We recently published an article here on our blog called “The Opioid Crisis in the United States: Update on Settlements with Opioid Manufacturers, Distributors, and Retailers.” In that article, we reviewed the landmark legal settlements reached between opioid producers, distributors, and retailers and government officials in all 50 states in the U.S.
While researching that article, we found a report that caught our attention:
We’re always looking for evidence-based strategies to mitigate the harm caused by the opioid epidemic. It’s one of our core goals. This report caught and held our attention not only because of the title and the subject matter, but also because of the impressive array of contributors. Authors of the report include representatives from Harvard University School of Health, Johns Hopkins School of Public Health, Yale University, Stanford University, and others – a group that sets the standard for excellence in scientific research. The contributors were organized by the non-profit advocacy group Partnership to End Addiction.
Here’s a description of the report from the introduction:
“This report was designed to support and empower state and local officials in making critical allocation decisions and consolidates the best research evidence to provide recommendations for high-impact investments that will improve the addiction treatment system, strengthen prevention and harm reduction programming, and address substance use disorder.”
It’s our goal to use this article to empower any of our current, former, or potential patients with the latest evidence on best clinical practices in the treatment of opioid use disorder (OUD). To accomplish this goal, we’ll offer a summary of the report, which we’ll call “The Partnership Report” for the rest of this article. We’ll describe the sources the study authors used to evaluate the evidence, the classification system they used to determine the effectiveness of the various treatment modalities. Finally, we’ll share the conclusions they reached about the modalities themselves.
The Partnership Report on Evidence-Based Practices for Treatment of Opioid Use Disorder (OUD)
First, we’ll review the sources the Partnership team used to review and evaluate the evidence for the various treatment modalities reviewed in the report.
The authors gathered evidence supporting treatment for opioid use disorder from five major scientific studies published on the topic since the beginning of the opioid crisis. Unless otherwise noted, these studies are the source of the authoritative content presented and discussed throughout the rest of this article:
- Medications for Opioid Use Disorder Save Lives, published by The National Academy of Sciences in 2019. Click here for the full .pdf document.
- Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, published by the National Institutes of Health in 2016. Click here for the full .pdf document.
- Facing Addiction in America: The Surgeon General’s Spotlight on Opioids, published by the National Institutes of Health in 2018. Click here for the full .pdf document.
- National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use, published by The American Society of Addiction Medicine in 2015. Click here for the full .pdf document
- Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence, published by The World Health Organization (WHO) in 2009. Click here for the full .pdf document.
The authors chose these studies because each involved a thorough analysis of all the available research, to date, on the specific topic addressed in the study. They gave preference to meta-analyses and review articles that included random-controlled trials (RCTs), real-world clinical trials, and large-scale population studies.
When considering each of the treatment modalities under review, authors used a classification system adopted by the Centers for Disease Control in 2011. Here’s how they ranked each modality:
- Well supported: Evidence includes data from multiple controlled trials and/or large-scale population studies.
- Supported: Evidence includes data from rigorous, well-designed, and well-reviewed studies, but from fewer studies with smaller sample sizes
- Promising: Evidence or findings not found in rigorous scientific studies, but is practical, sensible, and already in use in many treatment programs.
The study authors evaluated the primary components of integrated, personalized treatment plans based on best clinical practices for the treatment of opioid use disorder. Reviewed modalities included treatments in the following categories:
- Medications for opioid use disorder (MOUD)
- Behavioral therapies
- Recovery support
When a treatment program for people diagnosed with OUD includes modalities from all three categories, their chances of achieving sustainable recovery increase, compared to programs that don’t include treatments from all three categories.
We’ll now present the review of the evidence for these treatment modalities, beginning with medications for opioid use disorder (MOUD).
Medications for Opioid Use Disorder: What the Evidence Shows
There are the MOUDs approved by the Food and Drug Administration (FDA) for treating OUD: methadone, buprenorphine, and naltrexone. Treatment involving MOUDs is called medication-assisted treatment (MAT). The Substance Abuse and Mental Health Services Administration (SAMHSA) defines MAT as “…the use of medications, in combination with counseling and behavioral therapies, to provide a ‘whole-patient’ approach to the treatment of substance use disorders.”
