Effectiveness work for a specific population, but

Effectiveness of Various Opioid Intervention Methods and TreatmentsNeha S. DixitUniversity of Nebraska-Lincoln AbstractThis paper explores the effectiveness of different opioid addiction interventions among various populations utilizing six published articles.  The articles vary in their support for intervention methods and which are considered to be most effective in reducing opioid dependence. Raheb supports a systematic approach in treatment intervention, while Herbeck utilized a self-administered questionnaire to collect information from treatment providers and directors. All six studies investigated utilize a different approach to combating opioid dependence, but results are regarded as generally the same, in that opioid dependency can be successfully reduced through a wide variety of intervention methods. This paper will analyze articles to depict the importance of evaluating the effectiveness of various opioid treatment interventions, as well as addressing improvements that can be made to ensure that research can be applicable across all settings and populations. Effectiveness of Various Opioid Intervention Methods and Treatments The ongoing opioid epidemic has resulted in the conduction of numerous studies that focus on the origins of addiction, pharmacology, prevalence, pain management, and treatment. However, physicians and researchers often struggle trying to decide which intervention method is best, and whether a combination of treatments can effectively reduce opioid intake in contrast to one type of treatment. Federal guidelines state that opioid treatment programs should combine counseling, medication, and 12-step approaches. Furthermore, one type of intervention may work for a specific population, but may not work for another. This is another issue that physicians and clinics struggle with because relapse is a common problem. Effectiveness of these programs are due to various factors, such as length of treatment, frequency of monitoring patients, and the amount of accessible resources. This paper examines the effectiveness of opioid addiction interventions through a review of six published articles. It is important to understand that not all research is or can be conducted in the same manner. The issue with opioid addiction treatment is that the concept of pain can be completely subjective. While adding pain as a fifth vital sign has been heavily debated for years in regards to the fact and that it could change the way doctors perceive the concept of pain in their offices, conclusions cannot be reached unless the patient provides this information. Pain measures have to be provided through self-reports, and the debate of adding pain as a vital sign originates from the idea that accuracy may be flawed when self-reporting. If an opioid addicted individual is not experiencing pain in the same way as someone who is not addicted to opioids, this may introduce confounds in research conducted on opioid addiction. Therefore, researchers will conduct assessments prior to beginning treatments to determine if patients are eligible. In addition, the lack of a sample population can prevent research from becoming applicable to populations outside of the testing sample. This is why it is important to encourage the conduction of research in order to have a chance of treating opioid addiction in the long-term. Sometimes lack of resources or funding can prevent this. However, if research reports opioid addiction interventions that fail due to a certain medication approach taken, this can be beneficial because future research can be conducted utilizing other intervention methods that may work. Research on opioid interventions is especially important because the closer clinics are to implementing successful treatments and programs, the less money they have to spend on the actual treatment process. In addition, successful treatment methods can reduce patient mortality. However, all populations must be assessed, from young to old adults, in order to generalize obtained results. The articles selected for this paper address successful and unsuccessful treatment methods involving patients who are opioid dependent. Some studies analyze a particular type of treatment, such as medication assisted treatment involving naltrexone or buprenorphine, while other studies investigate non pharmacological methods to treating opioid addicted patients. In addition, standard and non-standard treatment options are explored. This is to gain understanding about the different approaches that can be taken to reducing and treating opioid addiction. To reiterate, the opioid epidemic has continued to develop among various populations across the world. Access to opioids is problematic because pain indicators have the potential to be completely subjective. For opioids addicts, this can mean easy access through a clinic or hospital. Understanding that opioid addiction may originate from addiction to other drugs and substances can potentially introduce additional research that investigates the relationship between addiction to multiple substances, and find successful interventions that treat those too. Literature ReviewA study conducted by Raheb, Khaleghi, Moghanibashi-Mansourieh, Farhoudian, and Teymouri (2016) investigated the effectiveness of taking a systematic approach to treat opioid addiction among various treatment centers. The research question that was evaluated, “does social work intervention with a systematic approach influence on increasing the general health of opioid addicts”, was conducted as a quasi experimental study from December 2013 to June 2014 (p. 310).  