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Research Summary

Buprenorphine-Naloxone Works for Prescription Opioid Dependence As Long As It Is Maintained

This 2-phase multisite randomized clinical trial examined the effectiveness of buprenorphine-naloxone (BUP/NX) treatment among 653 patients with prescription opioid dependence and assessed whether intensive counseling provided any additional benefit. Poor response* to brief treatment in Phase 1 (2-week BUP/NX stabilization followed by 2-week taper and 8-week postmedication follow-up) determined whether patients would continue on to receive extended treatment in Phase 2 (12-week BUP/NX stabilization followed by 4-week taper and 8-week follow-up). In each phase, patients were randomized to either standard medical management (SSM) (15–20 minute visits with a physician certified to prescribe BUP/NX) or SSM plus intensive opioid-dependence counseling (45–60 minute sessions with a trained mental-health professional).

  • Only 6.6% of patients were opioid-free after brief BUP/NX treatment, with no improvement added by intensive drug counseling.
  • Forty-nine percent of patients were opioid-free after extended BUP/NX treatment, but 8 weeks after the taper, this rate dropped to 8.6%, again with no improvement added by intensive drug counseling.
*Self-reported opioid use on >4 days in a month, 2 consecutive opioid-positive urine tests, additional substance use disorder treatment (other than self-help), or >1 missing urine sample.

Comments:

This study shows, yet again, that BUP/NX is an effective treatment for opioid dependence as long as it is maintained, and that a tapering detoxification strategy, regardless of duration, fails the majority of patients. As with the treatment of hypertension or diabetes, as long as the patient takes the medication, it works; when the medication is stopped, the disorder returns. The chronic nature of opioid dependence is worth reiterating in light of recovery-oriented orthodoxy and insurance requirements that mandate time limits on opioid agonist treatment. This study also found intensive counseling added nothing to SSM. Perhaps the time is coming when appropriate treatment will be called “counseling-assisted pharmacotherapy” rather than “medication-assisted treatment,” an acknowledgment that medication, not detoxification with counseling, should be the first-line treatment for opioid dependence. Peter D. Friedmann, MD, MPH

Reference:

Weiss RD, Potter JS, Fiellin DA, et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Arch Gen Psychiatry. 2011;68(12):1238–1246.

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