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 Counseling for Medication Assisted Recovery: Tools and Tips

by Gary Blanchard, MA, LADC1 - for Paradigm Magazine

For years, addiction treatment was provided in dedicated treatment programs; medication was not a usual component of treatment. With the recent introduction of medications like Suboxone and Vivitrol for opiate dependence and now Campral and Vivitrol for alcohol dependence, treatment has begun to shift from dedicated addiction treatment facilities to the physician’s office. This shift presents new challenges to addiction treatment professionals.

Traditionally, there is very strong sentiment that those engaged in medication-assisted recovery  (MAR) programs are “not really in recovery.” This attitude can be seen in professional treatment as well as in the self-help community. One of the first things that we, as addiction treatment professionals, need to ask ourselves is whether we accept, or can accept, the premise of MAR. As newer medications are placed on the market, more people will opt for this approach. If a clinician is able to change his or her attitude to accept that medication can play a role in recovery, he or she is in a position to have a tremendous impact. If the clinican is not able to accept MAR then he or she is best to concentrate on working within the drug-free treatment community and to continue to have an impact there.

A frequent criticism of MAR is that the client is simply exchanging one drug for another. This is true of some medications that are being used at this time; some of the newer medications, however, especially those still in development and testing, are focused on balancing brain chemistry rather than preventing withdrawal and craving. In any case, the use of medication may be the best way to first bring a person into the recovery process. There is no wrong door to the treatment process.

Fear of withdrawal and its physical effects is a prime motivator for continued use of mood-altering substances even after the negative consequences of use outweigh any benefit that the drug provides. For many, the idea that a prescribed medication can eliminate the need to use illicit drugs is enough to bring them into treatment. If, in becoming involved in a MAR program, they are also exposed to the idea that continued recovery also requires work, skills, and support, the person is more likely to succeed in treatment. In order for clients to get this message there is a need for trained addiction counseling professionals who are willing and able to work with the client while they are engaged with their prescriber and are taking medication.

Another attitude or belief that the addiction professional must face is the idea that the ultimate goal of all clients should be total abstinence from all mood-altering substances. While that goal is ideal, the fact is that many of our clients, in both drug-free and MAR programs, do not come to us with a goal of total abstinence. If the client is faced with a forced choice to accept a goal of total abstinence or to leave treatment, many will choose to leave treatment, even if they have entered treatment under compulsion. The job of the addiction treatment professional is to meet the client wherever he or she is at and help them meet their immediate goal, and from there to hopefully help to move them toward a goal of total abstinence.

Many clients in MAR programs feel that the medication will remove the cravings for use, thus eliminating the problem. Research, however, shows that in addiction, just as in the treatment of mood disorders, the combination of medication and therapy is the most efficient treatment. It is the role of the clinician to help the client recognize the difference between abstinence and recovery. The idea that simply abstaining from substance use equates to recovery is all too common. Often the client and his friends and family see abstinence as the goal. They fail to recognize that abstinence can be fleeting without a change in attitudes, beliefs, and behaviors.

Another common client belief is that one particular substance is the problem; if they can stop that substance, it is alright to continue use of other mood-altering substances. Thus, the client’s goal may not agree with the goal of the treatment professionals. Other times the client’s goal is not cessation of the drug of choice but simply “controlling” the use. This is less common in MAR, but does come up from time to time.

Frequently, clients involved in MAR have had previous experiences in addiction treatment programs and have made assumptions about the treatment they will receive from us. If they have ever taken part in a “drug-free” program while taking medication to assist recovery, they may very well expect to be judged and possibly rejected. They may feel that the clinician will want to exert his or her treatment plan rather than work with the client’s wishes. They may feel that the clinician has nothing to offer if the clinician hasn’t had the same experiences. While this challenge is the client’s, we as clinicians can help him or her meet this and find success in recovery.

The growth of Medication Assisted Recovery has not only expanded treatment options; it has also moved treatment out of specialized addiction treatment facilities into the doctor’s office. As a result, people who seek medication for recovery find themselves out of touch with those who can provide the cognitive and behavioral support they also need in order to be successful.

Some prescibers understand the need for a combination of medication and counseling, but others do not. It is the job of addiction counselors and other professionals to reach out to precribers and to form therapeutic alliances that help to assure that recovery becomes a reality.

It would be nice to believe that those physicians who choose to prescribe medications that assist in recovery would seek out area professionals, but that is not always the case. The addiction counselor needs to locate and reach out to prescribers and to form alliances with them. The pharmaceutical companies often provide web sites that list physicians who are trained to prescribe medications that treat addiction. I have gone to those lists and sent out information to the prescribers about my services and requesting a chance to meet with them to discuss how we can work together to help their patients succeed in recovery. Some doctors like to have someone who will come to their office to allow their patients to make one trip for both services. Others prefer to have the patient go to a different facility. I have worked with some physicians who believe that all of their MAR clients should have counseling; others feel counseling is only needed if the patient continues to use alcohol or other drugs. I have found it is good to begin working with the doctor in the way they prefer; as I form an alliance with the prescriber I am better able to get them to reconsider our approach to best help the person in treatment.

Most addiction counseling professionals are not used to networking. For years, the clients have sought us out. If we want to continue to be an effective part of the recovery process, however, we need to become networkers.

      In an ideal world, everyone who comes to us for treatment would come with an understanding of their problem and a deep-felt determination to change. In fact, many, if not most, of the people I have seen for treatment come under some type of compulsion. The reason may be legal problems, or family pressure, some type of employment problems, or some other outside force that has the person presenting for treatment before they have determined the need for treatment. In MAR, it is quite common for the person to decide that they want to control addiction to one substance but not be committed to abstinence from all mood-altering drugs. While this does not mean that treatment is impossible, it does make it difficult.

