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hensive approaches to chronic pain into their scope of services.

Health care systems can in- corporate nonjudgmental screen- ing, brief intervention, and refer- rals for further assessment and treatment of addiction into all clinical settings where opioids are prescribed. Conversely, addiction- treatment providers can screen patients for pain, recognizing that inadequately treated pain is a risk factor for relapse. Psychology Discussion Oipioid Use Paper

Payers, including Medicare and state Medicaid programs, can use data-analysis tools to spot the red flags of inappropriate prescribing and refer prescribers to medical boards or other state agencies for further review, education, and oversight. Prescription-drug mon- itoring programs can also identi- fy prescribers in need of assis- tance. Coherent, evidence-based review of clinical practice can be

conducted with the aim of supporting high-quality care

for both chronic pain and addic- tion — and avoiding the unin- tended consequence of deterring physicians from caring for pa- tients with complex needs.

Public and private insurers can provide as generous coverage for treatment of opioid-use disorder as they do for management of chronic pain. This standard is infrequently met — for example,

it is long past time for Medicare to begin covering the effective care provided in opioid-treatment programs.

It is also time for the FDA to address the intertwining of chron- ic pain and addiction farther up- stream in the drug-development cycle. The agency might consider creating a pathway for develop- ment and review of new products and indications for simultaneous treatment of chronic pain and opioid-use disorder. Building on its own work to advance the sci- ence of abuse-deterrent formula- tions, the FDA should also re- quire that prescription opioids meet basic deterrent standards and should facilitate the gradual reformulation of existing products to meet such standards. In declin- ing to apply such a standard to Zo- hydro, the agency noted that ex- isting deterrent mechanisms have had minimal impact by them- selves. However, even modest safeguards have been shown to reduce the potential for inappro- priate use.5 As part of a compre- hensive strategy, a set of reason- able requirements for opioid medications is well in line with the FDA’s public health mission. Taking such action will deter others with less expertise from filling a perceived void. Psychology Discussion Oipioid Use Paper

In the end, pointing the finger at Zohydro is not going to resolve

the tension that exists today be- tween chronic pain and addiction. All concerned about the treatment of chronic pain and all responding to the rise in overdose deaths need to come together to promote high- quality and effective prevention and treatment for both conditions.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

From the Institutes for Behavior Resources (Y.O.) and the Maryland Department of Health and Mental Hygiene (J.M.S.) — both in Baltimore.

This article was published on April 23, 2014, at NEJM.org.

1. Public health grand rounds — prescrip- tion drug overdoses: an American epidemic. Atlanta: Centers for Disease Control and Pre- vention, February 18, 2011 (http://www.cdc .gov/about/grand-rounds/archives/2011/ 01-February.htm). 2. Policy impact: prescription painkiller overdoses. Atlanta: Centers for Disease Con- trol and Prevention, July 2, 2013 (http:// www.cdc.gov/HomeandRecreationalSafety/ pdf/PolicyImpact-PrescriptionPainkillerOD .pdf). 3. FDA Commissioner Margaret A. Ham- burg statement on prescription opioid abuse. Silver Spring, MD: Food and Drug Administration, April 3, 2014 (http://www .fda.gov/NewsEvents/Newsroom/ PressAnnouncements/ucm391590.htm). 4. Federation of State Medical Boards of the United States. Pain management policies: board by board overview. February 2014 (http://www.fsmb.org/pdf/GRPOL_Pain_ Management.pdf). 5. Severtson SG, Bartelson BB, Davis JM, et al. Reduced abuse, therapeutic errors, and diversion following reformulation of extend- ed-release oxycodone in 2010. J Pain 2013; 14:1122-30.

DOI: 10.1056/NEJMp1404181

Copyright © 2014 Massachusetts Medical Society.

Chronic Pain, Addiction, and Zohydro

Medication-Assisted Therapies — Tackling the Opioid- Overdose Epidemic Nora D. Volkow, M.D., Thomas R. Frieden, M.D., M.P.H., Pamela S. Hyde, J.D., and Stephen S. Cha, M.D.

