best practice

Buprenorphine and methadone for opioid assisted withdrawal was found in a systematic review (Gowing et al., 2017, 27 RCTs, N = 3 048) to be equally effective in treatment outcomes and no difference between the two medications was detected in terms of:

• completion rates (RR 1.04, 95% CI 0.91 to 1.20, RCTs = 5; N = 457, moderate quality)
• average treatment duration (MD 1.30 days, 95% CI −8.11 to 10.72, RCTs = 2, N = 82, low quality)

Methadone maintenance therapy was found to be statistically more effective than Buprenorphine maintenance therapy in a systematic review (Mattick et al., 2014) in:

• improving retention in treatment
  • in flexible doses studies (RR 0.83, 95 % CI 0.72 to 0.95, 5 studies, N=788);
  • in low doses studies (MMT ≤ 40mg , BUP 2-6mg) (RR 0.67, 95 % CI 0.52 to 0.87, 3 studies, N=253);
• no difference was observed in reduction of opioid use as measured by urinalysis (SMD -0.11; 95 % CI -0.23 to 0.02, 8 studies, N=1027) or self-reported (SMD -0.11; 95 % CI -0.28 to 0.07, 4 studies, N=501)

However, at medium doses (MMT 40-85mg, BUP 7-15mg) and high doses (MMT ≥ 16mg, BUP ≥ 85mg) no difference was found between Methadone and Buprenorphine treatment in:

• improving retention in treatment
  • medium doses (RR 0.87, 95 % CI 0.69 to 1.10, 7 studies, N=780)
  • high doses (RR 0.79, 95 % CI 0. 02 to 3.16, 1 study, N=134)
• reducing opioid use as measured by urinalysis or self-reported

Buprenorphine substitution treatment was found to be more effective than placebo in a synthesis of evidence (WHO, 2009) and more recenlty in a systematic review (Mattick et al., 2014) in:

• improving retention in treatment
  • at low doses (2-6mg) (RR 1.50, 95 % CI 1.19 to 1.88, 5 studies, N=1131);
  • at medium doses (7-15mg) (RR 1.50, 95 % CI 1.19 to 1.88, 4 studies, N=887);
  • at high doses (≥ 16mg) (RR 1.82, 95 % CI 1.15 to 2.90, 5 studies, N=1001)
• reducing the number of morphine-positive urines only at high doses (SMD –1.17, 95 % CI –1.85 to –0.49, 3 studies, N=729)

Behavioural therapies (including cognitive behavioural therapies (CBT), motivational interviewing (MI) and contingency management) were found in a systematic review with meta-analysis (Gates et al., 2016, 23 RCTs, N=4 045) to be more effective than control conditions on:

• completing of treatment (effect size (ES) 0.71, 95 % CI 0.63 to 0.78, 11 studies, N=1 424)
• reducing use (MD 5.67, 95 % CI 3.08 to 8.26, six studies, N=1 144)
• improving abstinence (RR 2.55, 95 % CI 1.34 to 4.83, six studies, N=1 166)
• reducing symptoms of dependence (standardised mean difference (SMD) 4.15, 95 % CI 1.67 to 6.63, four studies, N=889)
• reducing cannabis-related problems (SMD 3.34, 95 % CI 1.26 to 5.42, six studies, N=2 202)

The same meta-analysis also found that:

• Interventions of more than four sessions delivered over longer than one month (high intensity) produced consistently improved outcomes (particularly in terms of cannabis use frequency and severity of dependence) in the short term as compared with low-intensity interventions
• The most consistent evidence supports the use of cognitive-behavioural therapy (CBT), motivational enhancement therapy (MET) and particularly their combination for assisting with reduction of cannabis use frequency and severity of dependence at early follow-up
• Data from five out of six studies supported the utility of adding voucher-based incentives for cannabis-negative urines to enhance treatment effect on cannabis use frequency

Evidence of drug counselling, social support, relapse prevention and mindfulness meditation was weak because identified studies were few, information on treatment outcomes insufficient and rates of treatment adherence low.

Behavioural therapies targeting specifically adolescents were analysed in a systematic review without meta-analysis (Hogue et al., 2014, 8 RCTs) arriving at the same conclusions: see comment for the rest of the text

• CBT is well established but was outperformed  by family-based treatments in several trials
• CBT at group level or at individual level are equally effective
• MI as a standalone approach has given mixed results
• Integrated models uniformly performed well

Compulsory drug treatment (including drug detention facilities, short (i.e. 21-day) and long-term (i.e. 6 months) inpatient treatment, community-based treatment, group-based outpatient treatment, and prison-based treatment) was found in a systematic review without meta-analysis (Werb et al., 2016, 9 studies, N=10 699) was found to have no effect on:

• drug use or criminal recidivism over other approaches (78% of the studies)
• two studies (22 %) detected negative impacts of compulsory treatment on criminal recidivism compared with control arms
• only two studies (22 %) observed a significant impact of long-term compulsory patient treatment on criminal recidivism: one reported a small effect size on recidivism after two years, and one found a lower risk of drug use within one week of release from compulsory treatment

Shared decision-making (SDM) as means to involve patients in medical decision- making and matching patients’ preferences to treatments were found in a systematic review without meta-analysis (Friedrichs et al., 2016, 25 studies, N=8 729) to have no effect in:

• decreasing substance use

Residential treatment was found in a systematic review without meta-analysis (Reif  et al., 2014, 8 review and 21 studies) mixed results when compared to other interventions in:

• improving treatment outcomes

Motivational interviewing was found in a systematic review with meta-analysis (Li et al., 2016, 10 RCT, N=1 466) to have no statistically significant effect in:

• changing drug use behaviours (d=0.05, 95% CI 0.06 - 0.17, p=0.36)

Internet-based interventions (including unguided stand-alone internet interventions and internet interventions as an add-on to treatment as usual) were found in a systematic review with meta-analysis (Boumparis et al., 2017, 17 RCTs, N = 2 836) to have no significant effect in:

• reducing stimulant use at post-treatment (P = 0.164, RCTs = 4, N = 481)

Brief interventions in emergency settings were found in a systematic review without meta-analysis (EMCDDA, 2016, 16 studies, N=8 875) to have no effect in:

• significantly decreasing substance use (mainly alcohol) and related harms 

The same results were confirmed in a more recent narrative systematic review (Kaczorowski et al., 2020, 12 studies) that focused specifically on ER-initiated interventions for opioid users.