relapse sensitive care: changing systems of addiction treatment · 2018. 11. 19. · white, w....
TRANSCRIPT
Relapse Sensitive Care: Changing
Systems of Addiction Treatment
Stacey C. Conroy LICSW, MPH
Richmond VA Medical Center - Supervisory Social
Worker Mental Health & Substance Abuse
1
Stacey C. Conroy LICSW, MPH,
Disclosures
2
• Stacey C. Conroy LICSW, MPH, has no financial
relationships to disclose.
The contents of this activity may include discussion of off label or investigative drug uses. The
faculty is aware that is their responsibility to disclose this information.
Planning Committee, Disclosures
3
AAAP aims to provide educational information that is balanced, independent, objective and free of bias and based on
evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone
in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This
disclosure information is listed below:
The following developers and planning committee members have reported that they have no commercial relationships
relevant to the content of this module to disclose: PCSSMAT lead contributors Frances Levin, MD and Adam Bisaga,
MD; AAAP CME/CPD Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten,
MD, Joji Suzuki, MD; AMERSA staff and faculty Colleen LaBelle, BSN, RN-BC, CARN, Doreen Baeder and AAAP
Staff Kathryn Cates-Wessel, Miriam Giles and Blair Dutra.
All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is
accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of
patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted
standards of experimental design, data collection, and analysis. The content of this CME activity has been reviewed and the
committee determined the presentation is balanced, independent, and free of any commercial bias. Speakers will inform the
learners if their presentation will include discussion of unlabeled/investigational use of commercial products.
Accreditation Statement
4
• American Academy of Addiction Psychiatry (AAAP)
is accredited by the Accreditation Council for
Continuing Medical Education to provide continuing
medical education for physicians.
Designation Statement
5
• American Academy of Addiction Psychiatry
designates this enduring material
educational activity for a maximum of one
(1)AMA PRA Category 1 Credit™.
Physicians should only claim credit
commensurate with the extent of their
participation in the activity.
Date of Release: March 15, 2016
Date of Expiration: March 15, 2019
System Requirements
6
• In order to complete this online module you will need
Adobe Reader. To install for free click the link below:
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Target Audience
7
• The overarching goal of PCSS-MAT is to make
available the most effective medication-assisted
treatments to serve patients in a variety of settings,
including primary care, psychiatric care, and pain
management settings.
Educational Objectives
8
• At the conclusion of this activity participants should be able to:
• Identify 2 factors that contribute to supporting a Relapse Sensitive Care model of addiction treatment
• Assess current practice for relapse sensitive care concepts
• Develop an action plan to implement relapse sensitive care in current practice
• Discuss Quality of Life as a potential Outcome Measure for addiction treatment
Treatment Completion Matters to
Outcomes
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• Patients who completed the treatment program used significantly fewer psychiatric inpatient bed days of care the year after they completed the program, both in comparison to their own prior use and in comparison to program dropouts.
• Graduates were more likely to be abstinent and less likely to fully relapse or be incarcerated at 6- month follow-up.
Wallace, A.E. & Weeks, W.B. (2004). Substance abuse intensive
outpatient treatment: Does program graduation matter?
Journal of Substance Abuse Treatment, 27-30.
Seeking But Not Completing Treatment
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56% of those who seek treatment do not complete treatment:
• Treatment completed: 44 percent
• Dropped out: 26 percent
• Transferred for further treatment: 15 percent
• Terminated by facility: 7 percent
• Other: 5 percent – failed to complete for other reasons
• Incarcerated: 2 percent
Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS): 2011. Discharges from Substance Abuse Treatment Services. BHSIS Series S-70, HHS Publication No. (SMA) 14-4846. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
• We would hope that the days are numbered in which the addictions field can argue that addiction is a primary health care problem while its clinicians continue to treat the primary symptoms of addiction as bad behavior subject to “disciplinary discharge.”
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White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006)
“It’s time to stop kicking people out of treatment.” Counselor.
Changing how Addiction is viewed…
A Few Common Administrative
Discharge Reasons
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• Failing to participate in service activities, e.g.,
missing counseling sessions.
• Possessing contraband in the treatment facility
(e.g., illicit drugs, cigarettes, prohibited food
items).
• Using alcohol or non-prescribed drugs.
• Failing to secure medication for a psychiatric
condition.
White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006)
“It’s time to stop kicking people out of treatment.” Counselor.
• What has OR does honesty about relapse lead to?
• Who created the “liars” in addiction
treatment? Hint: It was “Us” the providers
• What incentive do patients have to be
honest if discharge is the outcome?
