Downloaded from http://ebmh.bmj.com/ on June 8, 2015 - Published by group.bmj.com
Therapeutics
Behavioural treatment combined with buprenorphine does not reduce opioid use compared with buprenorphine alone doi:10.1136/eb-2013-101639
QUESTION Question: In the treatment of opioid dependence, does the addition of behavioural treatment to buprenorphine reduce opioid use compared with buprenorphine alone? Patients: In total, 202 people meeting Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revised (DSM-IV-TR) criteria for opioid dependence. Participants had to have good general medical and psychiatric health, no sensitivity to buprenorphine or naloxone, and no dependence on alcohol, benzodiazepines or any other drug. Setting: Outpatient clinical research centre in Los Angeles, California, USA. Intervention: In total, 16 weeks of buprenorphine with medical management plus either cognitive behavioural therapy (CBT, n=53), contingency management (CM, n=49), both CBT and CM (CBT+CM, n=49) or no behavioural treatment (n=51). CBT involved weekly 45 min sessions with a counsellor addressing topics relevant to drug use and recovery. CM involved receiving an increasing monetary reward for each consecutive opioid-negative urine result. Following the behavioural treatment phase, participants entered a 16-week buprenorphine-only phase. Outcomes: Opioid (opiate, oxycodone, propoxyphene and/ or methadone) use, as measured as by the Treatment Effectiveness Score (TES, the proportion of opioid negative urine results). Secondary outcomes included retention, withdrawal symptoms, craving, other drug use and adverse events.
W
Evid Based Mental Health May 2014 Vol 17 No 2
METHODS Design: Randomised controlled trial. Allocation: Concealed. Blinding: Unblinded. Follow-up period: 52 weeks. MAIN RESULTS All groups reported a significant reduction in heroin use during the past 30 days at the end of the behavioural treatment phase compared with baseline. There was no significant difference between groups in TES score during the behavioural treatment phase, the buprenorphine-only phase or at 40 or 52 weeks of follow-up. There was no significant difference in the percentage of participants with three or more or six or more consecutive opioid-negative urine results, or in the mean number of consecutive opioidnegative urine results. There was no significant difference in other drug use, retention, withdrawal or craving. CONCLUSIONS Behavioural treatments of CBT and/or contingency management combined with buprenorphine do not reduce opioid use compared with buprenorphine alone in people with opioid dependence who seek treatment. ABSTRACTED FROM Ling W, Hillhouse M, Ang A, et al. Comparison of behavioral treatment conditions in buprenorphine maintenance. Addiction 2013;108:1788–98. Correspondence to: Maureen Hillhouse, UCLA Integrated Substance Abuse Programs, 1640 S. Sepulveda Boulevard, Suite 120, Los Angeles, CA 90025, USA; [email protected] Sources of funding National Institute on Drug Abuse.
buprenorphine is never prescribed in the absence of some sort of medical management, which was provided in the three trials listed, and can be quite powerful. Buprenorphine prescribers regularly emphasise abstinence and medication adherence, and recommend attendance at mutual-help groups such as Narcotics Anonymous. These straightforward pieces of advice are critical to successful outcomes. The combination of buprenorphine plus ‘medical management’—which should be termed ‘medical counselling’—produces good outcomes in many patients. Some patients will, of course, require more intensive treatment than others; opioid use disorders, like most illnesses, are heterogeneous in severity and response to treatment. Physician practices are also heterogeneous; not all buprenorphine prescribers deliver the quality of medical counselling described above, so we should not generalise from these studies to say that patients receiving buprenorphine in office-based practice do not need counselling. However, it behooves the field to determine the
minimal level of counselling that patients should initially receive, and to develop strategies for matching the intensity of counselling to the specific needs of individual patients. Roger D Weiss Division of Alcohol and Drug Abuse, McLean Hospital, Harvard Medical School, Belmont, Massachusetts, USA Competing interests RDW receives support from grants U10 DA15831 and K24 DA022288 from the National Institute on Drug Abuse, USA.
