Running head: CASE STUDY TREATMENT PLAN
Case Study Treatment Plan
Charlotta Richardson
Advanced Biological Psychology
PSY7320
Capella University
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Case Study Treatment Plan
The diagnostic impression based on the information provided by Roberta during the
initial intake, it appeared that Roberta has developed a dependence on opioid prescription pain
medication and would likely be diagnosed with Opioid Use Disorder. Although her physician
believes that her condition has been resolved, Roberta has continued to find other means to
access prescription medication. Roberta’s continues to believe that she needs the medication and
is currently purchasing pills from alternative methods and seeking psychological treatment to
gain access to opioid prescription medication.There were additional symptoms expressed during
intake that causes Roberta to meet the criteria in the DSM-IV for the diagnosis. From the intake,
it would be appropriate to consider depression as an additional diagnosis. Roberta may be
dealing with feelings of inadequacy and uncertainty due to the injury she suffered.
Treatment Literature Review
The misuse of prescription opioids is defined as taking opioid medications in a manner or
dose other than prescribed or taking a medication to increase psychological pleasure or decrease
psychological pain (Davis et al., 2019). The opioid epidemic has increased the use of heroin in
recent years. In 2018, an estimated 11.8 million people 12 years and older were identified to have
misused opioids, with an estimated 42,000 people dying from opioid overdose in 2016 (CDC,
2017). There are prevailing rates of opioid use disorder among adolescents ages 12–17. In 2016,
3.6% of adolescents misused opioids (SAMHSA, 2017). More troubling is that of the millions of
adolescents who need substance use disorder treatment, including those with opioid use disorder,
less than 1% of them receive treatment (SAMHSA, 2017).
Opioid use has a significant impact on public health due to its elevated rates of morbidity,
mortality, and economic costs to society. Individuals may use substances in an effort to dull or
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escape their depressive and or anxiety symptoms, negatively reinforcing substance use (Baxley
et al., 2019). Medications for opioid use disorder have been found to be effective and have been
increasingly provided to patients in primary care settings (Angier et al., 2021). Research supports
the use of buprenorphine to reduce opioid use and has also been found to have positive impacts
on treatment retention (Angier et al., 2021). Additionally, behavioral interventions have been
shown to be effective in treating opioid use disorder (Davis et al., 2019). There have been
various behavioral treatments that have demonstrated effectiveness for opioid use disorder,
including cognitive-behavioral therapy (CBT), manualized motivational interviewing (MI), 12step facilitation, and adolescent community reinforcement approach (Davis et al., 2019).
The misuse of opioids and chronic pain coexist in pediatric populations, leading to
negative adverse outcomes that may persist into adulthood (Pielech et al., 2020). The connection
between chronic pain and opioid prescribing has been well documented with adults; however,
research continues to identify the long-term impact of opioid exposure during childhood (Pielech
et al., 2020). Pielech et al. (2020) identify that an estimated 25% of young people are affected by
chronic pain and chronic pain is a leading risk factor for opioid misuse. Opioid misuse can
increase pain sensitivity and pain-related disability due to opioid-induced chemical changes to
the nerve pathways involved in sensing pain (Pielech et al., 2020). When chronic pain and
opioid misuse are ineffectively treated, there is a substantial effect on society. Both conditions
can continue into adulthood, further perpetuating the public health crisis in America.
Baxley et al. (2019) report that opioid misuse during adolescence is often triggered by
exposure to opioids for acute pain management or through having access to leftover prescription
opioids from a friend or family member. Psychiatric comorbidities such as depression or anxiety
can influence adolescent vulnerability and the progression of opioid misuse (Pielech et al., 2020).
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Research suggests that a frequently identified motive for opioid abuse among adolescents from
varying samples is pain relief; however, it was not clear if the pain relief sought after was acute,
emotional, or chronic pain (Pielech et al., 2020).
Behavioral Treatments
There have been several treatments studied to determine effectiveness for opioid use
disorder. Behavioral therapies have been found to be clinically and cost-effective (Pielech et al.,
2020). Acceptance and commitment therapy (ACT) is a form of therapy that combines
mindfulness and practicing self-acceptance. This encourages clients to be committed and to
embrace behavior change strategies. In a recent clinical study referred to by Pielech et al. (2020),
participants with chronic pain and documented opioid misuse found that ACT and mindfulnessbased relapse prevention was effective and contributed to reductions in both chronic pain
disruption and opioid abuse at a 6-month follow up.
