CBT Doesn't Work for Heroin Addiction?

Study Suggests Buprenorphine is enough. I Disagree.

In the January 2013 edition of The American Journal of Medicine there is a clinical research study conducted by members of the Yale University of the School of Medicine entitled: A Randomized Trial of Cognitive Behaviour Therapy in Primary Care-based Buprenorphine. (Fiellin, et al., 2013). In the abstract for the study, the stated objective was “To determine the impact of cognitive behavioral therapy on outcomes in primary care, office-based buprenorphine/naloxone treatment of opioid dependence.” The abstract concludes: “Among patients receiving buprenorphine/naloxone in primary care for opioid dependence, the effectiveness of physician management did not differ significantly from that of physician management plus cognitive behavioural therapy.”

Already this article is causing misleading headlines. First up were the partisan Yale Daily News and the Yale News. The Yale Daily declares “Therapy Ineffective for Opioid Addiction(Goldberg, 2013) and the News “Cognitive behavioral therapy adds no value to drug treatment for opioid dependence (Dodson, 2013).  Medicalxpress.com makes similar claims and adds the study “could change how such dependence is viewed and treated in the U.S. healthcare system”. Medscape says there is “no additional benefit of CBT in Opioid Addiction”. Soon, no doubt, the mainstream press will have similar headlines and the general public and, more dangerously, policy makers will believe that all that we need to cure heroin addiction is enough doctors handing out Buprenorphine.

Taken at face value it seems an attractive prospect to be able to simply hand out a pill to addicts who come with a plethora of bio-social ills that have, until now it seems, required specialised and intensive interventions. Already we are seeing that 41% of those receiving Buprenorphine treatment in the United States are not getting any psycho-social treatment in their first month and 56% of doctors allowed to prescribe buprenorphine were in non-addiction specialties. (To read more about this and to find out how the Buprenorphine market is primarily the domain of the affluent, read this article at www.theFix.com: The Other Side of the Tracks). 

Even though the study includes a brief paragraph that outlines one or two study limitations, and the authors do address some of my concerns, I feel that this study is seriously limited in possible application. Here are my reasons:

It measures the wrong thing
The impression the article creates, and this impression is backed up by the subsequent quotes by the authors in the cited articles, is that they are measuring the effectiveness of treatment for heroin addiction. It doesn’t. It measures simply heroin abstinence, while on a partial opioid agonist. 

Heroin addiction is not heroin dependence. It is a lot more. This is demonstrated by the psycho-social and behavioural issues that addicts across the spectrum of addictions suffer. This study does not examine the quality of life, nor claim to. Does Buprenorphine help keep people off Heroin? Absolutely. We know that already. Buprenorphine is a very useful tool in the treatment of opioid addictions. In a few cases this migratione from opioid dependence to Buprenorphine dependence and the possible associated move away from “drug culture” is enough motivate a person from “addicted lifestyle” to “living”. But this is the exception.

Long-term drug use causes neurological changes and these are reflected in behaviours. Addicts have, through various processes, adopted a set of behaviours and thinking patterns that are not effective in achieving their long-term life goals. Most of us who treat addictions will agree that abstinence is only a very small part of the treatment process. Whatever theory or model of addiction you subscribe to, addiction is not simply about drug use. This thinking is reflected in the NIDA document Principles of Addiction Treatment where point 4 states: “Effective treatment attends to multiple needs of the individual, not just his or her drug abuse”.  

If this study had included some indicators that reflected quality of life, and it was shown that these individuals had improved in these areas, then perhaps it would have had more application in the all too real world of addiction.

Long-Term Sustainability
Further in the Principles of Addiction Treatment document we read: “Remaining in treatment for an adequate period of time is critical” and “Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse.”  What we have here is a limited time study of people who have not yet been detoxed. These are opioid addicts who have moved from opioid dependency to opioid agonist dependency. They are not “cured”. By cutting out the CBT component we are not providing any tools for living without pharmacological intervention. This is more in the line of harm reduction rather than treatment or rehabilitation. I’m a huge proponent of harm reduction and medium to long term substitution, but not at the expense of abstinence based psycho-social solutions geared towards effective living and functioning.

The big question is if this is sustainable. 6 months (the period of the study) is a short time when it comes to addiction treatment. The mean years of dependency in this study was around 8 years. How many of these patients will still be visiting their physician monthly for the next 8 years? How are they going to develop drug refusal behaviours or deal with underlying issues if their drug use is a form of self-medication or self-soothing if there are no real psycho-social interventions? Eventually many will either taper or simply end the medication, which costs between US$250 and US$500 per month to maintain. The study itself had a huge drop-off rate. (An interesting area of research would be to see if Motivational Interviewing before and during early treatment initiation would reduce dropout rates).

If the authors were suggesting Buprenorphine alone as a temporary holding pattern that primary health settings can initiate before treatment starts, then great. Unfortunately they are not saying that.

CBT as an Approach
The Yale study examines the impact of adding CBT to the Buprenorphine protocol. They do this probably because CBT is the preferred and most researched psychological intervention for addictive disorders. Personally I have found that while stimulant users get significant benefits from initial CBT interventions, heroin addicts respond more favourably to a psychodynamic approach which is less structured, seeks to examine personal history and has more focus on the therapeutic relationship. There is research (Gibbons, Crits-Christopn, & Hearon, 2007) to back this up and others I have consulted have also found this thinking to be useful. 

To use the blanket term “therapy” as some of these headlines do, is misleading.

Conclusion
If our goal is abstinence, reduced mortality amongst heroin users and less crime, then this study has some merits. However, if our goal is to help heal the addicted and to empower those who want to find long-term recovery without life-long dependence, this study says little and if adopted into our evidence base, could potentially do a lot of harm.

11 comments:

  1. Medical professionals, even those that specialize in addiction espousing the disease model, often get sidetracked by the physical dependency leaving the mental/emotional issues, the true disease, untreated by default.

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    Replies
    1. Yes, agreed. I included this quote in my January Newsletter: "The highly personal narratives of participants framed by equally complex social environments are not visible in the numbers. To epidemiologists and other like-minded health researchers, the numbers are the narrative and all that is required for informing and evaluating theories, models, interventions, treatment programs, or policy."

      In a similar way we often forget the effect on the "humanity" of the individual that addiction has.

      Delete
  2. Excellent read! I think you make excellent points regarding quality of life and lack of measuring various other markers of sustainable change.

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  3. Great job distilling some important ideas about addiction treatment in general, and opiate addiction in particular. Noting the difference between dependence and addiction is crucial and can't be said too often. Also, abstinence cannot be the only goal of treatment. However, here in the States, we have a major shortage of suboxone prescribers. It is a major problem. What I took away from the study is that if getting on a medication is all a person can do at first, it's a totally acceptable option. Also, if studies like these convince more docs to become suboxone prescribers by showing them that the simple act of making this medication available is clinically comparable to any other treatment modality (indeed far superior in some cases), then I would be grateful.
    Thanks for your efforts. I look forward to continuing to read your work.
    Ian

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  4. Thanks for your comment Ian. I would agree with the conclusions you have drawn from the study. My concern was with the resulting discussions and interviews in the press that seemed to take reasonable conclusions a step too far. I often see studies like this "slip into" mainstream thinking and get presented as "fact" - "oh, you don't need counselling/therapy/whatever, suboxone's enough, I read it in this study" kind of thing!

    I would also like to see more doctors, particularly general practitioners, become more familiar with and educated about addiction disorders in general, and OSTs in particular.

    Thanks for your contribution.

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