Journal of Social Work Practice in the Addictions ISSN: 1533-256X (Print) 1533-2578 (Online) Journal homepage: http://www.tandfonline.com/loi/wswp20 A Systematic Review of Psychosocial Interventions in Treatment of Opioid Addiction Aaron R. Brown To cite this article: Aaron R. Brown (2018): A Systematic Review of Psychosocial Interventions in Treatment of Opioid Addiction, Journal of Social Work Practice in the Addictions, DOI: 10.1080/1533256X.2018.1485574 To link to this article: https://doi.org/10.1080/1533256X.2018.1485574 Published online: 06 Jul 2018. Submit your article to this journal Article views: 18 View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wswp20 Journal of Social Work Practice in the Addictions, 00:1–21, 2018 Copyright © Taylor & Francis Group, LLC ISSN: 1533-256X print/1533-2578 online DOI: https://doi.org/10.1080/1533256X.2018.1485574 A Systematic Review of Psychosocial Interventions in Treatment of Opioid Addiction AARON R. BROWN, LCSW College of Social Work, University of Tennessee, Knoxville, Tennessee, USA Opioid addiction has become a U.S. epidemic. It is important to determine whether psychosocial interventions help prevent relapse. A total of 14 studies were included in this systematic review. Most studies compared psychosocial interventions in conjunction with pharmacological maintenance. Only 2 studies found that psychosocial interventions led to statistically significant benefits for outcomes related to opioid abuse when compared to maintenance and less or no psychosocial intervention. Psychosocial interventions were not found to be additive to pharmacological treatments during induction or maintenance stages. Further research is needed to determine effectiveness of psychosocial interventions during dose reduction and long-term relapse prevention. KEYWORDS addiction, intervention, maintenance, opioid, prevention, psychosocial, relapse, substance In the last 20 years, both therapeutic and illicit opioid use have escalated in the United States (Manchikanti et al., 2012). The total number of opioid prescriptions dispensed from U.S. outpatient retail pharmacies increased from 174.1 million in 2000 to 256.9 million in 2009 (Governale, 2010). Hydrocodone is not only the most commonly prescribed opioid, it is the most prescribed medication in the United States (Manchikanti et al., 2012). Manchikanti et al. (2012) stated, “Drug dealers are no longer the primary source of illicit drugs” (p. ES31). As the number of opioids prescribed has increased, so has their illicit use. According to the 2014 National Survey on Received March 11, 2017;revised June 6, 2016;accepted May 30, 2017. Address correspondence to Aaron R. Brown LCSW, College of Social Work, University of Tennessee, Knoxville, 1618 Cumberland Ave., Knoxville, TN 37996. E-mail: Abrown89@vols.utk.edu 1 2 A. R. Brown Drug Use and Health (NSDUH), prescription opioids have been the most frequently abused psychotherapeutic drug for more than a decade, and are second only to marijuana for all illicit drugs (Hedden et al., 2014). An estimated 4.3 million individuals 12 or older are current nonmedical users of prescription opioids, which represents 1.6% of the population aged 12 or older in the United States (Hedden et al.). The problem of opioid abuse is most prevalent among young adults. The same 2014 survey estimated that 2.8% of young adults aged 18 to 25 in the United States were current nonmedical users of opioids (Hedden et al.). Looking at the problem in a more local context, Wright et al. (2014) examined opioid abuse at the county level in Indiana and found a significant association between the rate of opioid dispensed and the rate of opioid abuse. A serious risk associated with prescription opioid abuse is the development of opioid addiction, which can be defined as a pattern of compulsive, prolonged use of opioids for nonmedical reasons or in excess of the amount necessary for legitimate medical use marked by psychological and physiological dependence and leading to significant impairment (American Psychiatric Association, 2013). An estimated 2.4 million Americans suffer from a substance use disorder related to prescription opioids, more than for cocaine and heroin combined and second only to marijuana for illicit drugs (Ali & Mutter, 2016; Hedden et al., 2014). Societal Cost Prescription opioid abuse is taking an increasingly large toll on the United States in terms of the costs related to its prevention and treatment as well as the losses it inflicts on families and communities. Between 2005 and 2011, the number of emergency room visits in the United States involving abuse of prescription opioids more than doubled from 168,379 to 366,181 (Crane, 2015). There has also been a substantial increase in those seeking treatment for opioid abuse. The number of individuals in the United States reporting substance abuse treatment related to prescription opioid abuse more than doubled between 2002 and 2014 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2015b). The mortality rate in the United States associated with opioid abuse drastically increased during this same time period, from 4,400 to 18,893 (Centers for Disease Control and Prevention, 