Retrospective analyses of additional services for methadone maintenance patients

Perceived social support in patients with chronic pain with and without opioid use disorder and role of medication for opioid use disorder

BACKGROUND

A significant predictor of treatment outcomes for patients with chronic non-cancer pain (CNCP) and opioid use disorder (OUD) is the degree and quality of social support they receive. Specifically, in patients with CNCP and on long-term opioid therapy, the development of OUD tends to be associated with losses in social support, while engagement in treatment for OUD improves support networks. Delivery of the evidence-based OUD treatment medications, methadone and buprenorphine, occurs in clinical environments which patently differ with respect to social support resources. The aims of this study were to describe perceived social support in patients with CNCP without OUD (no-OUD), with OUD and on buprenorphine (OUD-BP), and with OUD and on methadone (OUD-methadone).

METHODS

Using the Duke Social Support Index (DSSI), perceived social support in a sample of Caucasian patients with CNCP and on opioid therapy was compared between no-OUDs (n = 834), OUD-methadone (n = 83) and OUD-BP (n = 99) therapy. Average DSSI scores were compared across groups and a linear regression model computed to describe association between group and perceived social support.

RESULTS

No difference was observed in DSSI scores between no-OUDs and OUD-methadone, however scores were lower among OUD-BP participants than those receiving methadone (x = -5.2; 95% CI: -7.5, -2.9) and (x = -6.5, 95% CI: -8.2, -4.9).

CONCLUSIONS

Patients with CNCP and OUD on methadone therapy endorse levels of social support comparable to those without OUD, however those on buprenorphine therapy report significantly less support, bringing implications for OUD treatment outcomes.

Improving psychosocial health and employment outcomes for individuals receiving methadone treatment: a realist synthesis of what makes interventions work

BACKGROUND

For over 50 years, methadone has been prescribed to opioid-dependent individuals as a pharmacological approach for alleviating the symptoms of opioid withdrawal. However, individuals prescribed methadone sometimes require additional interventions (e.g., counseling) to further improve their health. This study undertook a realist synthesis of evaluations of interventions aimed at improving the psychosocial and employment outcomes of individuals on methadone treatment, to determine what interventions work (or not) and why.

METHODS

The realist synthesis method was utilized because it uncovers the processes (or mechanisms) that lead to particular outcomes, and the contexts within which this occurs. A comprehensive search process resulted in 31 articles for review. Data were extracted from the articles, and placed in four templates to assist with analysis. Data analysis was an iterative process and involved comparing and contrasting data within and across each template, and cross checking with original articles to determine key patterns in the data.

RESULTS

For individuals on methadone, engagement with an intervention appears to be important for improved psychosocial and/or employment outcomes. The engagement process involves attendance at interventions as well as an investment in what is offered. Three intervention contexts (often in some combination) support the engagement process: a) client-centered contexts (or those where clients' psychosocial and/or employment needs/issues/skills are recognized and/or addressed); b) contexts which address clients' socio-economic conditions and needs; and, c) contexts where there are positive client-counselor and/or peer relationships. There is some evidence that sometimes ongoing engagement is necessary to maintain positive outcomes. There is also some evidence that complete abstinence from drugs (e.g., cocaine, heroin) is not necessary for engagement.

CONCLUSIONS

It is important to consider how the contexts of interventions might elicit and/or support clients' engagement. Further research is needed to explore how an individual's background (e.g., involvement with different interventions over an extended period) may influence engagement. Long-term engagement may be necessary to sustain some positive outcomes although how long is unclear and requires further research. Engagement can occur without complete abstinence from such drugs as cocaine or heroin, but additional research is required as engagement may be influenced by the extent and type of drug use.

Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence

BACKGROUND

Maintenance treatments are effective in retaining patients in treatment and suppressing heroin use. Questions remain regarding the efficacy of additional psychosocial services.

OBJECTIVES

To evaluate the effectiveness of any psychosocial plus any agonist maintenance treatment versus standard agonist treatment for opiate dependence

SEARCH STRATEGY

We searched the Cochrane Drugs and Alcohol Group trials register (June 2011), Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2011), PUBMED (1996 to 2011); EMBASE (January 1980 to 2011); CINAHL (January 2003 to 2011); PsycINFO (1985 to 2003) and reference list of articles.

