About CE
"CE Corner" is a continuing education article offered by the APA Office of CE in Psychology.
To earn CE credit, after you read this article, purchase the online exam at www.apa.org/ed/ce/resources/ce-corner.
Upon successful completion of the test — a score of 75 percent or higher — you can immediately print your CE certificate.
The test fee is $25 for members and $35 for nonmembers. The APA Office of CE in Psychology retains responsibility for the program. For more information, call (800) 374-2721.
Overview
CE credits: 1
Learning objectives: After reading this article, CE candidates will be able to:
- Discuss the factors behind the growing use of opioids.
- Discuss the research-based treatments for opioid abuse.
- Discuss barriers to effective treatment.
It was an appalling milestone. In 2015, more than 33,000 people in the United States died from opioid-related overdoses, setting a new record. While the data for 2016 aren't in yet, there's every reason to believe the U.S. opioid crisis is continuing.
Opioids are a class of drugs used to reduce pain. They include prescription drugs, such as oxycodone (OxyContin), hydrocodone (Vicodin) and morphine, as well as the illegal drug heroin. These drugs are effective painkillers, and can produce feelings of relaxation and euphoria. Unfortunately, people can become both psychologically and physically dependent on these powerful substances.
According to a report from the Centers for Disease Control and Prevention (CDC) published in December, drug overdose deaths nearly tripled between 1999 and 2014. More than 60 percent of overdose deaths now involve an opioid ( MMWRopens in new window , 2016).
The trend can be traced, in large part, to easy access, says Brent Moore, PhD, a research psychologist at the Yale School of Medicine and the VA Connecticut Healthcare System who studies treatments for opioid use disorder. Since 1999, the number of prescription opioids sold in the United States nearly quadrupled, according to the CDC. As sales of opioids skyrocketed, so did dependence, Moore says.
Yet prescription use is only part of the problem. As new regulations have made it harder to obtain prescription opioids, many people who have become physiologically dependent on the drugs have turned elsewhere. An estimated 2.1 million people in the United States suffer from substance use disorders related to prescription opioid pain relievers, and an estimated 467,000 are addicted to heroin.
Deaths involving heroin and illicit synthetic opioids such as fentanyl increased sharply from 2014 to 2015, even as rates of deaths associated with prescription opioids began to level off, according to the December CDC report. And a recent study by Julie Gaither, PhD, MPH, at the Yale School of Medicine, and colleagues found that among adolescents ages 15 to 19, rates of hospitalization for heroin increased 161 percent between 1997 and 2012 ( JAMA Pediatricsopens in new window , 2016).
Despite the grim statistics, there are effective methods for treating opioid use disorders, says Keith Humphreys, PhD, a psychologist and professor of psychiatry at Stanford University and the VA Palo Alto Health Care System, and a former senior policy advisor in the White House Office of National Drug Control Policy. And while the first-line treatment is medical in nature, psychologists have a great deal to contribute, he says. "Medicine is becoming a team sport, and psychologists can be really important as part of the team."
Methadone and more
Early on, the medical community treated opioid use disorder as an acute problem. Patients would get the drugs out of their system in a short-term detox program, and then be sent on their way. But relapse rates were high. Over the last 15 years or so, Moore says, experts have come to think of opioid dependence as a chronic health problem like depression, diabetes or HIV.
"It's not like an infection where we can give people antibiotics. It's a condition people have to manage their whole lives," says Humphreys.
For many patients, the first step to managing that condition is opioid substitution therapy. Patients are prescribed longer acting but less euphoric opioids, such as methadone or buprenorphine, which help reduce cravings and prevent withdrawal symptoms. Typically, these drugs are distributed via structured clinical programs, though some can be prescribed for take-home use.
While medical management is the first line of defense, psychologists also have a variety of important roles to play in addressing the crisis. "Opioid substitution therapy gets a person out of a situation where they're constantly craving and seeking opportunities to use," Humphreys says. "That gives you a platform to do psychosocial interventions, such as cognitive-behavioral therapy (CBT), marital and family therapy and vocational counseling."
Precisely which approaches are best for which patients, however, remains an open question. CBT, for instance, has a strong evidence base for changing behavior. But when it comes to treating opioid use disorders, evidence is mixed, Moore says, and some subgroups of people are more likely to benefit from this therapy than others.
