EFFECTIVENESS BANK BULLETIN 31 March 2010
EFFECTIVENESS BANK BULLETIN 31 March 2010The entries below are our accounts of documents selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Entries were drafted after consulting related research, study authors and other experts and are © Drug and Alcohol Findings. Permission is given to distribute these entries or incorporate passages in other documents as long as the source is acknowledged including the web address http://findings.org.uk. However, the original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors; if displayed, click Request reprint to send or adapt the pre-prepared e-mail message. Abstracts are intended to summarise the findings and views expressed in the study. Below are comments from Drug and Alcohol Findings. Links to source documents are in blue. Hover mouse over orange text for explanatory notes.
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Should addiction services treat co-morbid depression and anxiety? ...
Little long-term disadvantage from choosing non-abstinence drinking goals ...
Largest analysis to date offers practice insights in to motivational interviewing ...
Buprenorphine is most effective detoxification medication ...
Integrated psychological treatment for substance use and co-morbid anxiety or depression vs. treatment for substance use alone: a systematic review of the published literature.Hesse M.
BMC Psychiatry: 2009, 9(6).
Most patients at drug and alcohol services suffer depression and/or anxiety, far too many and usually not severely enough to engage mental health services. Faced with this huge problem, should services offer special mental health therapies, or is substance-focused treatment sufficient?
Abstract The full text of the review is available free of charge by clicking on the title above. The issue it addressed is whether among patients suffering anxiety or depression, outcomes improve when substance use treatment is supplemented by therapies for those conditions. A search was conducted for studies of the treatment of adults with substance use disorders who also had symptoms of excessive depression or anxiety. Studies were sought which randomly allocated these patients to programmes focused solely on substance use, or to programmes which included elements also addressing depression or anxiety. Only studies testing psychosocial therapies Patients may also have been prescribed medications but not in such a way as to confuse the focal comparison. were included. Ten such studies were found which assessed outcomes at the end of treatment or later, evenly split between depression and anxiety. All which assessed substance use outcomes reported the proportion of days patients had remained abstinent, generally as assessed six months after treatment started, so the review adopted this as its indicator of substance use outcomes.
The five studies concerned with depression involved just 223 patients. Three evaluated therapies for depression (or depression complicated by substance use) based on cognitive or behavioural principles, one featured interpersonal psychotherapy, and the other a booklet to help patients focus on what matters to them and accept situations they cannot change. Results were aggregated using meta-analytic A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. techniques. Generally the aggregated results favoured (sometimes substantially) the combined treatments, but only in respect of abstinence were the differences statistically significant; details follow
Four studies used the standard Hamilton Rating Scale for Depression which is completed by staff on the basis of the patient's responses. On this scale, depression was less severe after combined than substance-only treatment, but not significantly so, and results varied substantially between the studies. Results were similar across the four studies (including three of the previous four) which assessed depression using questionnaires filled in by the patients. Across the three studies which reported abstinence, after combined treatment, patients were abstinent on about 14% more days than after substance use treatment alone, a statistically significant difference. Substantially, but not significantly, more patients dropped out of the substance-only treatments.
For technical reasons, results from the five studies relating to anxiety were not aggregated in a meta-analysis. A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. As part of the combined treatment option being tested, all five assigned patients to variants of cognitive-behavioural interventions specific to their anxiety-related complaints. Three studies found this reduced substance use more than treatment as usual, but in one an alternative therapy geared to preventing relapse to substance use produced slightly the best outcomes overall. In another study, accompanying cognitive-behavioural therapy for drinking problems with the same type of therapy for social anxiety actually reduced the impact on drinking. Just two of the five studies found the anxiety-related disorder responded better to a therapy geared to addressing it than to substance-only treatment.
The author concluded that his analysis consistently favoured combined treatments for depression and substance use, but cautioned that generally the results were not statistically significant, often varied between studies, studies featured different settings, types of interventions and criteria for depression, samples were small, in the largest study many patients could not be followed up, and other negative studies might have remained unpublished. Given these caveats, combining psychosocial therapies for depression with substance use treatment can only be considered promising rather than supported. Even this could not be said in respect of anxiety; there was little evidence that supplementing substance-focused treatment with psychosocial therapy for anxiety yields any significant benefit, and some that it could reduce the impact of substance use treatment.
It is important to bear in mind that this review and these comments concern mental ill-health which generally falls short of the severe mental illness dealt with in another Findings analysis.
This summary is expanded on under the subheadings which follow. Probably most patients at most British alcohol and drug treatment services suffer depression and/or anxiety, but not at levels or with complications warranting referral to mental health teams, meaning that it will often fall to substance use services to identify and respond to these problems. Based on the featured review and others, they may be reassured that patients often improve after usual substance-focused treatments, without services having to deploy specialist therapies, possibly because at least some of these emotional problems are generated by substance use and associated lifestyles.
But in the case of depression, it also seems likely that an appreciable number of patients would benefit substantially more from tackling this directly. Though there remains much uncertainty in the research, the prevalence of depression, and the potential for benefit, might be seen to justify training substance misuse treatment staff in relevant therapies. Since, for example, cognitive-behavioural approaches for depression are in principle similar to those for substance use, this step might not be such a big one in services which already have therapists trained in these principles. In England the recent government-funded expansion in the workforce offering cognitive-behavioural therapies (originating in a desire to tackle depression and anxiety) has created openings for staff such as those commonly employed in substance use treatment services to develop recognised basic competencies 'on the job'.
Guidelines internationally have in recent decades leaned towards simultaneously treating mental health and substance use problems. However, in the case of mild to moderate depression and anxiety, especially when patients have only experienced these while misusing drugs or alcohol, there is a case for waiting for a time to see if symptoms remit on the attainment of abstinence or controlled drug use, providing that sufficiently frequent and effective monitoring is in place. What seems broadly agreed is that patients at substance misuse services should routinely be screened for mental health problems, and that the less severe and worrying cases of depression and/or anxiety are most feasibly dealt with at those services, with support if need be from mental health teams.
The featured review analysed studies of fully integrated therapies addressing substance use, mental health and their inter-relationships, and treatments which at the same site and during the same time period included separate elements addressing substance use and mental health in parallel. With so few studies, finer distinctions would not have been meaningful, but potentially these ways of organising combined treatment have different consequences.