2016). There have been numerous indications that costs associated with the growing prescription opioid abuse problem in the United States are substantial. However, there are many aspects of the problem that incur costs, and research on the overall economic burden has been limited. These aspects can be grouped into categories of criminal justice, workplace, and health care costs. Two systematic analyses of the total U.S. societal costs of prescription opioid abuse estimated it at more than $50 billion as of 2007 (Birnbaum et al., Psychosocial Interventions and Opioid Addiction 3 2011; Hansen, Oster, Edelsberg, Woody, & Sullivan, 2011). Florence, Zhou, Luo, and Xu (2016) estimated the economic burden of prescription opioid overdose, abuse, and dependence to be $78.5 billion as of the end of 2013. Relapse Prevention and Opioid Abuse Prescription opioid use and abuse in the United States have significantly increased over the last decade. Given the substantial number of individuals with substance use disorders related to prescription opioid abuse and the increasing utilization of treatment for these disorders, outpatient clinicians are more and more likely to encounter individuals who abuse prescription opioids in their practice (Hedden et al., 2014; SAMHSA, 2015b). Typically, these clients seek assistance in preventing relapse to maintain abstinence from the abuse of prescription opioids. A better understanding of whether psychosocial interventions are effective for relapse prevention is needed. The first line of treatment for opioid use disorders is often medical detoxification, a short-term inpatient process of providing medical supervision to assist in the achievement of abstinence while treating the symptoms of withdrawal (Veilleux, Colvin, Anderson, York, & Heinz, 2010). The adverse symptoms associated with withdrawal are rarely medically serious, but fear of withdrawal might discourage individuals from seeking treatment and the discomfort experienced during withdrawal might lead clients to drop out of treatment (Gossop, 2006). For these reasons, detoxification is typically a prerequisite for admission to long-term abstinence-based treatment programs, whether residential or outpatient. Detoxification may positively influence long-term treatment outcomes for opioid use disorders, but it is not sufficient as a standalone intervention (Gossop, 2006; Veilleux et al., 2010). A relapse prevention phase is needed to help those suffering from opioid addiction achieve longterm recovery, even after detoxification. Relapse prevention often includes a pharmacological component such as the use of an opioid agonist and conjunctive psychosocial components. Pharmacological maintenance is sometimes derided as merely a substitution of one addictive drug for another. However, there is substantial evidence that medication-assisted therapies (MATs) are effective in preventing relapse when properly used (Mattick, Breen, Kimber, & Davoli, 2014; Volkow, Frieden, Hyde, & Cha, 2014). It is for this reason that the National Institute of Drug Abuse (NIDA) refers to these pharmacological components as treatments and not substitutions (NIDA, 2016). Psychosocial interventions are often strongly encouraged or required as a part of maintenance treatments in the United States (SAMHSA, 2015a). This leads to the question of whether psychotherapy is a useful component of relapse prevention, either in conjunction with pharmacological treatment or in medication-free treatment modalities. Previous systematic reviews have addressed similar questions pertaining to opioid addiction in general, but 4 A. R. Brown none has looked at psychosocial interventions in the specific context of prescription opioid addiction (Amato, Minozzi, Davoli, & Vecchi, 2011; Dugosh et al., 2016; Veilleux et al., 2010). Are psychosocial interventions effective for treating individuals with prescription opioid addiction during relapse prevention? Which psychosocial interventions are most effective for relapse prevention of prescription opioid addiction? Definition of Terms Relapse is defined as the use of nonmedical prescription opioids after a voluntary period of abstinence. Relapse prevention is defined as a treatment phase after voluntary abstinence has been achieved during which efforts are made to maintain an opioid-free lifestyle. Psychosocial intervention is defined as individual or group sessions with a licensed clinician implementing a behavioral intervention intended to prevent relapse for which the clinician has received sufficient training. Prescription opioid addiction is a pattern of compulsive, prolonged use of prescription opioids for nonmedical reasons or in excess of the amount necessary for legitimate medical use marked by psychological and physiological dependence and leading to significant impairment (American Psychiatric Association, 2013). Individuals recovering from opioid addiction are defined as Americans aged 18 years or older who have previously been diagnosed with opioid use disorder related to prescription opioid abuse according to Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM–5]) criteria and have achieved a voluntary period of abstinence. METHODS Inclusion and Exclusion