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Honesty
Relapse Sensitive Care (RSC)
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• A systemic philosophy of care with the goal of
maintaining an individual in addiction treatment to
enhance the potential for sustained recovery.
In certain settings this systemic philosophy of
care can be expanded to encompass an
individuals definition of recovery with outcomes
based on quality of life and not solely on
abstinence.
Something New
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Recovery Orientated
Systems of Care
Relapse Sensitive Care Harm Reduction
Development of Network of
Community Base Services
Development of Internal and
External Recovery Supports
– Single Agency
Often one component of
larger agency
Fully implemented in a few
places
Can be implemented in any
size agency or practice
Restrictions on
implementation due to
public opinion
May be abstinence based
with standard rate of
administrative d/c due to
substance use
Motivational/Values/
Quality-of-Life Based
Does not require that the
behavior with the negative
outcome stops, simply finds
a safer way to engage in
behavior while motivation
for change develops
Traditionally Abstinence
Based
Chronic Disease
Management
Public Health / Safety
Consider
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Relapse Sensitive Care
• Multiple opportunities to engage in treatment, stopping the revolving door of multiple treatment episodes
• Increase in recovery supports following a relapse while remaining in treatment (not a discharge and referral model)
• Explores additional measure of treatment success i.e. Quality of Life (QoL) Measures
Traditional Care
• One strike on substance use often leads to discharge
• Decreases recovery supports through discharge – often when a patient relapses they leave treatment which may include loss of housing, emotional supports, freedom due to legal issues
• Urine Drug Screen is most common measure of treatment success
Disease Model of Addiction
Not as New as People
Think
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Addiction Behavior or Biology…
Patients to be Treated
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• 1784 - Dr. Benjamin Rush’s Inquire into the effects of
Aberrant Sprits on the Human Mind and Body – argued
that this condition is a disease that physicians should be
treating
• 1810 - Dr. Rush calls for the establishment of a “Sober
House” to care for the confirmed “drunkard”
• 1891-1892 - Keeley League “Laws must realize a
leading fact: Medical not penal treatment reforms the
drunkard.”
White, W. (1998) Slaying the Dragon: The History of Addiction Treatment
and Recovery in America. Bloomington IL: Chestnut Health Systems
Public Health Issue
White, W. (1998) Slaying the Dragon: The History of Addiction Treatment
and Recovery in America. Bloomington IL: Chestnut Health Systems.
19
• 1944 - Marty Mann founds the National Committee for Education on Alcoholism (today the National Council on Alcoholism and Drug Dependence) around the following propositions:
1. Alcoholism is a disease.
2. The alcoholic, therefore, is a sick person.
3. The alcoholic can be helped.
4. The alcoholic is worth helping.
5. Alcoholism is our No. 4 public health problem, and our public responsibility.
Specialty Medicine
White, W. (1998) Slaying the Dragon: The History of Addiction Treatment
and Recovery in America. Bloomington IL: Chestnut Health Systems.
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• 1954 - Ruth Fox, MD establishes the New York City
Medical Society on Alcoholism, today known as the
American Society of Addiction Medicine (ASAM).
• 1967 - The American Medical Association passes
resolution identifying alcoholism as a "complex" disease
and a "disease that merits the serious concern of all
members of the health professions."
• 1967 - The New York Medical Society alters its mission
to become the American Society on Addiction Medicine.
Development of Medications
21
Diseases are treated with medications:
• Methadone – 1947 in powder form for compounding; 1973 tablet for suspension; 2010 solution oral
• Disulfiram (Antabuse) 1951
• Buprenorphine,(Suboxone, Subutex) 2002
• Acamprosate (Campral) 2004
• XR-Naltexone (Vivtrol) 2006
FDA/Center for Drug Evaluation and Research Office of Communications Division of Online Communications Update Frequency: Daily www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.Search_Drug_Name
Neuroscience Of Cue Induced
Relapse
AND
Reinstatement in Animal
Studies
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Drug Related Cue
Literature Review
These drug-related cues may be:
• Visual (seeing words, pictures or silent videos)
• Auditory (e.g., listening to imagery scripts)
• Audiovisual (combination of sights and sounds)
• Tactile or haptic (handling the corresponding paraphernalia)
• Olfactory or gustatory (smelling or tasting the substance)
• Increasingly often, multi-sensory drug cues are also employed (e.g., holding a cigarette while watching audio- videos of smoking)
• Induced Neuroadaptations in the Nac cAMP second messenger system in relapse
Jasinska A.J., Stein E.A., ,Kaiser J., ,Naumer M.J., Yalachkov Y. (2014).
Factors modulating neural reactivity to drug cues in addiction: A survey of
human neuroimaging studies. NeurosciBiobehavRev 38:1–16.
