In our treatment centers across the country, we support people with a wide variety of substance use disorders and co-occurring disorders. Patients who participate in our treatment programs may have developed the disordered use of the following types of substances:
- Depressants, including:
- Other sedatives
- Psychoactive drugs, including:
- Amphetamines, including:
Some of those substances belong to more than one category, but they all have one thing in common: they’re associated with a risk of misuse that can escalate to disordered use. We intentionally left one type of substance off this list, because it’s the subject of this article: opioids. Many or our patients meet the clinical criteria for opioid use disorder (OUD), which is a significant public health problem in the U.S. right now.
Most people know we’re in the midst of an epidemic of drug overdose fueled by the misuse and disordered use of opioids. Over the past twenty years, rates of overdose and addiction for all opioid related drugs have skyrocketed, creating what we now call the opioid crisis. To learn more about the opioid crisis, please read the following articles on our blog:
This article will discuss the gold-standard treatment for OUD, which is medication-assisted treatment, or MAT. When an intake evaluation indicates a new patient may benefit from MAT, we many recommend initiating MAT with a medication called buprenorphine.
But we’re getting ahead of ourselves: first, let’s talk about MAT in general, and how it helps people with OUD.
What is Medication-Assisted Treatment?
In simple terms, medication-assisted treatment, known as MAT, is a type of substance use disorder treatment that includes medication as a primary component at some point during the treatment process. MAT can be short-term, and only used during detoxification phase of treatment. In some case, MAT is a transition phase between active use and total abstinence. In other cases, MAT is the primary component of a long-term recovery plan.
The way MAT is used depends on the individual, the substance of misuse or disordered use, and the goals for treatment as determined by each patient, in collaboration with their treatment team. The type of MAT we discuss in this article is long-term MAT for people with opioid use disorder using the medication buprenorphine.
Before we continue, we’ll share the definition of MAT as published by the Substance Abuse and Mental Health Services Administration (SAMHSA), because two parts of their definition are important to the subject of our discussion in this article:
“Medication-assisted treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders. Medications used in MAT are approved by the Food and Drug Administration (FDA) and MAT programs are clinically driven and tailored to meet each patient’s needs.”
The two parts of this SAMHSA definition relevant to our discussion are in combination with counseling and behavioral therapies and programs are clinically driven and tailored to meet each patient’s needs. They’re important because evidence shows that time-in-treatment – especially MAT program with buprenorphine – has a direct impact on treatment outcomes.
More time-in-treatment typically leads to more favorable outcomes than less time-in-treatment. Tailoring the type and amount of therapy is similar: more immersive therapy and counseling typically lead to more favorable outcomes than less time in treatment.
However, there’s not a wide base of evidence that examines how these components interact in the context of MAT with buprenorphine. That’s why a study published in the Journal of Substance Abuse Treatment in March 2022 got our attention.
The Effect of Therapy on Treatment Adherence: About the Study
The paper “Psychosocial And Behavioral Therapy in Conjunction With Medication For Opioid Use Disorder: Patterns, Predictors, and Association With Buprenorphine Treatment Outcome” fills a void in research on the interaction between psychosocial/behavioral therapy and time-in-treatment for people with OUD in MAT programs with buprenorphine.
Here’s how the research team describes the situation, and the need for their work:
“Current evidence indicates that buprenorphine is a highly effective treatment for opioid use disorder (OUD), though premature medication discontinuation is common. Research on concurrent psychosocial and behavioral therapy services and related outcomes is limited.”
Translation: the research team recognized a need to add to our knowledge about whether therapy – psychotherapy or behavioral therapy – affected time-in-treatment and overall treatment outcomes for people in buprenorphine-based MAT programs. To explore this topic, the research team defined three clear goals for the study. They sought to:
- Define patterns of psychosocial and behavioral therapy services patients in MAT programs for OUD received in the first 6 months after initiating treatment with buprenorphine
- Identify the characteristics associated with the patterns defined in goal #1
- Examine common patterns of buprenorphine treatment, with a focus on the relationship between behavioral and psychosocial therapy and treatment duration
The overall idea here is that the more we know about the factors that keep people in treatment, the better providers can tailor treatment plans to emphasize those factors and improve outcomes.
Here’s how they conducted the study:
- Researchers examined publicly available data from Medicaid insurance claims for a five-year period, 2013-2018
- Claims included 61,076 patients 18-64 years old
- All patients initiated an MAT program with buprenorphine
- Patients stayed in treatment for at least 7 days
- Researchers followed claim data for 180 days – 6 months – to determine:
- Therapeutic services used
- Treatment adherence (time-in-treatment)
- Researchers compared treatment services used and treatment adherence to identify any stable patterns
Now let’s take a look at the results.
Did Therapy Increase Time-in-Treatment?
After collecting claim information using the database Marketscan Multistate Medicaid Database and applying advanced statistical analysis to the data, researchers reported several findings that confirmed what many treatment professionals know from firsthand experience, and several others that were somewhat surprising.
Here’s what they found.