Criteria A systematic review of studies comparing psychosocial interventions and outcome measures related to relapse prevention for prescription opioid abuse was conducted solely by the author. The inclusion criteria for this study were as follows: ● Studies published in the English language. ● Studies included in at least one of the following databases: Web of Science Core Collection: Citation Indexes, Social Work Abstracts, PsychINFO, Social Science Research Network, or Cochrane Library. ● Studies published after 2010, specifically, from January 1, 2010 until September 30, 2016. ● Studies that compared at least one psychosocial intervention as a primary condition. Psychosocial Interventions and Opioid Addiction ● ● ● ● ● ● ● ● 5 Studies conducted on individuals 18 years or older who were in treatment for prescription opioid addiction, whether in detox or a relapse prevention phase. Studies that examined outcomes related to relapse and opioid abuse such as opioid use, treatment completion, abstinence from opioid use, treatment duration, or treatment retention. Studies that included quantitative data analysis. Articles were excluded from this study based on the following criteria: Studies conducted outside of the United States. Studies that are qualitative. Studies that did not specifically describe the types of psychosocial interventions implemented. Studies that did not specifically describe the types of pharmacological interventions used if pharmacological interventions were used. Rationale for Inclusion and Exclusion Criteria This review is primarily concerned with the treatment of prescription opioid addiction in the United States due to the rapid growth of prescription opioid abuse over the last decade. For this reason, studies conducted outside of the United States were excluded. Because English is the language primarily used for research and publication in the United States, only studies published in English were included. This review’s focus on prescription opioid abuse required a wide catchnet of journals within multidisciplinary fields such as social work, counseling, psychology, psychiatry, pharmacology, substance abuse, addiction, and public health. Search databases were chosen based on whether they included journals related to these multidisciplinary fields of research. Studies were included that used quantitative data analysis. This inclusion criterion was chosen to focus on those studies that showed the most conclusive evidence to support the opioid abuse treatment protocols. Studies that were primarily qualitative were excluded to maximize homogeneity of outcome measures and form relevant conclusions across studies. This review was limited to studies published after 2010 to include only the most recent and relevant research related to a problem that has been increasing over the last decade. Also, to the author’s knowledge, the oft-cited reviews by Veilleux et al. (2010) and Amato et al. (2011) are the most recent and rigorous systematic reviews focused on comparing treatment protocols for opioid abuse that included both psychosocial and pharmacological interventions. Since these reviews, new relapse prevention interventions have been developed and studied. For instance, mindfulness-based relapse prevention (MBRP) is a recent and promising intervention that was first studied in a pilot randomized controlled trial by Bowen et al. (2009). 6 A. R. Brown Because the primary aim of this review was to identify whether and under which conditions psychosocial interventions are effective in prescription opioid addiction treatment, only those studies that implemented psychosocial interventions were included. Studies that focused on other types of treatment interventions (e.g., pharmacological ones) were also included so long as they included at least one psychosocial intervention as a component of comparison. Focusing only on reviewing studies of a specific type of intervention would limit best practice recommendations. It is important for clinicians to be informed about the most effective interventions with this population. It was also important for this review to exclude those studies that did not describe the specific interventions implemented. In their systematic review, Veilleux et al. (2010) found that targeted psychosocial interventions showed the most promise for use in treatment of opioid addiction. For best practice recommendations to be made, it was necessary to understand whether specific interventions were more effective than others, and to avoid the assumption that any pharmacological or any psychosocial intervention is as effective as others. Studies were also chosen based on population criteria. The focus of this review is on relapse prevention from prescription opioid abuse. As such, only those studies that specifically studied outcome measures related to relapse prevention and opioid abuse were included. Additionally, only studies that focused on adults, which is the population of interest for this review, were included. Data indicate that individuals 18 to 25 years old make up the largest percentage of those who abuse prescription opioids (Hedden et al., 2014). Search and Distillation Using the stated inclusion