February 6, 2018

Direct providership by American Academy of Addiction Psychiatry

Kenneth M. Carpenter, Ph.D. | Columbia University Medical Center, New York, NY, Center for Motivation and Change, New York, NY

Nicole Kosanke, Ph.D. | Center for Motivation and Change, New York, NY

View the Module

Module Description
NOTE: This module has been updated and is being re-released with new information and sources. The module also includes an audio option with Dr. Carpenter and Dr. Kosanke’s recording of their presentation.

This module provides an overview of four principles that may play an important role in facilitating behavior change among substance dependent individuals.  The combination of psychosocial and medication assisted treatment protocols can provide an additive benefit to individuals striving to alter their substance use. Empirically supported treatments vary in their theoretical orientation and the emphasis they place on specific dimensions of change.  Developing a psychosocial treatment plan that addresses these four domains (i.e. coping skills, competing reinforcers, how individuals talk about their change plan, and utilizing social supports)  can enhance the overall effectiveness of a medication assisted protocol.  This module also outlines the Community Reinforcement and Family Training (CRAFT) approach to treatment, a particularly effective framework for engaging family members in the treatment process.

Educational Objectives
At the conclusion of this activity participants should be able to:

  • Identify the importance of evidenced based practices for substance use disorders.
  • Identify four key components of a behavioral treatment protocol.
  • Provide examples for each of the four components.
  • Describe the basic tenets of the Community Reinforcement and Family Training approach. 

A Small Group Discussion with Drs. Carpenter and Kosanke was held on March 26, 2018.  The following is a synopsis of some of the questions asked and the responses given during the discussion:

  • Can the same provider implement both a behavioral treatment protocol and MAT at the same time?

ANSWER:  Yes. The four components of a behavioral protocol (skill building and practice, introducing alternative reinforcers, having clinical conversations in an Motivational Interviewing style, and building social supports), can be implemented by the same treatment provider and within the same treatment context that a MAT protocol is being utilized. For example, a Motivational Interviewing stance (and conversational strategies) can be utilized in conversations about medication adherence and address ambivalence a patient may have about their behavioral change plans. In addition, it can be useful to check-in with patients about high-risk situations they may come into contact with between appointments and spend some moments problem solving about ways to handle these situations. In addition, discussing strategies for coping with cravings and urges can be a helpful conversation. It can be also useful to ask patients to outline and record their goals in between sessions and checking back in with them at the next appointment.

  • Should patients in MAT treatment be required to participate in behavioral health treatment?

ANSWER: There is evidence to suggest utility in adding a psychosocial intervention in conjunction with MAT. However, the specific structure of the behavioral treatment plan can look different. Many controlled studies of Buprenorphine maintenance include structured and weekly Medication Management sessions that can explicitly discuss issues around adherence and addressing barriers to adhering to a change plan. Structured medication management protocols are rarely utilized in many medical settings, although can be an active component in the change process. Further, other factors such as high levels of opiate use at the time of seeking treatment, polydrug use, psychiatric distress, and continued opiate use in the context of MAT over time may be important indicators that augmenting MAT with a behavioral treatment platform would be beneficial to the patient. From a motivational standpoint, requiring participation in a behavioral health protocol should not serve as a barrier to initiating a MAT protocol. Addressing a patient’s ambivalence around a behavioral treatment component could be a topic to address within a regularly scheduled, structured medication management sessions with the goal of having a patient decide that the benefits of having more support and a skills oriented component can outweigh the cons.

  • How can patients with limited social support be assisted in a MAT framework?

ANSWER: Evidence suggests that including family members in the treatment process confers a better prognosis. This involvement has included family members just attending 1 or 2 counseling sessions to discuss the concerns they may have and ways they can support the patient’s change plan. It can also involve family members attending CRAFT sessions to learn a range of skills and strategies to support the patient’s change process. For patients with limited social support building a supportive structure is critical. Counseling sessions can incorporate elements of a 12-step facilitation https://www.drugabuse.gov/publications/principles-drug-addiction-treatment/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapies protocol to help patient’s connect with a social support system. The SAMSHA website findtreatment.samsha.gov offers links to various peer-to-peer and self-help groups which can be an important component for improving long term outcomes. It is important to discuss the types of peer support groups with the patient and check-in with the patient’s experiences while attending these meetings. The messaging around MAT is not always consistent across groups and patients may receive mixed messages (e.g. MAT is not being in recovery; is not the proper way to change). Thus, regularly checking in with the patient can correct any misinformation and help prepare them with communication strategies to respond to treatment-interfering messages.

Accreditation Statement 
American Academy of Addiction Psychiatry (AAAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Designation Statement
American Academy of Addiction Psychiatry (AAAP) designates this enduring material for a maximum of 1.5 (one and one-half) AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

PA Accreditation
AAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. PAs may receive a maximum of 1.5 Category 1 credits for completing this activity.

Method of participation in the learning process
In order to receive a maximum of 1.5 AMA PRA Category 1 Credit™, participants must participate in the entire module, answer post-test questions, pass with a 70% pass rate and complete an evaluation at the end of the activity.