A randomized, controlled trial of the efficacy of an interoceptive exposure-based CBT for treatment-refractory outpatients with opioid dependence

Cognitive behavioral therapy for anxiety and opioid use disorder: Development and pilot testing

INTRODUCTION

Anxiety disorders are highly prevalent among people with opioid use disorder (OUD), and they have a negative impact on disorder course and treatment outcomes. The objective of this Stage 1 A/1B behavioral treatment development trial was to develop a novel cognitive-behavioral therapy (CBT) protocol for co-occurring anxiety disorders and OUD.

METHODS

Following a period of iterative manual development involving patient interviews and feedback from content experts, we tested a 12-session individual CBT protocol in a small, open pilot trial (N = 5). This was followed by a small, randomized controlled trial (N = 32), comparing the new protocol to 12 sessions of manualized Individual Drug Counseling. All participants also received medication for OUD.

RESULTS

Overall, support for feasibility and acceptability was strong, based on recruitment and retention rates and patient satisfaction ratings. Within-subjects results identified 11-point reductions in anxiety symptom severity (on a 0-56 point scale); these gains were sustained through 3 months of follow-up. However, these changes did not differ between randomized conditions. With respect to opioid outcomes, 85 % of participants were abstinent in the prior month at the end of treatment. Opioid use outcomes also did not differ by treatment condition.

CONCLUSIONS

These results support the feasibility and acceptability of a CBT protocol for co-occurring anxiety and OUD. However, in this small pilot trial results do not show an initial benefit over an evidence-based psychosocial treatment targeted to OUD alone, in combination with medication for OUD.

The Effectiveness of Cognitive Behavioral Therapy Techniques for the Treatment of Substance Use Disorders: A Narrative Review of Evidence

ABSTRACT

Substance use disorders (SUDs) are characterized by a recurrent and maladaptive use of drugs and/or alcohol. Cognitive behavioral therapies (CBTs) comprise different types of interventions: traditional CBT and the more recent "third wave" behavior therapies, such as acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), mindfulness-based cognitive therapy (MBCT), and schema therapy (ST). We searched English-language articles published between 2014 and present. This review includes randomized controlled trials (RCTs), quasi-RCTs, pilot studies, and reviews of CBTs for SUDs available on PubMed. Results seem to indicate that CBT and MBCT are effective interventions for SUDs; however, the studies showed a high degree of heterogeneity, so no exhaustive conclusions could be outlined at this time. ACT and DBT in SUD management are limited to few studies and results are therefore inconclusive.

Does anxiety sensitivity predict addiction severity in opioid use disorder?

Increased anxiety sensitivity (AS), or the fear of anxiety-related cognitive, social, and physical symptoms which are misinterpreted as having harmful implications, has shown a relationship with substance use disorders. People with substance use disorders also experience addiction-related problems across domains of life functioning. However, few studies have evaluated the relationship between elevated AS and addiction-related problems across specific life areas. We evaluated, first, whether AS predicted addiction-related problems in a sample of treatment-refractory outpatients with opioid use disorders and, second, whether sex moderated the relationship between AS and addiction-related problems in this sample. Participants with treatment-refractory opioid use disorders (n = 92, 53.3% male) completed baseline assessments of AS (the Anxiety Sensitivity Index) and addiction-related problems (the Addiction Severity Index). Baseline AS total score was a significant independent predictor of both baseline Addiction Severity Index medical status (β = 0.29, t = 2.84, p = .006) and psychiatric status (β = 0.30, t = 2.99, p = .004) composite scores but was not associated with social, employment or legal difficulties. These findings were maintained when controlling for drug use severity, though baseline AS total score became a significant predictor of baseline legal difficulties (β = -0.23, t = -2.25, p = .027). There was no moderating role of sex on the relationship between baseline AS and addiction-related problems. Our findings suggest that, regardless of sex, elevated AS predicts increased addiction-related medical and psychiatric problems, and decreased legal problems when accounting for drug use severity, in outpatients with opioid use disorders.

