Maintenance Methadone Better than Quick Detox with Prolonged Psychosocial Activities for Opiate-Dependent Patients
Maintenance Methadone Better than Quick Detox with Prolonged Psychosocial Activities for Opiate-Dependent Patients
ABSTRACT & COMMENTARY
Synopsis: In treatment of opiate-dependent individuals, prolonged methadone maintenance does better than quick methadone withdrawal with 180 days of psychosocial detoxification.
Source: Sees KL, et al. JAMA 2000;283:1303-1310.
Despite the increase in cocaine abuse in the United States over the last 20 years, admissions to treatment programs for opioid dependency (heroin, etc.) surpassed the cocaine admissions in the United States in 1997. This has prompted the U.S. Department of Health and Human Services to consider changing the policy of federally registered methadone clinics in the United States. These changes would allow private or group practice physicians to provide opiate treatment outside methadone maintenance clinics. This in part may have been a response to a recent consensus conference that called for integrating substance abuse services into primary care in the United States.
Thus, there exists a significant impetus for a research on detoxification programs, possibly shortened by enhanced psychosocially enriched counseling. Sees and colleagues did just this.
Sees et al compared the outcomes of opiate-dependent patients treated with standard methadone maintenance therapy provided by a federally registered methadone maintenance clinic to an alternative treatment consisting of psychosocially enriched 180-day methadone assisted detoxification. This randomized, controlled trial consisted of 858 volunteers being screened and 179 adults being randomized. A total of 154 adults completed the 12 weeks of follow-up.
Ninety-one patients were randomized to methadone maintenance therapy (MMT), which in their study required two hours of psychosocial counseling during the six months of the study. Eighty-eight patients were randomized to detoxification requiring three hours of psychosocial counseling including 14 education sessions and an hour of group cocaine therapy (if they answered yes to cocaine abuse questions or tested positive for cocaine in the urine), with an additional six months of services provided afterward. In the detox program, the methadone was reduced rapidly over 60 days after 120 days of stabilization.
Sees et al found a higher treatment retention rate (438 vs 174) and lower heroin use in the MMT group than in the detox group. MMT also resulted in a lower rate of drug-related HIV risk behavior, but interestingly not a lower sex-related HIV risk behavior. Also looked at were employment, family functioning, and alcohol abuse, and no differences were found. The MMT group stayed in treatment longer. Neither group showed any difference in their illicit opioid use. The MMT group had a precipitous decline in heroin use, needle-related HIV risk behavior, and drug-related crimes.
Fifty percent of the patients in both groups used heroin at least once during any month in the treatment, cocaine use (among those at risk), sex-related HIV risk behaviors, employment problems, and family problems persisted despite either program.
Comment by len Scarpinato, do, facp, fccp
There has been a movement to limit the effect of methadone treatment centers by creating programs that are shorter in time, more intense in therapy, and possibly available at family care offices. The idea being that you can reduce methadone length of treatment by providing more psychosocial counseling. This study by Sees et al shows us that we can’t exactly do that. For the important parameters listed above, methadone maintenance therapy beat out the shorter version with more psychosocial counseling. Yet we have a long way to go when 50% are still using heroin once a month!
As a primary care physician who sees this dependency in a correctional medicine facility or my family practice setting, this study has important implications. I can’t just patch together an opioid withdrawal clinic "without walls." I would have to involve multiple services and increased psychosocial counseling, and not do better than MMT. What is needed is methadone (or other alternatives also discussed in this issue of JAMA). In a related editorial, Rounsaville and Kosten discuss another article by Weinrich and Stuart in the same issue of JAMA.1,2 This article discusses primary care physicians using methadone.2 Weinrich and Stuart report a 3- to 5-fold increase in the proportion of patients served secondary to a supervised methadone consumption program in a primary care clinician’s office. This may be the future in the United States, especially if the U.S. officials decide to take the consensus to heart.
References
1. Rounsaville BJ, Kosten TR. JAMA 2000;283:1337-1339.
2. Weinrich M, Stuart M. JAMA 2000;283:1343-1348.
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