Use of psychosocial treatments in conjunction with medication for opioid addiction—recommended, but research is sparse
Psychosocial interventions, used together with effective medications, are a key part of recommended treatment for opioid addiction. But while research generally supports the effectiveness of psychosocial treatments, there are major gaps in the evidence on their use in conjunction with medications, according to a review and update in the January/February Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine (ASAM).
"Given the current state of the opioid overdose epidemic, it is critical that patients seeking help for opioid addiction have access to comprehensive treatment that includes highly effective medications whose effects may be enhanced with the provision of psychosocial interventions," according to the report by Karen Dugosh, PhD, of Treatment Research Institute, Philadelphia, and colleagues.
Limited Evidence on Psychosocial Interventions for Opioid Addiction
Rates of opioid use, including fatal overdoses, have increased sharply over the past decade. A 2015 study estimated that more than 900,000 Americans used heroin in the previous year, while 4.3 million took prescription opioid pain medications for non-medical uses.
There are three approved types of medications that work in different ways to treat people with opioid addiction: methadone, buprenorphine, and naltrexone. The ASAM recently issued guidelines on the use of these medications, based on an extensive body of research evidence. The current review of the evidence on psychosocial treatments with medications was commissioned as part of the development of ASAM's guideline.
All three medications are approved for use "within the framework of medical, social, and psychological support," and ASAM's guideline recommends psychosocial treatment in conjunction with the use of medications. "However," Dr. Dugosh and coauthors add, "there is limited research addressing the efficacy of psychosocial interventions used in conjunction with medications to treat opioid addiction."
To assess the current state of the evidence, the researchers assembled and analyzed the findings of previous research, including three previous reviews and 27 new studies. They write, "The results generally support the efficacy of providing psychosocial interventions in combination with medications to treat opioid addiction."
But the review also found major limitations in the amount and quality of the evidence—particularly in terms of identifying the safest and most effective combinations of medications and psychosocial treatments. There were very few studies comparing different types of psychosocial approaches, or assessing their effectiveness at different treatment stages and in different patient subgroups.
Of the 27 newer studies, 14 evaluated psychosocial treatments in conjunction with methadone maintenance therapy. Nine of these studies showed significant benefits of psychosocial interventions in patients being treated with methadone, including reduced drug use and increased treatment attendance.
For buprenorphine, the results were "less robust"—only three of eight studies found positive effects of psychosocial interventions. Just three studies addressed the use of psychosocial treatments with oral naltrexone, all of which showed significant benefits. Extended-release injectable naltrexone, however, has not been studied as a standalone therapy without psychosocial treatment. Its efficacy was established only when used in combination with psychosocial treatment.
Dr. Dugosh and colleagues make recommendations for research on the role of psychosocial interventions as a part of "comprehensive, recovery-oriented treatment" for opioid use disorders. "As opioid use and overdose deaths in this country exceed epidemic proportions," they conclude, "the urgency for an expanded research agenda on best practices for comprehensive treatment could not be more critical."