Volume 4, Issue 3

The Necessity of Counseling in Bupenorphine Treatment
Louise Haynes
Medical University of South Carolina

I read with interest Dr. Junig’s provocative interview. The interview points out a number of areas with potential to improve the health benefits available through enhanced utilization of buprenorphine in the treatment of addiction. I would add that since buprenorphine first became available by prescription from primary care physicians in community practice, much has been learned, and addiction services have improved. I have observed in conservative areas of the country, like South Carolina where I live, that buprenorphine has been increasingly accepted as a legitimate, life-saving treatment. The initial compromises set forth in the enabling legislation gave many communities an opportunity to gain experience with buprenorphine and to adjust their misperception and belief that medications have no role in addictions treatment. As with any innovation, the lessons learned through experience often lead to changes that can improve effectiveness and further enhance the utilization and acceptability of the new practice. Perhaps some of what we have learned about the use of buprenorphine for the treatment of opioid dependence will allow us to individualize and, when appropriate, streamline care, thus improving the availability and effectiveness of treatment.

Dr. Junig points out that requiring counseling is one of the limitations on wider use of buprenorphine, and he asks, “Where are the data?” Through the NIDA Clinical Trials Network (CTN), investigators wanted to answer the question about the added value of counseling, and Roger Weiss and colleagues examined the benefits of counseling as an adjunct to medication for the treatment of opioid dependence. Consistent with Dr. Junig’s contention that some patients improve without counseling, investigators determined that overall study participants who received counseling did not have a better outcome. However, a subgroup of participants did show additional benefit from receiving counseling along with standard care. Participants with more severe addiction problems and who were adherent to the recommendation of counseling (i.e., who received sufficient counseling) did demonstrate enhanced benefit. The study was a secondary analysis designed to answer questions about the response of various subgroups to counseling.

Dr. Junig suggests that the treating physician is in the best position to determine which patients would benefit from counseling. Based on the CTN study, a critical factor in determining the treatment plan would be joint decision-making to include the client and an assessment of his or her willingness to attend counseling. In the CTN study, the mere offer of counseling was not sufficient for producing a successful outcome, regardless of the severity of the drug-related problems. No one would argue that there is no role for counseling in the treatment of opioid dependence, but requiring counseling for everyone, regardless of patient preference or need, adds barriers that inhibit best practice.

Reference
Weiss, R., Griffin, M., Potter, J., Dodd, D., Dreifuss, J., Connery, H. & Carroll, K. (2014) Who benefits from additional drug counseling among prescription opioid dependent patients receiving buprenorphine-naloxone and standard medical management, Drug and Alcohol Dependence 140: 118-122


 




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