Barriers to Medication Use: Myths, Money, & Management

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April 30, 2007
Barriers to medication use: Myths, money, and
management
By CHRISTOPHER W. SHEA, MA, CRAT, CAC-AD
An introduction from Addiction Professional's Editor This is the third in a series of six articles designed to provide you with
the latest inform ation on the use of medications in alcohol dependence treatm ent. 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 complem ent counseling techniques will help the addiction
counseling community optimally coordinate care of patients with other treatment providers. Thus, the article series
Pharm acotherapy: 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 b uild b etter relationships among addiction professionals and m edication
prescribers. The series will also examine the current barriers to medication use in treatment while offering potential
solutions.
The series began in the January/Feb ruary 2007 issue with an article by Carlo C. DiClem ente, 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 look ed at what some of the most
important study results from recent years have told us ab out the approved medications for alcohol dependence treatment.
In this third article, Christopher W. Shea, MA, CRAT, CAC-AD, examines how clinical professionals can help overcom e a
variety of biases and other b arriers 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 chem ical dependency and counseling, but who als o believe these myths without ques tion.
Blind belief of myths, propagated by both clinicians and patients, can create barriers that prevent comprehensive and
effective treatment of alcohol dependence. In som e cas es , the beliefs of clinicians may be better term ed “m is conceptions ”
or “misperceptions.”
For exam ple, for many years I have taught an “Introduction to Pharm acology” 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. Thes e s tudents understand and believe that addiction is a dis eas e, yet they experience a
dis connect when they fail to consider m edications as a form of treatment. This article will explore some of the com m on
myths or mis conceptions surrounding medication use for the treatm ent of alcohol dependence, and will provide s olutions
bas ed on research and practical experience to overcome these barriers to pharm acologic therapy.
Treatment provider barriers to medication use
Addiction counselors tend to be more familiar with behavioral couns eling approaches to alcohol dependence treatment
than with pharmacologic treatments and, therefore, are less likely to recom mend m edications . 1 For example, about 40 to
54% of counselors in one study reported that they did not know m uch 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 proces s . However, medication efficacy has virtually always been studied in com bination
with ps ychosocial therapy and thus is defined by its role as a com ponent part of treatment. The fact that alcohol
dependence is a diseas e with s everal contributing factors manifes ting in both physical and behavioral s ymptom s demands

a comprehensive approach to treatm ent, since exclusion or elevation of one as pect of the dis eas e fails to help distressed
patients fully. 2
Christopher W. Shea
This is an important point for consideration among clinicians who believe the us e of medication is inconsistent with the
philosophy of total abstinence, or who view the us e of medication as a crutch that takes away from the “neces sary” pain a
pers on needs to feel in early recovery. I do not presume to change another's program m atic philos ophical opinions, yet isn't
a “crutch” a tool? The crutch, in and of itself, does not heal or negate need for treatm ent. 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 proces s es , which can be fostered through cognitive-behavioral therapy or other forms of
counseling. Counselors need not fear medication interfering with the im portance of their role in the therapeutic process.
Patient-centered barriers
Many beliefs and “myths” held by patients are, in fact, patients' perceived realities bas ed on their pas t experiences.
Understanding this concept becom es vital to ass is ting our patients in moving beyond their current perceptions and
challenging them to new outlooks. Patient concerns or misconceptions that challenge the us e of medications in treatment
include concerns regarding medications ' efficacy, addictive properties, and neces s ary duration of us e. 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 characteris tics . 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 characteris tics.
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 determ ine the point in recovery at which
patients no longer need medications.
It is a common misconception that Alcoholics Anonymous (AA) dis courages medication us e as part of treatment. It has
been shown that patients involved in 12-Step therapy, and som e counselors who espous e this form of therapy, may be less
likely to view medications as acceptable forms of treatment.1,4 It is vital that counselors dis cus s with patients who attend
AA—especially those who may be experiencing peer press ure to avoid m edication us e—that AA advises its mem bers
against discouraging fellow members from taking medication.5
At the other end of the spectrum , som e patients might mis takenly believe that medication can be used as a substitute for
counseling. This is potentially very harmful to recovery becaus e thought proces s es and behaviors that drive dependent
individuals to alcohol will not neces sarily change as a res ult of medication us e. Counselors must em phasize to patients
the importance of the therapeutic process involving counseling.
Another barrier to medication us e 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 us e.7,8 When
recom mending medications as part of treatm ent, couns elors should consider whether medications are attainable and

affordable to patients . They should work with pres cribers to ensure that patients have adequate access to medications . In
some cases, when patients cannot afford medications, com pas s ionate use programs may provide them at dis counted
rates or free of charge. Overcom ing financial barriers and helping s ecure funding for medications and services will require
cooperation among treatment providers, policy makers , and the governm ent.9 Counselors als o m ay play an im portant role
in spearheading such initiatives.
Medication management
Adherence to treatment cons titutes one of the largest barriers to optimal use of medications, but counselors can us e the
therapeutic process to enhance adherence. Com m unicating 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 pos itive
reinforcement and reduce patient anxiety about relapse.10 Patients who unders tand m edication is helping them and not
“cheating” their recovery may be more likely to rem ain faithful to treatment.3,11,12 Establis hing a good relationship with
patients and creating a treatm ent environm ent in which patients are comfortable can also improve adherence.11
Certain aspects of medication us e can inherently interfere with medication adherence. For exam ple, side effects may
reduce adherence.3,12 While couns elors 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 com mon side effects of medications (or how long they may last) to help
prepare patients. Becaus e advers e effects from the approved m edications are us ually mild, patients' concerns might be
allayed by knowledgeable counselors . Motivational enhancement can support patients when m edications 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 increas e, medication adherence decreas es .10 In contrast, there is evidence that long-acting agents
requiring less frequent dosing can improve treatm ent adherence.13 Couns elors s hould cons ider dos ing regim ens when
recom mending different medication options , especially if adherence poses a concern. Counselors als o can provide advice
about sim ple reminders to help patients better remember to take medications. For example, taking m edications can be
correlated with certain cues or daily routines , such as eating and brus hing teeth.10
Certain couns eling techniques are also designed to improve medication adherence. Medical management and BRENDA
are brief form s of therapy that prom ote abs tinence and adherence to medication schedules.14,15 These techniques have
manuals that clinicians can follow and eas ily learn (s ee the additional reading list for more detailed inform ation on thes e
techniques ). Medical management was used in the Com bining Medications and Behavioral Interventions for Alcoholis m
(COMBINE) study, which examined the efficacy of acampros ate and naltrexone in com bination with behavioral interventions
and found improvement in drinking outcom es am ong all groups that received medical m anagem ent, even those receiving
placebo.16 Treatment adherence was also high in all groups.
The framework for BRENDA is based in the biopsychos ocial model of addiction and cons is ts of six stages : the clinician's
(1) biops ychosocial evaluation of the patient; (2) report of that assess m ent 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 necess ary adjus tments to the treatm ent plan.15
BRENDA has been effectively us ed in a trial of extended-release injectable naltrexone.17 And in a trial of oral naltrexone,
BRENDA improved treatment completion rates and medication adherence com pared with standard individual therapy.18
Other couns eling techniques specifically crafted to im prove medication adherence exist. For example, a form of compliance
therapy based on motivational interviewing and cognitive-behavioral principles was found to im prove 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 s olutions to those obstacles . Improved education,
knowledge, and communication among counselors and patients regarding m edication us e are vital to increase acceptance
of medications and ens ure their proper us e. Perhaps mos t 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.

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