Quality Counseling Makes the Difference!

Government guidelines say opioid treatment programs need to maintain a patient to counselor ratio of no more than fifty to one. That is, for every fifty patients enrolled, there should be one counselor. This is a minimum requirement. Obviously, the patients get better care with more time and attention from their addiction counselor.


I’ve asked some of the best counselors I know what they think of this ratio. One experienced counselor said it depended on the degree of patient engagement in treatment. She said if you have a caseload of patients that aren’t interested in counseling, they won’t take up much of your time. On the other hand, if you have a caseload of patients all eager for counseling and wanting to see positive change in their lives, fifty patients may be overwhelming. This professional said she could comfortably take care of thirty five patients if they were all active in counseling to some degree.

The amount of time patients need is also influenced by the patient mix. Clinics that accept Medicaid as payment for treatment obviously have a high percentage of Medicaid patients in their treatment program. Medicaid patients are sicker both physically and emotionally, since one of the reasons people qualify for Medicaid is because of disability. In other words, the sickest addicts have Medicaid. If anything, Medicaid patients may need more time than an average non-Medicaid patient for counseling. Unhappily, the Medicaid system requires so much extra paperwork that there’s less time is available for doing counseling.

Some opioid treatment programs take ratios more seriously than others. I once worked at a clinic where the patient to counselor ratio was consistently around 70 to 1. For a several months, they had one clinic with more than 100 patients to 1 counselor. I wrote an email to the head administrator, saying I felt our established patients weren’t getting the best care possible. This administrator said he was doing the best he could to hire new counselors. He refused to consider halting intakes, even temporarily.

At the next clinic where I worked, we had four counselors and clinic slowly increased in patient numbers. When we got to 200 patients, the administration stopped intakes until they could hire more counselors. I was impressed because of my previous negative experience, and because this new clinic was part of a large, for-profit chain.

I’ve been bragging about the clinic where I now work, The Stepping Stone of Boone. With around 130 patients, we have three full-time counselors. I feel like patients get more attention than they do at any other clinic where I’ve worked.

Some patients prefer not to participate in counseling. They may resent feeling pressured or hassled to meet with their counselor. Since the state and federal regulations say each patient must make clinical contact a minimum of twice per month, they still have to at least make an effort to see their counselors.

I tell patients that if they aren’t making use of the counselors, they aren’t getting their money’s worth. Methadone costs pennies per dose. What patients at opioid treatment programs are really paying for is for the counseling, and other personnel who work at OTPs.

Group meetings are important to have at opioid treatment centers. Many times the information we get about ourselves in a group setting can’t be obtained any other way. Some of our destructive ways of looking at the world are only evident when we interact with other people. And often, there are things we can see in other people that we just can’t see in ourselves.

Studies consistently show that patients with addiction do better with more counseling and patients on methadone are no exception. That’s why good programs make efforts to recruit and retain talented and compassionate addiction treatment professionals. I’m lucky that I work with such professionals.

5 responses to this post.

  1. Posted by Ira J Marion on December 1, 2011 at 3:20 pm

    You are absolutely correct. But, and the big but is that essentially, whether for profit or not, programs are businesses. I do not know whether counseling units of service result in revenue for your particular program, but revenues and expenses drive the system. I do know that the program I’ve worked at for most of my adult life would hire more counselors if they had more revenue. Instead, like you say, revenue depends on Medicaid and other public funds, all of which have decreased markedly in the past four years. Sad, but true.


    • My program charges a flat daily fee. Patients have unlimited access to their counselors and are charged the same whether they see the counselor twice a month or every day. They also can see me, the doctor, when they want, for no extra fee. These patients are all self-pay so they tend to be very motivated to get well.


      • Posted by Ira J Marion on December 1, 2011 at 11:04 pm

        This will all change with health care reform; flat fees will go away slowly when folks all have some form of insurance and will want their insurance to pay for their treatment – and substance abuse treatment, including OTP, will be covered in reform everywhere -even in states that do not now cover methadone treatment. Insurance companies, like Medicaid are service specific; that is, you bill them for units of service: a group, a family session, individual counseling, dosing and medication care management.

      • Hopefully a new system will be better than the one we have now.

      • Posted by tory on January 28, 2016 at 10:47 pm

        does Medicade pay for methodone treatment

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