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 has raged on despite the development of evidence-based treatment for opioid use disorders,” explained Kimberly Hu, MD, at the 

2022 American Psychiatric Association Annual Meeting

. “About 70% of the nearly 71,000 drug overdose deaths in 8 states involved opioids. That's a huge, staggering number.” 

Recognizing the role that insufficient access to medications plays in this epidemic, Hu and colleagues at the 

Ohio State University Wexner Medical Center

, designed and implemented an opioid use disorder (OUD) curriculum for third-year medical students. The students (n=405) were provided with in-person or virtual buprenorphine waiver training and in-person clinical experiences between January 2019 and April 2021. Pre- and post-intervention tests,along with self-reported clinical management surveys,assessedthe students’ability to screen patients with OUD and manage acute and chronic pain. Paired sample t-tests were estimated to assess improvement in knowledge and approach to clinical management principles.

Hu, a resident at the Ohio State University Wexner Medical Center, and colleagues found a statistically significant increase in both their knowledge as seen in the pre- and post-test scores as well as their self-reported understanding of management principles. A follow-up study at the end of the year also provided positive feedback. Hu reported: “83% [of the participants] said that they felt they knew how to manage acute pain, about 62% felt that they knew how to manage 

, and about 77% said that they knew how to screen the patient for opioid use disorder.” This is important no matter which specialty the students pursue, as these students will be able to “link patients with resources early and make sure that there aren’t patients slipping through the cracks,” Hu explained.

She noted that educating third-year medical students gives them—and their future patients—an advantage. “They're a little over halfway through medical school, and then they'll go into residency in a number of different specialties. So giving them this knowledge early helps them to incorporate [the information and skills] as they continue their training.”

Hu noted that the educational program is ongoing and supported by the 

Substance Abuse and Mental Health Services Administration

. Her study co-authors included Julie Niedermier, MD; Amanda Start, PhD;Casia Horseman, MD; and Julie Teater, MD.

“If we can educate the next generation physicians and increase access to care, this is one way we can combat the opioid crisis,” Hu concluded.

Are you attending the 2022 American Psychiatric Association Annual Meeting? We want to hear your thoughts! Share recaps, reflections, and experiences with us at PTEditor@mmhgroup.com. Be sure to visit us at booth 1852.

New research presented at the 2022 American Psychiatric Association Annual Meeting evaluated program to help address the opioid epidemic.

New Weapon in the Fight Against Opioid Use Disorders 

Tales From the Clinic: The Art of Psychiatry

Tales From The Clinic: The Art of Psychiatry,

 we follow the story of a young man who turned his life around for the sake of his spouse and child, but nevertheless struggled with the tribulations of normal upheaval. Recovery from 

 does not protect against normal life events, but our patients are more sensitive to stress than their nonsubstance user counterparts, increasing the potential for stigmatization. We visit the moral versus brain disease model of addictive processes through the case, and hope to help readers appreciate their own biases and open themselves to understanding the neurobiology of addiction. The aim of proper diagnosis and treatment is to have an objective conception of addiction rather than a morally framed conversation, when behaviors related to addiction are viewed through a negative prism.

“Mr Wallace” is a young man with opioid use disorder and major depressive disorder. He lost contact with his wife and young child as a consequence of his 

. His wife moved to another country, prompting him to get treatment “like I really mean it this time.” He gained sobriety on medication-assisted treatment (buprenorphine/naloxone) and did well, earning advanced certification in his field and increasing his earnings significantly. He also took up the hobby of synthetic music. His wife returned with their child, with subsequent stabilization of the relationship, the purchase of a house, and other life milestones.

The National Institute on Drug Abuse (NIDA) defines addiction as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain—they change its structure and how it works. These brain changes can be long lasting, and can lead to the harmful behaviors seen in people who abuse drugs.”

