New trends in opiate pharmacotherapy

English and American Drug Clients' Views of the Acceptability, Advantages, and Disadvantages of Treatment and Harm Reduction Interventions

Although drug abusers present to clinics and drop-in centers requesting various treatments and harm reduction interventions, clinicians and administrators have little direct empirical evidence of the degree to which clients find various therapies acceptable or the perceived advantages and disadvantages of specific interventions. A structured interview was administered to 48 male and female outpatient or detoxification ward clients in Nottingham, England, and 40 female residential treatment program clients in Northwest Ohio, to assess the acceptability of and related attitudes regarding a broad range of interventions. Large proportions of respondents in both samples, and especially in the English sample, reported somewhat or complete acceptance of various abstinence-oriented treatments and harm reduction interventions for those still taking drugs. Respondents also discriminated among these interventions, as evidenced by differing levels of acceptance of many and outright rejection of other interventions. Although there were differences in acceptance and experience of the specific interventions between the two samples, respondents in both countries provided balanced appraisals of the advantages and disadvantages of each intervention.

Counselor training and attitudes toward pharmacotherapies for opioid use disorder

BACKGROUND

Methadone and buprenorphine have been demonstrated to be effective in the treatment of opioid use disorder (OUD), especially when combined with psychosocial treatment. Despite buprenorphine's association with fewer withdrawal symptoms and lessened risk of abuse, compared with methadone, its adoption remains limited. Given the vital role that counselors may play in its successful implementation, their knowledge and perceptions of opioid agonist therapy may be facilitators or barriers to its acceptance.

METHODS

Informed by diffusion theory, the current study examined perceptions of buprenorphine's and methadone's acceptability among 725 counselors employed in a nationally representative sample of substance use disorder treatment centers. First, we provided descriptive statistics about medication diffusion, extent of training received about the medications, and perceptions of acceptability of each medication. Then, we compared acceptability of opioid agonists with other treatment approaches for OUD. Finally, we conducted 2 ordinary least squares regressions to examine counselor acceptability of buprenorphine and of methadone.

RESULTS

Descriptive statistics suggested that diffusion of information about buprenorphine and methadone was not complete, and training was not extensive for either medication. Counselors reported greater acceptability and training of buprenorphine compared with methadone. Methadone was rated as the least acceptable among all other treatment approaches. Multivariate analyses indicated regional differences, and that medication-specific training, adaptability, and educational attainment were positively related with perceptions of acceptability of either medication, even after controlling for organizational characteristics. Adherence to a 12-step orientation was negatively associated with acceptability.

CONCLUSIONS

Dissemination of information about opioid agonist therapy is occurring. Nevertheless, the fact that 20% of counselors admitted not knowing enough about either buprenorphine's or methadone's effectiveness is surprising in light of the extensive literature documenting their effectiveness. Future research should focus upon different types of training that can inform physicians, counselors, and patients about the use of opioid agonist therapy.

Impact of research network participation on the adoption of buprenorphine for substance abuse treatment

There is a growing body of research supporting the use of buprenorphine and other medication assisted treatments (MATs) for the rapidly accelerating opioid epidemic in the United States. Despite numerous advantages of buprenorphine (accessible in primary care, no daily dosing required, minimal stigma), implementation has been slow. As the field progresses, there is a need to understand the impact of participation in practitioner-scientist research networks on acceptance and uptake of buprenorphine. This paper examines the impact of research network participation on counselor attitudes toward buprenorphine addressing both counselor-level characteristics and program-level variables using hierarchical linear modeling (HLM) to account for nesting of counselors within treatment programs. Using data from the National Treatment Center Study, this project compares privately funded treatment programs (N=345) versus programs affiliated with the National Institute on Drug Abuse Clinical Trials Network (CTN) (N=198). Models included 922 counselors in 172 CTN programs and 1203 counselors in 251 private programs. Results of two-level HLM logistic (Bernoulli) models revealed that counselors with higher levels of education, larger caseloads, more buprenorphine-specific training, and less preference for 12-step treatment models were more likely to perceive buprenorphine as acceptable and effective. Furthermore, buprenorphine was 50% more likely to be perceived as effective among counselors working in CTN-affiliated programs as compared to private programs. This study suggests that research network affiliation positively impacts counselors' acceptance and perceptions of buprenorphine. Thus, research network participation can be utilized as a means to promote positive attitudes toward the implementation of innovations including medication assisted treatment.

Determinants of buprenorphine treatment for opioid dependence

This study assessed the social, demographic and clinical determinants of whether an opioid-dependent patient received buprenorphine versus an alternative therapy. A retrospective cohort analysis of opioid-dependent adults enrolled in Group Health Cooperative between January 1, 2006 and December 1, 2010 was performed. Increasing the number of physicians with DATA waivers in a region and living in a relatively-populated area increased the likelihood of being treated with buprenorphine, indicating that lack of access is a potential barrier. Comorbidity also appeared to be a factor in receipt of treatment, with the effect varying by diagnosis. Finally, patients with an insurance plan allowing health services to be sought from any provider, with increased cost sharing, were significantly more likely to receive buprenorphine, implying that patient demand is a factor. Programs integrating patient education, physician training, and support from addiction specialists would be likely facilitators of increasing access to this cost-effective treatment.

