__________________________________________________ Responsible Prescribing of Controlled Substances
another, the clinical benefits strongly support this treatment modality [87]. When compared to active street heroin users, these benefits include a four-times lower HIV seroprevalence rates, 70% fewer crime-days per year, and a one-year mortality rate of 1% (versus 8%) [91]. 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 [70; 92]. 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 [70]. 12-Step/Self-Help Programs Twelve-step programs for opioid abuse and dependence include Narcotics Anonymous (NA) and Methadone Anonymous (MA) and are modeled after Alcoholics Anonymous (AA), an abstinence-based support and self-improvement program that is based on the 12-step model of recovery. AA has helped hundreds of thousands of individuals with alcohol misuse disorder achieve sobriety [93]. The 12-step model emphasizes acceptance of dependence as a chronic, progressive disease that can be arrested through abstinence but not cured. Additional elements include spiritual growth, personal responsibility, and helping other addicted persons. By inducing a shift in the consciousness of the addict, 12-step programs offer a holistic solution and are a resource for emotional support [93]. Although research on efficacy and patient outcomes in NA and MA is very limited, many prominent researchers emphasize the important role that ongoing involvement in 12-step programs plays in recovery from substance abuse [94]. The understanding of drug dependence as a chronic and relapsing disorder has helped professionals gain a better com- prehension of the vital role played by 12-step programs. Every patient attempting to recover from a substance use disorder will encounter a time when he or she faces urges to use without the resources or assistance of healthcare professionals. Twelve-step programs are not considered treatment, nor are they intended as substitutes for treatment. Instead, they are organizations that provide ongoing and indefinite support in the achievement and maintenance of abstinence and in personal growth and character development [94].
Part of the effectiveness of NA and MA is related to their abil- ity to provide a competing and alternative reinforcer to drug use. Involvement in 12-step programs can enhance the qual- ity of social support and the social network of the member, a potentially highly reinforcing aspect the person stands to forfeit if they resume drug using. Other reinforcing elements of 12-step involvement include recognition for increasingly durable periods of abstinence and frequent awareness of the consequences of drug and alcohol use through attendance of meetings [95]. Research shows that establishing a pattern of 12-step program attendance early in treatment predicts the level of ongoing involvement. Emphasis and facilitation of early engagement in a 12-step program involvement are key [96]. Acupuncture Auricular acupuncture is the most common acupuncture approach for substance abuse, including opioid abuse and dependence, in the United States and the United Kingdom. This technique consists of bilateral insertion of acupuncture needles in the outer ears [97]. There is controversy surrounding the presumed mechanism of action of acupuncture. Western scientists attempt to explain its action on the body’s electro- magnetic system, with the acupuncture needle creating a dif- ference in electrical potential that stimulates extracellular ion flow. Chinese practitioners, who have been using acupuncture for several thousand years to treat a wide range of maladies, attribute its effects to unblocking or removing an excess of qi, or life energy, along key channels referred to as meridians [98]. Results from well-designed studies indicate that auricular acu- puncture treatment is not sufficient in efficacy as a stand-alone treatment for opioid dependence. The placebo response rate is substantial, and the body of evidence does not demonstrate the type of qualitative and quantitative rigor needed to vali- date acupuncture efficacy in the treatment of opioid-addicted patients. Common adverse events from acupuncture include needle pain, fatigue, and bleeding; fainting and syncope are uncommon. Feelings of relaxation are reported by as many as 86% of patients [97]. There is some evidence that differences in efficacy may be influenced by racial physiologic differences among persons of European and Asian descent [97]. A 2016 review of 199 studies found that contradictory results, intergroup differences, and acupuncture placebo effects made it difficult to evaluate the effectiveness of acupuncture for drug addiction treatment [99]. The authors of another review looked at clinical trials of 100-Hz electroacupuncture for detoxifica- tion treatment. They found a potential for the treatment to allay opioid-associated depression and anxiety but no effect for opioid craving [100]. Prognosis of Treatment for Opioid Use Disorder The relapse rate among patients receiving treatment for opioid dependence and other substance abuse is high (25% to 97%), comparable to that of other patients with chronic relapsing conditions, including hypertension and asthma. Many cases of relapse are attributable to treatment noncompliance and lack of lifestyle modification [2; 24; 101].
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