The study consisted of 280 patients from Iran. However, the total sample population was 70 patients who had the necessary requirements based on the following four subscales: between 20-60 years of age, 2-8 years of opioid addiction, able to read and write, married, and negative opioid addiction test results during time of study). From the selected 70 patients, 60 agreed to participate in the study. The researchers collected data from a demographic questionnaire that included four subscales, in addition to a 28-item questionnaire that would evaluate the type of treatment the patients would be assigned to. This could include individual, group, or family therapy. Based on the four subscales tested in the questionnaire, significant differences were not found. However, the researchers conducted a t-test that showed the intervention method was effective across all populations with regards to improving general health among patients addicted to drugs and other substances (p. 311). This confirms the notion that the general health of patients addicted to opioids and other drugs show a decline in mental health in comparison to individuals who are not addicted to drugs. The four subscales tested included insomnia, anxiety, social dysfunction, higher than normal rates of depression, and somatic symptoms (p. 310). When comparing the group that received intervention to the group that did not receive intervention, the group that underwent intervention showed remarkable improvements in the general health, including the reduction of the symptoms tested in the general health questionnaire. Of course, not all treatments can be effective due to various factors. This can include lack of resources, money, and education among treatment providers. A study conducted by Herbeck, Hser, and Teruya (2008) looked to evaluate the effectiveness of empirically supported treatment interventions based on the perspectives of treatment providers and physicians. This includes evaluating pharmacological intervention methods as well as psychosocial intervention methods (p. 699). The tested population included program directors and staff members. The 361 participants answered questions based on a self-administered test. These questions consisted of treatment approaches taken in the community, characteristics of the workforce, training underwent by directors and staff, and educational background. Results depicted that the program directors and staff members thought psychosocial interventions were effective (p. 705). However, the effectiveness regarding popular pharmacological treatment methods such as naltrexone and buprenorphine was not as well known. It was observed that the training the staff members underwent was positively correlated with intervention success (p. 707). This can also be tied to the education background of staff members, with higher education utilizing a pharmacological intervention as opposed to psychosocial intervention. In regards to opioid addiction, Hoa, Robbins, Westwood, Lezama, and Fishman (2016) feel as though there is not enough research being conducted among young adults and opioid addiction. While naltrexone and buprenorphine treatment interventions are common and also regarded as effective in adult populations, it cannot be concluded that the effectiveness parallels in young adult populations (p. 392). This study consisted of 56 participants from Rockville, Maryland undergoing treatment for opioid addiction through YAAP (Youth Adult Alternative Program). A majority of the patients, 93% to be exact, were involved in clinical sessions that occured 3-5 times a week. From this, there would be a tapering of drug administration over a 24 week period. The intervention also involved frequent and random urine testing the first several weeks, but lessened to once a week urine testing eventually. Retention at the 12 week period was about 65%; at 24 weeks, retention was around 40%. The 12 week period for the negative-opioid urine analysis was about 50% and 39% at 24 weeks (p. 392). When the urine analysis was conducted weekly, significant differences were not found. However, the buprenorphine group had lower levels of negative opioid levels in comparison to the naltrexone group. Females did not show as high of levels of opioid-negative weeks compared to males. The findings from this study portray that intervention methods involving medications, most commonly naltrexone and buprenorphine, can be successfully utilized in the treatment of opioid addiction among young adults (p. 395). There are exceptions when it comes to standard treatment options in that standard treatments do not work for all opioid addiction cases. For example, a study conducted by March, Oviedo-Joekes, Perea-Milla, Carrasco (2006) investigated intravenous injection of diacetylmorphine compared to oral methadone and how successful the treatment options would be among patients that did not experience an improvement in mental and physical health from prior treatments (p. 203). The study was conducted at a hospital in Granada, Spain. Participants were selected based on the following criteria: older than 18 years of age, residency status, addiction to opioids for at least 2 years, and diagnosed with diseases or mental health conditions. Street recruitment was utilized at locations that were known to be filled with drug-addicted individuals or places where drug dealers congregated often. The study divided participants into two groups: a control group and experimental group. The control group would take oral methadone once a day, while twice a day, DAM would be injected by the experimental group. In addition, the experimental group took oral methadone once a day. The doses were equivalent for both groups and continued to be taken for 9 months. In combination with the drug administration, the groups were offered psychosocial and medical treatments, which were known to be used according to the researchers. Researchers measured