REFERENCES 1.
2.
Weiss RD, Potter JS, Fiellin DA, et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence a 2-phase randomized controlled trial. Arch Gen Psychiatry 2011;68:1238–46. Fiellin DA, Barry DT, Sullivan LE, et al. A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. Am J Med 2013;126:74. e11–17.
e2
COMMENTARY
ith the introduction of buprenorphine, opioid-dependent patients could, for the first time, be treated with agonist pharmacotherapy as part of mainstream medicine. A requirement for physicians prescribing buprenorphine has been the capacity to provide ancillary treatment or refer patients for counselling. However, the study by Ling and colleagues is the third trial to show that additional behavioural therapy does not significantly improve outcomes over that achieved by buprenorphine plus medical management.1 2 Is buprenorphine so efficacious that counselling is not needed? Not really. Buprenorphine is very effective, but not to the same extent, for example, as penicillin for streptococcal pharyngitis. For example, in the Prescription Opioid Addiction Treatment Study, conducted by the National Institute on Drug Abuse (NIDA) Clinical Trials Network, only half of the study participants achieved successful outcomes (abstinence or near-abstinence from opioids) after 12 weeks of buprenorphine treatment.1 But
Patient follow-up: All 66% completed behavioural treatment, 50% completed 40-week follow-up and 49% completed 52-week follow-up.
Downloaded from http://ebmh.bmj.com/ on June 8, 2015 - Published by group.bmj.com
Behavioural treatment combined with buprenorphine does not reduce opioid use compared with buprenorphine alone Evid Based Mental Health 2014 17: e2 originally published online March 3, 2014
doi: 10.1136/eb-2013-101639 Updated information and services can be found at: http://ebmh.bmj.com/content/17/2/e2
These include:
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This article cites 3 articles, 0 of which you can access for free at: http://ebmh.bmj.com/content/17/2/e2#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Substance dependence (399) Neurology (1020) Substance withdrawal (17) Clinical trials (epidemiology) (955) Epidemiology (1495)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Therapeutics
Behavioural treatment combined with buprenorphine does not reduce opioid use compared with buprenorphine alone doi:10.1136/eb-2013-101639
QUESTION Question: In the treatment of opioid dependence, does the addition of behavioural treatment to buprenorphine reduce opioid use compared with buprenorphine alone? Patients: In total, 202 people meeting Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revised (DSM-IV-TR) criteria for opioid dependence. Participants had to have good general medical and psychiatric health, no sensitivity to buprenorphine or naloxone, and no dependence on alcohol, benzodiazepines or any other drug. Setting: Outpatient clinical research centre in Los Angeles, California, USA. Intervention: In total, 16 weeks of buprenorphine with medical management plus either cognitive behavioural therapy (CBT, n=53), contingency management (CM, n=49), both CBT and CM (CBT+CM, n=49) or no behavioural treatment (n=51). CBT involved weekly 45 min sessions with a counsellor addressing topics relevant to drug use and recovery. CM involved receiving an increasing monetary reward for each consecutive opioid-negative urine result. Following the behavioural treatment phase, participants entered a 16-week buprenorphine-only phase. Outcomes: Opioid (opiate, oxycodone, propoxyphene and/ or methadone) use, as measured as by the Treatment Effectiveness Score (TES, the proportion of opioid negative urine results). Secondary outcomes included retention, withdrawal symptoms, craving, other drug use and adverse events.
