BEHAVIORAL FAMILY COUNSELING AND NALTREXONE FOR MALE OPIOIDDEPENDENT PATIENTS

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BEHAVIORAL FAMILY COUNSELING AND NALTREXONE FOR
MALE OPIOID-DEPENDENT PATIENTS

William Fals-Stewart, Ph.D. Research Institute
on Addictions

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Heroin UseScope of the Problem

• In U.S., Growing Problem
• Most Common Primary Illicit Substance of Those
  Entering Treatment in U.S.
• Cost Estimated to Be 30 Billion Annually
• Only 20 of Those in Need of Treatment Actually
  Receive It
• Significant Problem Internationally

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Pharmacological Treatment NALTREXONE

• Opioid Antagonist
• Blocks Subjective Reinforcing Effects of
  Opioid-Based Drugs
• Positive Outcomes for Motivated Patients
• Physicians and Other Health Care Providers
• Those Facing Employment Termination
• Probationers and Others Facing Legal Sanctions

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Use of Naltrexone in Community-Based Practice

• Despite Early Promise of Naltrexone, Not Widely
  Used in Community Practice
• Engagement and Compliance Problems
• Common Delivery Approaches are Unwieldy
• Standard Medication Delivery Methods Lead to
  Rampant Noncompliance

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Enhancing Naltrexone Compliance Two Methods

• Voucher-Based Reinforcement Methods
• Family/Significant Other (SO) Approaches

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Voucher-Based Methods

• Recent Studies
• Preston et al., 1999
• Carroll et al., 2001
• Increase Compliance, Treatment Retention, and
  Opioid Abstinence During Period When
  Contingencies Were in Effect
• No Long-Term Follow-Up After Removal of
  Contingencies

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Family-Based ApproachBehavioral Family
Counseling (BFC)

• Spouse or Significant Other (SO) Observe
  Medication Taking
• Medication Contract is Established Between
  Patient and SO, Which is Monitored in Counseling
• SO Verbally (and Positively) Reinforces Patients
  Compliance

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Behavioral Family Counseling Medication
Compliance Previous Studies

• Disulfiram with Alcoholic Patients
• Naltrexone with Alcoholic Patients
• HIV Medication with Drug-Abusing Patients
• Lithium with Bipolar Patient

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Aims of Present Study

• Would the Use of Medication Contracts Between
  Opioid Dependent Patients and SOs Enhance
  Naltrexone Compliance During Primary Treatment?
• What Are the Durability of Observed Effects After
  Primary Treatment is Completed?

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Participants

• 124 Detoxified Opioid-Dependent Men Entering
  Outpatient Treatment
• Nonsubstance-Abusing SO (Intimate Partner,
  Parent, or Other Family Member) Willing to
  Participate in Treatment

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Sociodemographics/Background

• Age 32.4 (6.2) Years
• Education 13.2 (2.1) Years
• Race/Ethnicity 61 Minority
• Opioid Use 6.6 (4.4) Years
• Family Member
• Spouses 35
• Partner 13
• Parent 36
• Sibling 16

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Procedures

• Naltrexone Prescription to All Patients
• 50 mg/day
• Random Assignment
• Behavioral Family Counseling (BFC)
• Individual-Based Treatment (IBT)
• Monitoring Naltrexone Compliance
• Within-Treatment and 12-Month Follow-Up Outcomes
  (Substance Use, Psychosocial)

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Description of Treatments

• Behavioral Family Counseling (BFC)
• Included Individual, Group, and Family Counseling
  during 24 weeks
• Recovery Contract with Family Member Included
  Daily Monitoring of Naltrexone
• Individual-Based Treatment
• Included Individual and Group Counseling Only
  during 24 weeks
• No Recovery Contract

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Primary Measures

• Timeline Followback Interview
• Calendar Assessment of Substance Use Frequency
• Index Percent Days Abstinent (PDA)
• Addiction Severity Index (ASI)
• Composite Scores
• Urine Assay Results
• Pill Counts, Blister Packs

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Results Primary Outcomes

• Treatment Response Indicators
• Naltrexone Compliance
• Substance Use
• Posttreatment Outcomes
• Substance Use
• Psychosocial Functioning

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Treatment Response Indicators

• Effects During Primary Treatment

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Days of Naltrexone Ingestion
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Percentage of Opioid-Free Urines During Treatment
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Opioid Survival During Treatment
BFC
IBT
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Posttreatment Outcomes

• 12-Month Follow-Up

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Percent Days Abstinent (PDA) Opioids12-Month
Follow-Up
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Percent Days Abstinent (PDA) All Drugs12-Month
Follow-Up
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BFC
IBT
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12-Month Follow-UpASI Composite Scores
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Mechanisms of Action Mediational Analyses

• Examined Mediational Effect of Naltrexone
  Compliance on Treatment Response and Outcomes
• Days of Naltrexone Use Was a Significant Partial
  Mediator of
• Substance Use During Treatment
• Substance Use After Treatment
• ASI Composite Score Differences

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Summary

• Participants in BFC Had Significantly Better
  Treatment Response and Outcome Compared to IBT
• Treatment Effects Were Partially Mediated by
  Naltrexone Compliance

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Limitations

• Engagement of Participants
• Participant Recruitment Difficult
• Reluctance to Take Naltrexone
• Requires Positive Family Participation
• Often Difficult

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Ongoing Research

• Combination of Voucher Reinforcement and BFC
• BFC Naltrexone versus BFC w/o Naltrexone
• Cost-Benefit and Cost-Effectiveness Studies

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Support

• National Institute on Drug Abuse
• R01DA012189
• R01DA014402
• R01DA014402-Supplement
• R01DA015937
• R01DA016236
• National Institute on Alcohol Abuse and
  Alcoholism
• R21AA013690
• Alpha Foundation

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Contact

• William Fals-Stewart, Ph.D.
• Research Institute on Addictions
• 1021 Main Street
• Buffalo, NY 14203-1016
• wstewart_at_ria.buffalo.edu
• Slides available at www.addictionandfamilies.org