health, life quality, HIV and STD risk behavior, heroin usage, SES, and various addiction problems during the course of the study (p. 204). The randomized study yielded a 71% completion among the 62 patients initially assessed (p. 207). The experimental group and control group both improved in regards to the criteria tested by researchers. Although it was not significant, the experimental group had greater retention rates. Furthermore, physical health improvements were seen 2.5 times higher in the experimental group compared to the control group. HIV risk behavior was 1.6 times higher (p. 203). Heroin administration and crime involvement also decreased in the experimental group. It is important to note that both groups improved in all areas assessed even though different types of medication was received. Improvements in family and social life, mental and physical health, risk behavior, and criminal activity decrease was seen in both groups. The proposed hypothesis was supported, in that a heroin prescription intervention could be safely executed with noticeable improvements among patients where prior treatments have failed. DAM can be a potential treatment option in the future because it is known to be a safe option in the conduction of this study (p. 209). Strain, Bigelow, and Liebson (1999) conducted a study to compare the differences in effectiveness between moderate and high dosage of methadone hydrochloride treatment. The objective of the study was to use these comparisons to introduce a possible new treatment option in the world of opioid addiction (p. 1000). This double-blind clinical study was conducted from June 1992 to October 1995 that lasted approximately 40 weeks. Participants eligible would possess the following criteria: 18 years of age or older, current addictions to opioids through intravenous injections, a positive urine sample, lack of mental illness present, and other factors that will be further discussed (p. 1001). Random assignment was utilized to place participants in either the moderate dosage or high dosage group. The first five weeks had the moderate dosage group experiencing 2 mg/week increases, while the high dosage group had 10 mg/week increases. Week 6 involved increases by 80 mg/day for high dosage, and 40 mg/day for moderate dosage. From here, the dosage was tapered, and by week 40, the dosage had been at a consistent decline of 10% each week (p. 1001). At the conclusion of this part of the study, the groups were placed in counseling sessions to develop treatment plans. Results depicted that retention rates for both groups were not significant. However, both the moderate group and high dosage group showed decreased rates of opioid use, with the higher dosage group showing greater decrease in positive urine samples, at 61.9% in comparison to the 53% with the moderate dosage group (p. 1004). In the detoxification phase of the study, the higher dosage group continued to project lower rates of positive urine sample results in comparison to the moderate dosage group. All in all, both groups showed signs of effectiveness in opioid dependence decreases, but the high dosage group experienced greater decreases than the moderate dosage group. Opioid addiction can be safely and effectively treated through implementation of various dosages, as this study proved. Sees, Delucchi, Masson, Rosen, Clark, Robillard, Banys, and Hall (2000) conducted a study regarding the controversial methadone maintenance treatment for opioid dependence. The researchers goal was to evaluate the effectiveness of treating opioid dependent patients through methadone maintenance therapy versus detoxification. This study was conducted for 180 days during May of 1995 to April 1999 to ensure that the alternative proposed would satisfy the projected hypothesis. Participants were recruited randomly and 858 volunteers were screened before the researchers identified the 179 adults that would be the sample population (p. 1303). The participants were divided into two groups; one group would undergo detoxification and the other group would undergo methadone maintenance therapy. Main outcome measures included abstinence from heroin and cocaine, retention, risk behaviors, and problems in categories such as family, job, or alcohol consumption (p. 1303-1304). In addition, both groups in detoxification and MMT would participate in psychosocial therapy at least once a week.The greatest treatment retention occurred in methadone maintenance therapy, especially among heroin and cocaine users (p. 1309). With regards to detoxification, cocaine users showed higher levels of dropout in comparison to MMT. MMT did not show improvements in risk behaviors with HIV and other related disorders, but did show improvements with lowered drug use (p. 1303). Among the main outcome measures assessed, the researchers did not observe a difference. Overall, the main conclusions obtained from this study is that methadone maintenance therapy can potentially reduce the use of particular drugs such as heroin, as well as decrease risk behavior for HIV. However, for opioid dependence, both groups involved in MMT or detoxification continued to utilize the drugs (p. 1309). Therefore, long-term detoxification effectiveness cannot be ensured if other treatment interventions such as MMT are used.  