Behavioral counseling and abstinence-contingent take-home buprenorphine in general practitioners’ offices in Malaysia: a randomized, open-label clinical trial

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Background and aim: To address the widespread severe problems with opioid use disorder, buprenorphine–naloxone treatment provided by primary care physicians has greatly expanded treatment access; however, treatment is often provided with minimal or no behavioral interventions. Whether or which behavioral interventions are feasible to implement in various settings and improve treatment outcomes has not been established. This study aimed to evaluate two behavioral interventions to improve buprenorphine–naloxone treatment. Design: A 2 × 2 factorial, repeated-measures, open-label, randomized clinical trial. Settings: General medical practice offices in Muar, Malaysia. Participants: Opioid-dependent individuals (n = 234). Interventions: Participants were randomly assigned to one of four treatment conditions and received study interventions for 24 weeks: (1) physician management with or without behavioral counseling and (2) physician management with or without abstinence-contingent buprenorphine–naloxone (ACB) take-home doses. Measurements: The primary outcomes were proportions of opioid-negative urine tests and HIV risk behaviors [assessed by audio computer-assisted AIDS risk inventory (ACASI-ARI)]. Findings: The rates of opioid-negative urine tests over 24 weeks of treatment were significantly higher with [68.2%, 95% confidence interval (CI) = 65–71] than without behavioral counseling (59.2%, 95% CI = 56–62, P < 0.001) and with (71.0%, 95% CI = 68–74) than without ACB (56.4%, 95% CI = 53–59, P < 0.001); interaction effects between and among behavioral interventions and time were not statistically significant. Scores on ACASI-ARI decreased significantly from baseline across all treatment groups (P < 0.001) and did not differ significantly with or without behavioral counseling (P = 0.099) or with or without ACB (P = 0.339). Conclusions: Providing opioid-dependent patients in Muar, Malaysia with buprenorphine–naloxone and physician management plus behavioral counseling or abstinence-contingent buprenorphine–naloxone (ACB) resulted in greater reductions of opioid use compared with providing buprenorphine–naloxone and physician management without behavioral counseling or ACB.

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