Psychotherapy and Naltrexone in Opioid Dependence

2015

An issue of current importance to psychiatry is the efficacy of psychotherapy and phamacotherapy in comparison to one another and in combination. In addiction treatment, the importance of individual counseling for the successful use of opioid antagonists such as naltrexone has often been suggested but as yet there is insufficient data to support this contention. Furthermore, naltrexone efficacy studies have not controlled for the type or degree of patients’ involvement in interpersonal aspects of treatment. The present pilot study evaluated the effectiveness of naltrexone in conjunction with a high intervention treatment that included individual counseling as compared with a low intervention treatment that excluded such counseling.

Method

Sixty-six opioid-dependent volunteers were randomly assigned at intake to either a low intervention (N=31) or high intervention (N=35) treatment group. All subjects were over 18 years of age, had been addicted to opiates for at least one year, were free of serious medical and psychiatric illness and signed an informed consent. An attempt was made to match the two groups for level of opioid dependence immediately prior to entering the study and number of subjects who entered the study from long-term methadone maintenance as compared with those who entered with dependence on illicit opioids (street addicts). All subjects were new admissions to the treatment unit since it was felt that a prior treatment history at this facility would confound their assignment to groups.

Because naltrexone treatment has been limited by high drop-out rates before subjects even received the first naltrexone dose, subjects were assigned to their treatment group prior to detoxification in order to assess whether the intervention level would affect naltrexone induction rates. The detoxification period also seemed to be an opportune time to initiate a therapeutic relationship with subjects in the high intervention group.

All subjects were offered identical medical and nursing services which included detoxification from opioids followed by maintenance on naltrexone requiring three clinic visits per week. Each high intervention subject was additionally offered regularly scheduled psychotherapy sessions with an experienced therapist who closely monitored the patients’ clinical course and was available to provide a variety of services. The therapy included supportive, directive and insight-oriented techniques, depending on the orientation of the therapist, the needs of the patient, and what seemed to be most helpful at a particular point in time. In addition to offering at least one scheduled therapy session each week, the therapist maintained a high level of availability to assist with problems that my have emerged between the scheduled sessions. Therapists encouraged patients to contact them at the clinic or at home if there was a need for services outside the scheduled visits. Subjects were telephoned by therapists whenever they failed to appear for a scheduled clinic visit. In general, therapists made an active attempt to provide patients with continuing emotional support and develop a strong therapeutic alliance.

Low intervention subjects were assigned a case manager who provided only concrete services, referral to outside agencies, or crises intervention. The case managers were instructed to avoid engaging patients in a therapeutic relationship, i.e., no attempt was made to encourage discussions about personal problems or to contact subjects when a clinic visit was missed, Low intervention subjects requesting psychotherapy were referred to community agencies or private practitioners who could provide such services. In all cases an attempt was made to service the needs of low intervention subjects without promoting a close personal bond between the subject and staff members.

The frequency and duration of contacts with the staff were recorded for each subject. The contacts were classified as either: (1) Medical/Data Collection contacts, or, (2) counseling contacts. Contacts with the physician that primarily addressed medication issues, physical examinations and symptoms or with the project coordinator for obtaining data on mod or psychosocial functioning were designated Medical/Data Collection contacts. Contacts with the therapist, case manager or nurse that primarily concerned other issues were designated Counseling. For high intervention subjects counseling included formal therapy sessions as well as telephone and other contacts that provided advice, encouragement, or support on an informal basis. For low intervention subjects, Counseling contacts consisted of discussion about referrals to outside agencies or time spent providing crisis intervention.

Outcome evaluations were made with respect to: 1) detoxification success rates; 2) naltrexone retention rates, and 3) opiate use status at three and six months following the first naltrexone dose.

Results

Table “Demographic and drug history variables for high vs. low intervention groups” shows that before entering the study the high and low intervention subjects were comparable with respect to several key demographic, psychosocial, and drug use variables.