SELECTION CRITERIA

Randomised controlled trials and controlled clinical trial comparing any psychosocial plus any agonist with any agonist alone for opiate dependence.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality quality and extracted data.

MAIN RESULTS

35 studies, 4319 participants, were included. These studies considered thirteen different psychosocial interventions. Comparing any psychosocial plus any maintenance pharmacological treatment to standard maintenance treatment, results do not show benefit for retention in treatment, 27 studies, 3124 participants, RR 1.03 (95% CI 0.98 to 1.07), abstinence by opiate during the treatment, 8 studies, 1002 participants, RR 1.12 (95% CI 0.92 to 1.37), compliance, three studies, MD 0.43 (95% CI -0.05 to 0.92), psychiatric symptoms, 3 studies, MD 0.02 (-0.28 to 0.31), depression, 3 studies, MD -1.70 (95% CI -3.91 to 0.51) and results at the end of follow up as number of participants still in treatment, 3 studies, 250 participants, RR 0.90 (95% CI 0.77 to 1.07) and participants abstinent by opioid, 3 studies, 181 participants, RR 1.15 (95% CI 0.98 to 1.36). Comparing the different psychosocial approaches, results are never statistically significant for all the comparisons and outcomes.

AUTHORS' CONCLUSIONS

For the considered outcomes, it seems that adding any psychosocial support to standard maintenance treatments do not add additional benefits. Data do not show differences also for contingency approaches, contrary to all expectations. Duration of the studies was too short to analyse relevant outcomes such as mortality. It should be noted that the control intervention used in the studies included in the review on maintenance treatments, is a program that routinely offers counselling sessions in addition to methadone; thus the review, actually, did not evaluate the question of whether any ancillary psychosocial intervention is needed when methadone maintenance is provided, but the narrower question of whether a specific more structured intervention provides any additional benefit to a standard psychosocial support. These interventions probably can be measured and evaluated by employing diverse criteria for evaluating treatment outcomes, aimed to rigorously assess changes in emotional, interpersonal, vocational and physical health areas of life functioning.

Oral substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

Injecting drug users are vulnerable to infection with Human Immunodeficiency Virus (HIV) and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour

OBJECTIVES

To assess the effect of oral substitution treatment for opioid dependent injecting drug users on risk behaviours and rates of HIV infections

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO to May 2011. We also searched reference lists of articles, reviews and conference abstracts

SELECTION CRITERIA

Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two authors independently assessed each study for inclusion

DATA COLLECTION AND ANALYSIS

Two authors independently extracted key information from each of the included studies. Any differences were resolved by discussion or by referral to a third author.

MAIN RESULTS

Thirty-eight studies, involving some 12,400 participants, were included. The majority were descriptive studies, or randomisation processes did not relate to the data extracted, and most studies were judged to be at high risk of bias. Studies consistently show that oral substitution treatment for opioid-dependent injecting drug users with methadone or buprenorphine is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. However, because of the high risk of bias and variability in several aspects of the studies, combined totals were not calculated.

AUTHORS' CONCLUSIONS

Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.

Better retention of Malaysian opiate dependents treated with high dose methadone in methadone maintenance therapy

BACKGROUND

Methadone is a synthetic opiate mu receptor agonist that is widely used to substitute for illicit opiates in the management of opiate dependence. It helps prevent opiate users from injecting and sharing needles which are vehicles for the spread of HIV and other blood borne viruses. This study has the objective of determining the utility of daily methadone dose to predict retention rates and re-injecting behaviour among opiate dependents.

METHODS

Subjects comprised opiate dependent individuals who met study criteria. They took methadone based on the Malaysian guidelines and were monitored according to the study protocols. At six months, data was collected for analyses. The sensitivity and specificity daily methadone doses to predict retention rates and re-injecting behaviour were evaluated.

