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How does it affect us?

Opioid Use, Addiction, and Overdoses:

Read pages 177 – 189 in your text.

Opioid use, addiction, and overdoses have increased to alarming rates in the United States in recent years. Millions of Americans are affected by the opioid epidemic every day. Read Volkow et al.’s (2014) article and pages 1-4 in Brown’s (2018) article before discussing the following questions:

For this week’s main post, answer the following questions. Be sure to include factual, properly cited information in your post.

· What are some ways that opioid addiction is affecting the United States?

· What are some forms of treatment available to those suffering from opioid addiction?

· If you had a friend or family member suffering from opioid addiction, what sort of help would you recommend they seek?

References:

Brown, A. R. (2018). A systematic review of psychosocial interventions in treatment of opioid addiction, Journal of Social Work Practice in the Addictions. Advance online publication. doi:10.1080/1533256X.2018.1485574

Coon, D., Mitterer, J.O., & Martini, T. (2019). Introduction to psychology: Gateways to mind and behavior (15th ed.). Belmont, CA: Cengage Learning.

Volkow, N. D., Frieden, T. R., Hyde, P. S., & Cha, S. S. (2014). Medication-assisted therapies — tackling the opioid-overdose epidemic. New England Journal of Medicine, 370(22), 2063-2066. doi:10.1056/NEJMp1402780

Unable to score because there was no engagement in the discussion.

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n engl j med 370;22 nejm.org may 29, 201

P E R S P E C T I V E

206

hensive approaches to chronic pain

into their scope of services.

Health care systems can in-
corporate nonjudgmental screen-
ing, brief intervention, and refer-
rals for further assessment and
treatment of addiction into all
clinical settings where opioids are
prescribed. Conversely, addiction-
treatment providers can screen
patients for pain, recognizing that
inadequately treated pain is a risk
factor for relapse.

Payers, including Medicare and
state Medicaid programs, can use
data-analysis tools to spot the red
flags of inappropriate prescribing
and refer prescribers to medical
boards or other state agencies for
further review, education, and
oversight. Prescription-drug mon-
itoring programs can also identi-
fy prescribers in need of assis-
tance. Coherent, evidence-based
review of clinical practice can be

conducted with the
aim of supporting
high-quality care

for both chronic pain and addic-
tion — and avoiding the unin-
tended consequence of deterring
physicians from caring for pa-
tients with complex needs.

Public and private insurers can
provide as generous coverage for
treatment of opioid-use disorder
as they do for management of
chronic pain. This standard is
infrequently met — for example,

it is long past time for Medicare
to begin covering the effective
care provided in opioid-treatment
programs.

It is also time for the FDA to
address the intertwining of chron-
ic pain and addiction farther up-
stream in the drug-development
cycle. The agency might consider
creating a pathway for develop-
ment and review of new products
and indications for simultaneous
treatment of chronic pain and
opioid-use disorder. Building on
its own work to advance the sci-
ence of abuse-deterrent formula-
tions, the FDA should also re-
quire that prescription opioids
meet basic deterrent standards
and should facilitate the gradual
reformulation of existing products
to meet such standards. In declin-
ing to apply such a standard to Zo-
hydro, the agency noted that ex-
isting deterrent mechanisms have
had minimal impact by them-
selves. However, even modest
safeguards have been shown to
reduce the potential for inappro-
priate use.5 As part of a compre-
hensive strategy, a set of reason-
able requirements for opioid
medications is well in line with
the FDA’s public health mission.
Taking such action will deter
others with less expertise from
filling a perceived void.

In the end, pointing the finger
at Zohydro is not going to resolve

the tension that exists today be-
tween chronic pain and addiction.
All concerned about the treatment
of chronic pain and all responding
to the rise in overdose deaths need
to come together to promote high-
quality and effective prevention
and treatment for both conditions.

Disclosure forms provided by the authors
are available with the full text of this article
at NEJM.org.

From the Institutes for Behavior Resources
(Y.O.) and the Maryland Department of
Health and Mental Hygiene ( J.M.S.) — both
in Baltimore.

This article was published on April 23, 2014,
at NEJM.org.

1. Public health grand rounds — prescrip-
tion drug overdoses: an American epidemic.
Atlanta: Centers for Disease Control and Pre-
vention, February 18, 2011 (http://www.cdc
.gov/about/grand-rounds/archives/2011/
01-February.htm).
2. Policy impact: prescription painkiller
overdoses. Atlanta: Centers for Disease Con-
trol and Prevention, July 2, 2013 (http://
www.cdc.gov/HomeandRecreationalSafety/
pdf/PolicyImpact-PrescriptionPainkillerOD
).
3. FDA Commissioner Margaret A. Ham-
burg statement on prescription opioid
abuse. Silver Spring, MD: Food and Drug
Administration, April 3, 2014 (http://www
.fda.gov/NewsEvents/Newsroom/
PressAnnouncements/ucm391590.htm).
4. Federation of State Medical Boards of the
United States. Pain management policies:
board by board overview. February 2014
(http://www.fsmb.org/pdf/GRPOL_Pain_
Management ).
5. Severtson SG, Bartelson BB, Davis JM, et
al. Reduced abuse, therapeutic errors, and
diversion following reformulation of extend-
ed-release oxycodone in 2010. J Pain 2013;
14:1122-30.

DOI: 10.1056/NEJMp140418

Chronic Pain, Addiction, and Zohydro

Medication-Assisted Therapies — Tackling the Opioid-
Overdose Epidemic
Nora D. Volkow, M.D., Thomas R. Frieden, M.D., M.P.H., Pamela S. Hyde, J.D., and Stephen S. Cha, M.D.

The rate of death from over-doses of prescription opioids
in the United States more than
quadrupled between 1999 and

2010 (see graph), far exceeding
the combined death toll from co-
caine and heroin overdoses.1 In
2010 alone, prescription opioids

were involved in 16,651 overdose
deaths, whereas heroin was im-
plicated in 3036. Some 82% of
the deaths due to prescription

An audio interview
with Dr. Olsen

is available at NEJM.org

The New England Journal of Medicine
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P E R S P E C T I V E

n engl j med 370;22 nejm.org may 29, 20142064

opioids and 92% of those due to
heroin were classified as unin-
tentional, with the remainder be-
ing attributed predominantly to
suicide or “undetermined intent.”

Rates of emergency department
visits and substance-abuse treat-
ment admissions related to pre-
scription opioids have also in-
creased markedly. In 2007,
prescription-opioid abuse cost in-
surers an estimated $72.5 billion
— a substantial increase over
previous years.2 These health and
economic costs are similar to
those associated with other chron-
ic diseases such as asthma and
HIV infection.

These alarming trends led the
Department of Health and Hu-
man Services (HHS) to deem pre-
scription-opioid overdose deaths
an epidemic and prompted multi-
ple federal, state, and local ac-
tions.2 The HHS efforts aim to si-
multaneously reduce opioid abuse

and safeguard legitimate and
appropriate access to these med-
ications. HHS agencies are im-
plementing a coordinated, com-
prehensive effort addressing the
key risks involved in prescription-
drug abuse, particularly opioid-
related overdoses and deaths.
These efforts focus on four main
objectives: providing prescribers
with the knowledge to improve
their prescribing decisions and the
ability to identify patients’ prob-
lems related to opioid abuse, re-
ducing inappropriate access to
opioids, increasing access to effec-
tive overdose treatment, and pro-
viding substance-abuse treatment
to persons addicted to opioids.

