motivational enhancement/interviewing is generally beneficial.⁴³ This approach helps get people into treatment. It also supports behavior change and, thus, recovery.

•

Cognitive–behavioral therapy (CBT) has demonstrated efficacy in the treatment of SUDs, whether used alone or in combination with other strategies.⁴⁴ Clinical trials have not shown that CBT added to buprenorphine treatment with medical management is associated with significantly lower rates of illicit opioid use.^45,46 However, a secondary analysis of one of those trials found that CBT added to buprenorphine and medical management was associated with significantly greater reduction in any drug use among participants whose OUD was primarily linked to misuse of prescription opioids than among those whose OUD involved only heroin.⁴⁷ Thus, CBT may be helpful to those patients receiving buprenorphine treatment who have nonopioid drug use problems.

•

Case management helps establish the stability necessary for SUD remission.^48,49,50 Case management helps some people in SUD treatment get or sustain access to services and necessities, such as:

-

Food.

-

Shelter.

-

Income support.

-

Legal aid.

-

Dental services.

-

Transportation.

-

Vocational services.

•

Family therapy can address SUDs and various other family problems (e.g., family conflict, unemployment, conduct disorders). Several forms of family therapy are effective with adolescents⁵¹ and can potentially address family members' biases about use of medication for OUD.⁵²

•

There is more research on combined methadone treatment and various psychosocial treatments (e.g., different levels of counseling, contingency management) than on buprenorphine or naltrexone treatment in office-based settings. More research is needed to identify the best interventions to use with specific medications, populations, and treatment phases in outpatient settings.⁵³

•

Motivational intervention, case management, or both can improve likelihood of entry into medication treatment for OUD among people who inject opioids, according to a systematic review of 13 studies plus data from a prior systematic review.⁵⁴

•

Clinical trials have shown no differences in outcomes for buprenorphine with medical management between participants who get adjunctive counseling and those who don't (i.e., prescriber-provided guidance focused specifically on use of the medication).^55,56,57,58

Yet those trials:

-

Relied on well-structured medical management sessions that may not be typical in practice.

-

Excluded patients with certain co-occurring disorders or factors that complicated treatment.

•

Benefits from counseling may depend on factors such as the number of sessions and adherence. ⁶⁰

Box

RESOURCE ALERT.

Using a Recovery-Oriented Approach to Treating Patients With OUD

Counseling for OUD gives patients tools to manage their illness, achieve and sustain better health, and improve their quality of life. There are limits to how much medication alone can accomplish. OUD medication will improve quality of life,⁶¹ but many clients in addiction treatment have complex issues that may decrease quality of life, such as:

•

Other SUDs (e.g., alcohol use disorder, cannabis use disorder).^62,63,64

•

Mental distress⁶⁵ (i.e., high levels of symptoms) and disorders^66,67,68 (e.g., major depressive disorder, posttraumatic stress disorder).

•

Medical problems (e.g., hepatitis, diabetes).⁶⁹

•

History of trauma.^70,71

•

Poor diet, lack of physical activity, or both.⁷²

•

Lack of social support.⁷³

•

Unemployment.⁷⁴

Acknowledge many pathways to recovery

Recovery occurs via many pathways.⁷⁵ OUD medication may play a role in the beginning, middle, or entire continuum of care.

Support clients in making their own informed decisions about treatment. Counselors don't need to agree with clients' decisions but must respect them. Educate new clients about:

•

Addiction as a chronic disease influenced by genetics and environment.

•

How medications for OUD work.

•

What occurs during dose stabilization.

•

The benefits of longer term medication use and the risks of abruptly ending treatment.

SAMHSA'S GUIDING PRINCIPLES OF RECOVERY⁷⁶

•

Recovery emerges from hope.

•

Recovery is person driven.

•

Recovery occurs via many pathways.

•

Recovery is holistic.

•

Recovery is supported by peers and allies.

•

Recovery is supported through relationships and social networks.

•

Recovery is culturally based and influenced.

•

Recovery is supported by addressing trauma.

•

Recovery involves individual, family, and community strengths and responsibilities.

•

Recovery is based on respect.

Promote recovery for clients with OUD

Focus on addressing personal and practical problems of greatest concern to clients, which can improve their engagement in treatment.⁷⁷ Recovery supports can sustain the progress clients made in treatment and further improve their quality of life. Addressing the full range of client needs can improve clients' quality of life and lead to better long-term recovery outcomes. A recovery-oriented approach to traditional SUD counseling may help address client needs.^78,79

Increasing recovery capital supports long-term abstinence and improved quality of life, especially for clients who decide to stop medication. Clients with substantial periods of abstinence from illicit drugs identify these strategies for increasing recovery capital as helpful:^80,81,82

•

Forging new relationships with friends/family

•

Obtaining support from friends, family, partners, and communities

•

Using positive coping strategies

•

Finding meaning or a sense of purpose in life

•

Engaging in a church or in spiritual practices

•

Pursuing education, employment, or both

•

Engaging in new interests or activities (e.g., joining a community group, exercising)

•

Building confidence in ability to maintain abstinence (i.e., increasing abstinence-related self-efficacy)

•

Finding ways to help other individuals who are new to recovery

Box

RESOURCE ALERT.

Help clients further grow recovery capital by offering or connecting them to a range of services, such as:

•

Ancillary services (e.g., vocational rehabilitation, supported housing).

•

Additional counseling.

•

Medical services.

•

Mental health services.

Provide person-centered care

Clients' confidence in their ability to stay away from illicit substances, or self-efficacy, is an important factor in successful change. In person-centered care, also known as patient-centered care:

•

Clients control the amount, duration, and scope of services they receive.

•

They select the professionals they work with.

•

Care is holistic; it respects and responds to clients' cultural, linguistic, and socioenvironmental needs.⁸³

•

Providers implement services that recognize patients as equal partners in planning, developing, and monitoring care to ensure that it meets each patient's unique needs.⁸⁴

The confrontational/expert model that characterized much of SUD treatment in the past may harm some patients and inhibit or prevent recovery.⁸⁵

A person-centered approach to OUD treatment empowers clients in making decisions, such as:⁸⁶

•

Whether to take OUD medication.

•

Which medication to take.

•

Which counseling and ancillary services to receive.

Fragmented healthcare services are less likely to meet the full range of patients' needs. Integrated medical and behavioral healthcare delivery provides patient-focused, comprehensive treatment that meets the wide range of symptoms and service needs that patients with OUD may have. Significant demand remains for better integrated and coordinated SUD treatment (including OTP), medical, and mental health services.⁸⁷ Such improvements are particularly important for the many individuals with co-occurring substance use and mental disorders who receive OUD medication.^88,89 In a randomized trial of methadone patients with co-occurring mental disorders receiving onsite versus offsite mental health services, those receiving services onsite had less psychiatric distress at follow-up.⁹⁰

Promote family and social support

Support from family and friends can be the most important factor in long-term recovery, according to many people who have achieved long-term recovery from OUD.^91,92 Support from intimate partners helps all clients, especially women, avoid return to opioid use.^93,94 But the more people in clients' social networks who use drugs, the more likely clients are to return to use.^95,96

Box

RESOURCE ALERT.

Most clients are willing to invite a substance-free family member or friend to support their recovery.⁹⁷ Most have at least one nearby family member who does not use illicit drugs.⁹⁸ A client's community may provide a cultural context for their recovery and culturally specific supports that may not otherwise be available in treatment.⁹⁹

Help clients develop and support positive relations with their families by:

•

Suggesting that clients invite family and friends to aid in the recovery planning process (Exhibit 4.4).

•

Emphasizing the importance of relationships with family and friends who actively support recovery.

•

Supporting clients in mending broken relationships with loved ones.

•

Helping clients cut ties with individuals who still use drugs or enable clients' drug use.

•

Encouraging clients to build new relationships that support recovery.

Box

EXHIBIT 4.4. Engaging Reluctant Family Members in a Client's Treatment.

Provide trauma-informed care

Trauma-informed service requires providers to realize the significance of trauma. According to SAMHSA,¹⁰⁰ trauma-informed counselors know what trauma is and also:

•

Understand how trauma can affect clients, families, and communities.

•

Apply knowledge of trauma extensively and consistently in both practice and policy.

•

Know ways to promote recovery from trauma.

•

Recognize the signs and symptoms of trauma in clients, families, staff members, and others.

•

Resist things that may retraumatize or harm clients or staff.

Incorporate trauma-informed principles of care into recovery promotion efforts, because:

•

Trauma histories and trauma-related disorders may increase clients' risk for various problems, including early drop-out from treatment¹⁰¹ and greater problems with pain.¹⁰²

•

Childhood trauma is highly prevalent among people with OUD.^103,104

•

People often suffer multiple traumas during opioid misuse.¹⁰⁵

•

An intervention that integrated trauma treatment and standard care (which goes further than the trauma-informed care detailed here) had better outcomes than standard care alone in a diverse group of women treated in various settings, including an OTP.¹⁰⁶

Box

RESOURCE ALERT.

Quick Guide to Medications

This section introduces the neurochemistry and biology of OUD and the medications that treat it. Reading this section will familiarize counselors with terminology healthcare professionals may use in discussing patients who take OUD medication (see also Exhibit 4.1 and the comprehensive glossary in Part 5).

Learning How OUD Medications Work

The following sections describe how each of the OUD medications functions (Exhibit 4.5; see also Part 3 of this TIP for greater detail). Discuss questions or concerns about a patient's medication, side effects, or dosage with the patient's prescriber after getting the patient's consent.

Box

EXHIBIT 4.5. FDA-Approved Medications Used To Treat OUD: Key Points.

Buprenorphine

Buprenorphine reduces opioid misuse, HIV risk behaviors, and risk of overdose death.^{108,109,110,111} Buprenorphine only partially activates opioid receptors; it is a partial agonist. It binds to and activates receptors sufficiently to prevent craving and withdrawal and to block the effects of illicit opioids. Appropriate doses of buprenorphine shouldn't make patients feel euphoric, sleepy, or foggy headed.

Buprenorphine has the benefit of a ceiling effect. Its effectiveness and sedation or respiratory effects don't increase after a certain dosing level, even if more is taken. This lowers risk of overdose and misuse.¹¹² Groups at particular risk for buprenorphine overdose include children who accidentally ingest the medication¹¹³ and patients who also use CNS depressants like benzodiazepines or alcohol.^114,115 (See Part 3 of this TIP for more information on concurrent use of CNS depressants and buprenorphine.)

Buprenorphine is available outside of OTPs, through non-OTP healthcare settings (e.g., physicians' offices, outpatient drug treatment programs). Healthcare professionals (including nurse practitioners and physician assistants, per the Comprehensive Addiction and Recovery Act of 2016, and, until October 1, 2023, qualified clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives, per the SUPPORT for Patients and Communities Act of 2018) can prescribe it outside of an OTP, provided they have a specific federal waiver. This is often referred to as “being waivered” to prescribe buprenorphine.

