Buprenorphine + naloxone plus naltrexone for the treatment of cocaine dependence: the Cocaine Use Reduction with Buprenorphine (CURB) study

AIMS

To examine the safety and effectiveness of buprenorphine + naloxone sublingual tablets (BUP, as Suboxone(®) ) provided after administration of extended-release injectable naltrexone (XR-NTX, as Vivitrol(®) ) to reduce cocaine use in participants who met DSM-IV criteria for cocaine dependence and past or current opioid dependence or abuse.

METHODS

This multi-centered, double-blind, placebo-controlled study, conducted under the auspices of the National Drug Abuse Treatment Clinical Trials Network, randomly assigned 302 participants at sites in California, Oregon, Washington, Colorado, Texas, Georgia, Ohio, New York and Washington DC, USA to one of three conditions provided with XR-NTX: 4 mg/day BUP (BUP4, n = 100), 16 mg/day BUP (BUP16, n = 100, or no buprenorphine (placebo; PLB, n = 102). Participants received pharmacotherapy for 8 weeks, with three clinic visits per week. Cognitive behavioral therapy was provided weekly. Follow-up assessments occurred at 1 and 3 months post-intervention. The planned primary outcome was urine drug screen (UDS)-corrected, self-reported cocaine use during the last 4 weeks of treatment. Planned secondary analyses assessed cocaine use by UDS, medication adherence, retention and adverse events.

RESULTS

No group differences were found between groups for the primary outcome (BUP4 versus PLB, P = 0.262; BUP16 versus PLB, P = 0.185). Longitudinal analysis of UDS data during the evaluation period using generalized linear mixed equations found a statistically significant difference between BUP16 and PLB [P = 0.022, odds ratio (OR) = 1.71] but not for BUP4 (P = 0.105, OR = 1.05). No secondary outcome differences across groups were found for adherence, retention or adverse events.

CONCLUSIONS

Buprenorphine + naloxone, used in combination with naltrexone, may be associated with reductions in cocaine use among people who meet DSM-IV criteria for cocaine dependence and past or current opioid dependence or abuse.

Treatment outcomes in opioid dependent patients with different buprenorphine/naloxone induction dosing patterns and trajectories

BACKGROUND AND OBJECTIVES

Induction is a crucial period of opioid addiction treatment. This study aimed to identify buprenorphine/naloxone (BUP) induction patterns and examine their association with outcomes (opioid use, retention, and related adverse events [AEs]).

METHODS

The secondary analysis of a study of opioid-dependent adults seeking treatment in eight treatment settings included 740 participants inducted on BUP with flexible dosing.

RESULTS

Latent class analysis models detected six distinctive induction trajectories: bup1-started and remained on low; bup2-started low, shifted slowly to moderate; bup3-started low, shifted quickly to moderate; bup4-started high, shifted to low; bup5-started and remained on moderate; bup6-started moderate, shifted to high dose (Fig. 1). Baseline characteristics, including Clinical Opioid Withdrawal Scale (COWS), were important predictors of retention. When controlled for the baseline characteristics, bup6 participants were three times less likely to drop out the first 7 days than bup1 participants (adjusted hazard ratio (aHR) = .28, p = .03). Opioid use and AEs were similar across trajectories. Participants on ≥16 mg BUP compared to those on <16 mg at Day 28 were less likely to drop out (aHR = .013, p = .001) and less likely to have AEs during the first 28 days (aOR = .57, p = .03).

DISCUSSION AND CONCLUSIONS

BUP induction dosing was guided by an objective measure of opioid withdrawal. Participants with higher baseline COWS whose BUP doses were raised more quickly were less likely to drop out in the first 7 days than those whose doses were raised slower.

SCIENTIFIC SIGNIFICANCE

This study supports the use of an objective measure of opioid withdrawal (COWS) during BUP induction to improve retention early in treatment.

Buprenorphine/naloxone and methadone maintenance treatment outcomes for opioid analgesic, heroin, and combined users: findings from starting treatment with agonist replacement therapies (START)

OBJECTIVE

The objective of this secondary analysis was to explore differences in baseline clinical characteristics and opioid replacement therapy treatment outcomes by type (heroin, opioid analgesic [OA], or combined [heroin and OA]) and route (injector or non-injector) of opioid use.

METHOD

A total of 1,269 participants (32.2% female) were randomized to receive one of two study medications (methadone or buprenorphine/naloxone [BUP]). Of these, 731 participants completed the 24-week active medication phase. Treatment outcomes were opioid use during the final 30 days of treatment (among treatment completers) and treatment attrition.

