Psychotherapy with Opioid-Dependent Patients
Psychotherapy with Opioid-Dependent Patients
Psychotherapy as a sole treatment for noncoerced opioid addicts in outpatient settings has been shown to have little patient interest and low chances for success. However, when integrated into a treatment plan that includes methadone maintenance and drug counseling, it can be associated with additional benefits for patients who have moderate to severe levels of psychiatric symptoms.
The psychotherapy outcome often depends on who administers the therapy, thus making it difficult to separate therapy from therapist effects. The chances for improvement of psychiatric symptoms in opioid addicts during methadone maintenance are often better, however, if psychiatrically trained therapists are used to supplement paraprofessional drug counseling.
Efforts to control medical costs by restricting accessibility to methadone maintenance and reducing the availability of psychotherapy, drug counseling and medical services are inconsistent with the available data on treatment quality.
Prior to the advent of methadone maintenance in the mid-1960s, effective treatment for heroin addiction was limited to a small number of programs such as the public health hospitals in Lexington and Fort Worth, where patients were confined-often under coercion from the criminal justice system. Voluntary outpatient treatment was ineffective, as demonstrated by Marie Nyswander, M.D., who attempted psychotherapy with heroin addicts and saw little interest and high dropout rates (1958).
Methadone maintenance changed this situation. When administered according to principles outlined by Vincent Dole, M.D., and Nyswander (1965), methadone engaged heroin addicts in outpatient treatment; reduced drug craving, drug use and crime; and improved overall social adjustment. These results were obtained under strict experimental protocols with highly trained staff; patients were selected on the basis of chronic heroin addiction with few serious medical and psychiatric problems.
Methadone's success led to a rapid expansion in the number of programs available and, as it moved into the clinical realm, patients with serious medical and psychiatric disorders entered treatment. These new methadone programs were staffed by less experienced individuals, often one or more part-time physicians, a few nurses and social workers and drug counselors. Most of the psychosocial therapy was done by drug counselors who had little formal psychiatric or medical training. Treatment results were not always as good as reported in the early studies by Dole and Nyswander, and this observation resulted in efforts to improve outcome.
One idea that emerged from a series of meetings sponsored by the National Institute on Drug Abuse (NIDA) in the late 1970s was based on the observation that many methadone patients had psychiatric disorders and that these disorders seemed to intensify the course of the addiction. Though treatment for these disorders was usually effective in other populations, the staffing patterns of most methadone programs did not include people with psychiatric training; thus these additional psychiatric problems often were not treated. A criticism of these typical staffing patterns was that treatment of some of the most disturbed people in the public health system had been delegated to persons with the least psychiatric training.
Since combining psychotherapy with pharmacotherapy was usually helpful among nonaddicts, the question emerged: Would psychotherapy improve outcome if it were added to methadone maintenance and drug counseling? NIDA funded two studies in the late 1970s to address this question; these were followed by two related studies in the early 1990s.
The First Two Studies
Design: One study was done at Yale University and the other at the University of Pennsylvania/Veteran's Administration Medical Center (Penn/VA). Each involved random assignment of methadone-maintained heroin addicts to paraprofessional drug counseling alone (DC), or counseling plus psychotherapy.
Interpersonal psychotherapy (IPT) was used at Yale, and Supportive-Expressive (SE) or Cognitive-Behavioral (CB) therapy was used at Penn/VA. Counselors held a bachelor's degree or less. Psychotherapists were psychiatrists or clinical psychologists. Psychotherapy was made available to subjects for six months with follow-ups at 7 and 12 months.
Outcome was evaluated by the Addiction Severity Index (ASI), measures of psychiatric symptoms and urine test results. Efforts were made to oversample patients who had psychiatric disorders, such as depression, since they might benefit the most from psychotherapy. Methadone maintenance was continued throughout the study and afterwards; the average dose was 40 mg to 50 mg in each program.
Results: Each study found that most patients had a current or past psychiatric disorder in addition to the heroin addiction, and that all groups improved; however, the psychotherapy results differed. The Yale study found no difference in outcome between counseling and psychotherapy (Rounsaville et al., 1983), while the Penn/VA study found that psychotherapy patients did better (Woody et al., 1983).
The differences in outcome at Penn/VA were mainly among patients with high levels of psychiatric symptoms; psychotherapy was not associated with additional benefits in patients with low levels of psychiatric symptoms (Woody et al., 1984). In the Penn/VA study, patients with antisocial personality disorder (ASPD) and a current or past depressive illness who received psychotherapy improved in several areas as measured by the ASI, including drug use (Woody et al., 1985). Patients with ASPD and no additional psychiatric disorder also improved, but only in drug use. The better outcome associated with psychotherapy was sustained at the 12-month follow-up, six months after psychotherapy ended (Woody et al., 1987).
There were also significant differences in outcome between psychotherapists. One SE therapist was particularly effective; another produced less change than the drug counselors (Luborsky et al., 1985). These differences in outcome were most strongly associated with the patient's evaluation of the "helping relationship," but were also related to the degree to which the psychotherapist was able to comply with the techniques of the manual-guided psychotherapies. Overall, there were no clear advantages for SE as compared to CB.
In trying to understand the differences in results from Penn/VA and Yale, two factors emerged. First, psychotherapy was better accepted by patients at the Penn/VA program because more patients were interested and fewer dropped out. Penn therapists were more integrated into the daily operations of the methadone clinic than at Yale. Their offices were located in the methadone program and they had regular interactions with clinic staff; at Yale, the therapists' offices were in a nearby neighborhood but not in the program. These differences seem small, but they can have a significant impact on compliance and outcome (Umbricht-Schneiter et al., 1994).
The second factor is that the Yale program was run under a powerful contingency-patients were required to attend group therapy and produce "clean" urines within three months of beginning treatment; those who failed were discharged, according to H.D. Kleber (1998). This administrative procedure resulted in little room for finding differences between psychotherapy and counseling due to the combined effect of the contingency in changing behavior and discharge for nonresponsive patients.