and exclusion criteria, a search was conducted in three phases (see Figure 1). Phase I used Boolean terms to identify articles in any of the included databases. The following Boolean terms were used for topic search: opioid AND (addict* OR dependen* OR abuse OR misuse) AND (psychotherapy OR psychosocial OR counseling OR “relapse prevention”) NOT (child* OR adolesce* OR youth OR infant) NOT (cannabis OR marijuana OR cannabinoid OR cocaine OR alcohol* OR heroin OR methamphetamine). Searches were limited to those results written in English between January 2010 and October 2016. To capture studies that implemented counseling-only treatment protocols, a second search was conducted using the following Boolean terms in a title search: opioid AND (addict* OR dependen* OR abuse OR misuse OR “use disorder”) AND (psychotherapy OR psychosocial OR counsel* OR therapy OR behavioral OR “relapse prevention”) NOT (maintenance OR pharmacological OR naltrexone OR naloxone OR methadone OR Buprenorphine OR Psychosocial Interventions and Opioid Addiction 7 FIGURE 1 Phases of search and distillation. suboxone) NOT (child* OR adolesce* OR youth OR infant) NOT (cannabis OR marijuana OR cannabinoid OR cocaine OR alcohol* OR heroin OR methamphetamine). Phase I of the first search captured a total of 255 articles from Web of Science (n = 144), Social Work Abstracts (n = 0), PsycINFO (n = 38), Social Science Research Network (n = 0), and Cochrane Library (n = 73). Phases II and III implemented distillation per inclusion and exclusion criteria (see Figure 1). In Phase II, duplicates (n = 47) and articles with topics outside of inclusion criteria (n = 180) were excluded from the results. Then in Phase III of the first search, qualitative studies (n = 6), reviews (n = 9), and studies outside the United Stated (n = 5) were excluded. After distillation, eight articles were included from the first search. Phase I of the second search captured a total of 111 articles from Web of Science (n = 66), Social Work Abstracts (n = 0), PsycINFO (n = 33), Social Science Research Network (n = 0), and Cochrane Library (n = 12). In Phase II, duplicates (n = 37) and articles with topics outside of inclusion criteria (n = 51) were excluded from the results. Then in Phase III of the second search, qualitative studies (n = 5), reviews (n = 10), and studies outside the United States (n = 4) were excluded. Articles already included from previous search were also excluded (n = 1). After distillation, two articles were included from the second search. In an effort to capture more articles meeting inclusion criteria, the citations from already included articles were reviewed. A total of three articles 8 A. R. Brown meeting inclusion criteria were found among citations of those articles already included from two searches (Fiellin et al., 2013; Ling, Hillhouse, Ang, Jenkins, & Fahey, 2013; Moore et al., 2016). An additional article (Schwartz, Kelly, O’Grady, Gandhi, & Jaffe, 2012) was included based on a response written by Schwartz (2016) to a very recent systematic review that failed to include this relevant article (Dugosh et al., 2016). These articles were not captured by the search methodology used here, but they were deemed important to include due to their direct relevancy to this review and their meeting criteria for inclusion. These four articles were combined with the 10 captured by two searches for a total of 14 articles included in this review (see Table 1). FINDINGS Treatment Protocols Several types of psychosocial interventions were compared within the various articles. All but one of the studies included in this review used random assignment to treatment conditions (Barry, Cutter, Beitel, Liong, & Schottenfeld, 2015). As seen in Table 1, the most common psychosocial intervention studied was cognitive-behavioral therapy (CBT), which was compared in 6 of the 14 studies (Barry et al., 2015; Fiellin et al., 2013; Lander, Gurka, Marshalek, Riffon, & Sullivan, 2015; Ling et al., 2013; Moore et al., 2016; Otto et al., 2014). Other types of psychosocial interventions compared included mindfulnessoriented recovery enhancement (MORE), therapy groups, contingency management (CM), Web-based counseling, CBT for interoceptive cues (CBT–IC), acceptance and commitment therapy (ACT), distress tolerance (DT), and support groups (Garland et al., 2014; Ling et al., 2013; Otto et al., 2014; Smallwood, Potter, & Robin, 2016; Stein et al., 2015; Stotts et al., 2012; Weiss et al., 2011). Pharmacological treatment was compared in all but one of the 14 articles included in this review. The most common type of pharmacological treatment implemented was buprenorphine, which was used in nine of the studies (Barry et al., 2015; Fiellin et al., 2013; Lander et al., 2015; Moore et al., 2016; Smallwood et al., 2016; Stein et al., 2015; Tetrault et al., 2012; Weiss et al., 2011). Buprenorphine was typically used in combination with naloxone for maintenance induction. Methadone was used in four of the included studies (Marsch et al., 2014; Otto et al., 2014; Schwartz et al., 2012; Stotts et al., 2012). In all but one of the studies, pharmacological treatment was implemented for induction and maintenance. In one study (Stotts et al., 2012), instead of induction and maintenance, the groups were compared during methadone dose reduction with the goal of detoxification from methadone. 