Michael Gossop

Methadone maintenance treatment in opiate dependence: a review.

This paper examines the changes and advances in research and clinical practice and examines the role of treatment structure and programme characteristics in the delivery of methadone maintenance. Methadone prescribing has become much more available over the past decade, both in countries with a history of its use, such as the United Kingdom and Australia, and in countries around the world which previously had not endorsed substitute prescribing.1 There is a need to examine closely the framework in which this treatment is delivered to ensure that the modes of delivery most effective from both cost and benefit perspectives are utilised. This review focuses entirely on methadone maintenance because this is the most extensively evaluated and most used treatment, with about a quarter of a million drug misusers receiving methadone treatment globally. A small number of experimental diamorphine and buprenorphine substitute programmes are being evaluated in several countries. Most studies have come from the United States and focus on the long term use of methadone in a specific setting; in contrast, methadone treatment in the United Kingdom has received virtually no formal evaluation to date bar one study.2 There is concern that a considerable amount of the methadone prescribing could be having little impact on illicit drug use or risk taking behaviour,3 a recent study of drug users in police custody echoes this.4 The Advisory Council on the Misuse of Drugs has recommended a shift to a more structured approach for delivery of oral methadone maintenance. The organisation and regulation of methadone maintenance treatment varies widely, with explicit guidelines for programme operation in the United States and Australia and a virtual absence of structure and regulation in Britain. It is likely that policy analysts and treatment providers in countries with high levels of regulation and structured programmes …

The development of a short opiate withdrawal scale (SOWS)

In previous studies a 32-item Opiate Withdrawal Scale was found to provide a reliable and valid means of measuring the signs and symptoms of withdrawal among heroin (and other opiate) addicts. This paper describes the processes whereby a shorter 10-item version of the same scale was developed. The Short Opiate Withdrawal Scale (SOWS) is simple to understand and easy to administer, and it avoids the redundancy of items contained in the original scale. It is suggested that the SOWS provide a useful instrument which can be used both in research and clinical practice with opiate addicts.

Treatment retention and 1 year outcomes for residential programmes in England.

This paper reports changes in substance use behaviours at 1-year follow-up, and investigates the relationship between time in treatment and observed outcomes. A total of 408 clients were interviewed at intake to 23 residential treatment programmes, and 286 (70%) of these were interviewed at 1 year. Substantial improvements were found in terms of abstinence from opiates, psychostimulants and benzodiazepines. At 1 year, half of the clients were abstinent from heroin. Reductions in injecting, sharing injecting equipment, heavy drinking and criminal behaviour were found. Critical treatment thresholds were identified using multiple logistic regression analyses. Longer stays in treatment were predictive of better 1 year outcomes.

Outcomes after methadone maintenance and methadone reduction treatments: two-year follow-up results from the National Treatment Outcome Research Study

This paper provides a detailed analysis of the 2-year outcomes for 351 drug misusers allocated on an intention-to-treat basis to methadone maintenance or methadone reduction treatments. Both groups showed substantial reductions in their use of illicit drugs and in other outcome areas. However, whereas most methadone maintenance patients received maintenance, only about one third of those allocated to methadone reduction received methadone reduction, and many actually received a form of methadone maintenance. Reduction patients were more likely to receive low doses of methadone, and were less likely to remain in treatment. For maintenance patients, higher doses and retention in treatment were both associated with improvements in illicit heroin use at 2 years. For the reduction patients, the more rapidly the methadone was reduced, the worse the heroin use outcomes. For patients in both treatment conditions, reductions in heroin use were associated with improvements in other outcome areas. The more severely dependent patients showed better outcomes in methadone maintenance. Methadone reduction treatment processes were associated with poor outcomes, and many patients who were allocated to methadone reduction treatment did not receive reduction treatment as intended. This calls into question the appropriateness of either the initial treatment planning process or the treatment delivery process, or both. A clearer distinction should be made between methadone maintenance and methadone reduction. Treatment goals should be made explicit both to the patient and to the clinical staff at the start of treatment. We suggest the need for a reappraisal of the goals and procedures of methadone reduction treatment.

Clonidine and the treatment of the opiate withdrawal syndrome

Clonidine is a central alpha adrenergic agonist which can be used to treat the opiate withdrawal syndrome. It has been used in many controlled trials and a substantial body of research evidence is available about its effectiveness in this role. This paper reviews the literature regarding its introduction in the Yale studies, its effectiveness relative to gradual methadone reduction treatments, its side effects, and touches briefly upon its use in conjunction with opiate antagonists. It is concluded that clonidine produces marked reduction of withdrawal symptoms but does not eliminate them; that the pattern of withdrawal symptoms differs from that associated with methadone reduction schemes; that there is some disagreement about the clinical significance of hypotensive and other side effects; and that the drug has interesting possibilities for rapid withdrawal programmes when combined with naltrexone.

The differences between male and female drug users: community samples of heroin and cocaine users compared.

Although gender-related issues are often cited as playing an important part in determining patterns of illicit drug use, little is known about the differences between male and female drug users outside treatment settings. In the present study, 558 heroin and cocaine users recruited from a range of community settings were interviewed by Privileged Access Interviewers. The women were found to be younger than the men. Differences existed in their drug use; women used smaller amounts, for a shorter duration, and were less likely to inject than their male counterparts. No differences existed between treatment contact for the heroin users, but differences were found among the cocaine-using sample, with men being more likely to have contacted a treatment agency. Men were financing themselves through more criminal activities than women. Drug-using sexual partners were found to be an important influence over womens drug use, with most female injectors having been given their first injection by a male sexual partner. Structural differences in patterns of drug use found among female drug users and the influence of male sexual partners are likely to play an important role in determining appropriate treatment options for women drug users.