Buprenorphine can cause opioid withdrawal in patients who have recently taken a full opioid agonist (e.g., heroin, oxycodone). This occurs because buprenorphine pushes the full opioid activator molecules off the receptors and replaces them with its weaker, partially activating effect. For this reason, patients must be in opioid withdrawal when they take their first dose of buprenorphine.

The most common buprenorphine formulation contains naloxone to reduce misuse. Naloxone is an opioid antagonist. It blocks rather than activates receptors and lets no opioids sit on receptors to activate them. Naloxone is poorly absorbed under the tongue/against the cheek, so when taking the combined medication as directed, it has no effect. If injected, naloxone causes sudden opioid withdrawal.

Buprenorphine comes in two forms that melt on the inside of the cheek or under the tongue: films (combined with naloxone) or tablets (buprenorphine/naloxone or buprenorphine alone). For treatment of OUD, patients take the films or tablets once daily, every other day, or three times a week. Various companies manufacture these forms of the medication. Some are brand name, and some are generic. The different kinds vary in strength or number of milligrams, but they have been designed and tested to provide roughly the same amount of medication as the first approved product (Exhibit 3A.5 in Part 3).

Buprenorphine is also available in a long-acting implant and long-acting injection that specially trained healthcare professionals place under the skin (subdermal implant) and an extended-release formulation that is administered under the skin (subcutaneous injection). The implant is appropriate for patients who have been stable on low doses of the films or tablets. It lasts for 6 months and can be replaced once after 6 months. The extended release injection lasts for 1 month and can be repeated monthly. It is appropriate for patients who have been stabilized on the films or tablets for at least 7 days.

Healthcare professionals with waivers can prescribe buprenorphine. Physicians who take an 8-hour training and get a waiver can prescribe buprenorphine. Nurse practitioners and physician assistants are eligible to apply for waivers after 24 hours of training. Until October 1, 2023, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives also are eligible to apply for waivers after 24 hours of training. Recent buprenorphine practice guidelines provide an exemption to providers who are state licensed, possess a valid DEA registration, and wish to treat no more than 30 patients with buprenorphine. The “traditional” pathway of obtaining a waiver by undergoing the 8-hour training still exists and is required for providers who wish to treat more than 30 patients.¹¹⁶ Providers who wish to deliver buprenorphine implants must receive special training on how to insert and remove them.

Buprenorphine can cause side effects including constipation, headache, nausea, and insomnia. These often improve over time and can be managed with dosage adjustments or other approaches.

Methadone

Methadone is highly effective. Many studies over decades of research show that it:^117,118,119

•

Increases treatment retention.

•

Reduces opioid misuse.

•

Reduces drug-related HIV risk behavior.

•

Lowers risk of overdose death.

Methadone is slow in onset and long acting, avoiding the highs and lows of short-acting opioids. It is a full agonist. Patients who take the same appropriate dose of methadone daily as prescribed will neither feel euphoric from the medication nor experience opioid withdrawal.

Methadone is an oral medication that is taken daily under observation by a nurse or pharmacist and under the supervision of an OTP physician. Methadone is available as a liquid concentrate, a tablet, or an oral solution made from a dispersible tablet or powder.

Methadone blunts or blocks the euphoric effects of illicit opioids because it occupies the opioid receptors. This “opioid blockade” helps patients stop taking illicit opioids because they no longer feel euphoric if they use illicit opioids. When on a proper dose of methadone, patients can:

•

Keep regular schedules.

•

Lead productive, healthy lives.

•

Meet obligations (family, social, work).

Methadone can lead to overdose death in people who use a dose that's considerably higher than usual, as methadone is a full agonist. People who don't usually take opioids or have abstained from them for a while could overdose on a fairly small amount of methadone. Thus, patients start on low doses of methadone and gradually adjust upward to identify the optimal maintenance dose level.

Patients must attend a clinic for dose administration 6 to 7 days per week during the start of treatment. Healthcare professionals can thus observe patients' response to medication and discourage diversion to others. Visit frequency can lessen after patients spend time in treatment and show evidence of progress.

Methadone can cause certain side effects. Common potential side effects of methadone include:

•

Constipation.

•

Sleepiness.

•

Sweating.

•

Sexual dysfunction.

•

Swelling of the hands and feet.

Sleepiness can be a warning sign of potential overdose. Patients who are drowsy should receive prompt medical assessment to determine the cause and appropriate steps to take—which may require a reduction in methadone dose. Some patients may appear sleepy or have trouble staying awake when idle, even if there is no immediate danger of evolving overdose. These patients may need a lower dose or may be taking other prescribed or nonprescribed medications (e.g., benzodiazepines, clonidine) that are interacting with the methadone.

Naltrexone

Naltrexone stops opioids from reaching and activating receptors, preventing any reward from use. Naltrexone is an antagonist of the opioid receptors—it does not activate them at all. Instead, it sits on the receptors and blocks other opioids from activating them.

Naltrexone appears to reduce opioid craving¹²⁰ but not opioid withdrawal (unlike buprenorphine and methadone, which reduce both craving and withdrawal). Someone starting naltrexone must be abstinent from short-acting opioids for at least 7 days and from long-acting opioids for 10 to 14 days before taking the first dose. Otherwise, it will cause opioid withdrawal, which can be more severe than that caused by reducing or stopping opioid use.

Naltrexone comes in two forms: tablet and injection.

•

Patients take oral naltrexone as tablets daily or three times per week. Tablets are rarely effective, as patients typically stop taking them after a short time.^121,122,123

•

Highly externally monitored populations in remission may do well with the tablet,^124,125,126 such as physicians who have mandatory frequent urine drug testing and are at risk of losing their licenses.

•

The injected form is more effective than the tablet because it lasts for 1 month. Patients can come to a clinic to receive an intramuscular injection in their buttock.

Naltrexone can produce certain side effects, which may include:

•

Nausea.

•

Headache.

•

Dizziness.

•

Fatigue.

For the extended-release injectable formulation, potential reactions at the injection site include:

•

Pain.

•

Bumps.

•

Blistering.

•

Skin lesions (may require surgery).

Counselor–Prescriber Communications

OUD medication can support counselors' work with clients who have OUD, and counseling supports the work prescribers do with them. Good communication facilitates mutually supportive work (Exhibit 4.6). A counselor will probably:

Box

EXHIBIT 4.6. Example of Counselor–Prescriber Communication.

•

See patients more frequently than prescribers.

•

Have a more complete sense of patients' issues.

•

Offer providers valuable context and perspective.

•

Help patients take medications appropriately.

•

Ensure that patients receive high-quality care from their other providers.

Structuring Communications With Prescribers

Regular, structured communication can improve the flow of information between treatment teams. Some multidisciplinary programs produce regular reports for prescribers about patient progress. Exhibit 4.7 provides some strategies for discussing patient care with healthcare professionals.

Box

EXHIBIT 4.7. Tips for Discussing Patient Care With Prescribers.

Creation of a Supportive Counseling Experience

Counseling Patients on Overdose Prevention and Treatment

Know how to use naloxone to treat opioid overdose; share this information with patients and their family members and friends. Available by prescription (or without a prescription in some states), naloxone is an opioid antagonist that has successfully reversed many thousands of opioid overdoses. It comes in auto-injector and nasal spray formulations easy for laypeople to administer immediately on the scene of an overdose, before emergency responders arrive.

Ask patients if they have a naloxone prescription or help them get it without one if possible. Providers may prescribe naloxone in addition to OUD medication. Counselors should check state laws to learn their jurisdiction's naloxone prescription and dispensation policies (see “Resource Alert: Overdose Prevention/Treatment”).

Inform clients and their friends and families of any Good Samaritan laws in the jurisdiction, which protect against drug offenses for people who call for medical help while experiencing or observing overdose.

Emphasize that a person given naloxone to reverse overdose must go to the emergency department, because overdose can start again when naloxone wears off.

Consider working with the program administrator to place a naloxone rescue kit in the office, if one is not already available. To be ready for an emergency, learn:

•

The signs of overmedication (which may progress to overdose) and overdose itself.

•

What to do if an overdose is suspected.

•

How to administer naloxone.

Consider working with the program administrators to set up a program to distribute naloxone directly to patients. Many states allow organizations to do this under a standing order from a physician. Clients are more likely to access naloxone if their program provides it directly to them rather than sending them to another organization to get it. Learn more at Prescribe to Prevent (http://prescribetoprevent.org).

Box

RESOURCE ALERT.

Helping Patients Cope With Bias and Discrimination

Patients taking medication for OUD must deal with people—including family members, friends, colleagues, employers, and community members—who are misinformed or biased about the nature of OUD and effective treatments for it (Exhibit 4.8).

Box

EXHIBIT 4.8. Conversation: Addressing Misinformation.

Wherever possible, such as in a counseling session or a community education forum, counter misunderstandings with accurate information. Emphasize the message that addiction is governed by more powerful brain forces than those that determine habits. As a result, having a lot of positive intent, wanting to quit, and working hard at it sometimes won't be enough.

Remind patients about building recovery capital and sticking with their treatment plan and goals. A particularly good opportunity to do so arises when patients ask how to “get off medication.” Statements such as “The longer you take medication, the more of your life you can get back and the less likely you are to return to opioid use” and “We usually recommend continuing medication long term because it helps people maintain recovery” can help clients understand that they are following medical recommendations and doing a good job of caring for themselves (Exhibit 4.9).

Box

EXHIBIT 4.9. Addressing the Misconception That an Opioid Medication Is “Just Another Drug”.

People may think that addiction is just a bad habit or willful self-destruction and that someone who has difficulty stopping opioid misuse is lazy. They may view OUD medication as “just another drug” and urge patients to stop taking it.

Review a client's motivation for tapering or quitting medication (Exhibit 4.10) and have a conversation about the best timing for such a change (Exhibit 4.11). If the client has consented to communication with other providers, inform the client's prescriber about the client's desires or intent so that shared decision making can take place.

Box

EXHIBIT 4.10. When a Patient Wants To Taper Medication or Stop Altogether.

Box

EXHIBIT 4.11. Responding to a Patient's Desire To Taper Medication for OUD.

Be proactive in dispelling myths and providing facts about medications for OUD when countering misconceptions and judgmental attitudes. Point out that multiple organizations consider individuals to be in recovery if they take OUD medication as prescribed, including:

•

The American Medical Association.¹⁴²

•

The American Society of Addiction Medicine.¹⁴³

•

The National Institute on Drug Abuse.¹⁴⁴

•

The Office of the Surgeon General.¹⁴⁵

•

The World Health Organization.¹⁴⁶

Explain that alcohol and opioids are different substances with different effects on the body and brain. This counters the mistaken belief that people receiving buprenorphine or methadone are always “high” and as impaired as if they drank alcohol all day. People acquire tolerance to impairments that drinking causes in motor control and cognition. But this tolerance is partial; alcohol consumption always results in some deficits. Opioids don't have the same motor or cognitive effects. Complete tolerance develops to the psychoactive effects and related motor impairments opioids cause.

