Counselors shed an either-or mindset
The way North Carolina addiction counselor Linda Shaffer describes the progression in her thinking about medication treatments for addiction reflects her field's growing tendency to embrace multiple strategies for recovery. Having achieved her own sobriety through 12-Step support more than a generation ago, Shaffer stayed immersed in that approach early in her career, before gradually warming up to the idea that some medications made sense for some patients.
Shaffer still reserved great skepticism at first toward a suddenly surging interest in buprenorphine. However, “I started to get exposed to patients on Suboxone and saw what a monumental help it was,” she says. Today, about 85% of the private-practice counselor's patients are receiving buprenorphine for opioid dependence, and Shaffer works closely with physicians and physician extenders in a team approach to these patients' care.
If she has anything remotely negative to say about buprenorphine now, it might be that the medication arguably works too well to combat cravings. Some patients begin to believe that they need nothing else to move forward in life, and they try to avoid the regular 12-Step meeting attendance that Shaffer still considers critical to a healthy and full recovery. “The amount of pushback I get is stunning,” she says with regard to meetings.
Addiction Professional's second annual Quality of Life Survey (see Fall 2016 issue for other results) illustrated strong support among clinicians for both 12-Step approaches and medication treatment. A total of 54.8% of respondents called the Steps a key element at all levels of care, with another 31.2% saying they worked best for continuing care. These numbers were very close to the corresponding percentages of 51.6% and 32.8% that were seen in the 2015 Quality of Life Survey, which did not have an identical composition of participants.
The latest survey also asked participants for the first time to offer their views on medication-assisted treatment for addictions. While only 10.8% of respondents ranked medications as the most essential component of successful recovery, 79.4% said they were effective as long as counseling remained in the primary role. Just under 10% of respondents said medication-assisted treatment was unproven or worse.
Within Shaffer's treatment team in the Shelby area of western North Carolina, counseling is not an optional activity for buprenorphine patients. If the patients don't go to weekly therapy sessions, they don't continue to receive the medication, Shaffer explains. She sometimes gets the sense that some of her patients don't see therapy, and even more so meeting attendance, as important.
She says buprenorphine “provides them the breathing room, so they're not constantly looking for [drugs]. It sets everything in place. But if they don't get their motivation for life right, if they don't stop their addictive thinking patterns, they will end up relapsing when they taper down.”
The Steps and bonding
Survey respondent David Poles, a private-practice addiction and mental health counselor and coach in the suburban Boston area, says he sees addictive behaviors closely connected to a lack of attachment. He believes the Steps speak directly to fulfilling unmet needs going back as far as childhood.
“What I like about the 12-Step model is its focus on relationships, such as with a Higher Power, and a sponsor,” says Poles, who operates the Newton Counseling Center. “It is an opportunity for someone in recovery to form bonds. I like the spiritual component too. For a lot of folks, it can help people fill in the blanks.”
Poles also says he is in favor of medication treatments as long as the prescriber has training in working with patients with addictions. He maintains close ties on cases with a psychiatrist with whom he shares office space.
He does wonder about the potential efficacy of medication treatments for patients who continue to smoke marijuana while receiving treatment for other drug use. Perception of risk from marijuana continues to erode in his home state, where voters last fall approved a ballot initiative authorizing recreational use. In addition, “It's not too difficult to get a medical marijuana card,” he says.
Shaffer has been sober for more than 30 years and says many of her friends in early recovery saw the same benefit from 12-Step support that she enjoyed. The buprenorphine patients whom she counsels are generally maintained on a consistent dose for a year, with those who show progress in therapy and other life domains judged to be ready for a tapered dose at that point.
Participation in therapy and meeting attendance appear to be linked to better outcomes in areas such as work and family reunification, Shaffer says. The prescribers often don't see that a lack of progress in these areas might signal that the patient is not ready for a taper, she says.
Student loan debt
The burden of student loan debt continues to weigh heavily on many in the counseling profession. Among 848 respondents to the latest survey's question on student loan debt, 390 stated that they had outstanding debt, and the median balance for these individuals was just over $28,000—not an insignificant level in a profession with generally modest salaries.
Shaffer says she has been able to refinance and consolidate some of her loan debt over the years, though she hasn't been able to avail herself of loan forgiveness options through certain nonprofit work arrangements. Poles says he was fortunate to be able to avoid debt because of GI Bill benefits available through his past service in the Naval Reserves and the Army National Guard, but adds that he has encountered other clinicians for whom debt has caused a struggle.
More than 900 individuals replied to the second annual Quality of Life Survey, with 56.5% identifying themselves as counselors and just over one-third saying they had worked with patients with substance use disorders for at least 20 years.