 Although NIDA adheres to the brain disease model of addiction (

), there continues to be controversy surrounding whether addiction is a disease or a matter of choice. If addiction is viewed as a moral failing, as posited by the moral model of addiction, then there is the belief that the patient is responsible for their substance use and at fault for having a character defect or a weakness of will.

Advancements in neuroscience have made it possible to identify strong genetic, neurodevelopmental, and sociocultural components of addiction. Evidence pointing to the activation of reinforcement circuits (

) by drugs through the neurotransmitter dopamine in brain areas, such as the nucleus accumbens and ventral tegmental area, further supports irreversible changes in the brain’s structure and function resulting from substance use.

 Because of these permanent changes, it is postulated that individuals cannot exercise self-control over their behavior pertaining to addiction.

This biological approach, supported by animal models of addiction,

 has made room for pharmaceutical treatments of 

. This approach also supports liberation from the belief that addiction is a moral lapse in individuals who have deep character flaws. The disease model of addiction has often been assumed to diminish the attribution of free will to those with drug addictions, which could possibly have significant implications in the attribution of responsibility and stigma as well as the acceptance of treatment.

Critics of the purely brain disease model of addiction believe that categorizing substance use as a disease may further stigmatize individuals with addiction and prevent them from developing self-control, all while damaging their self-esteem.

 and simply diseasing addiction will only further stigmatize those who suffer from addictions. While proponents of the brain disease model of addiction believe adherence to this model will encourage treatment-seeking behaviors, critics believe it will erode the confidence of addicted individuals in their ability to overcome addiction if it is inherently viewed as permanent structural and functional changes in the brain. Research on addictions such as smoking finds that attribution of addiction to unchangeable intrinsic factors leads to lower levels of quitting intentions and quitting self-efficacy.

 Naysayers of the brain disease model of addiction also point out that a clear majority of addicted individuals recover naturally without requiring medical interventions.

Opponents of the brain disease model of addiction believe it: is insufficiently supported by animal-model and neuroimaging data; has only a modest impact on public policies toward drugs and addiction; and has not majorly contributed to the development of more effective treatments despite the decades of research.

 Evidence to support environmental approaches to reducing substance use cautions strongly against the possibility of policy makers and government officials being enticed by the allure of 

. There is some concern that an overly biological emphasis on addiction could take attention away from the necessary social and environmental interventions and divert resources to the production of expensive and perhaps risky medical interventions that can realistically only be accessed by a certain population. 

Proponents of the brain disease model of addiction postulate that adherence will encourage seeking of evidence-based medical assistance to overcome a brain disease. They believe this model lends itself to a collaborative approach between patients and physicians against addiction. However, critics believe the brain disease model of addiction lends itself to addicted individuals absolving themselves of personal responsibility. This results in infantilizing individuals with addictions while shifting the responsibility of overcoming addiction to medical professionals.

 This stark difference in how each model contributes to the physician-patient relationship sheds light on the topic of countertransference (

Mr Wallace later found out—after buying the house, buying a car, and moving back in with his wife and child—that his wife had not been faithful. This led to significant use of Adderall by Mr Wallace and ongoing relationship issues. He continues to have interpersonal issues in the relationship and struggles with maintaining the relationship for the sake of keeping access to his daughter.

, not only does the relationship between the clinician and the patient play a role, but so do the thoughts, beliefs, and experiences of the physician. Besides the brain disease model of addiction, there are several other models that seek to explain the development of substance use. The moral model describes addiction as resulting from a character flaw or moral failing; the choice model sees drug use as a voluntary but harmful behavior; and the psychosocial model regards substance use as related to economic, cultural, and other social factors.

These lead to beliefs about who claims responsibility for beginning and overcoming 

, including the medical model, which regards patients as requiring medical treatment and having low responsibility for the presence and resolution of use; the moral model, which places all responsibility on the patient; the enlightenment model, which states that the individual is responsible for the problem but not the solution; and the compensatory model, which states that the individual is not responsible for the problem but is responsible for the solution.