Relapse is Biological
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Each of these reinstatement relapse concepts has been reproduced in animal studies – absent of human psychosocial stressors
• Discrete cue-induced reinstatement
• Context-induced reinstatement
• Discriminative cue-induced reinstatement
• Reinstatement model
Bossert et al, (2013) The reinstatement model of drug relapse: recent
neurobiological findings, emerging research topics transitional research.
Pharmacology 229: 453-476.
History, Medicine, and Neuroscience
Are Telling Us…
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The messages outward are that:
• The client is not in control of their alcohol and/or drug
intake or its consequences.
• The client needs professional treatment to reacquire
such control.
• Reacquisition of control over [Alcohol & Other Drugs]
AOD use/nonuse decisions takes time and may be
preceded by one or more episodes of relapse.
• Long-term recovery is best supported by patience and
support rather than punishment and abandonment.
White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006)
“It’s time to stop kicking people out of treatment. Counselor.
Relapse Sensitive Care
• What would it be like if a patient were honest and remained in treatment following a relapse?
• How could we support them in their recovery process? Do we know our internal and external sources of recovery supports?
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Back to Honesty
How to Start Changing a System:
Change Can Be Challenging
For Patients AND Staff
Relapse Sensitive Care
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Begin with Assessment of Current
Policies and Procedures
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What happens in our system, facility, or practice if a patient
has a positive urine drug screen?
• d/c?
• d/c with referral – often a requirement for state funded
treatment programs?
• Maintained in treatment with a consequence and
support for ongoing treatment?
• Maintained in treatment with increase in recovery
supports?
What research supports our current policies and
procedures?
Recovery Supports
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• Addiction treatment and recovery support services have
repeatedly been shown to be effective with many
people achieving recovery. As with any chronic disease,
however, discrete treatment episodes, supported by
continuing recovery support services, are often needed
to help people achieve and maintain recovery.
Treatment for addictive disorders is not typically a “one-
shot” type of intervention.
Kaplan, L., The Role of Recovery Support Services in Recovery-Oriented Systems of Care. DHHS Publication No. (SMA) 08-
4315. Rockville, MD: Center for Substance Abuse Services, Substance Abuse and Mental Health Services Administration,
2008.
Identify Internal Recovery Supports
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• Do you have groups? Individual counseling?
• Do you have on site 12 step meetings?
• Do you have peer mentors?
What is your time frame for the additional
supports to assist the recovery process? 14
days, 30 days?
Recovery supports will not resolve a relapse
over night – what is the time frame in which
change is anticipated?
Identify External Recovery Supports
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• Do you have the ability to refer to other providers of group
or individual counseling?
Will you maintain treatment until referral provider
establishes and begins to implement a treatment plan?
• Can you provide 12 step meeting list?
Do you have the ability to explain types of meetings,
benefits of meetings, how to utilize meetings, along with
explaining the role of sponsors?
It is one thing to give a referral or send to meetings, it is
another to facilitate the referral with warm handoff
Educational Needs
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What education will be needed to
implement Recovery Sensitive Care
philosophy within our System of care?
First Level of Education
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Easy to implement (example):
• Pleasure Unwoven: inexpensive DVD outlining historical and modern concepts of calling addiction a disease – staff and patients
Increases discussion on the realities why relapse happens despite honest desire for recovery
Increases understanding of the biological aspect of addiction and why someone may relapse while in treatment
Increase understanding that RSC is part of a disease model of care for a chronic condition
McCauley, Kevin (producer) (2009). Pleasure Unwoven: a personal
journey about addiction. (DVD) Institute for Addiction Study.
Longer implementation process:
• Basic facts on neuroscience and relapse - reinforce the need for behavioral and social recovery supports to achieve desired recovery
• Why do I need 12 step meetings
Behavioral supports will assist when cravings come from a cue induced response you may not be aware of
• Why is MAT a good option for my recovery
While developing the behavioral and social supports for recovery MAT can assist in reducing neurological triggers for relapse which are a biological occurrence.
o Behavioral support will remain important if addiction has been to multiple substances
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Second Level Education
12 step concepts are well established connecting traditional
learning to newer neuroscience concepts may enhance the
buy-in for having RSC in place
• People
Cue induced drug-seeking and or craving
o Visual, audio, multisensory
• Places
Cue induced drug-seeking and or craving
o Visual, audio, olfactory multisensory
• Things
Stress induced drug-seeking and or craving
o Visual, audio, olfactory, multisensory
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Connecting Old and New Concepts for
Staff and Patients
Provider Role
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We often know if a patient is a “frequent flyer” -what do we offer this patient? How do we as providers adjust treatment for the at-risk patient?
