Drug Treatment (Hansard, 4 March 2003)

§ Ms Blears

Comprehensive reviews of the effectiveness of methadone have been provided by several authors (Hall et a;, 1998, Farrell et al., 1994, Bertschy 1995, Marsch, 1998). Most of those studies demonstrating the effectiveness of methadone are of ongoing maintenance treatment but the evidence generally becomes weaker as the duration of treatment shortens, with little systematic evidence to support short-term detoxification. Specific studies include Fontain & Ansseau, 1995, Glass, 1993 and Gossop, M. et al., 2001. High quality medical and psychosocial services, a clear orientation towards social rehabilitation, treatment longevity and slow detoxification of well-stabilised patients have all been identified as giving the best outcomes (Cacciola et al 1998, Bertschy 1995). Randomised controlled trials (RCTs) show a relationship between higher doses (>50 mg) and reduced illicit drug use with better treatment retention rates(Ward et al 1992, Ling et al 1996, Fontaine & Ansseau 1995 and D'Aunno & Vaughan 1992).

Buprenorphine has more recently been established as a potential effective alternative substitution treatment for some patients by a number of studies such as those concentrating on effective doses including Johnson et al., 1995, Ling et al., 1998 and Strain et al., 1994. Specific differences from methadone have been highlighted in other studies including Walsh et al., 1994, Reynaud et al., 1998, Bickel & Amass, 1995, Reisinger, 1997 and Barnett P.G. et al., 2001) and trials in Europe have been reviewed by Chapleo et al., 1997. Also see Uehlinger, C. et al. 1998 and Fischer, G. et al. 1999 for published studies.

The Cochrane review of buprenorphine maintenance for opioid dependence in August 2002 concluded `Buprenorphine is an effective intervention for use in the maintenance treatment of heroin dependence, but it is not more effective than methadone at adequate dosages.'

The effectiveness of naltrexone for relapse prevention has been demonstrated in controlled studies by Shufman et al., 1994 and Gerra et al., 1995. Probation-linked supervised naltrexone has been used as an alternative to custody in opiate-misusing offenders and studied by Brahen & Brewer, 1993. A recent systematic review of the efficacy of naltrexone maintenance treatment in opioid dependence by Kirt Mayer et al. 2002 noted limit support for naltrexone in its findings and this treatment is generally seen as appropriate for a minority of patients.

The Cochrane review of naltrexone maintenance for opioid dependence in January 2002 concluded 'The available trials do not allow a final evaluation of naltrexone maintenance treatment yet. A trend in 982W favour of treatment with naltrexone was observed for certain target groups (particularly people who are highly motivated), as has been previously described in the literature.'

There is a very limited experimental research base comparing specific psychotherapies. McLellan et al., 1994 reviewed the evidence and concluded that `successful outcomes are related to marked and consistent differences between counsellors,' and 'a study of whether the addition of counselling improved the efficacy of methadone maintenance programmes found that the addition of basic counselling on a weekly basis resulted in major and significant improvements'.

International literature (Gerstein D. R. et al., 1990, Kooyman M., 1993 and Hubbard, R., 1994) demonstrates improvements from residential rehabilitation with programmes offering additional services having improved outcomes. The National Treatment Outcome Research Study (Gossop et al. 2001) has confirmed benefits in the UK for those attending residential rehabilitation and found that time in residential treatment is predictive of superior outcomes.

Useful general references containing more detailed references as above: Community treatment of drug misuse: more than methadone. Nicholas Seivewright, Cambridge University Press 2000. The task force to review services for drug misusers—report of an independent review of drug treatment services in England (DH 1997). Methadone substitution therapy—policies and practices. Monograph series number one. Ghodse, A. M. et al. 1998. European Collaborating Centre in Addiction Studies (ECCAS).