From studies on treatment providers’ views on the brain disease model of addiction, there seems to be overall support for this concept, although with variations noted among different professions of providers. The strongest support was generally seen in psychiatrists, especially those who were older.

 Interestingly, there was significant evidence of an amalgamation of beliefs, with providers expressing support for multiple models and levels of patient responsibility. These findings extended from treatment providers to treatment settings as well, with examples provided of substance as a “self-induced disease,” bringing together the requirement for medical treatment with responsibility for the initiation and resolution of use belonging to the individual.

 This appears to reflect the complexity of 

 and its treatment, and suggests that the conceptualization of substance use may be tailored to the needs of a particular patient or to the needs of the patient population seeking treatment in a specific setting.

How a physician conceptualizes substance use plays a role in the countertransference experienced. Thinking a patient is willfully making bad choices will obviously decrease positive feelings or wanting to help them, or to go the extra mile in treatment planning. On the other hand, approaching substance use from the brain disease model of addiction helps patients overcome stigma and reduce guilt, as use is not conceptualized as a moral failure of the patient. This may help reduce negative countertransference toward patients with substance use by assisting in understanding frustrating, demanding, or confrontational behavior as not intentional or specifically directed at the provider. Negative countertransference could result in direct consequences, such as avoidance of the patient, difficulty with empathetic responses, and sessions cut short.

This could also increase protective or parental feelings toward patients, especially if they are viewed as helpless against the structural and chemical factors that contribute to their use.

 Such a “positive” countertransference can also lead to difficulty in the therapeutic relationship, as the clinician may take on the role of a parent, becoming overly engaged, protective, and permissive. If the patient then regresses and begins to act out or relapses, the clinician may feel betrayed and subsequently have difficulty in future encounters with the patient. A parental countertransference may also result in the clinician infantilizing the patient and minimizing their strengths and abilities.

 As with all forms of countertransference, the ability to identify and label the ensuing emotion is as critical as the adjustments the clinician must accordingly make.

Although there are many frequently underutilized medications for substance use disorder, a mainstay of treatment relies on naturalistic options such as Alcoholics Anonymous, Narcotics Anonymous, inpatient and outpatient rehabilitation programs, and similar offerings. The Anonymous groups generally involve a 12-step approach that includes concepts of acknowledging addiction as well as the difficulty in overcoming it, recognizing wrongs, making amends for those shortcomings, committing to a life with continued focus on sustained abstinence, and working to help others, especially those experiencing similar struggles with substance use (

Historically, and continuing in the present day, these programs tend to have a strong spiritual component to them, which can be off-putting for some individuals and make it harder to engage. Of the limited data available, there is evidence for the beneficial effect of involvement in 12-step programs for maintaining sobriety, both with and without attending a rehabilitation program. The impact seems to be strongest for those who started attending 12-step groups prior to entering a rehabilitation program and who continued to be involved after completion of rehabilitation. Most of the available evidence is in regard to alcohol use, with less data focused on other substances.

Medicine is far from the conceptualization of addiction as a sin, yet the belief in biological models still lags considerably, as evidenced by suboptimal prescribing of anti-craving medications. In general, evidence-based practices for addiction treatment are still not fully implemented at the scale they could be, and this is likely reflective of how addictive diseases are conceptualized in everyday practice.

is a psychiatry resident at Baylor College of Medicine. 

 is a PGY 3 general psychiatry resident at Menninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine in Houston, Texas. She plans to pursue a fellowship in forensic psychiatry after graduation.

is an addiction psychiatrist at Baylor College of Medicine and the director of the Consult Liaison Psychiatry service at the Ben Taub General Hospital- Harris Health System in Houston, Texas.

1. National Institute on Drug Abuse; National Institutes of Health. Drugs, brains, and behavior: the science of addiction. 2007. Accessed March 15, 2022. 

https://nida.nih.gov/sites/default/files/soa.pdf

Brain disease or biopsychosocial model in addiction? Remembering the Vietnam Veteran Study.

The science of making drug-addicted animals.