The contact time data shown in Figure “Mean weekly contact time between the subjects and staff for high vs. low intervention groups” indicates that although both groups received almost the same amount of time over medical issues and data collection, the high intervention group spent significantly more time with their therapist discussing interpersonal problem and issues concerning psychosocial functioning. Counseling contact time for high intervention subjects averaged about 70 minutes per week throughout the study. For low intervention subjects counseling time averaged less than 20 minutes per week during detoxification and then dropped to less than half that time until treatment termination. For both high and low intervention groups there was an average of 45 minutes per week in Medical/Data Collection contacts during the early phase of treatment, when all subjects were seen for 10-15 minutes 3-5 times a week for symptom review and medication adjustments.

Figure compares detoxification success rates (i.e., naltrexone induction rates) for the high and low intervention subjects. High intervention subjects showed greater detoxification success rates than low intervention subjects (73 percent vs. 57 percent) although this difference was not statistically significant (> .05).

Table “Time on naltrexone (weeks)” compares time on naltrexone for the two treatment groups. High intervention subjects tended to remain on naltrexone for a longer period of time and this finding was statistically significant for subjects who detoxified from illicit opioids but not for those who entered the study from methadone maintenance. Illicit opioid users who received the high intervention treatment remained on naltrexone an average of 9.3 weeks and as long as 26 weeks, whereas those who received the low intervention treatment remained on naltrexone an average of only 2.1 weeks and no longer than 7 weeks. These findings are also depicted graphically in Figure “naltrexone attrition rates for weeks 1 to 26 (6 mos.) for high vs. low intervention groups” which shows attrition rate curves for the two groups over the first 26 weeks.

The bar graph in Figure “Follow-up at three and six months after first naltrexone dose for high and low intervention groups” shows the percentage of subjects still opiate-free at three and six months after starting naltrexone and indicates a greater likelihood of opiate-free status for subjects in high intervention treatment: 73 percent vs 40 percent at 3 months and 54 percent vs. 40 percent at six months follow-up, Of those patients who were opioid dependent at follow-up, 70 percent from the high intervention group had entered methadone maintenance treatment and 30 percent were using illicit opioids, whereas only 33 percent from the low intervention group had entered methadone maintenance and the remaining 67 percent were using illicit drugs.

Discussion

We anticipated numerous problems in controlling the level of staff intervention in a therapeutically oriented clinic that requires frequent visits for medication. Specifically, we expected difficulty in limiting the services provided to low intervention subjects for two reasons: 1) all patients in the study were required to attend the clinic three times per week for medication and therefore would have frequent contact with the clinic staff; and 2) therapists assigned to case managers for low intervention patients would have difficulty in limiting service delivery since this would be contrary to their training and philosophy.

The present study shows that it was possible to control the amount and type of services rendered to patients by the therapists who participated in the study. However, it was very difficult for the majority of nursing and counseling staff not involved in the study to limit contacts with low intervention patients, my of whom received considerable unplanned and unrecorded intervention that my have had a significant impact upon treatment outcome.

The amount of time in Medical/Data Collection contacts was rather high during the early phases of treatment, although there was no difference between the two treatment groups. During these “medical” contacts there was substantial encouragement and emotional support given to the patients which may have obscured differences in detoxification success rates between the high and low intervention groups.

An additional factor which may have reduced outcome differences between the two treatment groups is that three of the six subjects in the low intervention group who were opiate-free at six months follow-up had been receiving regularly scheduled psychotherapy at other facilities.

 

Selections from the book: “Problems of Drug Dependence, 1980: Proceedings of the 42nd Annual Scientific Meeting, the Committee on Problems of Drug Dependence, Inc.” Louis S. Harris, Ph.D., ed. Comprehensive assemblage of ongoing research on drug abuse, addiction, and new compounds. National Institute on Drug Abuse Research Monograph 34, February 1981.