We’ll discuss each of these MOUDs, beginning with methadone.
Methadone: Evidence and Evaluation
Methadone is a full opioid agonist, meaning it occupies opioid receptors in the brain and prevents other opioids from occupying those receptors. Treatment with methadone can prevent/reduce symptoms of withdrawal from opioids and reduce cravings for opioids, without the extreme euphoria associated with most opioids. Methadone allows patients to achieve the psychological and emotional stability that allows them to participate in the counseling, treatment, and life-repair components of treatment.
The studies reviewed show robust evidence for the following outcomes for people with OUD who participate in MAT with methadone:
- Reduced number of overdoses
- Reduced overall mortality
- Decreased injection drug use
- Reduced transmission of infectious disease
- Increased social function
- Decreased criminal activity
- Decreased use of other opioids
After a review of the evidence, the study authors concluded methadone is a well-supported treatment for opioid use disorder.
Overall, experts in addiction treatment consider methadone the “gold standard” treatment for people with OUD.
Buprenorphine: Evidence and Evaluation
Like methadone, buprenorphine can prevent/reduce symptoms of withdrawal from opioids and reduce cravings for opioids, without the extreme euphoria associated with most opioids. Unlike methadone, buprenorphine is a partial opioid agonist. This creates both a benefit and a drawback. The benefit: it can’t produce the mild euphoria, or the respiratory depression associated with methadone. The drawback: it doesn’t prevent withdrawal symptoms and cravings as effectively as methadone. Overall, the benefits far outweighs the drawbacks, because it reduces the chance of diversion for illicit purposes, thereby drastically reducing likelihood of misuse and overdose.
The studies reviewed show robust evidence for the following outcomes for people with OUD who participate in MAT with buprenorphine:
- Improved overall patient outcomes
- Reduced overdose rates
- Increased time-in-treatment
- Reduced injection drug use
- Reduced transmission of infectious disease
- Increased social function
- Reduced criminal activity
- Reduced use of other opioids
Federal guidelines require pharmaceutical companies to combine buprenorphine with naloxone in a medication commonly known as Suboxone. When used as directed, naloxone remains inactive. However, when injected or ingested orally, it immediately occupies opioid receptors and precipitates withdrawal. This prevents diversion and drastically reduces the use of Suboxone for recreational purposes.
After a review of the evidence, the study authors concluded buprenorphine is a well-supported treatment for opioid use disorder.
Overall, experts in addiction treatment consider buprenorphine a “…second-line therapy [for OUD] for patients in whom methadone is unwanted, inappropriate, or ineffective.”
Naltrexone: Evidence and Evaluation
Naltrexone, unlike methadone and buprenorphine, which are opioid receptor agonists, is a full opioid receptor antagonist. This means it prevents other opioids from occupying opioid receptors without activating the opioid receptors themselves. This characteristic of naltrexone prevents the possibility of opioid intoxication/euphoria and opioid overdose. That makes naltrexone the safest of the three FDA-approved MOUDs.
Naltrexone may be an attractive alternative for some patients and prescribing physicians for three reasons. First, since it’s not an opioid or controlled substance, the DEA doesn’t require a special license to prescribe it: this makes it more accessible to patients seeking treatment. Second, there is no risk of diversion, since naltrexone does not induce euphoria or intoxication. Third, the only FDA-approved formulation of naltrexone – Vivitrol – is available only in extended release injections that last 30 days. Therefore, patients only need to see their doctor once a month to maintain treatment with naltrexone.
The studies reviewed show evidence for the following outcomes for people with OUD who participate in MAT with naltrexone:
- Decreased rates of opioid use
- Decreased opioid cravings
- Reduced polysubstance use
Naltrexone is most often recommended for patients who:
- Went through withdrawal in an abstinence-based program or while incarcerated, and want to prevent relapse
- Have completed an MAT program with methadone or buprenorphine and want to taper off all opioid medication completely
- Are younger: naltrexone is often preferred by adolescent or young adults
Note: Patients must be abstinent form opioids for three full days before initiating treatment with naltrexone.
After a review of the evidence, the study authors concluded buprenorphine is a supported treatment for opioid use disorder.