If a person takes a therapeutic dose of opioid agonist medication as prescribed, he or she may be as capable as anyone else of driving, being emotionally open, and working productively. Some people worry that OUD medication causes a “high” because they've seen patients taking OUD medication whose behavior was affected by other substances (e.g., benzodiazepines). Others may assume that someone is high on a medication for OUD who isn't taking any such medication at all.

Point out that many thousands of people are prescribed medication for OUD every year, are receiving appropriate treatment, and are indistinguishable from other people. People taking OUD medication rely on it to maintain daily function, like people with diabetes rely on insulin. Nevertheless, some people think that individuals taking buprenorphine or methadone are still addicted to opioids (Exhibit 4.9), even if they don't use illicit drugs. For people with OUD, the medication addresses the compulsion and craving to use. It also blocks the euphoric effects of illicit opioids, which over time helps people stop attempting to use. For people with diabetes, medication addresses the problems caused by inadequate production of insulin by the pancreas. Medication allows both populations to live life more fully.

It would be inappropriate for a medical team to refuse radiation for cancer patients because the team believes chemotherapy is always needed, or to refuse chemotherapy because they believe that radiation is always needed, regardless of each patient's diagnosis and condition. It would be just as inappropriate to refuse evidence-based treatment with medication for a patient with OUD, when that may be the most clinically appropriate course of treatment.

Focus on common ground—all patients want a healthy recovery, and judging or isolating someone for return to use doesn't aid anyone's recovery. A divide may occur between patients in a group setting over return to opioid use. People in the OUD community typically are forgiving of return to opioid use and recognize that it can occur on the path to long-term recovery. However, some people in mutual-help communities judge those who return to use (see the “Helping Clients Find Accepting Mutual-Help Groups” section). Address judgmental attitudes through this analogy: People with diabetes whose blood sugar spikes aren't condemned and ejected from treatment.

Dispel the myth that OUD medications make people sick. In fact, methadone and buprenorphine relieve opioid withdrawal, even if patients don't feel complete relief in the first few days. Taking naltrexone too soon after opioid use can cause opioid withdrawal, but withdrawal symptoms can generally be managed successfully. Point out that people taking medication for OUD sometimes get colds, the flu, or other illnesses, like everyone else. A similar misconception is that OUD medications make all patients sleepy. Exhibit 4.12 offers a sample dialog for responding to this misconception.

Box

EXHIBIT 4.12. Conversation: Redirecting a Concern to the Prescriber.

When return to opioid use comes up in a group counseling setting, messages about getting back on track and avoiding shaming and blaming apply just as much to the patients taking OUD medication as to other participants. This topic is an opportunity to address the dangers of overdose, especially the dangers of using an opioid after a period of abstinence or together with other CNS depressants.

Helping Patients Advocate for Themselves

Educate clients so they can advocate for their treatment and personal needs. Key topics include:

•

Addiction as a chronic disease influenced by genetics and environment.

•

The ways that medications for OUD work.

•

The process of dose stabilization.

•

The benefits of longer term medication use and risks of abrupt treatment termination.

•

The role of recovery supports (e.g., mutual-help groups) in helping achieve goals.

Offer clients' family and friends education on these topics, as well, so that they can advocate for their loved ones. Encourage patients to let family and friends know how important they are and how valuable their support is. Also urge patients to ask loved ones to help them express concerns or fears.

Role-playing can help patients self-advocate. It allows them to practice what to say, what reactions to expect, and ways to respond. Coach patients in active listening and in focusing on solutions rather than problems. Exhibit 4.13 gives an example of a counselor helping a client self-advocate.

Box

EXHIBIT 4.13. Conversation: Helping a Client Self-Advocate.

Urge patients to advocate for themselves beyond one-on-one conversations. Options include sharing educational pamphlets, inviting loved ones to a counseling session, or referring them to websites.

Addressing Discrimination Against Clients Who Take OUD Medication

Patients can face discriminatory actions when dealing with individuals, organizations, or systems that make decisions based on misinformation about, or biases against, the use of medication for OUD. The following sections highlight issues patients taking OUD medication may face and how counselors can help.

Help clients address employment-related issues

Under the Americans With Disabilities Act, employers cannot discriminate against patients taking medication for OUD.¹⁴⁷ However, the law doesn't always stop employers from taking such action. For example, some employers conduct workplace urine drug testing, either before offering employment or randomly during employment. The OUD medication they test for most frequently is methadone, but it's possible to test for buprenorphine. Naltrexone is generally not tested for. The TIP expert panel concludes, based on multiple patient experiences, that patients who take OUD medication find it intimidating to explain to their employers why their urine test results are positive for opioids. Yet if they offer no explanation, they don't get the callback for the job or are let go from the job they have.

Direct patients to legal resources and help them consider how to respond to discrimination at work based on misinterpreted drug tests. Offer to speak with their prospective/current employers to address concerns and misperceptions about OUD medication and its effect on their ability to do work tasks.

Box

RESOURCE ALERT.

Understand potential legal issues

This section describes issues that can affect access to care for patients involved in the justice system who take buprenorphine or methadone for OUD. These issues usually don't apply for naltrexone.

Many jails (short term) and prisons (long term) restrict or disallow access to OUD medication despite the federal mandate that people who are incarcerated have access to medical care.^148,149 For example:

•

A jail may not continue methadone treatment or allow methadone delivery by patients' OTPs.

•

Patients' medication may be seized upon arrest.

•

Jail health officials may deny patients' buprenorphine prescriptions.

Help negotiate patient access to OUD medication during incarceration. Negotiating access to OUD medication can be problematic and often requires multiple meetings between care providers and jail staff members to resolve successfully. Patients taking OUD medication may be forced to go without medication during incarceration. This increases their risk for opioid overdose if they return to use after reentering the community, given the decreased tolerance that results from interrupted treatment.

Encourage patients to reengage in treatment as soon as they're released. People with OUD released from prison or jail who don't take OUD medication have higher risk of overdose death during their first few weeks in the community. Early after release, they are at very high risk of overdose, given possible:

•

Decrease in opioid tolerance while incarcerated.

•

Lack of appropriate OUD therapy while incarcerated.

•

OUD medication initiation right before release.

•

Release without coordination or a slot for community-based treatment.

Patients who aren't opioid tolerant need a lower starting dose that prescribers will increase more slowly than usual. Extended-release injectable naltrexone can be an effective alternative for these patients.

Figure

Support patients in getting legal advice or counsel via their OUD medication prescribers' healthcare organization. Members of the TIP expert panel have observed situations in which law enforcement personnel arrested patients leaving methadone clinics and charged them with driving under the influence or arrested them after finding buprenorphine prescription bottles in their cars. Discussions among treatment organizations and local law enforcement leadership can help address such situations.

Address concerns and advocate for addiction specialists to select treatments best suited for each patient. Sometimes, authorities insist that patients enter a particular kind of treatment or follow particular rules related to their OUD. To ensure a patient-centered focus, help involve addiction specialists in determining what kind of treatment best meets patients' needs. This kind of advocacy works best when counselors and the programs for which they work have preexisting relationships with personnel in local employment, law enforcement, drug court, and child welfare facilities.

Address issues in dealing with healthcare providers

Misunderstandings about OUD and its treatment aren't rare among healthcare providers:

•

Patients admitted to the hospital for medical issues may face prejudice from hospital staff members.

•

Providers may not know how to manage patients' OUD medication during their hospital stay.

•

Some providers don't know how to manage pain in someone taking medication for OUD.

Help communicate issues to patients' prescribers, who can advocate for proper handling of OUD medication. It is also possible to help hospital staff members see the patient as a whole person who deserves respect and to provide them with essential information about treatment for OUD.

Inpatient SUD treatment facilities may refuse admission until patients are off buprenorphine or methadone. Sometimes, patients taking OUD medication seek admission to inpatient facilities for treatment of an additional SUD, a mental disorder, or both. If a facility won't accept someone on OUD medication, call on local or state regulatory authorities (e.g., the State Opioid Treatment Authority) and patients' healthcare professionals to intervene with the facility's professional staff and management.

Demonstrate awareness of pregnancy and parenting issues

Healthcare professionals may be unaware of current guidelines for treating pregnant women with OUD (Exhibit 4.14). As a result, they may inappropriately:

Box

EXHIBIT 4.14. Summary of Current Guidance for the Treatment of Pregnant Women With OUD.

•

Deny OUD medication to pregnant women.

•

Discourage breastfeeding by mothers taking OUD medication.

•

Direct women who become pregnant while taking OUD medication to undergo withdrawal from their medication and attempt abstinence.

Box

RESOURCE ALERT.

Hospital policies on screening infants for prenatal substance exposure vary considerably. A positive screen may trigger involvement of Child Protective Services. This may occur even when the positive screen results from treatment with OUD medication under a physician's care rather than opioid misuse.

Help pregnant and postnatal clients in these situations by:

•

Educating them and encouraging them to share pertinent information and resources with healthcare professionals involved in their care.

•

Coordinating with their prescribers to help them get prenatal and postnatal care from well-informed healthcare professionals.

•

Getting involved in efforts to educate the local healthcare community about best practices for the care of pregnant and postnatal women with OUD.

Legal problems can arise if Child Protective Services or legal personnel don't understand that parents receiving OUD medication are fully capable of caring for children and contributing to their families. Judges, probation or parole officers, or Child Protective Services workers may inappropriately request that patients discontinue medication as a condition of family reunification. Such orders are medically inappropriate and should be challenged. Possible ways to help:

•

Write letters to judges and lawyers explaining how effective OUD medication can be.

•

Send judges and lawyers literature about current medical recommendations (including this TIP).

•

Testify in court, if necessary.

Box

RESOURCE ALERT.

Helping Clients Find Accepting Mutual-Help Groups

Voluntary participation in 12-Step groups can improve abstinence and recovery-related skills and behaviors for some people with SUDs. Greater involvement (e.g., being a 12-Step sponsor) can increase these benefits.^{153,154,155,156} However, not much research has explored less widespread types of groups (e.g., groups that follow a given religion's principles, secular groups that downplay the spiritual aspects of 12-Step groups). Research exploring longitudinal outcomes for people with OUD who attend NA is limited, but findings link more frequent attendance with abstinence.^157,158,159

Clients taking medication for OUD may face challenges in attending mutual-help groups.

For example:

•

NA, the most widely available program, treats illicit opioids and OUD medications equally in gauging abstinence and recovery. NA doesn't consider people taking OUD medication “clean and sober.”¹⁶⁰

•

Local chapters of NA may decide not to allow people taking OUD medication to participate at meetings or may limit their participation (e.g., not allowing service work).

