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Behavioral therapy effective for some, not all, receiving buprenorphine

Using high-quality medical management in buprenorphine maintenance treatment may be effective for some patients, but not all, according to recent findings.

The researchers suggest that clinicians employ a stepped-care model for opioid addiction treatment.

“Four influential randomized trials evaluating the impact of adding counseling or other behavioral interventions to buprenorphine plus medical management have reported no difference in opioid use outcomes between patients receiving and those not receiving additional counseling,” Kathleen M. Carroll, PhD, of Yale University School of Medicine, and Roger D. Weiss, MD, of McLean Hospital and Harvard Medical School, wrote. “These findings have sparked controversy and confusion among clinicians regarding the role of behavioral interventions in office-based buprenorphine treatment.”

To assess the role of behavioral interventions in buprenorphine maintenance treatment, researches reviewed randomized controlled studies on the efficacy of adding a behavioral intervention to buprenorphine maintenance treatment.

Four studies showed no benefit to adding a behavioral intervention to buprenorphine plus medical management, while four studies indicated some benefit for specific behavioral interventions, particularly contingency management.

Findings from negative studies were reviewed in the context of the following questions:

• Is buprenorphine effective?
• Is medical management effective?
• Are behavioral interventions ineffective in this population?
• How has research design affected study results for buprenorphine plus behavioral treatment?
• What do we know about patient subgroups who do or do not benefit from behavioral interventions?
• What treatment outcomes should clinicians aim for with buprenorphine maintenance?

“While there is no question that buprenorphine maintenance is far more effective than treatments that do not involve approved medications for opioid use disorders, retention in buprenorphine treatment appears to be significantly poorer than in methadone maintenance treatment,” the researchers wrote. “Thus, while efforts to expand buprenorphine access are essential and urgent, there remains considerable room for improvement, given 6-month retention rates of about 50% and the significantly higher risk of relapse, overdose, and death that is associated with dropout. Given these risks, we must find means of improving retention in office-based buprenorphine maintenance.” – by Amanda Oldt

Disclosure: Carroll reports a role as member in trust of CBT4CBT LLC; her conflict of interest is managed by Yale University. Weiss reports serving as a consultant for GW Pharmaceuticals, Indivior, and US WorldMeds.