What were generally substantial aggregate gains associated with combined therapy for depression nevertheless usually failed Due possibly to small samples, few studies, and variability across studies. to be statistically significant. In respect of relieving depression, this seems mainly to have been due to the single largest study. Unexpectedly, it found patients offered therapy for depression were more Though this was not a statistically significant difference depressed at the end of treatment than patients simply treated for drinking problems. This finding dragged down the aggregate results, but was unreliable (data was missing for many of the patients) and a passing phase. Three and six months later the position was reversed; by then depression was less Though this was not a statistically significant difference severe among patients treated for it.
If further studies produced results similar to those to date, these might well justify solidifying the review's "promising" verdict in to support for combined treatment versus usual addiction treatment. In contrast, it remains entirely unclear whether approaches aimed at depression offer any benefit compared, not to usual addiction treatment, but to the same type of approach targeted at substance use. In respect of co-morbid anxiety, only a major change of direction in the trend of findings to date could alter the 'no significant benefit' conclusion.
Other recent reviews (1 2 3) have also found psychosocial therapies for depression or anxiety in substance using patients no better than 'promising'. Generally the conclusions were that with a few exceptions, these have not been found to outperform usual addiction treatment, but also that this failure might simply reflect the lack of large, rigorous studies; details below.
The most positive verdict was that approaches based on motivational interviewing can strengthen engagement with treatment which should (but has not yet been shown to) mean better substance use and mental health outcomes. Based on three studies, the same review argued that cognitive-behavioural approaches lead to modest but persisting improvements in substance use and/or depression. One study was included in the featured review, in another the cognitive-behavioural approach was focused on substance use and compared to supportive clinical management, and in a third it was aimed at depression, but the comparator was not cognitive-behavioural therapy for substance use. On the basis of these studies and the featured review, it seems that cognitive-behavioural therapies for substance use can benefit depressed substance users, just as they can benefit those who are not depressed, but it remains unclear whether versions aimed at depression offer any extra benefit.
A review focused on anxiety and substance use concluded that while patients improve after combined treatments, it remains unclear whether these are superior to other treatments. Sometimes, the review warned, addressing both problems in parallel seems to reduce the effectiveness of substance use treatments.
The featured review was concerned with psychosocial 'talking' therapies. An alternative or supplementary approach is to prescribe medications for depression or anxiety. These work as well with substance using patients as they do with other depressed or anxious patients (1 2 3). They have also been found to reduce substance use, but not always, and impacts have generally been minor, suggesting they are insufficient on their own to tackle both sorts of problems.
Elevated levels of depression and/or anxiety are the norm in British drug and alcohol treatment caseloads. In 2001–02 the COSMIC survey of statutory sector drug and alcohol teams Community health teams were also surveyed. in English cities found that 8 in 10 alcohol patients and just over two thirds at drug services suffered from these complaints, including respectively a third and a quarter with severe depression, and a third and a fifth with severe anxiety. Of the depressed patients, about a fifth were judged vulnerable enough to warrant referral to mental health teams, leaving the bulk of the problems to be addressed if at all by the substance misuse services or general medical services.
Three London boroughs were included in the COSMIC survey. In a different London borough, some form of psychiatric condition was identified by researchers in over 90% of alcohol and drug service clients. Of these, 79% and 43% respectively in alcohol and drug services suffered affective disorders including depression, and 82% and 57% anxiety.
If usual addiction treatment can lead to improvements in anxiety and sometimes in depression as great as those from specialised therapies, the question arises, how great are those improvements, and how much scope is there to do better? In respect of mental wellbeing in general, two large recent studies found worthwhile improvements after substance use treatment, but also that patients remained in poor mental health, while another suggested that further improvements might have been held back by failures to identify depressed and anxious patients and to meet their generally greater needs; details below.
In 2006 in England the Drug Treatment Outcomes Research Study (DTORS) recruited patients seeking help from drug treatment services and documented their progress. Patients' psychological wellbeing when they started treatment was poor; three to five months later it had improved and slightly more so at about a year, but improvements were modest, may have been an artefact of drop-out from the study, and still left patients well below The measure of mental wellbeing (SF12 scores) improved significantly by first follow-up (from 35 to 40) and later to 42, but stayed below the UK norm of 52, a gap which is likely to mean (see http://www.outcomes-umassmed.org/ALS/sf12.cfm) that the patients remained well within the lowest fifth of the population. the UK average. Similar findings emerged from UKATT (UK Alcohol Treatment Trial), Britain's largest alcohol treatment study. It recruited participants in England and Wales between 1999 and 2001 and supplemented usual treatment with psychosocial therapies focused on drinking. Once again, mental wellbeing improved significantly from a low base over the year of the follow-up, but patients remained in poor mental health The mean adjusted score of the mental component of the SF-36 rose from 30 to 37 at three months and to 39 at 12 months. The average score is 50. compared to the general population.
The COSMIC survey of statutory sector drug and alcohol teams in English cities, which found that depression and/or anxiety were the norm among their clients, also revealed that these patients reported greater health and social care needs Assessed using the Camberwell Assessment of Need (CAN) which generates data about the frequency of current needs, met and unmet needs, in 22 domains such as housing, money, physical health, and self-care, plus an overall measure of severity of need. and more unmet needs than patients without mental health problems, even after eliminating needs related specifically to mental health. Mental health problems too were often not specifically managed. Among patients whose sole mental health problems were in the spectrum including depression or anxiety, nearly half had not attended any service in respect of their mental health over the past year, and about half the remainder had just seen their GPs. Four in ten had been prescribed antidepressants and just one in ten had been in contact with mental health services. A greater gap between needs and provision among depressed and anxious patients was also apparent when keyworkers reported which substance use treatment interventions Such as counselling, detoxification, self-help groups and residential rehabilitation. their patients needed, and which they had received. Conceivably services did not make as much difference as they might have because they were unaware that patients had mental health problems. Half the patients revealed by research interviews to be abnormally anxious or depressed had not been identified as such by their keyworkers.
UK guidance avoids recommending any particular therapeutic approach to co-occurring substance use and mental health problems, and sees depression and anxiety among problem substance users as generally being dealt with by their substance use treatment services; details below.
Guidance for England stresses the 'mainstreaming' of treatment for severely mentally ill substance users within mental health services, but specifically excludes from that advice "many people who require help with substance misuse [who] suffer from a common mental health problem such as depression or anxiety ... many of whom do not require specialist support for both mental health and substance misuse". This formula implies that except for particularly severe or vulnerable cases, drug and alcohol services are expected to cater for those of their patients who suffer depression or anxiety, with support if need be from mental health teams. In turn this means those services must develop relevant competencies and programmes and/or work with GPs if they are not to leave a high proportion of their clients under-served.