•

Clients attending some NA meetings may encounter hostile attitudes toward the use of medication.

•

AA's official policy is more accepting of the use of prescribed medication, but clients may still encounter negative attitudes toward their use of medications for OUD.

•

Other groups, such as some religious mutual-help programs, SMART Recovery, and LifeRing Secular Recovery, also have policies that could challenge clients for taking medication for OUD.

Box

RESOURCE ALERT.

Prepare clients who take medication for OUD to attend mutual-help meetings

Clients will be better able to find supportive mutual-help groups if their counselor and program:

•

Evaluate attitudes toward medication for OUD among local mutual-help groups.

•

Keep on hand information about all mutual-help options available in the clients' area.

•

Recruit volunteers from mutual-help groups to help clients find and attend meetings (e.g., by providing transportation, serving as “sponsors,” introducing clients).

•

Do not mandate meeting attendance. Recommending participation is just as effective.¹⁶¹

•

Keep track of clients' experiences at different groups to ensure that meetings remain welcoming.

•

Help clients start onsite mutual-help groups.

•

Ask staff members to evaluate their own feelings and beliefs about mutual-help groups.¹⁶²

Facilitate positive mutual-help group experiences

•

Educate clients about mutual-help groups. Explore group types, risks and benefits of participation, and limitations of research in support of those risks and benefits.

•

Suggest buddying up. Clients can attend meetings with other people who take medication for OUD.

•

Review with clients their understanding of and prior experience with mutual help.

•

Explore clients' understanding of the benefits and risks of disclosure about taking OUD medication.

•

Develop a risk-reduction plan for disclosure if clients want to share their use of OUD medication (e.g., talking with an individual group member instead of disclosing to the entire group).

•

Help clients anticipate and learn to handle negative responses:

-

Develop sample scripts clients can use when questioned about their medication.

-

Role-play scenarios in which clients respond to questions about their use of medication.

•

Respect the privacy of clients' participation in mutual-help groups and recognize that some groups ask that participants not discuss what occurs in meetings.

•

Make sure clients know they can talk about their experiences in mutual-help groups but don't pressure them to disclose in these groups that they take OUD medication.

•

Consider mutual-help participation using groups more open to OUD medication (e.g., attending AA even if the client has no alcohol use disorder; attending groups for co-occurring substance use and mental disorders, such as Dual Recovery Anonymous or Double Trouble in Recovery). Clients with OUD who attend AA and not NA have similar recovery-related outcomes and retention rates.¹⁶³

Box

RESOURCE ALERT.

Online mutual-help groups

Before recommending an online group, check its content and tone on the use of medication. Mutual help using the Internet (either through real-time chat rooms or discussion boards where one posts and waits for responses) has been growing in popularity. This is an especially valuable resource for clients living in rural and remote areas. Groups range from general meetings for people with a particular SUD (e.g., online AA meetings) to those that are very specific (e.g., Moms on Methadone). Moderated groups are preferable to unmoderated groups. TIP 60, Using Technology-Based Therapeutic Tools in Behavioral Health Services, addresses many of the pros and cons of online support groups.¹⁶⁴ Part 5 of this TIP gives links for several groups that the TIP expert panel has identified as helpful.

Box

RESOURCE ALERT.

Mutual-help groups specific to OTPs

Although these meetings occur mostly on the premises of OTPs, it may be possible to use the models developed by OTPs in more general SUD treatment settings. Because they serve only patients receiving medication to treat OUD, OTPs can create and sustain onsite mutual-help groups specific to this population. Such groups include Methadone Anonymous (MA),¹⁶⁷ other variations on a 12-Step model,^168,169 and the mutual-help component of Medication-Assisted Recovery Services (MARS). MARS is a recovery community organization, not just a mutual-help program. MARS members design, implement, and evaluate a variety of peer-delivered recovery support services in addition to providing meetings. More information on these programs is in the articles cited and online resources presented in Part 5.

Facilitating Groups That Include Patients Taking OUD Medication

Foster acceptance via attitude and behavior when facilitating groups that include patients taking OUD medication:

•

Establish ground rules about being respectful, avoiding negative comments about group members, and keeping statements made in the group confidential—as with any group.

•

Be proactive. State up front that ground rules apply to everyone, regardless of a given person's decisions about whether to include OUD medication in his or her path to recovery.

•

Ask members to discuss how to address any negative comments, should they occur. This is especially important for mixed groups.

•

Ask group members to affirm that they will abide by the rules.

•

Provide consistent reminders throughout each session about the ground rules.

Group members may still make negative comments about medication for OUD. Avoid feeding the negativity with attention, which can worsen the situation. Reframe negative comments to express underlying motivations, often based on fear or misunderstanding. Remain positive; model expected behavior, which can benefit the person who made the negative remark (Exhibit 4.15).

Box

EXHIBIT 4.15. Redirecting Negative Comments.

Additional tips for leading mixed groups include the following:

•

Treat patients taking OUD medication the same as other patients in the group. Patients taking medication can participate in and benefit from individual and group counseling just like other patients. There is no need to have separate counseling tracks based on OUD medication status, nor should that status limit a participant's responsibilities, leadership role, or level of participation.

•

Meet with patients taking OUD medication in advance to prepare them for mixed-group settings. Advise them that they don't have to disclose their medication status to the group, just as they don't have to disclose any other health issues. Counsel them that if they choose to talk about their medication status, it helps to talk about how medication has helped shape their personal recovery.

•

Don't single out patients taking OUD medication. Let participants decide whether to tell the group about any issue they want to share, including medication status. If a patient chooses to disclose that status, follow up after the session to ensure that he or she is in a positive space and feels supported.

•

Keep the session's focus on the topic and not on the pros and cons of medication for OUD. If the person receiving medication for OUD or other group members have specific questions about such medications, have them ask their healthcare professionals.

•

Reinforce messages of acceptance. During the wrap-up discussion at the end of a session, members may comment on points that stood out for them. This is a chance to restate information accurately and model respect for each patient's road to recovery, whether it includes OUD medication or not.

•

Review confidentiality rules. Affirm that patients' OUD medication status will not be shared with other group members. Remind participants to think carefully before sharing personal details such as their medication status with the group, because other participants may not respect confidentiality even if they have agreed to do so as part of the group guidelines.

Other Common Counseling Concerns

Patients must sign releases to permit ongoing conversations between care providers in accordance with federal regulations on confidentiality of medical records for patients in treatment for an SUD (42 CFR Part 2). When patients' primary care providers, prescribers of medication for OUD, and addiction-specific counselors don't work for the same entity, patients must consent for them to share information.

It can be challenging when a patient refuses to consent to collaborative communication among his or her healthcare team members. In these cases, the professionals involved must decide whether they will continue to provide either medication or counseling services without permission to collaborate. In other words, is cross-communication among all providers required for collaborative care? The answer to this complicated question depends on each patient's circumstances.

The TIP expert panel recommends communication among providers as the standard of care for OUD treatment and recovery support. Carefully consider deviations from this standard, which should occur only rarely. That said, individualize decisions about collaborative communication among providers to each patient's unique preferences, needs, and circumstances.

Patients may not consent to communication among providers if they:

•

Have experienced discrimination in healthcare systems.

•

Have developed OUD after taking opioid pain medication.

•

Have legitimate cause not to trust providers (e.g., perceiving themselves as having been abused by a healthcare professional).¹⁷⁰

•

Are not ready to make primary care providers aware of their disorder, even (or especially) if those providers have been prescribing opioid pain medication.

•

Encounter problems in making progress toward recovery. After typically consenting to communication among providers, a patient's sudden revocation may signal trouble in recovery.

Exhibit 4.16 lists common collaborative care issues and responses counselors can consider. Suggested responses assume that patients have consented to open exchange of information among all providers.

Box

EXHIBIT 4.16. Common Collaborative Care Issues and Possible Counselor Responses.

