Research

Individual therapy and 12-step mutual-help group participation both associated with abstinence for those receiving medications for opioid use disorder

There are several safe and effective FDA-approved medications for individuals with opioid use disorder, such as buprenorphine (often prescribed in a formulation with naloxone and referred to by the brand name Suboxone). These medications help reduce opioid use and opioid-related overdose. Yet, the rate of returning to opioid use after treatment remains high. This underscores the need to better understand what other treatments and recovery support services can be paired with medication to enhance treatment outcomes. The current study compared the benefits associated with individual therapy, group therapy, and attendance at 12-step mutual-help groups such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) on opioid abstinence after 6 months of medication treatment.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Medications such as Suboxone and extended release naltrexone (often referred to by the brand name Vivitrol) are first-line treatments for opioid use disorder. The positive effects of these medications on short-term outcomes – e.g., reduced overdose, decreased opioid use and increased opioid abstinence, and withdrawal symptom relief – are well documented. Despite the availability of these lifesaving medications, long-term opioid abstinence rates remain low which highlights the need for the continued enhancement of existing treatments. However, there are still unanswered questions about the effects of adding other substance use disorder (SUD) treatment and recovery supports to medications in order to enhance outcomes. In a past review, for example, authors found studies adding cognitive-behavioral therapy to Suboxone did not enhance the stand-alone benefits of medication. On the other hand, a more comprehensive review showed that psychosocial treatments, including but not limited to cognitive-behavioral therapy, do improve outcomes beyond medication effects, but only when standard medical supportive therapy (i.e., “medication management”) was a small part of the intervention. Also, knowing how individuals taking opioid use disorder medications fare in both professional (e.g., psychotherapy) and non-professional (e.g., mutual-help) can inform more comprehensive recovery plans and potentially improve patient outcomes. In this study, authors used data from a large multisite clinical trial comparing two medications for opioid use disorder to examine the long-term effects of psychosocial interventions and mutual-help meeting attendance (e.g., NA) on the odds of achieving opioid abstinence after 6 months of medication treatment.

HOW WAS THIS STUDY CONDUCTED?

This study used data from 570 adults diagnosed with opioid use disorder enrolled in a nationwide multisite two-group randomized controlled 6-month clinical trial comparing Suboxone to extended release naltrexone as a treatment for opioid use disorder. The primary outcome was illicit opioid abstinence confirmed with urine analysis. All enrolled participants who did not attend follow-up visits were presumed to have returned to opioid use and included in the analysis as having relapsed (i.e., intent-to-treat). Participants were told what medication they were being given (i.e., open label trial). Throughout the 6-month trial, all participants were offered weekly individual or group counseling sessions, and 12-step groups were available in the community or at the treatment center. During each weekly clinical visit (weeks 1-24), participants provided a urine sample to assess opioid abstinence and reported the approximate number of hours they participated in individual therapy, group therapy, and mutual-help groups during the preceding week. 

Participants were 34 years old, on average and 70% identified as male. Most of the sample identified as White (75%) with the remaining identifying as Black (10%) and/or Hispanic/Latinx (13-20%). Most participants cited heroin as their primary substance (80%), more than 60% were individuals that use intravenously, and 35-40% had prior treatment. Other substance use in the past 30 days was common among the sample with endorsing stimulant, sedative, alcohol, and/or cannabis use. Nearly 70% reported a lifetime history of another co-occurring psychiatric disorder.

WHAT DID THIS STUDY FIND?

More hours of individual therapy and 12-step mutual-help groups during the trial was associated with increased odds of remaining abstinent at the end of the six months.

Greater hours of individual therapy and 12-step mutual-help group attended were independently linked to higher probability of abstinence at the end of the six-month trial. For individual therapy, this translates to each one-hour increase in individual therapy during the trial increasing the odds of being abstinent at the end of six-months by 1.8 times. For 12-step group attendance, each one-hour increase in attendance increases the odds of being abstinent at the end of the trial by 1.05 times. Interestingly, greater group therapy attendance was not associated with increased odds of maintaining abstinence. Importantly, attending individual therapy and 12-step groups simultaneously enhanced the effects of the other (i.e., there was statistical interaction effect between individual therapy and 12-step group attendance on opioid abstinence). In addition, older individuals and individuals employed fulltime tended to have a greater probability of maintaining opioid abstinence.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

For those taking medications for opioid use disorder, individual therapy and mutual-help group attendance were each significantly and independently associated with increased odds of remaining abstinent during the entire 6-month trial. These results are consistent with findings from other studies that consistently find mutual-help group attendance is associated with improved outcomes for those taking medication for opioid use disorder. In contrast, greater group therapy attendance was not associated with abstinence. This is an important finding because most frontline psychosocial substance use treatment is group based while most research on psychosocial substance use treatment focuses on individual therapy or 12-step facilitation. Also, it is important to note that participants were able to freely choose between the options and there is a range of reasons why someone might opt for individual vs. group-based recovery supports. Importantly, the benefits of individual therapy and mutual-help group attendance enhanced the effects of the other. This finding suggests that the combination of individual and 12-step groups may offer additional benefits above and beyond the direct effects of each treatment alone. Since individuals were not randomized to receive the adjunctive psychosocial services, it is also possible that individuals with a better chance of abstinence from the outset were more likely to attend individuals and 12-step mutual-help groups – for example, those with greater initial readiness to change. While authors controlled statistically for several variables, such as initial opioid problem severity, to try and isolate the effects of each service on abstinence – to boost our ability to say attendance caused improved abstinence – these findings indicate that these services are associated with better outcomes, though may not be directly responsible for them. That said, there is now good evidence that 12-step mutual-help participation in AA for alcohol use disorder is causally related to substantially higher abstinence and remission rates.