The rate of death from over-doses of prescription opioids in the United States more than quadrupled between 1999 and

2010 (see graph), far exceeding the combined death toll from co- caine and heroin overdoses.1 In 2010 alone, prescription opioids

were involved in 16,651 overdose deaths, whereas heroin was im- plicated in 3036. Some 82% of the deaths due to prescription

An audio interview with Dr. Olsen

is available at NEJM.org

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opioids and 92% of those due to heroin were classified as unin- tentional, with the remainder be- ing attributed predominantly to suicide or “undetermined intent.”

Rates of emergency department visits and substance-abuse treat- ment admissions related to pre- scription opioids have also in- creased markedly. In 2007, prescription-opioid abuse cost in- surers an estimated $72.5 billion — a substantial increase over previous years.2 These health and economic costs are similar to those associated with other chron- ic diseases such as asthma and HIV infection. Psychology Discussion Oipioid Use Paper

These alarming trends led the Department of Health and Hu- man Services (HHS) to deem pre- scription-opioid overdose deaths an epidemic and prompted multi- ple federal, state, and local ac- tions.2 The HHS efforts aim to si- multaneously reduce opioid abuse

and safeguard legitimate and appropriate access to these med- ications. HHS agencies are im- plementing a coordinated, com- prehensive effort addressing the key risks involved in prescription- drug abuse, particularly opioid- related overdoses and deaths. These efforts focus on four main objectives: providing prescribers with the knowledge to improve their prescribing decisions and the ability to identify patients’ prob- lems related to opioid abuse, re- ducing inappropriate access to opioids, increasing access to effec- tive overdose treatment, and pro- viding substance-abuse treatment to persons addicted to opioids.

A key driver of the overdose epidemic is underlying substance- use disorder. Consequently, ex- panding access to addiction- treatment services is an essential component of a comprehensive response.2 Like other chronic dis-

eases such as diabetes and hyper- tension, addiction is generally refractory to cure, but effective treatment and functional recov- ery are possible. Fortunately, cli- nicians have three types of medi- cation-assisted therapies (MATs) for treating patients with opioid addiction: methadone, buprenor- phine, and naltrexone (see table). Yet these medications are mark- edly underutilized. Of the 2.5 mil- lion Americans 12 years of age or older who abused or were depen- dent on opioids in 2012 (according to the National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration [SAMHSA]), fewer than 1 million received MAT.

When prescribed and moni- tored properly, MATs have proved effective in helping patients re- cover. Moreover, they have been shown to be safe and cost-effec- tive and to reduce the risk of over- dose. A study of heroin-overdose deaths in Baltimore between 1995 and 2009 found an association between the increasing availabil- ity of methadone and buprenor- phine and an approximately 50% decrease in the number of fatal overdoses.3 In addition, some MATs increase patients’ retention in treatment, and they all improve social functioning as well as re- duce the risks of infectious-disease transmission and of engagement in criminal activities. Nevertheless, MATs have been adopted in less than half of private-sector treat- ment programs, and even in pro- grams that do offer MATs, only 34.4% of patients receive them.4

A number of barriers contrib- ute to low access to and utilization of MATs, including a paucity of trained prescribers and negative attitudes and misunderstandings

Tackling the Opioid-Overdose Epidemic

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Opioid Sales, Admissions for Opioid-Abuse Treatment, and Deaths Due to Opioid Overdose in the United States, 1999–2010.

Data are from the National Vital Statistics System of the Centers for Disease Control and Prevention, the Treatment Episode Data Set of the Substance Abuse and Mental Health Services Administration, and the Automation of Reports and Consolidated Orders System of the Drug Enforcement Administration.

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Tackling the Opioid-Overdose Epidemic

about addiction medications held by the public, providers, and pa- tients. For decades, a common concern has been that MATs merely replace one addiction with another. Many treatment-facility managers and staff favor an ab- stinence model, and provider skepticism may contribute to low adoption of MATs.4 Systematic prescription of inadequate doses further reinforces the lack of faith in MATs, since the resulting return to opioid use perpetuates a belief in their ineffectiveness. Psychology Discussion Oipioid Use Paper

Policy and regulatory barriers are another concern. A recent re- port from the American Society of Addiction Medicine describing public and private insurance cov- erage for MATs highlights several policy-related obstacles that war- rant closer scrutiny. These barri- ers include utilization-manage- ment techniques such as limits on dosages prescribed, annual or lifetime medication limits, initial authorization and reauthorization

requirements, minimal counsel- ing coverage, and “fail first” cri- teria requiring that other thera- pies be attempted first (www.asam .org/docs/advocacy/Implications -for-Opioid-Addiction-Treatment). Although these policies may be intended to ensure that MAT is the best course of treatment, they may hinder access and appropriate care. For example, maintenance MAT has been shown to prevent relapse and death but is strongly discouraged by lifetime limits.5