Notes

• 1. Centers for Disease Control and Prevention. (2016). Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. Morbidity and Mortality Weekly Report, 65(50–51), 1445–1452. [PubMed: 28033313]
• 2. Center for Behavioral Health Statistics and Quality. (2020). Results from the 2019 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved April 28, 2021, from www​.samhsa.gov/data/
• 3. American Society of Addiction Medicine. (2011). Definition of addiction. Retrieved October 30, 2017, from www​.asam.org/resources​/definition-of-addiction
• 4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
• 5. Department of Health and Human Services, Office of the Surgeon General. (2016). Facing addiction in America: The Surgeon General's report on alcohol, drugs, and health. Washington, DC: Department of Health and Human Services. [PubMed: 28252892]
• 6. Substance Abuse and Mental Health Services Administration. (2015). Federal guidelines for opioid treatment programs. HHS Publication No. (SMA) PEP15-FEDGUIDEOTP. Rockville, MD: Substance Abuse and Mental Health Services Administration.
• 7. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.
• 8. National Cancer Institute. (n.d.). Remission. In NCI dictionary of cancer terms. Retrieved November 22, 2017, from www​.cancer.gov/publications​/dictionaries​/cancer-terms?cdrid=45867
• 9. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
• 10. Manchikanti, L. (2007). National drug control policy and prescription drug abuse: Facts and fallacies. Pain Physician, 10, 399–424. [PubMed: 17525776]
• 11. Jones, C. M. (2013). Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers—United States, 2002–2004 and 2008–2010. Drug and Alcohol Dependence, 132(1–2), 95–100. [PubMed: 23410617]
• 12. Hedegaard, H., Chen, L. H, & Warner, M. (2015). Drug-poisoning deaths involving heroin: United States, 2000–2013. NCHS Data Brief, No. 190. Hyattsville, MD: National Center for Health Statistics. [PubMed: 25932890]
• 13. Centers for Disease Control and Prevention. (2016). Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. Morbidity and Mortality Weekly Report, 65(50–51), 1445–1452. [PubMed: 28033313]
• 14. Substance Abuse and Mental Health Services Administration. (n.d.). Opioid treatment program directory. Retrieved October 19, 2017, from https://dpt2​.samhsa.gov​/treatment/directory.aspx
• 15. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
• 16. Carroll, K. M., & Weiss, R. D. (2016). The role of behavioral interventions in buprenorphine maintenance treatment: A review. American Journal of Psychiatry, 174(8), 738–747. [PMC free article: PMC5474206] [PubMed: 27978771]
• 17. McLellan, A. T., Lewis, D. C., O'Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. JAMA, 284(13), 1689–1695. [PubMed: 11015800]
• 18. Connery, H. S. (2015). Medication-assisted treatment of opioid use disorder: Review of the evidence and future directions. Harvard Review of Psychiatry, 23(2), 63–75. [PubMed: 25747920]
• 19. Fullerton, C. A., Kim, M., Thomas, C. P., Lyman, D. R., Montejano, L. B., Dougherty, R. H., … Delphin-Rittmon, M. E. (2014). Medication-assisted treatment with methadone: Assessing the evidence. Psychiatric Services, 65(2), 146–157. [PubMed: 24248468]
• 20. Thomas, C. P., Fullerton, C. A., Kim, M., Montejano, L., Lyman, D. R., Dougherty, R. H., … Delphin-Rittman, M. E. (2014). Medication-assisted treatment with buprenorphine: Assessing the evidence. Psychiatric Services, 65(2), 158–170. [PubMed: 24247147]
• 21. American Society of Addiction Medicine. (2015). The ASAM national practice guideline for the use of medications in the treatment of addiction involving opioid use. Chevy Chase, MD: Author. [PMC free article: PMC4605275] [PubMed: 26406300]
• 22. Sordo, L., Barrio, G., Bravo, M. J., Indave, B. I., Degenhardt, L., Wiessing, L., … Pastor-Barriuso, R. (2017). Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. British Medical Journal (Clinical Research Ed.), 357, j1550. [PMC free article: PMC5421454] [PubMed: 28446428]
• 23. Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 2014(2), 1–84. [PMC free article: PMC10617756] [PubMed: 24500948]
• 24. Auriacombe, M., Fatséas, M., Dubernet, J., Daulouède, J. P., & Tignol, J. (2004). French field experience with buprenorphine. American Journal on Addictions, 13(Suppl. 1), S17–S28. [PubMed: 15204673]
• 25. Degenhardt, L., Randall, D., Hall, W., Law, M., Butler, T., & Burns, L. (2009). Mortality among clients of a state-wide opioid pharmacotherapy program over 20 years: Risk factors and lives saved. Drug and Alcohol Dependence, 105(1–2), 9–15. [PubMed: 19608355]
• 26. Gibson, A., Degenhardt, L., Mattick, R. P., Ali, R., White, J., & O'Brien, S. (2008). Exposure to opioid maintenance treatment reduces long-term mortality. Addiction, 103(3), 462–468. [PubMed: 18190664]
• 27. Merlo, L. J., Greene, W. M., & Pomm, R. (2011). Mandatory naltrexone treatment prevents relapse among opiate-dependent anesthesiologists returning to practice. Journal of Addiction Medicine, 5(4), 279–283. [PMC free article: PMC3223377] [PubMed: 22107877]
• 28. Minozzi, S., Amato, L., Vecchi, S., Davoli, M., Kirchmayer, U., & Verster, A. (2011). Oral naltrexone maintenance treatment for opioid dependence. Cochrane Database of Systematic Reviews, 2011(4), 1–45. [PMC free article: PMC7045778] [PubMed: 21491383]
• 29. Fullerton, C. A., Kim, M., Thomas, C. P., Lyman, D. R., Montejano, L. B., Dougherty, R. H., … Delphin-Rittmon, M. E. (2014). Medication-assisted treatment with methadone: Assessing the evidence. Psychiatric Services, 65(2), 146–157. [PubMed: 24248468]
• 30. Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 2014(2), 1–84. [PMC free article: PMC10617756] [PubMed: 24500948]
• 31. Kresina, T. F., & Lubran, R. (2011). Improving public health through access to and utilization of medication assisted treatment. International Journal of Environmental Research and Public Health, 8(10), 4102–4117. [PMC free article: PMC3210600] [PubMed: 22073031]
• 32. Krupitsky, E., Nunes, E. V., Ling, W., Illeperuma, A., Gastfiend, D. R., & Silverman, B. L. (2011). Injectable extended-release naltrexone for opioid dependence: A double-blind, placebo-controlled, multicentre randomized trial. Lancet, 377(9776), 1506–1533. [PubMed: 21529928]
• 33. Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 2014(2), 1–84. [PMC free article: PMC10617756] [PubMed: 24500948]
• 34. Timko, C., Schultz, N. R., Cucciare, M. A., Vittorio, L., & Garrison-Diehn, C. (2016). Retention in medication-assisted treatment for opiate dependence: A systematic review. Journal of Addictive Diseases, 35(1), 22–35. [PMC free article: PMC6542472] [PubMed: 26467975]
• 35. Fiellin, D. A., Schottenfeld, R. S., Cutter, C. J., Moore, B. A., Barry, D. T., & O'Connor, P. G. (2014). Primary care-based buprenorphine taper vs maintenance therapy for prescription opioid dependence: A randomized clinical trial. JAMA Internal Medicine, 174(12), 1947–1954. [PMC free article: PMC6167926] [PubMed: 25330017]
• 36. Kakko, J., Svanborg, K. D., Kreek, M. J., & Heilig, M. (2003). 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: A randomised, placebo-controlled trial. Lancet, 361(9358), 662–668. [PubMed: 12606177]
• 37. Sees, K. L., Delucchi, K. L., Masson, C., Rosen, A., Clark, H. W., Robillard, H., … Hall, S. M. (2000). Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: A randomized controlled trial. JAMA, 283(10), 1303–1310. [PubMed: 10714729]
• 38. Weiss, R. D., Potter, J. S., Fiellin, D. A., Byrne, M., Connery, H. S., Dickinson, W., … Ling, W. (2011). Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: A 2-phase randomized controlled trial. Archives of General Psychiatry, 68(12), 1238–1246. [PMC free article: PMC3470422] [PubMed: 22065255]
• 39. Amato, L., Davoli, M., Minozzi, S., Ferroni, E., Ali, R., & Ferri, M. (2013). Methadone at tapered doses for the management of opioid withdrawal. Cochrane Database of Systematic Reviews, 2013(2), 1–68. [PMC free article: PMC7017622] [PubMed: 23450540]
• 40. Bart, G. (2012). Maintenance medication for opiate addiction: The foundation of recovery. Journal of Addictive Diseases, 31(3), 207–225. [PMC free article: PMC3411273] [PubMed: 22873183]
• 41. Fiellin, D. A., Schottenfeld, R. S., Cutter, C. J., Moore, B. A., Barry, D. T., & O'Connor, P. G. (2014). Primary care-based buprenorphine taper vs maintenance therapy for prescription opioid dependence: A randomized clinical trial. JAMA Internal Medicine, 174(12), 1947–1954. [PMC free article: PMC6167926] [PubMed: 25330017]
• 42. White, W. L. (2012). Medication-assisted recovery from opioid addiction: Historical and contemporary perspectives. Journal of Addictive Diseases, 31(3), 199–206. [PubMed: 22873182]
• 43. Substance Abuse and Mental Health Services Administration. (1999). Enhancing motivation for change in substance abuse treatment. Treatment Improvement Protocol (TIP) Series 35. HHS Publication No. (SMA) 13-4212. Rockville, MD: Substance Abuse and Mental Health Services Administration. [PubMed: 22514841]
• 44. McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive behavioral therapy for substance use disorders. Psychiatric Clinics of North America, 33(3), 511–525. [PMC free article: PMC2897895] [PubMed: 20599130]
• 45. Ling, W., Hillhouse, M., Ang, A., Jenkins, J., & Fahey, J. (2013). Comparison of behavioral treatment conditions in buprenorphine maintenance. Addiction, 108(10), 1788–1798. [PMC free article: PMC3866908] [PubMed: 23734858]
• 46. Fiellin, D. A., Barry, D. T., Sullivan, L. E., Cutter, C. J., Moore, B. A., O'Connor, P. G., & Schottenfeld, R. S. (2013). A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. American Journal of Medicine, 126(1), 74.e11– 74.e17. [PMC free article: PMC3621718] [PubMed: 23260506]
• 47. Moore, B. A., Fiellin, D. A., Cutter, C. J., Biondo, F. D., Barry, D. C., Fiellin, L. E., … Schottenfeld, R. S. (2016). Cognitive behavioral therapy improves treatment outcomes for prescription opioid users in primary care buprenorphine treatment. Journal of Substance Abuse Treatment, 71, 54–57. [PMC free article: PMC5119533] [PubMed: 27776678]
• 48. Abbott, P. J. (2010). Case management: Ongoing evaluation of patients' needs in an opioid treatment program. Professional Case Management, 15(3), 145–152. [PubMed: 20467277]
