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BEHAVIORAL FAMILY COUNSELING AND NALTREXONE FOR MALE OPIOID-DEPENDENT PATIENTS

This study explores the use of behavioral family counseling and naltrexone to enhance compliance and treatment outcomes for male opioid-dependent patients. The effectiveness of medication contracts and the durability of observed effects after primary treatment are also examined. The study shows that participants in behavioral family counseling had better treatment response and outcomes compared to individual-based treatment.

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BEHAVIORAL FAMILY COUNSELING AND NALTREXONE FOR MALE OPIOID-DEPENDENT PATIENTS

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  1. BEHAVIORAL FAMILY COUNSELING AND NALTREXONE FOR MALE OPIOID-DEPENDENT PATIENTS William Fals-Stewart, Ph.D. Research Institute on Addictions

  2. Heroin Use:Scope 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

  3. 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

  4. 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

  5. Enhancing Naltrexone Compliance: Two Methods • Voucher-Based Reinforcement Methods • Family/Significant Other (SO) Approaches

  6. 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

  7. Family-Based Approach:Behavioral 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 Patient’s Compliance

  8. 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

  9. 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?

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

  11. 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%

  12. 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)

  13. 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

  14. 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

  15. Results: Primary Outcomes • Treatment Response Indicators • Naltrexone Compliance • Substance Use • Posttreatment Outcomes • Substance Use • Psychosocial Functioning

  16. Treatment Response Indicators Effects During Primary Treatment

  17. Days of Naltrexone Ingestion

  18. Percentage of Opioid-Free Urines During Treatment

  19. Opioid Survival: During Treatment BFC IBT

  20. Posttreatment Outcomes 12-Month Follow-Up

  21. Percent Days Abstinent (PDA) Opioids:12-Month Follow-Up

  22. Percent Days Abstinent (PDA) All Drugs:12-Month Follow-Up

  23. BFC IBT

  24. 12-Month Follow-UpASI Composite Scores

  25. 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

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

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

  28. Ongoing Research • Combination of Voucher Reinforcement and BFC • BFC + Naltrexone versus BFC w/o Naltrexone • Cost-Benefit and Cost-Effectiveness Studies

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

  30. Contact William Fals-Stewart, Ph.D. Research Institute on Addictions 1021 Main Street Buffalo, NY 14203-1016 wstewart@ria.buffalo.edu Slides available at: www.addictionandfamilies.org

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