Corresponding guidance in Scotland also sees the response to severe mental illness complicated by substance use as being led by mental health services. When substance problems are severe, but mental health problems milder, substance misuse services are seen as taking the lead, a category which would include most depressed or anxious patients seen at substance use services.
The COSMIC survey team found that English drug and alcohol teams were providing mental health interventions to some of their patients, but that just as many had needs which were unmet, not fully assessed, or not even identified. They recommended that at a minimum, non-psychotic patients with depressive and/or anxiety disorders should be offered specialist psychiatric assessment and if appropriate, specialist intervention. Without effective management, they warned that these problems are likely to impede effective drug and alcohol treatment.
UK advice can be placed in the context of guidance internationally on treating affective (includes depression) and anxiety disorders among substance users. After analysing such guidance, If published in English between 1990 and 2002. analysts identified a shift in recommended approaches, from treating substance use problems before providing mental health care, to simultaneously treating both. This was they thought driven by findings that mental disorders usually precede substance use problems, suggesting these disorders are not simply a side effect of substance use, and by the unsuitability of short-term substance use treatments for the management of chronic mental illness. However, some authorities have argued for not initially addressing depression or anxiety in some cases. Details below.
Guidelines generally agreed that patients at substance use services should be screened to identify mental health problems, and that further assessment should reconstruct the history of both problems. This is partly to help identify whether one might be causing the other, a determination the guidelines agree should form part of the initial assessment. They also generally agree that friends and family should be contacted to obtain corroborating diagnostic information, and recommend some form of combined treatment addressing both conditions in at least a coordinated fashion. Unfortunately, the review also found that this recommendation, those relating to the sequencing of substance use and mental health treatment, and most others, rested solely on expert opinion rather than research which had tested their validity.
Given uncertainty about what best practice consists of, the risk of deterring patients or unnecessarily intruding on their lives through onerous multiple therapies, the evidence that sometimes treatment for anxiety can impede substance use treatment, and in the interests of the conservation of resources, the advice given by a team of authors from Australia was to try the least intrusive treatment first. They identified at least one assessment tool designed to distinguish between substance-induced and more lasting mental health disorders. For patients whose depression and/or anxiety problems have only occurred during substance use periods, they recommended a short period of systematic monitoring to see if these problems remit when substance use is controlled. If not, or when immediate mental health treatment does seem indicated, they suggest starting with the least intrusive therapy likely to succeed, monitoring patient progress, and adjusting the therapy in the light of their progress. Their recommendations are of course contingent on the service frequently and effectively monitoring how patients respond to treatment.
Thanks for their comments on this entry in draft to Morten Hesse of the Centre for Alcohol and Drug Research at Aarhus University in Denmark and Michael Farrell, of the National Addiction Centre in London. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 27 March 2010 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Psychosocial interventions for people with both severe mental illness and substance misuse REVIEW 2008
Antidepressants curb depression but add little to strong 'talking therapies' NUGGET 2006
A meta-analysis of motivational interviewing: twenty-five years of empirical studies REVIEW 2010
Dual diagnosis add-on to mental health services improves outcomes NUGGET 2004
Continuing care research: what we have learned and where we are going REVIEW 2009
Initial preference for drinking goal in the treatment of alcohol problems: II. Treatment outcomes.Adamson S.J., Heather N., Morton V. et al. Request reprint
Alcohol and Alcoholism: 2010, 45(2), p. 136–142.
Data from Britain's largest alcohol treatment trial is used to address possibly the most contentious issue in the field – whether services should offer moderation as well as abstinence goals to dependent clients. 'Let the patient choose' seems the general conclusion.
Abstract As documented in previous Findings analyses (1 2), the UKATT United Kingdom Alcohol Treatment Trial. study recruited 742 patients seeking treatment for alcohol problems at seven specialist treatment services in England and Wales. Additional to other treatment elements like detoxification, they were randomly allocated either to three sessions of motivational enhancement Based on motivational interviewing. therapy or eight of social behaviour and network therapy, This integrated cognitive-behavioural, community reinforcement and other elements with the aim of building social networks supportive of positive change in the patient's drinking. each spread over eight to 12 weeks. Twelve months after therapy started, 85% of the participants who were still alive were re-interviewed. After both therapies, alcohol consumption over the past three months had fallen by 45% and other measures Including severity of alcohol dependence, alcohol-related problems, psychological health, and savings in health and social care costs. also improved to roughly equivalent degrees, nor were there the expected indications It was expected that the non-confrontational style of motivational interviewing would defuse the hostility of patients prone to react angrily, and help those relatively devoid of motivation find reasons to curb their drinking. The network option was expected to particularly help patients with poor family relationships or few regular associates who were not also heavy drinkers. that certain types of patients would respond better to one therapy than the other.
The featured report examined the same dataset, not to search for differences in outcomes between the therapies, but between patients opting and not opting for abstinence as an initial treatment goal. An earlier report had documented differences at study entry between those who (according to the judgement of intake treatment staff) were probably aiming versus not aiming for abstinence. The caseload was fairly evenly split, 54% aiming for abstinence, 46% not. In general, Around 70% could be correctly classified as aiming versus not aiming for abstinence on the basis of their being a woman, drinking more heavily but on fewer days, having been detoxified immediately before entering the study, having a social network less supportive of drinking – and to a lesser degree a relative lack of social support in general – and having recently experienced relatively severe alcohol-related problems. Compared to the remainder, clients judged as opting for abstinence were also relatively motivated to change their drinking and confident they could resist drinking, more likely to be out of employment, had more positive expectations about the effects of drinking, and suffered greater mental and physical health problems. abstinence-aiming clients were drinking more intensely and experiencing greater drink-related and other problems, and were more socially isolated, especially in their attempts to control their drinking.
This later report investigated whether treatment goals were related to drinking and drink-related problems three months after joining the study (shortly after the UKATT treatments had ended) and again at 12 months. As its primary yardstick of a successful outcome, the study adopted either total abstinence over the previous three months, or the total absence of drink-related problems as assessed by a
questionnaire
The Alcohol Problems Questionnaire assesses problem with friends, money, the police, physical health, emotions, marriage, children, and work – see http://dx.doi.org/10.1016/0376-8716(94)90080-9.
covering health, relationships, family, legal and financial issues. On this criterion, three months after joining the study patients judged as aiming for abstinence were significantly more likely to have been successful (22% v. 13%). Generally they did so by abstaining, while the successes among those not aiming for abstinence generally took the form of non-problem drinking. This difference in the type of successful outcome persisted to the 12-month follow-up. However, by then the gap in the overall success rate had narrowed (30% v. 23%) to the point where it was no longer statistically significant chart. This was the case whether or not the drinking and personal characteristics associated with choosing an abstinence goal were taken in to account. At both stages those aiming for abstinence actually were abstinent on significantly more days (at 12 months, 55% v. 43%). A measure of dependence on alcohol showed no difference between the groups at either stage.
