"...over time, tremendously important behavioral and social aspects to being [opioid dependent] develop—such as loss of social and occupational function—which must be seen as integral to the disease itself. Thus, the fact that the underlying origin of the disease is modified brain function does not alter the need of treatment to attend to all aspects of the disorder—biological, behavioral, and social."¹

Behavioral Counseling Can Be Vital to Treatment²
Pharmacotherapy can be an important part of the treatment for opioid dependence because it helps to manage cravings and withdrawal symptoms that may threaten to distract patients from other areas of their lives.

Behavioral counseling can be equally important to the success of opioid dependence treatment. Several studies have shown that behavioral counseling significantly increases the likelihood of treatment success when used in conjunction with pharmacotherapy.^3-5

Some of the many benefits counseling can offer include helping patients identify the causes of their dependence, helping patients stay focused on their recovery, providing support, and peer acceptance. Ongoing or longer-term counseling is one of the most effective ways for patients to learn the skills to help manage triggers and other situations that increase their vulnerability to relapse. Furthermore, it permits both informal and formal monitoring of patients' treatment progress.⁶

Talking to Patients
Patients are more likely to be honest about their use when they feel their physician will provide or facilitate the most appropriate treatment.^7,8 Demonstrating empathy during the intervention conveys that you are listening and trying to understand that patient's specific situation, which, in addition to facilitating patient assessment, is also very effective for encouraging patients' self-esteem.⁸

In addition, projecting confidence and knowledge about substance abuse is also important, as many patients have a positive response to caretakers they perceive as competent and interested.⁸

Brief Interventions—A First Step
The Center for Substance Abuse Treatment defines brief interventions as "those practices that aim to investigate a potential problem and motivate an individual to begin to do something about his or her substance abuse."⁵

The overarching goal of a brief intervention is to motivate patients to take action to control their opioid use, but within this framework, the details are flexible. Brief interventions can be as simple as suggestions to reduce nonmedical opioid use—not every intervention will (or should) culminate in a patient's receiving pharmacotherapy. Brief interventions can be particularly valuable as an intermediate-term approach for encouraging action, particularly if more extensive treatment is unavailable or if the patient is resistant to such treatment.⁵

Brief interventions stress that the ultimate responsibility for change lies with the patient. By raising an individual's awareness of his or her substance abuse, the brief intervention can act as a powerful catalyst for change.⁵

Types of Counseling
The wide range of counseling methods and settings available to patients being treated for opioid dependence allows everyone the flexibility to chose an approach that works best for him or her. Regardless of the technique or method practiced, certain aspects of counseling are fairly consistent across the board, for instance, the goals of therapy:

• Reassure the patient that change is possible
• Target the symptom, not its causes
• Define clear treatment goals that are understood by both you and your patient
• Aim for immediate results and measurable outcomes
• Rely on a strong client-therapist relationship
• Place responsibility for change on the patient

Counseling in Your Practice
Effective behavioral counseling can be performed in either an individual or a group setting. Primary care physicians may refer patients to a therapist trained in the treatment of substance abuse or bring in a trained counselor to lead weekly group sessions

Physicians who believe that a patient's needs exceed what their practices can reasonably provide are encouraged to make use of the following resources:

• SAMHSA Physician Locator
• Resource referral lists from the substance abuse agency in your state
• Local hospitals, medical clinics, and social services agencies also can be sources for information on and referrals for substance abuse counseling