Data shows that in comparison to other MOUDs, naltrexone has the lowest rates of initiation and shortest average time-in-treatment. While it is extremely effective in preventing relapse, overdose, and opioid-related euphoria, the specific characteristics of naltrexone make it a less attractive option for many patients.
That’s the evidence contained in the Partnership Report on treatment for opioid use disorder with MOUDs. Next, we’ll look at the evidence for behavioral therapies.
Behavioral Therapies for Opioid Use Disorder: What the Evidence Shows
Behavioral therapies for people diagnosed with OUD generally take two forms: counseling and psychotherapy. Both are similar in that these interventions revolve around formalized, structured interactions between the patient in treatment and the counselor or therapist. In general, both counselors and therapists are trained and licensed professionals. Therapists have more training in treating mental health disorders, while addiction counselors are trained to support people in recovery from the disordered use of substances.
Contingency Management: Evidence and Evaluation
About Contingency Management
Contingency management is a type of addiction counseling that’s effective alone, and more effective when combined with medication-assisted treatment. Treatment programs often pair contingency management with cognitive behavioral therapy (CBT) and family therapy. The process of contingency management involves giving small, practical rewards for behavior that aligns with the recovery goals of a patient in treatment for OUD. Rewards can include vouchers for shopping at local stores or vouchers for desired recreational activities, such as going to a movie.
The studies reviewed show evidence for the following outcomes for people with OUD who engage in the contingency management modality:
- Longer time-in-treatment
- Increased rates of abstinence
- Improved social functioning
- Improved personal functioning
After a review of the evidence, the study authors concluded contingency management is a well-supported treatment for opioid use disorder.
Evidence shows contingency management is most effective when people in MAT programs identify take-home medication as a reward for negative drug tests and when people in MAT programs identify vouchers for goods or services as a reward for negative drug tests.
Cognitive Behavioral Therapy (CBT): Evidence and Evaluation
CBT is a well-researched approach to the treatment of a variety of mental health and substance use disorders. During CBT sessions, a trained therapist helps patients identify counterproductive, negative thoughts and feelings or behaviors and replace them with positive, productive thoughts and feelings. In most cases, CBT therapists teach patients practical tools to accomplish this goal. In treatment for opioid use disorder, the primary goal of CBT is to help patients identify and replace patterns of thought and behavior associated with opioid use with patterns of thought and behavior associated with recovery.
The studies reviewed show evidence for the following outcomes for people with OUD who engage in cognitive behavioral therapy (CBT):
- Improved stress management
- Improved general coping skills
- Increased ability to refuse drugs
- Improved problem-solving skills
- Enhanced self-control
After a review of the evidence, the study authors concluded cognitive behavioral therapy is a well-supported treatment for opioid use disorder.
The American Society of Addiction Medicine (ASAM) found that CBT shows “evidence of superiority” compared to other behavioral therapies when used in MAT programs with MOUD, and the National Academies of Science found that CBT is “empirically supported” when combined with MOUD.
Family Therapy: Evidence and Evaluation
About Family Therapy
The underlying assumption behind the use of family therapy in addiction is that in order to understand an individual, it’s essential to understand the dynamic web of human relationships within which that individual grew up. When suggesting family therapy to a patient in OUD treatment, for instance, a therapist might say something like this:
“To get to know you, it will help if we get to know your family, too.”
In addition, when family members know what a person in treatment is going through, they know how to better support them upon discharge from treatment.
The studies reviewed show family therapy during OUD treatment can lead to the following beneficial outcomes:
- Longer time-in-treatment
- Increased treatment engagement
- Improved overall treatment experience
- Improved communication skills
After a review of the evidence, the study authors concluded family therapy is a well-supported treatment for opioid use disorder.
The study authors point out that family therapy can improve interpersonal family relationships and basic interpersonal communication skills. These skills can translate to reduced baseline levels of stress and reduced baseline levels of interpersonal conflict, which can decrease likelihood of relapse and improve the chance of achieving long-term recovery.
That’s the evidence the Partnership Report provides for the effectiveness of behavioral therapies in treatment for opioid use disorder (OUD). The third and final category of treatment addressed in the report is Recovery Support, which we’ll discuss now.