The authors cautioned that the superiority of overall outcome in the abstinence-goal group may not have been due to their choice of goal, but to their being more motivated to change their drinking. They also suggested that equally good outcomes on the measure of dependence indicates that patients aiming or not aiming for abstinence were equally satisfied with the changes they had made. Addressing the implications for practice, they advised that as a basis for negotiation, each client's personal drinking goals should routinely be discussed during initial assessments. Findings that patients who achieve success generally do so in ways concordant with their initial goals indicate that these goals should be taken seriously. Clinicians should also identify and support changes in goal as an unexceptional aspect of treatment which need not jeopardise good outcomes. As to which goal should be advocated, they say their findings do not support advising abstinence irrespective of the patient's preferences or problem severity, an insistence which might alienate or deter some patients. Where abstinence is the client's objective, the service should support it. Unless there are medical contraindications to continued drinking, similarly those opting for goals including lower risk drinking should also be supported if their choice is maintained after informed consideration of the alternative.
The report sees abstinence-aiming patients as achieving the best results overall, but this judgement depends on how one draws the line between success and not success. Drawn differently, non-abstinence aiming patients did best. Also, while the study's success criterion accounted for the difficulties drinkers experienced with their drinking status, it did not do the same for abstainers. Several studies have found that the lives of people who aim for and/or achieve abstinence are not necessarily more satisfactory overall than those of patients who did not. On the study's own criterion, by the 12-month follow-up the gap was no longer statistically significant after the drinking and personal characteristics associated with choosing abstinence were taken in to account. In other words, by the final follow-up, people with those characteristics could not be shown to have done significantly worse by virtue of having chosen a non-abstinence goal instead. However, there was a non-significant advantage for choosing abstinence. This might have been a chance finding, but probably reflects a real effect, if one fading a year after the choice of treatment goal was recorded. While the study was concerned with choice of goal at the start of treatment, it is of interest to note that by 12 months 16% of the patients who could be classified were abstinent, 10% drinking without problems, and 12% drinking with problems but having reduced these by at least two thirds.
Neither this study nor most others support arguments that an exclusive abstinence or controlled drinking goal should be integral to treatment programmes for dependent drinkers, nor do they offer much support for requiring or imposing goals in the face of the patient's wishes. In general it seems that (perhaps especially after a little time in treatment) patients themselves gravitate towards what for them are feasible and suitable goals, without services having to risk alienating them by insisting on a currently unfavoured goal. Such findings are consistent with British guidance which warns against insisting on an abstinence gaol, while cautioning that generally this goal gives severely dependent patients the best chances of success. More below and fuller documentation in the background notes.
For details and corroboration of these comments background notes. Analyses like this which, after the data has been collected, divide up a study's participants in ways not intended in advance, in order to test propositions also not specified in advance, are best seen as suggesting that something might (or might not) be worth investigating further. Analysts give less weight to such findings than findings from studies explicitly designed to test a proposition specified in advance.
Though in the featured report some advantages associated with an abstinence goal were statistically significant, more striking was the similarity in the degree of success, regardless of this initial objective; details below.
The study chose a criterion which made abstinence successful by definition, no matter how the patient was faring in the rest of their life, but required drinkers to be free of associated difficulties. Yet in societies where not drinking at all is in statistical and social terms 'abnormal', and leisure and social activities often involve drinking and drinking venues, abstinence is not necessarily an unproblematic choice. This may be particularly the case among some former heavy drinkers whose social lives revolved around drink and drinkers, for whom drinking served psychological purposes, or who find sustaining abstinence a constant battle. As with controlled drinkers, on balance they will almost always be substantially better off than when drinking heavily, but there may still be some abstinence- (rather than drinking-) related deficits and difficulties in their lives.
Since abstinence was more common among those who aimed for it, this criterion favoured these patients, but still the differences were slight. Were the criterion changed to, at a minimum, appreciable By at least a third. problem reduction, then non-abstinence aiming patients would have been judged to have done slightly better. Also, slightly more (46% v. 40%) abstinence-aiming patients had unambiguously poor outcomes, either not appreciably improving or getting worse. Similarly, a less stringent criterion would have reversed the conclusion that abstinence-aiming patients generally achieved successful outcomes by doing what they had intended from the start.
Guidance on the importance of goal choice comes from a review which searched studies published from 1977–2005 for the most consistent predictors of successful treatment outcomes. Choice of abstinence as a goal was one of the top five. On the basis of this review and further studies, it seems that while opting for abstinence is commonly associated with better drinking outcomes, this is by no means universal.
From the featured report and other British (1 2 3) and European studies, it also seems that even when abstinence-aiming patients do end up drinking less, this does not always mean their lives overall are more satisfactory than those of patients who did not opt for abstinence. The 'recovery' agenda in addiction treatment emphasising the overall wellbeing of the patient has most closely been associated with abstinence-oriented approaches. However, a focus on the patient's self-experienced quality of life now being advocated for treatment could as justifiably be seen as requiring flexibility in drinking goals. See next section for the British studies and turn to the background notes for more on reviews of the literature and selected overseas studies.
The support patients receive in achieving controlled drinking or abstinence goals, the optimism they and their associates feel and express about being able to implement these goals, the availability of post-treatment relapse prevention options geared to these goals such as mutual aid groups, and therefore the sustainability of these recovery options, are all likely to be heavily dependent on the local drinking culture and the positions taken by treatment staff and services on the desirability and feasibility of these goals. In turn this environment is likely to affect the extent to which patients adopt controlled drinking or abstinence goals. For UK clinicians, this places a premium on studies conducted in Britain.
Before the featured study, there seem to have been four British studies (described more fully in the background notes), all conducted at NHS hospital inpatient alcohol treatment units: two at the same Liverpool unit (1 2) and another (1 2) at a different unit in the city. Like the featured report, all four found that choice of goal was meaningful in the sense that successful outcomes generally took a corresponding form. The three Liverpool studies also agreed that overall success rates in eliminating risky drinking were similar whether or not abstinence was chosen. Another study in Northampton found that opting for abstinence was more likely to be followed by non-problem drinking, but did not report whether lesser degrees of improvement were also more common among these patients.
