Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence
Abstract
Background
Methadone maintenance at proper doses is effective in retaining patients in treatment and suppressing heroin use. Questions remain regarding the efficacy of the psychosocial services that are offered by most maintenance programs.
Objectives
To evaluate the effectiveness of any psychosocial plus any agonist maintenance treatment versus any agonist treatment alone for opiate dependence in retaining adult patients in treatment, reducing the use of substances and improving health and social status.
Search methods
We searched the Cochrane Drugs and Alcohol Group's trials register (14 April 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2003), MEDLINE (January 1966 to April 2003), EMBASE (January 1980 to April 2003), PsycINFO (January 1985 to April 2003) and reference lists of articles.
Selection criteria
Randomised studies comparing any psychosocial plus any agonist with any agonist maintenance alone intervention for opiate dependence.
Data collection and analysis
Three reviewers independently assessed trial quality and extracted data.
Main results
Twelve trials involving 981 people were included. These studies considered eight different psychosocial interventions and one pharmacological treatment: Methadone Maintenance (MMT). The results show additional benefit in adding any psychosocial treatment to standard methadone maintenance treatment in relation to the use of heroin during the treatment Relative Risk 0.69 (95% confidence interval 0.53 to 0.91); no statistically significant additional benefit was shown in terms of retention in treatment relative risk 0.94 (95% confidence interval 0.85 to 1.02); and results at follow‐up relative risk 0.90 (95% confidence interval 0.76 to 1.07).
Authors' conclusions
The present evidence suggests that adding any psychosocial support to Standard MMT significantly improves the non‐use of heroin during treatment. Retention in treatment and results at follow‐up are also improved, although this finding did not achieve statistical significance. Insufficient evidence is available on other possible relevant outcomes such as Psychiatric symptoms/psychological distress, Quality of life.
Limitations to this review are imposed by the heterogeneity of the trials both in the interventions and the assessment of outcomes. Duration of the studies was also too short to analyse other relevant outcomes such as mortality. In order to study the possible added value of any psychosocial treatment over an already effective treatment such as standard MMT, only big multi site studies could be considered which define experimental interventions and outcomes in the most standardized way as possible.
PICOs
Plain language summary
Abuse and dependence on opioid drugs are major health and social issues in many societies. Different interventions are available to deal with problems related to opiate dependence. Substituting opioids with the agonist methadone at proper doses effectively keeps drug users in treatment, reduces their use of heroin and helps to limit the risks associated with use of street drugs. Yet a majority of people relapse back into heroin use. Support services are routinely made available in agonist maintenance treatment and include standard counseling sessions, group discussions, social work services and psychiatric care.
The review authors identified 12 controlled trials with 981 adults randomised to methadone maintenance treatment with or without structured psychosocial treatment for treatment of opiate dependence. Over three quarters of the drug addicts were male and the average age was 36 years (range 27 to 41 years). These studies considered eight different psychosocial interventions over two to eight months and were conducted in the US. Structured psychosocial treatment gave added benefit on reducing the use of heroin during treatment (relative risk 0.7). There was a trend but no clear benefit to additional psychosocial treatment on people staying in treatment and heroin use at follow up. Insufficient evidence was available on psychiatric symptoms, distress and quality of life in terms of employment or study and positive lifestyle changes.