Evaluating comparative effectiveness of psychosocial interventions adjunctive to opioid agonist therapy for opioid use disorder: A systematic review with network meta-analyses

BACKGROUND

Guidelines recommend that individuals with opioid use disorder (OUD) receive pharmacological and psychosocial interventions; however, the most appropriate psychosocial intervention is not known. In collaboration with people with lived experience, clinicians, and policy makers, we sought to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy (OAT) among persons with OUD.

METHODS

A review protocol was registered a priori (CRD42018090761), and a comprehensive search for randomized controlled trials (RCT) was conducted from database inception to June 2020 in MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Established methods for study selection and data extraction were used. Primary outcomes were treatment retention and opioid use (measured by urinalysis for opioid use and opioid abstinence outcomes). Odds ratios were estimated using network meta-analyses (NMA) as appropriate based on available evidence, and in remaining cases alternative approaches to synthesis were used.

RESULTS

Seventy-two RCTs met the inclusion criteria. Risk of bias evaluations commonly identified study limitations and poor reporting with regard to methods used for allocation concealment and selective outcome reporting. Due to inconsistency in reporting of outcome measures, only 48 RCTs (20 unique interventions, 5,404 participants) were included for NMA of treatment retention, where statistically significant differences were found when psychosocial interventions were used as an adjunct to OAT as compared to OAT-only. The addition of rewards-based interventions such as contingency management (alone or with community reinforcement approach) to OAT was superior to OAT-only. Few statistically significant differences between psychosocial interventions were identified among any other pairwise comparisons. Heterogeneity in reporting formats precluded an NMA for opioid use. A structured synthesis was undertaken for the remaining outcomes which included opioid use (n = 18 studies) and opioid abstinence (n = 35 studies), where the majority of studies found no significant difference between OAT plus psychosocial interventions as compared to OAT-only.

CONCLUSIONS

This systematic review offers a comprehensive synthesis of the available evidence and the limitations of current trials of psychosocial interventions applied as an adjunct to OAT for OUD. Clinicians and health services may wish to consider integrating contingency management in addition to OAT for OUD in their settings to improve treatment retention. Aside from treatment retention, few differences were consistently found between psychosocial interventions adjunctive to OAT and OAT-only. There is a need for high-quality RCTs to establish more definitive conclusions.

TRIAL REGISTRATION

PROSPERO registration CRD42018090761.

Combined Pharmacotherapy and Cognitive Behavioral Therapy for Adults With Alcohol or Substance Use Disorders: A Systematic Review and Meta-analysis

IMPORTANCE

Substance use disorders (SUDs) represent a pressing public health concern. Combined behavioral and pharmacological interventions are considered best practices for addiction. Cognitive behavioral therapy (CBT) is a first-line intervention, yet the superiority of CBT compared with other behavioral treatments when combined with pharmacotherapy remains unclear. An understanding of the effects of combined CBT and pharmacotherapy will inform best-practice guidelines for treatment of SUD.

OBJECTIVE

To conduct a meta-analysis of the published literature on combined CBT and pharmacotherapy for adult alcohol use disorder (AUD) or other SUDs.

DATA SOURCES

PubMed, Cochrane Register, MEDLINE, PsychINFO, and Embase databases from January 1, 1990, through July 31, 2019, were searched. Keywords were specified in 3 categories: treatment type, outcome type, and study design. Collected data were analyzed through September 30, 2019.

STUDY SELECTION

Two independent raters reviewed abstracts and full-text articles. English language articles describing randomized clinical trials examining CBT in combination with pharmacotherapy for AUD and SUD were included.

DATA EXTRACTION AND SYNTHESIS

Inverse-variance weighted, random-effects estimates of effect size were pooled into 3 clinically informative subgroups: (1) CBT plus pharmacotherapy compared with usual care plus pharmacotherapy, (2) CBT plus pharmacotherapy compared with another specific therapy plus pharmacotherapy, and (3) CBT added to usual care and pharmacotherapy compared with usual care and pharmacotherapy alone. Sensitivity analyses included assessment of study quality, pooled effect size heterogeneity, publication bias, and primary substance moderator effects.