Several North American experts (1 2 3) have recently reviewed studies on goal choice in alcohol dependence treatment, concerned that the dominant abstinence-orientation of their services might unnecessarily restrict access to treatment and limit what counts as success. Their views are separately summarised in the background notes.
Among the points they made are that this dominance is partly due to concern that acknowledging the feasibility of controlled drinking for previously dependent drinkers would undermine patients' commitment to abstinence, leading them to try controlled drinking solutions they were unable to sustain. This concern seems supported by studies which have found abstinence to be a more stable post-treatment drinking pattern than controlled drinking, and less likely to transition to problem drinking (see for example 1 2). However, such findings do not mean that patients who opt for or (even if only for a time) achieve non-problem drinking, would have done better had the service insisted on an abstinence goal; many may simply have rejected or quickly dropped out of treatment, failing to benefit at all. Reviewers also identified an understandable 'play safe' mentality among treatment staff, who are unwilling to advocate a non-abstinence gaol for an individual in the absence of any definitive indication from the research of who would be able to sustain controlled drinking. In response it has been argued that research suggests there is no added harm in patients trying moderation as opposed to abstinence, so the balance of clinical advantage lies in widening treatment access by permitting choice.
Reviewers also generally agree that drinking goals change during treatment and need to be regularly re-evaluated, leading if required to corresponding changes to the treatment programme. To avoid premature drop-out, one Swedish centre implemented such a re-evaluation schedule and found more patients started and stayed in treatment. The evaluation of this initiative found that over two years 44% of patients changed between abstinence and controlled drinking goals, with no apparent detriment to their recovery.
While insufficient to determine individual treatment, research does indicate that in general successful non-abstinent outcomes are associated with younger and female patients, those who are relatively socially integrated and psychologically stable, less severely alcohol dependent, and who strongly believe in their ability to moderate their drinking. Goals short of abstinence are contraindicated by certain medical or psychological conditions exacerbated by continued drinking, or when medicines interact dangerously with alcohol. Moderation is less likely to be sustained by patients who have repeatedly been unable to maintain reduced-risk drinking or have a history of severe alcohol withdrawal symptoms. Such patients who nevertheless will not accept an abstinence goal may be persuaded to try this for a trial period, or agree to revert to an abstinence goal if reduced drinking is not working out. Some authorities recommend that if controlled drinking is chosen, patients should be encouraged to be specific about their intended limits so the goal is clear, meaning it will also be clear when this option is not working out.
This advice based on research and expert opinion is consistent with alcohol treatment guidance published in 2006 by England's Department of Health and National Treatment Agency for Substance Misuse, quoted more fully in the background notes. It stressed that drinkers who opt for moderation or even decline to set change goals should not be excluded from services, while recognising that abstinence will be the preferred goal for many of the more heavily dependent drinkers. The guidance observed that moderation or controlled drinking is more acceptable to some (especially less dependent) drinkers, and is worth pursuing for patients who would normally be advised to abstain but currently find this unacceptable, and may offer a stepping-stone to abstinence.
Thanks for their comments on this entry in draft to Nick Heather of Northumbria University and Trevor McCarthy. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 26 March 2010 Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Still hard to find reasons for matching patients to therapies NUGGET 2008
A randomized trial of individual and couple behavioral alcohol treatment for women STUDY 2009
Brief motivational therapy minimises health care costs except among more problematic drinkers NUGGET 2001
Changing network support for drinking: Network Support Project 2-year follow-up STUDY 2009
Style not content key to matching patients to therapeutic approaches NUGGET 2008
UK trial bolsters case for well-supervised alcohol therapy NUGGET 2006
'Real-world' studies show that medications do suppress heavy drinking NUGGET 2005
A meta-analysis of motivational interviewing: twenty-five years of empirical studies REVIEW 2010
My way or yours? THEMATIC REVIEW 2006
A meta-analysis of motivational interviewing: twenty-five years of empirical studies.Lundahl B.W, Kunz C., Brownell C. et al. Request reprint
Research on Social Work Practice: 2010, 20(2), p. 137–160.
Better than 'treatment as usual' but not than other specific therapies are the headlines from the most comprehensive synthesis of motivational interviewing studies to date. Along the way are insights in to the equivocal value of manuals and of feeding back assessment results to patients.
Abstract A team of authors from the USA has produced the most comprehensive synthesis yet of studies of the influential counselling approach, motivational interviewing. The breadth of the analysis has enabled them to conduct detailed sub-analyses of relevance to practitioners and service planners.
The review aimed to isolate motivational interviewing's contribution to client/patient improvements when implemented as a sole or additional intervention, and to do so across the entire range of targeted behaviours and across caseloads ranging from healthy and well functioning individuals to those with diagnosable illness or dysfunction. It was not confined to randomised controlled trials, but included studies did have to feature a no- or alternative-treatment comparison group against which to benchmark the motivational intervention. The analysis contrasted findings on 'classical' motivational interviewing against those on generally more structured versions featuring feedback of assessment or screening results, often known as motivational enhancement therapy.
During 2007 an unusually comprehensive search yielded 119 studies in peer-reviewed journals which provided sufficient information for their results to be aggregated using meta-analytic A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. techniques. Together these studies evaluated 132 implementations of motivational interviewing. Most A given implementation might be evaluated against a comparison group on several outcomes. Alcohol was involved in 68 of these comparisons, miscellaneous drugs in 27, tobacco in 24, and cannabis in 17. evaluated substance use outcomes. Other outcomes or intermediary behaviours included diet, exercise, safe sex, gambling, and engagement in treatment.
Across all 132 comparisons, motivational interventions were associated with a statistically significant improvement in outcomes whose effect size A standard way of expressing the magnitude of a difference (eg, between outcomes in control and experimental groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of the variability in the outcome across both groups. the most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. at 0.22 is conventionally considered to represent a small impact. In a quarter of cases, the motivational intervention was roughly equivalent to the comparator, in another quarter it was associated with small positive improvements, and in a half with substantial improvements. The added benefits showed no signs of fading up to two years or more after intervention, though few studies tested this beyond a year.
