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Another study finds no benefit from cognitive behavioral therapy and contingency management with opiate replacement treatment. [CORRECTED: See below]

Background and aims
The Controlled Substances Act requires physicians in the United States to provide or refer to behavioral treatment when treating opioid-dependent individuals with buprenorphine; however no research has examined the combination of buprenorphine with different types of behavioral treatments. This randomized controlled trial compared the effectiveness of 4 behavioral treatment conditions provided with buprenorphine and medical management (MM) for the treatment of opioid dependence.

Design
After a 2-week buprenorphine induction/stabilization phase, participants were randomized to 1 of 4 behavioral treatment conditions provided for 16 weeks: Cognitive Behavioral Therapy (CBT=53); Contingency Management (CM=49); both CBT and CM (CBT+CM=49); and no additional behavioral treatment (NT=51).

Setting
Study activities occurred at an outpatient clinical research center in Los Angeles, California, USA.

Participants
Included were 202 male and female opioid-dependent participants.

Measurements
Primary outcome was opioid use, measured as a proportion of opioid-negative urine results over the number of tests possible. Secondary outcomes include retention, withdrawal symptoms, craving, other drug use, and adverse events.

Findings
No group differences in opioid use were found for the behavioral treatment phase (Chi-square=1.25, p=0.75), for a second medication-only treatment phase, or at weeks 40 and 52 follow-ups. Analyses revealed no differences across groups for any secondary outcome.

Conclusion
There remains no clear evidence that cognitive behavioural therapy and contingency management reduce opiate use when added to buprenorphine and medical management in opiates users seeking treatment.

The question remains, why do patients on opiate replacement receive no benefit from these additional treatments? Particularly when they have been repeatedly shown to benefit addicts not on opiate replacement?

A recent post mentioned an expert’s observation that patients on opioids seem to “opt out of life.”

Are these patients less available to participate in other treatments? We asked this question in our position paper on buprenorphine maintenance.

[Correction: I appear to have had too many tabs open and made a stupid mistake. Thanks to Ian McLoone for pointing out the error. The prevous version erroneously said: “This time the drug is methadone. (It’s worth noting that the study received funding from the manufacturer of Suboxone. There have been similar findings about Suboxone and behavioral therapies. I guess they wanted to show that methadone is no better in this respect.)”]

Twelve-Step attendance trajectories over 7 years among adolescents

Hmmm. Doesn't look too young to me.

More evidence for the benefits of 12 step facilitation for adolescents:

Results of multivariate logistic GEE models indicated that adolescents with continued 12-Step attendance had better outcomes over time, whereas those in the early but not continued group had no different long-term outcomes compared to those in the low/no attendance group.

A problem, of course, is relatively low participation rates:

The majority (60%) had no or low attendance throughout 7 years. About one-fourth had high probability of attendance in the first year post-treatment entry but discontinued afterwards. Fewer than 15% continued 12-Step attendance throughout the 7 years

Conclusion:

Among adolescents with substance use disorders, overall 12-Step attendance was low post-treatment, but robust connection with 12-Step groups was associated with better long-term outcomes. Findings highlight the importance of 12-Step attendance in supporting long-term recovery among adolescents, and suggest that strategies are needed to facilitate 12-Step attendance. Additional research is needed on how the frequency, intensity and duration of 12-Step meeting attendance, as well as the type of activity, is associated with beneficial effects, and whether the relationships vary for different subgroups. Policies to address specific adolescent subgroups, based on severity, age or other characteristics could then be developed for targeting 12-Step facilitation efforts.

Treating depression and substance use: no significant difference from control

On the Threshold of Eternity
Image via Wikipedia

Another study finds treatment as usual to be just as effective as specialized CBT:

Few integrated substance use and depression treatments have been developed for delivery in outpatient substance abuse treatment settings. To meet the call for more “transportable” interventions, we conducted a pilot study to test a group cognitive–behavioral therapy (CBT) for depression and substance use that was designed for delivery by outpatient substance abuse treatment counselors. Seventy-three outpatient clients were randomized to usual care enhanced with group CBT or usual care alone and assessed at three time points (baseline and 3 and 6 months postbaseline). Our results demonstrated that the treatment was acceptable and feasible for delivery by substance abuse treatment staff despite challenges with recruiting clients. Both depressive symptoms and substance use were reduced by the intervention but were not significantly different from the control group. These results suggest that further research is warranted to enhance the effectiveness of treatment for co-occurring disorders in these settings.

Ritalin Gone Wrong

Ritalin

Not surprisingly, we get a lot of clients who have been diagnosed with ADD or ADHD. Many are concerned about suggestions to discontinue prescription stimulants.

This NYT opinion piece has gotten a lot of buzz over the last couple of days:

In 30 years there has been a twentyfold increase in the consumption of drugs for attention-deficit disorder. …

TO date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems, the very things we would most want to improve. …

But in 2009, findings were published from a well-controlled study that had been going on for more than a decade, and the results were very clear. The study randomly assigned almost 600 children with attention problems to four treatment conditions. Some received medication alone, some cognitive-behavior therapy alone, some medication plus therapy, and some were in a community-care control group that received no systematic treatment. At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.

Indeed, all of the treatment successes faded over time…

He draws these conclusions:

Our present course poses numerous risks. First, there will never be a single solution for all children with learning and behavior problems. While some smaller number may benefit from short-term drug treatment, large-scale, long-term treatment for millions of children is not the answer.

Second, the large-scale medication of children feeds into a societal view that all of life’s problems can be solved with a pill and gives millions of children the impression that there is something inherently defective in them.

Finally, the illusion that children’s behavior problems can be cured with drugs prevents us as a society from seeking the more complex solutions that will be necessary. Drugs get everyone — politicians, scientists, teachers and parents — off the hook. Everyone except the children, that is.

 

a thousand pasts and no future

“Choose [your memories] carefully. Memories are all we end up with … You’ll have a thousand pasts and no future.” –The Secret Behind Their Eyes (film)

forget about the sunshine by whatmegsaid

A friend shared this On Point episode with me and made a connection between it and resentments.

This matter of appropriate, helpful, deliberate forgetting is very fascinating.

We’ve talked before about role of the brain’s memory circuits. I’ve also been very interested in the similarities between PTSD and addiction. Both are characterized by intrusive, powerful, multi-sensory, involuntary memories.

The On Point episode discusses that the capacity this helpful forgetting relies on executive function which we’ve discussed is impaired AND depleted.

So…addicts may have limited capacity for this kind of helpful forgetting. Maybe this explains and supports 12 step recovery’s emphasis on letting go of resentments.

Further, the idea in the quote above may help explain the emphasis on gratitude and the power of gratitude lists. Aren’t gratitude lists really an attempt to choose what to remember?