RESULTS

Sixty-four patients volunteered to participate but only 35 (54.69%) remained active and 29 (45.31%) were inactive at 6 months of treatment. Higher doses were significantly correlated with retention rate (p < 0.0001) and re-injecting behaviour (p < 0.001). Of those retained, 80.0% were on 80 mg or more methadone per day doses with 20.0% on receiving 40 mg -79 mg.

CONCLUSIONS

We concluded that a daily dose of at least 40 mg was required to retain patients in treatment and to prevent re-injecting behaviour. A dose of at least 80 mg per day was associated with best results.

A review of the community reinforcement approach in the treatment of opioid dependence

This article reviews the Community Reinforcement Approach (CRA) in the treatment of opioid dependence. It covers the use of CRA with both methadone maintenance patients and patients withdrawing from opioids. The data reviewed in the use of CRA in combination with methadone maintenance shows improvement in a number of areas. These include the reduction of opioid use, as well as other drugs of abuse, improved legal status, less psychiatric symptoms, and improved vocational and social functioning. CRA coupled with vouchers can assist in retaining patients in treatment long enough to improve opioid detoxification rates from buprenorphine and coupled with naltrexone may sustain abstinence. Further, the use of a standardized computerized format may extend the utility of CRA.

Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence

BACKGROUND

Maintenance treatments are effective in retaining patients in treatment and suppressing heroin use. Questions remain regarding the efficacy of additional psychosocial services offered by most maintenance programs.

OBJECTIVES

To evaluate the effectiveness of any psychosocial plus any agonist maintenance treatment versus standard agonist treatment for opiate dependence in respect of retention in treatment, use of substances, health and social status.

SEARCH STRATEGY

We searched: Cochrane Drugs and Alcohol Group's Register of Trials (February 2008), Cochrane Central Register of Controlled Trials (CENTRAL - The Cochrane Library issue 1, 2008), MEDLINE (January 1966 to February 2008), EMBASE (January 1980 to February 2008), CINAHL (January 2003-February 2008), PsycINFO (January 1985 to April 2003), reference lists of articles.

SELECTION CRITERIA

Randomised studies comparing any psychosocial plus any agonist with any agonist alone intervention for opiate dependence.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Twenty eight trials, 2945 participants, were included. These studies considered twelve different psychosocial interventions and three pharmacological maintenance treatments. Comparing any psychosocial plus any maintenance pharmacological treatment to standard maintenance treatment, results do not show benefit for retention in treatment, 23 studies, 2193 participants, Relative Risk (RR) 1.02 (95% CI 0.97 to 1.07), use of opiate during the treatment, eight studies, 681 participants, RR 0.86 (95% CI 0.65 to 1.13), compliance, three studies, MD 0.43 (95% CI -0.05 to 0.92), psychiatric symptoms, four studies, MD 0.02 (-0.19 to 0.23), depression, four studies, MD -1.30 (95% CI -3.31 to 0.72) and results at follow up as number of participants still in treatment at the end of the follow-up , 289 participants, RR 0.91 (95% CI 0.77 to 1.06). In spite of results at follow up as number of participants abstinent at the end of the follow-up, five studies, 232 participants, show a benefit in favour of the associated treatment RR1.15 (95% CI 1.01 to 1.32). The remaining outcomes were analysed only in single studies considering a limited number of participants.Comparing the different psychosocial approaches, results are never statistically significant for all the comparisons and outcomes.

AUTHORS' CONCLUSIONS

Results suggest that adding any psychosocial support to maintenance treatments improve the number of participants abstinent at follow up; no differences for the other outcome measures. Data do not show differences between different psychosocial interventions also for contingency approaches, contrary to all expectations. Duration of the studies was too short to analyse relevant outcomes such as mortality.

Substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour.

OBJECTIVES

To assess the effect of oral substitution treatment for opioid dependent injecting drug users on rates of HIV infections, and high risk behaviours.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO to March 2007. We also searched reference lists of articles, reviews and conference abstracts

SELECTION CRITERIA

Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two reviewers independently assessed studies for inclusion.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data from included studies, assessed quality and confirmed decisions by consulting with all other reviewers.