Treatment Trajectories, Treatment Adherence, and The Effect of Therapy
- Patients in MAT programs followed three primary trajectories:
- No therapy: 73.8%
- Low-intensity therapy: 17.2%
- High-intensity therapy: 9.0%
- Patient characteristics associated with the three trajectories:
- No therapy:
- Records showed patients in this group had fewer co-occurring mental health disorders
- Records showed patients in this group had fewer previous claims for overdose-related services
- Low-intensity therapy:
- Records indicated presence of higher rates of co-occurring disorders in this group, compared to the no therapy group
- Records indicated a higher rate of claims for overdose-related health services in this group, compared to the no therapy group
- High-intensity therapy:
- Records indicated higher rates of co-occurring disorders for this group, compared to patients in the no therapy group
- Records indicated higher rates of claims for overdose-related health services for this group, compared to patients in the no therapy group
- Effect on treatment adherence, a.k.a. time-in-treatment:
- Patients who did not engage in therapy had the highest risk of discontinuing treatment before six months
- Among patients who engaged in therapy, those in the low-intensity group showed the lowest risk of discontinuing treatment before six months
- Patients in the high-intensity group showed higher risk of discontinuing treatment than patients in the low-intensity group
- Other relevant findings:
- Patients in the high-intensity group showed:
- Increased risk of opioid-related health care events during treatment
- Increased risk of opioid overdose during treatment
- Patients in both therapy groups – low- and high-intensity – showed higher rates of polysubstance misuse, including cannabis and stimulants
- Patients in the high-intensity group showed:
- No therapy:
As we mention above, those results confirm what most treatment professionals know and understand: therapy increases likelihood of treatment retention for people in buprenorphine-based MAT programs.
However, there are elements of this data set that were surprising, which we should discuss.
The Results: Unexpected Outcomes in One Group of Patients
Specifically, we should talk about the results related to patients in the high-intensity therapy group.
These patients had a higher risk of discontinuing treatment, higher risk of opioid-related medical problems during treatment, and higher risk of opioid overdose during treatment. These phenomena are related to another component of the data: the increased prevalence of co-occurring mental health disorders and polysubstance misuse among patients in the high-intensity group. What this data tells us is that patients with this specific array of disorders – OUD, co-occurring mental health disorders, and polysubstance misuse – are at increased risk of adverse events during the course of their MAT program, and therefore may benefit from intentional, targeted therapy and support that follows the integrated treatment model.
That’s important for researchers and treatment professionals to know. For researchers, it can inform future avenues of research. For treatment professionals, it can help tailer treatment programs to meet the specific needs of these high-risk patients.
That brings us to a related topic we have not yet discussed: what kinds of therapy are typically included in MAT programs?
We’ll answer that question now.
Therapy During MAT: Primary Modes and Methods
As defined by SAMHSA, an MAT program includes a combination of medication, counseling, and behavioral therapies. The goal of MAT is to provide a holistic, whole-patient approach to treating OUD. Evidence shows the best way to provide this type of treatment is with the intentional application of the integrated model of treatment.
To learn more about integrated treatment, please click the link above, or navigate to our blog and read this article:
The integrated treatment model includes a wide range of support for people in treatment for OUD, which that article describes in detail. What we want to share now is not the entire integrated treatment picture, but rather the components of integrated treatment – behavioral therapy and psychotherapy – discussed in the research study we explored above.
Here are the most common modes of behavioral therapy and psychotherapy associated with SUD treatment in general, and with MAT programs for people with OUD in particular:
- Cognitive-Behavioral Therapy (CBT)
- Dialectical Behavior Therapy (DBT)
- Acceptance and Commitment Therapy (ACT)
- Motivational Interviewing (MI)
- Mindfulness-Based Cognitive Therapy (MBCT)
- Trauma-informedCBT, DBT, ACT, MI, and MBCBT
Most people associate these types of therapy with mental health disorders like depression or anxiety, because those are the types of disorders clinicians use these to treat. However, these techniques are essential in SUD treatment for two reasons. First, people with co-occurring disorders might have a mental health disorder such as depression or anxiety. Second, people with SUD benefit by exploring many of the same emotional and behavioral topics people with co-occurring disorders explore.
How These Therapies Help People in SUD Treatment
The primary goals of cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) for SUD treatment are to connect patterns of thought and emotions with patterns of behavior, and learn how those patterns impact the disordered use of substances. Whereas CBT focuses on the connection between patterns of thought and emotion, DBT focuses on the connection between patterns of emotion and patterns of behavior, while emphasizing distress tolerance skills and teaching patients skills to manage challenging situations.
On the other hand, acceptance and commitment therapy (ACT) and motivational interviewing (MI) work to help patients decide what they want and create a clear plan of action to achieve goals they determine themselves.
Mindfulness-based cognitive therapy uses CBT techniques and skills and adds components of meditation and mindful awareness to help patients achieve balance, recognize automatic responses to certain situations, and manage difficult symptoms associated with both SUD and any co-occurring disorders.
When any of these therapies are called trauma-informed, that means the clinician providing the therapy has undergone extensive training – and often pursued additional licensure and accreditation – in the various significant ways trauma can impact both the course of a substance use and/or mental health disorder and the specific treatment needs associated with that disorder. In some cases, what works for one person with SUD may not help person with SUD and a history of trauma: it’s critical for a therapist to recognize these distinctions and implement appropriate treatment techniques.
The research we discuss in this article helps us understand how we can tailor treatment to increase time-in-treatment, because we know that for people in buprenorphine-based MAT programs, outcomes improve with greater treatment adherence. This new information can help us use therapy to keep patients engaged in recovery: for people with OUD, that can mean the difference between life and death.