RESULTS

Non-opioid substance dependence diagnoses and injecting differentiated heroin and combined users from OA users. Non-opioid substance dependence diagnoses and greater heroin use differentiated injectors from non-injectors. Further, injectors were more likely to be using at end of treatment compared with non-injectors. OA users were more likely to complete treatment compared with heroin users and combined users. Non-injectors were more likely than injectors to complete treatment. There were no interactions between type of opioid used or injection status and treatment assignment (methadone or BUP) on either opioid use or treatment attrition.

CONCLUSIONS

Findings indicate that substance use severity differentiates heroin users from OA users and injectors from non-injectors. Irrespective of medication, heroin use and injecting are associated with treatment attrition and opioid misuse during treatment. These results have particular clinical interest, as there is no evidence of superiority of BUP over methadone for treating OA users versus heroin users.

Pain and continued opioid use in individuals receiving buprenorphine-naloxone for opioid detoxification: secondary analyses from the Clinical Trials Network

Pain complaints are common among individuals with opioid dependence. However, few studies investigate pain during opioid detoxification or the impact this pain has on continued opioid use. This secondary analysis utilized data from two Clinical Trials Network randomized controlled trials of buprenorphine-naloxone for short-term opioid detoxification to examine the extent to which pain was associated with continued opioid use during and immediately following a 13-day detoxification protocol. At follow-up, more severe pain was associated with a greater number of self-reported days of opioid use during the prior 30 days (p < .05) but was not associated with urine toxicology results collected at follow-up. These results, although mixed, have potentially important clinical implications for assessing and addressing pain during opioid detoxification. Pain that is experienced during and immediately following medically monitored detoxification may be associated with continued opioid use. These findings lend further support for continued research on pain among patients with opioid dependence.

Predicting in-treatment performance and post-treatment outcomes in methamphetamine users

AIMS

This study examines the utility of individual drug use and treatment characteristics for predicting in-treatment performance and post-treatment outcomes over a 1-year period.

DESIGN, SETTING AND PARTICIPANTS

Data were collected from 420 adults who participated in the Methamphetamine Treatment Project (MTP), a multi-site study of randomly assigned treatment for methamphetamine dependence. Interviews were conducted at baseline, during treatment and during three follow-up time-points: treatment discharge and at 6 and 12 months following admission.

MEASUREMENTS

The Addiction Severity Index (ASI); the Craving, Frequency, Intensity and Duration Estimate (CFIDE); and laboratory urinalysis results were used in the current study.

FINDINGS

Analyses addressed both in-treatment performance and post-treatment outcomes. The most consistent finding is that pre-treatment methamphetamine use predicts in-treatment performance and post-treatment outcomes. No one variable predicted all in-treatment performance measures; however, gender, route of administration and pre-treatment methamphetamine use were significant predictors. Similarly, post-treatment outcomes were predicted by a range of variables, although pre-treatment methamphetamine use was significantly associated with each post-treatment outcome.

CONCLUSIONS

These findings provide useful empirical information about treatment outcomes for methamphetamine abusers, and highlight the utility of assessing individual and in-treatment characteristics in the development of appropriate treatment plans.

The Addicted-Self Model of Addictive Behavior Cessation: Does it Predict Recovery for Gender, Ethnic, Age and Drug Preference Populations?

Although previous research provided empirical support for the main assumptions of the Addicted-Self (A-S) Model of recovery, it is not known whether the model predicts recovery for various gender, ethnic, age, and drug preference populations. It may be that the model predicts recovery only for some groups of addicts and should not be viewed as a general theory of the recovery process. Addressing this concern using data from the Los Angeles Target Cities Drug Treatment Enhancement Project, it was determined that only trivial population differences exist in the primary variables associated with the A-S Model. The A-S Model predicts abstinence with about the same degree of accuracy and parsimony for all populations. The findings indicate that the A-S Model is a general theory of drug and alcohol addictive behavior cessation.

Replicating the Addicted-Self Model of recovery

The purpose of this investigation is to replicate previous studies supporting a developing model of recovery from alcohol and drug addiction, the Addicted-Self Model [Fiorentine & Hillhouse, 2000c; Journal of Drug Issues 31 (2002a) 395; American Journal on Addictions (2002b) in press]. Data was utilized from the first phase of the Los Angeles Target Cities Treatment Enhancement Evaluation, a 2-year prospective study of 260 alcohol and drug treatment outpatients. The Addicted-Self Model is briefly outlined and four hypotheses are tested. Consistent with the assumptions of the model, low controlled use self-efficacy and a decline in controlled use self-efficacy over time predicts: (1) higher levels of the perceived certainty of negative consequences resulting from continued alcohol and drug use, (2) higher levels of abstinence acceptance, and (3) higher rates of abstinence from alcohol and drug use. Also consistent with the Addicted-Self Model, high controlled use self-efficacy does not predict lower levels of alcohol and drug use for those who relapse or continue to use these substances. These findings replicate previous findings supporting the developing Addicted-Self Model of recovery. Study limitations and directions for future research are discussed.

