Is There a Role for Behavioral Interventions in Buprenorphine Treatment?

• Although counseling is a required part of office-based buprenorphine treatment of opioid use disorders, the nature of what constitutes appropriate – or effective – counseling is unclear and controversial.
• This paper reports on a careful review of multiple randomized controlled studies testing the efficacy of adding a behavioral intervention to buprenorphine maintenance treatment, including an examination of the NIDA Clinical Trials Network’s Prescription Opiate Abuse Treatment Study (POATS, CTN-0030).

   

Four key studies showed no benefit from adding a behavioral intervention to buprenorphine plus medical management, and four studies indicated some benefit for specific behavioral interventions, primarily contingency management.

The authors examined the findings from those 4 negative trials in the context of six questions:

• Is buprenorphine that effective?
• Is medical management that effective?
• Are behavioral interventions that ineffective in this population?
• How has research design affected the results of studies of buprenorphine plus behavioral treatment?
• What do we know about subgroups of patients who do and do not seem to benefit from behavioral interventions?
• What should clinicians aim for in terms of treatment outcome in buprenorphine maintenance?

Conclusions: While buprenorphine is far more effective than treatments that do not involve medications for opioid use disorder, retention in buprenorphine treatment appears to be significantly poorer than in methadone maintenance treatment.  High-quality medical management may suffice for some patients, but it’s hard to know which patients that might be. Physicians might consider a stepped-care model, starting new patients out with relatively low intensity treatment, adding more care and intervention for patients who appear to struggle early on. Finally, with 6-month retention rates seldom exceeding 50% and poor outcomes following dropout, innovative strategies for enhancing retention in buprenorphine treatment must be explored.

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