In a recent randomized trial, for instance, Moore and colleagues found that heroin users and prescription opioid users had different responses to CBT. Among heroin users, there was no difference in outcomes between those who received buprenorphine alone and those who received the drug as well as CBT. Yet among patients who abused prescription opioids, those in the CBT group had more than twice the mean number of weeks of drug abstinence compared with those who received medical management alone ( Journal of Substance Abuse Treatmentopens in new window , 2016).
Other types of psychotherapy can also be helpful. Family or marital counseling, for example, can help repair relationships damaged by substance use disorders. "No matter what type of therapy you're doing, certain common elements predict good outcomes," Humphreys says. "If psychotherapy sessions are characterized by trust and respect, and both parties agree on the goals, you'll have a better result."
And while psychologists sometimes question the utility of 12-step mutual help programs, Humphreys's research shows that they have value. "These programs have a huge advantage in that you can stay in those communities as long as you need to."
Providing incentives
Moore also sees promise in developing psychological interventions that go beyond traditional individual or group therapy settings. He's begun investigating automated interventions that people can call for support whenever and wherever they need them.
In a pilot study, he tested a telephone "recovery line" that patients receiving methadone could call any time. The automated system provided interactive recorded messages based on CBT that were designed to improve coping. They found patients were more likely to report abstinence from opioids on days they called into the system ( Journal of Substance Abuse Treatmentopens in new window , 2013).
Psychologists are making an impact on the opioid crisis in other ways as well. For example, they have been instrumental in helping to design contingency management programs, says Nancy Petry, PhD, a psychologist who studies contingency management at the University of Connecticut School of Medicine. In these programs, patients earn rewards for staying off illicit drugs. In some cases, the rewards are prizes or vouchers that can be redeemed for goods such as food or movie tickets. In other programs, patients earn privileges such as the right to take-home doses, so they don't have to come to the methadone clinic every day.
Most opioid substitution programs now use such contingency management-like strategies based around dosing schedules, Petry says. Others use the approach to help people on opioid substitution therapy abstain from other substances, such as cocaine or methamphetamine, since opioid replacements don't directly impact those types of drug use.
Unfortunately, though, most clinics don't administer contingency management the way the research indicates, Petry says. To achieve the best outcomes, participants should be tested often and given rewards promptly. That might mean testing urine samples twice a week, and giving a reward every time they test negative for drug use. In practice, clinics might test randomly once a month, and only provide rewards after three consecutive months of clean samples, for example. "It's a watered-down version of contingency management," she says.
Still, the idea is catching on. Twenty years ago many clinicians were skeptical of contingency management. Today many clinics have adopted the methods, and in 2011 the Department of Veterans Affairs began using contingency management to treat users of stimulants such as cocaine and methamphetamine. Now the program is being expanded to treat stimulant use in those with opioid use disorders.
But outside the VA, cost remains a big hurdle. Until such programs are covered by insurance, they'll remain out of reach for many patients who could benefit from them, Petry says. "We've been researching these interventions for years. We know how well they work. Now we have to move to the policy step to get them widely implemented so patients—and society—can benefit."
Some critics have argued that while contingency management is helpful in the short term, its beneficial effects decrease in the months after the intervention ends. But that's true for all treatments for opioid use disorders, Petry says, including CBT and opioid replacement therapy. Indeed, that's the nature of treating a chronic disease.
Linking patients to care
Clinical psychologists can be proactive in helping to prevent and intervene with opioid-use disorders, says Kelly Dunn, PhD, a research psychologist at Johns Hopkins University School of Medicine who studies opioid treatments. One way to do that, she says, is to reach out to physicians who might be considering treating patients with opioid dependency. The Drug Addiction Treatment Act of 2000 allows physicians to apply to the Substance Abuse and Mental Health Services Administration for waivers that will allow them to prescribe or dispense approved buprenorphine medications, which can be taken home rather than administered in a clinical setting. Without these waivers, physicians may not prescribe the drugs.
If more physicians provided such treatments, it could have a big impact, especially in rural areas where there are few methadone clinics. But so far, physicians have been slow to apply for the waivers, and those who have them don't usually prescribe the drugs to as many patients as they're permitted, Dunn says.