9 (Continued ) 67 141 Fiellin et al. (2013) Garland et al. (2014) 90 Sample Size Barry et al. (2015) Authors Opioid Abuse Outcome(s) Both CBT and EC groups sustained decreases in nonmedical opioid use, whereas nonmedical opioid use increased for PM-only group. Results Limitations For both groups nonmedical PM was provided with greater opioid use significantly frequency than typical in decreased and number of standard practice. Attrition led weeks abstinent significantly to missing data, which was increased. There was no accounted for in statistical significant difference between analysis. group outcomes. 1. Mindfulness-oriented recovery Desire for opioids The MORE group had Attrition rate was relatively high enhancement (MORE)2. (self-report); significantly less desire for at 42%. The SF homework Support group (SG) nonmedical opioid opioids at posttreatment. Both might have led to rumination use (self-report); groups had significantly less on symptoms and thus status of opioid use nonmedical opioid abuse at affected pain and cravings for disorder posttreatment. The MORE nonmedical use. group was significantly less likely to still meet criteria for an opioid use disorder at posttreatment. The differences between groups were not significant at 3-month followup. 1. Buprenorphine and physician Opioid use (urine) management (PM)2. Buprenorphine, PM, and cognitive-behavioral therapy (CBT)3. Buprenorphine, PM, and educational counseling (EC) 1. Buprenorphine and PM2. Opioid use (urine Buprenorphine, PM, and CBT and self-report) Comparison Groups TABLE 1 Articles Included in Review. 10 45 202 160 48 Ling et al. (2013) Marsch et al. (2014) Moore et al. (2016) Sample Size Lander et al. (2015) Authors Comparison Groups Results Limitations There wasn’t enough statistical power to detect significant group differences. The sample was 75% male. Attrition rates were high in both groups (~40%). Dose exposure of counseling was low (~12 sessions). The study was low-powered due Opioid use (selfThere were no significant report and urine); differences between groups to sample size, so it was treatment retention for either outcome variable, unable to achieve statistical however women in the significance for primary female-only group were 25% outcome measures. less likely to relapse than Additionally, attrition was women in the mixed-gender about 50% overall. group. Relapse rates were 37% and 50% for the female-only and mixed-gender groups, respectively. Opioid use (urine); All groups benefited from One exclusion criterion treatment treatment. No significant group eliminated individuals with retention; craving differences were found. health issues, which limits the generalizability of the results. Opioid Abuse Outcome(s) 1. Buprenorphineand CBT2. Buprenorphineand contingency management (CM)3. Buprenorphine, CBT, and CM4. Buprenorphine only 1. Methadone and in-person Opioid use (urine); Both groups benefited from individual counseling2. treatment retention treatment, but the mixed Methadone and mixed counseling groups improved individual and Web-based significantly more than the counseling: Therapeutic standard treatment group. Education System (TES) There was no significant difference in retention between groups. 1. Buprenorphine and PM2. Opioid use (urine The CBT group had better Buprenorphine and CBT and self-report) outcomes, but no group differences were statistically significant. 1. Buprenorphine and mixedgender CBT therapy group;2. Buprenorphine and femaleonly CBT therapy group TABLE 1 (Continued) 11 230 25 49 Schwartz et al. (2012) Smallwood et al. (2016) Stein et al. (2015) (Continued ) 78 Otto et al. (2014) 1. Buprenorphine and distress tolerance (DT) 2. Buprenorphine and HE 1. Methadone and counseling2. Methadone and higher dose of counseling3. Methadone only for 120 days then counseling added 1. Buprenorphine and acceptance and commitment therapy (ACT)2. Buprenorphine and health education (HE) 1. Methadone and individual counseling2. Methadone and CBT for interoceptive cues (CBT–IC) Both groups benefited from treatment. There was no significant difference between groups for opioid use as measured by saliva, but the CBT–IC group reported significantly less opioid use. Opioid use (selfAll three groups showed report and urine) reduction in opioid use. There were no significant group differences for reduction in opioid use. Brain MRI data; Results indicated that those in the opioid craving ACT group had reduced (self-report) activation in brain regions linked to pain processing. No differences between groups for opioid craving were reported. Opioid use (selfDT led to a small statistically report and urine); insignificant reduction in treatment retention opioid use during the first 3 months of treatment. No group difference was found for treatment retention. Opioid use (selfreport and saliva) Fixed buprenorphine dosing might have limited its benefits. Attrition was about 25%. Only participants who had responded poorly to standard treatment were recruited. Results differed by outcome measure: self-report vs. toxicology. 