A key driver of the overdose
epidemic is underlying substance-
use disorder. Consequently, ex-
panding access to addiction-
treatment services is an essential
component of a comprehensive
response.2 Like other chronic dis-

eases such as diabetes and hyper-
tension, addiction is generally
refractory to cure, but effective
treatment and functional recov-
ery are possible. Fortunately, cli-
nicians have three types of medi-
cation-assisted therapies (MATs)
for treating patients with opioid
addiction: methadone, buprenor-
phine, and naltrexone (see table).
Yet these medications are mark-
edly underutilized. Of the 2.5 mil-
lion Americans 12 years of age or
older who abused or were depen-
dent on opioids in 2012 (according
to the National Survey on Drug
Use and Health conducted by the
Substance Abuse and Mental
Health Services Administration
[SAMHSA]), fewer than 1 million
received MAT.

When prescribed and moni-
tored properly, MATs have proved
effective in helping patients re-
cover. Moreover, they have been
shown to be safe and cost-effec-
tive and to reduce the risk of over-
dose. A study of heroin-overdose
deaths in Baltimore between 1995
and 2009 found an association
between the increasing availabil-
ity of methadone and buprenor-
phine and an approximately 50%
decrease in the number of fatal
overdoses.3 In addition, some
MATs increase patients’ retention
in treatment, and they all improve
social functioning as well as re-
duce the risks of infectious-disease
transmission and of engagement
in criminal activities. Nevertheless,
MATs have been adopted in less
than half of private-sector treat-
ment programs, and even in pro-
grams that do offer MATs, only
34.4% of patients receive them.4

A number of barriers contrib-
ute to low access to and utilization
of MATs, including a paucity of
trained prescribers and negative
attitudes and misunderstandings

Tackling the Opioid-Overdose Epidemic

N
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. p

o
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la

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o

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)

3
4
1

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

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Kilograms of opioids
sold (per 10,000)

Deaths due to opioid
overdose (per 100,000)

Admissions for opioid-abuse
treatment (per 10,000)

AUTHOR:

FIGURE:

ARTIST:

OLF:Issue date:

AUTHOR, PLEASE NOTE:
Figure has been redrawn and type has been reset.

Please check carefully.

Volkow

mst

5-29-14 4-23-14

Opioid Sales, Admissions for Opioid-Abuse Treatment, and Deaths Due to Opioid
Overdose in the United States, 1999–2010.

Data are from the National Vital Statistics System of the Centers for Disease Control
and Prevention, the Treatment Episode Data Set of the Substance Abuse and Mental
Health Services Administration, and the Automation of Reports and Consolidated
Orders System of the Drug Enforcement Administration.

The New England Journal of Medicine
Downloaded from nejm.org at UNIVERSITY OF TENNESSEE – KNOXVILLE on May 10, 2018. For personal use only. No other uses without permission.
Copyright © 2014 Massachusetts Medical Society. All rights reserved.

n engl j med 370;22 nejm.org may 29, 2014

P E R S P E C T I V E

2065

Tackling the Opioid-Overdose Epidemic

about addiction medications held
by the public, providers, and pa-
tients. For decades, a common
concern has been that MATs
merely replace one addiction with
another. Many treatment-facility
managers and staff favor an ab-
stinence model, and provider
skepticism may contribute to low
adoption of MATs.4 Systematic
prescription of inadequate doses
further reinforces the lack of
faith in MATs, since the resulting
return to opioid use perpetuates
a belief in their ineffectiveness.

Policy and regulatory barriers
are another concern. A recent re-
port from the American Society
of Addiction Medicine describing
public and private insurance cov-
erage for MATs highlights several
policy-related obstacles that war-
rant closer scrutiny. These barri-
ers include utilization-manage-
ment techniques such as limits
on dosages prescribed, annual or
lifetime medication limits, initial
authorization and reauthorization

requirements, minimal counsel-
ing coverage, and “fail first” cri-
teria requiring that other thera-
pies be attempted first (www.asam
.org/docs/advocacy/Implications
-for-Opioid-Addiction-Treatment).
Although these policies may be
intended to ensure that MAT is
the best course of treatment, they
may hinder access and appropriate
care. For example, maintenance
MAT has been shown to prevent
relapse and death but is strongly
discouraged by lifetime limits.5

In addition, although Medicaid
covers buprenorphine and metha-
done in every state, some Medic-
aid programs or their managed-
care organizations apply the
utilization-management policies
described above. Most commer-
cial insurance plans also cover
some opioid-addiction medications
— most commonly buprenorphine
— but coverage is generally lim-
ited by similar policies, and ac-
cess to care may be limited to
in-network providers. Few private

insurance plans provide coverage
for the depot injection formula-
tion of naltrexone, and most do
not cover methadone provided
through opioid treatment pro-
grams.

Implementation of the Afford-
able Care Act (ACA) will increase
access to care for many Ameri-
cans, including persons with ad-
diction. This expansion builds on
the Mental Health Parity and Ad-
diction Equity Act, which re-
quires insurance plans that offer
coverage for mental health or
substance-use disorders to pro-
vide the same level of benefits
that they do for general medical
treatment. The ACA significantly
extends the reach of the parity
law’s requirements, ensuring that
more Americans have coverage
for mental health and substance-
use disorders and that coverage
complies with the federal parity
requirements. These reforms pre-
sent new opportunities for reduc-
ing prescription-opioid abuse and

Characteristics of Medications for Opioid-Addiction Treatment.

Characteristic Methadone Buprenorphine Naltrexone

Brand names Dolophine, Methadose Subutex, Suboxone, Zubsolv Depade, ReVia, Vivitrol

Class Agonist (fully activates opioid re-
ceptors)

Partial agonist (activates opioid recep-
tors but produces a diminished re-
sponse even with full occupancy)

Antagonist (blocks the opioid receptors
and interferes with the rewarding
and analgesic effects of opioids)

Use and effects Taken once per day orally to reduce
opioid cravings and withdrawal
symptoms

Taken orally or sublingually (usually
once a day) to relieve opioid crav-
ings and withdrawal symptoms

Taken orally or by injection to diminish
the reinforcing effects of opioids
(potentially extinguishing the asso-
ciation between conditioned stimuli
and opioid use)

Advantages High strength and efficacy as long
as oral dosing (which slows brain
uptake and reduces euphoria) is
adhered to; excellent option for
patients who have no response
to other medications

Eligible to be prescribed by certified
physicians, which eliminates the
need to visit specialized treatment
clinics and thus widens availability

Not addictive or sedating and does not
result in physical dependence; a re-
cently approved depot injection for-
mulation, Vivitrol, eliminates need
for daily dosing

Disadvantages Mostly available through approved
outpatient treatment programs,
which patients must visit daily

Subutex has measurable abuse liability;
Suboxone diminishes this risk by in-
cluding naloxone, an antagonist
that induces withdrawal if the drug
is injected

Poor patient compliance (but Vivitrol
should improve compliance); initi-
ation requires attaining prolonged
(e.g., 7-day) abstinence, during
which withdrawal, relapse, and early
dropout may occur

P E R S P E C T I V E

n engl j med 370;22 nejm.org may 29, 20142066

its consequences by expanding
the number of high-risk people
who receive MATs through either
public or private insurance. The
importance of access to MATs
and other treatment services for
substance-use disorder is under-
scored by the recent recognition
of increased heroin use; what
may be less widely recognized is
that the majority of these new
heroin users initially abused pre-
scription opioids before shifting
to heroin.

HHS agencies are actively col-
laborating with public and private
stakeholders in efforts to expand
access to and improve utilization
of MATs, in tandem with other
targeted approaches to reducing
opioid overdoses.2 For example,
the National Institute on Drug
Abuse (NIDA) is funding research
to improve delivery of MATs to
vulnerable populations, includ-
ing those in the criminal justice
system. NIDA is also working to
develop new pharmacologic treat-
ments for opioid addiction and
helping to fund “user friendly”
delivery systems for naloxone (i.e.,
intranasal rather than injection).
SAMHSA is encouraging MAT
use in its state funding of sub-
stance-abuse treatment programs
through the Substance Abuse
Prevention and Treatment Block
Grant and regulatory oversight of
methadone and buprenorphine for
opioid addiction. Furthermore,

SAMHSA supports production
and dissemination of educational
resources to MAT prescribers, as
well as an “Opioid Overdose Tool-
kit” to educate first responders,
treatment providers, and patients
about ways to prevent and inter-
vene in opioid-overdose cases.