Why extensive participation in treatment and twelve-step programs is associated with the cessation of addictive behaviors: an application of the addicted-self model of recovery

Applying the Addicted-Self Model of recovery to explain why extensive participation in recovery activities predicts abstinence, it was hypothesized that high levels of participation in treatment and Twelve-step programs promote abstinence because these activities reinforce the notion that controlled use is not possible for dependent alcohol and drug users. Findings from a prospective treatment outcomes study (n = 356) indicate general support for this hypothesis. Yet the cognitive transformation described by the Addicted-Self Model involving acknowledgement of loss of control over alcohol and other drugs is only a partial explanation of why extensive participation in recovery activities promotes recovery. Reiterating the conclusion that "more is better," frequent counseling participation, treatment completion, and weekly or more frequent participation in Twelve-Step programs promote absti- nence independently from their influence on controlled use self-efficacy. Theoretical and clinical implications, and directions for future research are discussed.

When Low Self-efficacy is Efficacious: Toward an Addicted-self Model of Cessation of Alcohol- and Drug-dependent Behavior

The relationship between self-efficacy and the cessation of alcohol- and drug-dependent behavior was examined in this study. Evidence suggests that the Relapse Prevention Approach may incorrectly specify a relationship between self-efficacy and recovery. Instead of high situational coping self-efficacy, it may be that the acknowledgment of a loss of control over alcohol and drug use, or low controlled use self-efficacy, promotes recovery because the addict embraces the need for lifelong abstinence. Findings from a prospective study of 356 drug treatment outpatients indicate that low controlled use self-efficacy predicted higher levels of abstinence acceptance independent from the possible influences of alcohol and drug use histories and treatment history. A decrease in controlled use self-efficacy overtime was associated with an increase in abstinence acceptance, and high and increasing levels of abstinence acceptance predicted alcohol and drug abstinence. Contrary to the Relapse Prevention Approach, controlled use self-efficacy does not predict severity or level of use for those who relapse or continue to use alcohol and other drugs. These findings suggest a new social-cognitive theory of recovery--the Addicted-Self Model. This model asserts that the cessation of alcohol- and drug-dependent behavior is more likely to occur when the addict attributes the loss of control over drug and alcohol use to a stable, permanent property of the self and embraces the need for life-long abstinence.

12-Step Program Participation and Effectiveness: Do Gender and Ethnic Differences Exist?

Although 12-Step is increasingly utilized as a recovery resource and is viewed by many addiction specialists as an integral component of treatment and long-term recovery, questions regarding participation and effectiveness of 12-Step programs for women and ethnic minorities have been raised. Utilizing data from the Los Angeles Target Cites Evaluation Project (n = 356), participants in adult outpatient alcohol and drug treatment were followed for 24 months and rates of 12-Step participation and effectiveness were assessed for all gender and ethnic groups. Contrary to reports that 12-Step is more appropriate for European-American males, statistical analyses reveals that women and ethnic minorities are equally likely to attend 12-Step programs, and to recover In conjunction with such participation as European-American males. Although 12-Step may not appeal to all seeking to cease alcohol and drug use, the clinical implications for treatment providers and other addiction specialists points to the benefits of Integrating 12-Step components into traditional treatment programs and recommending 12-Step participation for clients of all gender and ethnic groups.

The Addicted-Self Model: An Explanation of “Natural” Recovery?

This investigation examines whether the Addicted-Self Model of cessation of alcohol and drug dependent behavior (Fiorentine & Hillhouse, 2000b; in press) is able to predict unassisted or “natural” recovery. Four hypotheses are tested using a prospective investigation of individuals who drop out in the First week of outpatient treatment, do not re-enter any type of treatment or aftercare, and attend no Twelve-step meetings during the study period (n =78). Consistent with the assumptions of the model, acknowledgement of loss of control over alcohol and drug use, or low controlled use self-efficacy, predicts greater acceptance of the need for life-long abstinence. A decrease in controlled use self-efficacy is associated with an increase in abstinence acceptance. High and increasing abstinence acceptance predicts higher levels of alcohol and drug abstinence. Consistent with the Addicted-Self Model, but contrary to the Relapse Prevention Approach (Marlatt & Gordon, 1980,1985), high controlled use self-efficacy does not predict less severe relapse or lower levels of alcohol and drug use for those who continue to use these substances. Clinical implications and directions for future research are discussed.

Self-efficacy, expectancies, and abstinence acceptance: further evidence for the addicted-self model of cessation of alcohol- and drug- dependent behavior

The Addicted-Self Model of the cessation of alcohol- and drug-dependent behaviors is outlined briefly, and five hypotheses consistent with the predictions of the model are examined. All five hypotheses are confirmed, broadening the support for the Addicted-Self Model of recovery. These findings also suggest modifications of the assumptions underlying alcohol and drug expectancy research. These modifications are discussed, and directions for further research are suggested.

