Barriers to medication use: Myths, money, and management

An introduction from Addiction Professional's Editor This is the third in a series of six articles designed to provide you with the latest information on the use of medications in alcohol dependence treatment. Medications (pharmacotherapy) used as adjuncts to counseling techniques and biopsychosocial, educational, and spiritual therapies are an increasingly important part of a comprehensive treatment approach for alcohol dependence.

Expanding knowledge of how medications may interact with and complement counseling techniques will help the addiction counseling community optimally coordinate care of patients with other treatment providers. Thus, the article series Pharmacotherapy: Integrating New Tools Into Practice will not only provide the latest efficacy and safety data on these medications, it will also explore how we can build better relationships among addiction professionals and medication prescribers. The series will also examine the current barriers to medication use in treatment while offering potential solutions.

The series began in the January/February 2007 issue with an article by Carlo C. DiClemente, PhD, who discussed recovery from alcohol dependence as a process of change and examined how medications might facilitate that process. The series continued with an article in the March/April 2007 issue by Carlton K. Erickson, PhD, who looked at what some of the most important study results from recent years have told us about the approved medications for alcohol dependence treatment. In this third article, Christopher W. Shea, MA, CRAT, CAC-AD, examines how clinical professionals can help overcome a variety of biases and other barriers against greater use of medications in the treatment of alcohol dependence.

In my years of chemical dependence counseling and teaching at the collegiate level, I have encountered many people who have not only heard myths about chemical dependency and counseling, but who also believe these myths without question. Blind belief of myths, propagated by both clinicians and patients, can create barriers that prevent comprehensive and effective treatment of alcohol dependence. In some cases, the beliefs of clinicians may be better termed “misconceptions” or “misperceptions.”

For example, for many years I have taught an “Introduction to Pharmacology” course to chemical dependence counseling students, many of whom have lamented having to learn about medications and neurobiology when their goal was simply to counsel addicts and alcoholics. These students understand and believe that addiction is a disease, yet they experience a disconnect when they fail to consider medications as a form of treatment. This article will explore some of the common myths or misconceptions surrounding medication use for the treatment of alcohol dependence, and will provide solutions based on research and practical experience to overcome these barriers to pharmacologic therapy.

Treatment provider barriers to medication use

Addiction counselors tend to be more familiar with behavioral counseling approaches to alcohol dependence treatment than with pharmacologic treatments and, therefore, are less likely to recommend medications. 1 For example, about 40 to 54% of counselors in one study reported that they did not know much about the efficacy of oral naltrexone. 1 Perhaps this lack of understanding about medications contributes to a concern among counselors that medications will negate and replace their role in the recovery process. However, medication efficacy has virtually always been studied in combination with psychosocial therapy and thus is defined by its role as a component part of treatment. The fact that alcohol dependence is a disease with several contributing factors manifesting in both physical and behavioral symptoms demands a comprehensive approach to treatment, since exclusion or elevation of one aspect of the disease fails to help distressed patients fully. 2


Christopher W. Shea

This is an important point for consideration among clinicians who believe the use of medication is inconsistent with the philosophy of total abstinence, or who view the use of medication as a crutch that takes away from the “necessary” pain a person needs to feel in early recovery. I do not presume to change another's programmatic philosophical opinions, yet isn't a “crutch” a tool? The crutch, in and of itself, does not heal or negate need for treatment. The use of medication to curb physical symptoms, such as cravings, serves only to allow the patient the mental capacity to learn from his or her past and thus develop new, rational thought processes, which can be fostered through cognitive-behavioral therapy or other forms of counseling. Counselors need not fear medication interfering with the importance of their role in the therapeutic process.

Patient-centered barriers

Many beliefs and “myths” held by patients are, in fact, patients' perceived realities based on their past experiences. Understanding this concept becomes vital to assisting our patients in moving beyond their current perceptions and challenging them to new outlooks. Patient concerns or misconceptions that challenge the use of medications in treatment include concerns regarding medications' efficacy, addictive properties, and necessary duration of use. Thus, one of the counselor's roles is that of educator to allay patient concerns.

There is ample evidence supporting the efficacy of medications approved for alcohol dependence treatment, and none of these medications exhibits addictive characteristics. Patients who believe medications are helping with their sobriety are more likely to remain adherent to treatment.3 It is therefore important for clinicians to be able to educate patients about how medications work so that patients can better understand their potential efficacy as well as non-addictive characteristics.

The question about duration of use cannot be definitively answered. Studies have rarely examined medication use beyond one year, but it is logical to think that treatment providers and patients can jointly determine the point in recovery at which patients no longer need medications.

