Carla Marienfeld, MD: Outcome Assessment, Stigma Of Behavioral Therapy for Addiction

Carla Marienfeld, MD

Carla Marienfeld, MD, presented a discussion on behavioral and non-opioid therapies for addiction treatment at the "Evolving Approaches in Pain Management" conference in San Diego on August 14.

She discussed treatment markers of behavioral therapies with HCPLive®, as well as the overarching issue of stigma surrounding accessibility and even the use of the phrase "addiction".

HCPLive®: Do you find there are different treatment markers in behavioral therapies that clinicians can follow, compared to pharmacologic treatment?

Marienfeld: We have lots of different ways where we can assess the outcomes for the patient. It depends a little bit on the patient's goals. If their goal is abstinence, which is often an important goal for many people, it is easy to use a urine drug screen or to use other biological markers to determine whether or not the person is meeting that goal.

Sometimes we approach things from what we call a harm reduction approach, where ideally, the person wouldn't have any harms associated with their substance use. But, if they do, we try to reduce the substance use to a point where they're not having any consequences for themselves or other people related to that as much as we can.

Depending on what the goal is, how you might determine success would change a little bit. We can still use biological markers of use or not use in any setting to help us determine whether the therapy is effective or not.

We can also set other goals around using particular coping skills, improvements and other co-occurring psychiatric disorders. Improvements in anxiety and depression, for example, reduction in symptom burden related to trauma or other things, we make a diagnosis of a substance use disorder based on 11 criteria.

If we are approaching the person as a whole person who might have lots of different potential consequences associated with their substance use, we can track those individual criteria to see if we're seeing improvements in those particular consequences in that person's life. There's a whole bunch of different ways that we can think about as somebody making improvements.

Overall, in psychiatry, whenever we make any kind of a diagnosis, whether it's substance use or behavioral health, mental health, otherwise, it has to have some impairment in the person's functioning. Ultimately, the way we determine if somebody is improving as if they're functioning in their lives is improving or not.

That may or may not be in conjunction with abstinence with a substance, oftentimes, absence from the substance does help improve their functioning. But that's ultimately what we're looking at to determine if what we're doing is helpful.

HCPLive®: Have you seen any barriers in using these therapies or an unwillingness to use these therapies in favor of more medication based treatments?

Marienfeld: Particularly for opioid use disorder, we really do advocate medication. First, the benefits of medication for mortality for functioning for cessation of use, are just so robust that we really wouldn't advocate for not using medications. In addition, people can benefit from these kinds of therapies. However, there are a lot of barriers to accessing treatment.

For accessing medications, many of the barriers are around stigma. People don't want to go to a clinic that has an addiction in the title, or people don't know that these medications exist, or people have misconceptions, that they're just another drug or other things like that, that are inaccurate and can be harmful and help people access the right medications.

For the therapies, there's also the stigma that that is a problem for some patients, access is limited by insurance coverage and time and availability. Depending on where you live, there may not be a lot of therapists around.

There are also personal barriers. Some patients really struggle in group based settings, particularly if they have a history of trauma.

For example, if they have certain psychiatric conditions that might make them paranoid, other patients often say they don't prefer groups, but actually find that they can be quite beneficial if they find a good peer group to work with. Individual therapy can be more challenging to get there.

Unfortunately, there are a lot more patients than there are providers, both in terms of psychiatrists, as well as psychologists and social workers and other drug and alcohol counselors.

So, having a sustained individual therapy can be a challenge in accessing it that way, making sure that you have long term coverage from your insurance where you can continue it can be a challenge.

In addition, you want to make sure that the therapy that you're doing is a good fit for the patient and their goals. Sometimes when we're doing more manualized therapies, which have a lot of evidence for being very helpful, patients can feel like they're just going through a workbook. It's not personalized, or it's not targeting their specific problems that they want to address at that time.

Those are important conversations to have to make sure that you're addressing the right problems, and that you're making progress and what you're trying to do to help the person

HCPLive®: Is there anything else you'd like to add that you think is important to mention?

Marienfeld: This talk is about pain management. I don't think that I really fully addressed it in my slides, but I think it's important when we're thinking about new initiatives for pain management that we recognize the role of therapy and treating co occurring mental health and substance use disorders, on the patient's experience of pain, and their outcomes of improving pain.

When we're talking about medications for opioid use disorder, those can have some ancillary benefits for pain. But, when we're talking about non medication treatments for substance use disorder, those addressed the substance use disorder, they also typically will address co occurring, anxiety, depression, all of those things are moderators of how people experience pain and their outcomes for pain treatment.

It's important to understand that these things exist, understand a little bit about how they work in order to then improve the patient's experience and outcomes for pain in addition to providing medication and other non medication treatments for pain.