• 49. Morgenstern, J., Neighbors, C. J., Kermis, A., Riordan, A., Blanchard, K. A., McVeigh, K. H., … McCredie, B. (2009). Improving 24-month abstinence and employment outcomes for substance-dependent women receiving temporary assistance for needy families with intensive case management. American Journal of Public Health, 99(2), 328–333. [PMC free article: PMC2622781] [PubMed: 19059855]
• 50. Substance Abuse and Mental Health Services Administration. (2000). Comprehensive case management for substance abuse treatment. Treatment Improvement Protocol (TIP) Series 27. HHS Publication No. (SMA) 15-4215. Rockville, MD: Substance Abuse and Mental Health Services Administration.
• 51. National Institute on Drug Abuse. (2012). Principles of drug addiction treatment: A research-based guide (3rd ed.). NIH Publication No. 12–4180. Bethesda, MD: Author.
• 52. Woo, J., Bhalerao, A., Bawor, M., Bhatt, M., Dennis, B., Mouravska, N., … Samaan, Z. (2017). “Don't judge a book by its cover”: A qualitative study of methadone patients' experiences of stigma. Substance Abuse: Research and Treatment, 11, 1–12. [PMC free article: PMC5398333] [PubMed: 28469424]
• 53. Dugosh, K., Abraham, A., Seymour, B., McLoyd, K., Chalk, M., & Festinger, D. (2016). A systematic review on the use of psychosocial interventions in conjunction with medications for the treatment of opioid addiction. Journal of Addiction Medicine, 10(2), 93–103. [PMC free article: PMC4795974] [PubMed: 26808307]
• 54. Roberts, J., Annett, H., & Hickman, M. (2011). A systematic review of interventions to increase the uptake of opiate substitution therapy in injecting drug users. Journal of Public Health, 33(3), 378–384. [PubMed: 21047870]
• 55. Fiellin, D. A., Barry, D. T., Sullivan, L. E., Cutter, C. J., Moore, B. A., O'Connor, P. G., & Schottenfeld, R. S. (2013). A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. American Journal of Medicine, 126(1), 74.e11–74.e17. [PMC free article: PMC3621718] [PubMed: 23260506]
• 56. Ling, W., Hillhouse, M., Ang, A., Jenkins, J., & Fahey, J. (2013). Comparison of behavioral treatment conditions in buprenorphine maintenance. Addiction, 108(10), 1788–1798. [PMC free article: PMC3866908] [PubMed: 23734858]
• 57. Weiss, R. D., Potter, J. S., Fiellin, D. A., Byrne, M., Connery, H. S., Dickinson, W., … Ling, W. (2011). Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: A 2-phase randomized controlled trial. Archives of General Psychiatry, 68(12), 1238–1246. [PMC free article: PMC3470422] [PubMed: 22065255]
• 58. Ling, W., Hillhouse, M., Ang, A., Jenkins, J., & Fahey, J. (2013). Comparison of behavioral treatment conditions in buprenorphine maintenance. Addiction, 108(10), 1788–1798. [PMC free article: PMC3866908] [PubMed: 23734858]
• 59. National Institute on Drug Abuse. (2012). Principles of drug addiction treatment: A research-based guide (3rd ed.). NIH Publication No. 12–4180. Bethesda, MD: Author.
• 60. Weiss, R. D., Griffin, M. L., Potter, J. S., Dodd, D. R., Dreifuss, J. A., Connery, H. S., & Carroll, K. M. (2014). Who benefits from additional drug counseling among prescription opioid-dependent patients receiving buprenorphine-naloxone and standard medical management? Drug and Alcohol Dependence, 140, 118–122. [PMC free article: PMC4053488] [PubMed: 24831754]
• 61. Connock, M., Juarez-Garcia, A., Jowett, S., Frew, E., Liu, Z., Taylor, R. J., … Taylor, R. S. (2007). Methadone and buprenorphine for the management of opioid dependence: A systematic review and economic evaluation. Health Technology Assessment, 11(9), 1–171, iii–iv. [PubMed: 17313907]
• 62. De Maeyer, J., Vanderplasschen, W., & Broekaert, E. (2010). Quality of life among opiate-dependent individuals: A review of the literature. International Journal on Drug Policy, 21(5), 364–380. [PubMed: 20172706]
• 63. Carpentier, P. J., Krabbe, P. F., van Gogh, M. T., Knapen, L. J., Buitelaar, J. K., & de Jong, C. A. (2009). Psychiatric comorbidity reduces quality of life in chronic methadone maintained patients. American Journal on Addictions, 18(6), 470–480. [PubMed: 19874168]
• 64. Muller, A. E., Skurtveit, S., & Clausen, T. (2016). Many correlates of poor quality of life among substance users entering treatment are not addiction-specific. Health and Quality of Life Outcomes, 14, 1–10. [PMC free article: PMC4778354] [PubMed: 26940259]
• 65. De Maeyer, J., Vanderplasschen, W., & Broekaert, E. (2010). Quality of life among opiate-dependent individuals: A review of the literature. International Journal on Drug Policy, 21(5), 364–380. [PubMed: 20172706]
• 66. Carpentier, P. J., Krabbe, P. F., van Gogh, M. T., Knapen, L. J., Buitelaar, J. K., & de Jong, C. A. (2009). Psychiatric comorbidity reduces quality of life in chronic methadone maintained patients. American Journal on Addictions, 18(6), 470–480. [PubMed: 19874168]
• 67. Fei, J. T. B., Yee, A., Habil, M. H. B., & Danaee, M. (2016). Effectiveness of methadone maintenance therapy and improvement in quality of life following a decade of implementation. Journal of Substance Abuse Treatment, 69, 50–56. [PubMed: 27568510]
• 68. Millson, P., Challacombe, L., Villeneuve, P. J., Strike, C. J., Fischer, B., Myers, T., … Hopkins, S. (2006). Determinants of health-related quality of life of opiate users at entry to low-threshold methadone programs. European Addiction Research, 12(2), 74–82. [PubMed: 16543742]
• 69. Krebs, E., Kerr, T., Wood, E., & Nosyk, B. (2016). Characterizing long-term health related quality of life trajectories of individuals with opioid use disorder. Journal of Substance Abuse Treatment, 67, 30–37. [PMC free article: PMC4908824] [PubMed: 27296659]
• 70. Millson, P., Challacombe, L., Villeneuve, P. J., Strike, C. J., Fischer, B., Myers, T., … Hopkins, S. (2006). Determinants of health-related quality of life of opiate users at entry to low-threshold methadone programs. European Addiction Research, 12(2), 74–82. [PubMed: 16543742]
• 71. De Maeyer, J., Vanderplasschen, W., & Broekaert, E. (2010). Quality of life among opiate-dependent individuals: A review of the literature. International Journal on Drug Policy, 21(5), 364–380. [PubMed: 20172706]
• 72. Muller, A. E., Skurtveit, S., & Clausen, T. (2016). Many correlates of poor quality of life among substance users entering treatment are not addiction-specific. Health and Quality of Life Outcomes, 14, 1–10. [PMC free article: PMC4778354] [PubMed: 26940259]
• 73. Cavaiola, A. A., Fulmer, B. A., & Stout, D. (2015). The impact of social support and attachment style on quality of life and readiness to change in a sample of individuals receiving medication-assisted treatment for opioid dependence. Substance Abuse, 36(2), 183–191. [PubMed: 25839214]
• 74. Millson, P., Challacombe, L., Villeneuve, P. J., Strike, C. J., Fischer, B., Myers, T., … Hopkins, S. (2006). Determinants of health-related quality of life of opiate users at entry to low-threshold methadone programs. European Addiction Research, 12(2), 74–82. [PubMed: 16543742]
• 75. Center for Substance Abuse Treatment. (2007). National Summit on Recovery: Conference report. HHS Publication No. (SMA) 07–4276. Rockville, MD: Substance Abuse and Mental Health Services Administration.
• 76. Substance Abuse and Mental Health Services Administration. (2012). SAMHSA's working definition of recovery. Retrieved November 24, 2017, from https://store​.samhsa​.gov/product/SAMHSA-s-Working-Definition-of-Recovery​/PEP12-RECDEF
• 77. Jackson, L. A., Buxton, J. A., Dingwell, J., Dykeman, M., Gahagan, J., Gallant, K., … Davison, C. (2014). Improving psychosocial health and employment outcomes for individuals receiving methadone treatment: A realist synthesis of what makes interventions work. BMC Psychology, 2, 1–20. [PMC free article: PMC4269989] [PubMed: 25566385]
• 78. Kaplan, L. (2008). The role of recovery support services in recovery-oriented systems of care. HHS Publication No. (SMA) 08-4315. Rockville, MD: Substance Abuse and Mental Health Services Administration.
• 79. White, W. L., & Mojer-Torres, L. (2010). Recovery-oriented methadone maintenance. Retrieved October 23, 2017, from www​.williamwhitepapers​.com/pr/2011%20Bamber-White​%20Dialogue​%20on%20Recovery-Oriented​%20Methadone%20Maintenace.pdf
• 80. Hser, Y. I. (2007). Predicting long-term stable recovery from heroin addiction: Findings from a 33-year follow-up study. Journal of Addictive Diseases, 26(1), 51–60. [PubMed: 17439868]
• 81. Laudet, A. B., & White, W. L. (2008). Recovery capital as prospective predictor of sustained recovery, life satisfaction, and stress among former poly-substance users. Substance Use and Misuse, 43(1), 27–54. [PMC free article: PMC2211734] [PubMed: 18189204]
• 82. Skinner, M. L., Haggerty, K. P., Fleming, C. B., Catalano, R. F., & Gainey, R. R. (2011). Opiate-addicted parents in methadone treatment: Long-term recovery, health, and family relationships. Journal of Addictive Diseases, 30(1), 17–26. [PMC free article: PMC3025601] [PubMed: 21218307]
• 83. Substance Abuse and Mental Health Services Administration. (2016). Person- and family-centered care and peer support. Retrieved October 23, 2017, from www​.samhsa.gov/section-223​/care-coordination​/person-family-centered
• 84. Robinson, J. H., Callister, L. C., Berry, J. A., & Dearing, K. A. (2008). Patient-centered care and adherence: Definitions and applications to improve outcomes. Journal of the American Academy of Nurse Practitioners, 20(12), 600–607. [PubMed: 19120591]
• 85. White, W., & Miller, W. (2007). The use of confrontation in addiction treatment: History, science and time for change. Counselor, 8(4), 12–30.
• 86. Lindgren, B. M., Eklund, M., Melin, Y., & Graneheim, U. H. (2015). From resistance to existence—Experiences of medication-assisted treatment as disclosed by people with opioid dependence. Issues in Mental Health Nursing, 36(12), 963–970. [PubMed: 26735504]
• 87. Stoller, K. B., Stephens, M. A. C., & Schorr, A. (2016). Integrated service delivery models for opioid treatment programs in an era of increasing opioid addiction, health reform, and parity. Retrieved October 23, 2017, from www​.aatod.org/wp-content​/uploads/2016/07/2nd-Whitepaper-.pdf
• 88. Brooner, R. K., King, V. L., Kidorf, M., Schmidt, C. W., Jr., & Bigelow, G. E. (1997). Psychiatric and substance use comorbidity among treatment-seeking opioid abusers. Archives of General Psychiatry, 54(1), 71–80. [PubMed: 9006403]
• 89. Savant, J. D., Barry, D. T., Cutter, C. J., Joy, M. T., Dinh, A., Schottenfeld, R. S., & Fiellin, D. A. (2013). Prevalence of mood and substance use disorders among patients seeking primary care office-based buprenorphine/naloxone treatment. Drug and Alcohol Dependence, 127(1–3), 243–247. [PMC free article: PMC3525769] [PubMed: 22771144]