The Centers for Disease Con-
trol and Prevention is working to
empower states to implement com-
prehensive strategies, including
MATs, for preventing prescrip-
tion-drug overdoses. These strat-

egies focus primarily on address-
ing the overdose epidemic through
enhanced surveillance, effective
policies, and clinical practices that
establish statewide prescribing
norms. Such efforts can be en-
hanced by using data sources to
identify and intervene in cases of
patients or providers who fall out-
side those norms. And the Centers
for Medicare and Medicaid Ser-
vices is working to enhance access
to MATs by Medicaid programs
through improved benefit design
and application of the Mental
Health Parity and Addiction Equi-
ty Act. But to be successful, all
these initiatives require the active
engagement and participation of
the medical community.

The epidemic of prescription-
opioid overdose is complex. Ex-
panding access to MATs is a
crucial component of the effort
to help patients recover. It is also
necessary, however, to implement

primary prevention policies that
curb the inappropriate prescrib-
ing of opioid analgesics — the
key upstream driver of the epi-
demic — while avoiding jeopar-
dizing critical or even lifesaving
opioid treatment when it is need-
ed. Essential steps for physicians
will be to reduce unnecessary
or excessive opioid prescribing,
routinely check data from pre-
scription-drug–monitoring pro-
grams to identify patients who
may be misusing opioids, and
take full advantage of effective
MATs for people with opioid ad-
diction.

Disclosure forms provided by the au-
thors are available with the full text of this
article at NEJM.org.

From the National Institute on Drug Abuse,
National Institutes of Health, Bethesda
(N.D.V.), the Substance Abuse and Mental
Health Services Administration, Rockville
(P.S.H.), and the Center for Medicaid and
CHIP Services, Centers for Medicare and
Medicaid Services, Baltimore (S.S.C.) — all
in Maryland; and the Centers for Disease
Control and Prevention, Atlanta (T.R.F.).

This article was published on April 23, 2014,
and updated on May 1, 2014, at NEJM.org.

1. Jones CM, Mack KA, Paulozzi LJ. Pharma-
ceutical overdose deaths, United States,
2010. JAMA 2013;309:657-9.
2. Addressing prescription drug abuse in the
United States: current activities and future
opportunities. Atlanta: Centers for Disease
Control and Prevention, 2013 (http://www
.cdc.gov/homeandrecreationalsafety/
overdose/hhs_rx_abuse.html).
3. Schwartz RP, Gryczynski J, O’Grady KE,
et al. Opioid agonist treatments and heroin
overdose deaths in Baltimore, Maryland,
1995-2009. Am J Public Health 2013;103:917-
22.
4. Knudsen HK, Abraham AJ, Roman PM.
Adoption and implementation of medica-
tions in addiction treatment programs. J Ad-
dict Med 2011;5:21-7.
5. Clark RE, Baxter JD. Responses of state
Medicaid programs to buprenorphine diver-
sion: doing more harm than good? JAMA In-
tern Med 2013;173:1571-2.

DOI: 10.1056/NEJMp1402780
Copyright © 2014 Massachusetts Medical Society.

Tackling the Opioid-Overdose Epidemic

A key driver of the overdose epidemic is
underlying substance-use disorder.
Consequently, expanding access to

addiction-treatment services is an essential
component of a comprehensive response.

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A Systematic Review of Psychosocial Interventions
in Treatment of Opioid Addiction

Aaron R. Brown

To cite this article: Aaron R. Brown (2018): A Systematic Review of Psychosocial Interventions
in Treatment of Opioid Addiction, Journal of Social Work Practice in the Addictions, DOI:

.1080/1533256X.2018.1485574

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Published online: 06 Jul 2018.

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A Systematic Review of Psychosocial
Interventions in Treatment of Opioid Addiction

AARON R. BROWN, LCSW
College of Social Work, University of Tennessee, Knoxville, Tennessee, USA

Opioid addiction has become a U.S. epidemic. It is important to
determine whether psychosocial interventions help prevent relapse.
A total of 14 studies were included in this systematic review. Most
studies compared psychosocial interventions in conjunction with
pharmacological maintenance. Only 2 studies found that psycho-
social interventions led to statistically significant benefits for out-
comes related to opioid abuse when compared to maintenance and
less or no psychosocial intervention. Psychosocial interventions
were not found to be additive to pharmacological treatments dur-
ing induction or maintenance stages. Further research is needed to
determine effectiveness of psychosocial interventions during dose
reduction and long-term relapse prevention.

KEYWORDS addiction, intervention, maintenance, opioid,
prevention, psychosocial, relapse, substance

In the last 20 years, both therapeutic and illicit opioid use have escalated in
the United States (Manchikanti et al., 20

). The total number of opioid
prescriptions dispensed from U.S. outpatient retail pharmacies increased
from 174.1 million in 2000 to 256.

million in 2009 (Governale, 2010). Hydro-
codone is not only the most commonly prescribed opioid, it is the most
prescribed medication in the United States (Manchikanti et al., 2012).

Manchikanti et al. (2012) stated, “Drug dealers are no longer the primary
source of illicit drugs” (p. ES31). As the number of opioids prescribed has
increased, so has their illicit use. According to the 2014 National Survey on

Received March

, 2017;revised June 6, 2016;accepted May 30, 2017.
Address correspondence to Aaron R. Brown LCSW, College of Social Work, University of

Tennessee, Knoxville, 1618 Cumberland Ave., Knoxville, TN 37996. E-mail: Abrown89@vols.utk.edu

Journal of Social Work Practice in the Addictions, 00:1–21, 2018
Copyright © Taylor & Francis Group, LLC
ISSN: 1533-256X print/1533-2578 online
DOI: https://doi.org/10.1080/1533256X.2018.1485574

http://orcid.org/0000-0002-9108-0338

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Drug Use and Health (NSDUH), prescription opioids have been the most
frequently abused psychotherapeutic drug for more than a decade, and are
second only to marijuana for all illicit drugs (Hedden et al., 2014). An esti-
mated 4.3 million individuals 12 or older are current nonmedical users of
prescription opioids, which represents 1.6% of the population aged 12 or
older in the United States (Hedden et al.). The problem of opioid abuse is
most prevalent among young adults. The same 2014 survey estimated that
2.8% of young adults aged 18 to 25 in the United States were current non-
medical users of opioids (Hedden et al.). Looking at the problem in a more
local context, Wright et al. (2014) examined opioid abuse at the county level
in Indiana and found a significant association between the rate of opioid
dispensed and the rate of opioid abuse.

A serious risk associated with prescription opioid abuse is the develop-
ment of opioid addiction, which can be defined as a pattern of compulsive,
prolonged use of opioids for nonmedical reasons or in excess of the amount
necessary for legitimate medical use marked by psychological and physiolo-
gical dependence and leading to significant impairment (American Psychiatric
Association, 2013). An estimated 2.4 million Americans suffer from a substance
use disorder related to prescription opioids, more than for cocaine and heroin
combined and second only to marijuana for illicit drugs (Ali & Mutter, 2016;
Hedden et al., 2014).

Societal Cost

Prescription opioid abuse is taking an increasingly large toll on the United States
in terms of the costs related to its prevention and treatment as well as the losses it
inflicts on families and communities. Between 2005 and 2011, the number of
emergency room visits in the United States involving abuse of prescription
opioids more than doubled from 168,379 to 366,181 (Crane, 2015). There has
also been a substantial increase in those seeking treatment for opioid abuse. The
number of individuals in the United States reporting substance abuse treatment
related to prescription opioid abuse more than doubled between 2002 and 2014
(Substance Abuse and Mental Health Services Administration [SAMHSA], 2015b).
The mortality rate in the United States associated with opioid abuse drastically
increased during this same time period, from 4,400 to 18,893 (Centers for Disease
Control and Prevention, 2016).