Figure 1.

Taken together, these findings suggest that engagement in individual treatment while taking medications for opioid use plus mutual-help group attendance provides the greatest chance to achieve long-term abstinence for individuals with opioid use disorder. Previous research has found support for mutual-help groups as useful adjuncts in the treatment of other substance use disorders (e.g., Alcoholics Anonymous for persons with Alcohol Use Disorder). This study shows benefits from mutual-help group attendance promote long-term abstinence for those with opioid use disorder. These findings need to be contextualized alongside other research showing for those taking Suboxone and attending NA, in particular, they may interact with individuals who have negative medication attitudes, believing individuals cannot be “truly abstinent” while taking such medications for opioid use disorder,  a view documented in NA’s written materials. Accordingly, more research is needed to better understand how to help individuals taking medications for opioid use disorder benefit from mutual-help group attendance, via work to overcome potentially negative medication messages in NA, or to attend other more medication-friendly organizations, such as Medication Assisted Recovery Anonymous (MARA).

LIMITATIONS
  1. The authors did not provide any information regarding how many hours on average individuals engaged with any of the recovery supports. This makes it difficult to determine the relative differences in attendance nor make any recommendations about frequency of attendance from these analyses.
  2. The was primarily designed to test the efficacy of pharmacotherapies for opioid use disorder, and thus, did not prioritize methodological control of adjunctive recovery supports. As mentioned above in ‘Implications of Study Findings’, the utilization of such supports in the current study may have been influenced by participants access to such supports, financial resources, and motivational factors.
  3. The log responsible for tracking the number of hours a participant used a recovery support was self-report. While this is a valid approach, it is possible that participants provided inaccurate or incomplete data due to concerns about how the researchers will perceive them (i.e., social desirability) or problems with recall.
  4. Authors exclusively focused on the number of hours each participant use a support each week. However, this does not take into account the training or experience of individual and group therapy counselors as well as their theoretical orientation or approach.
  5. The authors did not examine interactions between medication type and services attended. It is possible that better or worse outcomes could be seen in these untested combinations.

BOTTOM LINE

  • For individuals and families seeking recovery: This study showed that for those taking medications to treat opioid use disorder both individual therapy and mutual-help group attendance were both independently and synergistically associated with long-term opioid abstinence. This is important as some members of 12-step mutual-help groups, especially Narcotics Anonymous (NA), see individuals taking opioid medications as not “truly abstinent,” a view documented in NA’s written materials. In contrast, AA’s written materials suggest that medication choices are a private matter to be discussed and worked through between the AA member and their physician. While more research is needed to flesh out the best ways for individuals taking medications for opioid use disorder to engage with community-based mutual-help groups, this study suggests individuals give themselves the best chance of long-term abstinence via engagement in both services.
  • For treatment professionals and treatment systems: This study showed that for those taking medications to treat opioid use disorder both individual therapy and mutual-help group attendance were both independently and synergistically associated with long-term opioid abstinence. This is important because both options come with their misconceptions. Some members of 12-step mutual-help groups, especially Narcotics Anonymous (NA), see individuals taking opioid agonist medications as not “truly abstinent”, a view documented in NA’s written materials. In contrast, AA’s written materials suggest that medication choices are a private matter to be discussed and worked through between the AA member and their physician. Evidence suggests that those with primary drug use disorders achieve similarly strong abstinence rates whether they attend NA or AA. Understanding these nuances is important for treatment providers. A recent survey found that 30% of individuals receiving medications for opioid use disorder were worried about encountering negative attitudes related to taking these medications and only 33% reported their provider discussed this with them prior to attending a meeting. Patient outcomes may be improved with thoughtful conversation about what type of community-based recovery support services will best meet their individual needs. 
  • For scientists: This study showed that for those taking medications to treat opioid use disorder both individual therapy and mutual-help group attendance were both independently and synergistically associated with long-term opioid abstinence. More research is warranted to understand how disclosing medications for opioid use disorder status at 12-step meetings, where medication use may be discouraged, impacts meeting attendance, active involvement, and ultimately, substance use outcomes. Also, the absence of an effect for group therapy is striking, given how frequent this is the primary mode of therapy a person with substance use disorder receives. More research is needed to better understand how to improve group therapy for substance use given its prevalence in front-line treatment centers in the US and abroad.
  • For policy makers: This study showed that for those taking medications to treat opioid use disorder both individual therapy and mutual-help group attendance were both independently and synergistically associated with long-term opioid abstinence. Attendance at mutual help group meetings does not appear to impede medications for opioid use disorder or vice versa. Given that medication treatment and 12-step mutual-help groups are two evidence informed approaches to addressing the opioid epidemic, funding research studies that examine these approaches in combination could help improve outcomes and reduce the public health burden of opioid use disorder.

CITATIONS

Harvey, L. M., Fan, W., Cano, M. Á., Vaughan, E. L., Arbona, C., Essa, S., Sanchez, H., & de Dios, M. A. (2020). Psychosocial intervention utilization and substance abuse treatment outcomes in a multisite sample of individuals who use opioidsJournal of Substance Abuse Treatment. 112, 68-75. doi10.1016/j.jsat.2020.01.016 

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