• Bill Wilson, co-founder of Alcoholics Anonymous, and
Marty Mann, founder of the National Council on Alcoholism and Drug Dependence, were both treatment recidivists (ten prior treatments between them before finding sobriety).
White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006)
“It’s time to stop kicking people out of treatment. Counselor.
Change is a Process
for Treatment Providers
37
• MAT treatment was once considered to be outside of the
mainstream of addiction treatment- though in recent years
it has gained wider acceptance as Evidence Based
Practice.
• Relapse Sensitive Care may be the Next Change –
keeping those who seek treatment engaged to improve
outcomes.
• BUT what constitutes a desired “Outcome”?
If Negative Urine Drug Screens is
Not the Outcome Measure
then What Is?
Quality of Life
QoL
38
Outcomes?
Quality of Life as a Recovery Outcome
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• SAMHSA has established a working definition of recovery that
defines recovery as a process of change through which
individuals improve their health and wellness, live self-
directed lives, and strive to reach their full potential.
Recovery is built on access to evidence-based clinical
treatment and recovery support services for all populations.
SAMHSA's Working Definition of Recovery Pub id: PEP12-RECDEF,
Publication Date: 2/2012, Format: Brochure
SAMHSA’s Working Definition of Recovery — 2012.
Quality of Life as Treatment Outcome
Measures
Psychoactive Drugs, 47:2, 149-157. 40
Mitchell et al (2015)
• Findings were statistically significant (all ps < .001).
Continued treatment enrollment was significantly associated
with improved psychological, environmental and social
aspects 6 months into treatment
Quality of Life
measure (QoL)
Change at six month follow up
during treatment
Overall improvement 10.8% increase
Psychological 7.6% increase
Environmental 8.5% increase
Social 11.2% increase
Mitchell, S.G., Gryczynski, J., Robert P. Schwartz, R.P., Myers, C.P., O’Grady, K.E., Olsen, Y.K.,
& Jaffe, J.H. (2015) Changes in Quality of Life following Buprenorphine Treatment: Relationship with
Treatment Retention and Illicit Opioid Use, Journal of
QoL as treatment outcome measure
41
Dhawan, A., & Chopra, A. (2013)
• Examined QoL scores: Continued treatment enrollment
was associated with significant increases in four Quality of
Life measures at 9 months, including the physical, social,
psychological and environmental QoL domains. (p<.001)
QoL measure Baseline data 9 month follow up
during treatment
Physical 50.3 61.3
Social 45.8 56.2
Psychological 43.6 57.9
Environmental 42.3 54.3
Dhawan, A., & Chopra, A. (2013). Does buprenorphine maintenance improve the quality of life of opioid
users? The Indian Journal of Medical Research, 137(1), 130–135.
QoL and Evidenced Based Practices
42
Outcome data from a Quality of Life measure can be
incorporated into SAMHSA Evidence Based Practices:
• Motivational Interviewing: Reviewing readiness and confidence scales with patients
in context of QoL measures during treatment
• Acceptance and Commitment Therapy:
Focusing on valued direction in life, psychological flexibility –
energies/tasks moving you towards QoL, towards your valued
outcomes
Miller, W. R., and Rollnick, S. (2013) Motivational Interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.
Wilson, K.G. and DuFrene, T. (2012) The wisdom to know the difference an acceptance and commitment therapy workbook for overcoming
substance abuse. Oakland, CA: New Harbinger Publications.
Safety Matters
43
• Medical based safety will still need to be considered
especially in MAT. Drug interactions or potential for
accidental OD
Discharging a patient for reason other than medical
safety should be done only after several attempts to
engage them in treatment have been made
o This includes barrier identification to maintaining
recovery
o Naloxone – OD prevention recourses for every
discharge based on medical safety
Safety Matters
44
Residential program may consider RSC in context of type of
relapse:
In the community vs. bring drugs/alcohol into the
program
o Returning to the program under the influence is a
symptom and not the equivalent to bringing
drugs/alcohol into the program
• An assault is a legal issue and constitutes a choice to
end treatment
Summary
45
Relapse Sensitive Care:
• Supported by Disease Model
• Supported by Neuroscience which provides evidence on
biological reasons for relapse
Treatment engagement, not punitive measures for
return of biological-based symptoms
• Supports the SAMHSA definition of recovery which
includes, health, wellness, and self determination
• Supports Quality of Life as an outcome rather than solely
on negative urine drug screens
Summary
46
Relapse Sensitive Care Implementation:
• Assessment of current policies and procedures
• Current recovery support resources
Internal and external
• Education
Patients and Staff
• Incorporating Quality of Life as on outcome measure
• QoL patient data incorporated into EBPs
References
47
Bossert et al, (2013) The reinstatement model of drug relapse: recent recent neurobiological findings,
emerging research topics transitional research. Pharmacology 229: 453-476.