23% of participants did not finish treatment. Amount of counseling was at most once per week (higher dose group). Counseling was generally less structured than CBT. Low sample size and high attrition (50%) led to insufficient power. 12 Weiss et al. (2011) Tetrault et al. (2012) Stotts et al. (2012) Authors 653 47 56 Sample Size Opioid use (selfreport and urine); detoxification status; detoxification fear Opioid Abuse Outcome(s) Results Limitations No significant differences Adherence and competence between groups were found ratings were high for for opioid use. 37% of ACT counseling, but some participants successfully processes were implemented completed detoxification by less often than others, which end of treatment compared to might have attenuated results. 19% of DC participants. ACT Therapy training time was was also favorable for fear of greater in the ACT condition. detoxification outcome. 1. Buprenorphine and PM2. Opioid use (urine There were no differences Small sample size reduced ability Buprenorphine, PM, and and self-report); between groups in outcome to detect between-group enhanced medical treatment retention measures related to opioid use differences. Counseling was management (EMM) or retention. implemented by nurses. 1. Buprenorphine, PM, and self- Opioid use (selfAdding individual counseling did Participants received PM and help groups2. Buprenorphine, report and urine); not improve outcomes. There counseling weekly, and PM, self-help groups, and treatment retention were no significant differences variations of more counseling individual counseling between groups for opioid use and less PM might affect outcomes. Secondary analysis outcomes. (Weiss et al., 2014) revealed that participants who had ever used heroin benefited from counseling if they adhered to treatment. Comparison Groups 1. Methadone dose reduction and ACT2. Methadone dose reduction and drug counseling (DC) TABLE 1 (Continued) Psychosocial Interventions and Opioid Addiction 13 Measures The most common outcome measure for the included studies was opioid use, which was typically measured by urine toxicology and self-report and was measured in 12 of the 14 included articles. Treatment retention was measured in all studies, but was only considered a primary outcome measure in about half of the included articles. Evidence Across Studies None of the 14 articles reviewed showed evidence of adverse effects as a result of psychosocial interventions. Across all studies reviewed, the inclusion of psychosocial interventions was found to be at least as effective if not more effective than comparison groups with either a lower dose of psychosocial intervention or none at all. Of the 13 studies that compared psychosocial interventions in conjunction with pharmacological treatment, only 2 resulted in statistically significant differences between groups for outcomes related to opioid abuse. Barry et al. (2015) found that either CBT or educational counseling in conjunction with buprenorphine treatment was favorable to no psychosocial treatment, but did not find significant differences between the two psychosocial interventions. Stotts et al. (2012) did not find significant differences between groups for opioid use; however, they did find that ACT led to a significantly higher success rate for detoxification from methadone. Other studies (Moore et al., 2016; Otto et al., 2014; Stein et al., 2015) found evidence that psychosocial interventions might improve outcomes in conjunction with pharmacological treatment, but they were unable to achieve statistical significance due to low sample size and low statistical power. Garland et al. (2014) found that MORE led to significant benefits over a support group condition when assessed at posttreatment, but at 3-month follow-up there were no longer any significant differences between the two conditions. The results of this review contribute to conclusions similar to those made in previous reviews of psychosocial interventions and opioid relapse prevention (Amato et al., 2011; Dugosh et al., 2016; Veilleux et al., 2010). The evidence across studies indicates that although for some opioid users (particularly those in pain management) psychosocial interventions can be beneficial on their own (Garland et al., 2014), they are generally not additive to pharmacological maintenance for opioid relapse prevention. However, psychosocial interventions might be beneficial in helping those recovering from opioid abuse achieve detoxification from pharmacological maintenance and sustain long-term abstinence from opioid abuse. Additionally, psychosocial interventions during pharmacological maintenance might benefit certain subgroups of participants, such as those with cooccurring polysubstance use disorders (Weiss et al., 2014; Weiss et al., 2014). 