Cognitive-behavioral therapy (CBT) for the treatment of substance use disorders,
including opioid use disorder, has been found to be effective in both individual and group
formats. Targeting operant learning processes, motivational barriers to improvement, and other
cognitive-behavioral interventions are the basis for the use of CBT for opioid use disorder.
Various interventions could be utilized to target the needs of each individual. CBT interventions
have demonstrated efficacy in controlled trials and may be combined with one another or with
pharmacotherapy to provide more significant outcomes (Pielech et al., 2020).
Motivational interventions, such as motivational interviewing, address the motivational
barriers that impact behavior change related to substance use (Pielech et al., 2020). It has been
found to be effective as a standalone intervention as well as in conjunction with other treatment
strategies for opioid use disorder (Pielech et al., 2020). Motivational interviewing has been
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shown to be an effective means of treatment for both voluntary patients as well as those required
to attend treatment for legal reasons or by way of family pressure (Pielech et al., 2020). The
main concept of motivational interviewing is for the patient to overcome the internal battle over
their desire to stop abusing drugs and address the desire to continue using.
Contingency management has also been found to be effective as a treatment for opioid
use disorder. Contingency management strive to counter the reinforcing effects of the drug with a
non-drug reinforcer (Pielech et al., 2020). Although contingency management may not be the
most cost-effective means of treatment, its efficacy has proven significant in studies involving
those with substance use disorders, primarily opioids, and cocaine (Pielech et al., 2020). Some
studies offered an escalating reinforcement, in which the value of the reinforcement increased as
the duration of abstinence increased (Pielech et al., 2020).
Relapse prevention is another CBT intervention that has supportive evidence of efficacy.
Relapse prevention assists patients with identifying high-risk situations that would trigger the
patient to engage in substance use and training them to activate alternative response cues
(Pielech et al., 2020). This collaborative effort includes psychoeducation to help the patient
make an informed choice in a high-risk situation. Establishing a relapse prevention plan with
patients can give them a sense of control over how they interact and respond in threatening
situations, with the hopes that they will make an informed choice to not engage in substance use.
Behavioral treatment, when delivered alone, has shown to have limited efficacy in
addressing the complex symptomatology and physical aspects of opioid use disorder (Angier et
al., 2021). However, when behavioral treatment has been implemented following the completion
of a detox and stabilization program, there has been significant success in relapse prevention.
Behavioral therapy will assist with building the skills for resilience to maintain abstinence.
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Pharmacological Treatments
Pharmacological treatments have been found to be effective for treating opioid use
disorder. Medication-assisted treatment combined with some form of behavioral therapy or
counseling has been identified as the gold standard when working with individuals diagnosed
with opioid use disorder. Methadone, buprenorphine and naltrexone have been approved by the
FDA as treatment of opioid use disorder (Angier, 2020).
Methadone is considered an opioid agonist which suppresses opioid withdrawal
symptoms and cravings (Angier, 2020). Methadone is one of the most widely known
pharmacological treatments for opioid use disorder and has been used since the 1960s (Angier,
2020). Methadone treatment has shown to effectively reduce illicit opioid use, induce opioid
tolerance, and improve retention in treatment (Angier, 2020). Methadone can also be used for
pain management and has shown to be effective in patients' ability to reclaim active and
meaningful lives (SAMHSA, 2017).
Buprenorphine is a partial opioid agonist and is considered to be a weaker opioid agonist
than methadone (SAMHSA, 2017). Buprenorphine is known to diminish the physical effects of
dependency similar to methadone. One of the primary benefits of buprenorphine is that it can be
delivered in primary care settings, increasing accessibility to patients (Angier, 2020). There is a
lower risk of abuse potential and overdose due to the ceiling effect, where it reaches a plateau,
and kappa-opioid receptors are activated (Angier, 2020). Research has shown that
buprenorphine, although a weaker opioid agonist, still proves to be as effective as methadone in
reducing opioid use (Pielech et al., 2020).
Naltrexone, unlike methadone and buprenorphine, is an antagonist of opioid receptors.