MAIN OUTCOMES AND MEASURES

Substance use frequency and quantity outcomes after treatment and during follow-up were examined.

RESULTS

The sample included 62 effect sizes from 30 unique randomized clinical trials that examined CBT in combination with some form of pharmacotherapy for AUD and SUD. The primary substances targeted in the clinical trial sample were alcohol (15 [50%]), followed by cocaine (7 [23%]) and opioids (6 [20%]). The mean (SD) age of the patient sample was 39 (6) years, with a mean (SD) of 28% (12%) female participants per study. The following pharmacotherapies were used: naltrexone hydrochloride and/or acamprosate calcium (26 of 62 effect sizes [42%]), methadone hydrochloride or combined buprenorphine hydrochloride and naltrexone (11 of 62 [18%]), disulfiram (5 of 62 [8%]), and another pharmacotherapy or mixture of pharmacotherapies (20 of 62 [32%]). Random-effects pooled estimates showed a benefit associated with combined CBT and pharmacotherapy over usual care (g range, 0.18-0.28; k = 9). However, CBT did not perform better than another specific therapy, and evidence for the addition of CBT as an add-on to combined usual care and pharmacotherapy was mixed. Moderator analysis showed variability in effect direction and magnitude by primary drug target.

CONCLUSIONS AND RELEVANCE

The present study supports the efficacy of combined CBT and pharmacotherapy compared with usual care and pharmacotherapy. Cognitive behavioral therapy did not perform better than another evidence-based modality (eg, motivational enhancement therapy, contingency management) in this context or as an add-on to combined usual care and pharmacotherapy. These findings suggest that best practices in addiction treatment should include pharmacotherapy plus CBT or another evidence-based therapy, rather than usual clinical management or nonspecific counseling services.

A pilot feasibility randomised controlled trial of an adjunct brief social network intervention in opiate substitution treatment services

BACKGROUND

Approximately 3% of people receiving opioid substitution therapy (OST) in the UK manage to achieve abstinence from prescribed and illicit drugs within three years of commencing treatment. Involvement of families and wider social networks in supporting psychological treatment may be an effective strategy in facilitating recovery, and this pilot study aimed to evaluate the impact of a social network-focused intervention for patients receiving OST.

METHODS

A two-site, open feasibility trial randomised patients receiving OST for at least 12 months but still reporting illicit opiate use in the past 28 days to one of three treatments: 1) treatment as usual (TAU), 2) Brief Social Behaviour and Network Therapy (B-SBNT) + TAU, or 3) Personal Goal Setting (PGS) + TAU. The two active interventions consisted of 4 sessions. There were 3 aims: 1) test the feasibility of recruiting OST patients to a trial of B-SBNT, and following them up over 12 months; 2) test the feasibility of training clinicians to deliver B-SBNT; 3) test whether B-SBNT reduces heroin use 3 and 12 months after treatment, and to explore potential mediating factors. The primary outcome for aim 3 was number of days of heroin use in the past month, and a range of secondary outcome measures were specified in advance (level of drug dependence, mental health, social satisfaction, therapist rapport, treatment satisfaction, social network size and support).

RESULTS

A total of 83 participants were randomised, and 70 (84%) were followed-up at 12 months. Fidelity analysis of showed that B-SBNT sessions were clearly distinguishable from PGS and TAU sessions, suggesting it was possible to train clinical staff to an adequate level of competence. No significant differences were found between the 3 intervention arms in the primary or secondary outcome measures. Attendance at psychosocial treatment intervention sessions was low across all three arms (44% overall).