One potential barrier is that physicians often do not know where to refer opioid treatment patients for counseling and other services that are not generally provided in primary care. Lack of knowledge about counseling may be holding them back, according to a not-yet-published survey of physicians that Dunn recently completed. "Physicians said if they knew how to link patients to counseling, they might be more willing to prescribe [buprenorphine]," she says. Psychologists could help by reaching out to local physicians to make them aware of their services.
Psychologists in clinical practice and in school settings can also help patients spot warning signs of opioid abuse or physical dependence early on, Dunn says. Clinicians should familiarize themselves with the signs of an opioid use disorder, including depression, sleep problems, failure to fulfill obligations, problems with family and friends, changes in appearance and physical withdrawal symptoms. "There's value in trying to catch people before they get to these severe stages where they need extended maintenance treatment," she says.
Unfortunately, patients are often ill informed about the medications. In a national poll conducted by the Washington Post and the Kaiser Family Foundation last fall, a third of Americans who have taken prescription opioids for at least two months reported that they'd become addicted to or physically dependent on the drugs. While nearly all of the survey respondents said they began taking the drugs because of a prescription, 60 percent said their doctors did not offer advice about how or when to stop using the drugs.
Indeed, health-care providers, including psychologists, should do a better job helping patients manage their opioid use, says Carl Hart, PhD, a professor of psychology and psychiatry at Columbia University who studies drug use and addiction. He argues that psychologists can have a bigger impact by emphasizing safe use rather than abstinence. "Opioid use isn't going away, nor should it," he says. "These medications have been with us for centuries because they relieve pain and enhance human experience."
In reality, he adds, most people who take prescription opioids do so without becoming addicted. A review by Kevin Vowles, PhD, at the University of Mexico, and colleagues found that just 8 percent to 12 percent of patients who took opioids for chronic pain became addicted to them ( Painopens in new window , 2015). In fact, according to data from the National Survey on Drug Use and Health, the majority of people who develop opioid use disorders start by taking prescription medication that was prescribed for someone else.
What's more, most opioid-related deaths occur when people combine the drugs with other sedatives such as alcohol and benzodiazepines like Valium, Hart notes. Not all opioid users become addicted, he adds, and research psychologists can fill an important knowledge gap by helping to identify which social and environmental risk factors increase the likelihood that a person will develop an opioid use disorder.
Breaking down barriers
Unfortunately, for the people who do develop an opioid use disorder, there are still many barriers to obtaining effective treatment.
Experts agree that more research is needed to better identify the most promising approaches to maximize a patient's chance of recovery. And so far, little is known about the best counseling strategies for different groups of opioid users, such as those with chronic pain, those with co-existing psychiatric conditions, prescription versus illicit opioid users, and even women versus men.
There are still big questions about opioid substitution therapy as well. In the past, health-care providers thought of methadone and similar drugs as temporary measures. As the medical field has shifted to think of opioid abuse as a chronic disease, that's changing. Just as people with diabetes will take insulin for the rest of their lives, some experts argue that people with chronic opioid use disorders should stay on opioid replacements indefinitely. But the replacement drugs can cause some unpleasant side effects such as drowsiness, nausea and mood swings, and many patients want to try to wean themselves from the drugs, Dunn says. "We need more research on how to taper [off the drugs] effectively."
The availability of substitution therapy programs is another serious hurdle. "A lot of states have very limited access to opioid replacement therapy," says Moore. His program in Connecticut treats many patients who drive all the way from Vermont—some four hours each way, every single day.
Even when local clinics exist, they're often at maximum capacity. And because people might stay on opioid replacements for years, new spaces in such programs are in short supply. That forces many people to enter short-term, hospital-based detoxification programs instead, says Dunn. Unfortunately, relapse after detox is very high, she adds. "Those programs aren't in place because they're the best standard of care, but because logistically that's all that's available."
Access to psychological therapies also varies widely. "Some methadone programs have very sophisticated group and individual counseling programs. Others have worked toward providing the medication and not much else," says Moore.
Stigma is another barrier standing in the way of recovery. In addition to preventing physicians from providing services to patients with opioid use disorders, stigma can prevent clinical psychologists from raising the issue of opioid use before it reaches a crisis point.
A lot of psychologists don't get training in addiction, Humphreys says. "Even if they do, they don't want to deal with it, and might pretend they don't notice."
Earn more CE on substance use and addiction issues
The APA Office of Continuing Education is offering several programs on substance use disorders this spring via video-on-demand.
