Psychotherapy May Up Buprenorphine Adherence in Opioid Use Disorder

Nancy A. Melville

December 12, 2017

SAN DIEGO, California ― Psychotherapy as an adjunct to buprenorphine maintenance treatment is linked to a significant improvement in long-term treatment retention rates compared to standard counseling provided by prescribing physicians.

The findings contradict some studies that suggest that psychotherapy offers no benefit over standard counseling,

"Our observational study suggests that receipt of psychotherapy in the first year of buprenorphine treatment is associated with greater retention," said first author Ajay Manhapra, MD, lead physician at the Advanced PACT Pain Clinic at Hampton VA Medical Center in Virginia.

The findings were presented here at the American Academy of Addiction Psychiatry (AAAP) 28th Annual Meeting.

Poor Retention Rates

Opioid substitution therapy with buprenorphine can play a key, and sometimes lifesaving, role in the treatment of opioid use disorder. Buprenorphine offers an advantage over methadone in that it is available in the outpatient setting.

However, retention rates are typically less than 50%. Usually, insurance plans will cover the cost of treatment with buprenorphine only on the condition that patients also be given psychotherapy and counseling. There is debate over the extent of counseling needed to truly make a difference in adherence rates.

A recent review of studies on the issue found that in some studies, the addition of a behavioral intervention yielded no benefit, whereas others found that specific behavioral interventions were beneficial. The investigators note that large population-based studies in real-world practice are lacking.

To further examine the issue, the investigators identified 16,190 patients in the national Marketscan database of commercially insured patients who were prescribed buprenorphine for opioid use disorder starting in 2011.

The research is part of a larger ongoing study evaluating 3-year retention rates for buprenorphine treatment.

The mean duration of buprenorphine treatment was 1.23 years (SD, 1.16); 15% of patients complied with their treatment regimen for 30 days or less, 40% for 31 days to a year, 31% for 1 and 3 years, and 14% for more than 3 years.

Among those patients who complied with their buprenorphine therapy for up to 30 days, 30.29% received outpatient psychotherapy. Of those who complied for 31 days to 1 year, 35.30% received psychotherapy. For those who adhered to their treatment for 3 years, 37.59% received psychotherapy, and for those who followed their buprenorphine regimen for more than 3 years, 39.20% received psychotherapy.

Adjusted analyses showed that the receipt of any psychotherapy in 2011 was associated with a significantly reduced risk for discontinuation of buprenorphine treatment (hazard ratio, 0.86; 95% confidence interval, 0.83 - 0.89; P < .0001).

Dr Manhapra noted that some of the most favorable results in the treatment of opioid use disorder have been achieved with contingency management. However, an important limitation is that not all patients can access psychotherapy, he added.

"The fact is that many people cannot participate in psychotherapy because it interferes with their daily life significantly, and it is also expensive in both direct and indirect costs. So we may be selecting out patients who have higher chance of failure," he said.

Likewise, it may be a challenge for some primary care practices to offer professional psychotherapy, and incentives to add such services may be undermined by findings from some clinical trials that show that not all patients benefit from behavioral therapy.

Dr Manhapra underscored that the study is observational and that causal conclusions cannot be made.

"Impressive Findings"

Commenting on the findings, Kathleen M. Carroll, PhD, who coauthored the review of behavioral interventions in buprenorphine maintenance, said the current study offers important insights from a sizable cohort.

"Coming from such a big sample, [the findings] are pretty impressive," she told Medscape Medical News.

"It extends the existing literature that suggests fairly strong and consistent relationships between retention in buprenorphine and accessing some behavioral intervention," said Dr Carroll, who is the Albert E. Kent professor of psychiatry at Yale University School of Medicine, in New Haven, Connecticut.

She said that it is important to note that in previous studies that concluded that behavioral intervention did not improve buprenorphine retention, behavioral therapy was used in conjunction with fairly intensive medical management, including weekly visits with a supportive physician.

"That level of medical management is probably very rare in clinical practice," she said.

Dr Carroll's own review concluded that, in light of the conflicting study results, a "stepped care" model be used. In that model, patients for whom treatment with buprenorphine alone is not sufficient are offered a more intensive approach.

She noted that for many patients, behavioral therapy is as necessary as opioid substitution medication.

"Methadone is a drug, not a treatment, meaning that stabilizing a person on methadone is only half the battle. The rest is changing their behavior and addressing the problems that got them into opioid addiction in the first place," she said.

Dr Carroll and her team have developed a Web-based cognitive-behavioral therapy program called CBT4CBT that has been well established in clinical trials as an effective outpatient adjunct for patients with substance abuse. She noted that her team is currently working to adapt the program for use in office-based settings.

Dr Manhapra and Dr Carroll have disclosed no relevant financial relationships.

American Academy of Addiction Psychiatry (AAAP) 28th Annual Meeting. Abstract A5, presented December 9, 2017.

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