best practice

Opioid withdrawal with antagonists under heavy sedation or anaesthesia was compared to withdrawal managed with reducing doses of methadone in a systematic review (Gowing 2010,  8 RCTs, N=1109) ) and no difference was found:

• in heroin use after 6 months (RR 0.97, 95 % CI 0.88 to 1.08);
• rates of retention in treatment at 12 months (RR 0.95, 95 % CI 0.69 to 1.30).

Methadone or buprenorphine appeared equally effective to treat pharmaceutical opioid dependent patients as presented in a systematic review (Nielsen et al., 2016, 6 RCT, N= 607). The review found no difference between methadone and buprenorphine in:

• reducing opioid use
  • self-reported opioid use (risk ratio (RR) 0.37, 95 % confidence interval (CI) 0.08 to 1.63)
  • opioid positive urine drug tests (RR 0.81, 95 % CI 0.56 to 1.18)
• retaining people in treatment (RR 0.69, 95 % CI 0.39 to 1.22)
• adverse effects (RR 1.10, 95% CI 0.64 to 1.91)

Psychosocial interventions in addition to Methadone maintenance treatment were found in a systematic review (WHO 2009, 3 RCTs, N=500) to be no different from methadone maintenance treatment only in:

• retaining patients in treatment (RR 0.94, 95 % CI 0.85 to 1.02).

Opioid substitution treatment was found to be effective in a systematic review, without meta-analysis, (Fingleton et al., 2015, N=22 studies, 19 RCTs and 3 national cohort studies), in:

• improving mental health outcomes, eg. psychiatric, depressive and psychopathology symptoms, anxiety and stress (significant positive outcomes in 14 out of the 22 studies). Improvements were greatest in the first six months and studies with a longer follow-up reported no further improvement or that the improvements were not sustained.

A recent systematic review with meta-analysis (Bolivar et al., 2021, RCT= 74, N=10 444) found contingency management for patietns receiving medication for opioid use disorder to have:

• medium-large effect size for abstinence from stimulants, Cohen d = 0.70 [95% CI, 0.49-0.92]; cigarette use, Cohen d = 0.78 [95% CI, 0.43-1.14]; illicit opioid use, Cohen d = 0.58 [95% CI, 0.30-0.86] and improved medication adherence, Cohen d = 0.75 [95% CI, 0.30-1.21]),
• small-medium effect size for increased absitnence from polysubstance use, Cohen d = 0.46 [95% CI, 0.30-0.62] and improved therapy attendance, d = 0.43 [95% CI, 0.22-0.65]).
• Collapsing across abstinence and adherence categories, contingency management was associated with medium effect sizes for abstinence (Cohen d = 0.58; 95% CI, 0.47-0.69) and treatment adherence (Cohen d = 0.62; 95% CI, 0.40-0.84) compared with controls.

Contingency management was found in a systematic review (EMCDDA 2016, studies = 20, N=1 676) to be effective in:

• helping opioid users in substitution treatment to reduce cocaine use (10 out of 13 studies reported statistically significant results in favour of CM)
• helping opioid users in substitution treatment to improve cocaine abstinence (8 out of 8 studies reported statistically significant results in favour of CM)
• helping opioid users in detoxification to improve retention in treatment (2 out of 3 studies reported statistically significant results in favour of CM) as well as opioids and cocaine abstinence (7 out of 10 studies reported statistically significant results in favour of CM)

Heroin plus methadone prescription for maintenance treatment in adult chronic opioid users who failed previous methadone treatment attempts was found to be effective in a systematic review (Ferri et al. 2011, 8 RCT, N=2.007) in:

• remaining in treatment until the end of the study (RR 1.44, 95 % CI 1.19 to1.75);
• probably reducing the risk of death (RR 0.65,  95 % CI 0.25 to1.69).

The risk of adverse events was coherently high in all the seven studies providing comparable data (RR 13.50, 95 % CI 2.55 to 71.53).

Alpha2-adrenergic agonists (Clonidine and lofexidine) were found in a systematic review (Gowing et al., 2016, 26 RCT, N=1 728) to be more effective than placebo in:

• ameliorating withdrawal in terms of the likelihood of severe withdrawal (risk ratio (RR) 0.32, 95 % CI 0.18 to 0.57, 3 studies, N=148)
• increasing completion of treatment (RR 1.95, 95 % CI 1.34 to 2.84, 3 studies, N=148)

When compared to reducing doses of methadone

• duration of treatment was significantly longer with reducing doses of methadone (SMD -1.07, 95 % CI -1.31 to -0.83, 3 studies, N=310)
• hypotensive or other adverse effects were significantly more likely with alpha2-adrenergic agonists (RR 1.92, 95 % CI 1.19 to 3.10, 6 studies, N=464)
• no significant difference in rates of completion of withdrawal treatment were found (RR 0.85, 95 % CI 0.69 to 1.05, 9 studies, N=659)

The Job Seekers Workshop (JSW) is a model that provides short-term, small group sessions focusing on locating available jobs, making “cold calls” to potential employers, and rehearsing job interview skills. JSW is among the interventions/programmes aimed at improving employment outcomes evaluated in a narrative review (Magura et Marshall, 2020, 14 studies).

The review showed no significant effect on:

• improving employment outcomes

The other interventions reviewed are: Individual Placement and Support (IPS), Customized Employment Supports (CES), Therapeutic Workplace (TW), Drug court employment interventions.

Customised employment supports for methadone maintenance clients focusing on individualised interventions to promote vocational skills and reduction of non-vocational barriers (e.g. low self-efficacy) was found to be effective in one RCT (n = 168; Magura et al., 2007, cited in EMCDDA, 2012 - Online appendix):

• 41 % of intervention vs. 25.5 % of standard vocational counselling participants had paid employment (full or part time) during both follow-up periods;
• regression analysis showed that having prior paid employment, full intervention and receiving the intervention rather than the control were significant predictors of having any paid employment at follow-up;
• there was, however, no difference in mean income during the study period.

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

• mixed evidence, thus not conclusive, on the effectiveness in relation to social outcomes, eg, housing and employment.