Addiction treatment

While deaths from overdoses of Vicodin, OxyContin, and other prescription opioids have decreased over the same time period, legal painkiller deaths are still about three times more common than heroin deaths.

According to Jennifer Sharpe Potter, PhD, a substance abuse researcher at the University of Texas Health Science Center in San Antonio, these figures indicate an increasingly prevalent occurrence. She claims that as prescription opioids become more difficult to obtain, people are turning to heroin for a quicker high.

"It just makes sense," says Potter, the assistant dean for research and student programs, "both in terms of the availability of heroin, the price of heroin, and the ratcheting up of regulatory limitations on prescription opioids." "It's a natural evolution," says the narrator.

For example, new laws have made it more difficult for doctors to prescribe opioids and for consumers to "doctor shop," or get prescriptions from different doctors. OxyContin's maker changed the medicine to make it more difficult to inject or snort. Furthermore, heroin is significantly less expensive than prescription medications. According to a 2014 report in The Washington Post, a fix of street heroin costs approximately $10, but an identical quantity of OxyContin sold on the street costs eight times more.

According to new research by Theodore J. Cicero, PhD, of the University of Washington School of Medicine and colleagues, these and other developments have resulted in a shift in who uses heroin (JAMA Psychiatry, 2014).

In the past, heroin users were mostly young, low-income, racial and ethnic minorities from metropolitan regions, but this is no longer the case. According to Cicero's examination of data from a continuing survey of patients in substance abuse treatment facilities, today's heroin users are progressively older whites from more affluent suburbs and rural areas. In contrast to previous users who began with heroin, three-quarters of current patients were first exposed to opioids through prescription medications.

Treatment is also evolving. While medication is still the gold standard for treating opiate addiction, psychologists are looking into how to help people who are addicted to heroin and prescription drugs, according to Potter. They're looking into whether adding counseling to people on medication-assisted treatment improves their outcomes. They're also looking into new ways to deliver treatment to patients, whether it's through basic care or through a computer.

Adding to pharmacological treatment

The majority of opioid addiction treatment is based on pharmacological treatment, such as methadone and buprenorphine. Is it possible to improve the chances of treatment success by including psychological interventions?

"On that, the jury is still out," Potter says.

She emphasizes that most treatment programs contain a behavioral component. In reality, federal law mandates that outpatient providers of buprenorphine give some form of wraparound or behavioral treatment, including as instruction in life management skills, symptom reduction, and other recovery-related issues. And methadone dispensing, whether in a clinic or at home, is heavily controlled and necessitates rigorous case management.

However, clinical trial evidence on whether behavioral therapy improves pharmaceutical treatment for opioid addiction remains ambiguous, according to Potter.

Potter and her co-authors discovered that individual drug counseling provided no significant benefit over and above routine buprenorphine therapy in a randomized controlled study of 653 outpatients addicted to prescription opioids (JAMA Psychiatry, 2011).

"That doesn't rule out the possibility that the behavioral treatment was beneficial to those individuals," she says. "However, that wasn't something we were able to capture as improving outcomes in that study design."

According to Potter, the problem could have been the treatment's mix or duration, or the demographic to which it was given. She and her colleagues discovered evidence in a more recent trial that patients with the most severe addictions benefited more from drug counseling than those with less severe forms of the condition (Drug and Alcohol Dependence, 2014).

"It's a bit of a mixed picture," Potter explains. "What we're attempting to figure out right now is under what conditions does whatever sort of behavioral treatment work?"

Contingency management, a behavioral technique that employs incentives to urge patients to stay drug-free, is a favorite of psychologist Nancy M. Petry, PhD, professor and director of the REWARD Center at the University of Connecticut School of Medicine. Patients who achieve and maintain abstinence have the opportunity to win cash rewards if they achieve and maintain abstinence.