A review of opioid dependence treatment: Pharmacological and psychosocial interventions to treat opioid addiction

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Abstract

Opioid dependence is a problem of national concern, especially with dramatically increased rates of abuse and dependence of prescription opioids. The current article provides an up-to-date review of the literature on opioid dependence treatment, with a focus on conclusions drawn by experts in the field (e.g., Cochrane reviews and meta-analyses) and methodologically rigorous studies (e.g., randomized controlled trials). We describe the major classes of drug treatments available, including opioid agonist (e.g., methadone, buprenorphine, LAAM), antagonist (e.g., naltrexone) and non-opioid pharmacotherapies (e.g., alpha2 adrenergic agonists). These treatments are discussed in the context of detoxification and long term treatment options such as abstinence-based and maintenance strategies. We review the state of the literature as to prevention of opioid overdose and discuss the widespread problem of comorbidity among opioid-dependent populations. We also focus prominently on evidence for inclusion of psychosocial approaches in treatment regimens, either as stand-alone or in conjunction with psychopharmacological options.

Introduction

Morphine, a drug derived from the natural juice of the opium poppy, is considered to be the most potent analgesic painkiller available, in addition, the drug is known to induce relaxation and euphoria. Given these properties, all opioids, including morphine, heroin, and prescription analgesics, such as Vicodin and OxyContin, have extremely high abuse potential. Dependence on these drugs is associated with a multitude of health and social problems, such as increased risk for HIV, mortality, crime, unemployment, legal issues, and interpersonal breakdowns (Haug, Sorensen, Gruber, & Song, 2005). For these reasons, opioid addiction, has been termed a “chronic, relapsing disease,” (Leshner, 1998a) and presents a substantial public health concern.

Although typically the territory of psychiatry or substance-specific intervention centers, it is important that researchers and practicing psychologists understand and appreciate the mechanisms of opioid addiction and are knowledgeable about available treatment options. As rates of prescription opioid use continue to climb (McCabe, Cranford, & West, 2008), clinicians are considerably more likely to encounter opioid abusers in their practice. Fortunately, research on treatment of opioid abuse and dependence is plentiful, perhaps to the point of being overwhelming; a brief search of PsychInfo using the terms ‘opioid’ or ‘heroin’ combined with ‘treatment’ yields over 18,000 articles in peer-reviewed journals. The majority of this research has focused on the development and effectiveness of pharmacological treatments (e.g., methadone), with a comparative dearth of studies on psychosocial treatment regimens or components. Considering the half-life of scientific knowledge and rapid advances in treatments for opioid dependence, the current review aims to synthesize to the current status of opioid dependence treatment.

Section snippets

Epidemiology

Worldwide, the annual prevalence of opioid use among persons aged 15–64 has remained relatively stable at 0.4% for the past decade (United Nations Office on Drugs & Crime, 2008). However, lifetime prevalence rates indicate that 1.7% of people aged 19–30 have tried heroin, and a staggering 18.7% have used other opioids, with Vicodin and OxyContin the two most popular opioid prescription drugs (Johnston, O'Malley, Bachman, & Schulenberg, 2008b). Indeed, non-medical prescription opioid use is on

Pharmacological treatment options

As mentioned previously, treatment of opioid dependence typically includes a pharmacological option. After reviewing the neural mechanism of opioids, we will discuss the three major classes of pharmacological treatments for opioid dependence: opioid agonists, opioid antagonists, and drugs that do not work directly on the opioid receptors.

Efficacy of treatment strategies

Our goals for presenting efficacy research below are two-fold. First, we wish to provide an up-to-date review of efficacious opioid treatment across all treatment strategies. We first turned to the Cochrane reviews (Cochrane Collection, 2009) on treatment for opioid dependence, as these systematic reviews provide a rigorous examination of well-designed studies (e.g., randomized controlled trials, controlled prospective studies) using meta-analytic techniques whenever possible. Although there

Crisis management

Fatal overdoses are one of the most common causes of death for heroin addicts (van de Brink & Haasen, 2006), and non-fatal overdoses due to opioids seem to be increasing; from 2004 to 2005, hospital visits due to opioids increased by 24% (SAMHSA, 2005). The first line of treatment for overdose is the short-acting opioid antagonist naloxone (Darke and Hall, 2003, van de Brink and Haasen, 2006). Naloxone, which has no effect on non-opioid dependent individuals and has no abuse potential, is

Summary and conclusions

Opioids have been used and abused for hundreds of years. In recent years, research on the treatment of opioid dependence has flourished and many treatment options are available. Active research programs now extend from animal models to large-scale clinical trials, many of which are focused on evaluation of both longstanding and newer treatments. Several points, gleaned from the above review, are worthy of additional mention.

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