There have been numerous indications that costs associated with the
growing prescription opioid abuse problem in the United States are substan-
tial. However, there are many aspects of the problem that incur costs, and
research on the overall economic burden has been limited. These aspects can
be grouped into categories of criminal justice, workplace, and health care
costs. Two systematic analyses of the total U.S. societal costs of prescription
opioid abuse estimated it at more than $50 billion as of 2007 (Birnbaum et al.,

2 A. R. Brown

2011; Hansen, Oster, Edelsberg, Woody, & Sullivan, 2011). Florence, Zhou,
Luo, and Xu (2016) estimated the economic burden of prescription opioid
overdose, abuse, and dependence to be $78.5 billion as of the end of 2013.

Relapse Prevention and Opioid Abuse

Prescription opioid use and abuse in the United States have significantly
increased over the last decade. Given the substantial number of individuals
with substance use disorders related to prescription opioid abuse and the
increasing utilization of treatment for these disorders, outpatient clinicians are
more and more likely to encounter individuals who abuse prescription opioids
in their practice (Hedden et al., 2014; SAMHSA, 2015b). Typically, these clients
seek assistance in preventing relapse to maintain abstinence from the abuse of
prescription opioids. A better understanding of whether psychosocial inter-
ventions are effective for relapse prevention is needed.

The first line of treatment for opioid use disorders is often medical
detoxification, a short-term inpatient process of providing medical supervision
to assist in the achievement of abstinence while treating the symptoms of
withdrawal (Veilleux, Colvin, Anderson, York, & Heinz, 2010). The adverse
symptoms associated with withdrawal are rarely medically serious, but fear of
withdrawal might discourage individuals from seeking treatment and the
discomfort experienced during withdrawal might lead clients to drop out of
treatment (Gossop, 2006). For these reasons, detoxification is typically a
prerequisite for admission to long-term abstinence-based treatment programs,
whether residential or outpatien

Detoxification may positively influence long-term treatment outcomes for
opioid use disorders, but it is not sufficient as a standalone intervention (Gossop,
2006; Veilleux et al., 2010). A relapse prevention phase is needed to help those
suffering from opioid addiction achieve longterm recovery, even after detoxifica-
tion. Relapse prevention often includes a pharmacological component such as
the use of an opioid agonist and conjunctive psychosocial components. Pharma-
cological maintenance is sometimes derided as merely a substitution of one
addictive drug for another. However, there is substantial evidence that medica-
tion-assisted therapies (MATs) are effective in preventing relapse when properly
used (Mattick, Breen, Kimber, & Davoli, 2014; Volkow, Frieden, Hyde, & Cha,
2014). It is for this reason that the National Institute of Drug Abuse (NIDA) refers
to these pharmacological components as treatments and not substitutions (NIDA,
2016). Psychosocial interventions are often strongly encouraged or required as a
part of maintenance treatments in the United States (SAMHSA, 2015a).

This leads to the question of whether psychotherapy is a useful compo-
nent of relapse prevention, either in conjunction with pharmacological treat-
ment or in medication-free treatment modalities. Previous systematic reviews
have addressed similar questions pertaining to opioid addiction in general, but

Psychosocial Interventions and Opioid Addiction 3

none has looked at psychosocial interventions in the specific context of
prescription opioid addiction (Amato, Minozzi, Davoli, & Vecchi, 2011;
Dugosh et al., 2016; Veilleux et al., 2010). Are psychosocial interventions
effective for treating individuals with prescription opioid addiction during
relapse prevention? Which psychosocial interventions are most effective for
relapse prevention of prescription opioid addiction?

Definition of Terms

Relapse is defined as the use of nonmedical prescription opioids after a
voluntary period of abstinence. Relapse prevention is defined as a treatment
phase after voluntary abstinence has been achieved during which efforts are
made to maintain an opioid-free lifestyle. Psychosocial intervention is defined
as individual or group sessions with a licensed clinician implementing a
behavioral intervention intended to prevent relapse for which the clinician
has received sufficient training.

Prescription opioid addiction is a pattern of compulsive, prolonged use
of prescription opioids for nonmedical reasons or in excess of the amount
necessary for legitimate medical use marked by psychological and physiolo-
gical dependence and leading to significant impairment (American Psychiatric
Association, 2013). Individuals recovering from opioid addiction are defined
as Americans aged 18 years or older who have previously been diagnosed
with opioid use disorder related to prescription opioid abuse according to
Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM–5]

)

criteria and have achieved a voluntary period of abstinence.

METHODS

Inclusion and Exclusion Criteria

A systematic review of studies comparing psychosocial interventions and
outcome measures related to relapse prevention for prescription opioid
abuse was conducted solely by the author. The inclusion criteria for this
study were as follows:

● Studies published in the English language.
● Studies included in at least one of the following databases: Web of

Science Core Collection: Citation Indexes, Social Work

Abstract

s,
PsychINFO, Social Science Research Network, or Cochrane Library.

● Studies published after 2010, specifically, from January 1, 2010 until
September 30, 2016.

● Studies that compared at least one psychosocial intervention as a
primary condition.

4 A. R. Brown

● Studies conducted on individuals 18 years or older who were in
treatment for prescription opioid addiction, whether in detox or a
relapse prevention phase.

● Studies that examined outcomes related to relapse and opioid abuse
such as opioid use, treatment completion, abstinence from opioid use,
treatment duration, or treatment retention.

● Studies that included quantitative data analysis.
● Articles were excluded from this study based on the following criteria:
● Studies conducted outside of the United States.
● Studies that are qualitative.
● Studies that did not specifically describe the types of psychosocial

interventions implemented.
● Studies that did not specifically describe the types of pharmacological

interventions used if pharmacological interventions were used.

Rationale for Inclusion and Exclusion Criteria

This review is primarily concerned with the treatment of prescription opioid addic-
tion in the United States due to the rapid growth of prescription opioid abuse over
the last decade. For this reason, studies conducted outside of the United States were
excluded. Because English is the language primarily used for research and publica-
tion in the United States, only studies published in English were included.

This review’s focus on prescription opioid abuse required a wide catch-
net of journals within multidisciplinary fields such as social work, counseling,
psychology, psychiatry, pharmacology, substance abuse, addiction, and pub-
lic health. Search databases were chosen based on whether they included
journals related to these multidisciplinary fields of research.

Studies were included that used quantitative data analysis. This inclusion
criterion was chosen to focus on those studies that showed the most con-
clusive evidence to support the opioid abuse treatment protocols. Studies that
were primarily qualitative were excluded to maximize homogeneity of out-
come measures and form relevant conclusions across studies.

This review was limited to studies published after 2010 to include only
the most recent and relevant research related to a problem that has been
increasing over the last decade. Also, to the author’s knowledge, the oft-cited
reviews by Veilleux et al. (2010) and Amato et al. (2011) are the most recent
and rigorous systematic reviews focused on comparing treatment protocols for
opioid abuse that included both psychosocial and pharmacological interven-
tions. Since these reviews, new relapse prevention interventions have been
developed and studied. For instance, mindfulness-based relapse prevention
(MBRP) is a recent and promising intervention that was first studied in a pilot
randomized controlled trial by Bowen et al. (2009).

Psychosocial Interventions and Opioid Addiction 5

Because the primary aim of this review was to identify whether and
under which conditions psychosocial interventions are effective in prescrip-
tion opioid addiction treatment, only those studies that implemented psycho-
social interventions were included. Studies that focused on other types of
treatment interventions (e.g., pharmacological ones) were also included so
long as they included at least one psychosocial intervention as a component
of comparison. Focusing only on reviewing studies of a specific type of
intervention would limit best practice recommendations. It is important for
clinicians to be informed about the most effective interventions with this
population.

