Supports that can save lives

Psychologist-designed programs for patients with opioid use disorder that involve housing, work, and family interventions are showing potential.

12/21/202210 min read

Kevin Scott began abusing drugs and alcohol when he was in his early adolescence. Since then, he's been homeless and has suffered from chronic pain as a result of back, neck, and head injuries.

Scott, aged 48, has established a solid foundation in life, thanks in part to the fact that he now owns a home. If he does drugs, he won't lose his housing in Seattle's Plymouth Housing program; in reality, Scott isn't completely drug-free. Scott has been able to significantly limit his use now that he is no longer exposed to the stress and uncertainty of the streets, thanks to the Harm Reduction Research and Treatment (HaRRT) Center and Harborview Medical Center's combined behavioral and pharmacological program. He was able to move from heavy narcotics like heroin and methamphetamines to cannabis and minimize his alcohol consumption thanks to the program. He goes to vocational rehabilitation, has an emotional support dog, and cooks community meals for others in his apartment complex. Scott says, "It's been my anchor."

His story is only one example of how psychological support can make a difference in people's lives. Opioid addiction is unique in that there are drugs that effectively block opioid receptors, reducing cravings and even saving lives in the event of an overdose. However, due of the insecurity in their lives, some people are hesitant to utilize drugs or are unable to keep to a treatment plan. Others wish to gradually wean themselves off pharmaceuticals or relearn how to live without them, according to Katie Witkiewitz, PhD, a psychology professor at the University of New Mexico Center on Alcoholism, Substance Abuse, and Addictions. Psychosocial support programs that focus on getting substance users into secure housing, bringing their families and loved ones together, addressing work issues, and dealing with legal issues originating from their drug use can help people stick to a broader treatment plan.

Witkiewitz explains, "A lot of the work focuses on the underlying issues that lead them to addiction in the first place."

These resources can make all the difference for someone suffering from an opioid addiction.

A safe haven

Clinical psychologist Susan Collins, PhD, co-director of the HaRRT Center at the University of Washington School of Medicine in Seattle, notes that traditionally, housing programs have required people with substance use problems to "prove" themselves before receiving housing. Before they were judged "housing-ready," they may have had to commit to substance abuse treatment programs or provide negative drug tests.

Collins, on the other hand, believes that philosophy is flawed. "The more stable elements of the homeless community were gaining housing, according to the agencies. The people who were struggling the most—those who were the most marginalized—weren't, however "she explains.

Will Williams, a member of the HaRRT Center's community advisory board, was originally hesitant to even apply for permanent housing because he felt he would "fuck it up" if he had to follow conditions such as not smoking cigarettes or marijuana.

"You might be amazed how damaging it is to be told you can't do anything to someone who already feels pushed about, pushed around, pushed around," Williams adds.

As a result, the "housing first" attitude was developed. Housing First initiatives, the first of which began in 1988, attempt to place homeless persons in housing with little restrictions, whether or not they use narcotics.

Karen DuBois-Walton, PhD, a clinical psychologist and president of the Elm City Communities/Housing Authority in New Haven, Connecticut, states, "We know that housing offers the basic foundation that persons need in order to even begin to think about how to heal."

Housing First initiatives are already in place in several locations around the United States, and they are funded by a combination of federal subsidies, resident rent payments, grants, and contributions. According to DuBois-Walton, funding is always lagging behind need, especially when home prices and rentals have risen faster than income in recent decades, making affordable housing increasingly scarce.

Housing First communities provide an entrée into treatment for those who are accepted, with services ranging from on-site case management to behavioral health treatments. Defaulting on your rent will not result in eviction. Late rent, according to DuBois-Walton, is considered as a first sign that someone is relapsing or in need of assistance. Many of the supportive housing communities that serve persons with opioid addiction histories provide naloxone (commonly known as Narcan) to residents and staff, as well as training on how to utilize the kits in the event of an overdose.

When compared to research on the utilization of the Housing First method with alcohol or polysubstance users, there is a dearth of study on opioid users. However, polysubstance use is common among patients with opioid use disorder, according to Collins, and the research suggests the intervention is effective across the board: People do not become abstinent as a result of obtaining accommodation, but they also do not begin to use more, as some opponents have predicted. They appear to have fewer unfavorable health consequences and a better chance of receiving treatment in general.

