best practice

A narrative review (Fischer et al., 2015), without meta-analysis, concluded that there is:

• mixed and short-term evidence, so not conclusive, on the effectiveness of the distribution of crack use paraphernalia on morbidity and mortality outcomes.

A narrative review (Fischer et al., 2015), without meta-analysis, concluded that, despite the fairly substantive body of largely controlled studies, there is:

• mixed and short-term evidence, so not conclusive, on the effectiveness of targeted behavioural harm reduction measures, eg. peer-delivered intervention (‘EachOneTea-chOne’; EOTO), enhanced peer-delivered HIV education interventions, standard HIV prevention programs.

Pharmacotherapies were found in a systematic review of reviews (Ronsley et al., 2020, 29 systematic reviews examining eleven intervention modalities) to have no effect in:

• reducing stimulant use
• improving abstinence

The pharmacotherapies evaluated are:

1. antidepressants
2. disulfiram
3. dopamine agonists
4. antipsychotics
5. anticonvulsants - with a focus on Topimarate
6. opioid agonists
7. N-acetylcysteine

Treatment with psychostimulants was found to have promising results and warrants further investigation (see separate entry).

Population characteristics of the included reviews showed a higher proportion of males in most studies, and predominantly cocaine users, with few studies focusing on methamphetamine use or stimulant use more broadly.

A narrative review (Fischer et al., 2015), without meta-analysis, concluded that, despite the availability of a numerous body of studies and agents tested:

• no pharmacological option has proven to date to be effective.

A narrative review (Fischer et al., 2015), without meta-analysis, concluded that there is:

• some evidence to support the effectiveness of contingency management in outcomes such as retention in treatment and behavioural outcomes, eg, reduce use, abstinence yet mixed evidence in relation to social outcomes, eg, housing and employment albeit in the short-term of treatment.

Evidence-based international guidelines (WHO, 2014) strongly recommend to advise opioid dependent pregnant women to use substitution treatment rather than attempt opioid detoxification.

Evidence does not support detoxification as a recommended treatment intervention as a result of low detoxification completion rates, high rates of relapse, and limited data regarding the effect of detoxification on maternal and neonatal outcomes beyond delivery (Dashe et al, 2018).

Evidence-based international guidelines (WHO, 2014) strongly recommend to advise opioid dependent pregnant women to start or continue substitution treatment with either methadone or buprenorphine.

Substitution treatment for pregnant women was found effective in 2 systematic review (EMCDDA 2014, Minozzi et al., 2020 - 3RCTS methadone vs buprenorphine, 1 RCT methadone vs slow-release morphine) in:

• reducing drop-out rates RR 0.66, 95 % CI 0.37 to 1.20, 3 studies, N=223 (no differences between OST medications)
• higher birth weight (may be higher in the buprenorphine group)
• reducing use during pregnancy (RR 1.81, 95 % CI 0.70 to 4.68, 2 studies, N=151)
• new-borns treated for neonatal abstinence syndrome RR 1.19, 95% CI 0.87 to1.63 (no differences between OST medications)

A systematic review with meta-analysis (Zedler et al, 2016, 3 RCTs, N= 223 and 15 observational studies, N=1 923), compared buprenorphine with methadone to treat pregnant women with opioid use disorder and found:

• lower risk of preterm birth (RR =0.40, 95 % CI = 0.18-0.91)
• greater birth weight (weighted mean difference (WMD) =277g, 95 % CI = 104-450)
• larger head circumference (WMD=0.90cm, 95 % CI=0.14-1.66)

A systematic review (Link et al., 2020, 5 RCTS, N= 1 875) found that substitution treatment with buprenorphine-naloxone have similar pregnancy outcomes when compared to women undergoing treatment with other forms of OST.

Combined psychosocial (contingency management, community reinforcement, psychotherapeutic counselling and family therapy) and pharmacological assistance were found to be effective in a systematic review of five randomised control trials (N=184 participants, WHO 2009) in:

• increasing rates of completion of treatment (RR 1.68, 95 % CI 1.11 to 2.55, moderate quality evidence);
• reducing rates of relapse at follow-up (RR 0.41, 95 % CI 0.27 to 0.62, moderate-quality evidence).

Methadone treatment plus psychosocial intervention compared with methadone treatment only was found in a systematic review of (WHO, 2009, 3 RCTs, N=388) to be more effective in:

• reducing heroin use (RR 0.69, 95 % CI 0.53 to 0.91)

Patients who received opioid agonist pharmacotherapy with psychological support were found in a national cohort study (Pierce et al., 2015, N=151 983) to be:

• less at risk for fatal drug-related poisoning when compared to those enrolled only in psychological intervention (adjusted hazard ratio for only psychological support, aHR = 2.07, 95 % CI 1.75 – 2.46)

Methadone substitution treatment was found in a systematic review (WHO, 2009, 3RCTs, N=505) to be more effective than opioid withdrawal followed by placebo in:

• increasing retention in treatment (RR 3.05, 95 % CI 1.75 to 5.35);
• reducing illicit opioid use (RR 0.32, 95 % CI 0.23 to 0.44).

Observational studies found the mortality rate in methadone treatment to be approximately one-third the rate out of treatment (RR 0.37, 95 % CI 0.29 to 0.48).

Methadone was found in one RCT (N=253) to reduce the risk of HIV infection by approximately 50 % (RR 0.45, 95 % CI 0.35 to 0.59) and a similar reduction in seroconversion rates was found in 3 observational studies (N=43 035) (RR 0.36, 95 % CI 0.19 to 0.66) when compared to withdrawal or no treatment.