Over the last few years the number of opioids being prescribed has

Over the last few years, the number of opioids being prescribed has increased drastically, which has contributed to the misuse and dependence of opioids, heroin, and other synthetic opioids among individuals leading to the current opioid epidemic (Schuckit, 2016). The literature on the opioid crisis is extensive, affecting a variety of populations and demographics (Schuckit, 2016). The data regarding the opioid epidemic has been conducted through several meta- analysis studies, systematic reviews, literature reviews, and some experimental studies. This literature review will briefly cover what opioid dependence is, the magnitude of how this epidemic affects our public health system, the involvement, prognosis, and rehabilitation process of medicated assisted treatment compared to behavioral therapies in opioid misusers.

The purpose of this literature review is to determine whether the effectiveness of evidence-based behavioral therapies or medication- assisted treatments is a better intervention in the recovery process of opioid misusers. The literature review will address any limitations or lack of validity concerning the studies found in these evidence- based treatments.

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Theoretical ConsiderationsIn the public health system, the ecological model has been analyzed to explain human behavior specifically behaviors regarding drug use. Humans interact and learn from one another in their environment in differing ways, including at an individual, institutional, community, and policy level (Saloner, 2018). Multiple factors are involved in why individuals may turn to drugs or have the drive to use drugs. Structural factors such as education, discrimination, homelessness, socio-economic status, quality of resources, and experiences of trauma are all factors that reflect social and economic conditions (Saloner, 2018).

