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Bao Y-P., Liu Z-M., Epstein D.H. et al.
Journal of Drug and Alcohol Abuse: 2009, 35(1), p. 28–33.
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For the first time an analysis of relevant studies has assessed the relative contributions of higher doses and flexibility in setting doses to improving retention in opiate substitute prescribing programmes. Both it seems help retain patients in treatment.
Summary For the first time an analysis of relevant studies has assessed the relative contributions of higher doses and flexibility in setting doses to improving retention in methadone maintenance treatment for opiate dependence. The conclusion was that both were independently associated with longer retention.
The analysis aimed to use 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. to estimate the influence of different methadone dose ranges and dosing strategies on retention. A systematic literature search identified 18 randomised controlled trials evaluating methadone dose and retention involving 2831 patients, of whom 1797 were prescribed methadone. Retention was defined as the percentage of patients remaining in treatment either in the short term (3–6 months) or in the longer term (6–12 months). Doses were categorised as at least equal to or below the 60mg per day recommended as the minimum effective maintenance dose for most patients in a consensus statement from the US National Institutes of Health. Dose-setting strategies were characterised as either fixed dose for all patients or individualised, flexible dosing. Raw figures showed that either higher doses or flexible dosing raised the percentage of patients retained by 12–13% from below 50% to about 60%. Except for short-term retention at higher doses, flexible dosing significantly raised retention in both dose level categories. Further analysis Multilevel logistic regression. estimated the independent contribution of dose and dose strategy when the other variable (and also length of follow-up) was statistically controlled. Each variable still significantly predicted retention. Doses at or above 60mg daily (compared to lower doses) and flexible dosing (compared to set doses) each raised the proportion of retained patients by just over 70%. The authors concluded that retention will probably be greatest when the dosing strategy is flexible and doses are relatively high.
commentary Effectively the analysis answers two questions. First, if dose levels are taken out of the equation, does flexibility still improve retention, or is it only that flexibly set doses tend to be higher? Secondly, if flexibility is taken out of the equation, do higher doses still improve retention, or is it only that clinics which prescribe higher doses also tend to be flexible? The answers were that each makes its own contribution, implying that a clinic will maximise retention by prescribing adequate doses on average, and further improve retention by also determining dose according to how each individual patient responds. These are of course not the only ways to improve retention, but they are the most basic ones on which other strategies can be built. The featured study offers further support to UK guidelines on the treatment of drug problems, which recommend flexible doses generally in the range 60–120mg. The same message was found in a review of the research conducted for the English National Treatment Agency for Substance Misuse. Yet when in 2004/05 English services were audited, at 60% methadone doses averaged under 60mg a day.
Though the analysis confined itself to retention, the importance of its findings is that retention at least up to one year is associated with better health and crime outcomes for patients and for society.
Last revised 17 March 2009
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REVIEW 2009 Efficacy of opiate maintenance therapy and adjunctive interventions for opioid dependence with comorbid cocaine use disorders: a systematic review and meta-analysis of controlled clinical trials