Who benefits from additional drug counseling among prescription opioid-dependent patients receiving buprenorphine–naloxone and standard medical management?

Abstract

Background In the multi-site Prescription Opioid Addiction Treatment Study (POATS), conducted within the National Drug Abuse Clinical Trials Network, participants randomly assigned to receive individual drug counseling in addition to buprenorphine-naloxone and medical management did not have superior opioid use outcomes. However, research with other substance dependent populations shows that subgroups of participants may benefit from a treatment although the entire population does not. Method We conducted a secondary analysis of POATS data to determine whether a subgroup of participants benefited from drug counseling in addition to buprenorphine-naloxone and medical management, either due to greater problem severity or more exposure to counseling as a result of greater treatment adherence. Problem severity was measured by a history of heroin use, higher Addiction Severity Index drug composite score, and chronic pain. Adequate treatment adherence was defined a priori as attending at least 60% of all offered sessions. Results Patients who had ever used heroin and received drug counseling were more likely to be successful (i.e., abstinent or nearly abstinent from opioids) than heroin users who received medical management alone, but only if they were adherent to treatment and thus received adequate exposure to counseling (OR=3.7, 95% CI=1.1-11.8, p=0.03). The association between severity and outcome did not vary by treatment condition for chronic pain or ASI drug severity score. Conclusions These findings emphasize the importance of treatment adherence, and suggest that patients with prescription opioid dependence are a heterogeneous group, with different optimal treatment strategies for different subgroups.

The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review

“…This is notable because not only did heroin users as a group have worse overall outcomes in both the POATS main trial and in a 42-month follow-up study of the POATS population (45), but heroin users have repeatedly demonstrated worse treatment outcomes when compared with those who exclusively use prescription opioids (5, 49, 50). These findings emphasize the importance of treatment adherence, and suggest that patients with prescription opioid dependence are a heterogeneous group and that optimal treatment strategies may vary by subgroups (47). …”

“…A secondary analysis of the POATS study focused on subgroups of participants who benefited from counseling in addition to buprenorphine and medical management, either due to greater problem severity or more exposure to counseling as a result of greater treatment adherence (47). Problem severity was measured alternately by a history of heroin use, a higher Addiction Severity Index (ASI) drug composite score (48), and presence of current chronic pain.…”

Prescription Opioid Misuse, Abuse, and Treatment in the United States: An Update

“…Specifically, contingency management protocols have shown promise in enhancing retention and compliance among patients with opioid use disorders (56). However, recent research specific to prescription opioid use disorders suggested no overall additional benefit from counseling (50), although subpopulations with more severe opioid use that included heroin may receive added benefit when engaged in counseling coupled with medical management (57). At present, the data are insufficient to provide guidance on the type (or inclusion) of psychosocial treatment—contingencymanagement, relapse prevention, support groups like Narcotics Anonymous—that might be most effectively partnered with opioid substitution therapy.…”

A preliminary randomized controlled trial of a distress tolerance treatment for opioid dependent persons initiating buprenorphine

“…Opioid replacement may have lessened the effect of a behavioral intervention; we chose a buprenorphine dose (16 mg) associated with rates of retention higher than rates seen in studies of 8 mg (Mattick et al, 2008). Still, fixed buprenorphine dosing is a study limitation; symptom-based dosing may lead to higher average daily doses greater than 16mg and perhaps better outcomes (Weiss et al, 2014). Over one-third of participants were fully abstinent over the 3-month follow-up; most others reported only infrequent used of illicit opioids (to be positive at the monthly assessment a participant had to report any use during the month or have a positive toxicology).…”

“…Meta-analyses indicate that cognitive-behavioral intervention for the treatment for substance use disorder is efficacious (Magill and Ray, 2009). However, recent trials evaluating cognitive-behavioral treatment (Fiellin et al, 2013; Ling et al, 2013) and additional drug counseling (Weiss et al, 2014) have not shown significant benefit over physician management for patients taking buprenorphine (Amato et al, 2011). But earlier studies have not initiated behavioral treatment prior to buprenorphine initiation in preparation for the increased challenge of opioid withdrawal and the risk of early lapse.…”