MAIN RESULTS

Thirty-three studies, involving 10,400 participants, were included. The majority were not randomised controlled studies and there were problems of confounding and bias. The studies varied in several aspects limiting the extent of quantitative analysis. Studies consistently show that oral substitution treatment for opioid-dependent injecting drug users is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection.

AUTHORS' CONCLUSIONS

Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.

Evaluation of the overall program effectiveness of HIV-related intervention programs in a community in Sichuan, China

OBJECTIVES

The study evaluates the overall effectiveness of intervention programs among female sex workers in a Chinese community.

STUDY DESIGN

Behavioral surveillance data in 2003, 2004, and 2005 obtained from 2 communities (intervened and control) were compared.

RESULTS

The baseline data (2003) of the 2 counties were not significantly different. In 2004 and 2005, the intervened county had significantly higher prevalence of condom use with their clients and regular sex partners (last-time and consistent use in the last month; OR = 2.2-33.2 in 2004 and 3.8-8.3 in 2005), higher HIV-related knowledge level (OR = 7.9 in 2004 and 17.3 in 2005), and lower STD prevalence (OR = 0.22 in 2004 and 0.11 in 2005). Coverage rates of HIV antibody testing and HIV-related services increased in the intervened county but decreased in the control county.

CONCLUSIONS

Intervention programs may result in substantial behavioral changes in a community within a few years.

Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence

BACKGROUND

Methadone maintenance at proper doses is effective in retaining patients in treatment and suppressing heroin use. Questions remain regarding the efficacy of the psychosocial services that are offered by most maintenance programs.

OBJECTIVES

To evaluate the effectiveness of any psychosocial plus any agonist maintenance treatment versus any agonist treatment alone in retaining patients in treatment, reducing the use of substances and improving health and social status.

SEARCH STRATEGY

We searched the Cochrane Central Register of Trials (CENTRAL) issue 3, 2003; MEDLINE 1966-2003; EMBASE 1980-2003; PsycINFO 1985-2003; relevant web sites; scan of reference list of relevant articles. There were no language or publication restrictions.

SELECTION CRITERIA

RCTs which focus on any psychosocial plus any agonist compared to any agonist maintenance intervention for opiate dependence. People aged less than 18 and pregnant women were excluded. Psychosocial in combination with antagonist maintenance treatment are excluded too.

DATA COLLECTION AND ANALYSIS

The trials were independently assessed for inclusion and methodological quality by the reviewers. Data were extracted independently and double checked.

MAIN RESULTS

The searching process resulted in the identification of 77 different studies: 12 studies met the inclusion criteria. These studies considered 8 different psychosocial interventions and 1 pharmacological treatment: Methadone Maintenance (MMT). The results show additional benefit in adding any psychosocial treatment to standard methadone maintenance treatment in relation to the use of heroin during the treatment RR 0.69 (95% CI 0.53-0.91); no statistically significant additional benefit was shown in terms of retention in treatment RR 0.94 (95% CI 0.85-1.02); and results at follow-up RR 0.90 (95% CI 0.76-1.07).

REVIEWERS' CONCLUSIONS

The present evidence suggests that adding any psychosocial support to Standard MMT significantly improves the non-use of heroin during treatment. Retention in treatment and results at follow-up are also improved, although this findings did not achieve statistical significance. Insufficient evidence is available on other possible relevant outcomes such as Psychiatric symptoms/psychological distress, Quality of life. Limitations to this review are imposed by the heterogeneity of the trials both in the interventions and the assessment of outcomes. Results of studies were sometimes in disagreement and because of lack of detailed information no meta analysis could be performed to analyse the results related to the outcomes more often reported as positive results in the single studies. Duration of the studies was also too short to analyse other relevant outcomes such as mortality. In order to study the possible added value of any psychosocial treatment over an already effective treatment such as standard MMT, only big multi-site studies could be considered which define experimental interventions and outcomes in the most standardized way as possible.

Substitution treatment of injecting opioid users for prevention of HIV infection

BACKGROUND

Injecting drug users are vulnerable to infection with HIV and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour.

OBJECTIVES

To assess the effect of oral substitution treatment for opioid dependent injecting drug users on rates of HIV infections, and high risk behaviours.

