PAC 610 Module 8 Clinical Applications and Current Issues Example

Medication in a Counseling Program: A Brief on Overdose Prevention, Prescribing Trends and the Antidepressant Debate

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 610: Psychopharmacology

Instructor Name

Month Day, Year

Medication in a Counseling Program: A Brief on Overdose Prevention, Prescribing Trends and the Antidepressant Debate

To: Director, Ridgeview Recovery Center. From: Counseling staff. Subject: Whether to offer medication for opioid use disorder on site, and related medication issues. Ridgeview, the Knoxville outpatient program used throughout these papers and invented for them, currently refers clients who need buprenorphine to outside prescribers, and about a third of clients referred never attend the first appointment, according to the program's own tracking. The director has asked staff to review the evidence and recommend whether the program should hire a prescriber. This brief addresses that decision and two related issues in psychopharmacology that bear on the program's practice.

Issue One: The Treatment Gap for Opioid Use Disorder

Wakeman et al. (2020) used insurance records to compare treatments received by more than 40,000 adults with opioid use disorder. People who received buprenorphine or methadone had far fewer overdoses and episodes of serious opioid-related acute care, at both three and twelve months, than people who received no treatment. Other common treatments, including detoxification, inpatient or residential care and intensive behavioral programs, were not associated with comparable protection. Yet only about one in eight people in the sample received buprenorphine or methadone; most received other treatment or none. The study is observational, so it cannot prove that the medication caused the difference, but its size and consistency with the mortality evidence reviewed earlier in this course make it hard to dismiss.

Issue Two: Prescribing Without Diagnosis

Mojtabai and Olfson (2011) analyzed national data on office visits and found that the share of antidepressant prescriptions made without any recorded psychiatric diagnosis grew substantially over the period studied, to a large majority of such visits by the late 2000s. Most prescriptions came from primary care rather than psychiatry. The authors raised the concern that some patients receive antidepressants without careful assessment, while others who need treatment receive too little follow-up. For a counseling program, the finding means that clients often arrive already taking medication prescribed elsewhere, sometimes without a clear diagnosis or monitoring, and that counselors may be the professionals who see them most often.

Issue Three: The Antidepressant Debate

Kirsch et al. (2008) obtained data submitted to the United States Food and Drug Administration for four newer antidepressants, including trials that had not been published. They found that the average difference between drug and placebo was small, that it grew with the severity of depression and that it reached a widely used threshold for clinical significance only in very severe depression, largely because placebo response fell in more severe cases. The analysis received wide public attention. Later and larger reviews, such as the network meta-analysis discussed in Module 3, found every antidepressant more effective than placebo, though by modest margins. The fair reading for counselors is that antidepressants help many people, the average advantage over placebo is modest, severity matters and psychotherapy deserves an equal place in treatment.

Options for the Program

Recommendations

First, the program should bring buprenorphine prescribing on site, beginning with a partnership that brings a prescriber to Ridgeview twice weekly and moving to a part-time hire if demand supports it. The evidence on overdose, together with the program's own drop-off between referral and first appointment, supports reducing the steps between asking for treatment and starting it. Second, counselors should complete training on medications for opioid use disorder so that they can answer clients' and families' questions and address the belief that medication is not real recovery. Third, at intake, counselors should record every medication a client takes, who prescribed it and for what, so that the on-site prescriber can identify medications prescribed without clear diagnosis or follow-up. Fourth, the program should adopt shared care: the prescriber and counselor should review clients jointly each month, with the counselor reporting side effects, adherence and warning signs and the prescriber deciding on medication.

Measuring Success

If the director accepts these recommendations, the program should judge them after a year. Four measures would show whether the change worked: the share of clients who ask for buprenorphine and start it within a week; the share still taking it at ninety days; the number of known overdoses among current and recent clients; and counselors' confidence, measured by a short survey before and after training, in discussing medications with clients and families. Ridgeview already gathers most of this information, and the rest costs little to add, and they connect directly to the evidence on which the recommendations rest.

Risks and Safeguards

On-site prescribing brings responsibilities. The program will need written policies on storing any medication kept on site, on preventing diversion and on what happens when a client misses appointments or uses other drugs. These policies should aim to keep clients in treatment rather than discharge them, given the evidence that the weeks after leaving treatment are among the most dangerous. Staff attitudes also matter: if counselors privately regard medication as second-best recovery, clients will notice, so training should invite those views into the open.

The Counselor's Place in Medication Care

Across this course, the counselor's role has stayed constant: not to prescribe, but to understand enough to explain, notice, support and refer. Counselors explain how medications work in plain terms. They notice side effects, interactions, withdrawal and nonadherence, often before prescribers do. They support clients' decisions and address stigma, including their own. And they bring concerns to prescribers promptly. An on-site prescriber would make this work easier, closer and more effective.

Conclusion

Medication for opioid use disorder is associated with large reductions in overdose, yet most people who could benefit do not receive it. Antidepressants are widely prescribed, often without a recorded diagnosis, and their benefit over placebo is real but modest and greatest in severe depression. For Ridgeview, the evidence supports bringing a prescriber on site and building shared care in which counselors and prescribers each do what they do best.

References

Kirsch, I., Deacon, B. J., Huedo-Medina, T. B., Scoboria, A., Moore, T. J., & Johnson, B. T. (2008). Initial severity and antidepressant benefits: A meta-analysis of data submitted to the Food and Drug Administration. PLoS Medicine, 5(2), Article e45. https://doi.org/10.1371/journal.pmed.0050045

Mojtabai, R., & Olfson, M. (2011). Proportion of antidepressants prescribed without a psychiatric diagnosis is growing. Health Affairs, 30(8), 1434-1442. https://doi.org/10.1377/hlthaff.2010.1024

Wakeman, S. E., Larochelle, M. R., Ameli, O., Chaisson, C. E., McPheeters, J. T., Crown, W. H., Azocar, F., & Sanghavi, D. M. (2020). Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Network Open, 3(2), Article e1920622. https://doi.org/10.1001/jamanetworkopen.2019.20622