It was also important for this review to exclude those studies that did not
describe the specific interventions implemented. In their systematic review,
Veilleux et al. (2010) found that targeted psychosocial interventions showed
the most promise for use in treatment of opioid addiction. For best practice
recommendations to be made, it was necessary to understand whether spe-
cific interventions were more effective than others, and to avoid the assump-
tion that any pharmacological or any psychosocial intervention is as effective
as others.

Studies were also chosen based on population criteria. The focus of this
review is on relapse prevention from prescription opioid abuse. As such, only
those studies that specifically studied outcome measures related to relapse
prevention and opioid abuse were included. Additionally, only studies that
focused on adults, which is the population of interest for this review, were
included. Data indicate that individuals 18 to 25 years old make up the largest
percentage of those who abuse prescription opioids (Hedden et al., 2014).

Search and Distillation

Using the stated inclusion and exclusion criteria, a search was conducted in
three phases (see Figure 1). Phase I used Boolean terms to identify articles in
any of the included databases. The following Boolean terms were used for
topic search: opioid AND (addict* OR dependen* OR abuse OR misuse) AND
(psychotherapy OR psychosocial OR counseling OR “relapse prevention”)
NOT (child* OR adolesce* OR youth OR infant) NOT (cannabis OR marijuana
OR cannabinoid OR cocaine OR alcohol* OR heroin OR methamphetamine).
Searches were limited to those results written in English between January 2010
and October 2016.

To capture studies that implemented counseling-only treatment proto-
cols, a second search was conducted using the following Boolean terms in a
title search: opioid AND (addict* OR dependen* OR abuse OR misuse OR “use
disorder”) AND (psychotherapy OR psychosocial OR counsel* OR therapy OR
behavioral OR “relapse prevention”) NOT (maintenance OR pharmacological
OR naltrexone OR naloxone OR methadone OR Buprenorphine OR

6 A. R. Brown

suboxone) NOT (child* OR adolesce* OR youth OR infant) NOT (cannabis OR
marijuana OR cannabinoid OR cocaine OR alcohol* OR heroin OR
methamphetamine).

Phase I of the first search captured a total of 255 articles from Web of
Science (n = 144), Social Work Abstracts (n = 0), PsycINFO (n = 38), Social
Science Research Network (n = 0), and Cochrane Library (n = 73). Phases II
and III implemented distillation per inclusion and exclusion criteria (see
Figure 1). In Phase II, duplicates (n = 47) and articles with topics outside of
inclusion criteria (n = 180) were excluded from the results. Then in Phase III
of the first search, qualitative studies (n = 6), reviews (n = 9), and studies
outside the United Stated (n = 5) were excluded. After distillation, eight
articles were included from the first search.

Phase I of the second search captured a total of 111 articles from Web of
Science (n = 66), Social Work Abstracts (n = 0), PsycINFO (n = 33), Social
Science Research Network (n = 0), and Cochrane Library (n = 12). In Phase II,
duplicates (n = 37) and articles with topics outside of inclusion criteria
(n = 51) were excluded from the results. Then in Phase III of the second
search, qualitative studies (n = 5), reviews (n = 10), and studies outside the
United States (n = 4) were excluded. Articles already included from previous
search were also excluded (n = 1). After distillation, two articles were included
from the second search.

In an effort to capture more articles meeting inclusion criteria, the cita-
tions from already included articles were reviewed. A total of three articles

FIGURE 1 Phases of search and distillation.

Psychosocial Interventions and Opioid Addiction 7

meeting inclusion criteria were found among citations of those articles already
included from two searches (Fiellin et al., 2013; Ling, Hillhouse, Ang, Jenkins,
& Fahey, 2013; Moore et al., 2016). An additional article (Schwartz, Kelly,
O’Grady, Gandhi, & Jaffe, 2012) was included based on a response written by
Schwartz (2016) to a very recent systematic review that failed to include this
relevant article (Dugosh et al., 2016). These articles were not captured by the
search methodology used here, but they were deemed important to include
due to their direct relevancy to this review and their meeting criteria for
inclusion. These four articles were combined with the 10 captured by two
searches for a total of 14 articles included in this review (see Table 1).

FINDINGS

Treatment Protocols

Several types of psychosocial interventions were compared within the various
articles. All but one of the studies included in this review used random
assignment to treatment conditions (Barry, Cutter, Beitel, Liong, & Schotten-
feld, 2015). As seen in Table 1, the most common psychosocial intervention
studied was cognitive-behavioral therapy (CBT), which was compared in 6 of
the 14 studies (Barry et al., 2015; Fiellin et al., 2013; Lander, Gurka, Marshalek,
Riffon, & Sullivan, 2015; Ling et al., 2013; Moore et al., 2016; Otto et al., 2014).
Other types of psychosocial interventions compared included mindfulness-
oriented recovery enhancement (MORE), therapy groups, contingency man-
agement (CM), Web-based counseling, CBT for interoceptive cues (CBT–IC),
acceptance and commitment therapy (ACT), distress tolerance (DT), and
support groups (Garland et al., 2014; Ling et al., 2013; Otto et al., 2014;
Smallwood, Potter, & Robin, 2016; Stein et al., 2015; Stotts et al., 2012; Weiss
et al., 2011).

Pharmacological treatment was compared in all but one of the 14 articles
included in this review. The most common type of pharmacological treatment
implemented was buprenorphine, which was used in nine of the studies
(Barry et al., 2015; Fiellin et al., 2013; Lander et al., 2015; Moore et al., 2016;
Smallwood et al., 2016; Stein et al., 2015; Tetrault et al., 2012; Weiss et al.,
2011). Buprenorphine was typically used in combination with naloxone for
maintenance induction. Methadone was used in four of the included studies
(Marsch et al., 2014; Otto et al., 2014; Schwartz et al., 2012; Stotts et al., 2012).
In all but one of the studies, pharmacological treatment was implemented for
induction and maintenance. In one study (Stotts et al., 2012), instead of
induction and maintenance, the groups were compared during methadone
dose reduction with the goal of detoxification from methadone.

8 A. R. Brown

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e
n
cy

m
an
ag
e
m
e
n
t

(C
M
)3
.
B
u
p
re
n
o
rp
h
in
e
,
C
B
T
,

an
d
C
M
4
.
B
u
p
re
n
o
rp
h
in
e
o
n
ly

O
p
io
id
u
se

(u
ri
n
e
);

tr
e
at
m
e
n
t

re
te
n
ti
o
n
;
cr
av
in
g

A
ll

g
ro
u
p
s

b
e
n
e
fi
te
d
fr
o
m

tr
e
at
m
e
n
t.

N
o
si
g
n
if
ic
an

t
g
ro
u
p

d
if
fe
re
n
ce
s
w
e
re

fo
u
n
d

O
n
e
e
x
cl
u
si
o
n
cr
it
e
ri
o
n

e
li
m
in
at
e
d

in
d
iv
id
u
al

s
w
it
h

h
e
al
th

is
su
e
s,
w
h
ic
h
li
m
it
s
th
e

g
e
n
e
ra
li
za
b

il
it
y

o
f
th
e
re
su
lt
s.

M
ar
sc
h

e
t
al
.
(2
0
1
4
)

1
6
0

1
.

M
e
th
ad

o
n
e

d
in
-p
e
rs
o
n

in
d
iv
id
u
al

u
n
se
li
n
g
2
.

M
e
th
ad
o
n
e
an
d
m
ix
e
d
in
d
iv
id
u
al

an
d
W
e
b
-b
as
e
d

co
u
n
se
li
n
g
:
T
h
e
ra
p
e
u
ti
c

E
d
u
ca
ti
o
n
Sy
st
e
m

(T
E
S)

O
p
io
id
u
se
(u
ri
n
e
);

tr
e
at
m
e
n
t
re
te
n
ti
o
n

B
o
th
g
ro
u
p
s
b
e
n
e
fi
te
d
fr
o
m

tr
e
at
m
e
n
t,

b
u
t
th
e

m
ix
e
d

co
u
n
se
li
n
g
g
ro
u
p
s
im

p
ro
v
e
d

si
g
n
if
ic
an

tl
y
m
o
re

th
an
th
e
st
an

d
ar
d
tr
e
at
m
e
n
t
g
ro
u
p
.

