Quality & Science

Is Counseling Essential to Successful Treatment Outcomes?

by Mark Publicker | February 15, 2013

A recent study[1] and recent op-ed pieces have concluded that counseling is not an essential requirement for successful outcome in the treatment of prescription opiate addiction.

Arguments can be valid or invalid depending on whether the conclusion logically follows the premises, whether or not they are true, and sound or unsound if either of both is incorrect. I propose that the argument regarding counseling is unsound. Can the premises of the POATS study be the basis of the conclusion that medication alone can be sufficient treatment for prescription opiate addiction? As is always the case in clinical trials, the study population conditions the outcome. Does this study population accurately represent our patients? I practice addiction medicine in Maine. We have among the highest rates of prescription opiate addiction in the nation. Our state is largely rural and poor. Drug selection is based on availability and culture. My patients are young: in the adolescent buprenorphine trial we participated in, some 19 year olds have a five year history of drug addiction. They’re poor. Many come from multi-generations of alcohol and drug addiction. They’re uneducated. Their social networks are all drug-based. They have histories of sexual, physical and emotional abuse and neglect. They abuse multiple drugs: virtually all abuse or are dependent on benzodiazipines and all are cannabis dependent. Many other patients came to their opiate addiction by way of treatment for pain. Most have seen their lives ruined: lost jobs, family, and even homes. They require more intensive treatment than office-based counseling. And as we’ve become more effective in decreasing the inappropriate prescription of opioids, heroin has flooded in. This trend has been described nationally. So, is there a distinct difference between prescription drug-addicted and heroin-addicted patients?

So what are my concerns about the conclusion that pharmacotherapy alone is sufficient treatment for opiate addiction and whatever happened to the ASAM Criteria? The promotion of medication only treatment is a reductionist argument, similar to the oft-stated concept that depression is a serotonin deficiency disorder. As a result of the latter insurers limited access to psychotherapy and psychiatrists became psychopharmacologists. Insurers, both public and private will seize on this conclusion to deny care. This conclusion will alienate us from the recovering community and the drug and alcohol treatment world. And finally, our specialty is based on the bio-psycho-social and spiritual paradigm. We must integrate the advances in neuroscience and pharmacotherapy with the humanistic heart of ASAM.

What do you think?

[1] Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence. Arch Gen Psychiatry. 2011;68(12):1238-1246. doi:10.1001/archgenpsychiatry.2011.121

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  1. Alan Wartenberg MD Mar 18, 2013 - 03:19 PM
    I think the issue is not that prescription opioid abuse can be treated with less counseling, but that a very large proportion of those with prescription drug abuse represent a different demographic than those "traditional" opioid addicts, mostly starting with heroin, whom we have experience treating.  

    Many of the former patients actually had good coping styles and intact family and work structures prior to the development of their addiction, and are far more likely to find their way back to these life patterns with less assistance.  The traditional group we treat essentially need "habilitation," starting virtually from scratch, while those latter patients can be more easily "rehabilitated."

    There is significant overlap, and individualized assessment of each patient will always be required to develop appropriate treatment plans.  

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