Article type
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Abstract
Background: As of January 2004 the Cochrane review group on Drugs and Alcohol published 19 reviews and 13 review protocols; 5 reviews focused on efficacy and acceptability of substitutive maintenance treatments for opioid dependence. Details of the methods and results of each review are available in the Cochrane Library.
Objectives: To summarise the major findings of the 5 reviews on substitutive maintenance treatment for opioid dependence, with comparison of quantitative data where possible. Methods: 52 were the studies included, with 12.075 participants. The treatments considered were: methadone, buprenorphine, LAAM and heroin. All the included studies are RCTs but ten are Controlled Perspective Studies, and their analysis is presented separately. The mean length of treatment was 32 weeks (range 2-192). The countries of origin of studies were: USA (75%), Australia, Netherlands, Switzerland, Italy, United Kingdom, Austria, China, Thailand, Spain and Sweden. The comparisons considered were: Methadone Maintenance Treatments (MMT) vs Methadone Detoxification Treatments (MDT), vs no treatment, MMT at different dosages, Buprenorphine maintenance treatments (BMT) vs MMT, BMT at different dosages, Heroin maintenance vs Methadone, LAAM maintenance vs MMT. The outcomes were: signs and symptoms of withdrawal, retention in treatment, heroin use, use of other drugs, mortality, criminal activity, quality of life. Results are presented as RR and 95% CI in brackets.
Results: RETENTION IN TREATMENT: MMT is more effective than MDT RR 3.86 (1.09 to 13.75), no treatment RR 2.50 (1.56-3.99), BMT RR 1.23 (1.04-1.44), LAAM both at 3 RR 2.18 (1.43-3.25) and 12 months RR 1.43 (1.14-1.78) and heroin if given together with methadone injected RR 1.17 (0.99-1.38) or inhaled RR 1.27 (1.11-1.46). MMT proved to be less effective than injected heroin alone RR 0.35 (0.21-0.59). High doses of methadone resulted more effective than medium and low: 60-109 mg vs 40-59 mg RR 1.23 (1.05-1.45), 60-109 mg vs 1-39 mg RR 1.36 (1.13-1.63). USE OF HEROIN DURING THE TREATMENT:.MMT is more effective than waiting list RR 0.32 (0.23-0.44), and less effective than LAAM RR 1.23, (1.10-1.39), no differences with injected heroin RR 0.91, (0.66-1.27). Heroin mean 509 mg/day proved to be better than any other conventional drug treatment RR 0.33, (0.15-0.72). MORTALITY- CRIMINAL ACTIVITY: No statistically significant differences in the 19 studies reporting these results. QUALITY OF LIFE: no difference was observed between methadone and injected heroin in the study reporting this result.
Conclusions: Data from systematic reviews show MMT at appropriate doses the most effective in retaining patients in treatment and suppressing heroin use. The available evidence calls for two different actions in terms of clinical practice and research. On one side, proper methadone therapy should be offered to patients but on the other side future clinical trials should select clinically relevant alternative interventions to compare, include a diverse population of study participants, recruit participants from heterogeneous practice settings and heterogeneous social contexts, and collect data on a broad range of health outcomes.
Objectives: To summarise the major findings of the 5 reviews on substitutive maintenance treatment for opioid dependence, with comparison of quantitative data where possible. Methods: 52 were the studies included, with 12.075 participants. The treatments considered were: methadone, buprenorphine, LAAM and heroin. All the included studies are RCTs but ten are Controlled Perspective Studies, and their analysis is presented separately. The mean length of treatment was 32 weeks (range 2-192). The countries of origin of studies were: USA (75%), Australia, Netherlands, Switzerland, Italy, United Kingdom, Austria, China, Thailand, Spain and Sweden. The comparisons considered were: Methadone Maintenance Treatments (MMT) vs Methadone Detoxification Treatments (MDT), vs no treatment, MMT at different dosages, Buprenorphine maintenance treatments (BMT) vs MMT, BMT at different dosages, Heroin maintenance vs Methadone, LAAM maintenance vs MMT. The outcomes were: signs and symptoms of withdrawal, retention in treatment, heroin use, use of other drugs, mortality, criminal activity, quality of life. Results are presented as RR and 95% CI in brackets.
Results: RETENTION IN TREATMENT: MMT is more effective than MDT RR 3.86 (1.09 to 13.75), no treatment RR 2.50 (1.56-3.99), BMT RR 1.23 (1.04-1.44), LAAM both at 3 RR 2.18 (1.43-3.25) and 12 months RR 1.43 (1.14-1.78) and heroin if given together with methadone injected RR 1.17 (0.99-1.38) or inhaled RR 1.27 (1.11-1.46). MMT proved to be less effective than injected heroin alone RR 0.35 (0.21-0.59). High doses of methadone resulted more effective than medium and low: 60-109 mg vs 40-59 mg RR 1.23 (1.05-1.45), 60-109 mg vs 1-39 mg RR 1.36 (1.13-1.63). USE OF HEROIN DURING THE TREATMENT:.MMT is more effective than waiting list RR 0.32 (0.23-0.44), and less effective than LAAM RR 1.23, (1.10-1.39), no differences with injected heroin RR 0.91, (0.66-1.27). Heroin mean 509 mg/day proved to be better than any other conventional drug treatment RR 0.33, (0.15-0.72). MORTALITY- CRIMINAL ACTIVITY: No statistically significant differences in the 19 studies reporting these results. QUALITY OF LIFE: no difference was observed between methadone and injected heroin in the study reporting this result.
Conclusions: Data from systematic reviews show MMT at appropriate doses the most effective in retaining patients in treatment and suppressing heroin use. The available evidence calls for two different actions in terms of clinical practice and research. On one side, proper methadone therapy should be offered to patients but on the other side future clinical trials should select clinically relevant alternative interventions to compare, include a diverse population of study participants, recruit participants from heterogeneous practice settings and heterogeneous social contexts, and collect data on a broad range of health outcomes.