No Additional Benefit of CBT in Opioid Addiction

Pam Harrison

January 10, 2013

The addition of cognitive behavioral therapy (CBT) to medical treatment for opioid dependence does not significantly enhance outcomes compared with medical treatment alone, new research shows.

David Fiellin, MD, and colleagues from the Yale University School of Medicine, New Haven, Connecticut, found that CBT provided by trained clinicians did not improve abstinence from opioid use or retention rates in treatment programs when added to physician management alone.

"You need to consider the spectrum of patients who were entered into the trial in that we excluded patients with untreated psychiatric disorders as well as those who had addictions to other substances, among whom it may well be that CBT is beneficial," Dr. Fiellin told Medscape Medical News.

"But for patients who are able to be treated in less of a specialty setting, we were unable to detect an additive benefit of CBT, so it may be that medication along with low levels of physician contact is adequate for a certain spectrum of patients with opioid dependence."

The study is published in the January issue of the American Journal of Medicine.

The study involved 141 opioid-dependent patients recruited from a primary care clinic.

Patients were randomly assigned to physician management or physician management plus CBT.

Physician management consisted of a brief and medically focused visit, during which patients received the combination of buprenorphine/naloxone at a dose of 16 mg daily throughout the 24-week trial.

The dose of buprenorphine could be increased to 20 and 24 mg a day, depending on the patient's level of discomfort or on evidence of ongoing illicit opioid use.

Patients receiving additional CBT were treated with the same medication but were offered additional CBT in the form of up to 12 50-minute weekly sessions during the first 12 weeks of treatment.

"Of 8 possible physician management sessions, patients assigned to physician management alone attended an average...of 5.9 sessions compared with those in the physician management plus cognitive behavioral therapy treatment arm," investigators report (P = .002).

Patients receiving additional CBT attended an average of 6.7 out of 12 possible CBT sessions as well.

Both approaches resulted in a reduction in the mean self-reported frequency of opioid use from 5.3 days per week at baseline to 0.6 days during the first 12 weeks of the trial.

This dropped to a mean of 0.4 days from weeks 12 to 24, when the combination group was no longer receiving CBT.

A significant reduction in negative urine test results was also observed from the first 12 weeks of treatment to the second 12 weeks of treatment (P < .001).

The number of patients who needed to be transferred to methadone maintenance because of ongoing opioid use or for acute psychiatric decompensation also did not differ between the 2 treatment groups.

"Among primary care providers, there is still a level of hesitancy to provide treatment for opioid dependence out of concern that they may not have the appropriate counseling skills," Dr. Fiellin said.

"But our study indicates that certainly for the spectrum of patients included in our study, many of them can do without sophisticated psychosocial counseling, and this can be considered a good thing."

The study was funded by the National Institute on Drug Abuse. Dr. Fiellin has received honoraria from ParagonRx and Pinney Associates for serving on external advisory boards monitoring the abuse and diversion of buprenorphine.

Am J Med. 2013:126:74.e11-74.e17. Full article