Dhawan, A., & Chopra, A. (2013). Does buprenorphine maintenance improve the quality of life of opioid
users? The Indian Journal of Medical Research, 137(1), 130–135.
FDA/Center for Drug Evaluation and Research Office of Communications Division of Online
Communications Update Frequency: Daily
www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.Search_Drug_Name
Jasinska A.J., Stein E.A., ,Kaiser J., ,Naumer M.J., Yalachkov Y. (2014). Factors modulating neural
reactivity to drug cues in addiction: A survey of human neuroimaging studies. NeurosciBiobehavRev 38:1–
16.
Kaplan, L., The Role of Recovery Support Services in Recovery-Oriented Systems of Care. DHHS
Publication No. (SMA) 08-4315. Rockville, MD: Center for Substance Abuse Services, Substance Abuse
and Mental Health Services Administration, 2008.
McCauley, Kevin (producer) (2009). Pleasure Unwoven: a personal journey about addiction. (DVD) Institute
for Addiction Study.
References
48
Miller, W. R., and Rollnick, S. (2013) Motivational Interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.
Mitchell, S.G., Gryczynski, J., Robert P. Schwartz, R.P., Myers, C.P., O’Grady, K.E., Olsen, Y.K., & Jaffe, J.H. (2015) Changes in Quality of Life following Buprenorphine Treatment: Relationship with Treatment Retention and Illicit Opioid Use, Journal of Psychoactive Drugs, 47:2, 149-157.
SAMHSA's Working Definition of Recovery Pub id: PEP12-RECDEF, Publication Date: 2/2012, Format: Brochure SAMHSA’s Working Definition of Recovery — 2012.
Self, D. W.; Nestler, E. J. (1998) Relapse to drug-seeking: neural and molecular mechanisms. Drug and alcohol dependence 51: 49-60.
Shannon Gwin Mitchell Ph.D., Jan Gryczynski Ph.D., Robert P. Schwartz M.D., C. Patrick Myers M.A., Kevin E. O’Grady Ph.D., Yngvild K. Olsen M.D. & Jerome H. Jaffe M.D. (2015) Changes in Quality of Life following Buprenorphine Treatment: Relationship with Treatment Retention and Illicit Opioid Use, Journal of Psychoactive Drugs, 47:2, 149-157.
Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
References
49
Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS): 2011. Discharges from Substance Abuse Treatment Services. BHSIS Series S-70, HHS Publication No. (SMA) 14-4846. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
Wallace, A.E. & Weeks, W.B. (2004). Substance abuse intensive outpatient treatment: Does program graduation matter? Journal of Substance Abuse Treatment, 27, 27-30.
White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006) It’s time to stop kicking people out of treatment. Counselor.
White, W. (1998) Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington IL: Chestnut Health Systems.
Wilson, K.G. and DuFrene, T. (2012) The wisdom to know the difference an acceptance and commitment therapy workbook for overcoming substance abuse. Oakland, CA: New Harbinger Publications.
PCSS-MAT Mentoring Program
50
• PCSS-MAT Mentor Program is designed to offer general information to
clinicians about evidence-based clinical practices in prescribing
medications for opioid addiction.
• PCSS-MAT Mentors comprise a national network of trained providers with
expertise in medication-assisted treatment, addictions and clinical
education.
• Our 3-tiered mentoring approach allows every mentor/mentee relationship
to be unique and catered to the specific needs of both parties.
• The mentoring program is available, at no cost to providers.
For more information on requesting or becoming a mentor visit:
pcssmat.org/mentoring
PCSS-MAT Listserv
Have a clinical question? Please click the box below!
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Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for
Medication Assisted Treatment (5U79TI024697) from SAMHSA. The views expressed in written
conference materials or publications and by speakers and moderators do not necessarily reflect the
official policies of the Department of Health and Human Services; nor does mention of trade names,
commercial practices, or organizations imply endorsement by the U.S. Government.
PCSSMAT is a collaborative effort led by American Academy
of Addiction Psychiatry (AAAP) in partnership with: American
Osteopathic Academy of Addiction Medicine (AOAAM),
American Psychiatric Association (APA), American Society of
Addiction Medicine (ASAM) and Association for Medical
Education and Research in Substance Abuse (AMERSA).
For More Information: www.pcssmat.org
Twitter: @PCSSProjects
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