Does Counseling Add to Suboxone’s Efficacy?
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 rapidfire 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 Psychiatry 2011;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.
Helping the Severely Mentally Ill to Help Themselves
“Self-management” is a newly popular buzzword among clinicians treating the seriously mentally ill. Self-management programs include psychoeducation for patients about their illness, training to help patients communicate more effectively with their doctors, and instruction on how to advocate for themselves in treatment settings.
One of the more popular self-management programs is Wellness Recovery Action Planning (WRAP). In WRAP, trained peer instructors lead weekly sessions consisting of group exercises, lectures, and voluntary homework. Group topics include such items as maintaining wellness, recognizing symptoms, managing crises, and learning where to obtain credible information about one’s condition. In a controlled trial early last year, patients of public mental health clinics who participated in WRAP had fewer psychiatric symptoms and an enhanced quality of life than those not receiving WRAP training (Cook JA et al, Schiz Bull 2011;online ahead of print).
One possible explanation for the efficacy of WRAP is that it facilitates a patient’s self-determination and builds self-advocacy skills. To test this hypothesis, the researchers randomized 555 community mental health patients, most of whom had been diagnosed with psychotic or mood disorders (but no substance use disorders), to either a two-month WRAP intervention (276 patients) or to treatment as usual (279 patients). All patients continued to receive medications, case management, and therapy if and when indicated. “Self-advocacy” was measured by the Brashers’ Patient Self-Advocacy Score (PSAS). This scale consists of three subscales: education, the patient’s willingness to learn about his/her illness; assertiveness, the patient’s ability to be assertive during a health-care encounter; and mindful non-adherence, the patient’s inclination to disregard a provider’s recommendations (while we often consider “non-adherence” an undesirable outcome, in this case, it represents the patient’s ability to act autonomously in an informed way) (Brashers et al, Health Communication 1999;11(2):97–121).
Patients who received WRAP training had greater self-advocacy scores over time than those assigned to treatment as usual. This was particularly true on the measure of mindful non-adherence; scores on the other subscales did not change significantly. Higher overall self-advocacy scores were significantly correlated with higher levels of hopefulness (correlation coefficient r = 0.45), better quality of life (r = 0.28), and lower symptom severity, as measured by the Brief Symptom Inventory (BSI) Global Severity Index (r = -0.23). (Jonikas JA et al, Comm Ment Health J Dec 2011;online ahead of print).
TCPR’s Take: WRAP training appears to be a simple and inexpensive way of increasing the assertiveness of the seriously mentally ill. We’d like to see longer term follow-up, but meanwhile we recommend referring patients to such a program if you can find one in your community.