Counseling plus Buprenorphine–Naloxone for Opioid Dependence
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《新英格兰医药杂志》
To the Editor: Two points in the report by Fiellin et al. (July 27 issue)1 on the use of counseling plus buprenorphine–naloxone maintenance therapy for opioid dependence warrant further discussion. First, the authors report that patients' adherence to treatment with buprenorphine–naloxone correlated significantly with the outcome. It would be informative to know what the relationship was between adherence to counseling and the treatment outcome. My colleagues and I recently reported on adherence to counseling in a clinical trial of buprenorphine for the treatment of combined opioid and cocaine dependence in medication-adherent patients.2 There was a significant positive association between adherence to counseling and treatment outcome. Second, Fiellin et al. report no significant differences in the percentage of cocaine-negative urine specimens among the three treatment groups, but they do not state whether there was any change from baseline (data they do report for opioid use) or whether there was an association between the daily dose of buprenorphine (sublingual tablet; mean dose, 17.5±2.5 mg, and maximum dose, 24 mg) and cocaine use. Previous work by the authors' group3 and by others4 suggests that high-dose buprenorphine (16 mg in a sublingual solution, roughly equivalent to a 32-mg sublingual tablet) reduces the use of cocaine and opioids.
David A. Gorelick, M.D., Ph.D.
National Institute on Drug Abuse
Baltimore, MD 21224
dgorelic@intra.nida.nih.gov
References
Fiellin DA, Pantalon MV, Chawarski MC, et al. Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence. N Engl J Med 2006;355:365-374.
Montoya ID, Schroeder JR, Preston KL, et al. Influence of psychotherapy attendance on buprenorphine treatment outcome. J Subst Abuse Treat 2005;28:247-254.
Schottenfeld RS, Pakes J, Ziedonis D, Kosten TR. Buprenorphine: dose-related effects on cocaine and opioid use in cocaine-abusing opioid-dependent humans. Biol Psychiatry 1993;34:66-74.
Montoya ID, Gorelick DA, Preston KL, et al. Randomized trial of buprenorphine for treatment of concurrent opiate and cocaine dependence. Clin Pharmacol Ther 2004;75:34-48.
The authors reply: Gorelick inquires about the relationship between adherence to counseling and outcomes. Our primary aims were to assess the effect of two "doses" of counseling and two dispensing regimens. We did not find a significant association between adherence to counseling and outcomes. Because nurses provided counseling at the same time that the patients received their buprenorphine–naloxone, adherence to counseling may not have been as variable in our study as in others. Regarding changes in cocaine use according to treatment group, cocaine-dependent patients were excluded from our study, unlike the studies cited by Gorelick. In our study, 20 to 21% of patients had evidence of recent cocaine use at baseline and 24 to 29% of urine samples collected during treatment showed evidence of cocaine use. No differences according to treatment group were noted for this outcome. Finally, regarding the dose of buprenorphine and cocaine use in our study, the buprenorphine dose was increased in response to evidence of ongoing opioid use, cocaine use, or the patient's symptoms. Consistent with this approach was the finding that ongoing illicit-drug use was highly correlated with the buprenorphine dose.
David A. Fiellin, M.D.
Brent A. Moore, Ph.D.
Richard S. Schottenfeld, M.D.
Yale University School of Medicine
New Haven, CT 06511
david.fiellin@yale.edu
David A. Gorelick, M.D., Ph.D.
National Institute on Drug Abuse
Baltimore, MD 21224
dgorelic@intra.nida.nih.gov
References
Fiellin DA, Pantalon MV, Chawarski MC, et al. Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence. N Engl J Med 2006;355:365-374.
Montoya ID, Schroeder JR, Preston KL, et al. Influence of psychotherapy attendance on buprenorphine treatment outcome. J Subst Abuse Treat 2005;28:247-254.
Schottenfeld RS, Pakes J, Ziedonis D, Kosten TR. Buprenorphine: dose-related effects on cocaine and opioid use in cocaine-abusing opioid-dependent humans. Biol Psychiatry 1993;34:66-74.
Montoya ID, Gorelick DA, Preston KL, et al. Randomized trial of buprenorphine for treatment of concurrent opiate and cocaine dependence. Clin Pharmacol Ther 2004;75:34-48.
The authors reply: Gorelick inquires about the relationship between adherence to counseling and outcomes. Our primary aims were to assess the effect of two "doses" of counseling and two dispensing regimens. We did not find a significant association between adherence to counseling and outcomes. Because nurses provided counseling at the same time that the patients received their buprenorphine–naloxone, adherence to counseling may not have been as variable in our study as in others. Regarding changes in cocaine use according to treatment group, cocaine-dependent patients were excluded from our study, unlike the studies cited by Gorelick. In our study, 20 to 21% of patients had evidence of recent cocaine use at baseline and 24 to 29% of urine samples collected during treatment showed evidence of cocaine use. No differences according to treatment group were noted for this outcome. Finally, regarding the dose of buprenorphine and cocaine use in our study, the buprenorphine dose was increased in response to evidence of ongoing opioid use, cocaine use, or the patient's symptoms. Consistent with this approach was the finding that ongoing illicit-drug use was highly correlated with the buprenorphine dose.
David A. Fiellin, M.D.
Brent A. Moore, Ph.D.
Richard S. Schottenfeld, M.D.
Yale University School of Medicine
New Haven, CT 06511
david.fiellin@yale.edu