Low and high methadone maintenance in the out-patient treatment of the hard core heroin adict

A randomized investigation of methadone doses at or over 100 mg/day, combined with contingency management

BACKGROUND

Methadone maintenance for heroin dependence reduces illicit drug use, crime, HIV risk, and death. Typical dosages have increased over the past few years, based on strong experimental and clinical evidence that dosages under 60 mg/day are inadequate and that dosages closer to 100mg/day produce better outcomes. However, there is little experimental evidence for the benefits of exceeding 100 mg/day, or for individualizing methadone dosages. We sought to provide such evidence.

METHODS

We combined individualized methadone dosages over 100 mg/day with voucher-based cocaine-targeted contingency management (CM) in 58 heroin- and cocaine-dependent outpatients. Participants were randomly assigned to receive a fixed dose increase from 70 mg/day to 100mg/day, or to be eligible for further dose increases (up to 190 mg/day, based on withdrawal symptoms, craving, and continued heroin use). All dosing was double-blind. The main outcome measure was simultaneous abstinence from heroin and cocaine.

RESULTS

We stopped the study early due to slow accrual. Cocaine-targeted CM worked as expected to reduce cocaine use. Polydrug use (effect-size h=.30) and heroin craving (effect-size d=.87) were significantly greater in the flexible/high-dose condition than in the fixed-dose condition, with no trend toward lower heroin use in the flexible/high-dose participants.

CONCLUSIONS

Under double-blind conditions, dosages of methadone over 100mg/day, even when prescribed based on specific signs and symptoms, were not better than 100mg/day. This counterintuitive finding requires replication, but supports the need for additional controlled studies of high-dose methadone.

Methadone maintenance at different dosages for opioid dependence

BACKGROUND

Methadone maintenance treatment (MMT) is a long term opioid replacement therapy, recognised as effective in the management of opioid dependence. Even if MMT at high dosage is recommended as therapy for reducing illicit opioid use and promoting longer retention in treatment, at present day "the organisation and regulation of the methadone maintenance treatment varies widely".

OBJECTIVES

To evaluate the efficacy of different dosages of MMT for opioid dependence in modifying health and social outcomes and in promoting patients' familial, occupational and relational functioning.

SEARCH STRATEGY

The following sources were scanned: - MEDLINE (OVID 1966-2001)- EMBASE (1988-2001)- ERIC (1988-2001)- Psychinfo (1947-2001)- Cochrane Controlled Trials Register (CCTR) (1947-2001)- Register of the Cochrane Drug and Alcohol Group (CDAG) (1947-2001)The CDAG search strategy was applied together with a specific MESH strategy. Further studies were searched through: letters to the authors of selected trials or to experts in order to obtain unpublished data. check of references of relevant reviews.

SELECTION CRITERIA

Randomised Controlled Trials (RCT) and Controlled Prospective Studies (CPS) evaluating methadone maintenance at different dosages in the management of opioid dependence were included in the review. Non-randomised trials were included when proper adjustment for confounding factors was performed at the analysis stage.

DATA COLLECTION AND ANALYSIS

Extraction of data was performed separately by two reviewers. Discrepancies were resolved by a third reviewer. RevMan software was used for analysis. Quality assessments of the methodology of studies were carried out using CDAG checklist.

MAIN RESULTS

22 studies were excluded from the review. 21 studies were included; of them, 11 were RCTs with 2279 people randomised and 10 were CPSs with 3715 people followed-up.

OUTCOMES

Retention rate - RCTs: High vs low doses at shorter follow-ups: RR=1.36 [1.13,1.63], and at longer ones: RR=1.62 [0.95,2.77]. Opioid use (self reported), times/w - RCTs: high vs low doses WMD= -2.00 [-4.77,0.77] high vs middle doses WMD= -1.89[-3.43, -0.35] Opioid abstinence, (urine based) at >3-4 w - RCTs: high vs low ones: RR=1.59 [1.16,2.18] high vs middle doses RR=1.51[0.63,3.61] Cocaine abstinence (urine based) at >3-4 w - RCTs: high vs low doses RR=1.81 [1.15,2.85]Overdose mortality - CPSs: high dose vs low dose at 6 years follow up: RR=0.29 [0.02-5.34] high dose vs middle dose at 6 years follow up: RR=0.38 [0.02-9.34] middle dose vs low dose at 6 years follow up: RR=0.57 [0.06-5.06]

REVIEWER'S CONCLUSIONS

Methadone dosages ranging from 60 to 100 mg/day are more effective than lower dosages in retaining patients and in reducing use of heroin and cocaine during treatment. To find the optimal dose is a clinical ability, but clinician must consider these conclusions in treatment strategies.

The effects of methadone maintenance with opioid takers. A review and some findings from one British city

Various benefits claimed for methadone maintenance in the treatment of opioid drug takers are reviewed. It is said to stop illicit drug use, maintain treatment contact, reduce morbidity, mortality and crime, and improve social adjustment. Little firm evidence is found to support these claims. Results are reported comparing 26 drug takers on methadone prescriptions with 16 illicit opioid takers. The measures used are Stimson's (1972) 'Patterns of Behaviour' questionnaire and direct behavioural measures of social functioning. The groups are found not to differ in terms of treatment contact, work status and involvement with other drug takers. There is some evidence that the methadone group is involved in less criminal activity. However, no association is found between amounts of drugs prescribed and numbers of local pharmacy thefts. It is concluded that the benefits of methadone maintenance have been exaggerated.