Free will and the brain disease model of addiction: the not so seductive allure of neuroscience and its modest impact on the attribution of free will to people with an addiction.

Addiction and moralization: the role of the underlying model of addiction.

6. Harackiewicz JM, Sansone C, Blair LW, et al. 

Attributional processes in behavior change and maintenance: smoking cessation and continued abstinence.

The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?

Drug and alcohol treatment providers’ views about the disease model of addiction and its impact on clinical practice: a systematic review.

Countertransferential and attitudinal considerations in the treatment of drug abuse and addiction.

11. Thomas S, Monico N. The 12 steps of Alcoholics Anonymous. American Addiction Centers. Updated December 20, 2021. Accessed March 15, 2022. 

https://www.alcohol.org/alcoholics-anonymous/

Recovery from addiction does not protect against normal life events...

Normal Life Stress, They Say…

What is the current state of the opioid epidemic, and what role does naloxone play in the emergency treatment of patients with known or suspected opioid overdose?

These questions and more were addressed in this installment of the custom Around the Practice video program. Panelists for this important discussion included Matthew A. Torrington, MD; Daniel E. Buffington, PharmD, MBA; Thomas R. Kosten, MD; and Bill H. McCarberg, MD.

“This is not a new epidemic,” said Kosten, adding the opioid crisis started as early as 2015. “One can say it was led by the overprescribing of opiates, but what has taken over [the expanding crisis] is fentanyl.”

The panel agreed it has spread across age groups, making it everyone’s problem.

Naloxone may be a solution, Buffington explained, but it may need to be administered several times to counter opioid overdose in emergency situations due to the “increased prevalence of higher-potency fentanyl products” in recent years.

A 27-year-old man presents for evaluation in extreme pain from a car accident. He has a past history significant for substance use disorder, high blood pressure, and diabetes. He takes buprenorphine 2 mg, lisinopril 20 mg, and metformin 500 mg per day. During the next 4 hours, his pain levels vary. Imaging shows a broken ankle, a broken rib, and a small hairline fracture on his clavicle; a CT and MRI show no tissue or brain damage. He gets a cast for his ankle and is started on low-dose opioid therapy—1 oxycodone acetaminophen every 4 to 6 hours as needed for pain for 5 days, until he can see his primary care provider.

This is where the real problems begin, the panel agreed, as the patient is discharged without appropriate pain management. “If you don’t do enough to treat this guy’s pain, you can drive him to the illicit market, and that’s when he becomes the real victim of overdose,” explained Torrington. “I see as a lot of this substandard pain treatment, which makes people—even reasonable people—go to the illicit market to get something else to help them with their discomfort... If we don’t do an adequate job, they’ll take matters into their own hands.”

Acknowledging that this patient is at risk for overdose, the panel discussed the potential use of naloxone.

Kosten recommended 8 mg of naloxone, stating, “If he did go to the illicit market, unfortunately, fentanyl might be in that and you’re going to need a big dose of naloxone to do something.”

McCarberg agreed that this patient is a good candidate for naloxone. “This person has an opioid use disorder—I assume he was given the buprenorphine because of treatment for the opioid use disorder, even though it was a subtherapeutic dose,” he explained. “He’s still drinking, he’s smoking cigarettes, all of which put him at high risk for going outside of the standard prescribing realm to get medication...So he really is high risk given all of these factors together. This is the guy that needs the naloxone and a discussion with the wife or whoever’s the other members of the family about what to look out for if he overdoses.”

A 49-year-old unemployed male truck driver is found semiresponsive, and an opioid overdose is suspected. He has a past medical history of high blood pressure, diabetes, obesity, and chronic pain, as well as opioid use following a previous motor vehicle accident. He smokes 1 pack of cigarettes a day, is recently divorced, and lost his job during the pandemic. During the physical exam, he is hypertensive and unresponsive to sternal rub. During the clinical work-up, he has pinpoint pupils, has gone pale, and has clammy skin. His blood pressure is 60/40 mm Hg. His heart rate is 28 beats per minute.