T
h
e
re
w
as
n
o
si
g
n
if
ic
an
t
d
if
fe
re
n
ce

in
re
te
n
ti
o
n

b
e
tw

e
e
n
g
ro
u
p
s.

T
h
e
sa
m
p
le

w
as

7
5
%

m
al
e
.

A
tt
ri
ti
o
n
ra
te
s
w
e
re

h
ig
h
in

b
o
th

g
ro
u
p
s
(~
4
0
%
).
D
o
se

e
x
p
o
su
re

o
f
co

u
n
se
li
n
g
w
as

lo
w

(~
1
2
se
ss
io
n
s)
.

M
o
o
re

e
t
al
.

(2
0
1
6
)

4
8

1
.
B
u
p
re
n
o
rp
h
in
e
an
d
P
M
2
.
B
u
p
re
n
o
rp
h
in
e
an
d
C
B
T
O
p
io
id
u
se
(u
ri
n
e
an
d
se
lf
-r
e
p
o
rt
)

T
h
e
C
B
T
g
ro
u
p
h
ad

b
e
tt
e
r

o
u
tc
o
m
e
s,
b
u
t
n
o
g
ro
u
p

d
if
fe
re
n
ce
s
w
e
re

st
at
is
ti
ca
ll
y

si
g
n
if
ic
an
t.
T
h
e
re

w
as
n
’t
e
n
o
u
g
h
st
at
is
ti
ca
l

p
o
w
e
r
to

d
e
te
ct

si
g
n
if
ic
an

t
g
ro
u
p
d
if
fe
re
n
ce
s.

O
tt
o
e
t
al
.

(2
0
1
4
)

7
8

1
.
M
e
th
ad

o
n
e
an

d
in
d
iv
id
u
al

co
u
n
se
li
n
g
2
.
M
e
th
ad

o
n
e
an

d
C
B
T
fo
r
in
te
ro
ce
p
ti
v
e
cu

e
s

(

C
B
T
–
IC

)

O
p
io
id
u
se
(s
e
lf
–
re
p
o
rt
an

d
sa
li
v
a)

B
o
th
g
ro
u
p
s
b
e
n
e
fi
te
d
fr
o
m

tr
e
at
m
e
n
t.
T
h
e
re

w
as
n
o
si
g
n
if
ic
an
t
d
if
fe
re
n
ce
b
e
tw
e
e
n

g
ro
u
p
s
fo
r
o
p
io
id

u
se

as
m
e
as
u
re
d
b
y
sa
li
v
a,

b
u
t
th
e
C
B
T
–
IC

g
ro
u
p
re
p
o
rt
e
d

si
g
n
if
ic
an
tl
y
le
ss
o
p
io
id
u
se
.

O
n
ly

p
ar
ti
ci
p
an

ts
w
h
o
h
ad

re
sp
o
n
d
e
d
p
o
o
rl
y
to

st
an
d
ar
d

tr
e
at
m
e
n
t
w
e
re

re
cr
u
it
e
d
.

R
e
su
lt
s
d
if
fe
re
d
b
y
o
u
tc
o
m
e

m
e
as
u
re
:
se
lf
-r
e
p
o
rt
v
s.

to
x
ic
o
lo
g
y
.
2
3
%

o
f
p
ar
ti
ci
p
an

ts
d
id

n
o
t
fi
n
is
h
tr
e
at
m
e
n
t.

Sc
h
w
ar
tz

e
t
al
.

(2
0
1
2
)

2
3
0

1
.
M
e
th
ad
o
n
e
an
d
co
u
n
se
li
n
g
2
.
M
e
th
ad
o
n
e
an

d
h
ig
h
e
r

d
o
se

o
f
co

u
n
se
li
n
g
3
.
M
e
th
ad

o
n
e
o
n
ly

fo
r
1
2
0
d
ay
s
th
e
n

co
u
n
se
li
n
g
ad

d
e
d
O
p
io
id
u
se
(s
e
lf
–
re
p
o
rt
an

d
u
ri
n
e
)

A
ll
th
re
e
g
ro
u
p
s
sh
o
w
e
d

re
d
u
ct
io
n

o
p
io
id

u
se
.
T
h
e
re

w
e
re
n
o
si
g
n
if
ic
an
t
g
ro
u
p

d
if
fe
re
n
ce
s
fo
r
re
d
u
ct
io
n
in

o
p
io
id
u
se
.

A
m
o
u
n
t
o
f
co

u
n
se
li
n
g
w
as

at
m
o
st

o
n
ce

p
e
r
w
e
e
k
(h
ig
h
e
r

d
o
se

g
ro
u
p
).
C
o
u
n
se
li
n
g
w
as

g
e
n
e
ra
ll
y
le
ss

st
ru
ct
u
re
d
th
an

C
B
T
.

Sm
al
lw

o
o
d

e
t
al
.
(2
0
1
6
)
2
5
1
.
B
u
p
re
n
o
rp
h
in
e
an

d
ac
ce
p
ta
n
ce

an
d
co

m
m
it
m
e
n
t

th
e
ra
p
y
(A
C
T
)2
.

B
u
p
re
n
o
rp
h
in
e
an

d
h
e
al
th

e
d
u
ca
ti
o
n
(H

E
)

B
ra
in

M
R
I
d
at
a;

o
p
io
id
cr
av
in
g

(s
e
lf
-r
e
p
o
rt
)

R
e
su
lt
s
in
d
ic
at
e
d

th
at

th
o
se

in
th
e

A
C
T
g
ro
u
p
h
ad

re
d
u
ce
d

ac
ti
v
at
io
n
in

b
ra
in

re
g
io
n
s

li
n
k
e
d
to

p
ai
n
p
ro
ce
ss
in
g
.
N
o

d
if
fe
re
n
ce
s
b
e
tw
e
e
n
g
ro
u
p
s
fo
r
o
p
io
id

cr
av
in
g
w
e
re

re
p
o
rt
e
d
.

Lo
w

sa
m
p
le
si
ze

an
d
h
ig
h

at
tr
it
io
n
(5
0
%
)
le
d
to

in
su
ff
ic
ie
n
t
p
o
w
e
r.

St
e
in

e
t
al
.
(2
0
1
5
)

4
9

1
.
B
u
p
re
n
o
rp
h
in
e
an

d
d
is
tr
e
ss

to
le
ra
n
ce

(D
T
)
2
.

B
u
p
re
n
o
rp
h
in
e
an

d
H
E

O
p
io
id
u
se
(s
e
lf
–
re
p
o
rt
an
d
u
ri
n
e
);
tr
e
at
m
e
n
t
re
te
n
ti
o
n

D
T
le
d
to

a
sm

al
l
st
at
is
ti
ca
ll
y

in
si
g
n
if
ic
an

t
re
d
u
ct
io
n
in

o
p
io
id
u
se

d
u
ri
n
g
th
e
fi
rs
t
3

m
o
n
th
s
o
f
tr
e
at
m
e
n
t.
N
o
g
ro
u
p

d
if
fe
re
n
ce
w
as

fo
u
n
d
fo
r

tr
e
at
m
e
n
t
re
te
n
ti
o
n
.

F
ix
e
d
b
u
p
re
n
o
rp
h
in
e
d
o
si
n
g

m
ig
h
t
h
av
e
li
m
it
e
d
it
s
b
e
n
e
fi
ts
.

A
tt
ri
ti
o
n
w
as

ab
o
u
t
2
5
%
.