Variation in impact was partly accounted for by the strength of the comparator. Compared to another specific intervention such as cognitive-behavioural therapy or a 12-step programme, motivational interventions were roughly equivalent; The effect size was 0.09, only slightly and non-significantly favouring motivational interviewing. The term 'equivalent' is used here as shorthand for the more correct formulation that no reliable difference was found in outcome. Proving that two interventions are essentially equivalent, as opposed to not being able to show they are differ in effectiveness, requires different analytic techniques. participants may have benefited from both, but across all 39 such comparisons there was no appreciable or statistically significant extra benefit from using a motivational approach. In contrast, motivational interventions significantly outperformed every one of the weaker alternatives including treatment as usual (effect size 0.24, a small advantage), being handed health education booklets or other written materials, being placed on a waiting list, or offered no intervention at all. This pattern of results held with substance use problems in particular and across caseloads with problems of differing severity; At each severity level, motivational interventions were not significantly more effective than other specific approaches, but were more effective than either treatment as usual, no intervention, or just handing the participant written materials details below.
The pattern of no difference compared to other specific therapies, but small, statistically significant gains compared to weaker alternatives, applied to each of the substances whose use had been evaluated. Compared to weaker alternatives, motivational interventions recorded a small advantage in alcohol-related outcomes, aggregating to an effect size of 0.2; for smoking and cannabis outcomes, the advantage was slightly greater, for miscellaneous drugs, slightly less. Among the other variables assessed, engagement with treatment followed the same pattern; motivational interviewing further deepened engagement only when the comparator was treatment as usual, no intervention, or nothing more than handing the participant written materials.
Though generally motivational interventions were no more effective than other specific therapies, certain ways of doing them might have been. Incorporating assessment feedback to the patient did not help; these types of intervention remained no better than the alternatives. The only distinction which did make a significant difference was whether motivational therapists had been trained to follow a manual. If they had, then they did no better than therapists using a specific alternative approach. But if they were not guided Or at least, there was no mention of it in the study. by a manual, motivational therapists produced significantly better outcomes, aggregating to a small to medium effect size of 0.45. This was most apparent in the few studies in which a motivational intervention prepared patients for the main treatment, still substantial and significant when it was the sole therapy, and least apparent (failing to achieve statistical significance) when additional to another treatment component.
While generally clients improved to roughly the same degree, on average motivational interventions took three and half hours, alternative approaches, just over five, a difference of about 100 minutes which, though large, just failed to meet the criterion for statistical significance.
Across all the studies motivational interventions were more effective than weaker alternatives (treatment as usual, handing the participant written materials, no intervention, waiting lists). They were most effective of all when they incorporated feedback to the patient on the results of assessments or screening tests; these implementations led to significantly greater improvements than classical motivational interviewing. Longer interventions also led to relatively greater improvements in patients. Training therapists to follow a manual did not diminish effectiveness. All these findings contrast with those from studies which compared motivational interventions with specific alternative therapies.
The main conclusion was that motivational interventions exert small though significant positive effects across a wide range of problems as well as deepening engagement in treatment. Their economy of time and widespread applicability The analysts argued that widespread applicability probably reflects the fact that motivational interventions address processes common to change efforts at various stages and in relation to various behaviours, such as strengthening the working alliance with a client, managing resistance, expressing empathy, and building motivation to change while addressing ambivalence. suggest services should consider their adoption. Motivational interventions can be used as a prelude to another treatment, an enhancement, or as a standalone intervention, though deploying them solely as a group therapy seems to diminish their impact.
Decisions on which therapy to use must be taken in the light of the alternative approaches. Compared to the 'treatment as usual' found in the reviewed studies, or to just handing over written materials, motivational interventions clearly foster more positive change in patients and clients. But compared to other specific therapies, they are equivalent. The implication is that the choice between alternative therapies is best based on features like ease of learning, cost and fit with the agency's ethos; motivational interventions may have the edge in terms of the time required for a programme of therapy.
Classical motivational interviewing is best suited to integration with other approaches or as a set of principles running through all a service's therapeutic work, and may work best as a prelude to further treatment. Motivational enhancement formats incorporating feedback to the patient seem best as additive or standalone interventions. Though perhaps easier to learn, these require standardised assessments to have been conducted. Training therapists to follow a manual confers no benefits, and seems to eliminate any advantage motivational interventions have over specific alternative therapies. However, this finding requires confirmation in studies designed to test its validity.
Run this search for other relevant Findings analyses, and see in particular these Findings reviews (1 2).
The featured review adds its considerable weight to the common conclusion that any well structured therapy is as good as any other. However, this may be partly because studies inappropriately standardise the treatment of individuals seeking help, and equivalence of impact applies only on average across the entire caseload. It remains the case that different therapeutic styles are more or less suited to different people or people at different stages in their commitment to change. Additional to the conclusions drawn in the review itself, what we can tentatively take from the findings is that when individuals seek treatment for their individual problems, individualising the response is important. However, this is not (or not so much) the case in public health programmes which involve identifying people who are not seeking help at all, but have been identified through screening. All these issues are explored further below.
One disappointment is that the analysis did not identify whether participants were seeking treatment for the problems addressed by the interventions. The motivational state of people who decide they have a problem and seek treatment is likely to be very different from that of, for example, people intercepted by screening programmes while routinely visiting their GPs. Appropriate comparators also differ; for people seeking intervention, the key issue is whether motivational interventions are preferable to others; denying help is not usually considered appropriate. For people identified through screening, the key issue is whether having an intervention 'seek them' through active screening and recruitment is better than doing nothing.
This leaves treatment services wondering which bits of the analysis are relevant to them, and screening and brief intervention practitioners wondering the same. Though a clear distinction is not possible, we can guess that the more problematic participants and those offered a specific alternative therapy are most likely to have been seeking treatment, the well-functioning 'community' samples, and those for whom the alternative to motivational intervention was a booklet or nothing at all, most likely to have been identified through screening. In line with this expectation, 14 of the 16 alcohol/drug studies listed in the review which compared motivational interventions to a specific alternative therapy appear to have involved help-seeking patients rather than people identified through screening programmes. This commentary analyses the results with these assumptions in mind.
The fact that motivational interventions did not outperform alternative therapies suggests that what is important is not the specific therapy, but the degree to which it is convincing and coherent, generating optimism among both patient and therapist that there is a way forward and identifying it in a way which secures the patient's collaboration. Though this applied at each of the levels of distress/pathology of the samples, it was best established They were involved in 29 such comparisons. Just five relevant comparisons involved the well-functioning community samples least likely to have been seeking treatment. among the participants most likely to have been seeking help – those with at least moderately severe problems. More below.