After confirming his airway is clear, he is given supportive breathing and then 8 mg of naloxone intranasally. He is monitored for opioid withdrawal and/or non–naloxone resistance.

“I think you have to think about longer-term treatment,” Kosten said. “Based on the 8 mg of naloxone that it took to reverse him and what is on the street, he probably did get fentanyl in his system. Then the question is: What do you want to treat him with? Could you treat him with naltrexone?” Kosten posed. “An injectable naltrexone lasts a month, so you do not have compliance problems. If he is not opiate dependent, that’s a real possibility.”

“This person absolutely needs comprehensive individualized multimodal treatment over time that’s biologic, psychologic, social, spiritual, and nutritional to have the best possible chance of overcoming his challenges,” Torrington added. “There are so many things that you could do with this teachable moment, but I’m afraid that in real life, many times this guy wakes up and goes home, and not that much else happens.”

The panel noted it was important to involve the family to prevent negative outcomes.

“I had a recent overdose rescue in my practice, and what struck me was that the wife said, ‘I didn’t know if I should give it or not. I couldn’t tell.’ The question comes up: Should she use it when she’s not sure? Should we be advising family members to use the drug if they’re not absolutely certain that it’s an overdose? The side effects, the risk-benefit profile for using the drug is so much in favor of using the drug if you’re not sure because of the fact that there hardly are any side effects from the drug. There are withdrawal side effects, but if you don’t know, it’s better to use it than to not use it because a side effect or a withdrawal is much better than a death. If you don’t know for sure, error on the side of something that is less harmful to the patient.”

The panel further agreed that to keep patients off the streets looking for medications, care needs to go beyond undertreating pain.

Kosten concluded: “[Providers] have to have an open mind that substance abuse and major psychiatric disorders are not totally divergent—that they, unfortunately, are totally convergent and come together. You can die of suicide. You can also die of an overdose just as easily and a whole lot more quickly.”

is a board-certified family medicine and addiction medicine physician practicing in Culver City, CA. Mr Buffington is president and CEO at Clinical Pharmacology Services in Tampa, FL.

is the Jay H. Waggoner Endowed Chair and professor of psychiatry, pharmacology, immunology, and neuroscience, as well as vice-chair for psychiatry, and codirector of the Dan L. Duncan Institute for Clinical and Translational Research, and a professor of at the Baylor College of Medicine in Houston, TX. He is also on the editorial board for

is founder of the Chronic Pain Management Program for Kaiser Permanente and adjunct assistant clinical professor at the University of California San Diego School of Medicine.

If you missed out on the custom Around the Practice video program on naloxone, we've got you covered. Read a recap here. 

Naloxone as a Tool to Fight the Opioid Epidemic

At the American Pharmacists Association 2022 Annual Meeting and Exposition, one poster titled “Youth Opioid Safety Knowledge and Perceived Impact of an Educational Game: A Nationally Representative Sample,” explored the importance of adolescent’s perception of dangerously addictive opioids. Claire A. Rosenberger; Olufunmilola Abraham, PhD, MS, BPharm; Jen Birstler, MS; and Kathleen Tierney demonstrated how an educational game could be used to improve opioid awareness in young people.

Using a 67-item questionnaire, the investigators surveyed 592 American youths aged 12 to 18 about their existing knowledge of opioids. Sample questions included “Have you heard of the drug naloxone (Narcan)?” and “Is it ok to take someone else’s opioid medication if you had the same prescription in the past?”

One question posed to the young participants asked, “Is the opioid crisis harming teenagers in the US?” Nearly 500 participants said yes.

When asked if an educational video game would increase their awareness of opioid medication safety, more than 450 of the participants said yes.

Results showed differences in opioid knowledge among different gender, race, grade, and age. Most adolescents knew the opioid epidemic is harmful, but many were unaware of naloxone. The investigators concluded that future studies should investigate the use of an educational game to educate adolescents on opioid safety.

