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Title and link for copying Comment/query to editor Drug Matrix Alcohol Matrix

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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Drug Treatment Matrix cell C3: Management/supervision; Medical treatment

S Leaders affect performance of methadone maintenance clinics (1991). In six intensively documented US clinics, effective and experienced directors were associated with reduced drug use, injecting and crime among patients. “Our interpretation … is that patients in programs with a rehabilitation and long-term maintenance orientation, which also delivered more counseling services to patients and had more effective directors, tended to have better outcomes than patients in programs … where there was emphasis on administrative functioning rather than provision of services.”

S Methadone minus counselling can be suboptimal (1993) From Philadelphia a randomised trial analysed in these background notes (2006; see under the heading, “Are cut-down services a viable alternative to more comprehensive programmes?”) found barebones methadone maintenance much less effective at suppressing illegal opiate and cocaine use than weekly counselling. Supplementary social and other services helped even more, though weekly counselling was most (1997) cost-effective. Related studies (1 2) and reviews (1 2) below seem to have varying implications. For discussion click and scroll down to highlighted heading.

K No added benefit from counselling in methadone maintenance (2012). US randomised trial found cut-down methadone programmes reduced substance use and crime (and risk of blood-borne disease; 2013; free source at time of writing) as effectively as standard programmes with more counselling, including among patient under criminal justice supervision (2013; free source at time of writing). Related studies above and below and reviews below (1 2). For discussion click and scroll down to highlighted heading.

K No added value from psychosocial therapy for buprenorphine patients (2013). Across relatively uncomplicated patients treated at a primary care clinic, US study found no benefit from supplementing buprenorphine maintenance with cognitive-behavioural therapy. Related studies above (1 2) and reviews below (1 2). For discussion click and scroll down to highlighted heading.

K Supplementing medical care with drug counselling does not improve opioid detoxification outcomes (2011). From the USA, a large-scale trial involving patients dependent on prescription opioids found that despite wanting to detoxify, all but a few relapsed after withdrawal from buprenorphine. Random allocation to specialist drug counselling did not improve on medical care alone. Related review below. For related discussion click and scroll down to highlighted heading.

K Training leads doctors to see methadone maintenance as a medical treatment (1996). Based on experience in Australia, how to train-out socially derived attitudes derived from seeing methadone maintenance as a policy solution to a social problem, and train-in attitudes based on locating the treatment within mainstream medical practice. Findings were incorporated in an article (2000) from the same author on quality improvement in methadone services.

K Training in client-centred approach needs receptive trainees (2004). US study at a medical centre’s addictions programme suggests that recruiting the ‘right’ clinicians who have not been trained in motivational interviewing would be better than choosing the ‘wrong’ ones who have been, and the former gain most from training. Simple indices of experience and qualifications did not identify proficient clinicians.

K Supervising medication consumption cuts methadone deaths (2010). From the mid-1990s British addiction treatment clinics started to routinely require patients to take their methadone under clinical supervision. Records suggest that by preventing diversion to non-patients, the change prevented thousands of overdose deaths. Related studies (1 2 3) and review below focusing on impacts on the patients themselves. For discussion click and scroll down to highlighted heading.

K No benefits for UK patients from enforcing three months’ supervised consumption (2014) Found that the (at the time) recommended three months of supervised consumption of methadone or buprenorphine conferred no significant advantages over supervising only for up to the first four weeks among patients for whom random allocation was thought feasible and safe. Earlier trial (2012) from same lead author found that at Scottish clinics extending supervision beyond three months meant more patients left treatment and did not further curb heroin use, though it may have reduced heavy drinking. Related studies above and below (1 2) and review below. For discussion click and scroll down to highlighted heading.

K Methadone programme loosens up, increases capacity, patients do just as well (2004). Canadian study documents what happens when you ‘deregulate’ methadone prescribing (relaxing supervised consumption and urine tests and not insisting on abstinence from illegal drug use) and permit greater patient choice in treatment and treatment goals: room for more patients, less conflict, and no decrease in effectiveness. At the time of writing the two cited articles are freely available (1 2). Related studies above (1 2) and below and review below. For related discussion click and scroll down to highlighted heading.

K British GPs as effective as specialist methadone clinics (2003). A two-year follow-up of opiate dependent patients sampled by the national English NTORS study showed that experienced or supported GPs can provide methadone maintenance treatment at least as effectively as specialist clinics. The clinics’ imposition of supervised consumption was a major difference in the regimens. Related studies above (1 2 3) and review below. For related discussion click and scroll down to highlighted heading.

K Why not let methadone patients choose their dose? (2002). US study shows that methadone maintenance patients allowed to set their own doses do not escalate excessively. Benefits may include improved patient-therapist relations and reduced illicit drug use. Extended text reviews other relevant studies. Related review below. For discussion click and scroll down to highlighted heading.

K Patients who value a ‘clear mind’ prefer buprenorphine to methadone (2010). The minority of opioid maintenance patients at a clinic in England who chose buprenorphine rather than methadone tended to do so because they wanted to divorce themselves both from illicit and prescribed opioids. Few were successful, and retention was greater on methadone, but those who opted for buprenorphine valued it because it had less intense opiate-type effects (a ‘clearer mind’) and made them less vulnerable to the charge that they were ‘still addicts’. Patient perspectives were similar (2015) in Scotland. Related review below.

