For clinicians who haven't trained in substance use disorders, it can seem overwhelming to figure out how to address the issue when it comes up with patients. In response, three APA divisions have developed a resource guide to help clinical psychologists respond to the opioid crisis. APA's "The Opioid Guide: A Resource Guide for Practicing Psychologists" was written by a cross-divisional task force of representatives from APA's Div. 12 (Society of Clinical Psychology), Div. 28 (Society for Psychopharmacology and Substance Use) and Div. 50 (Society of Addiction Psychology).
The guide is meant to be a practical handbook, says R. Kathryn McHugh, PhD, a psychologist in the substance use disorders division at McLean Hospital, assistant professor of psychology at Harvard Medical School, and a co-author of the resource guide. "So many psychologists want to know, 'What do I do when…?'" she says. "We wanted to create a really practical primer to help psychologists as they work with this population."
The guide covers a lot of ground, from understanding different types of opioids and recognizing their misuse to identifying evidence-based treatments and resources for family members of those with opioid use disorder. Here are some key takeaways from the guide.
Recognizing overdose risk. "Opioid use disorder is highly fatal," says Sharon Walsh, PhD, a professor of behavioral science at the University of Kentucky College of Medicine and a co-author of the guide. "People can come into care and be doing well, and just one slip can be fatal." Risk factors for overdose include decreased tolerance due to recent reductions in use, mixing drugs, a history of overdose, physical illness, using different opioids that vary in strength, switching to injecting opioids and using drugs alone. Naloxone is a medication that reverses opioid overdose. It has no abuse potential and few side effects. In some locations, a prescription is required for the drug. Clinicians should consider formal training in the use of naloxone, and counsel family members of opioid users to get training themselves (see Training front-line psychologists).
Identifying misuse. Misuse of prescription opioids often leads to opioid use disorder. The earlier that opioid misuse is identified, the better the long-term prognosis. The guide's authors recommend that clinical psychologists ask all patients about opioid use with a simple screening question: "How many times in the past year have you used an illegal drug or a prescription medication for nonmedical reasons (for example, because of the experience or feeling it caused)?" Anyone who says they have done so even once should then be given a detailed screening to assess for problematic substance use.
Evidence-based treatment programs. Outpatient treatments that include the medications buprenorphine, methadone or naltrexone are the most effective for opioid use disorder. Behavioral treatments such as contingency management and cognitive-behavioral therapy, used in addition to medication, may improve medication adherence and address problems not treated by medication, such as interpersonal difficulties and stress. Psychologists who identify opioid misuse should refer patients to a substance use disorder treatment specialist, who can help to determine the right level of care based on the patient's needs and the severity of the problem. Higher-quality treatment programs offer medication-assisted treatment, provide family support and are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and accredited by the Joint Commission or the Commission on Accreditation of Rehabilitation Facilities. The guide offers resources for locating and evaluating local providers and programs.
Resources for families. Research shows that involving family members in treatment can be helpful for people with substance use disorders, but accessing family-based services can be a challenge. Whether or not a person with opioid use disorder seeks treatment, his or her family members can suffer greatly. Psychologists can help them manage difficulties such as guilt, anger, shame, fear, financial challenges and confusion about setting limits. Psychologists can also help family members connect with support groups.
Social support groups. Mutual help groups may be useful for people with opioid use disorder. These groups can provide social support, reinforce recovery goals, teach skills that support recovery and provide structure and drug-free activities. However, some groups aren't welcoming to patients receiving medication-assisted therapy, since the use of the medications themselves is often stigmatized. By familiarizing themselves with support groups in their region, psychologists can help direct patients to groups that are most likely to be a good fit.
Cultural competencies. Health-care disparities have implications for the assessment and treatment of opioid use disorder. To address interactions among race, ethnicity, socioeconomic status, cultural context and geography, psychologists must first develop a working knowledge of possible treatment barriers among racial/ethnic minorities, with consideration of health-care system, provider and patient factors. Second, clinicians should assess patients' beliefs and expectancies regarding treatment for opioid use disorder. Finally, clinicians should deliver culturally appropriate care for opioid use disorder.
Misuse by adolescents. Youth who misuse prescription opioids have a high risk of transitioning to heroin use. The American Academy of Pediatrics recommends that all youth with a severe opioid use disorder be offered medication treatment in addition to behavioral therapy. Ideally, their families should be included in the treatment plan.
Managing chronic pain. Millions of people are prescribed opioids for chronic pain. Several opioid risk assessment tools assess the risk of opioid misuse and dependence. These tools should be used with patients with chronic pain who are considering long-term opioid therapy. Nonpharmacological treatments are also recommended for people with chronic pain. The most widely studied and efficacious interventions for chronic pain include cognitive-behavioral therapy, acceptance and commitment therapy, exposure to feared movements, exercise, physical therapy and interdisciplinary rehabilitation.
Critical skills for clinicians. Many clinical psychologists receive minimal training in substance use disorders, McHugh says, so it's not surprising that they may feel wary about treating people who are struggling with opioid misuse. Clinicians don't need to be experts to make a difference, however. "It's unrealistic to think that the whole psychology workforce will specialize in this area or feel competent to offer these treatments themselves," she says.
But at a minimum, anyone working in mental health should be able to do two basic things, McHugh adds. "It's critical that people know how to identify opioid use disorder, and that they know where to send people for evidence-based treatments, if they can't manage it themselves. If we can check those two boxes, that would be a huge improvement over where we are now."