SEARCH STRATEGY

Multiple electronic databases were searched. Reference lists of retrieved studies, reviews and conference abstracts were handsearched.

SELECTION CRITERIA

Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered.

DATA COLLECTION AND ANALYSIS

Each potentially relevant study was independently assessed by two reviewers. For studies that met the inclusion criteria, key information was extracted by one reviewer and confirmed by consultation between all four reviewers.

MAIN RESULTS

Twenty-eight studies, involving 7900 participants, were included. The majority were not randomised controlled studies. Issues of confounding and bias are discussed. The studies varied in several aspects limiting the extent of quantitative analysis.

REVIEWERS' CONCLUSIONS

Oral substitution treatment for opioid-dependent injecting drug users is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review. However, these findings add to the stronger evidence of effectiveness of substitution treatment on drug use, and treatment retention outcomes shown by other systematic reviews. On this basis, the provision of substitution treatment for opioid dependence in countries with emerging HIV and injecting drug use problems as well as in countries with established populations of injecting drug users should be supported.

A systematic review of the effectiveness of the community reinforcement approach in alcohol, cocaine and opioid addiction

The community reinforcement approach (CRA) has been applied in the treatment of disorders resulting from alcohol, cocaine and opioid use. The objectives were to review the effectiveness of (1) CRA compared with usual care, and (2) CRA versus CRA plus contingency management. Studies were selected through a literature search of RCTs focusing on substance abuse. The search yielded 11 studies of mainly high methodological quality. The results of CRA, when compared to usual care: there is strong evidence that CRA is more effective with regard to number of drinking days, and conflicting evidence with regard to continuous abstinence in the alcohol treatment. There is moderate evidence that CRA with disulfiram is more effective in terms of number of drinking days, and limited evidence that there is no difference in effect in terms of continuous abstinence. Furthermore, there is strong evidence that CRA with "incentives" is more effective with regard to cocaine abstinence. There is limited evidence that CRA with "incentives" is more effective in an opioid detoxification program. There is limited evidence that CRA is more effective in a methadone maintenance program. Finally, there is strong evidence that CRA with abstinence-contingent "incentives" is more effective than CRA (non-contingent incentives) treatment aimed at cocaine abstinence.

Abstinence at intake for marijuana dependence treatment predicts response

Abstinence prior to entering treatment is common among individuals seeking substance abuse treatment. The current study examined the relationship between abstinence at a pretreatment intake assessment and treatment response during outpatient treatment for marijuana dependence. At the intake assessment, 142 marijuana-dependent individuals completed past 30 day calendars of daily drug use. Forty-four (31%) participants were pretreatment abstainers, as defined by reports of one or more consecutive days of marijuana abstinence prior to the day of the intake assessment. Non-abstainers (69%) reported marijuana use the day prior or the day of the assessment. Pretreatment abstainers were more likely to enter treatment (P < 0.05) and showed better treatment response than non-abstainers. Abstainers provided 50% more marijuana-negative urine screens during treatment (P < 0.05), and more than three times as many abstainers reported no marijuana use (P < 0.01). The groups did not differ on treatment completion. Marijuana abstinence at the time of initial clinic contact appears to be a strong predictor of success during treatment. Pretreatment abstinence may prove useful as a pretreatment matching strategy that could improve outcomes and cost-effectiveness. Clinical trials might consider including pretreatment abstinence status as a stratification variable during participant assignment or as a covariate in outcome analyses.

Access to services in the substance abuse treatment system. Variations by facility characteristics

In view of the importance of type and intensity of services during substance abuse treatment, this chapter looks at treatment and support services that substance abuse clients have access to during treatment. Trends in services over recent years are described. Services available to clients in the current treatment system are reviewed. Several facility characteristics affecting access to services are examined. Different ways of defining access to services are discussed. Findings from the Alcohol and Drug Services Study are used to illustrate service patterns in the national substance abuse treatment system. Variations in service patterns by facility characteristics such as type of care, treatment setting, ownership, percent of facility dependence on public revenue, and level of affiliation are analyzed. The implication is that clients who enter into treatment at different types of facilities are likely to have access to certain types of services.