Can a game improve children and adolescents knowledge of the opioid crisis? 

Fun and Games: Improving Youth Opioid Awareness

 is common for US adults and even more pervasive for patients presenting in psychiatric settings. Estimates of previous experience of traumatic events is 51% to 84% in the general adult population and 76% to 91% in those seen in psychiatric settings.

 The most prevalent comorbid disorders among adults with 

 (SMI) are substance use disorders (SUDs).

 Despite trauma symptoms often being underreported, 30% to 60% of individuals seeking treatment for SUD also meet criteria for 

 Acknowledgment of “dual diagnosis dates back decades, into the early 1980s; however, the classification of PTSD and SUD as 

 is inadequate to capture the range of symptoms and impairments of this diverse patient population.

 Greater understanding of approaches to SUD and related support services may help psychiatric providers provide multifaceted, comprehensive support to patients with SMI, PTSD, and SUD.

Evidence-based treatments exist for both PTSD and SUD; however, the approaches are rarely integrated, despite recognition of frequent cooccurrence. There are trends to further integrate 

 (TIC) in both SUD and psychiatric settings,

 but these services are seldom cohesive. To combat the SUD epidemic, availability of medication-assisted treatment/recovery has focused on primary care and the treatment of SUD as a chronic health condition. There is also greater opportunity for psychiatric providers to strengthen their care of patients with comorbid SMI, PTSD, and SUD by continually linking emergent evidence with clinical care. As the SUD epidemic has further intensified during the 

 the need for trauma-informed psychiatric care addressing SMI and SUD is even greater.

Treatment of SMI-related distress or symptomatology in isolation from SUD fails to address the whole person and is likely to result in suboptimal outcomes.

 Without integration of SUD and SMI care, providers risk inappropriately generalizing diagnoses without recognizing the context and lens of SMI symptoms. Addressing an epidemic requires the responsiveness of all providers.

 As SUD services, treatment, and research have advanced, we highlight 5 practices that are useful in supporting psychiatric clinicians as they effectively integrate trauma-informed SUD and SMI treatment.

There is substantial evidence that clinicians do not routinely ask patients about trauma history in clinical settings.

 Despite growing recognition of the impact of adverse childhood experiences on individuals and awareness of trauma prevalence, both institutional and intrinsic barriers interfere with provider inquiries about 

 Although a psychiatric history often includes inquiries about traumatic experiences, TIC requires routine attention to symptomatology and reactions to trauma. Documentation of a single question within an initial evaluation is inconsistent with TIC, but consistently attending to previous experiences with and responses to trauma throughout care is imperative.

 Trauma assessments at initial visits may underreport traumatic experiences, as patients may not feel comfortable disclosing these at a first-time appointment.

Similarly, inquiring about substance use and recurrence of substance use must be an ongoing practice. Patients may not disclose substance use right away for a multitude of reasons. As the provider learns this information, the trajectory of care may change, much like when we are asking about trauma. Assessment around SUD also requires being trauma-informed, as increased 

 Patient omission of disclosing a substance use recurrence is common in psychiatric care, often related to fears of losing care or prescription medication. To mitigate this risk and develop space for honest disclosure, clinicians can share their policies or practices related to substance use and foster open discussions—discussions that acknowledge cravings and recurrence are likely to increase with stress and trauma.

Recognize Trauma as a Primary Pathway to Substance Use

For decades, the pervasive narrative around 

 was the “gateway hypothesis,” which has now been widely refuted. The gateway hypothesis—that consumption of a particular substance will lead to or increase the likelihood of progressive substance use—came to prominence after publication by Kandel in 1975. The 4-stage sequence of drug consumption—from beer and wine, to tobacco and hard liquor, to cannabis, to other illicit drugs—indicates that only individuals who use 1 drug have a chance of progressing through the sequence.

 Although substance use is associated with use of other substances, a causal relationship where alcohol and/or cannabis are gateway drugs has been disproven.