Recovery Support for Opioid Use Disorder: What the Evidence Shows
Recovery support refers to a broad range of services for people with OUD. In most cases, recovery support refers to non-treatment modalities that help patients in treatment focus on the treatment and recovery process, rather than the details of life outside of treatment.
We’ll discuss these supports and the evidence base for this category of treatment in a different way than we did for MOUDs and behavioral therapy, primarily because – with two notable exceptions – recovery support is a relatively new concept in addiction treatment. As of 2023, a credible evidence base exists for two recovery support modalities: drug-free housing and mutual self-help groups are well-supported modalities for opioid use disorder (OUD). The rest of the modalities we discuss next are considered promising modalities for opioid use disorder (OUD).
Recovery support services include the following:
- Patients in treatment live in housing that requires drug testing, along with other patients in treatment for OUD or other substance use disorders.
- Evidence-based benefits of drug-free housing include sustained abstinence, reduced substance use, increased employment, and reduced illegal activity.
Mutual Self-Help Groups
- Mutual self-help groups are commonly known as 12-step groups and include peer support meetings like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).
- AA and NA are two of the most extensively studied addiction treatment modalities.
- Experts conclude AA/NA type-program are effective components of treatment and recovery for people with OUD, or any other substance use disorder.
- This is exactly what it appears to be: helping parents in treatment by arranging childcare when they’re actively engaged in treatment activities.
- While there’s little evidence to support outcomes for childcare during treatment, it’s logical to assume that offering childcare services could increase both treatment initiation and retention, and reduce overall stress that can contribute to substance use and relapse to substance use.
Employment Counseling and Support
- This is also exactly what it sounds like: helping patients in treatment seek and secure gainful employment.
- Like with childcare, there’s little evidence to support improved outcomes for vocational counseling/support during treatment. And like childcare, it’s logical to assume that helping people find and keep a job can improve self-esteem, address housing and food instability, and reduce overall stress that can contribute to substance use and relapse to substance use.
- Some treatment centers offer case management services. Case managers help people manage non-treatment details/support related to treatment. These include healthcare beyond addiction treatment, such as care for physical and mental illness. Case managers help patients identify and access all the support available to them, as provide by private insurance, their treatment program, or public social services.
- As of now, there is no real evidence base that indicates case management improves outcomes. However, as with childcare and vocational support, it’s logical to assume that case management can improve overall treatment outcomes. Therefore, it’s a recommended component of effective treatment programs.
Peer Support/Peer Support Specialists
- Many treatment centers engage the help of peer support specialists, who are people in recovery with direct, personal, experiential knowledge of the treatment and recovery process.
- When people in recovery from OUD meet and spend time with other people with OUD who are further down the road to recovery, the relationships they form can become pivotal components to treatment.
- A person in treatment may be more likely to listen to someone who has literally “been there and done that” as opposed to a clinician with no personal history of substance use and no direct experience with the recovery process outside of their professional work.
- This is a widespread, sensible practice. People in recovery cite the value of peer support and peer specialists, but as of now, there’s no real evidence base for this type of peer support, as there is for programs like AA or NA.
That’s the information the Partnership Report provides for the effectiveness of recovery support services in treatment for opioid use disorder (OUD). We’ll add that recovery support – although the least supported by evidence – is an important and promising component of OUD treatment. It’s also worth reiterating that Alcoholics Anonymous (AA) is a type of recovery support. It’s one of the most effective and extensively researched modalities in addiction treatment, and the AA model of honest, open, non-judgmental peer support suffuses most evidence-based treatment programs available.
How This Information Helps
The primary reason we wrote this article is to share the evidence base for the treatment modalities we use at Pinnacle Treatment Centers. We offer almost all of the treatment modalities above at almost all of our treatment centers nationwide. We’re proud of our clinical standards and proud of our commitment to evidence-based treatment for opioid use disorder (OUD). That means we were pleased when we found this report. It confirmed something we knew already: our approach to OUD treatment is well-supported by an extensive evidence base.
But our pride and happiness with our offerings is unimportant. What’s important is that any current, potential, or former patient – and their family and friends – can rest assured that the personalized addiction programs we offer at Pinnacle Treatment Centers are well-supported by the latest peer-reviewed scientific research and evidence.