Models for Providing Psychosocial Services

Psychosocial supports, such as counseling or therapy, may be implemented in conjunction with medication for opioid use disorder (MOUD). There is evidence to support use of psychosocial services because they encourage continued use of medication, improve retention in care, and make MOUD treatment more effective. Psychosocial services aim to improve medication adherence by addressing psychosocial problems patients are experiencing, including other substance use disorders co-occurring with opioid use disorder (OUD), such as alcohol and other drugs; traumas; and mental health issues, such as depression and anxiety.

Rural programs providing MOUD can consider different approaches for integrating psychosocial services for patients, such as individual counseling, group therapy, and 12-step programs.

Individual Counseling

Individual counseling for OUD typically consists of one-on-one sessions with a counselor, psychologist, or therapist. Individual counseling typically focuses on goals, setbacks, and progress, and may involve the use of specific approaches to address any or all of these elements. For example, to address setbacks, contingency management (CM) might be used to reinforce positive behaviors (such as staying off opioids) through the use of incentives or rewards. Motivational enhancement therapy (MET) might be used to increase individual motivation, whether to begin or stick with a specific treatment approach.

Cognitive behavioral therapy (CBT) is one of the more commonly used therapy approaches for OUD. CBT focuses on recognizing negative behaviors, teaching individuals how to break patterns, cope with stressful situations, and change thinking. The Association for Behavioral and Cognitive Therapies highlights a number of specific ways CBT might be used to address OUD, including:

Identifying triggers for drug use
Managing those triggers by increasing coping and problem-solving skills
Working to identify low-risk alternatives to drug use and avoid high-risk situations

CBT can be particularly helpful in managing issues that frequently co-occur with OUD, such as chronic pain or depression. Additionally, although CBT is frequently used as an individual therapy approach, it can be used in group therapy as well.

Group Therapy

As with individual counseling, group therapy for OUD can rely on multiple different approaches (including cognitive behavioral therapy, as noted above) and provides a mechanism for multiple people to share their experiences during recovery. The American Psychological Association advises patients considering group psychosocial support to understand the difference between open and closed groups.

Open – typically ongoing in duration with individuals able to come and go as needed
Closed – typically having a set number of weeks or months with the same group of individuals

Programs looking to include a group psychosocial support option for patients in an MOUD program should understand specific considerations for group therapy in addiction treatment programs. Open therapy groups are more likely to be part of residential or inpatient settings, while closed groups are more likely to be used in outpatient settings. Traditional group therapy might be tailored to a specific topic or be more general.

Group-based opioid treatment (GBOT) is an emerging approach that consists of a group of providers treating a group of individuals recovering from OUD. GBOT consists of a combination of group psychotherapy and shared medical appointments, typically of individuals with similar chronic and/or co-occurring conditions.

12-Step Programs

Another model to support recovery is a 12-step approach, such as through Narcotics Anonymous (NA) or Medication-Assisted Recovery Anonymous (MARA). The 12-step approach may be used alone or in conjunction with other group or individual therapy approaches, providing an additional tool for managing addiction. All 12-step programs rely on peer support, such as through group meetings and sponsors. More traditional 12-step recovery approaches (such as NA and Alcoholics Anonymous) focus on complete abstinence, which can sometimes create an unwelcoming environment for individuals who use medication as part of their recovery efforts. MARA is a newer approach to the 12-step program, developed as an alternative to address this specific challenge.

Implementation Considerations

Several elements can contribute to variation in psychosocial services offered in MOUD programs. These elements may include, but are not limited to:

Medication type (methadone, buprenorphine, or naltrexone)
Treatment setting (including whether prescribers and psychosocial service providers are co-located)
Type of psychosocial service provider
Type and frequency of psychosocial services

Many types of practitioners can provide psychosocial supports, including but not limited to counselors, physicians, nurses, nurse practitioners, and social workers. These providers may have different training, including in counseling approaches or addiction. As a result, some rural MOUD programs may only be able to offer a specific type of psychosocial services (for example, a 12-step approach) due to the availability of providers.

Some rural MOUD programs require that patients begin therapy along with medication, while others encourage or recommend it. Federal requirements to offer psychosocial services along with MOUD vary depending on the treatment setting. Ultimately, requiring psychosocial services immediately may be a barrier to some patients, due to stigma, logistics, access, transportation, and other factors. To address barriers, rural MOUD programs can consider implementing telemedicine for behavioral health, providing support services to address social determinants of health, and ensuring a whole patient approach to care.

Program Clearinghouse Examples

Resources to Learn More

Building a Group-Based Opioid Treatment (GBOT) Blueprint: A Qualitative Study Delineating GBOT Implementation
Document
Identifies six core components for implementing a group-based opioid treatment (GBOT) design plan. Highlights 14 malleable components for GBOT implementation and offers a conceptual framework to help providers decide how to apply these components.
Author(s): Sokol, R., Albanese, M., Chew, A. et al.
Citation: Addiction Science & Clinical Practice, 14(47)
Date: 12/2019