A stress-coping profile of opioid dependent individuals entering naltrexone treatment: a comparison with healthy controls.

Abuse of heroin and prescription opioids remains a significant public health concern despite the availability of effective pharmacotherapies such as naltrexone, methadone, buprenorphine, and the buprenorphone/naloxone combination (Comer, Sullivan & Hulse, 2007). Of these medications, orally administered naltrexone is the only approved opioid antagonist that blocks the euphoric effects of opioids and which serves as a non-dependence-forming alternative to opioid agonists such as methadone and buprenorphine. The clinical utility of naltrexone follows from operant conditioning models of behavior which predict that opioid use will extinguish if not reinforced by opioid effects on brain reward circuits (Tucker & Ritter, 2000). Cognitively, naltrexone may deter opioid use by creating the expectancy that users will not experience the drug’s effects. Despite the strong theory in support of its use and the unequivocal pharmacologic effectiveness of naltrexone in blocking the actions of opioids, naltrexone has not lived up to its potential with treatment programs typically struggling with poor adherence and high drop-out rates (Comer et al., 2007; Kirchmayer, et al. 2002; Rounsaville, 1995; Tucker & Ritter, 2000). Reasons given for poor adherence include naltrexone’s absence of reinforcing properties, the requirement of a detoxification and an opioid-free period prior to initiation, adverse neuropsychiatric and gastrointestinal effects possibly caused by naltrexone itself, discomfort associated with protracted withdrawal symptoms (e.g., nervousness; sleep difficulty), the absence of negative consequences for abrupt discontinuation, and a lack of genuine motivation to achieve abstinence (Comer et al., 2007; Rounsaville, 1995; Tucker & Ritter, 2000). Another possible contributor to the adherence problems associated with this form of treatment is that naltrexone treated opioid abusers in early recovery experience high levels of stress which may increase drug craving and relapse susceptibility. Indeed, stress plays a role in drug craving and addiction relapse (Sinha, 2008), and evidence suggests that naltrexone treated opioid abusers demonstrate vulnerability to stress induced craving and hyper-arousal responses despite opioid effects being blocked by four to six weeks of chronic naltrexone treatment (Hyman, et al. 2007). Considering that naltrexone does not protect against stress in opioid abusers, gaining a better understanding of stress-related factors (e.g., coping, social support) that could be targeted to reduce stress-related vulnerability to addiction may improve treatment outcomes. Stress is conceptualized as a relationship between an individual and his/her environment that is appraised as exceeding coping resources and has the potential to endanger well-being (Lazarus & Folkman, 1984). Stress plays a prominent role in the perpetuation of drug addiction (Goeders, 2003; 2004; Sinha, 2001; 2005; 2008; Turner & Lloyd, 2003; Wills, 1990) and may be particularly taxing during early recovery as opioid dependent individuals attempt to cope with stressors (e.g., legal and relationship problems, job loss, financial debt) and unremitting protracted withdrawal symptoms without resorting to opioid use. Indeed, their overall level of stress, the manner by which they cope with their difficulties, and the strength of their social support networks (conceptualized as a coping resource for the purposes of the current study) may help determine their success at averting stress-related relapse and attaining a drug-free lifestyle. Regarding personal coping resources, there is evidence that substance abusers who actively take steps to overcome problems (e.g., through problem solving, conflict resolution, and healthy affect regulation) as compared with those who more commonly avoid facing problems or focus on venting emotions in response to stress (e.g., yelling at others; slamming doors) typically meet with better outcomes (Beutler, Moos, & Lane, 2003; Eftekhari, Turner, & Larimer, 2004; Wills & Hirky, 1996). Supportive relationships may also facilitate recovery efforts (Broome, Simpson, & Joe, 2002; Ellis, Bernichon, Yu, Roberts, & Herrell, 2004; Havassy, Hall, & Wasserman, 1991; McMahon, 2001; Warren, Stein, & Grella, 2007) by assisting with coping and promoting less threatening interpretations of negative life events (Cohen, 2004; DeLongis & Holtzman, 2005; Ozbay, Johnson, Dimoulas, Morgan III, Charney, & Southwick, 2007), and moderating the impact that stress has on cravings (Ames & Roitzsch, 2000). For these reasons, assessment of perceived stress, coping, and social support at treatment entry may identify strengths and deficits that could help inform treatment planning and stress-focused intervention. Importantly, these are all factors that are amenable to change. Thus, our study had two goals: The first was to compare opioid dependent individuals entering naltrexone treatment to healthy controls on measures of perceived stress, coping, and social support to identify their relative strengths and deficits. Our second goal was to examine the effects of coping and social support on stress within the sample and explore whether the relationship between social support/coping and perceived stress would be different for opioid dependent versus healthy control participants. We hypothesized that: 1) opioid dependent individuals would report greater stress, less use of adaptive coping strategies (problem and emotion-focused coping), greater use of maladaptive/avoidant coping strategies, and less social support than healthy social drinking controls, and 2) social support and coping would be associated with perceived stress. We also examined the exploratory hypothesis that the relation between coping strategies/social support and perceived stress would be different for the opioid dependent versus healthy control individuals.