Monday, January 7, 2013

Counseling Adds Nothing to Buprenorphine Alone for Opioid Addiction

In a surprising new study, David Fiellin and his colleagues at Yale found that adding cognitive behavior therapy (CBT) to buprenorphine plus medical management along did not change outcomes. That's right, folks, nothing. This adds to the growing evidence that the primary reason people get better with Suboxone (buprenorphine is the primary ingredient) is the drug not the counseling. In another recent study, Roger Weiss and colleagues with the NIDA Clinical Trials Network found that the intensity of counseling made no difference in outcomes. Of course, they also found that after 11 weeks of Suboxone maintenance, when subjects were tapered off, the relapse rate within 8 weeks was more than 90%.

Here's a graph showing the final comparative outcomes. Note that in the first 12 week, pharmacotherapy management along (PM) actually had better outcomes, although not significantly so.

This will be hard to hear for many who are deeply committed to and believe passionately that it's the other way around, that counseling is the primary ingredient of treatment. That's why SAMHSA and others have tip-toed around this issue, calling treatment with Suboxone or methadone (another drug used to treat opioid addiction) Medication Assisted Treatment. Well, guess what? With opioid addiction it's the other way around: Counseling Assisted Medication. Or maybe: medical treatment with counseling as needed for problems other than opioid addiction. Hhhhmmmm. Sound familier? Let's see now, isn't that how we treat diabetes, hypertension, heart disease, stroke, allergies, whatever?

So for all you flat-earthers out there who cling to 12-Step or other counseling as the Holy Grail, I suggest you consult The Farmers Almanac, your horoscope, the I Ching, tea leaves, Tarot cards and the Mayan Calendar for guidance. Because you certainly don't seek any from science.



David A. Fiellin, MD, Declan T. Barry,  et al., A Randomized Trial of Cognitive Behavioral Therapy in Primary Care-based Buprenorphine. The American Journal of Medicine, Volume 126, Issue 1, January 2013, Pages 74.e11–74.e17

Weiss, R. D., J. S. Potter, et al. (2011). "Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence: A 2-Phase Randomized Controlled Trial." Arch Gen Psychiatry: 68: 2011-2121.


  1. The above posting is why I love research. Never in my life would I have thought the outcomes stated were possible, and yet there it is. I have to ask myself do I do the work for myself, my philosophy, or the well-being of the client. The answer is the well-being of the client. Follow the data. Thanks, Mark!

  2. Mark, I am a strong believer in harm reduction and even long-term OST, but this research says nothing about addiction treatment. I have argued this point in an article to be found here:
    This is a quick article and depending on the response I may write a more detailed response sometime in the future. Your comments would be welcomed.

  3. "Let's see now, isn't that how we treat diabetes, hypertension, heart disease, stroke, allergies, whatever?... So for all you flat-earthers out there who cling to 12-Step or other counseling..."

    lol Doc, as a longtime advocate of a disease model for addictions, I have to point out that compliance with treatment is the biggest single problem medicine faces with chronic disorders, including the ones you name. In fact I've always suspected that most cardiologists and endocrinologists will kill for a ubiquitous 24 hour free support organization for their chronic patients...

    I hate to interrupt a good rant, but seriously, on this point you're not very well grounded in reality, either.

  4. I've been thinking a bit about Shaun's post above so I looked into the studies described for your post, Mark. The David A. Fiellin, MD, Declan T. Barry, et al article used the outcome measures stated below:

    "The primary outcome measures were self-reported frequency of illicit opioid use and the maximum number of consecutive weeks of abstinence from illicit opioids, as documented by urine toxicology and self-report."

    And the Weiss, R. D., J. S. Potter, et al. used the outcome measures stated below:

    "Predefined "successful outcome" in each phase: composite measures indicating minimal or no opioid use based on urine test-confirmed self-reports."

    I'm wondering what we would have seen if other outcome measurements were used such as work attendance, crimial activity, subjective relationship satisfaction and collateral relational satisfaction, quality of life ratings, etc... Any thoughts?


Comments are welcome.