Voucher-based reinforcement of opiate abstinence during methadone detoxification. Abstinence incentive effects in a short-term outpatient detoxification program. Effects of adding behavioral treatment to opioid detoxification with buprenorphine. Contingency management interventions: effects on treatment outcome during methadone detoxification. A randomized trial of one-day vs. three-day buprenorphine inpatient detoxification protocols for heroin dependence. Psychotherapy for opiate addicts. Does it help? Facilitating outpatient treatment entry following detoxification for injection drug use: a multisite test of three interventions.
Methadone detoxification is often used in the treatment of opiate dependence. This procedure, however, is frequently associated with continued opiate use, and high rates of attrition and relapse. In this study, a 90-day methadone detoxification was enhanced by adding voucher-based reinforcement of opiate abstinence before, during and after the dose tapering schedule. After 4 weeks of standard methadone maintenance (baseline), subjects were randomized to either the abstinence (n=26), or attendance reinforcement (n=22) condition. During the remaining 22 weeks of the study, the abstinence reinforcement group could receive vouchers with monetary value three times per week for providing opiate-negative urine specimens, while subjects in the attendance reinforcement group received vouchers of equal value for attending the clinic, regardless of urinalysis results. Methadone maintenance continued during weeks 5-10, dose tapering was implemented during weeks 11-23, and during weeks 24-26 the voucher schedule remained in effect but no medication was provided. Fifty percent of clients in both groups completed dose tapering, and 40% completed the vouchers-only phase. Subjects in the abstinence as compared with the attendance reinforcement group had lower rates of opiate use during the maintenance and detoxification phases, and longer periods of opiate abstinence during the detoxification phase. Cocaine use was also lower in the abstinence than the attendance reinforcement group during the maintenance and detoxification phases. In addition, abstinence as compared with attendance reinforcement subjects reported significantly fewer intravenous injections during the detoxification phase. Voucher-based reinforcement procedures could be useful for successfully transitioning patients into opiate antagonist therapy, or drug-free treatments. Despite being widely available, outpatient detoxification has limited efficacy as a stand-alone treatment. This study examined whether abstinence-contingent incentives would improve outcomes for patients entering outpatient opiate detoxification. Participants (N = 211) received a 100 US dollars voucher on the last day of detoxification either contingent on opiate and cocaine abstinence or noncontingently. Urine samples were collected at intake, on Wednesday, Friday (the last day of detoxification), and the following Monday. Among contingent-voucher participants, 31% were drug-free on Friday compared with 18% of noncontingent controls (Z = 2.4, p < .05). Few (12-13%) participants tested negative on Monday. Results support the ability of vouchers to produce modest improvements in abstinence initiation rates during brief detoxification but suggest that additional interventions are needed to sustain improvements.
                Copyright 2004 APA. This trial assessed whether behavioral treatment improves outcome during a 26-week outpatient opioid detoxification. Thirty-nine opioid-dependent adults were assigned randomly to a buprenorphine dose-taper combined with either behavioral or standard treatment. Behavioral treatment included (a) a voucher incentive program for providing opioid-free urine samples and engaging in verifiable therapeutic activities and (b) the community reinforcement approach, a multicomponent behavioral treatment. Standard treatment included lifestyle counseling. Fifty-three percent of the patients receiving behavioral treatment completed treatment, versus 20% receiving standard treatment. The percentage of patients achieving 4, 8, 12, and 16 weeks of continuous opioid abstinence were 68, 47, 26, and 11 for the behavioral group and 55, 15, 5, and 0 for the standard group, respectively. Behavioral treatment improved outcomes during outpatient detoxification. We examined the effectiveness of a contingency management program in preventing relapse to illicit opiate use and increasing treatment retention during outpatient methadone detoxification treatment. Twenty male opiate addicts were randomly assigned to an experimental or control group. Following a 3-week methadone stabilization period, men in both groups received identical gradual methadone dose reductions during Weeks 4 through 9 and were maintained on placebo during Weeks 10 through 13. Beginning in Week 4, control patients received $5.00 for providing a specimen twice weekly. Experimental patients received $10.00 and a take home methadone dose for each opiate-free urine specimen but forfeited the incentives and participated in more intensive clinic procedures when specimens were opiate positive. The contingency management