In addition, although Medicaid covers buprenorphine and metha- done in every state, some Medic- aid programs or their managed- care organizations apply the utilization-management policies described above. Most commer- cial insurance plans also cover some opioid-addiction medications — most commonly buprenorphine — but coverage is generally lim- ited by similar policies, and ac- cess to care may be limited to in-network providers. Few private

insurance plans provide coverage for the depot injection formula- tion of naltrexone, and most do not cover methadone provided through opioid treatment pro- grams.

Implementation of the Afford- able Care Act (ACA) will increase access to care for many Ameri- cans, including persons with ad- diction. This expansion builds on the Mental Health Parity and Ad- diction Equity Act, which re- quires insurance plans that offer coverage for mental health or substance-use disorders to pro- vide the same level of benefits that they do for general medical treatment. The ACA significantly extends the reach of the parity law’s requirements, ensuring that more Americans have coverage for mental health and substance- use disorders and that coverage complies with the federal parity requirements. These reforms pre- sent new opportunities for reduc- ing prescription-opioid abuse and

Characteristics of Medications for Opioid-Addiction Treatment.

Characteristic Methadone Buprenorphine Naltrexone

Brand names Dolophine, Methadose Subutex, Suboxone, Zubsolv Depade, ReVia, Vivitrol

Class Agonist (fully activates opioid re- ceptors)

Partial agonist (activates opioid recep- tors but produces a diminished re- sponse even with full occupancy)

Antagonist (blocks the opioid receptors and interferes with the rewarding and analgesic effects of opioids)

Use and effects Taken once per day orally to reduce opioid cravings and withdrawal symptoms

Taken orally or sublingually (usually once a day) to relieve opioid crav- ings and withdrawal symptoms

Taken orally or by injection to diminish the reinforcing effects of opioids (potentially extinguishing the asso- ciation between conditioned stimuli and opioid use)

Advantages High strength and efficacy as long as oral dosing (which slows brain uptake and reduces euphoria) is adhered to; excellent option for patients who have no response to other medications

Eligible to be prescribed by certified physicians, which eliminates the need to visit specialized treatment clinics and thus widens availability

Not addictive or sedating and does not result in physical dependence; a re- cently approved depot injection for- mulation, Vivitrol, eliminates need for daily dosing

Disadvantages Mostly available through approved outpatient treatment programs, which patients must visit daily

Subutex has measurable abuse liability; Suboxone diminishes this risk by in- cluding naloxone, an antagonist that induces withdrawal if the drug is injected

Poor patient compliance (but Vivitrol should improve compliance); initi- ation requires attaining prolonged (e.g., 7-day) abstinence, during which withdrawal, relapse, and early dropout may occur

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n engl j med 370;22 nejm.org may 29, 20142066

its consequences by expanding the number of high-risk people who receive MATs through either public or private insurance. The importance of access to MATs and other treatment services for substance-use disorder is under- scored by the recent recognition of increased heroin use; what may be less widely recognized is that the majority of these new heroin users initially abused pre- scription opioids before shifting to heroin.

HHS agencies are actively col- laborating with public and private stakeholders in efforts to expand access to and improve utilization of MATs, in tandem with other targeted approaches to reducing opioid overdoses.2 For example, the National Institute on Drug Abuse (NIDA) is funding research to improve delivery of MATs to vulnerable populations, includ- ing those in the criminal justice system. NIDA is also working to develop new pharmacologic treat- ments for opioid addiction and helping to fund “user friendly” delivery systems for naloxone (i.e., intranasal rather than injection). SAMHSA is encouraging MAT use in its state funding of sub- stance-abuse treatment programs through the Substance Abuse Prevention and Treatment Block Grant and regulatory oversight of methadone and buprenorphine for opioid addiction. Furthermore,

SAMHSA supports production and dissemination of educational resources to MAT prescribers, as well as an “Opioid Overdose Tool- kit” to educate first responders, treatment providers, and patients about ways to prevent and inter- vene in opioid-overdose cases.

