Predictors of outcome for short-term medically supervised opioid withdrawal during a randomized, multicenter trial of buprenorphine–naloxone and clonidine in the NIDA clinical trials network drug and alcohol dependence

Abstract

Few studies in community settings have evaluated predictors, mediators, and moderators of treatment success for medically supervised opioid withdrawal treatment. This report presents new findings about these factors from a study of 344 opioid dependent men and women prospectively randomized to either buprenorphine-naloxone or clonidine in an open-label 13-day medically-supervised withdrawal study. Subjects were either inpatient or outpatient in community treatment settings; however not randomized by treatment setting. Medication type (buprenorphine-naloxone versus clonidine) was the single best predictor of treatment retention and treatment success, regardless of treatment setting. Compared to the outpatient setting, the inpatient setting was associated with higher abstinence rates but similar retention rates when adjusting for medication type. Early opioid withdrawal severity mediated the relationship between medication type and treatment outcome with buprenorphine-naloxone being superior to clonidine at relieving early withdrawal symptoms. Inpatient subjects on clonidine with lower withdrawal scores at baseline did better than those with higher withdrawal scores; inpatient subjects receiving buprenorphine-naloxone did better with higher withdrawal scores at baseline than those with lower withdrawal scores. No relationship was found between treatment outcome and age, gender, race, education, employment, marital status, legal problems, baseline depression, or length/severity of drug use. Tobacco use was associated with worse opioid treatment outcomes. Severe baseline anxiety symptoms doubled treatment success. Medication type (buprenorphine-naloxone) was the most important predictor of positive outcome; however the paper also considers other clinical and policy implications of other results, including that inpatient setting predicted better outcomes and moderated medication outcomes.

Smoking and Opioid Detoxification: Behavioral Changes and Response to Treatment

“…At one study site, the rate of nicotinedependent OA patients was 96% (Figure 1). This is consistent with findings in opioid-addicted populations treated at community treatment programs (Reid et al, 2011;Ziedonis et al, 2009). …”

“…A recent investigation in a large nonsubstance abusing population reported that active smokers treated for chronic pain were less likely to complete methadone taper (Hooten, Townsend, Bruce, & Warner, 2009). Ziedonis et al (2009) found that smoking was a predictor of negative opioid detoxification outcome in a multisite trial and argued for the need to study the impact of tobacco on opioid withdrawal. We identified an association between active smoking and opioid withdrawal and craving intensity, in combination with lower rates of detoxification completion.…”

“…Reduced smoking has been recorded during heroin, buprenorphine, or methadone taper (Bigelow, Stitzer, Griffiths, & Liebson, 1981;Mello et al, 1985;Mello, Mendelson, Sellers, & Kuehnle, 1980), though cigarette craving and relapse into higher smoking rates have been described shortly after detoxification (Conner, Stein, Longshore, & Stacy, 1999). Tobacco users are less likely to successfully withdraw from opioids (Ziedonis et al, 2009), and some clinicians have argued that an attempt to quit smoking might interfere with a concurrent effort to discontinue other drug use (Campbell, Wander, Stark, & Holbert, 1995;Weinberger, Reutenauer, Vessicchio, & George, 2008). In addition, medications commonly used in detoxification, such as naltrexone and clonidine have been studied in smoking cessation with mixed results (David, Lancaster, Stead, & Evins, 2006;Herman & Sofuoglu, 2010).…”

Long-term Suboxone Treatment and its Benefit on Long-Term Remission for Opiate Dependence

“…Additional large-scale, clinical trials evaluated predictors and mediators of treatment success for inpatients who received either Suboxone or clonidine. Contrary to what was hypothesized, higher rates of treatment success were observed for patients who had high baseline withdrawal scores [23]. More specifically, inpatients with high baseline withdrawal symptoms were four times more likely to achieve detoxification and sustained abstinence than inpatients with lower baseline withdrawal symptoms.…”

“…Although comparable in efficacy, buprenorphine carries a lower risk of overdose [21]. Furthermore, it is important that buprenorphine therapy is initiated at the onset of withdrawal symptoms as research indicates that inpatients without a history of substance abuse that have high baseline withdrawal scores appear to benefit the most from long-term Suboxone treatment [22,23]. An additional disadvantage of buprenorphine therapy involves its potential inefficacy in individuals who required high methadone doses prior to buprenorphine treatment.…”