Drug Treatment Matrix cell A3: Interventions; Medical treatment

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Interventions; Medical treatment

Key studies on the effectiveness of medical interventions and treatment in medical settings.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text Unfold supplementary text

S Original methadone maintenance trial (1965). Vincent Dole and Marie Nyswander’s report paved the way for the world’s most widespread effective treatment for opiate addiction. For related discussion click here and scroll down to highlighted heading.

S Study seen as endorsing switch to methadone in Britain (1980). Unique trial conducted in London in the early 1970s randomly allocated patients seeking injectable heroin prescriptions to their desired treatment or to oral methadone. Results favoured heroin, but not clearly enough to reverse the trend to methadone. See study 1 in linked PDF file. Related study below.

S Methadone treatment saves lives in Sweden (1990). Restrictions on methadone maintenance in Sweden enabled its value to be convincingly demonstrated. The death rate leapt when maintenance was banned and detoxification and drug-free treatment took over. Reviewed with other Swedish studies in The Swedish experience (2000) on p. 6 of linked PDF file. This study and related Scandinavian studies discussed in ‘bite’ commentary on cell A1. For related discussion click here and scroll down to highlighted heading.

S Even when detoxification hidden from patient, outcomes worse than from maintenance (1979). Patients in Hong Kong maintained on methadone were convicted at half the rate of patients unknowingly detoxified from methadone and then prescribed a placebo. By the end of the three-year study just one of 50 detoxified patients remained in treatment compared to 28 of 50 maintained patients, largely due to persistent heroin use in detoxified patients. Patients who dropped out and were readmitted for methadone maintenance had the same retention-rate as the original treatment group. Similar studies (1 2) and related review below. For related discussions click here and here and scroll down to highlighted headings.

K Lasting benefits but methadone in England could do better (2000 and 2001). Reports from the 1990s NTORS study (still the major English treatment study; see cell A2) confirmed that the benefits of methadone persist to at least two years after treatment entry, though nearly a fifth of patients did not respond well to often ill-defined programmes undermined by under-dosing and poor initial assessment. For related discussion click here and scroll down to highlighted heading.

K Maintenance improves even on ‘enriched’ methadone-based detoxification (2004). US randomised trial (2000; alternative source at time of writing) tested whether enriching methadone-based detoxification with intensive psychosocial services and aftercare would enable it to match minimal-support methadone maintenance. After detoxification patients had been withdrawn, maintained patients used illicit opiates less often, had fewer legal troubles, and were at lower risk of blood-borne diseases, translating (2004; free source at time of writing) into a low-cost way of extending patients’ lives. Similar studies above and below and related review below. For related discussions click here and here and scroll down to highlighted headings.

K Maintain rather than detoxify buprenorphine patients to prevent illegal opiate use (2014). US primary care patients dependent on non-injected prescription opioids were randomly allocated to buprenorphine maintenance or a three-week taper followed by naltrexone to sustain abstinence. Despite a less severe profile than heroin injectors, few detoxified patients stayed in treatment throughout the trial, just two of 57 transferred to naltrexone, and they used more illegally obtained opiate-type drugs than maintained patients. Similar studies above (1 2) and related review below. For related discussions click here and here and scroll down to highlighted headings.

K Methadone’s failure respond to prescribed heroin (2010). In the first British randomised trial, a ‘continental-style’ heroin prescribing programme featuring on-site supervised injecting retained patients and suppressed illegal heroin use much more effectively than oral methadone and somewhat more than injected methadone; broader health, mental health and crime benefits were equivocal. In London concerns about crime and disorder in the clinic’s locality proved unfounded (1 2). Related study above.

K Long-acting naltrexone implants help sustain abstinence (2012). Russian study found naltrexone implants preferable to the oral form of the drug for sustaining post-detoxification abstinence. See also similar Australian trial (2009). Russian study’s lead author also found (2013) long-acting naltrexone more effective than a placebo. Implants have been tried with some success in the UK but are not licensed for medical use. More studies of long-acting naltrexone below. For discussion click here and scroll down to highlighted heading.

K Prescribe an opioid or an opioid blocker after detoxification? (2017). Randomised trial in Norway found injections of the opiate-blocker naltrexone (active for four weeks) no less effective than daily buprenorphine, an opiate-type drug. Similar trial in Malaysia (2008) found buprenorphine superior to oral naltrexone, largely because more patients stopped taking their naltrexone (risking overdose deaths that might not have happened (2014; free source at time of writing) had they been prescribed an opiate substitute). Normally UK patients are offered these opposing types of treatment on the basis of which seems best for them, not in a blanket or random way. More on long-acting naltrexone above. For discussion click here and scroll down to highlighted heading.