The Centers for Disease Con- trol and Prevention is working to empower states to implement com- prehensive strategies, including MATs, for preventing prescrip- tion-drug overdoses. These strat-

egies focus primarily on address- ing the overdose epidemic through enhanced surveillance, effective policies, and clinical practices that establish statewide prescribing norms. Such efforts can be en- hanced by using data sources to identify and intervene in cases of patients or providers who fall out- side those norms. And the Centers for Medicare and Medicaid Ser- vices is working to enhance access to MATs by Medicaid programs through improved benefit design and application of the Mental Health Parity and Addiction Equi- ty Act. But to be successful, all these initiatives require the active engagement and participation of the medical community.

The epidemic of prescription- opioid overdose is complex. Ex- panding access to MATs is a crucial component of the effort to help patients recover. It is also necessary, however, to implement

primary prevention policies that curb the inappropriate prescrib- ing of opioid analgesics — the key upstream driver of the epi- demic — while avoiding jeopar- dizing critical or even lifesaving opioid treatment when it is need- ed. Essential steps for physicians will be to reduce unnecessary or excessive opioid prescribing, routinely check data from pre- scription-drug–monitoring pro- grams to identify patients who may be misusing opioids, and take full advantage of effective MATs for people with opioid ad- diction. Psychology Discussion Oipioid Use Paper

Disclosure forms provided by the au- thors are available with the full text of this article at NEJM.org.

From the National Institute on Drug Abuse, National Institutes of Health, Bethesda (N.D.V.), the Substance Abuse and Mental Health Services Administration, Rockville (P.S.H.), and the Center for Medicaid and CHIP Services, Centers for Medicare and Medicaid Services, Baltimore (S.S.C.) — all in Maryland; and the Centers for Disease Control and Prevention, Atlanta (T.R.F.).

This article was published on April 23, 2014, and updated on May 1, 2014, at NEJM.org.

1. Jones CM, Mack KA, Paulozzi LJ. Pharma- ceutical overdose deaths, United States, 2010. JAMA 2013;309:657-9. 2. Addressing prescription drug abuse in the United States: current activities and future opportunities. Atlanta: Centers for Disease Control and Prevention, 2013 (http://www .cdc.gov/homeandrecreationalsafety/ overdose/hhs_rx_abuse.html). 3. Schwartz RP, Gryczynski J, O’Grady KE, et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. Am J Public Health 2013;103:917- 22. 4. Knudsen HK, Abraham AJ, Roman PM. Adoption and implementation of medica- tions in addiction treatment programs. J Ad- dict Med 2011;5:21-7. 5. Clark RE, Baxter JD. Responses of state Medicaid programs to buprenorphine diver- sion: doing more harm than good? JAMA In- tern Med 2013;173:1571-2.

DOI: 10.1056/NEJMp1402780 Copyright © 2014 Massachusetts Medical Society.

Tackling the Opioid-Overdose Epidemic

A key driver of the overdose epidemic is underlying substance-use disorder. Consequently, expanding access to

addiction-treatment services is an essential component of a comprehensive response.

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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

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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 psycho- social interventions led to statistically significant benefits for out- comes 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 dur- ing induction or maintenance stages. Further research is needed to determine effectiveness of psychosocial interventions during dose reduction and long-term relapse prevention. Psychology Discussion Oipioid Use Paper

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). Hydro- codone 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

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

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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 esti- mated 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 non- medical 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 develop- ment 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 physiolo- gical 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). Psychology Discussion Oipioid Use Paper

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 substan- tial. 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.,

2 A. R. Brown

 

 

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 inter- ventions are effective for relapse prevention is needed. Psychology Discussion Oipioid Use Paper

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 detoxifica- tion. Relapse prevention often includes a pharmacological component such as the use of an opioid agonist and conjunctive psychosocial components. Pharma- cological maintenance is sometimes derided as merely a substitution of one addictive drug for another. However, there is substantial evidence that medica- tion-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 compo- nent of relapse prevention, either in conjunction with pharmacological treat- ment or in medication-free treatment modalities. Previous systematic reviews have addressed similar questions pertaining to opioid addiction in general, but

Psychosocial Interventions and Opioid Addiction 3

 

 

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. Psychology Discussion Oipioid Use Paper

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 physiolo- gical 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.

4 A. R. Brown

 

 

● 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.