Discussion There are alternative ways of interpreting the results from these articles based on the evidence provided in the studies. First off, Raheb’s study evaluated the effectiveness of utilizing a systematic approach to improve the general health of patients who are opioid dependent. It can also make a difference on who is treating the patients, and the study found that social workers improved the general health of these patients during the process of therapy (whether it was biological, psychological, social, or family therapy). However, mental health also needs to be accounted when determining which treatment option is best for an individual. This study parallels the findings from Amiri et al’s study in that behavioral based therapies are effective in reducing addiction-like behavior and physical health. To summarize Herbeck’s study, the researchers investigated the effectiveness of various treatment approaches utilized in the workforce. The study found that treatment methods were successful generally due to the training and educational backgrounds of the staff and director, but ambiguous results were obtained in regards to particular treatment methods, such as pharmacological ones. This is a limitation that needs to be further assessed in communities due to the interview imbalance between program directors and staff members (30 versus 331). As indicated in the article, the most effective treatment approach was psychosocial, which was also found in an earlier study conducted by Roy-Byrne et al., 2003; Willenbring, et al, 2004. Younger populations were assessed in a study conducted by Vo in 2016. The effectiveness of naltrexone and buprenorphine is known among adults. The study found that these medications could successfully be incorporated as a standard treatment method for younger populations as well. This aids additional evidence that other researchers may be looking for in the conductions of studies in the future. Furthermore, these results can potentially change the type of care being offered to patients during the opioid epidemic today. Standard treatments may not be the best option for some individuals, as illustrated in March’s 2006 study. To summarize, the study seeked to compare intravenous diacetylmorphine and oral methadone and which better improved physical and mental health among opioid addicted patients. The results provided evidence that supported the hypothesis, in that these treatment interventions could be incorporated into clinics and hospitals. There was less heroin usage seen, in addition to lower crime rates and HIV risk behaviors. The article states that future studies should focus more on patients outside of clinic settings to see if these results can be replicated.Strain (1999) looked into the differences of administering methadone with moderate and high dosages, and differences were found. The high dosage group significantly decreased opioid usage in comparison to the moderate dosage group. Alternative ways of interpreting these results can include evaluating whether dosage amounts greater than 100 mg would yield lower rates of opioid usage, but this cannot be concluded unless future studies conduct research regarding this. Additional research should be conducted in non-clinical settings to generalize results to outside populations. To reiterate, relapse is a common concern during treatment for opioid dependence. Sees (2000) conducted a study utilizing methadone maintenance therapy in contrast to detoxification and its effectiveness on opioid addiction. The study yielded results that supported the hypothesis in that MMT can effectively reduce opioid frequency, but did not provide support among patients who underwent detoxification. These interventions were not conducted for the same amount of time, with methadone detoxification being conducted for 180 days and methadone maintenance for 14 months. The study could potentially have yielded different results if done so. Conclusion To gain a complete understanding of opioid dependence and the current epidemic will take many years of research in regards to the most effective treatment options. Some articles that were evaluated indicated that a combination of methods may yield the most success, while other articles yielded results that strongly support one treatment approach. In addition, results obtained for one population could differ when testing another population, such as younger and older adults. Prevention of opioid dependence is a concern among researchers, but different factors such as money, resources, and time need to be considered. However, research regarding this problem needs to be encouraged in order to terminate the ongoing crisis and mortality rates due to opioids. ReferencesGrabowski, J. (1999). Moderate- vs High-Dose Methadone for Opioid Dependence. JAMA: The Journal of the American Medical Association,282(22), 2121-2123. doi:10.1001/jama.282.22.2121Herbeck, D. M., Hser, Y., & Teruya, C. (2008). Empirically supported substance abuse treatment approaches: A survey of treatment providers perspectives and practices. Addictive Behaviors,33(5), 699-712. doi:10.1016/j.addbeh.2007.12.003March, J. C., Oviedo-Joekes, E., Perea-Milla, E., & Carrasco, F. (2006). Controlled trial of prescribed heroin in the treatment of opioid addiction. Journal of Substance Abuse Treatment,31(2), 203-211. doi:10.1016/j.jsat.2006.04.007Raheb, G., Khaleghi, E., Moghanibashi-Mansourieh, A., Farhoudian, A., & Teymouri, R. (2016, November 17). Full text Effectiveness of social work intervention with a systematic approach t | PRBM. Retrieved December 08, 2017, from https://www.dovepress.com/effectiveness-of-social-work-intervention-with-a-systematic-approach-t-peer-reviewed-fulltext-article-PRBMSees, K. L., Delucchi, K. L., Masson, C., Rosen, A., Clark, H. W., Robillard, H., . . . Hall, S. M. (2000). Methadone Maintenance vs 180-Day Psychosocially Enriched Detoxification for Treatment of Opioid Dependence. JAMA: The Journal of the American Medical Association,283(10), 1303-1310. doi:10.1001/jama.283.10.1303Vo, H. T., Robbins, E., Westwood, M., Lezama, D., & Fishman, M. (n.d.). Relapse prevention medications in community treatment for young adults with opioid addiction. Retrieved December 08, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/26820059