 Conversely, marijuana use has been associated with reductions in 

Drug use sequences and initiation vary based on cultural context and on unmeasured common causes that are understood to be more impactful on subsequent drug use than initial use of a particular substance.

 There is clearly an association between experiences of trauma and 

, as patients meeting criteria for PTSD are 14 times more likely to have a comorbid SUD when compared with patients without PTSD.

 Both initiation of opioid use and transition to injection opioid use from other routes may be related to experiences of trauma.

One notable evidence-based approach is integrated treatment for cooccurring disorders (ITCOD). Integrating treatment approaches for mental illness and SUDs requires looking at combining efficacious existing treatments while modifying interventions that may be outdated or lack reliable benefit.

 ITCOD is a multifaceted approach to treatment and care that captures the importance of individual therapy, assertive outreach, social support interventions, and long-range perspective via a patient-centered framework.

As we unlearn the non–evidence-based “gateway hypothesis,” a deeper dive into traumatic experiences and their relation to substance use is likely to serve both provider and patient. Often, substance use initiation is related to seeking relief from pain as well as traumatic events and symptoms.

 Providers can more fully explore events preceding substance use initiation or transition to nonprescribed medication with compassionate understanding, recognizing that 

 may have been the only accessible and available coping tool at that time.

When we sit in the office with a 40-year-old patient, for example, imagine, as they are sharing memories of their traumatic upbringing with you, that they are 12 years old and not in your office, but in their home—terrified of the trauma there. They have no resources or outlets. A substance is introduced, and it temporarily provides some relief of the awful feelings that they are experiencing. That is not a moral weakness or deficiency. One can imagine what one would do in that situation, but the context and the patient’s experience are of utmost importance, and we need to remove our own opinions from the equation. Intergenerational trauma is another prevalent reality, and the cycle perpetuates. When someone comes to see us for help, it is our job to use our expertise and understanding to facilitate their healing and 

Partner With Patients Across Multiple Pathways to Recovery

Substance-specific 12-step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous are often considered synonymous with peer-led recovery. These programs have benefited millions of people over the course of decades. However, these models are based on an abstinence-only philosophy with religious/spiritual elements, wherein sobriety is the explicit goal for group members. These programs have provided effective support for countless individuals and families, but they do not fit all people seeking or maintaining recovery.

Abstinence-only models are not a panacea. Many individuals suffering from SUD are not able or ready to totally discontinue use or are turned off by the religious basis of these groups, resulting in disengagement from these services.

 Alternatives to spiritually based and abstinence-only peer-led mutual support groups exist and should be considered viable recovery pathways for patients. They include SMART Recovery, Secular Organizations for Sobriety, Moderation Management, LifeRing, Women for Sobriety, and Celebrate Recovery, among others.

 In addition to these peer-led groups, harm reduction services—including peer-led groups and/or syringe services programs—can be a critical low-barrier access point to engage patients with SUD who are not interested in abstinence. Abstinence and 

 are often conceptualized as diametrically opposed; in reality, they serve as different engagement points on a continuum. Appropriate service or program recommendations are dynamic, contingent upon individual differences in needs and desires surrounding treatment and recovery.

Instead of referring patients to treatments that are not well suited to the individual, acknowledging the multiple pathways to treatment and recovery is imperative. We have heard of the challenging routes patients have faced on their journey to treatment and recovery, such as a provider telling them they could not be seen “until they go to AA and stop drinking.” This advice is as good as telling your patient to leave your office and never come back again. Supporting multiple pathways helps meet patients where they are, learn where patients are in their willingness to engage in treatment, and determine which modalities may be the best fit for them. It is important to engage in a shared decision-making process and provide options, rather than providing a paternalistic recommendation that does not take patient preference or prior experiences into consideration.