14 A. R. Brown Due to the high level of heterogeneity for types of psychosocial interventions implemented across the studies in this review, conclusions about a specific intervention being most effective cannot be made. However, there is growing evidence that interventions such as ACT, MORE, and MBRP that incorporate mindfulness and are targeted for treatment of substance dependence might be more effective than other protocols (Bowen et al., 2009; Garland et al., 2014; Smallwood et al., 2016; Stotts et al., 2012). Limitations Small sample size, low statistical power, and not achieving statistical significance were the most common limitations across articles included for this review. Attrition rates across the studies ranged from about 25% to 50%, which likely contributed to the limitation of low statistical power. It is likely that effect size differences when comparing pharmacological treatment to conjunctive psychosocial interventions are quite small, meaning that large sample sizes are needed to achieve statistical significance. Of those studies that compared psychosocial interventions in conjunction with pharmacological treatment, the comparison group conditions often included regular meetings with the prescribing physician for brief 15- to 20minute physician management (PM) or health education (HE) sessions. These PM sessions were often similar in frequency to counseling, weekly or biweekly, and as such might have reduced the power of between-group comparisons. For methadone maintenance, it is particularly difficult to achieve adequate effect sizes for between-group comparisons, because in the United States counseling is a required component (SAMHSA, 2015a). Schwartz et al. (2012) took advantage of an exception that allows for the use of methadone maintenance while on a waiting list for counseling, which is limited to the first 120 days of methadone treatment. Their study comparing interim methadone treatment with methadone plus weekly individual counseling used a relatively large sample size (n = 230), and although both groups showed significant reductions in opioid use, there were no significant between-group differences. This review did not capture evidence about the use of psychosocial interventions as replacements for maintenance treatments in opioid relapse prevention, so conclusions could only be made about their use in conjunction with pharmacological maintenance treatments. However, Mattick, Breen, Kimber, and Davoli (2009) conducted a systematic review comparing methadone maintenance to drug-free opioid relapse prevention and found methadone maintenance to be more effective for treatment retention and opioid use. A major limitation of this systematic review was failing to capture articles that examined the effectiveness of psychosocial interventions after detoxification from maintenance treatment. Additionally, this review only captured one study (Stotts et al., 2012) that compared psychosocial interventions during Psychosocial Interventions and Opioid Addiction 15 dose reduction from maintenance. That study found positive results, but one study does not provide sufficient evidence for conclusions about whether psychosocial interventions are beneficial during the dose-reduction stage of relapse prevention. It is possible that psychosocial interventions are most effective during dose-reduction and after pharmacological maintenance has ended, but this review failed to capture enough evidence to form these conclusions. This review attempted to examine the use of psychosocial interventions to treat specifically prescription opioid addiction during relapse prevention. In attempting to only capture studies about prescription opioid addiction, many relevant studies might have been excluded. For example, studies were excluded because they sampled individuals who used illicit opioids such as heroin or other illicit drugs. Excluding studies of illicit opioids might have been unnecessary as differences in treatment outcomes for prescription and illicit opioids are likely minimal. Finally, this review was conducted solely by its author. Ideally a systematic review should make use of multiple reviewers for search, distillation, and extraction to minimize bias and avoid exclusion of eligible articles. Although the author took great care in these processes, attempting to strictly adhere to inclusion and exclusion criteria and consulting with a senior faculty member throughout the process of conducting and writing this review, it is important to acknowledge this limitation. DISCUSSION The primary goal of this systematic analysis was to determine what the most recent evidence indicates about the effectiveness of psychosocial interventions in the relapse prevention phase of treatment. Based on the articles included in this systematic review, psychosocial interventions are not additive to pharmacological treatments using methadone or buprenorphine during induction or maintenance stages of relapse prevention. However, there is some indication that psychosocial interventions might be more effective during dose reduction and long-term relapse prevention stages (Stotts et al., 2012). Implications for Social Work Policy, Practice, and Research Medication-assisted therapies for opioid addiction are severely underutilized in the United States despite evidence that they are more effective than drugfree treatments (Mitchell et al., 2016; Volkow et al., 2014). Existing policies that limit availability of medication-assisted therapies for opioid addiction or require participation in psychosocial interventions as a condition