The psychological effects such as euphoria and sedation are blocked by naltrexone as it binds
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and blocks the opioid receptors thus, reducing cravings (Angier, 2020). There are no withdrawal
symptoms when patients discontinue use, and there does not appear to be any abuse or diversion
potential (SAMHSA, 2017). Research has been inconsistent with the efficacy of naltrexone due
to the difficulty of initiation and poor compliance for opioid use disorder (Angier, 2020).
Ironically, it would appear that naltrexone would be the ideal medication for relapse prevention
due to the blocking of the rewarding effects experienced by those with opioid use disorder;
unfortunately, high dropout rates have prevented significant outcomes for treatment retention and
opioid use (Angier, 2020).
Methadone, buprenorphine, and naltrexone have presented sufficiently in treatments for
opioid use disorder. Medication-assisted treatment is beneficial as it assists with sustaining
recovery as well as reduction and often times prevention of overdose. Of these three medications
only buprenorphine has been approved for adolescents age 16 year and older. As previously
mentioned buprenorphine can be prescribed in office-based outpatient settings, including primary
care providers, and can be taken home, which can then involve parents monitoring and ensuring
that the medication is being taken and taken correctly. Studies suggest that buprenorphine
treatment improves the likelihood of opioid abstinence and treatment retention among youth
(Davis et al., 2019).
Legal and Ethical Ramifications
Although many of the behavioral treatments and medication-assisted treatments have
demonstrated effectiveness for opioid use disorder, much of the research to date relating to the
effectiveness of these interventions have been conducted with adults (Davis et al., 2019).
Clinicians have an ethical duty to ensure that the treatment method provided to the client would
be effective for the individual so that it reduces the risk for a return to opioid use, recognizing
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that youth may respond differently to existing treatments. Different types of treatment may be
more effective for adolescents based on their developmental age, so it would be important that
the clinician consider effective treatments for all adolescents and one that would be appropriate
for the child's developmental stage.
When treating adolescents, confidentiality is always something to consider. Some parents
will want to be overly involved in the treatment, especially if trust between the parent and child
has been broken. Clinicians have an ethical duty to maintain confidentiality, and it would be
imperative for them to explain limits to confidentiality and set clear boundaries for the disclosure
of information. When adolescents perceive that the information shared will not remain
confidential, they are less likely to seek care, particularly for reproductive health matters or
substance abuse (Davis et al., 2019). When treating adolescents for sensitive health conditions
such as substance abuse, confidentiality should be honored. Adolescents are able to consent to
alcohol and drug treatment in most states, but the involvement of the family is optimal in most
cases (Davis et al., 2019). The process of working with adolescents and their families, both
concerning making treatment decisions and managing confidential information, requires
sensitive appraised judgment by clinicians.
Legal rules play a significant role in framing the decision-making processes by which
some choices are made by and on behalf of adolescents by their parents. However, in some
instances, decision-making should be driven by clinical and personal considerations of the
circumstances presented by each adolescent in need of treatment services. As with informed
consent, the law requires mental health providers to disclose essential information about a
therapeutic intervention's costs and benefits and ascertain the patient's assent. Should a
medication intervention be recommended and attempted and the clinician fails to disclose the
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risks associated with the treatment and the patient suffers adverse effects, the court can hold that
clinician responsible for negligence or malpractice. Clinicians owe a duty to their clients to make
reasonable disclosure of all significant facts or be held legally responsible if they fail to do so.
Diversity Issues
Minority adolescents, despite reporting higher levels of pain, are usually less likely to be
prescribed opioids for the treatment of pain (Wilson et al., 2020). Research also suggests that
adolescents from lower socioeconomic groups are also less likely to receive medical care from a
specialized pain clinic (Wilson et al., 2020). However, if they are prescribed opioids for pain,
exposure to positive analgesic and stress-reducing aspects of opioids is likely to impact
neurophysiological function and risk for continued use (Wilson et al., 2020). Adolescents will
essentially continue to use opioids to address other psychological issues, such as stress, anxiety,
and depression resulting from their socioeconomic status or ethnicity.