R Buprenorphine works but methadone works better (Cochrane review, 2012). High-dose buprenorphine curbs illegal opiate use but when the two were compared in randomised trials, longer retention meant methadone was on average more effective. See also a later US-focused review (2014) commissioned by the US government. Related studies above.

R High-dose methadone most effective (Cochrane review, 2006). Systematic review finds doses averaging across a caseload 60 to 100 mg/day are more effective than lower dosages in retaining patients and reducing heroin and cocaine use during treatment. Related study above. For related discussions click here and here and scroll down to highlighted headings.

R Strategies for incorporating evidence into practice ([Australian] National Centre for Education and Training on Addiction, 2008). Lessons from health promotion and medical care on how to improve addiction treatment practice by introducing research-based innovations, including common medical education and training strategies.

R Trials neither for nor against supervised consumption of methadone and other opioid substitutes (2017). Trials challenge the need for the widely accepted policy of making opioid-dependent patients take their methadone or other opioid substitutes at the clinic or pharmacy, but ‘no difference’ findings may be due to the limitations of the research. Related studies above (1 2 3 4). For discussion click and scroll down to highlighted heading.

R Worth training clinicians in motivational interviewing (2013). Free source at time of writing. Across medical care clinicians who adopt a motivational interviewing style achieve significantly better outcomes than those who offer usual care, and training clinicians in motivational interviewing improves (2013) motivational skills.

R Prescribing therapy with methadone and counselling does not help (Cochrane review, 2011). Review of rigorous studies found that adding psychosocial therapy to opiate substitute prescribing plus routine counselling has overall made no significant difference to retention or substance use. Similar review (Cochrane review, 2011) of opioid detoxification found little evidence that extra counselling or therapy promoted completion, but more for systematically applied rewards and sanctions. Related studies above (1 2 3 4) and review below. For discussion click and scroll down to highlighted heading.

R G In medication-based programmes focus on generic relationship-forming, not intervention packages (2017). From England a specialist drug dependence psychiatrist and clinical psychologist tease out the practical implications of the evidence on psychosocial adjuncts to opiate substitution treatment, arguing for individualisation rather than blanket application or denial and a focus on “broad, non-specific skills such as therapist empathy and therapeutic alliance, but also tightly controlled interventions to achieve a specific outcome such as reduced symptoms of depression, better parenting or increased levels of employment.” Related studies (1 2 3 4) and review above. For discussion click and scroll down to highlighted heading.

G Medication-based treatment as a route to recovery ([UK] National Treatment Agency for Substance Misuse, 2012). UK clinical consensus on how methadone clinics and other medication-based treatment services can be (re)oriented to long-term recovery. See also report ([UK] Advisory Council on the Misuse of Drugs, 2015) on the same issue from official UK government advisers on drug policy. For discussion click and scroll down to highlighted heading.

G K Failings of detoxification procedures in the independent sector ([UK] Care Quality Commission, 2017). Official regulator of health and adult social care in England sums up results of inspections of services offering residential care to people undergoing detoxification from drugs and alcohol, often preparatory to residential rehabilitation. Poor management was a major underlying cause of the failings which risked safety and effectiveness at almost two-thirds of services. Flip side of the failings constitute good practice recommendations.

G Don’t set time limits to opioid maintenance ([UK] Advisory Council on the Misuse of Drugs, 2014). Rather than being ‘parked’ on methadone, generally UK patients leave too soon to fully benefit, argue official UK government advisers on drug policy. Their report countered concerns within the government over long-term methadone maintenance and rejected the call for time limits, which “may have significant unintended consequences”, including increasing more crime, overdose deaths, and blood-borne infections. For related discussions click here and here and scroll down to highlighted headings.

G Pharmacological treatment of opioid dependence (World Health Organization, 2009). Chapter five of the document analysed in this Effectiveness Bank entry offers guidelines for programme managers and clinical leaders. For related discussion click and scroll down to highlighted heading.

G Pharmaceutical services for drug users ([UK] National Treatment Agency for Substance Misuse, 2006). How pharmacies can/should contribute to treating and reducing harm from problem drug use.

G What should managers expect of doctors caring for substance users? ([UK] Royal College of Psychiatrists, Royal College of General Practitioners, 2012). Guidance from UK professional associations for GPs and for psychiatrists on the competencies, training and qualifications expected of doctors involved in caring for substance users, from generalists to addiction specialists. Other UK ([UK] Public Health England, Royal College of Psychiatrists, Royal College of General Practitioners, 2014) and US ([US] American Society of Addiction Medicine, 2014) guides focus on specialists.

G Staff development toolkit ([UK] National Treatment Agency for Substance Misuse, 2003). Workforce development guidance for managers in drug and alcohol services from what was the special health authority responsible for promoting addiction treatment in England.

G How to assess the performance of specialist doctors ([US] American Society of Addiction Medicine, 2014). Indices designed to evaluate an individual doctor’s performance against standards of care ([US] American Society of Addiction Medicine, 2014) for specialist addiction physicians.

G Treating substance use service clients with mental health problems ([Australian] National Drug and Alcohol Research Centre, 2016). Funded by the Australian government. Recommends services screen all patients for the full range of mental health problems from mild to severe and that mental illness should not be a barrier to treating substance use problems. Research shows these patients can benefit as much as others from routine treatments for problem substance use. UK guidelines ([UK] National Institute for Health and Care Excellence, 2016) on managing severe mental illness and substance use envisage the lead being taken by mental health services.

more Search for all relevant Effectiveness Bank analyses or for subtopics go to the subject search page. Also see hot topic on counselling in methadone programmes.

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