• 90. Brooner, R. K., Kidorf, M. S., King, V. L., Peirce, J., Neufeld, K., Stoller, K., & Kolodner, K. (2013). Managing psychiatric comorbidity within versus outside of methadone treatment settings: A randomized and controlled evaluation. Addiction, 108(11), 1942–1951. [PMC free article: PMC3833440] [PubMed: 23734943]
• 91. Hser, Y. I., Evans, E., Grella, C., Ling, W., & Anglin, D. (2015). Long-term course of opioid addiction. Harvard Review of Psychiatry, 23(2), 76–89. [PubMed: 25747921]
• 92. Flynn, P. M., Joe, G. W., Broome, K. M., Simpson, D. D., & Brown, B. S. (2003). Recovery from opioid addiction in DATOS. Journal of Substance Abuse Treatment, 25(3), 177–186. [PubMed: 14670523]
• 93. Havassy, B. E., Hall, S. M., & Wasserman, D. A. (1991). Social support and relapse: Commonalities among alcoholics, opiate users, and cigarette smokers. Addictive Behaviors, 16(5), 235–246. [PubMed: 1663695]
• 94. Tuten, M., & Jones, H. E. (2003). A partner's drug-using status impacts women's drug treatment outcome. Drug and Alcohol Dependence, 70(3), 327–330. [PubMed: 12757970]
• 95. Schroeder, J. R., Latkin, C. A., Hoover, D. R., Curry, A. D., Knowlton, A. R., & Celentano, D. D. (2001). Illicit drug use in one's social network and in one's neighborhood predicts individual heroin and cocaine use. Annals of Epidemiology, 11(6), 389–394. [PubMed: 11454498]
• 96. Trocchio, S., Chassler, D., Storbjörk, J., Delucchi, K., Witbrodt, J., & Lundgren, L. (2013). The association between self-reported mental health status and alcohol and drug abstinence 5 years post-assessment for an addiction disorder in U.S. and Swedish samples. Journal of Addictive Diseases, 32(2), 180–193. [PMC free article: PMC3854960] [PubMed: 23815425]
• 97. Kidorf, M., Latkin, C., & Brooner, R. K. (2016). Presence of drug-free family and friends in the personal social networks of people receiving treatment for opioid use disorder. Journal of Substance Abuse Treatment, 70, 87–92. [PMC free article: PMC5117814] [PubMed: 27692194]
• 98. Kidorf, M., Latkin, C., & Brooner, R. K. (2016). Presence of drug-free family and friends in the personal social networks of people receiving treatment for opioid use disorder. Journal of Substance Abuse Treatment, 70, 87–92. [PMC free article: PMC5117814] [PubMed: 27692194]
• 99. Substance Abuse and Mental Health Services Administration. (2014). Improving cultural competence. Treatment Improvement Protocol (TIP) Series 59. HHS Publication No. (SMA) 14-4849. Rockville, MD: Substance Abuse and Mental Health Services Administration. [PubMed: 25356450]
• 100. Substance Abuse and Mental Health Services Administration. (2014). SAMHSA's concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration.
• 101. Kumar, N., Stowe, Z. N., Han, X., & Mancino, M. J. (2016). Impact of early childhood trauma on retention and phase advancement in an outpatient buprenorphine treatment program. American Journal on Addictions, 25(7), 542–548. [PubMed: 27629823]
• 102. Barry, D. T., Beitel, M., Cutter, C. J., Garnet, B., Joshi, D., Rosenblum, A., & Schottenfeld, R. S. (2011). Exploring relations among traumatic, posttraumatic, and physical pain experiences in methadone-maintained patients. Journal of Pain, 12(1), 22–28. [PMC free article: PMC2962776] [PubMed: 20646965]
• 103. Sansone, R. A., Whitecar, P., & Wiederman, M. W. (2009). The prevalence of childhood trauma among those seeking buprenorphine treatment. Journal of Addictive Disorders, 28(1), 64–67. [PubMed: 19197597]
• 104. Lawson, K. M., Back, S. E., Hartwell, K. J., Moran-Santa, M. M., & Brady, K. T. (2013). A comparison of trauma profiles among individuals with prescription opioid, nicotine, or cocaine dependence. American Journal of Addiction, 22(2), 127–131. [PMC free article: PMC3681508] [PubMed: 23414497]
• 105. Jessell, L., Mateu-Gelabert, P., Guarino, H., Vakharia, S. P., Syckes, C., Goodbody, E., … Friedman, S. (2017). Sexual violence in the context of drug use among young adult opioid users in New York City. Journal of Interpersonal Violence, 32(19), 2885–2907. [PMC free article: PMC4740284] [PubMed: 26240068]
• 106. Amaro, H., Dai, J., Arévalo, S., Acevedo, A., Matsumoto, A., Nieves, R., & Prado, G. (2007). Effects of integrated trauma treatment on outcomes in a racially/ethnically diverse sample of women in urban community-based substance abuse treatment. Journal of Urban Health, 84(4), 508–522. [PMC free article: PMC2219564] [PubMed: 17356904]
• 107. Volkow, N. D., Koob, G. F., & McLellan, A. T. (2016). Neurobiologic advances from the brain disease model of addiction. New England Journal of Medicine, 374(4), 363–371. [PMC free article: PMC6135257] [PubMed: 26816013]
• 108. Edelman, E. J., Chantarat, T., Caffrey, S., Chaudhry, A., O'Connor, P. G., Weiss, L., … Fiellin, L. E. (2014). The impact of buprenorphine/naloxone treatment on HIV risk behaviors among HIV-infected, opioid-dependent patients. Drug and Alcohol Dependence, 139, 79–85. [PMC free article: PMC4029496] [PubMed: 24726429]
• 109. Gibson, A., Degenhardt, L., Mattick, R. P., Ali, R., White, J., & O'Brien, S. (2008). Exposure to opioid maintenance treatment reduces long-term mortality. Addiction, 103(3), 462–468. [PubMed: 18190664]
• 110. Rosenthal, R. N., Ling, W., Casadonte, P., Vocci, F., Bailey, G. L., Kampman, K., … Beebe, K. L. (2013). Buprenorphine implants for treatment of opioid dependence: Randomized comparison to placebo and sublingual buprenorphine/naloxone. Addiction, 108(12), 2141–2149. [PMC free article: PMC4669043] [PubMed: 23919595]
• 111. Sullivan, L. E., Moore, B. A., Chawarski, M. C., Pantalon, M. V., Barry, D., O'Connor, P. G., … Fiellin, D. A. (2008). Buprenorphine/naloxone treatment in primary care is associated with decreased human immunodeficiency virus risk behaviors. Journal of Substance Abuse Treatment, 35(1), 87–92. [PMC free article: PMC2587397] [PubMed: 17933486]
• 112. Substance Abuse and Mental Health Services Administration. (2016). Buprenorphine. Retrieved October 23, 2017, from www​.samhsa.gov/medication-assisted-treatment​/treatment/buprenorphine
• 113. Lovegrove, M. C., Mathew, J., Hampp, C., Governale, L., Wysowski, D. K., & Budnitz, D. S. (2014). Emergency hospitalizations for unsupervised prescription medication ingestions by young children. Pediatrics, 134(4), e1009–e1016. [PMC free article: PMC4651431] [PubMed: 25225137]
• 114. Hakkinen, M., Launiainen, T., Vuori, E., & Ojanpera, I. (2012). Benzodiazepines and alcohol are associated with cases of fatal buprenorphine poisoning. European Journal of Clinical Pharmacology, 68(3), 301–309. [PubMed: 21927835]
• 115. Schuman-Olivier, Z., Hoeppner, B. B., Weiss, R. D., Borodovsky, J., Shaffer, H. J., & Albanese, M. J. (2013). Benzodiazepine use during buprenorphine treatment for opioid dependence: Clinical and safety outcomes. Drug and Alcohol Dependence, 132(3), 580–586. [PMC free article: PMC3916951] [PubMed: 23688843]
• 116. Department of Health and Human Services. (2021, April 28). Practice guidelines for the administration of buprenorphine for treating opioid use disorder. HHS Notice, 86 Fed. Reg. 22439. Retrieved April 28, 2021, from www​.federalregister.gov​/documents/2021/04​/28/2021-08961/practice-guidelines-for-the-administration-of-buprenorphine-for-treating-opioid-use-disorder#:~:text​=The​%20Practice%20Guidelines​%20for%20the%20Administration​%20of%20Buprenorphine,training​%2C%20counseling%20and​%20other%20ancillary​%20services%20%28i.e%20
• 117. Fullerton, C. A., Kim, M., Thomas, C. P., Lyman, D. R., Montejano, L. B., Dougherty, R. H., … Delphin-Rittmon, M. E. (2014). Medication-assisted treatment with methadone: Assessing the evidence. Psychiatric Services, 65(2), 146–157. [PubMed: 24248468]
• 118. Gibson, A., Degenhardt, L., Mattick, R. P., Ali, R., White, J., & O'Brien, S. (2008). Exposure to opioid maintenance treatment reduces long-term mortality. Addiction, 103(3), 462–468. [PubMed: 18190664]
• 119. Gowing, L. R., Farrell, M., Bornemann, R., Sullivan, L. E., & Ali, R. L. (2006). Brief report: Methadone treatment of injecting opioid users for prevention of HIV infection. Journal of General Internal Medicine, 21(2), 193–195. [PMC free article: PMC1484643] [PubMed: 16336624]
• 120. Lee, J. D., Friedmann, P. D., Kinlock, T. W., Nunes, E. V., Boney, T. Y., Hoskinson, R. A., Jr., … O'Brien, C. P. (2016). Extended-release naltrexone to prevent opioid relapse in criminal justice offenders. New England Journal of Medicine, 374(13), 1232–1242. [PMC free article: PMC5454800] [PubMed: 27028913]
• 121. Merlo, L. J., Greene, W. M., & Pomm, R. (2011). Mandatory naltrexone treatment prevents relapse among opiate-dependent anesthesiologists returning to practice. Journal of Addiction Medicine, 5(4), 279–283. [PMC free article: PMC3223377] [PubMed: 22107877]
• 122. Washton, A. M., Gold, M. S., & Pottash, A. C. (1984). Successful use of naltrexone in addicted physicians and business executives. Advances in Alcohol and Substance Abuse, 4(2), 89–96. [PubMed: 6524509]
• 123. Minozzi, S., Amato, L., Vecchi, S., Davoli, M., Kirchmayer, U., & Verster, A. (2011). Oral naltrexone maintenance treatment for opioid dependence. Cochrane Database of Systematic Reviews, 2011(4), 1–45. [PMC free article: PMC7045778] [PubMed: 21491383]
• 124. Cornish, J. W., Metzger, D., Woody, G. E., Wilson, D., McLellan, A. T., Vandergrift, B., & O'Brien, C. (1997). Naltrexone pharmacotherapy for opioid dependent federal probationers. Journal of Substance Abuse Treatment, 14(6), 529–534. [PubMed: 9437624]
• 125. Minozzi, S., Amato, L., Vecchi, S., Davoli, M., Kirchmayer, U., & Verster, A. (2011). Oral naltrexone maintenance treatment for opioid dependence. Cochrane Database of Systematic Reviews, 2011(4), 1–45. [PMC free article: PMC7045778] [PubMed: 21491383]
• 126. Merlo, L. J., Greene, W. M., & Pomm, R. (2011). Mandatory naltrexone treatment prevents relapse among opiate-dependent anesthesiologists returning to practice. Journal of Addiction Medicine, 5(4), 279–283. [PMC free article: PMC3223377] [PubMed: 22107877]
• 127. Substance Abuse and Mental Health Services Administration. (2016). Medication-assisted treatment of opioid use disorder pocket guide. HHS No. (SMA) 16-4892PG. Rockville, MD: Substance Abuse and Mental Health Services Administration.
• 128. Faggiano, F., Vigna-Taglianti, F., Versino, E., & Lemma, P. (2003). Methadone maintenance at different dosages for opioid dependence. Cochrane Database of Systematic Reviews, 2003(3), 1–45. [PubMed: 12917925]