One study led by Philip Appel of the New York State Office of Alcoholism and Substance Abuse Services looked at a Housing First program in New York and found that about half of homeless, mentally ill methadone patients who got housing stayed on their medication three years later, compared to only 20% of those who didn't get housing (Journal of Addictive Diseases, Vol. 31, No. 3, 2012).

Another study led by Sara Miller-Archie of the New York City Department of Health and Mental Hygiene found that polysubstance users who were placed in supportive housing were less likely to be hospitalized, used emergency rooms less frequently, and were more likely to begin substance use treatment than those who were not (Annals of Epidemiology, in press).

However, a study by Simon Fraser University clinical psychologist Julian Somers, PhD, and colleagues of homeless adults receiving methadone maintenance treatment in Vancouver, Canada, found that Housing First programs did not improve methadone treatment adherence any more than treatment as usual, leading the authors to conclude that housing supports were not sufficient in themselves to improve treatment adherence (International Journal of Drug Policy, Vol. 56, 2018). Other outcomes, such as hospitalizations, were not examined in that study.

Workplace assistance

Issues with steady work go hand-in-hand with housing struggles for many persons who use opioids. However, according to Kenneth Silverman, PhD, a professor of psychiatry and behavioral services at The Johns Hopkins University School of Medicine, there are few direct workplace assistance for persons who use opioids. Silverman and his colleagues conduct a labor program for persistently unemployed adults with substance use disorders. The program utilizes a contingency-management approach: participants are paid to enter data, and they must also provide substance-free urine samples on a regular basis to earn the full salary. The researchers discovered that a combination of employment incentives and medication treatment appears to be the key to achieving abstinence, demonstrating how social support and medical treatment can function together (Drug and Alcohol Dependence, Vol. 197, 2019). Employees are not dismissed if they relapse, as they may be in a traditional company.

"More than a second chance is required for our people," Silverman argues.

Silverman claims that his federally financed initiative would be difficult to replicate in most workplaces. Employee assistance programs, which are frequently confined to short-term counseling and referrals, are likely to be used by most organizations to address employees with substance use problems who aren't simply fired.

However, some employers are becoming more interested in providing further assistance and second chances. Belden, a computer and telecoms hardware manufacturer, has a "Pathways to Employment" program that allows job seekers who have been turned down due to a failed drug test to go through rehabilitation and try again. Contractors like American Substance Abuse Professionals Inc. collaborate with businesses to design therapies for employees who have failed drug tests, especially in jobs that need a high level of safety, like transportation and nuclear energy.

Silverman and his colleagues are currently conducting a research in which participants labor for 90 days in their data-entry firm before working with an employment consultant for a year to find paid work outside of the study. They are paid a stipend as long as they remain abstinent during this time.

"High-magnitude incentives are required, and they must be maintained over lengthy periods of time," Silverman argues. "One of the motives for adopting employment is that it can provide long-term high-magnitude incentives."

Therapy for the whole family

Loved ones can also play an important role in helping people recover from opioid addiction. Family therapy can assist families in creating a healthy environment for a member who is using drugs, repairing relationships that have been shattered by drug use, and supporting their loved one's recovery.

"Whether you're a kid, a young adult, or a 40-year-old, you have family, and your family may either support or hinder your recovery," says Gayle Dakof, PhD, a clinical psychologist and professor of public health at the University of Miami and the director of MDFT International.

According to Hortensia Amaro, PhD, a psychologist at Florida International University who founded Entre Familia, a long-standing residential drug use treatment program for Latina mothers in Boston, patients often come to treatment still entangled in relationships with other substance users. According to Amaro, these patients must rebuild their social circles and develop skills to negotiate or withdraw from toxic connections.

According to Kimberly Kirby, PhD, a professor of psychology at Rowan University in New Jersey, family engagement is extremely crucial for teenagers who use substances, and programs have been established to aid even when a loved one is resistant to treatment. CRAFT stands for Community Reinforcement and Family Training, and it teaches families how to interact with a substance-abusing family member by using positive reinforcement and increasing communication and other interpersonal skills. According to studies by Hendrick G. Roozen, PhD, of Erasmus University Medical Centre in Rotterdam, this strategy has been proved for decades to bring more persons with substance use disorders into treatment than other family support choices like Al-Anon and Nar-Anon or traditional therapies (Addiction, Vol. 105, No. 10, 2010).

Treatment entry training, or teaching families to seek for the short times when loved ones may be amenable to treatment and how to phrase their requests for aid, has been proven to be beneficial on its own in raising treatment entry rates by Kirby and her team (Psychology of Addictive Behaviors, Vol. 31, No. 7, 2017).

