Opiate dependence Effective treatment and Lanarkshire practices

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Opiate dependence Effective treatment and
Lanarkshire practices
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What is a systematic review?

• Unmanageable amounts of information
• Integrate valid information in an efficient way
• Establish where
• effects are consistent
• research results can be generalised
• effects may vary significantly
• Limit bias and reduce chance effects
• (Cochrane Reviewers Handbook, 2002)

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Papers Identified, Retrieved Included
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Methadone Maintenance

• Primary Outcomes
• Improved abstinence
• Reduced illicit opiate use
• Increased retention in treatment
• Withdrawal symptoms reduced
• Mortality reduced
• Secondary Outcomes
• Acquisitive crime reduced
• Drug related crime reduced
• Injecting reduced
• Sharing reduced
• Employment and housing status improved

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Aspects of Programme Delivery

• Higher doses give better outcomes lt50mg-65mg
• Contingency contracts e.g. take home doses
  contingent on clean urine sample
• Also
• the provision of more and better psychosocial and
  medical services
• having a treatment goal of successful ongoing
  maintenance rather than abstinence
• low staff turnover rates and better staff-client
  relationships
• the use of psychotherapy and
• the inclusion of non-using significant others

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Tell us something we dont know!

• Three variables identified as being important to
  the effectiveness of a treatment programme were
  used in the Dole and Nyswander (1965) model of
  methadone maintenance. They are
• the use of high doses of methadone.
• the provision of extensive ancillary services.
• successful maintenance on methadone as a goal of
  treatment rather than an abstinent life.

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Buprenorphine Maintenance

• Effectiveness comparable with methadone across
  primary outcomes
• Further research required with an extended range
  of doses
• U.K.-based comparative cost-effectiveness study
  highlighted as a research gap

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Naltrexone

• Currently used to assist relapse prevention with
  a relatively small number of patients in
  Lanarkshire
• Shown to be effective with highly-motivated
  clients
• Has been linked elsewhere with overdose risk
• Use of implants could improve effectiveness of
  Naltrexone

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Community Detoxification

• Lofexidine is preferable to clonidine due to
  fewer adverse effects on blood pressure
• Methadone is more effective than lofexidine
• Buprenorphine alone is probably preferable to
  lofexidinebuprenorphine
• Buprenorphine is probably more effective than
  methadone, but more U.K.-based research is
  required
• But ..
• High rates of relapse are common with all
  approaches

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Residential rehabilitation

• Key finding of inadequate evidence, primarily due
  to poorly-designed studies
• Programmes may contribute towards reducing
  illicit opiate use and criminal activity, and
  improving employment, providing that clients are
  retained in and complete the programme
• Follow-up studies of clients in the community
  following discharge is a crucial research gap

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Summary of implications for Lanarkshire

• Give methadone a chance?
• Low-dosing perpetuates the misconception that
  this is an ineffective treatment
• Contingent reinforcement can optimise maintenance
  treatment
• Economic factors are important when evaluating
  treatment options
• The link between community detox and psychosocial
  services should be explored
• Ultra-rapid withdrawal warrants considerable
  caution

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Limitations

• Majority of studies in USA
• Exclusion criteria
• Major co-morbidity
• Dual dependency
• UK lacking RCTs