New Approaches Seek To Expand Naltrexone Use in Heroin Treatment
Naltrexone, an opiate treatment medication, is used to help patients
make the transition from illicit opiate use to a drug-free life. Patients
in naltrexone treatment are first detoxified from their dependence
on opiates and then take thrice-weekly doses of naltrexone and participate
in weekly group therapy sessions.
The medication provides a safety net for patients because it blocks
the euphoric effects they normally would feel if they slip and use
heroin or any other opiate. As a result, even relapse, which is common
in addiction treatment, may have a therapeutic effect as repeated failure
to get high may eventually break the neurobiological and behavioral
links between taking drugs and the rewards that lead patients to resume
regular drug use. With successful naltrexone treatment, slips to drug
use become less frequent, the medication is discontinued, and patients
continue behavioral treatment if needed.
Naltrexone treatment has been successful mainly with patients who
are highly motivated to stop using opiates. Such patients include health
care professionals who must stop using opiates to retain their licenses
to practice medicine and individuals subject to criminal justice sanctions
for relapse to illicit opiate use. The severe penalties that these
patients would incur if they fail treatment enable them to overcome
naltrexone's main drawback: It eliminates the powerful rewarding effects
of opiates without any replacement to help patients cope with lingering
effects of withdrawal.
| Voucher
Incentives Increase Retention In Naltrexone Treatment |
In a study with 127 heroin-addicted patients
receiving naltrexone therapy, the 12-week dropout
rate was about 50 percent among those in two groups
that received voucher-based contingency management,
and about 75 percent among those who did not. |
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Naltrexone's lack of a reinforcing effect has made it an unattractive
treatment option for other patients who lack a strong external incentive
to stop using drugs and do not want to go through detoxification and
withdrawal from opiates. Most of these patients opt for treatment with
medications such as LAAM and methadone, both of which help them to
cope with the absence of the intense and rapid high that they are accustomed
to getting from heroin by replacing it with a more moderate, stabilizing
effect that can help them to maintain a nonaddicted lifestyle.
Despite its limited clinical use, naltrexone has many qualities that
make it an attractive option for treating a broader range of opiate-dependent
patients. It is not addicting, has few adverse effects, can be prescribed
without concerns about diversion to the illicit drug market, and is
not subject to the restrictive regulatory requirements that limit the
use of methadone and LAAM to specialized clinics. Thus, like the recently
approved opiate treatment medication buprenorphine, naltrexone can
be administered in many settings, including private physicians' offices,
making it more attractive to individuals who are reluctant to enter
clinics.
Naltrexone's desirable therapeutic traits have continued to spark
interest in finding new ways to expand its usefulness and application
in practice. Two recent studies show that adjunctive behavioral and
new pharmacological approaches may help to increase naltrexone's effectiveness
for a wider range of opiate-addicted patients.
Voucher Reinforcement Increases Naltrexone's Effectiveness
A NIDA-supported treatment study that rewarded heroin-dependent patients
with vouchers whenever they took their naltrexone or tested negative
for drug use has found that this basic behavioral reinforcement approach
achieved significantly better results than standard naltrexone treatment
alone in keeping patients in treatment longer, having them complete
treatment, and reducing their opiate use.
"A significant boost in treatment adherence was achieved not with
highly motivated patient groups that have generally responded well
to naltrexone treatment, but with predominantly unemployed 'street
addicts,' most of whom had a history of extensive involvement with
drug abuse treatment and the legal system," says Dr. Dorynne Czechowicz
of NIDA's Division of Treatment Research and Development. She also
maintains that the results are promising for expanding the types of
patients who would benefit from naltrexone treatment.
The 12-week study, led by Dr. Kathleen Carroll of the Yale University
School of Medicine, randomly assigned 127 recently detoxified opioid-dependent
patients to 1 of 3 treatment conditions: standard treatment with naltrexone
3 times a week; standard naltrexone treatment plus a behavioral reinforcement
approach called contingency management (CM); or standard naltrexone
treatment and CM plus involvement of a significant other (SO) in up
to 6 family counseling sessions. SO treatment was added to CM for patients
in the third group to test the idea that encouragement and positive
reinforcement from a significant other might help patients cope with
any protracted drug withdrawal symptoms and remain in treatment longer.
Patients in all three groups participated in weekly cognitive-behavioral
group counseling sessions.
Patients in the CM groups could earn vouchers, which they could exchange
for goods and services, in separate tracks for naltrexone compliance
or drug-free tests. In each track, the voucher value started at $0.80,
escalated in $0.40 increments for continuous compliance or abstinence,
and were reset to the starting point for each failure to take the medication
or pass a drug test. Over the course of the study, patients in the
CM groups earned an average of $189 in vouchers out of the maximum
$561 that could be earned for perfect medication compliance and all
negative drug tests.
The researchers found that on average, patients in the two CM groups
stayed in treatment 7.4 weeks, significantly longer than the 5.6 weeks
for those in standard treatment. A much higher percentage of CM patients
also completed the full 12-week treatment period--47 percent of CM
plus SO patients, 42.9 percent in the CM group, and 25.6 percent of
patients in the standard treatment group. These retention rates with
CM added to standard treatment also compare favorably with rates achieved
in previous studies of standard naltrexone treatment, which have reported
that 60 to 70 percent of patients dropped out of treatment over a 12-week
period, Dr. Carroll notes.
Patients in the CM groups also had significantly better treatment
outcomes than those in the standard naltrexone group--more days of
abstinence, longer periods of continuous abstinence, more opiate-free
tests, and a higher percentage of drug-free specimens. Additional analyses
suggested CM patients made greater reductions than standard treatment
patients in the frequency with which they used opiates as the study
progressed. Thus, 100 percent of patients reported weekly opioid use
at the beginning of the study, but fewer than 10 percent of those who
completed treatment reported weekly use over the last 4 weeks of the
study. Although adding SO to CM did not improve most treatment outcomes,
further analysis suggested it did produce a significant reduction in
family problems over time.
"Our study shows you can really bump up medication compliance and
outcomes with very simple behavioral interventions," Dr. Carroll says. "It
doesn't take much effort or cost for treatment programs to do this,
particularly if you look at the potential savings from keeping patients
in treatment longer where they can learn how not to be drug users."
Carroll, K.M., et al. Targeting behavioral therapies to enhance naltrexone
treatment of opioid dependence: Efficacy of contingency management
and significant other involvement. Archives of General Psychiatry 58(8):755-761,
2001. [Abstract] |