It is a common misconception that Alcoholics Anonymous (AA) discourages medication use as part of treatment. It has been shown that patients involved in 12-Step therapy, and some counselors who espouse this form of therapy, may be less likely to view medications as acceptable forms of treatment.1,4 It is vital that counselors discuss with patients who attend AA—especially those who may be experiencing peer pressure to avoid medication use—that AA advises its members against discouraging fellow members from taking medication.5

At the other end of the spectrum, some patients might mistakenly believe that medication can be used as a substitute for counseling. This is potentially very harmful to recovery because thought processes and behaviors that drive dependent individuals to alcohol will not necessarily change as a result of medication use. Counselors must emphasize to patients the importance of the therapeutic process involving counseling.

Another barrier to medication use is financial. Addiction treatment services as a whole are often not properly reimbursed,6 and medication cost is cited as a reason by both patients and clinicians for inadequate medication use.7,8 When recommending medications as part of treatment, counselors should consider whether medications are attainable and affordable to patients. They should work with prescribers to ensure that patients have adequate access to medications. In some cases, when patients cannot afford medications, compassionate use programs may provide them at discounted rates or free of charge. Overcoming financial barriers and helping secure funding for medications and services will require cooperation among treatment providers, policy makers, and the government.9 Counselors also may play an important role in spearheading such initiatives.

Medication management

Adherence to treatment constitutes one of the largest barriers to optimal use of medications, but counselors can use the therapeutic process to enhance adherence. Communicating with and educating patients are vital. First, counselors can explain the rationale for medications and how they can support patients' goal of sobriety. This can create positive reinforcement and reduce patient anxiety about relapse.10 Patients who understand medication is helping them and not “cheating” their recovery may be more likely to remain faithful to treatment.3,11,12 Establishing a good relationship with patients and creating a treatment environment in which patients are comfortable can also improve adherence.11

Certain aspects of medication use can inherently interfere with medication adherence. For example, side effects may reduce adherence.3,12 While counselors may not directly manage adverse events from medications, they can help set and manage patients' expectations about side effects before they actually occur. Again, counselors must know and communicate specific information about the most common side effects of medications (or how long they may last) to help prepare patients. Because adverse effects from the approved medications are usually mild, patients' concerns might be allayed by knowledgeable counselors. Motivational enhancement can support patients when medications are not achieving their desired effect.

Medication dosing is another concern, because it has been demonstrated that as the frequency and complexity of medication regimens increase, medication adherence decreases.10 In contrast, there is evidence that long-acting agents requiring less frequent dosing can improve treatment adherence.13 Counselors should consider dosing regimens when recommending different medication options, especially if adherence poses a concern. Counselors also can provide advice about simple reminders to help patients better remember to take medications. For example, taking medications can be correlated with certain cues or daily routines, such as eating and brushing teeth.10

Certain counseling techniques are also designed to improve medication adherence. Medical management and BRENDA are brief forms of therapy that promote abstinence and adherence to medication schedules.14,15 These techniques have manuals that clinicians can follow and easily learn (see the additional reading list for more detailed information on these techniques). Medical management was used in the Combining Medications and Behavioral Interventions for Alcoholism (COMBINE) study, which examined the efficacy of acamprosate and naltrexone in combination with behavioral interventions and found improvement in drinking outcomes among all groups that received medical management, even those receiving placebo.16 Treatment adherence was also high in all groups.

The framework for BRENDA is based in the biopsychosocial model of addiction and consists of six stages: the clinician's (1) biopsychosocial evaluation of the patient; (2) report of that assessment back to the patient; (3) empathy for the patient's situation; (4) needs identification by both patient and clinician; (5) direct advice to the patient on how to meet those needs; and (6) assessment of the patient's reaction to that advice as well as any necessary adjustments to the treatment plan.15 BRENDA has been effectively used in a trial of extended-release injectable naltrexone.17 And in a trial of oral naltrexone, BRENDA improved treatment completion rates and medication adherence compared with standard individual therapy.18

Other counseling techniques specifically crafted to improve medication adherence exist. For example, a form of compliance therapy based on motivational interviewing and cognitive-behavioral principles was found to improve medication adherence in a trial of acamprosate.19

Conclusion

There are many barriers to medication use for alcohol dependence treatment—more than can be fully covered here. But through several techniques, addiction counselors can effectively provide solutions to those obstacles. Improved education, knowledge, and communication among counselors and patients regarding medication use are vital to increase acceptance of medications and ensure their proper use. Perhaps most important, treatment providers and patients alike must understand that medications can be a tool that allows patients the ability to more fully participate in counseling treatment, which is needed for long-term recovery.

Christopher W. Shea, MA, CRAT, CAC-AD, is Clinical Director at Father Martin's Ashley in Havre de Grace, Maryland.

References

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Supported by an educational grant from Alkermes, Inc., and Cephalon, Inc.