R Medications ease opiate withdrawal but relapse common (Cochrane review, 2012). Review comparing tapering doses of methadone to other medications finds all help complete withdrawal but most patients then return to illegal opiate use, highlighting the need for follow-on treatment or to opt for maintenance (see review below) instead.

R Methadone maintenance on average preferable to detoxification (Cochrane review, 2009). A surprisingly small basket of randomised trials (but confirmed by other studies) supports the superiority of methadone maintenance over detoxification for patients prepared to be allocated to either. See also this later (2014) US-focused review commissioned by the US government. Related studies above (1 2). For related discussion click here and scroll down to highlighted heading.

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.

R Drug treatments for opiate dependence (2010). Draws together findings from authoritative reviews of research trials conducted for the Cochrane collaboration and later studies concerned with the pharmacological and psychosocial treatment of dependence on opiates, including withdrawal and maintenance.

R What maintenance feels like for the patient (2013). Free source at time of writing. Synthesises findings from studies which asked opiate users about their views and experiences of long-term maintenance, and explores how these might impede recovery. Rare view from the inside of the good and not so good about being on methadone and allied medications in cultural contexts which may denigrate these treatments as second-best to ‘full’ recovery. For related discussion click here and scroll down to highlighted heading.

R Motivational interviewing is for medics too (2013). Reviews this popular counselling approach (which importantly for non-specialist settings, lends itself to brevity) as applied in medical care settings for substance-related and other conditions. Concludes, “if you can devote a small amount of extra time with your patients to build relationship and evoke change talk [patient’s intentions or commitments to change, thought the main way motivational interviewing works], you can expect 10–15% additional improvement.” Impacts on problem drinking and cannabis use were among the strongest.

R Decades-long search and still no accepted medication for stimulant dependence (2013). Free source at time of writing. Our title reflects the review’s disappointing conclusion. Some medications have shown initial promise, but the difficulty of persuading patients to keep taking them undermines their potential. Counselling and psychosocial therapy remain the dominant approaches.

R G Comprehensive review/guidance from the British Association for Psychopharmacology (2012). Guidance based on review of evidence for drug-based treatments for substance use problems. Covers alcohol, nicotine, opioids, benzodiazepines, stimulants, cannabis, ‘club drugs’ and the ‘polydrug’ use of several drugs together, focusing on dependence rather than ‘harmful use’ or ‘abuse’. Sections on patients with psychological disorders, young people, the elderly, and treatment during pregnancy. Book (2014) from the publishing arm of American Psychiatric Association provides a similar but more extended US-oriented account. For discussion click here and scroll down to highlighted heading.

G UK clinical guidelines on treating drug problems ([UK] Department of Health, 2017). Comprehensive, practice-oriented official clinical guidelines including psychosocial aspects of treatment as well as pharmacotherapies.

G Choose substitute drug on an case-by case basis ([UK] National Institute for Health and Care Excellence, 2007, reviewed 2016). After examining the evidence for oral methadone and buprenorphine in the treatment of opiate addiction, the UK’s official health advisory authority recommended both substitutes for illegal opiate-type drugs, and said the choice between them should be based on benefits and risks for each individual patient.

G Use methadone or buprenorphine for withdrawal ([UK] National Institute for Health and Care Excellence, 2007, reviewed 2014). UK’s official health advisory authority recommends prescribing methadone and buprenorphine to help dependent patients withdraw from opiates, and counsels against anaesthetising or heavily sedating patients to accelerate withdrawal using opiate-blocking drugs.

G Substitute prescribing for opioid dependence in primary care ([UK] Royal College of General Practitioners, 2011). Guidance for GPs in the UK on how to manage the withdrawal of patients dependent on heroin or other opioids, or instead to maintain them by long-term prescribing of legal substitutes. Focuses on the prescribing of methadone and buprenorphine.

G How clinicians can identify and respond to cannabis use problems ([Australian] National Cannabis Prevention and Information Centre, 2009). Evidence-based guidance for all clinicians (but especially GPs), funded by the Australian government. Covers the range of cannabis use interventions from brief advice for users identified by screening through to managing withdrawal and treating dependence.

more All relevant Effectiveness Bank analyses.
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