Subject:
SUBSTANCE ABUSE

Short Description:
Does Counseling Add to Suboxone’s Efficacy?

Background:

The combination of buprenorphine and naloxone (Suboxone) has become a popular replacement therapy for heroin dependence. However, it’s not yet clear how effective it is for prescription opioid dependence, or whether adjunctive counseling provides any additional benefit over the drug alone.

In a recent study of 653 outpatients who were dependent on prescription opioids, these questions were put to the test. The study involved two phases. Phase 1 was a “brief treatment” trial, in which patients were randomly assigned to either standard medical management (SMM: 15-minute visits every one or two weeks), or SMM plus opioid dependence counseling (ODC). ODC consisted of hour-long visits once or twice per week, focusing on relapse prevention and lifestyle change.

Regardless of which treatment group they were assigned to, all patients were placed on Suboxone, were continued on it for two weeks, were tapered off the medication over two weeks, and were followed off meds for eight weeks. As you might predict, only a small number of patients responded to this rapid-fire protocol—43 of 653 patients (6.6%) were “successful,” which was defined as using opioids on no more than four days in a month and having less than two consecutive opioid-positive urine tests. There was no difference in outcome between those who did or did not receive additional ODC.

More than 200 patients dropped out of the study, leaving 360 patients (who failed phase 1) to enter phase 2 of the trial. This involved a more leisurely 12 weeks of Suboxone, a four week taper, and eight weeks of medication-free follow-up. While these patients had good success while taking Suboxone (49.2% success after three months), after eight weeks off the drug their success was a dismal 8.6%, again with no difference between those who received SMM or SMM plus counseling (Weiss RD et al, Arch Gen Psychiatry2011;68(12):1238–1246).

TCPR's Take:
The good news is that this study shows that maintenance Suboxone treatment works pretty well for patients addicted to prescription opioids. (We’ll leave it up to readers to decide if four days of drug use per month should really be considered successful treatment, as it is in the study.) But once you taper the medication, expect a high rate of relapse. In this study, adding ODC to Suboxone was not helpful. So does this mean all opioid users should be put on Suboxone indefinitely, with no counseling? Not so fast. All patients in this study had weekly doctor visits of 15 to 20 minutes in length; that’s more than in the typical Suboxone practice, so the “no counseling” group may in fact have received significant amounts of therapy of some sort. It’s likely that the more closely you follow your Suboxone patients, the better they will do.