procedure slowed the rate of relapse to illicit opiate use. Experimental patients provided significantly more opiate-free urines during the methadone dose reduction in Weeks 4 through 9 than control patients, although the difference between groups was no longer significant during placebo administration in Weeks 10 through 13. In addition, the contingency management program improved treatment retention and reduced symptom complaints during the detoxification. The usefulness and limitations of contingency management procedures for outpatient methadone detoxification are discussed. Detoxification from opioids remains an important first step in the treatment of many patients with opioid dependence. Several pharmacologic regimens have been used for opioid detoxification. In the United States, the partial mu-opioid agonist, buprenorphine (BUP) is the most recently approved pharmacotherapy for opioid detoxification and replacement. The literature in recent years has described detoxification protocols using a single high dose of BUP and a three-day BUP regimen. In many settings, such as drug-free programs, a single-dose detoxification protocol would be of significant benefit. There have been no prior studies comparing one-day and three-day BUP-assisted opioid withdrawal. In this pilot study, we conducted an open-label, randomized trial of one-day vs. three-day BUP/naloxone sublingual tablet-assisted opioid withdrawal. Twenty patients from a therapeutic community treatment program were randomly assigned to receive either 32 mg sublingual BUP over one hour (one-day group), or 32 mg sublingual BUP over three days (three-day group). Nine of 10 subjects (90 percent) in each group completed seven days in the detoxification protocol. There was no statistically significant difference between the two groups in all other outcome variables, including retention in the treatment program, intensity of withdrawal signs and symptoms, amounts of adjunct medications used, and ability to produce opiate-free urine. This study further validates the feasibility of the single high dose of BUP as a rapid detoxification method. Opiate addicts beginning a new treatment episode on a methadone maintenance program were offered random assignment to drug counseling alone or to counseling plus six months of either supportive-expressive psychotherapy or cognitive-behavioral psychotherapy. Sixty percent of patients meeting the study criteria expressed an interest and 60% of these actually became engaged. One hundred ten subjects completed the study intake procedure and kept three or more appointments within the first six weeks of the project. Measures including standardized psychological tests, independent observer ratings, and continuous records of licit and illicit drug use were done at baseline and seven-month follow-up. All three treatment groups showed significant improvement, but patients receiving the additional psychotherapies showed improvement in more areas and to a greater degree than those who received counseling alone, and with less use of medication. More than a third of opiate addicts in our treatment program thus both were interested in professional psychotherapy and apparently benefitted from it. Certain administrative procedures appear necessary to maximize the chances that psychotherapy can be used effectively with drug-addicted patients. A multisite, randomized trial within the National Drug Abuse Treatment Clinical Trials Network (CTN) was conducted to test 3 interventions to enhance treatment initiation following detoxification: (a) a single session, therapeutic alliance intervention (TA) added to usual treatment; (b) a 2-session, counseling and education, HIV/HCV risk reduction intervention (C&E), added to usual treatment; and (c) treatment as usual (TAU) only. Injection drug users (n=632) enrolled in residential detoxification at 8 community treatment programs were randomized to 1 of the 3 study conditions. TA participants reported entering outpatient treatment sooner and in greater numbers than TAU participants. Reported treatment entry for C&E fell between TA and TAU with no significant differences between C&E and the other conditions. There were no differences among the interventions in retention, as measured by weeks of outpatient treatment for all participants who reported treatment entry. Alliance building interventions appear to be effective in facilitating transfer from detoxification to outpatient treatment, but additional treatment engagement interventions may be necessary to improve retention.
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Psychosocial treatments offered in addition to pharmacological detoxification treatments are effective in terms of completion of treatment, use of opiate, participants abstinent at follow-up and clinical attendance. The evidence produced by this review is limited due to the small number of participants included in the studies, the heterogeneity of the assessment or the lack of detailed outcome information that prevented the possibility of cumulative analysis for several outcomes. Nevertheless it seems desirable to develop adjunct psychosocial approaches that might make detoxification more effective.