(C
o
n
ti
n
u
ed
)
11

T
A
B
L
E
1
(C
o
n
ti
n
u
e
d
)
A
u
th
o
rs
Sa
m
p
le
Si
ze
C
o
m
p
ar
is
o
n
G
ro
u
p
s
O
p
io
id
A
b
u
se
O
u
tc
o
m
e
(s
)
R
e
su
lt
s
Li
m
it
at
io
n
s

St
o
tt
s
e
t
al
.

(2
0
1
2
)

5
6

1
.
M
e
th
ad

o
n
e
d
o
se

re
d
u
ct
io
n

an
d
A
C
T
2
.
M
e
th
ad

o
n
e
d
o
se

re
d
u
ct
io
n
an

d
d
ru
g

co
u
n
se
li
n
g
(D

C
)
O
p
io
id
u
se
(s
e
lf
–
re
p
o
rt
an
d
u
ri
n
e
);

d
e
to
x
if
ic
at
io
n

st
at
u
s;

d
e
to
x
if
ic
at
io
n
fe
ar

N
o
si
g
n
if
ic
an

t
d
if
fe
re
n
ce
s

b
e
tw

e
e
n
g
ro
u
p
s
w
e
re

fo
u
n
d
fo
r
o
p
io
id

u
se
.
3
7
%

o
f
A
C
T

p
ar
ti
ci
p
an

ts
su
cc
e
ss
fu
ll
y

co
m
p
le
te
d
d
e
to
x
if
ic
at
io
n
b
y

e
n
d
o
f
tr
e
at
m
e
n
t
co

m
p
ar
e
d
to

1
9
%

o
f
D
C
p
ar
ti
ci
p
an

ts
.
A
C
T

w
as

al
so

fa
v
o
ra
b
le

fo
r
fe
ar

o
f

d
e
to
x
if
ic
at
io
n
o
u
tc
o
m
e
.

A
d
h
e
re
n
ce

an
d
co

m
p
e
te
n
ce

ra
ti
n
g
s
w
e
re

h
ig
h
fo
r

co
u
n
se
li
n
g
,
b
u
t
so
m
e

p
ro
ce
ss
e
s
w
e
re

im
p
le
m
e
n
te
d

le
ss

o
ft
e
n
th
an

o
th
e
rs
,
w
h
ic
h

m
ig
h
t
h
av
e
at
te
n
u
at
e
d
re
su
lt
s.

T
h
e
ra
p
y
tr
ai
n
in
g
ti
m
e
w
as

g
re
at
e
r
in

th
e
A
C
T
co

n
d
it
io
n
.

T
e
tr
au

lt
e
t
al
.

(2
0
1
2
)

4
7

1
.
B
u
p
re
n
o
rp
h
in
e
an
d
P
M
2
.
B
u
p
re
n
o
rp
h
in
e
,
P
M
,
an

d
e
n
h
an

ce
d
m
e
d
ic
al

m
an

ag
e
m
e
n
t
(E
M
M
)

O
p
io
id
u
se
(u
ri
n
e

an
d
se
lf
-r
e
p
o
rt
);

tr
e
at
m
e
n
t
re
te
n
ti
o
n
T
h
e
re
w
e
re

n
o
d
if
fe
re
n
ce
s

b
e
tw

e
e
n
g
ro
u
p
s
in

o
u
tc
o
m
e

m
e
as
u
re
s
re
la
te
d
to

o
p
io
id
u
se

o
r
re
te
n
ti
o
n
.

Sm
al
l
sa
m
p
le

si
ze

re
d
u
ce
d
ab

il
it
y

to
d
e
te
ct

b
e
tw

e
e
n
-g
ro
u
p

d
if
fe
re
n
ce
s.
C
o
u
n
se
li
n
g
w
as

im
p
le
m
e
n
te
d
b
y
n
u
rs
e
s.

W
e
is
s
e
t
al
.

(2
0
1
1
)

6
5
3

1
.
B
u
p
re
n
o
rp
h
in
e
,
P
M
,
an

d
se
lf
–

h
e
lp

g
ro
u
p
s2
.
B
u
p
re
n
o
rp
h
in
e
,

P
M
,
se
lf
-h
e
lp

g
ro
u
p
s,
an

d
in
d
iv
id
u
al
co
u
n
se
li
n
g
O
p
io
id
u
se
(s
e
lf
–
re
p
o
rt
an
d
u
ri
n
e
);
tr
e
at
m
e
n
t
re
te
n
ti
o
n

A
d
d
in
g
in
d
iv
id
u
al

co
u
n
se
li
n
g
d
id

n
o
t
im

p
ro
v
e

o
u
tc
o
m
e
s.

T
h
e
re

w
e
re
n
o
si
g
n
if
ic
an
t
d
if
fe
re
n
ce
s
b
e
tw

e
e
n
g
ro
u
p
s
fo
r
o
p
io
id

u
se

o
u
tc
o
m
e
s.
Se
co

n
d
ar
y
an

al
y
si
s

(W
e
is
s
e
t
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Measures

The most common outcome measure for the included studies was opioid use,
which was typically measured by urine toxicology and self-report and was
measured in 12 of the 14 included articles. Treatment retention was measured
in all studies, but was only considered a primary outcome measure in about
half of the included articles.

Evidence Across Studies

None of the 14 articles reviewed showed evidence of adverse effects as a
result of psychosocial interventions. Across all studies reviewed, the inclusion
of psychosocial interventions was found to be at least as effective if not more
effective than comparison groups with either a lower dose of psychosocial
intervention or none at all.

Of the 13 studies that compared psychosocial interventions in conjunc-
tion with pharmacological treatment, only 2 resulted in statistically significant
differences between groups for outcomes related to opioid abuse. Barry et al.
(2015) found that either CBT or educational counseling in conjunction with
buprenorphine treatment was favorable to no psychosocial treatment, but did
not find significant differences between the two psychosocial interventions.
Stotts et al. (2012) did not find significant differences between groups for
opioid use; however, they did find that ACT led to a significantly higher
success rate for detoxification from methadone.

Other studies (Moore et al., 2016; Otto et al., 2014; Stein et al., 2015)
found evidence that psychosocial interventions might improve outcomes in
conjunction with pharmacological treatment, but they were unable to achieve
statistical significance due to low sample size and low statistical power. Gar-
land et al. (2014) found that MORE led to significant benefits over a support
group condition when assessed at posttreatment, but at 3-month follow-up
there were no longer any significant differences between the two conditions.

The results of this review contribute to conclusions similar to those made
in previous reviews of psychosocial interventions and opioid relapse preven-
tion (Amato et al., 2011; Dugosh et al., 2016; Veilleux et al., 2010). The
evidence across studies indicates that although for some opioid users (parti-
cularly those in pain management) psychosocial interventions can be bene-
ficial on their own (Garland et al., 2014), they are generally not additive to
pharmacological maintenance for opioid relapse prevention. However, psy-
chosocial interventions might be beneficial in helping those recovering from
opioid abuse achieve detoxification from pharmacological maintenance and
sustain long-term abstinence from opioid abuse. Additionally, psychosocial
interventions during pharmacological maintenance might benefit certain sub-
groups of participants, such as those with cooccurring polysubstance use
disorders (Weiss et al., 2014; Weiss et al., 2014).

Psychosocial Interventions and Opioid Addiction 13

Due to the high level of heterogeneity for types of psychosocial inter-
ventions implemented across the studies in this review, conclusions about a
specific intervention being most effective cannot be made. However, there is
growing evidence that interventions such as ACT, MORE, and MBRP that
incorporate mindfulness and are targeted for treatment of substance depen-
dence might be more effective than other protocols (Bowen et al., 2009;
Garland et al., 2014; Smallwood et al., 2016; Stotts et al., 2012).