Change and stability of change after treatment of drug misuse: 2-year outcomes from the National Treatment Outcome Research Study (UK)

The National Treatment Outcome Research Study (NTORS) is a longitudinal, multisite, prospective cohort study that assesses changes in illicit drug use and other problems after treatment in national (UK) drug misuse treatment programmes. Clients were recruited from 54 residential and community-based drug treatment programmes throughout England. Four modalities were studied: inpatient drug dependence units, residential/rehabilitation programmes, methadone maintenance, and methadone reduction programmes. Data on substance use behaviours and physical and psychological health were collected by structured face-to-face interviews at intake, 1- and 2-year follow-up. Data are presented for 549 clients. A majority of clients achieved widespread improvements across a range of outcome measures after treatment in existing treatment services. For most outcomes, reductions in problem behaviours at the group level occurred within the first year and were maintained at 2 years. Considerable stability of outcomes at the individual level was also found. Abstinence from illicit drugs was substantially increased among clients from both residential and community programmes, and there were also substantial reductions in frequency of use of heroin, nonprescribed methadone, benzodiazepines, and crack cocaine. Injecting and shared use of injecting equipment was also reduced. Heavy drinking was common at intake and was not reduced at follow-up. Psychological and physical health problems were reduced on both groups at follow-up. These changes represent important clinical benefits to the individual clients, to their families, and to society.

Prevalence and clinical relevance of corrected QT interval prolongation during methadone and buprenorphine treatment: a mortality assessment study

AIMS To determine the prevalence of corrected QT interval (QTc) prolongation among patients in opioid maintenance treatment (OMT) and to investigate mortality potentially attributable to QTc prolongation in the Norwegian OMT programme. PARTICIPANTS AND SETTING Two hundred OMT patients in Oslo were recruited to the QTc assessment study between October 2006 and August 2007. The Norwegian register of all patients receiving OMT in Norway (January 1997-December 2003) and the national death certificate register were used to assess mortality. Mortality records were examined for the 90 deaths that had occurred among 2382 patients with 6450 total years in OMT. DESIGN AND MEASURES The QTc interval was assessed by electrocardiography (ECG). All ECGs were examined by the same cardiologist, who was blind to patient history and medication. Mortality was calculated by cross-matching the OMT register and the national death certificate register: deaths that were possibly attributable to QTc prolongation were divided by the number of patient-years in OMT. FINDINGS In the QTc assessment sample (n = 200), 173 patients (86.5%) received methadone and 27 (13.5%) received buprenorphine. In the methadone group, 4.6% (n = 8) had a QTc above 500 milliseconds; 15% (n = 26) had a QTc interval above 470 milliseconds; and 28.9% (n = 50) had a QTc above 450 milliseconds. All patients receiving buprenorphine (n = 27) had QTc results <450 milliseconds. A positive dose-dependent association was identified between QTc length and dose of methadone, and all patients with a QTc above 500 milliseconds were taking methadone doses of 120 mg or more. OMT patient mortality, where QTc prolongation could not be excluded as the cause of death, was 0.06/100 patient-years. Only one death among 3850 OMT initiations occurred within the first month of treatment. CONCLUSION Of the methadone patients, 4.6% had QTc intervals above 500 milliseconds. The maximum mortality attributable to QTc prolongation was low: 0.06 per 100 patient-years.

Reductions in acquisitive crime and drug use after treatment of addiction problems: 1-year follow-up outcomes

The relationship between acquisitive crime and drug misuse problems was studied among 753 clients recruited to the National Treatment Outcome Research Study (NTORS). More than 17000 offences were reported during the 90-day period prior to treatment. Half of the clients committed no acquisitive crimes during this period whereas 10% committed 76% of the crimes. At 1-year follow-up, the number of crimes was reduced to one third of intake levels, and criminal involvement was reduced by about half. Reductions in regular heroin use were strongly associated with reductions in crime. The reduction in crime following treatment is of great importance and provides immediate benefit to society through the reduced economic costs of crime.

Patterns of improvement after methadone treatment: 1 year follow-up results from the National Treatment Outcome Research Study (NTORS)

One year outcomes for substance use behaviours, health and criminal behaviour, and variation in treatment response, are reported for patients recruited to methadone maintenance and methadone reduction treatment programmes as part of NTORS. Significant reductions in the use of all illicit target drugs were found at follow-up for patients recruited to the methadone maintenance and methadone reduction modalities. Because of similarities in the treatments received by clients in the two modalities we caution against interpreting these findings as showing that methadone maintenance and reduction treatments lead to similar outcomes. At this stage, it is suggested that these outcomes be regarded as reflective of exposure to some general methadone substitution treatment. Further investigation of the outcomes for the two modalities will be conducted. Cluster analyses were used to classify patients according to level of improvement in drug use. Four groups were identified. Two groups (59% of cases) showed substantial reductions in their illicit drug use and criminality as well as reduced physical and psychological symptoms. Twenty two percent of cases showed poor outcomes across a range of measures. Results for alcohol consumption were less satisfactory for patients in all groups. A majority of patients achieved widespread improvements across a range of outcome measures after treatment in existing methadone treatment services. These changes represent important clinical benefits to the individual clients, to their families and to society.