CONCLUSIONS

Patients receiving OST can be recruited into a trial of a social network-based intervention, but poor attendance at treatment sessions makes it uncertain whether an adequate dose of treatment was delivered. In order to achieve the benefits of psychosocial interventions, further work is needed to overcome poor engagement.

TRIAL REGISTRATION

ISRCTN Trial Registration Number: ISRCTN22608399 . Date of registration: 27/04/2012. Date of first randomisation: 14/08/2012.

Interoception in Psychiatric Disorders: A Review of Randomized, Controlled Trials with Interoception-Based Interventions

Interoception, or the process of sensing, interpreting, and integrating internal bodily signals, has increasingly been the subject of scientific research over the past decade but is still not well known in clinical practice. The aim of this article is to review clinical treatment interventions that use interoception, to synthesize the current research knowledge, and to identify the gaps where future research is needed. We conducted a comprehensive literature search on randomized, controlled trials that both include interoception in treatment interventions for individuals with psychiatric disorders and measure aspects of interoception using self-report measures. Out of 14 randomized, controlled trials identified, 7 found that interventions with interoception were effective in ameliorating symptoms. These studies included individuals with anxiety disorders, eating disorders, psychosomatic disorders, and addictive disorders. All of the intervention studies with positive clinical outcomes also demonstrated changes on interoceptive measures; however, these measures were often related to specific illness symptoms. Interoception may be a mechanism of action in improving clinical symptomatology, though studies incorporating general, symptom-independent interoceptive measures remain scarce. To further our understanding of the role interoception has in psychiatric disorders and their treatment, more studies integrating interoceptive measures are needed, along with a clearer definition of interoceptive terms used.

Randomized Pilot of an Anxiety Sensitivity-Based Intervention for Individuals in a Substance Use Day Program

Anxiety sensitivity (AS), or the tendency to appraise physical symptoms as intolerable or dangerous, may maintain the cycle between co-occurring anxiety and substance use disorders. This study examined preliminary efficacy of a brief intervention targeting AS for individuals with heterogeneous substance use disorders. Forty-one patients with high AS entering an addictions day program were randomized to treatment as usual (TAU) or to TAU plus a nine-hour AS-focused intervention that consisted of interoceptive exposures, psychoeducation about the cycle of problematic substance use and anxiety, and a single session of cognitive challenging (e.g., reviewing common cognitive distortions and decatastrophizing anxiety symptoms). Mixed-effects intent-to-treat models suggested that participants in the AS condition showed greater decreases in AS at post-treatment, but this effect was lost at follow-up three months later. Intervention conditions did not differ in change in percent days abstinent or self-reported anxiety, with both conditions showing significant improvement at post-treatment. Results suggest that the nine-hour AS-focused intervention led to a short-term benefit over TAU alone, but this benefit was not sustained at three months' follow-up. Future AS interventions may need to target specific subconstructs of AS for selected populations, or target emotional distress tolerance more broadly.

Anxiety sensitivity and working memory capacity: Risk factors and targets for health behavior promotion

Understanding the nature and influence of specific risk profiles is increasingly important for health behavior promotion. The purpose of this article is to document the value of two factors-anxiety sensitivity (AS) and working memory capacity (WMC)-for enhancing risk for the initiation and/or maintenance of a range of negative health behaviors. AS is a distress-related risk factor that potentiates avoidance/coping motivations for negative health behaviors. Stress provides the conditions for negative somatic and affective states, and AS amplifies the aversiveness of these experiences and correspondingly hinders adaptive functioning. In contrast, low WMC is hypothesized to exert its effect by decreasing the capacity to filter out current temptations, attenuating a focus on longer-term goals and impairing the application of relevant coping skills at times of stress. In this review, we provide conceptual models for the separate roles of high AS and low WMC in negative health behaviors, review the influence of these factors on specific health behavior exemplars (eating behaviors/obesity, physical activity, smoking, alcohol use, and sleep promotion), provide preliminary evidence for their value as independent treatment targets for health-behavior promotion, and encourage specific research directions in relation to these variables.