Limitations

Small sample size, low statistical power, and not achieving statistical signifi-
cance were the most common limitations across articles included for this
review. Attrition rates across the studies ranged from about 25% to 50%,
which likely contributed to the limitation of low statistical power. It is likely
that effect size differences when comparing pharmacological treatment to
conjunctive psychosocial interventions are quite small, meaning that large
sample sizes are needed to achieve statistical significance.

Of those studies that compared psychosocial interventions in conjunction
with pharmacological treatment, the comparison group conditions often
included regular meetings with the prescribing physician for brief 15- to 20-
minute physician management (PM) or health education (HE) sessions. These
PM sessions were often similar in frequency to counseling, weekly or
biweekly, and as such might have reduced the power of between-group
comparisons. For methadone maintenance, it is particularly difficult to achieve
adequate effect sizes for between-group comparisons, because in the United
States counseling is a required component (SAMHSA, 2015a). Schwartz et al.
(2012) took advantage of an exception that allows for the use of methadone
maintenance while on a waiting list for counseling, which is limited to the first
120 days of methadone treatment. Their study comparing interim methadone
treatment with methadone plus weekly individual counseling used a relatively
large sample size (n = 230), and although both groups showed significant
reductions in opioid use, there were no significant between-group differences.

This review did not capture evidence about the use of psychosocial
interventions as replacements for maintenance treatments in opioid relapse
prevention, so conclusions could only be made about their use in conjunction
with pharmacological maintenance treatments. However, Mattick, Breen, Kim-
ber, and Davoli (2009) conducted a systematic review comparing methadone
maintenance to drug-free opioid relapse prevention and found methadone
maintenance to be more effective for treatment retention and opioid use.

A major limitation of this systematic review was failing to capture articles
that examined the effectiveness of psychosocial interventions after detoxifica-
tion from maintenance treatment. Additionally, this review only captured one
study (Stotts et al., 2012) that compared psychosocial interventions during

14 A. R. Brown

dose reduction from maintenance. That study found positive results, but one
study does not provide sufficient evidence for conclusions about whether
psychosocial interventions are beneficial during the dose-reduction stage of
relapse prevention. It is possible that psychosocial interventions are most
effective during dose-reduction and after pharmacological maintenance has
ended, but this review failed to capture enough evidence to form these
conclusions.

This review attempted to examine the use of psychosocial interventions
to treat specifically prescription opioid addiction during relapse prevention. In
attempting to only capture studies about prescription opioid addiction, many
relevant studies might have been excluded. For example, studies were
excluded because they sampled individuals who used illicit opioids such as
heroin or other illicit drugs. Excluding studies of illicit opioids might have
been unnecessary as differences in treatment outcomes for prescription and
illicit opioids are likely minimal.

Finally, this review was conducted solely by its author. Ideally a systema-
tic review should make use of multiple reviewers for search, distillation, and
extraction to minimize bias and avoid exclusion of eligible articles. Although
the author took great care in these processes, attempting to strictly adhere to
inclusion and exclusion criteria and consulting with a senior faculty member
throughout the process of conducting and writing this review, it is important to
acknowledge this limitation.

DISCUSSION

The primary goal of this systematic analysis was to determine what the most
recent evidence indicates about the effectiveness of psychosocial interven-
tions in the relapse prevention phase of treatment. Based on the articles
included in this systematic review, psychosocial interventions are not additive
to pharmacological treatments using methadone or buprenorphine during
induction or maintenance stages of relapse prevention. However, there is
some indication that psychosocial interventions might be more effective dur-
ing dose reduction and long-term relapse prevention stages (Stotts et al.,
2012).

Implications for Social Work Policy, Practice, and Research

Medication-assisted therapies for opioid addiction are severely underutilized
in the United States despite evidence that they are more effective than drug-
free treatments (Mitchell et al., 2016; Volkow et al., 2014). Existing policies that
limit availability of medication-assisted therapies for opioid addiction or
require participation in psychosocial interventions as a condition of

Psychosocial Interventions and Opioid Addiction 15

pharmacological treatment should be revised in accordance with current
evidence. Evidence does not indicate that conjunctive psychosocial interven-
tions during maintenance have any adverse effects. However, given the costs
associated with providing psychosocial treatments and their unproven efficacy
during maintenance, evidence does not support their use during maintenance.
Psychosocial interventions might be more beneficial and thus cost-effective at
other stages of relapse prevention. Policies that increase participation in
psychosocial services while in dose reduction or aftercare from medication-
assisted therapies for opioid addiction seem favorable, but further research is
needed to determine what types of psychosocial interventions and at which
stages of treatment are most effective.

Existing attitudes among social workers toward pharmacological mainte-
nance for opioid addiction treatment might contribute to its underutilization.
Although achieving complete abstinence is a valid goal for those receiving
treatment for opioid addiction, requiring or expecting complete cessation
early in treatment has been shown to reduce treatment retention and success
(Dobkin, Civita, Paraherakis, & Gill, 2002; Hartzler, Cotton, Calsyn, Guerra, &
Gignoux, 2010). Lushin and Anastas (2011) argued that given the evidence
supporting harm reduction strategies such as medication-assisted therapies for
treating opioid addiction, social workers should adopt a more pragmatic view of
substance abuse treatment by seeking to “develop and successfully use con-
textualized, client-centered approaches to addiction treatment instead of rely-
ing on obsolete positive worldview and the outdated disease model” (p. 99).

Prevention and education are important to prevent initial use and to
attenuate the development of dependence and addiction. Psychosocial inter-
vention research is needed, but so is research into preventative programs and
wrap-around services to reduce the problem of opioid addiction before it
even develops. Heroin abuse has generally been confined to urban areas in
the past. However, the growing opioid epidemic has especially affected rural
areas such as the Appalachian region (Cicero, Surratt, Inciardi, & Munoz, 2007;
Paulozzi & Xi, 2008; Rossen, Bastian, Warner, Khan, & Chong, 2016). New
efforts are needed to help educate and prevent opioid abuse in communities
that are struggling with opioid addiction now more than ever.

Although the articles included in this review compared several different
psychosocial interventions along with two major types of pharmacological
maintenance, there are likely many other psychosocial interventions that
could be compared for opioid relapse prevention. The interventions com-
pared among the articles in this review do represent the current state of
evidence-based interventions in substance abuse treatment, but is it possible
that interventions not included in this review are more effective for opioid
relapse prevention? More research is needed to determine if targeted psycho-
social interventions are effective across the different stages of opioid addiction
treatment.

16 A. R. Brown

CONCLUSION

Although psychosocial interventions that directly target opioid abuse during
maintenance are not supported by this review, those that target cooccurring
disorders to minimize risk for relapse are important. Existing evidence indi-
cates that when cooccurring psychiatric disorders are left untreated, risk of
relapse is significantly increased (Bradizza, Stasiewicz, & Paas, 2006; Brady &
Sinha, 2005; Flynn & Brown, 2008). Social workers should seek to provide
services and linkage for those clients with cooccurring disorders participating
in pharmacological maintenance.

Further research is needed to determine effectiveness of psychosocial
interventions in long-term relapse prevention. Medication-assisted therapies
have been shown to be effective at helping individuals replace prescription
and illicit opioids with agonists as a means to increase functioning and reduce
harm, but these treatments amount to management and eventually detoxifica-
tion from replacement therapies is needed. If psychosocial interventions can
help individuals detoxify from replacement therapies and achieve complete
abstinence with long-term relapse prevention, then they would be a way to
move from management to complete remission.

Opioid addiction treatment is not a one-size-fits-all endeavor. Evidence-
based interventions are needed for each phase of prevention and treatment
that consider the complex risk and protective factors associated with success
at each phase. Social workers are uniquely qualified to help those with opioid
addiction minimize risks for relapse and maximize protective factors. By
targeting each phase with contextualized interventions, social workers will
be able to reduce the number of people affected by opioid addiction.

ORCID

Aaron R. Brown http://orcid.org/0000-0002-9108-0338

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