In recent years, the opioid epidemic and discussions about the opioid crisis have focused
primarily on the impact that it has had on White families, while the most significant increase of
opioid-involved deaths in 2017 was of people of color (Wilson et al., 2020). Palermo and Kerns
(2020) report that White participants had the highest completion rate (50%) of treatment, while
Hispanic (47%) and African American (40%) participants were significantly lower. Those from
different social, economic, or cultural backgrounds may find it more challenging to feel
connected and identify with other patients, ultimately feeling isolated, which could decrease
treatment retention and continued substance abuse.
Davis et al. (2019) also conducted a study to determine the most effective treatment for
adolescents with opioid use disorder. The treatments considered included adolescent community
reinforcement approach, motivational enhancement therapy coupled with cognitive behavioral
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therapy and cognitive behavioral therapy alone. It would be essential to know what treatment
options are most effective depending on the gender of the client. Davis et al. (2019) found that
the particular type of treatment for adolescent females with opioid use disorder did not appear to
be important, as all three treatments assessed displayed comparable effectiveness. The research
suggested that treatments involving CBT with or without motivational enhancement best helped
to delay opioid use for adolescent males (Davis et al., 2019).
Age also plays a factor in the type of treatment that should be considered for adolescents.
Davis et al. (2019) research also found evidence that suggests that adolescents can benefit from
attendance at 12-step meetings in addition to outpatient substance use treatment; however,
engagement in these programs by adolescents is low. Adolescents report a lack of attendance due
to boredom or lack of fit, low perceived need, or no external exigence for attendance (Davis et
al., 2019). Another reason reported for low attendance is adolescents having trouble connecting
with the adult members that primarily attend these groups (Davis et al., 2019). It appears that
research suggests that specific treatment approaches may perform better than others depending
on patients’ developmental age group and sex and should be considered prior to implementing
treatment.
Treatment Plan
The treatment plan that I would recommend for Roberta, given the research would be as
follows:

Referral to a MD
o to assess if buprenorphine would be appropriate: buprenorphine is the only
medication approved by the FDA for adolescents.
o pain management
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
occupational/ physical therapy
Psychotherapy
o Cognitive behavioral therapy
o Substance abuse treatment, 12-step program
o Psychoeducation, coping skills

Al-Anon/support group for parents
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References
Angier, H., Fleishman, J., Gordon, L., Cohen, D. J., Cantone, R. E., & Bailey, S. R. (2021). Tierbased treatment for opioid use disorder in the primary care setting. Families, Systems, &
Health, 39(2), 345–350. https://doi.org/10.1037/fsh0000619
Baxley, C., Weinstock, J., Lustman, P. J., & Garner, A. A. (2019). The influence of anxiety
sensitivity on opioid use disorder treatment outcomes. Experimental and Clinical
Psychopharmacology, 27(1), 64–77. https://doi.org/10.1037/pha0000215
Centers for Disease Control and Prevention/National Center for Health Statistics. (2017).
National Vital Statistics System. Atlanta, GA.
Davis, J. P., Prindle, J. J., Eddie, D., Pedersen, E. R., Dumas, T. M., & Christie, N. C. (2019).
Addressing the opioid epidemic with behavioral interventions for adolescents and young
adults: A quasi-experimental design. Journal of Consulting and Clinical
Psychology, 87(10), 941–951. https://doi.org/10.1037/ccp0000406.supp (Supplemental)
Palermo, T. M., & Kerns, R. D. (2020). Psychology’s role in addressing the dual crises of
chronic pain and opioid-related harms: Introduction to the special issue. American
Psychologist, 75(6), 741–747. https://doi.org/10.1037/amp0000711
Pielech, M., Lunde, C. E., Becker, S. J., Vowles, K. E., & Sieberg, C. B. (2020). Comorbid
chronic pain and opioid misuse in youth: Knowns, unknowns, and implications for
behavioral treatment. American Psychologist, 75(6), 811–824.
https://doi.org/10.1037/amp0000655
Substance Abuse and Mental Health Services Administration. (2017). Key substance use and
mental health indicators in the United States: Results from the 2016 National Survey on
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Drug Use and Health (HHS Publication No. SMA 17–5044, NSDUH Series H-52).
Rockville, MD.
Wilson, A. C., Morasco, B. J., Holley, A. L., & Feldstein Ewing, S. W. (2020). Patterns of opioid
use in adolescents receiving prescriptions: The role of psychological and pain
factors. American Psychologist, 75(6), 748–760. https://doi.org/10.1037/amp0000697