Another study finds no benefit from cognitive behavioral therapy and contingency management with opiate replacement treatment. [CORRECTED: See below]
Background and aims
The Controlled Substances Act requires physicians in the United States to provide or refer to behavioral treatment when treating opioid-dependent individuals with buprenorphine; however no research has examined the combination of buprenorphine with different types of behavioral treatments. This randomized controlled trial compared the effectiveness of 4 behavioral treatment conditions provided with buprenorphine and medical management (MM) for the treatment of opioid dependence.Design
After a 2-week buprenorphine induction/stabilization phase, participants were randomized to 1 of 4 behavioral treatment conditions provided for 16 weeks: Cognitive Behavioral Therapy (CBT=53); Contingency Management (CM=49); both CBT and CM (CBT+CM=49); and no additional behavioral treatment (NT=51).Setting
Study activities occurred at an outpatient clinical research center in Los Angeles, California, USA.Participants
Included were 202 male and female opioid-dependent participants.Measurements
Primary outcome was opioid use, measured as a proportion of opioid-negative urine results over the number of tests possible. Secondary outcomes include retention, withdrawal symptoms, craving, other drug use, and adverse events.Findings
No group differences in opioid use were found for the behavioral treatment phase (Chi-square=1.25, p=0.75), for a second medication-only treatment phase, or at weeks 40 and 52 follow-ups. Analyses revealed no differences across groups for any secondary outcome.Conclusion
There remains no clear evidence that cognitive behavioural therapy and contingency management reduce opiate use when added to buprenorphine and medical management in opiates users seeking treatment.
The question remains, why do patients on opiate replacement receive no benefit from these additional treatments? Particularly when they have been repeatedly shown to benefit addicts not on opiate replacement?
A recent post mentioned an expert’s observation that patients on opioids seem to “opt out of life.”
Are these patients less available to participate in other treatments? We asked this question in our position paper on buprenorphine maintenance.
[Correction: I appear to have had too many tabs open and made a stupid mistake. Thanks to Ian McLoone for pointing out the error. The prevous version erroneously said: “This time the drug is methadone. (It’s worth noting that the study received funding from the manufacturer of Suboxone. There have been similar findings about Suboxone and behavioral therapies. I guess they wanted to show that methadone is no better in this respect.)”]
Recovery Review 
I am actually seeing that this drug is also Buprenorphine (Subutex), just as the previous study. Correct me if I am wrong…
BTW – to me, these findings are consistent with the fact that the opioid-dependent brain has undergone structural changes that are permanent or very long-lasting. Thus, pharmacological interventions seem to be the only consistent way to “normalize” the brain function. The “opt-out of life” judgment is a harsh, moralistic one that is not doing anyone any favors, and in fact, could very easily be interpreted in a way that would prevent someone from seeking help – the very thing professionals would NOT want to happen.
Ian
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You’re correct about the methadone/buprenorphine mistake. Thanks for pointing it out. I guess I was looking at too many tabs at once.
Are opioid addicted doctors immune to behavioral treatments?
The whole premise of this article was that there is evidence that behavioral treatments like CM and CBT are effective in treating opioid dependence, but the evidence is less clear when combined with buprenorphine.
Here’s what the author’s said:
As for the “opt out of life” comment. It fits with our small program’s anecdotal experience. We’ve had scores of families and clients seeking detox from buprenorphine because, while it reduced opioid misuse, the ORT patient hadn’t re-entered life. They weren’t working or in school, they were hiding in the basement playing video games, little social interaction, etc.
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BTW – Regarding harsh and judgmental approaches, knowing that physicians enjoy terrific outcomes with abstinence-based treatment, some people might say that a physician assuming that non-physican opioid addicts are incapable of abstinence-based recovery is harsh and judgmental.
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Can you send me that study you often reference re: opioid-dependent physicians?
I know of several physicians who got sober with suboxone.
Bottom line, for me, is that outcomes improve are greatly improved with the aid of opioid-replacement meds. I don’t know of a single study that shows abstinence-based Tx to be as effective. The informed consent argument is as simple as informing clients of the fact that these meds are out there and have a long, proven track record. However, they are nothing more than a tool to be placed in the client’s toolbox and assist them in their overall recovery.
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Here are a few references.
First though, one of the dismissals of physician recovery program outcomes is that physicians are different. Note that they have high rates of opiate addiction, prior treatments and co-morbidity. It’s also reported that their addiction tends to go undetected longer than most addicts and is, therefore, more advanced. They have easy access to drugs and often have staff and family to protect protect them from consequences of their addiction. In short, for every reason they may be easier to treat, there’s another reason that they may be harder to treat.
DuPont et al. report on Physician Heath Program outcomes from 904 physicians in 16 states.
In their lit review, they report:
They describe the kind of treatment addicted physicians receive this way:
Participant characteristics included:
The only info on co-morbidity is this:
In another article, DuPont et al. surveyed PHP programs in 49 states to find out what they look like:
Goals [emphasis mine]:
Problems at admission:
Treatment:
Pharmacotherapy:
Long-term support and monitoring:
Mayo Clinic Proceedings also has a review of treatment for addicted physicians.
Mayo Clinic Proceedings has another article on the use of buprenorphine with health care professionals.
They also published an editorial that had a couple of complaints about the article but said:
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One more link. Not scholarly, but germane and thought-provoking:
From the ASAM blog:
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I thought this Fix.com article on the subject was interesting – made me rethink my idea of PHPs:
http://www.thefix.com/content/whats-wrong-with-addicted-doctor-PHP-programs00389?page=all
I wouldn’t say that doctors are inherently special – and that they, too, should have access to maintenance. One thing to keep in mind, however, is that higher education level, social and familial supports, and threat of serious career and financial consequences are all things that are highly correlated with successful outcomes.
The average opioid treatment client doesn’t have all of these things going for him/her. Any tool that we can give them that helps increase their chances of success is a good thing – and something we should feel obligated to provide.
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We’re in agreement that, from a treatment perspective, I have no interest in forcing anything on anyone. If a patient prefers ORT, I have no interest in getting in their way.
The bottom line is that PHPs appear to work better than anything else we have and we fail to offer that model to other opioid addicts. And, we maintain this two-tier treatment model with an assumption of physician-exceptionalism. I find that troubling and unpersuasive. Are physicians generally better patients with better outcomes?
Regarding the article on PHPs, I’m all for researching the mechanisms of change in PHPs. Maybe they can be trimmed down or substitutions could be identified for particular mechanisms of change. However, the article reads like a rejection of evidence in favor of a search for evidence to support a preferred conclusion.
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