A multi-level analysis of counselor attitudes toward the use of buprenorphine in substance abuse treatment

Despite evidence that buprenorphine is effective and safe and offers greater access as compared with methadone, implementation for treatment of opiate dependence continues to be weak. Research indicates that legal and regulatory factors, state policies, and organizational and provider variables affect adoption of buprenorphine. This study uses hierarchical linear modeling to examine National Treatment Center Study data to identify counselor characteristics (attitudes, training, and beliefs) and organizational factors (accreditation, caseload, access to buprenorphine, and other evidence-based practices) that influence implementation of buprenorphine for treatment of opiate dependence. Analyses showed that provider training about buprenorphine, higher prevalence of opiate-dependent clients, and less treatment program emphasis on a 12-step model predicted greater counselor acceptance and perceived effectiveness of buprenorphine. Results also indicate that program use of buprenorphine for any treatment purpose (detoxification, maintenance, and/or pain management) and time (calendar year in data collection) was associated with increased diffusion of knowledge about buprenorphine among counselors and with more favorable counselor attitudes toward buprenorphine.

Consumer and treatment provider perspectives on reducing barriers to opioid substitution treatment and improving treatment attractiveness

In New Zealand approximately 4600 people receive opioid substitution treatment (OST) for opioid dependence, primarily methadone maintenance treatment. This study explored ways in which OST could be improved, given the significant waiting times for treatment. Two parallel surveys were conducted: 1) peer interviews with 85 regular daily or almost daily opioid drug users (51.8% receiving OST, 18.8% not currently receiving OST, and 29.4% never received OST) and; 2) a census of all 18 specialist OST service providers. When asked how OST might be improved, the four categories most commonly cited by the opioid users were 'better treatment by staff', 'more flexibility', 'better takeaway arrangements', and 'decreased waiting time'. Both opioid users and specialist services rated 'restricted takeaways' and 'having to go on a waiting list' in the top three perceived barriers to OST. Almost all services reported significant resource issues and barriers to the transfer of stable clients from specialist services to continuing treatment in primary care. The findings from this study indicate how OST can be made more accessible and attractive and thus achieve better uptake and retention.

From opioid maintenance to abstinence: a literature review

It appears that the literature on agonist maintenance therapies for opioid dependence pays more attention to outcomes during, rather than after, treatment. This review aims to (a) estimate to what extent opioid abstinence can be expected from former maintenance patients, (b) examine possible relationships between patient and treatment characteristics and abstinence rates and (c) assess the need for research in the field of abstinence-orientated maintenance treatment in general, and time-limited buprenorphine maintenance treatment in particular. Database searches supplemented by cross-references resulted in 12 studies included in the review. The studies were mostly naturalistic follow-up studies of former methadone maintenance patients, authored by US researchers in the 1970s. Buprenorphine was used in only one of the studies, and then as a transition between methadone and abstinence. There were considerable variations in definition and assessment of abstinence. Pooled abstinence rates ranged from 22% to 86%. The single factor associated most frequently with abstinence was voluntary participation in detoxification programmes with eligibility criteria ('therapeutic detoxification'). When 'therapeutic detoxification' was compared to 'non-therapeutic detoxification' the pooled abstinence rates were 48% and 22%, respectively. Abstinence-orientated maintenance therapy may be suitable for a subgroup of patients, but there is a substantial need for research updates.

Dancing with strangers: will U.S. substance abuse practice and research organizations build mutually productive relationships?

The scientific knowledge gained from research has not been extensively integrated into the U.S. substance abuse treatment system. A clear call to arms has been issued by the U.S. federal treatment and research agencies to bring research and practice together to create a better treatment system and a more responsive research agenda. The current federally sponsored initiatives to "close the gap" between research and practice are large and well funded. The field appears ready to change and realize the mutual benefits that can be achieved from the increased "bleeding" of research and practice. However, while the music has started and the partners seem willing, there are still many obstacles to a successful dance.

Buprenorphine: blending practice and research

Although pharmacotherapy has been a mainstay in opiate addiction, not much research in the development of new opiate medications has been translated into clinical practice. In part, this is because opiate pharmacotherapy has not been an integral element of mainstream medical practice and because new medications developed by research are not available to clinicians. All that will change with the availability of buprenorphine for addiction treatment. For the first time in nearly a century, clinicians will be able to treat opiate addicts in the general medical setting, in the same manner they treat other patients. The unique pharmacological properties of buprenorphine, with its high patient acceptance, favorable safety profile, and ease of clinical administration, should facilitate its clinical integration. However, successful implementation will require changes in the understanding and attitude of clinicians, policymakers, and society.