_________________________________________________________________________ Opioid Use Disorder
with drug counseling alone or with drug counseling plus sup- portive expressive therapy or cognitive-behavioral therapy. Patients with moderate-level symptoms did somewhat better if they received additional psychotherapy, and patients with more severe psychiatric symptoms had substantially better outcomes with additional psychotherapy than with drug counseling alone. Improvements were observed in employment, legal, psychiatric, and drug use indices. Patients with opioid depen- dence and antisocial personality disorder did not benefit from additional psychosocial therapy beyond drug use reduction, but patients with opioid dependence, antisocial personality, and depression exhibited improvement in multiple areas [163]. Therapist variables played an important role in outcome, with better results associated with therapists who formed a positive, helping relationship with the patient. There is also some evi- dence that the best patient outcomes come from methadone programs with a higher level of services that include counseling, medical, and psychiatric services [163]. Abstinence-Oriented Therapies The primary goal of abstinence-oriented interventions is cure, which is defined as long-term, stable abstinence from all opi- oids. Abstinence is achieved in two phases: detoxification and relapse prevention. Outcomes in abstinence-oriented programs are generally poor [77]. The primary goal of pharmacotherapy during detoxification is to alleviate opioid withdrawal severity and associated distress/ medical complications and to enhance patient motivation to continue treatment. Withdrawal can also be reduced by psycho- social measures, such as contingency management or counsel- ing, and as discussed, the addition of psychosocial therapy to pharmacologic treatment increases efficacy. Buprenorphine and clonidine are both used to manage withdrawal symptoms, but buprenorphine’s advantages, compared with clonidine, are related to its favorable side effect profile and positive effects on well-being and psychosocial variables [77]. Opioid Antagonist Therapy Relapse-prevention programs have traditionally involved long- term residential placement of nine months or more, often using the therapeutic community format. More recently, pharmacotherapeutic agents, such as naltrexone, have been added to reduce relapse risk. A drawback with opioid antago- nist therapy is the high dropout rate during detoxification, which results in highly selective patient samples in most of the naltrexone maintenance studies. Naltrexone maintenance or relapse-prevention treatment should be reserved only for those patients who are able to give informed consent, are fully with- drawn from opioids, and have no specific contraindications for this treatment [107]. Relapse prevention with naltrexone may also be suitable for pregnant women who are unable to stabilize on methadone or buprenorphine. Patients should be warned that reduced tolerance following naltrexone treatment may increase the risk of overdose [77].
The primary problem with naltrexone treatment is low compliance, with retention in treatment ranging from 6% to 45% [30; 107]. Strategies to improve treatment compliance include combining naltrexone maintenance with contingency management, involving the provision of vouchers redeemable for goods and services contingent on naltrexone intake and drug-free urines [86]. The authors of one investigation evalu- ated prescribing patterns for opioid use disorder medications among a commercially insured population in the United States from 2010 to 2014. The evaluation revealed consistently low treatment completion rates for two forms (e.g., injectable, oral) of naltrexone. At 30 days post-initiation, 52% of individuals treated with injectable naltrexone had discontinued treat- ment, and 70% of individuals treated with oral naltrexone had discontinued treatment. The proportion of patients treated with either form of naltrexone grew over time, but the discontinuation rates were significantly higher compared with individuals treated with sublingual or oral-mucosal buprenor- phine/naloxone [164]. Although the focus of this investigation was not on the reasons for treatment discontinuation, it did highlight the poor treatment compliance with naltrexone. The extended-release injectable naltrexone formulation may help overcome the compliance issues associated with the oral formulation [107]. Naltrexone is contraindicated in patients with hypersensitivity reactions to the agent, in patients with current physical and physiologic dependence on opioids, and in patients in acute opioid withdrawal [107]. At present, reviewers conclude “there is no sufficient evidence of efficacy of naltrexone to justify its use in the maintenance treatment of opioid dependence” [165]. Psychosocial Monotherapy There is no data to support psychosocial interventions as a sole intervention for opioid dependence [140; 141]. Psychosocial treatments alone are not adequately proven treatment modali- ties, nor are they superior to any other type of treatment for opioid dependence [166]. However, psychosocial treatments offered in addition to pharmacologic detoxification treatments are effective in terms of treatment completion, opioid use, and participant abstinence at follow-up [141].
For patients with opioid use disorder for whom opioid use disorder pharmacotherapy is contraindicated, unacceptable, or unavailable, the Department of Veterans Affairs Work Group has found there is insufficient evidence to recommend for or
against any specific psychosocial interventions. (https://www.healthquality.va.gov/guidelines/MH/sud/ VADoDSUDCPG.pdf. Last accessed March 21, 2024.) Strength of Recommendation : Neither for not against
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MDRI2026
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