Methadone, therapy are key to heroin treatment

An NIH panel recommends easier access to methadone and behavioral therapy to treat heroin addiction.

By Beth Azar
Monitor staff

Heroin addiction is a chronic medical disorder and, just like people with diabetes and hypertension, addicts deserve easy access to treatment, according to a panel of impartial scientific and legal experts. That means the United States needs to increase the availability of methadone maintenance therapy to address the physiological addiction, as well as behavioral therapy to treat psychosocial aspects of the illness.

Addiction treatment researchers are applauding the findings of the panel, which presided over a consensus conference organized by the National Institutes of Health (NIH) to review the research and report on the most effective treatment of heroin addiction. But many behavioral researchers believe their work is just beginning. Increased access to methadone still leaves the challenge of getting addicts into treatment, keeping them there and preventing relapse.

Behavioral research is crucial to understanding these aspects of addiction treatment, says D. Dwayne Simpson, PhD, director of the Institute of Behavioral Research at Texas Christian University, who presented research on behavioral aspects of addiction therapy to the NIH panel. Also, some addicts either can?t or won?t use methadone?some want to go totally drugfree and some can?t tolerate methadone. For them, finding nonpharmacological treatments is imperative. Behavioral researchers are working on both fronts, finding the psychosocial keys to successful addiction treatment and testing purely cognitive-behavioral therapies.

Addiction as disease

The NIH panel of researchers and legal experts, whom NIH chose because they had no professional knowledge of heroin addiction or treatment, spent Nov. 17?19 listening to the latest research on heroin and other opiate addiction and writing their conclusions. Their final report recommends expanding access to methadone, an opiate agonist that works by binding up the same brain receptors that heroin normally binds to, but without the euphoric effect. The report also emphasized that complementary behavioral therapies are pivotal to successful methadone maintenance therapy.

?The scientific data strongly support that methadone, combined with psychosocial treatment?including counseling and vocational rehabilitation?significantly enhances positive clinical outcomes,? said Lewis Judd, MD, chairman of the consensus committee. But, he added, ?psycho-social treatment without methadone is not effective.?

Indeed, methadone is crucial to successful treatment of opiate addiction for most addicts, says psychologist John Grabowski, PhD, director of the Substance Abuse Research Center and professor of psychiatry and behavioral sciences at the University of Texas?Houston. The drug acts as an important precursor to cognitive-behavioral therapies by removing patients? physical craving for heroin and allowing clinicians to work on underlying behavioral and psychosocial problems, says Grabowski, who presented research on behavioral treatments to the NIH panel.

?Methadone allows the cognitive-behavioral therapies to work,? agrees Simpson.

But the consensus report didn?t emphasize enough the critical importance of cognitive-behavioral aspects of opiate addiction treatment, he says. Without such an emphasis, expanded methadone access may not significantly decrease the number of heroin addicts.

Predicting treatment success

Simpson and his colleagues have conducted some of the largest efficacy trials on heroin-addiction treatment as part of several National Institute on Drug Abuse-funded projects, including the Drug Abuse Treatment Outcome Study (DATOS), which collected data on more than 10,000 patients admitted to nearly 100 addiction treatment programs in 11 cities. And they have begun to tease apart the social and behavioral factors that predict whether a person succeeds in treatment.

One major predictor of treatment success in a methadone maintenance program is the length of treatment, says Simpson. In turn, retention in treatment depends on many different factors, including psychosocial adjustment, motivation and the relationship between the patient and the therapist.

Several cognitive-behavioral techniques can influence whether patients become engaged by a treatment program. For example, patients are more likely to participate in a program that rewards continued abstinence with vouchers for food, housing or clothes or even gold stars, Simpson and his colleagues find. A special issue of Psychology of Addictive Behaviors (Vol. 11, No. 4) summarizes the most recent findings from DATOS.

When more isn?t better

As Simpson?s and others? research shows, the longer people stay in treatment, the more likely they are to stay off drugs. However, it may not be the case that more treatment is better than less, according to a recent study by Grabowski and his colleagues.

In a randomized controlled study of 150 opiate-dependent patients, they found that treatment was more successful for heroin addicts who visited a treatment clinic two days a week than for those who visited the clinic five days a week. They randomly assigned patients to four groups that received 50 mg or 80 mg of methadone and attended a clinic two or five days a week.

?In this case, more is not necessarily better?at least for the behavioral aspect of the treatment,? says Grabowski.

Instead, patients who visited the clinic two days a week had a lower dropout rate and used less heroin than patients who had to visit the clinic five days a week. Even those who received 50 mg?a methadone dose generally regarded as inadequate?were less likely to drop out if they were assigned to twice-weekly visits as opposed to five-day-a-week visits. These findings are published in the January issue of the American Journal of Public Health (Vol. 88, No. 1, p. 34?39).

Although the NIH consensus panel concluded that no nondrug-based treatments have been proven to effectively treat heroin addiction, Johns Hopkins University psychologist Maxine Stitzer, PhD, hopes that in a few years she?ll have evidence that some alternatives do work. She has designed and begun to evaluate a purely cognitive-behavioral treatment program for opiate addicts who won?t take methadone or other addiction maintenance drugs.

She bases her program on several cognitive-behavioral treatments designed and proven effective for cocaine addiction, for which there is no pharmacological treatment. The treatments include:

? Relapse prevention, which teaches addicts skills that help them maintain a drug-free life.

? Contingent reinforcement, which gives addicts some type of reward if they stay drugfree.

? Community reinforcement, which enhances addicts? drug-free side of life.

In her program she has interwoven contingent reinforcement into community reinforcement, providing a menu of rewards such as paid housing in a recovery house; transportation to the treatment facility and lunch for that day; recreation programs that include billiards, bowling and movies. During treatment sessions, therapists provide relapse prevention training.

Pilot data look promising, says Stitzer, who is moving into a large-scale clinical trial to evaluate the program. As far as she knows she?s the only researcher investigating a purely behavioral treatment for heroin addiction.

Full text of the NIH consensus conference report is available on the Internet at http://odp.od.nih.gov/consensus/statements/cdc/108/108_stmt.html.