of 16 A. R. Brown pharmacological treatment should be revised in accordance with current evidence. Evidence does not indicate that conjunctive psychosocial interventions during maintenance have any adverse effects. However, given the costs associated with providing psychosocial treatments and their unproven efficacy during maintenance, evidence does not support their use during maintenance. Psychosocial interventions might be more beneficial and thus cost-effective at other stages of relapse prevention. Policies that increase participation in psychosocial services while in dose reduction or aftercare from medicationassisted therapies for opioid addiction seem favorable, but further research is needed to determine what types of psychosocial interventions and at which stages of treatment are most effective. Existing attitudes among social workers toward pharmacological maintenance for opioid addiction treatment might contribute to its underutilization. Although achieving complete abstinence is a valid goal for those receiving treatment for opioid addiction, requiring or expecting complete cessation early in treatment has been shown to reduce treatment retention and success (Dobkin, Civita, Paraherakis, & Gill, 2002; Hartzler, Cotton, Calsyn, Guerra, & Gignoux, 2010). Lushin and Anastas (2011) argued that given the evidence supporting harm reduction strategies such as medication-assisted therapies for treating opioid addiction, social workers should adopt a more pragmatic view of substance abuse treatment by seeking to “develop and successfully use contextualized, client-centered approaches to addiction treatment instead of relying on obsolete positive worldview and the outdated disease model” (p. 99). Prevention and education are important to prevent initial use and to attenuate the development of dependence and addiction. Psychosocial intervention research is needed, but so is research into preventative programs and wrap-around services to reduce the problem of opioid addiction before it even develops. Heroin abuse has generally been confined to urban areas in the past. However, the growing opioid epidemic has especially affected rural areas such as the Appalachian region (Cicero, Surratt, Inciardi, & Munoz, 2007; Paulozzi & Xi, 2008; Rossen, Bastian, Warner, Khan, & Chong, 2016). New efforts are needed to help educate and prevent opioid abuse in communities that are struggling with opioid addiction now more than ever. Although the articles included in this review compared several different psychosocial interventions along with two major types of pharmacological maintenance, there are likely many other psychosocial interventions that could be compared for opioid relapse prevention. The interventions compared among the articles in this review do represent the current state of evidence-based interventions in substance abuse treatment, but is it possible that interventions not included in this review are more effective for opioid relapse prevention? More research is needed to determine if targeted psychosocial interventions are effective across the different stages of opioid addiction treatment. Psychosocial Interventions and Opioid Addiction 17 CONCLUSION Although psychosocial interventions that directly target opioid abuse during maintenance are not supported by this review, those that target cooccurring disorders to minimize risk for relapse are important. Existing evidence indicates that when cooccurring psychiatric disorders are left untreated, risk of relapse is significantly increased (Bradizza, Stasiewicz, & Paas, 2006; Brady & Sinha, 2005; Flynn & Brown, 2008). Social workers should seek to provide services and linkage for those clients with cooccurring disorders participating in pharmacological maintenance. Further research is needed to determine effectiveness of psychosocial interventions in long-term relapse prevention. Medication-assisted therapies have been shown to be effective at helping individuals replace prescription and illicit opioids with agonists as a means to increase functioning and reduce harm, but these treatments amount to management and eventually detoxification from replacement therapies is needed. If psychosocial interventions can help individuals detoxify from replacement therapies and achieve complete abstinence with long-term relapse prevention, then they would be a way to move from management to complete remission. Opioid addiction treatment is not a one-size-fits-all endeavor. Evidencebased interventions are needed for each phase of prevention and treatment that consider the complex risk and protective factors associated with success at each phase. Social workers are uniquely qualified to help those with opioid addiction minimize risks for relapse and maximize protective factors. By targeting each phase with contextualized interventions, social workers will be able to reduce the number of people affected by opioid addiction. ORCID Aaron R. Brown http://orcid.org/0000-0002-9108-0338 REFERENCES Ali, M. M., & Mutter, R. (2016). The CBHSQ Report: Patients who are privately insured recieve limited follow-up services after opioid-related hospitalization. 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