• 129. Fareed, A., Casarella, J., Amar, R., Vayalapalli, S., & Drexler, K. (2010). Methadone maintenance dosing guideline for opioid dependence, a literature review. Journal of Addictive Diseases, 29(1), 1–14. [PubMed: 20390694]
• 130. Substance Abuse and Mental Health Services Administration. (2015). Clinical use of extended-release injectable naltrexone in the treatment of opioid use disorder: A brief guide. HHS Publication No. (SMA) 14-4892R. Rockville, MD: Substance Abuse and Mental Health Services Administration.
• 131. National Library of Medicine. (2015). VIVITROL – naltrexone. Retrieved October 23, 2017, from https://dailymed​.nlm​.nih.gov/dailymed/drugInfo​.cfm?setid=cd11c435-b0f0-4bb9-ae78-60f101f3703f
• 132. Fiellin, D. A., Schottenfeld, R. S., Cutter, C. J., Moore, B. A., Barry, D. T., & O'Connor, P. G. (2014). Primary care-based buprenorphine taper vs maintenance therapy for prescription opioid dependence: A randomized clinical trial. JAMA Internal Medicine, 174(12), 1947–1954. [PMC free article: PMC6167926] [PubMed: 25330017]
• 133. Kakko, J., Svanborg, K. D., Kreek, M. J., & Heilig, M. (2003, February 22). 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: A randomised, placebo-controlled trial. Lancet, 361(9358), 662–668. [PubMed: 12606177]
• 134. Sees, K. L., Delucchi, K. L., Masson, C., Rosen, A., Clark, H. W., Robillard, H., … Hall, S. M. (2000). Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: A randomized controlled trial. JAMA, 283(10), 1303–1310. [PubMed: 10714729]
• 135. Weiss, R. D., Potter, J. S., Fiellin, D. A., Byrne, M., Connery, H. S., Dickinson, W., … Ling, W. (2011). Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: A 2-phase randomized controlled trial. Archives of General Psychiatry, 68(12), 1238–1246. [PMC free article: PMC3470422] [PubMed: 22065255]
• 136. Confidentiality of Substance Use Disorder Patient Records; HHS Final Rule, 82 Fed. Reg. 6052 (January 18, 2017) (to be codified at 42 CFR pt. 2). Retrieved November 13, 2017, from www​.federalregister.gov​/documents/2017/01​/18/2017-00719/confidentiality-of-substance-use-disorder-patient-records
• 137. Jost, T. S. (2006). Appendix B: Constraints on sharing mental health and substance-use treatment information imposed by federal and state medical records privacy laws. In Institute of Medicine (US) Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders, Improving the quality of healthcare for mental and substance-use conditions. Quality Chasm Series. Washington, DC: National Academies Press. Retrieved January 3, 2018, from www​.ncbi.nlm.nih.gov/books/NBK19829 [PubMed: 20669433]
• 138. Coviello, D. M., Zanis, D. A., Wesnoski, S. A., & Alterman, A. I. (2006). The effectiveness of outreach case management in re-enrolling discharged methadone patients. Drug and Alcohol Dependence, 85(1), 56–65. [PubMed: 16675163]
• 139. Goldstein, M. F., Deren, S., Kang, S. Y., Des Jarlais, D. C., & Magura, S. (2002). Evaluation of an alternative program for MMTP drop-outs: Impact on treatment re-entry. Drug and Alcohol Dependence, 66(2), 181–187. [PubMed: 11906805]
• 140. Duncan, B. (2010). On becoming a better therapist. Psychotherapy in Australia, 16(4), 42–51.
• 141. Wampold, B. E. (2011). Qualities and actions of effective therapists.
• 142. American Medical Association. (2017). End the epidemic. Retrieved October 23, 2017, from https:​//end-overdose-epidemic.org/
• 143. Kampman, K., & Jarvis, M. (2015). 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, 9(5), 358–367. [PMC free article: PMC4605275] [PubMed: 26406300]
• 144. National Institute on Drug Abuse. (n.d.). Effective treatments for opioid addiction. Retrieved October 23, 2017, from www​.drugabuse.gov/publications​/effective-treatments-opioid-addiction​/effective-treatments-opioid-addiction
• 145. Office of the Surgeon General. (2016). Facing addiction in America: The Surgeon General's report on alcohol, drugs, and health. Washington, DC: Department of Health and Human Services. [PubMed: 28252892]
• 146. Carter, A., & Hall, W. (2007). The ethical use of psychosocially assisted pharmacological treatments for opioid dependence. Geneva, Switzerland: WHO Press.
• 147. Equal Employment Opportunity Commission. (1992). A technical assistance manual on the employment provisions (Title I) of the Americans with Disabilities Act. Washington, DC: Author.
• 148. Friedmann, P. D., Hoskinson, R., Gordon, M., Schwartz, R., Kinlock, T., Knight, K., … Frisman, L. K. (2012). Medication-assisted treatment in criminal justice agencies affiliated with the Criminal Justice-Drug Abuse Treatment Studies (CJ-DATS): Availability, barriers & intentions. Substance Abuse, 33(1), 9–18. [PMC free article: PMC3295578] [PubMed: 22263709]
• 149. Legal Action Center. (2011). Legality of denying access to medication assisted treatment in the criminal justice system. Retrieved October 23, 2017, from www​.lac.org/assets/files​/MAT_Report_FINAL_12-1-2011.pdf
• 150. World Health Organization. (2009). Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva, Switzerland: WHO Press. [PubMed: 23762965]
• 151. Soyka, M., Träder, A., Klotsche, J., Haberthür, A., Bühringer, G., Rehm, J., & Wittchen, H. U. (2012). Criminal behavior in opioid-dependent patients before and during maintenance therapy: 6-year follow-up of a nationally representative cohort sample. Journal of Forensic Sciences, 57(6), 1524–1530. [PubMed: 22845057]
• 152. Substance Abuse and Mental Health Services Administration. (2016). A collaborative approach to the treatment of pregnant women with opioid use disorders. HHS Publication No. (SMA) 16-4978. Rockville, MD: Substance Abuse and Mental Health Services Administration.
• 153. Donovan, D. M., Ingalsbe, M. H., Benbow, J., & Daley, D. C. (2013). 12-step interventions and mutual support programs for substance use disorders: An overview. Social Work in Public Health, 28(3–4), 313–332. [PMC free article: PMC3753023] [PubMed: 23731422]
• 154. Humphreys, K., Blodgett, J. C., & Wagner, T. H. (2014). Estimating the efficacy of Alcoholics Anonymous without self-selection bias: An instrumental variables re-analysis of randomized clinical trials. Alcoholism: Clinical and Experimental Research, 38(11), 2688–2694. [PMC free article: PMC4285560] [PubMed: 25421504]
• 155. McCrady, B. S., & Tonigan, S. (2014). Recent research into twelve-step programs. In R. K. Ries, D. A. Fiellin, S. C. Miller, & R. Saitz (Eds.), The ASAM principles of addiction medicine (pp. 1043–1059). Philadelphia, PA: Wolters Kluwer.
• 156. Crape, B. L., Latkin, C. A., Laris, A. S., & Knowlton, A. R. (2002). The effects of sponsorship in 12-step treatment of injection drug users. Drug and Alcohol Dependence, 65(3), 291–301. [PubMed: 11841900]
• 157. Monico, L. B., Gryczynski, J., Mitchell, S. G., Schwartz, R. P., O'Grady, K. E., & Jaffe, J. H. (2015). Buprenorphine treatment and 12-step meeting attendance: Conflicts, compatibilities, and patient outcomes. Journal of Substance Abuse Treatment, 57, 89–95. [PMC free article: PMC4560966] [PubMed: 25986647]
• 158. Gossop, M., Stewart, D., & Marsden, J. (2008). Attendance at Narcotics Anonymous and Alcoholics Anonymous meetings, frequency of attendance and substance use outcomes after residential treatment for drug dependence: A 5-year follow-up study. Addiction, 103(1), 119–125. [PubMed: 18028521]
• 159. Parran, T. V., Adelman, C. A., Merkin, B., Pagano, M. E., Defranco, R., Ionescu, R. A., & Mace, A. G. (2010). Long-term outcomes of office-based buprenorphine/naloxone maintenance therapy. Drug and Alcohol Dependence, 106(1), 56–60. [PMC free article: PMC3263699] [PubMed: 19717249]
• 160. Narcotics Anonymous World Services. (2016). Narcotics Anonymous and persons receiving medication-assisted treatment. Chatsworth, CA: Author.
• 161. Monico, L. B., Gryczynski, J., Mitchell, S. G., Schwartz, R. P., O'Grady, K. E., & Jaffe, J. H. (2015). Buprenorphine treatment and 12-step meeting attendance: Conflicts, compatibilities, and patient outcomes. Journal of Substance Abuse Treatment, 57, 89–95. [PMC free article: PMC4560966] [PubMed: 25986647]
• 162. White, W., Galanter, M., Humphreys, K., & Kelly, J. (2016). The paucity of attention to Narcotics Anonymous in current public, professional, and policy responses to rising opioid addiction. Alcoholism Treatment Quarterly, 34(4), 437–462.
• 163. Kelly, J. F., Greene, M. C., & Bergman, B. G. (2014). Do drug-dependent patients attending Alcoholics Anonymous rather than Narcotics Anonymous do as well? A prospective, lagged, matching analysis. Alcohol and Alcoholism, 49(6), 645–653. [PMC free article: PMC4849344] [PubMed: 25294352]
• 164. Substance Abuse and Mental Health Services Administration. (2015). Using technology-based therapeutic tools in behavioral health services. Treatment Improvement Protocol (TIP) Series 60. HHS Publication No. (SMA) 15-4924. Rockville, MD: Substance Abuse and Mental Health Services Administration. [PubMed: 26889536]
• 165. White, W. L. (2011). Narcotics Anonymous and the pharmacotherapeutic treatment of opioid addiction in the United States. Chicago, IL: Great Lakes Addiction Technology Transfer Center and Philadelphia Department of Behavioral Health and Intellectual Disability Services.
• 166. White, W., Galanter, M., Humphreys, K., & Kelly, J. (2016). The paucity of attention to Narcotics Anonymous in current public, professional, and policy responses to rising opioid addiction. Alcoholism Treatment Quarterly, 34(4), 437–462.
• 167. Ginter, W. (2012). Methadone Anonymous and mutual support for medication-assisted recovery. Journal of Groups in Addiction and Recovery, 7(2–4), 189–201.
• 168. Ronel, N., Gueta, K., Abramsohn, Y., Caspi, N., & Adelson, M. (2011). Can a 12-step program work in methadone maintenance treatment? International Journal of Offender Therapy and Comparative Criminology, 55(7), 1135–1153. [PubMed: 20921264]
• 169. Glickman, L., Galanter, M., Dermatis, H., Dingle, S., & Hall, L. (2004). Pathways to recovery: Adapting 12-step recovery to methadone treatment. Journal of Maintenance in the Addictions, 2(4), 77–90.
• 170. Palis, H., Marchand, K., Peng, D., Fikowski, J., Harrison, S., Spittal, P., … Oviedo-Joekes, E. (2016). Factors associated with perceived abuse in the health care system among long-term opioid users: A cross-sectional study. Substance Use and Misuse, 51(6), 763–776. [PubMed: 27096889]