Shared Decision Making and Medication-Assisted Treatment: A Supportive Approach to Initiating and Sustaining Addiction Recovery
Current American Society of Addiction Medicine (ASAM, 2015) guidelines call for integrating shared decision making into clinical practice. This represents an important evolution in attitudes about people with opioid use disorders.
What is shared decision making (SDM)? Why is it important to recovery-oriented practice?
The Informed Medical Decisions Foundation defines SDM as “a collaborative process that allows patients and their providers to make health care decisions together. It takes into account the best clinical evidence available, as well as the patient's values and preferences.”
(1) The choice of available treatment options for addiction involving opioid use should be a shared decision between the clinician and the patient.
(2) Clinicians should consider the patient's preferences, past treatment history, and treatment setting when deciding between the use of methadone, buprenorphine, and naltrexone in the treatment of addiction involving opioid use.
ASAM, June 2015
A 2001 landmark report from the Institute of Medicine (IOM),Crossing the Quality Chasm, helped to usher in the era of patient-centered care across physical and behavioral health services. IOM suggested ten rules to guide the redesign of the health system; four of them have specific relevance to informed choice in a recovery-oriented system of care:
- The patient as the source of control;
- Shared knowledge and the free flow of information;
- The need for transparency; and
- Customization based on patient needs and values.
Until recently, medication-assisted treatment (MAT) for opioid use disorders involved one choice: “yes” or “no” to methadone. With increasing availability of new medications and an array of treatment options, SDM needs to be an integral part of client engagement, treatment planning and recovery support.
Consider the following decision pathway. Each of these questions represents a significant client choice and potential platform for engagement in meaningful dialogue.
- Whether medication/treatment is right for me?
- Which medication/treatment is right for me?
- How does medication/treatment fit into my recovery, my life and lifestyle?
- What kinds of supports do I have/need/want?
To effectively discuss and make informed decisions about treatment and recovery support, individuals need objective and accurate information in plain language. This information can help people consider the risks and benefits of each available option in light of their personal priorities. For example, people benefit from understanding:
- Treatment options, contraindications, costs, lifestyle impact, and risks and benefits.
- Comparative outcomes for medications used as an adjunct to treatment and recovery support.
- Phases of MAT, length of treatment, and issues involved in stopping medications.
One of the greatest benefits of introducing shared decision making into clinical practice is its potential to support the process of recovery. For example,
- The SDM framework offers a structured process for making informed choices, thereby supporting the acquisition of better decision making skills, in general.
- Many people looking for help with an opioid use disorder glean hope from accurate, objective information about their condition and the full range of treatment options available.
- Accessible, transparent information encourages informed dialogue and collaborative decision making with treatment providers. This can help individuals to consciously integrate personal values and preferences into the decision making process. Shared decision making is crucial for people in long term recovery when any mood altering medication is prescribed.
- Shared decision making helps individuals exercise a degree of choice over the health care decisions that affect them. Exercising choice is a fundamental aspect of the recovery process.
Individuals in recovery from opioid use disorders face a high risk of relapse. Safeguarding their recovery requires personal vigilance, especially in light of the current opioid epidemic and increased opioid prescribing rates. Individuals who are willing and able to proactively discuss the risks of using a medication with abuse potential with their prescriber are better able to safeguard their recovery. The decisions people in recovery make every single day have always been their own, but they do not have to make these decisions alone.
Where can I learn more about shared decision making?
SAMHSA’s Recovery to Practice initiative offers webinars on SDM including an archived August 2016 Recovery to Practice series with presentations specific to SDM applications in treatment for substance use disorders.
SAMHSA also offers a number of resources for SDM in behavioral health. Two decision-support tools for medication-assisted treatment (MAT) for opioid use disorders have been recently released.
The MATx app offers health care practitioners information and clinical support tools.
A patient-focused tool, Decisions in Recovery: Treatment for Opioid Use Disorder offers information about medication-assisted treatment and recovery for people with opioid use disorder and treatment providers.
A decision support tool on the role of antipsychotic medications in recovery and related materials can be downloaded from http://store.samhsa.gov.
This article was developed in partnership with Niki Miller and Laurie Curtis of Advocates for Human Potential, Inc.
Keris Myrick, MBA, MS
Director, Office of Consumer Affairs
A leading mental health advocate and executive, Keris is renowned for her innovative and inclusive approach to mental health reform.Through the SAMHSA Center for Mental Health Services (CMHS) Office of Consumer Affairs, she supports the inclusion of peer perspectives and issues throughout the agency and across programs, such as the Voice Awards, SAMHSA Wellness Initiatives, and Wellness Week. Before joining SAMHSA, Keris was president and CEO ofProject Return Peer Support Network, a Los Angeles-based, peer-run nonprofit, which manages more than 150 self-help groups and a range of peer-run services.