The main alternative psychological approach is cognitive-behavioural therapy. An earlier analysis found that the equivalent-impact finding also applied specifically to comparisons between this approach and those based on motivational interviewing (though the latter took less time). Confirming this verdict, but from the point of view of cognitive-behavioural therapy, an analysis of substance use treatment studies found this family of therapies confers little if any benefit relative to other similarly extensive and coherent approaches. In respect of psychological therapy for drinking problems, another analysis found that any structured approach grounded in an explicit model seemed as effective in curbing drinking as any other.
However, for at least three reasons, the 'it doesn't matter' message does not necessarily apply to individual patients or different types of patients.
First, across psychological therapies (including those for substance use problems), implementing the client's informed choice of their preferred therapy nearly halves drop-out rates and significantly if modestly improves outcomes.
Second, relative to treatment as usual or directive advice consonant with their decisions,
motivational sessions
When Findings analysed these studies, we spotlighted the inflexible manualised motivational programmes which insisted that patients re-examine the pros and cons of whether they really did want to stop using drugs or commit to treatment and aftercare, when they had already decided to do so and started the process.
can worsen outcomes for patients who already see themselves as committed to and engaged in a process of change. For less committed patients, motivational interviewing has been more consistently beneficial.
Third, while the specific therapeutic programme may not be directly relevant, some programmes are more conducive to certain interpersonal styles than others, and these styles
suit some patients
Directiveness has, for example, emerged as an important factor; clients who need 'a push' or like to be led respond well to directive therapists; those who react against being led, respond badly. True-to-type motivational interviewing, when not unduly constrained by a set, manualised programme, encourages a non-directive style; cognitive-behavioural therapy, with its emphasis on training and skills, encourages greater directiveness. In the large US Project MATCH alcohol treatment trial, motivational therapists were significantly less directive than those implementing cognitive-behavioural therapy, and it was this difference in style which accounted for how different types of patients reacted. Complicating this formulation is the fact that whether therapists feel the need to be and/or come across as directive depends at least partly on what feels 'natural' in that culture.
more than others.
When, without being able to make these fine distinctions, analyses like those in the featured study find an overall equivalence between different therapies, this probably masks the fact that different therapies have done better or worse with different types of clients, the ups and downs evening out to the 'equivalent' verdict.
A previous analysis which, like the featured review, covered substance use and other types of behaviours and treatment-seeking and non-seeking participants, also found that motivational interventions which have not been standardised through a manual were on average more effective. The same conclusion emerged from a Findings analysis of motivational interventions as a way of preparing patients for the main substance use treatment. Though there are methodological concerns, This finding may indicate that non-manualised implementations of all such therapies work best, rather than that this is peculiar to motivational interventions. The conclusion was reached by identifying studies in which the motivational intervention was not conducted according to a manual. However, no such selection was made in respect of the alternative therapies. Had only studies in which these too were non-manualised been selected, it might have been that non-manualised motivational interventions were no more effective than non-manualised alternatives. This seems however unlikely, as major alternative therapies like 12-step and cognitive-behavioural programmes are inherently more structured than motivational interviewing. Even if the therapist is not explicitly following a manual, they entail a more or less standard series of steps with all patients. In contrast, because of its client-centred and client-led nature, classical motivational interviewing is inherently non-standardised. the featured analysis adds that this advantage for non-manualised interventions is confined to comparisons with specific alternative therapies which mainly involve help-seeking patients and clients.
One tentative way to make sense of these findings A possibly related finding is that incorporating feedback augments the impact of motivational interventions in relation to weaker alternatives, but offers no advantage in comparison to the generally treatment-seeking caseloads in studies which offer specific alternative therapies. Even if only in the prescription of the feedback, these implementations are inherently more standardised than classical motivational interviewing. Often the standardisation goes further, prescribing what should be fed back, how and when, and other elements of the encounter. If these assumptions are valid then this finding would be another instance of standardisation being more appropriate for people not seeking help than for those who have identified they have a problem and have sought treatment. is that individuals seeking help at treatment services both expect and respond best to individualised therapies which respond to their responses rather than following a set programme. They have problems they themselves have identified which from their perspective are unique to them, even if they share some similarities to those of other people, and for which they have a right as a patient to expect a patient-centred response. In contrast, people identified through screening programmes, the ones most likely to be in studies with weaker comparators, have no such investment in 'their' unique set of problems; as far as many knew before the screening test, they did not even have the identified problems. Typically people are identified by someone else as embodying a common public health problem involving the contravention of an impersonal standard of healthy behaviour/status such as drinking over national limits or not eating five portions of vegetables and fruit a day.
Such rationalisations offered 'after the event' are at best speculative, and in this case are hampered by the fact that the featured analysis did not explicitly distinguish participants who were and were not seeking treatment.
Thanks to Luke Mitcheson of the South London and Maudsley NHS Trust for the points made about this entry in draft. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
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Cognitive-behavioral treatment with adult alcohol and illicit drug users: a meta-analysis of randomized controlled trials REVIEW ABSTRACT 2009
Motivational arm twisting: contradiction in terms? THEMATIC REVIEW 2006
Brief interventions short-change some heavily dependent cannabis users NUGGET 2005
The motivational hallo THEMATIC REVIEW 2005
My way or yours? THEMATIC REVIEW 2006
Dismantling motivational interviewing and feedback for college drinkers: a randomized clinical trial STUDY 2009
Counselor skill influences outcomes of brief motivational interventions STUDY 2009
Motivational interviews as a standalone or treatment-entry response to stimulant use NUGGET 2003
Soup kitchen turned into therapeutic setting NUGGET 2006
The grand design: lessons from DATOS KEY STUDY 2002
A comparison of methadone, buprenorphine and alpha2 adrenergic agonists for opioid detoxification: a mixed treatment comparison meta-analysis.Meader N. Request reprint
Drug and Alcohol Dependence: 2010, 108, p. 110–114
A new methodology to combine the results of relevant studies suggests buprenorphine has the edge over methadone among the main medications used to help dependent patients complete withdrawal from heroin and allied drugs.
Abstract For the first time this meta-analytic A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. review applied a new methodology to combine results from comparisons of the main medications used to help dependent patients comfortably complete withdrawal ('detoxification') from opiate-type drugs like heroin. It enabled the analysis to include indirect comparisons between two medications which, even though they may not have not been compared head-to-head, have been compared to the same third medication. The principle is similar to the logic that if A is better than B, and B is better than C, then A must also be better than C. It means more trials can contribute data to the comparison, potentially giving a more secure indication of the preferable medication.