W
Evid Based Mental Health May 2014 Vol 17 No 2
METHODS Design: Randomised controlled trial. Allocation: Concealed. Blinding: Unblinded. Follow-up period: 52 weeks. MAIN RESULTS All groups reported a significant reduction in heroin use during the past 30 days at the end of the behavioural treatment phase compared with baseline. There was no significant difference between groups in TES score during the behavioural treatment phase, the buprenorphine-only phase or at 40 or 52 weeks of follow-up. There was no significant difference in the percentage of participants with three or more or six or more consecutive opioid-negative urine results, or in the mean number of consecutive opioidnegative urine results. There was no significant difference in other drug use, retention, withdrawal or craving. CONCLUSIONS Behavioural treatments of CBT and/or contingency management combined with buprenorphine do not reduce opioid use compared with buprenorphine alone in people with opioid dependence who seek treatment. ABSTRACTED FROM Ling W, Hillhouse M, Ang A, et al. Comparison of behavioral treatment conditions in buprenorphine maintenance. Addiction 2013;108:1788–98. Correspondence to: Maureen Hillhouse, UCLA Integrated Substance Abuse Programs, 1640 S. Sepulveda Boulevard, Suite 120, Los Angeles, CA 90025, USA; [email protected] Sources of funding National Institute on Drug Abuse.
buprenorphine is never prescribed in the absence of some sort of medical management, which was provided in the three trials listed, and can be quite powerful. Buprenorphine prescribers regularly emphasise abstinence and medication adherence, and recommend attendance at mutual-help groups such as Narcotics Anonymous. These straightforward pieces of advice are critical to successful outcomes. The combination of buprenorphine plus ‘medical management’—which should be termed ‘medical counselling’—produces good outcomes in many patients. Some patients will, of course, require more intensive treatment than others; opioid use disorders, like most illnesses, are heterogeneous in severity and response to treatment. Physician practices are also heterogeneous; not all buprenorphine prescribers deliver the quality of medical counselling described above, so we should not generalise from these studies to say that patients receiving buprenorphine in office-based practice do not need counselling. However, it behooves the field to determine the
minimal level of counselling that patients should initially receive, and to develop strategies for matching the intensity of counselling to the specific needs of individual patients. Roger D Weiss Division of Alcohol and Drug Abuse, McLean Hospital, Harvard Medical School, Belmont, Massachusetts, USA Competing interests RDW receives support from grants U10 DA15831 and K24 DA022288 from the National Institute on Drug Abuse, USA.
REFERENCES 1.
2.
Weiss RD, Potter JS, Fiellin DA, et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence a 2-phase randomized controlled trial. Arch Gen Psychiatry 2011;68:1238–46. Fiellin DA, Barry DT, Sullivan LE, et al. A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. Am J Med 2013;126:74. e11–17.
e2
COMMENTARY
ith the introduction of buprenorphine, opioid-dependent patients could, for the first time, be treated with agonist pharmacotherapy as part of mainstream medicine. A requirement for physicians prescribing buprenorphine has been the capacity to provide ancillary treatment or refer patients for counselling. However, the study by Ling and colleagues is the third trial to show that additional behavioural therapy does not significantly improve outcomes over that achieved by buprenorphine plus medical management.1 2 Is buprenorphine so efficacious that counselling is not needed? Not really. Buprenorphine is very effective, but not to the same extent, for example, as penicillin for streptococcal pharyngitis. For example, in the Prescription Opioid Addiction Treatment Study, conducted by the National Institute on Drug Abuse (NIDA) Clinical Trials Network, only half of the study participants achieved successful outcomes (abstinence or near-abstinence from opioids) after 12 weeks of buprenorphine treatment.1 But
Patient follow-up: All 66% completed behavioural treatment, 50% completed 40-week follow-up and 49% completed 52-week follow-up.
Downloaded from http://ebmh.bmj.com/ on June 8, 2015 - Published by group.bmj.com
Behavioural treatment combined with buprenorphine does not reduce opioid use compared with buprenorphine alone Evid Based Mental Health 2014 17: e2 originally published online March 3, 2014
doi: 10.1136/eb-2013-101639 Updated information and services can be found at: http://ebmh.bmj.com/content/17/2/e2
These include:
References Email alerting service
Topic Collections
This article cites 3 articles, 0 of which you can access for free at: http://ebmh.bmj.com/content/17/2/e2#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Substance dependence (399) Neurology (1020) Substance withdrawal (17) Clinical trials (epidemiology) (955) Epidemiology (1495)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