      If a client who enters our office does not feel he or she has a problem, it may be difficult to get them to fully engage; without engagement, change will not come about. Our first job, therefore, is to work with that person in a way that might help them come to their own decision to make changes in their life.

It is important for a clinician to recognize the process and stages of change. It is here that an understanding of the Stages of Change model and learning about the various Motivational Interviewing and Motivational Enhancement Therapy techniques becomes necessary. More information on this is readily available from many sources; I would highly recommend TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment. This guide is focused on the use of Motivational Enhancement Therapy for substance abuse treatment and is available free of charge through SAMHSA.

Cognitive/Behavioral Therapy (CBT) is another highly effective tool for treatment of addictions and is quite compatible with MAR. Albert Ellis, the developer of Rational Emotive Behavior Therapy (REBT), has applied these techniques to addiction treatment as did Jack Trimpey, founder of Rational Recovery. Hazelden Publishing, a well-respected name in the addiction treatment field, has published a number of books that incorporate CBT and REBT techniques.

An important part of the counseling process in MAR is to provide recovery skills that will allow the person to prevent relapse not only while on medication but also once the medication has been eliminated. Personally, I like to refer to this as building continuing recovery skills rather than as relapse prevention as it gives the person in treatment a focus on success rather than a focus on not failing.

Among the recovery skills that are vital for people in MAR are improved communication, the ability to be aware of and to express feelings, self-awareness, connection with positive people, and recognizing recovery barriers and planning to overcome them. It is vital that those in MAR programs realize that recovery is more than not taking a drug; it is creating a new outlook on life and developing a whole new way to live.

This leads us to the transitioning process. Most of the physicians who prescribe medications to assist recovery see these medications as a short-term intervention. While some see medications as a tool for maintaining recovery, the general view seems to be that medication is a good way to help the person become stable enough to develop the skills needed for long-term recovery without medication.

The timing for this transition needs to be a cooperative process. The prescriber obviously has a lead role in this; they are, after all, the ones with the most knowledge of the medication and what is required medically for the transition. Counselors have an important role in helping the physician evaluate the client’s readiness to support recovery without medication. The client also has an important part to play, since they are the ones who need to go through the physical changes and make sure that their recovery continues.

In many cases, the prescriber may have a general rule for the length of time for medication. It may not always agree with our timeline or the client’s. I have seen some people try to transition too soon; they have not yet developed the skills to maintain recovery without the medication. Other times the client may be afraid to let go of the security that the medication provides. The counselor’s job is to help the client assess their readiness and to make good decisions regarding their care.

It is, perhaps, inevitable that we will not always agree with the physician on the correct timing of the client’s transitioning. That is to be expected. There are ways that this can be handled that will not have a negative effect on the needed balance of the physician/counselor/client relationship.

First of all, any disagreement between the doctor and the counselor must be handled outside of the client’s view. The client needs to feel that his or her treatment providers are a reliable team. We must also present our concerns in a rational way that presents solid backing for our concerns about the client’s ability to succeed. Remember that our job description includes the ability to present goals in measurable terms. If we can do this, it is easier for the physician to weigh our input and to better respond to that input.

As I continue to work with doctors, I find that my interactions with them grow and improve. Many medical doctors are not used to working with counselors, and many counselors are not used to dealing with doctors. After time I find that we build mutual understanding and respect and there are fewer times that we disagree.

Addiction counselors have specialized knowledge and are professionals in our field. Doctors also have specialized knowledge and are professionals in their field. It can be easy to have ego clashes when two professionals have an overlap in treatment. Both must recognize that the needs of the patient overrule the need for the professionals to be “right.”

Once the team decides on the right time for the client to move from medication, they must help the client to develop a continuing recovery plan. A lot of the responsibility for this rests with the counselor and the client.

The continuing recovery plan should include several things. First, the client should be able to identify his or her recovery tools. That “tool box” should contain a variety of resources that can meet a variety of situations. The client should be able to identify potential triggers for relapse and should have plans in place to deal with them. The client needs to have support in place and know who to contact in case of impending relapse.

The client and counselor should also set a period of time for continued sessions after the medication is discontinued. There should be a minimum number of sessions set with the understanding that the number could be extended if the client feels the need or desire to do so. It is important that the client be discouraged from discontinuing medication and counseling at the same time as that may increase the possibility of relapse. The doctor may want to have some follow-up with the client after the medication is discontinued; that should be arranged between the client and the doctor.

Ultimately, the goal is for the client to be just as successful in the maintenance phase of recovery as he or she was in the action phase. This goal can be best met if the team of the client, counselor, and the physician is working together efficiently.

            Medication to assist the recovery process has come a long way. Physicians and addiction counselors can view one another as competitors, or they can work together to improve the lives of those caught in the web of addiction. We need to acknowledge that, while our focuses may differ, our ultimate goal is the same. If we can also accept that there are different ways to treat addiction, and that clients have many different needs that require different approaches, we are one step closer to making success in recovery a reality for all. The time for division is over; we need to work as team to help those in need.

Biography:

      Gary Blanchard began his career in the addiction treatment field in 1998; he received a Masters in Addictions Counseling from Vermont College of Norwich University in 2002. He has worked in drug-free and medication assisted recovery programs and currently is in private practice in Ware, MA. He is a licensed alcohol and drug counselor and is the author of Counseling for Medication Assisted Recovery, Success-Centered Addiction Recovery Facilitation, and Building and Maintaining Recovery. He has presented at many local and national conferences.