Multisystemic therapy (MST) and multidimensional family therapy are two other excellent family-oriented techniques (MDFT). Both programs differ from CRAFT in that they concentrate on both treating substance abuse and strengthening family bonds. There are some distinctions between the two programs. MST, for example, focuses on treating adolescents in their families, schools, and communities, and includes parents in all counseling sessions with children. MDFT is used in community settings as well as inpatient facilities, and it recommends both solo and joint therapy sessions with kids. Both, however, ultimately aim to heal the family and increase good social support. MST has been found to be one of the most effective interventions for adolescent substance abusers with behavioral issues (Substance Abuse: Research and Treatment, Vol. 6, 2012). According to a meta-analysis by Thimo van der Pol of Leiden University and colleagues, MDFT, which is Dakof's therapy focus, is similarly highly rated for efficacy (Journal of Child Psychology and Psychiatry, Vol. 53, No. 5, 2017). The sessions in which opioid-using youth and their families gather to establish an overdose prevention and safety plan are a very important part of MDFT for them.

"The goal is to elicit an emotional conversation about drugs, overdose, death and life, and so on, in order to urge people to help one another," Dakof explains.

These programs have a high success rate, but a constant issue, according to Kirby, is that they aren't offered everywhere and that families are unaware of them. She claims that access to these family-centered substance abuse therapies is "actually not fantastic."

Not punishment, but support

People who use drugs frequently end up in the criminal justice system rather than receiving good treatment. With the opioid crisis worsening, police, district attorneys, and the courts are increasingly serving as lifelines rather than disciplinary authorities.

The situation is critical. As of 2009, 58 percent of state convicts and 63 percent of sentenced jail inmates matched the drug usage or dependence requirements (Bureau of Justice Statistics, 2017). Jails and jails aren't drug-free zones; Seattle's Scott claims to have been imprisoned a few years ago. He became addicted to methamphetamines after his release.

He claims that "jail isn't a nice place for addicts."

Incarceration and its consequences, in particular, can be life-threatening for those with opioid use disorders. Overdose deaths in this cohort increase three to eightfold within the first four weeks of release from prison, according to one meta-analysis, because persons with opioid use disorder lose their tolerance to heroin and other opioids if they don't use regularly while incarcerated (Merrall, E., et al., Addiction, Vol. 105, No. 9, 2010).

Another meta-analysis discovered that providing drugs for addiction treatment may be beneficial—treatment with methadone, buprenorphine, or naltrexone while incarcerated increases substance use treatment entry, and methadone also reduces opioid usage following release (Moore, K.E., et al., Journal of Substance Abuse Treatment, Vol. 99, 2019).

States are starting to notice: in 2016, Rhode Island began screening all inmates for opioid use disorder and providing therapy and treatment. The California Department of Health Care Services is sponsoring the expansion of opioid addiction medicine therapy in 22 counties' correctional facilities. The federal prison system, too, is steadily changing. The First Step Act, a criminal justice reform bill, was signed into law by President Donald Trump in December. The law requires the federal prison system to enhance evidence-based treatment for opioid addiction, which includes both medicine and "holistic" treatments, according to the statute.

A more well-established option is to refer persons with substance use disorders to drug courts, where a judge oversees all aspects of treatment and recovery. According to Dakof, these courts are popular because they minimize recidivism and cost less than the traditional court and correctional process. The first drug court opened in Miami in 1989, and there are now over 3,000 around the country.

However, according to Dakof, drug courts do not always use the most effective evidence-based treatments. Few, for example, use MDFT or MST with juveniles, despite the fact that these treatments offer some of the greatest evidence for long-term effects.

According to Richard Wiener, PhD, a professor of psychology at the University of Nebraska–Lincoln, "since high-quality service is fundamental to a successful drug court, psychologists can play a major role in them, and not simply in treatment."

"It's getting to the point where people are thinking about drug court responsibility and professionalization. Psychologists play an important function, perhaps the most important of which is organizational and research "Wiener explains.

Wiener is currently working on guidelines for Nebraska's mental health courts, which are an extension of the drug-court paradigm. Psychologists can help lawyers, who are trained to defend their clients, think about the best way to obtain them treatment and services, in addition to writing standards, he says.

"Things like education, housing, job, social support, social security, and insurance are being looked at," Wiener says. "It's not just about substance abuse and mental health issues. It's a list of things that people require in order to be successful."