Exploring the additive effects of drug misuse treatment and Twelve-Step involvement: does Twelve-Step ideology matter?

Previous research revealed an additive effect of recovery activities in that those who attended Twelve-Step meetings on a weekly basis during and after outpatient drug-user treatment had higher rates of abstinence compared to those who participated in either treatment or Twelve-Step programs alone. The current investigation extends the previous research by examining the possible effects of Twelve-Step ideology on participation in Twelve-Step programs and abstinence from drug use. The findings from this treatment outcomes study indicate that the acceptance of Twelve-Step ideology, particularly strong agreement with the need for frequent, lifelong attendance at Twelve-Step meetings, and the need to surrender to a "higher power" are significant predictors of weekly or more frequent attendance at Twelve-Step meetings independent from other potentially mediating variables. Twelve-Step ideology, specifically the notion that controlled or nonproblematic drug use is not possible, predicted abstinence independent from Twelve-Step participation and other potentially mediating variables. These findings often a number of implications concerning group process and recovery from drug misuse which are addressed in the Discussion section under the following topics: 1) spirituality and group cohesion, 2) spiritual transcendence, social transcendence, and recovery; 3) spirituality and the obstruction of recovery; 4) Twelve-Step ideology and learning; 5) perceived control of drug use, self-efficacy theory, and recovery; and 7) perceived control of drug use and optimistic illusions. Directions for future research are discussed.

Drug treatment and 12-step program participation: the additive effects of integrated recovery activities

The dramatic rise in the number of 12-step programs and participants raises questions concerning client participation in drug treatment and 12-step programs, and their separate and combined effects on recovery. The results of a treatment outcomes study indicate that rather than recovery alternatives, drug treatment and 12-step programs are utilized by the client as integrated recovery activities. Treatment participants with pretreatment 12-step involvement stayed in treatment longer, and were more likely to complete the 24-week program. Both pretreatment 12-step involvement and duration of participation in drug treatment are associated with subsequent 12-step involvement. Most importantly, there is an additive effect of these recovery activities in that those who participated concurrently in both drug treatment and 12-step programs had higher rates of abstinence than those who participated only in treatment or in 12-step programs.

Drug treatment outcomes: investigating the long-term effects of sexual and physical abuse histories

Individuals in drug treatment, particularly women, generally report high levels of past sexual and physical abuse. Although histories of sexual and physical abuse are associated with greater prevalence and severity of depression, anxiety, phobias, and interpersonal difficulties for individuals seeking substance-related treatment, several recent studies failed to show that prior sexual or physical abuse compromised short-term drug treatment outcomes. This study examined the possible effects of sexual and physical abuse on a wide array of behavioral domains over a two-year posttreatment period. The findings indicate few differences between those with and without past histories of such abuse in terms of drug use, drug treatment and 12-Step program participation, criminality, income sources, intimate relationships, family functioning, and psychiatric symptoms. There are specific exceptions, but they apply only to men. Overall, the findings indicate that the impact of sexual and physical abuse histories on relatively long-term treatment outcomes is minimal. Addressing the sexual and physical abuse histories of those seeking treatment for drug abuse may be justified on humanistic grounds, but it will not significantly improve the long-term effectiveness of drug treatment, nor will it substantially enhance the lives of those with histories of abuse.

Drug Treatment Effectiveness and Client-Counselor Empathy: Exploring the Effects of Gender and Ethnic Congruency

This study examined the possible effects of client-counselor gender and ethnic congruency on perceived counselor empathy, client engagement in treatment and the maintenance of abstinence during and after out-patient drug treatment. The findings indicate that client-counselor gender and ethnic congruence were significantly associated with higher levels of perceived counselor empathy for all gender, ethnic, and age groups. Contrary to expectation, however, client-counselor gender and ethnic congruence were not consistently associated with higher levels of treatment engagement and abstinence for all gender, ethnic, and age groups. The findings support a recommendation of routinely matching clients to counselors of the same gender for women, Latinos, and clients 35 years or older, but they do not support a recommendation of matching clients to ethnically-congruent counselors, with the possible exception of female clients. The findings also indicate that, with the exception of Latino clients, a policy of matching a client to an empathic counselor regardless of gender or ethnicity of the counselor would lead to a more favorable treatment outcome than would a policy of matching clients solely to gender and ethnically-congruent counselors. This study highlights the need for additional studies examining the client-counselor relationship. Further understanding of this relationship could lead to a greater understanding of the drug treatment process and suggest ways to generally improve the delivery of drug treatment.