Approach With Unconditional Positive Regard

When assessing patients, the longstanding OLDCARTS (onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, severity) acronym utilized in general medicine can be adapted for psychiatric evaluation and assessment. Information gathering in a psychiatric evaluation is not a rigid, linear, “checking off the boxes” process—there is, of course, an 

art to facilitating an informative interview

. Asking our patients when the symptom or trauma started or occurred and ascertaining what was going on in their life around the time that they started using substances are crucial to assembling the pieces of the puzzle each of our patients presents. Often, a silent “Aha!” moment occurs when these connections are made, relating the timing of trauma to the onset of substance use or to an increase in one’s patterns of use. This is important to recognize upon evaluation, and it is important to keep that context for ongoing treatment, especially as individuals who have experienced trauma are likely to experience trauma again in their lives. This can make individuals in recovery more susceptible to recurrence of substance use.

Approaching our patients from a place of unconditional positive regard, a concept expanded upon by Carl Rogers, is central to facilitating a safe space for our patients to share with us what is going on without judgment, and without fear of disappointing us as providers. Our interactions with patients are timebound, limited, and within a physical space most often that is “our” home turf: our office space.

Ongoing self-reflection and assessing areas of one’s own implicit biases are imperative. A systematic review looking at health care professionals’ attitudes toward patients with SUDs found negative attitudes toward this patient population, which impacted patient outcomes unfavorably.

 There are often inciting events for these views, and the outward expression is likely most often unintentional. As lifelong learners, we are well served to recognize when inaccurate conceptualizations (eg, the gateway hypothesis) have led us astray in oversimplifying substance use within our visits.

Engage in Ongoing Knowledge and Skill Development

A systematic review of negative provider views impacting patient outcomes identifies needs for education, training, and improved structure to better support complex patients.

 Formal educational opportunities including fellowships in 

, addiction certification, and Suboxone waiver training are increasing in availability and accessibility.

 All health care providers practicing clinically are required to participate in continuing education. Due to the 

, many states have specifically added requirements for continuing education related to opioid prescribing and opioid use disorders. It is quite beneficial to seek out and take advantage of learning opportunities in areas that are not necessarily our daily focus or in those we studied quite a while ago.

There are peer-facilitated learning opportunities, as well as the PACT-MAT ECHO model,

 which is an all-teach, all-learn approach. These sessions have many benefits, especially since comorbidity of a psychiatric disorder along with a SUD is often an area where clinicians appreciate feedback and recommendations for ongoing care. It is also an excellent opportunity to network and for clinicians to become familiar with other area resources and referral locations.

As psychiatric care providers amid a challenging health care landscape and a global pandemic, we are tasked with providing optimal care to our patients and meeting their needs. The evidence, as we have noted, continues to evolve, and this provides all of us with the opportunity to self-reflect and continue adapting in our own practice and methods. Opportunities for collaboration and growing our knowledge base abound, and within the field we are lucky to have colleagues and mentors to support us along this journey.

is a psychiatric-mental health nurse practitioner in the Seacoast, New Hampshire, area, and a clinical assistant professor and program director of the Post-Masters Psychiatric-Mental Health Nurse Practitioner Certificate Program, Department of Nursing, University of New Hampshire, Durham.

serves as the project manager for the Harm Reduction Education and Technical Assistance project, a multiorganization collaboration dedicated to reducing drug-related harms, based at the Department of Nursing, University of New Hampshire. She is also an adjunct professor in the university’s Department of Social Work.

is a family nurse practitioner in community health and an assistant professor of nursing at the University of New Hampshire. Dr Nolte’s research focus is reducing drug-related harms.

Does trauma-related training have a relationship with, or impact on, mental health professionals’ frequency of asking about, or detection of, trauma history? A systematic literature review.

2. Integrated treatment for co-occurring disorders. Substance Abuse and Mental Health Services Administration. 2009. Accessed January 7, 2022. 

https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf

3. Rasmussen IS, Arefjord K, Winje D, Dovran A.

 Childhood maltreatment trauma: a comparison between patients in treatment for substance use disorders and patients in mental health treatment.

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