Wednesday, April 30, 2014

Who Benefits from Additional Drug Counseling among Prescription Opioid Dependent Patients on Suboxone?

In a secondary analysis of the Prescription Opioid Addiction Treatment Study (POATS), the original study's author, Roger Weiss, and colleagues parse the data to determine if there are common characteristics among those who benefited from additional opioid dependence counseling (ODC) - above and beyond the standard medical management (SMM) and buprenorphine-naloxone medication. It is a very good question, considering the host of recent studies which found no additional benefit to counseling in terms of measured outcomes, including the large and highly-regarded POATS.

In searching for an answer, the authors looked at two sources of variability - patient characteristics, and adherence to treatment. Specifically, the authors sought to answer three questions: 1) Did participants with more severe problems have better outcomes with SMM + ODC than with SMM alone (N=360)? 2) Among participants with adequate adherence to treatment, were those assigned to SMM + ODC more likely to have successful outcomes than those receiving SMM alone, regardless of severity (n = 266)? And 3), among participants with adequate adherence to treatment, were those with more severe problems more likely to succeed with additional counseling than with standard medical management only (n = 266)?

In response to question 1, the analysis found that "the association between severity and outcome did not vary by treatment condition for any of the three severity measures." Those without past use of heroin had more favorable outcomes across the entire study. Regarding question 2, "adequate adherence" was defined as attending at least 60% of scheduled scheduled sessions in both treatment conditions, and most participants (73.9%) attended at least 60% of sessions. Subjects in the SMM-only condition were more likely meet this criterion but, once again, outcomes did not differ by treatment condition. Finally, in answering question 3, the authors found that, "Among participants who had ever used heroin, those assigned to SMM + ODC were more likely to succeed than those in SMM only (66.7% vs. 35.0%, n = 70, χ2(1) = 6.88, p=.016)."

 Table 1
Likelihood of successful opioid use outcomes at Phase 2, weeks 9–12. a
95% CI      p Value
(a) All participants ( n= 360)
Main effects
1.3–3.3      .004

Chronic pain
0.8–2.0      .240

Drug severity
0.2–58.2    .484

Interaction with Phase 2 treatment
0.6–4.2      .342

Chronic pain
0.2–1.4      .218

Drug severity
0.0–76.8    .585
(b) Participants with adequate adherence to treatment ( n= 266)
Main effect of Phase 2 treatment
0.4–1.1     .107

Interaction with Phase 2 treatment
1.1–11.8     .03

Chronic pain
0.2–1.5      .213

Drug severity
0.001–4023.5   .915

a All models were adjusted for Phase 1 treatment condition.

Treatment outcomes did not appear to differ among those who had never used heroin, suggesting that prescription opioid-addicted patients with a history of heroin use may be the participants who are most likely to benefit from additional counseling in suboxone treatment. Importantly, those patients had to also attend enough sessions (and receive an adequate "dose" of counseling) in order to see their outcomes improve to rates similar to those without a history of heroin use.

So, do these results line up with the experience of the readers of this blog? Are there populations with whom you believe counseling is especially important? Or, do the results simply reinforce the lessons of past studies? Let us know

1 comment:

  1. These results seem important, as they identify a patient subgroup (heroin use history) needing more intensive services. It's also not surprising. While the pharmacodynamics of heroin and prescription opioids are generally similar, the pharmacokinetics of IV heroin use results in greater reward and reinforcement, and perhaps more durable post-acute withdrawal phenomenon including drug craving that requires a more aggressive approach to promote abstinence. It may also be possible that some folks preferentially gravitate to heroin on the basis of pre-existing psychiatric or psychosocial factors, which also complicate recovery and elevate relapse risk.
    Mark Edmund Rose, MA
    Licensed Psychologist