Saturday, July 27, 2013

Buprenorphine: 4 Counseling: 0

It hasn’t been a good couple years for counseling in the buprenorphine treatment literature. Yet another study, authored by a team led by the venerable Walter Ling, and currently available in Addiction Journal’s “early view” section online, has shown that counseling adds nothing to buprenorphine maintenance, in terms of measured outcomes. By our count, this makes four consecutive studies to show basically the same thing: counseling, while by no means harmful, has not been shown to add anything to buprenorphine maintenance in opioid-dependent patients without significant co-occurring psychiatric disorders.

Ling, et al.’s study is arguably the most convincing study yet. The team performed a randomized control trial in which patients were randomized to one of four behavioral treatment conditions, as adjuncts to buprenorphine maintenance: cognitive behavioral therapy (CBT), contingency management (CM), both CBT and CM, and no behavioral treatment. Counselors were master’s-level trained counselors who met with patients weekly for the initial phase of the study.

The results showed no differences in opioid use after the behavioral treatment phase, during the second (medication-only) phase, or at follow-ups at weeks 40 or 52. In addition, there were no statistically-significant differences in any of the secondary measures (retention, other drug use, withdrawal and craving, addiction severity index ratings, and adverse events).


Interestingly, there were differences in reported treatment satisfaction ratings. While the majority of participants reported being “very satisfied” with treatment, and 85% reported Suboxone was “very effective”, just 60% reported that their behavioral treatment was “very effective”. On the other hand, 21% of the no-treatment group reported that their behavioral treatment was “not effective”, compared to 3% of the CBT group and 0% of the CBT + CM group.

As a student of behavioral health counseling, this science is particularly hard to swallow. However, it does seem to affirm the fact that, for patients with opioid-use disorders, ensuring easy and affordable access to maintenance medications is currently our best and most important tool for their treatment.

What do you think?

4 comments:

  1. Ian, I like your comment regarding the research. As professionals within an empirically driven field aimed at creating maximum outcomes for the individuals we serve we need to understand how our biases can reduce our effectiveness. Ultimately, the evidence base is there to direct our work regardless of our personal biases. If one is not able to practice in this way I wonder if one should be practicing...

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  2. This IS hard to swallow but science is science. What I'm wondering is just how many people with opioid dependence DON'T have co-occurring disorders. Isn't it true that, in studies like this, such people are screened out and, as such, don't reflect the "real world" of patients?

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    1. Yes, Anne, it is true - in this study, participants had to have "good physical and psychiatric health", which would rule out significant COD. While opioid-use disorders and psychiatric disorders often co-occur, it's not as prevalent as is commonly believed - the 50% number that is often referenced is too high. But that is certainly a limitation, and likely where counseling would have a much different effect on outcomes.
      Interestingly, in a recent study published in the journal Drug and Alcohol Dependence, one of the patient characteristics positively correlated with successful opioid use outcomes (in suboxone patients receiving Tx for addiction to prescription opioids) was "past-year or lifetime diagnosis of major depressive disorder". So, we should in no way assume that folks with a history of mental illness cannot also benefit from buprenorphine maintenance.

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  3. The evidence certainly is mounting, and I have certainly had to change my views from "mildly optimistic" to "strongly in favor" when it comes to MT. One thing that strikes me about the study is that they actually used a very direct form of contingency management to ensure retention levels - they paid a gift-card incentive for each visit to the total of $410. The other issue is that there were twice weekly urine tests, and some counseling or certainly contact occurred during these interactions. There was also careful monitoring of dosage during the study. For these reasons I think we need to look more closely at the WAY buprenorphine maintenance is managed. I would suggest that optimal dosage and retention in treatment are the vital components, and perhaps points of contact which help keep the individual focused.

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