Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence: A 2-Phase Randomized Controlled Trial.
Weiss, Roger D. MD; Potter, Jennifer Sharpe PhD; Fiellin, David A. MD; Byrne, Marilyn MSW; Connery, Hilary S. MD, PhD; Dickinson, William DO; Gardin, John PhD; Griffin, Margaret L. PhD; Gourevitch, Marc N. MD, MPH; Haller, Deborah L. PhD; Hasson, Albert L. MSW; Huang, Zhen MS; Jacobs, Petra MD; Kosinski, Andrzej S. PhD; Lindblad, Robert MD; McCance-Katz, Elinore F. MD; Provost, Scott E. MSW; Selzer, Jeffrey MD; Somoza, Eugene C. MD, PhD; Sonne, Susan C. PharmD; Ling, Walter MD
[Article]
Archives of General Psychiatry.
68(12):1238-1246, December 2011.
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Context: No randomized trials have examined treatments for prescription opioid dependence, despite its increasing prevalence.
Objective: To evaluate the efficacy of brief and extended buprenorphine hydrochloride-naloxone hydrochloride treatment, with different counseling intensities, for patients dependent on prescription opioids.
Design: Multisite, randomized clinical trial using a 2-phase adaptive treatment research design. Brief treatment (phase 1) included 2-week buprenorphine-naloxone stabilization, 2-week taper, and 8-week postmedication follow-up. Patients with successful opioid use outcomes exited the study; unsuccessful patients entered phase 2: extended (12-week) buprenorphine-naloxone treatment, 4-week taper, and 8-week postmedication follow-up.
Setting: Ten US sites.
Patients: A total of 653 treatment-seeking outpatients dependent on prescription opioids.
Interventions: In both phases, patients were randomized to standard medical management (SMM) or SMM plus opioid dependence counseling; all received buprenorphine-naloxone.
Main Outcome Measures: Predefined "successful outcome" in each phase: composite measures indicating minimal or no opioid use based on urine test-confirmed self-reports.
Results: During phase 1, only 6.6% (43 of 653) of patients had successful outcomes, with no difference between SMM and SMM plus opioid dependence counseling. In contrast, 49.2% (177 of 360) attained successful outcomes in phase 2 during extended buprenorphine-naloxone treatment (week 12), with no difference between counseling conditions. Success rates 8 weeks after completing the buprenorphine-naloxone taper (phase 2, week 24) dropped to 8.6% (31 of 360), again with no counseling difference. In secondary analyses, successful phase 2 outcomes were more common while taking buprenorphine-naloxone than 8 weeks after taper (49.2% [177 of 360] vs 8.6% [31 of 360], P < .001). Chronic pain did not affect opioid use outcomes; a history of ever using heroin was associated with lower phase 2 success rates while taking buprenorphine-naloxone.
Conclusions: Prescription opioid-dependent patients are most likely to reduce opioid use during buprenorphine-naloxone treatment; if tapered off buprenorphine-naloxone, even after 12 weeks of treatment, the likelihood of an unsuccessful outcome is high, even in patients receiving counseling in addition to SMM.
Trial Registration: clinicaltrials.gov Identifier: NCT00316277
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