A search for English-language reports in (among other sources) Additional papers were found by searching the references of retrieved articles, tables of contents of relevant journals, previous systematic reviews and meta-analyses of drug misuse, and through written requests to experts. major databases up to May 2006 yielded 23 trials Excluded were studies with less than 10 patients per group, whose patients averaged under 16 years of age, or which extended treatment over longer than 12 weeks. which randomly allocated in all 2112 participants to at least two detoxification options based on tapering doses of the opiate-type drugs methadone or buprenorphine, or the non-opiate medications clonidine or lofexidine. The latter subdue some Lofexidine is an analogue of clonidine. Both are alpha2 adrenergic agonists which dampen withdrawal-induced hyperactivity in certain brain centres, relieving symptoms such as chills, cramps, and diarrhoea. of the body's reactions to the sudden absence of opiates. The criterion of effectiveness was completing Typically defined as being retained to the final day of the planned duration, taking the final dose of the medication being tested in the study, or reaching a zero dose of the medication. the detoxification programme. Completion data was available from 20 trials; four compared methadone and clonidine, two methadone and lofexidine, three methadone and buprenorphine, eight buprenorphine and clonidine, one buprenorphine and lofexidine, and two clonidine and lofexidine.
The main difference made by extending the analysis to indirect comparisons was to elevate the relative performance of buprenorphine. Taking all the data in to account, it was estimated that for every 100 people who completed a methadone detoxification, 164 would complete if prescribed buprenorphine. In contrast, across the three head-to-head comparisons the medications seemed roughly equivalent, with a very slight difference in favour of methadone. Other than this, results confined to direct comparisons were in the same direction and of the same order of magnitude as results based on both direct and indirect comparisons. Across the fuller dataset, from 1.6 to nearly four times as many people completed procedures based on the two opiate-type medications (buprenorphine and methadone) than those based on either of the non-opiate medications (lofexidine and clonidine). Of the two non-opiate medications, lofexidine was preferable, 150 people completing for every 100 prescribed clonidine.
However, the range within which the true estimates might have lain was usually so wide that the reverse conclusion could not confidently be eliminated. Only the comparisons between buprenorphine (the most effective medication) and clonidine (least effective) met conventional criteria for statistical significance, indicating that these differences were highly unlikely to have occurred by chance. Despite this uncertainty, there was an 85% chance that buprenorphine really did lead to the highest completion rates of all the medications, a 12% chance for methadone, and near zero for lofexidine and clonidine.
The author concluded that the opiate-type medications were both probably more effective than clonidine and lofexidine and that (with a greater degree of uncertainty) buprenorphine seemed the most effective of all at promoting completion of a detoxification programme.
This summary is expanded on in the background notes.
Like the featured analysis, another major meta-analysis also found that buprenorphine probably has the edge over methadone in terms of completing withdrawal, and confirmed that it is considerably superior to non-opiate medications; details in background notes. Despite the uncertainties, possibly greater effectiveness allied with the fact that overdose deaths are less likely with buprenorphine than methadone seems sufficient to make it clinically preferable. What might tip the balance for a service is that buprenorphine costs more than methadone. Set against this, buprenorphine programmes can be completed in a shorter time and in some inpatient studies, after a single dose, saving costs (1 2 3 4; details in background notes).
Unless there are overriding contraindications, choice of medication in respect of an individual patient can largely be based on their informed preferences. British studies (1 2; details in background notes) have found that patients who choose what the featured analysis found to be one of the least effective medications (lofexidine) do as well as those who choose the most effective (methadone or buprenorphine), possibly because the least dependent and perhaps most motivated patients opt to do without opiate-type medications.
British guidance (1 2; details in background notes) adds that patients already being prescribed methadone or buprenorphine on a maintenance basis or to stabilise them prior to detoxification should normally continue with the same medication. In particular, the transfer from methadone to buprenorphine has to be carefully managed to avoid precipitating withdrawal symptoms, though it may offer a way to detoxify patients who find stopping methadone difficult. Though this should not override patient preference, the guidance sees clonidine and lofexidine as most suitable for patients with low levels of dependence or who may not be dependent at all, advice which means these medication should have a bigger role in detoxifying young people.
Completion of detoxification was the criterion used by the featured review, and of course this is an appropriate aim for such a procedure. However, completion is a mixed blessing. The guidance cited above warns that the loss of tolerance (the ability to tolerate higher doses after becoming used to regularly taking a drug) following detoxification heightens the risk of overdose and death if patients return to opiate-type drugs, especially if at the same time they drink or take benzodiazepines. This risk is greatest among patients who complete the detoxification phase of the programme (1 2 3), highlighting the need to carefully select and prepare detoxification candidates and to invest in aftercare. Programmes which achieve high rates of completed withdrawal through isolation (such as inpatient programmes and those which precipitate withdrawal under sedation) seem particularly likely to lead patients who are not yet ready for an opiate-free life to lose their protective tolerance. Ironically, outpatient programmes which test the patient's resolve in real-world conditions may be safer because relapse is more likely to occur before tolerance is eliminated. See fuller discussion in background notes.
As the author acknowledged, the review was limited to the main medications used in conventional medicine. There is evidence that herbal remedies can ameliorate opiate withdrawal symptoms to roughly the same degree as the non-opiate drugs lofexidine and clonidine. Also, two types of detoxification programmes were not explicitly analysed by the review. First are the rapid procedures conducted normally in a single day under anaesthesia or sedation, during which withdrawal is precipitated by an opiate-blocking drug, typically naltrexone. These can ensure that a high proportion of patients complete detoxification and start treatment (usually itself based on naltrexone) to sustain abstinence, but many relapse meaning the longer term benefit relative to conventional methods remains unclear. Second are the regimens common in Britain which reduce doses of methadone over several months and not according to a pre-determined protocol. These are largely unresearched except for the NTORS study in England, which recruited patients in 1995. It found these often became maintenance regimens in all but name and (especially for more severely dependent patients) were less successful at curbing heroin use and improving health, other drug use, and crime.
Thanks for their comments on this entry in draft to Nicholas Meader of the Royal College of Psychiatrists' Research and Training Unit and Lucinda Cockayne of NHS Fife Addiction Services. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 03 April 2010 Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Lofexidine safe and effective in opiate detoxification NUGGET 2003
Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence REVIEW 2009
International review and UK guidance weigh merits of buprenorphine versus methadone maintenance NUGGET 2008
Rapid detoxification facilitates transfer to naltrexone but gains fade NUGGETTE 2004
High risk of overdose death for opiate detoxification completers NUGGET 2008
Rapid opiate detox guarantees completion, but abstinence depends on what follows NUGGET 2002
Traditional medicine in the treatment of drug addiction REVIEW 2009