These structural factors reflect social disadvantage and inequalities in society, which negatively impact individuals' lives and can have an adverse effect on the individual, social, and economic environments of these communities (Saloner, 2018). The public health system's ecological approach presents that harmful drug use is closely associated with social structures. The opioid epidemic has created an economic burden for the public health system. Vast increases in spending on treatment and saving lives, incarceration and criminal justice involvement, and diseases being spread from the use of shared needles are all ways in which the public health system have been affected (Saloner, 2018).Body of Literature ReviewOpioid dependence is described by habitual, prolonged self-administration of natural, semisynthetic, or synthetic opioids that results in developing a tolerance to the drug in which withdrawal symptoms occur if an individual suddenly stops taking the drugs (Tkacz, Severt, Cacciola, &Ruetsch, 2011). The withdrawal side effects can be extremely uncomfortable and dangerous, if an individual abruptly discontinues the substance without medical care. Relapsing is one of the biggest obstacles for these individuals to overcome, due to several factors that may increase the risk of using again. Life stressors, environmental agents, genetic predisposition, and physical changes in the brain's structure or functionality in the chemistry and neurotransmitter levels, all contribute to an individual's threat of relapsing (Tkacz et al., 2011). Due to the high risk of relapse, it is important to treat the withdrawal symptoms and taper an opioid misuser off instead of strictly abstaining from the drug. Medication- Assisted Treatments (MATs) such as methadone and buprenorphine are two of the most well- known effective evidence based pharmacological treatments used today.Methadone and BuprenorphineMethadone, a full opioid agonist, was approved in 1972 by the Food and Drug Administration with the purpose to prevent or reduce withdrawal symptoms and cravings for heroin and other opioids. (McGovern &Carroll, 2003). Methadone is a long- acting opioid agonist and stabilizes opioid receptors for approximately 24 hours (Williams, 2018). Methadone has been used for short- and long-term maintenance and has shown decreases in drug use, psychiatric symptoms, and criminal activity, and also shown increases in employment (McGovern &Carroll, 2003). Buprenorphine is another opioid agonist that has saved lives and aided in public health. The FDA approved Buprenorphine in 2002, and like methadone, is a medication-assist treatment for opioid dependence except it only partially activates opioid receptors, limiting the ability for overdose (Williams, 2018). Buprenorphine is safer than methadone, has a mild addictive/dependence potential, has slightly fewer stigmas, and patients have more freedom because it can be prescribed by a trained medical physician in general outpatient settings, unlike methadone in which you have to be involved in an opioid treatment clinic/program. (Williams, 2018). Tkacz et al., 2011, researched buprenorphine as an effective treatment for preventing relapse in opioid dependent individuals. Tkacz et al., 2011, wanted to examine whether individuals who were compliant with taking buprenorphine were going to be less likely to relapse. A total of 2,194 opioid dependent participants were recruited and enrolled in the study from October 2008 to January 2009 (Tkacz, et al, 2011). These participants were then randomly assigned into two different groups, both groups being treated with buprenorphine. Buprenorphine compliance was operationally defined as taking the medication for at least 22 out of 28 days each month, and those participants who took the medication fewer than 22 days were coded as noncompliant (Tkacz, et al, 2011). The results indicated that those who were noncompliant in taking buprenorphine as scheduled, were ten times more likely to relapse using opioids than the med-compliant patients who took buprenorphine as scheduled. In another study, a multivariable analysis compared the characteristics and treatment outcomes for 1 year from patients taking methadone and buprenorphine. In over one year's time frame, patients had to remain opioid- negative each month and successful treatment was defined as achieving opioid negative results on the drug screens for at least six months and remaining in treatment for the full year (Fingerhood et. al., 2014). Results indicated that patients on methadone had a slightly higher mean number of opioid negative months and higher mean number of months in treatment, compared to the patients taking buprenorphine (Fingerhood et. al., 2014). It has been reported from meta-analyses, that there are moderately higher retention rates in methadone treatment than buprenorphine, although studies do distinctly show that both medicated assisted treatments (MATs) are more effective than not receiving any treatment at all (Fingerhood et. al., 2014) While both of these pharmacological therapies have demonstrated strong empirical abilities to improve the quality of lives, reduce drug use, reduce mortality, and help our public health system, there are quite a few limitations and concerns regarding these medication-assisted treatments. Individuals who are taking buprenorphine usually vary in population than the individuals taking methadone. Individuals may not be able to continue to maintain taking these treatments due to a variety of factors such as lack of providers, access to methadone clinics, money, health insurance, and self-motivation to change. Methadone requires users to participate in a methadone clinic treatment program in which the methadone is administered early in the mornings from clinical team members (Tkacz et al., 2011). Not all individuals can find access to such clinics or have the insurance to cover such costs. Buprenorphine is prescribed by specifically trained individuals and must obtain a DEA waiver (Williams, 2018). These clinicians with this specific training may be more uncommon and also depending on insurance, costs are left to pay out of pocket. (Williams, 2018). Buprenorphine is self-administered once the individual has possession of the medication, which requires individuals to be highly self-reliant and also compliant with medication directives regarding dosing and timing (Tkacz et al., 2011). Several structural and environmental factors affect one's ability to safely and successfully remain in treatment and complete treatment without relapsing. Cognitive Behavioral Therapy and Motivational InterviewingSeveral large scale trials and quantitative reviews demonstrate the effectiveness and success of Cognitive- behavioral therapy for alcohol and drug use disorders (McHugh,Hearon, & Otto, 2010). CBT is based on principles of social learning theory and operant conditioning. This behavioral intervention restructures individuals' thoughts on drug use experiences, teaches them consequences of opioid use, teaches them the skills and knowledge to recognize the situations in which they are most vulnerable to use drugs, and teaches/ utilizes coping strategies to fight the urge to use again (Caroll & Onken, 2005). A functional analysis of the individual in CBT helps opioid misusers to understand feelings, thoughts, experiences, and situations in which they would be at risk for relapsing and developing skills on how to cope with these thoughts to prevent negative behaviors from occurring (Kelly, 2015). Motivational interviewing is an approach that targets individuals who are ambivalent about making changes in their life regarding their opioid use behaviors (McHugh et al., 2010). Like CBT, this intervention can be used alone or in combination with other interventions or pharmacotherapies. Contingency ManagementThis psychosocial intervention has been utilized as well as an evidence-based treatment intervention with drug and alcohol abusers. Its purpose is to give patients rewards or incentives for abstaining from drug use or meeting certain goals in therapy (Caroll & Onken, 2005). Like cognitive-behavioral therapy, this treatment intervention has principles rooted in operant conditioning, in which a behavior that elicits positive consequences, is more likely to become repeated (Caroll & Onken, 2005). For example, a patient is allowed the privilege of taking home a methadone dose, depending on if the patient has provided a negative drug screen (Caroll & Onken, 2005). This type of reward system also works with food vouchers and other positive incentives dependent upon if the patient is succeeding with the treatment and maintaining negative drug screens and is associated with abstaining from engaging in opioids and other drugs (Caroll & Onken, 2005). Limitations and Conclusion Opioid Addiction is an extremely pervasive issue in today's society. The goals of MAT and psychosocial interventions are to help decrease the withdrawal side effects and cravings from opioids misusers while restructuring healthy behavior and coping mechanisms to maintain a positive, beneficial lifestyle. Data on behavioral approaches and medication-assisted therapy have been seen in a positive light, however additional research needs to be found and conducted regarding this topic. More research needs to be conducted on treatment outcomes using both behavioral/psychosocial therapies in conjunction with MAT therapies. Due to the heterogenous populations, these treatment interventions are very powerful and noteworthy but not all individuals will show measurable, positive, and beneficial outcomes. The internal validity is fairly strong for these studies; however, the external validity is weak because we cannot generalize these results to broader populations. Not all individuals will improve as quickly or as desired, because everyone is different, and those differences are very challenging to account for with this type of situation. Not everyone that is in treatment may be ready to change their life, their structural and social environments may not be as stable, and they may have significant barriers that are keeping them from getting the help they want or need. The different psychosocial therapies may help each individual in a different way or may not help at all. Some of the data found in the literature was based off of self-report, which has a social desirability element which is also a limitation to consider. From the literature review conducted, it appears that medication assisted therapy is imperative for the opioid dependent individual and does show successful outcomes, however there is not enough evidence to support that both, behavioral and medication assisted therapy used in combination with each other is the most effective (Dugosh et., al).