COUNSELLING DURING SUBSTITUTION TREATMENT: NOT ENOUGH IS TOO MUCH?
Article first published online: 4 APR 2012
© 2012 The Authors, Addiction © 2012 Society for the Study of Addiction
Volume 107, Issue 5, pages 954–956, May 2012
How to Cite
DUNLOP, A. (2012), COUNSELLING DURING SUBSTITUTION TREATMENT: NOT ENOUGH IS TOO MUCH?. Addiction, 107: 954–956. doi: 10.1111/j.1360-0443.2012.03842.x
- Issue published online: 4 APR 2012
- Article first published online: 4 APR 2012
- opioid related disorders
Schwartz and colleagues  have contributed significantly regarding our understanding of the benefits of methadone maintenance treatment, particularly with regard to treatment approaches in the United States, where methadone treatment is typically available in clinic settings only and provided in combination with supervised dosing, case management and the mandatory provision of counselling services.
Previously, Schwartz and colleagues have demonstrated the advantages of ‘interim’ methadone treatment for heroin dependence—essentially providing medical assessment, case management and high-dose methadone, with minimal or no counselling services over no treatment . This confirmed previous work by Yancovitz and colleagues , that adequate-dose methadone without mandatory counselling has major benefits, especially when compared to patients waiting for treatment. It should be noted that for most countries that provide methadone treatment outside the United States, ‘interim’ methadone is equivalent to ‘standard’ methadone treatment.
Having established that methadone with minimal counselling leads to substantial health benefits compared to not receiving any active drug treatment, Schwartz and colleagues have continued to explore this concept from the reverse perspective—how much does the provision of counselling services benefit patients on high-dose methadone maintenance, compared to methadone without counselling? Their current study found that there was no additional benefit of counselling 4 months after randomization to methadone and counselling or methadone alone , nor was there any difference 8 months later, after all groups subsequently received counselling . Adequate doses of methadone were used across all groups. This suggests a very limited role, if any, for any requirement to provide, or have patients attend, for counselling in combination with methadone maintenance. Indeed, as the authors cite, only one randomized controlled trial (RCT) has demonstrated more intensive counselling and medical services offering enhanced outcomes for opioid-dependent veterans on methadone .
The lack of a robust evidence base for insisting on counselling as a key part of treatment is probably the reason most other countries do not adopt such strict conditions on allowing methadone treatment only when counselling services are provided in conjunction with assessment and dosing services. Having a stipulation that counselling must be provided is a costly requirement to methadone treatment that does not seem to have a clear benefit over optional and/or voluntary provision of psychosocial services—an important issue, when many countries are in the midst of experiencing the global financial squeeze with reductions in health budgets including addiction treatment.
Indeed, the benefits of psychosocial interventions over standard methadone treatment (including some level of counselling) have been the subject to a Cochrane Review, with the finding that consistent benefits are difficult to establish . Of course, this fits with what many clinicians experience—some heroin users require counselling as part of treatment, but many do not. Identifying those who do need more intensive treatment is critical.
The major benefit from opiate substitution treatment would appear to occur from providing just that—safe and adequate levels of methadone or buprenorphine (or heroin and other opiates for those countries that permit these medications) by trained and experienced clinical staff. While not suggesting that a minimal approach to treatment is best for all—clearly some patients need intensive treatment—major benefits occur from opiate substitution treatment without counselling.
As noted by Schwartz and colleagues, the requirement in the United States for counselling as part of methadone treatment has resulted in counselling effectively being a rate-limiting step in providing treatment, and has been part of the reason that there has been an under-supply of opiate treatment in the United States. As is often seen in the drug and alcohol field, policy changes infrequently follow advances in the evidence base, even when treatments thought to be necessary are not shown to be so.
Of course, there have been significant changes to the availability of opiate treatment in the United States over the past decade, due not to changes in counselling requirements, but to the introduction of a second treatment ‘system’—buprenorphine (usually as buprenorphine–naloxone), provided by office-based physicians (typically family doctors) not limited by mandated counselling requirements or supervised medication dosing. A rapid increase in the numbers in buprenorphine treatment has followed .
We should refocus our understanding on how ‘successful’ countries are in providing methadone and other substitution treatments to opiate-dependent people. Providing treatment safely and in adequate doses to the maximum number possible should be the public health goal.
In conjunction, countries should continually assess the availability and accessibility of opiate treatment for those who need it. Clearly, caution should be adopted in interpreting estimates of numbers of heroin users not in treatment—an inexact science. However, attempts to measure how successful countries are in providing treatment to those who need treatment adjusted by overall population size permits such estimates and comparisons.
There will always be arguments of quality (treatment intensity) versus quantity (how many can be treated); the current research assists in this determination.
Declaration of interests
In 2007 AD received travel assistance and an honorarium from Schering Plough, at that time licence holders of buprenorphine, to attend and speak at a scientific meeting.
- 7Outpatient drug utilization trends for buprenorphine years 2002–2009. Paper presented at the Buprenorphine Meeting, 10–11 May 2010, Washington D.C, USA. Available from http://buprenorphine.samhsa.gov/meetings.html (accessed 28 March 2012).