Transcript Substance Misuse – Outcomes

Substance Misuse –
Outcomes
Jonathan Wood
May 2012
Introduction
• Difficulties with detailing outcomes
• Alcohol treatment outcomes
• Opiate treatment
• Cocaine treatment outcomes
• Injectable Diamorphine - RIOTT trial
Who is the population under study
Alcohol treatment outcomes
• Pragmatic randomised trial based wound
Birmingham, Cardiff and Leeds
• Randomised two forms of therapy for Alcohol
problems.
• Looked at 3 and 12 months after treatment
starting
Characistics
•
•
•
•
Age 41.6 (SD 10.1)
70% men
64% no qualifications
35% employed, 35% on sick/disabled, 20 %
unemployed
• 55% said goal was to abstain
Outcome measures
Baseline
3 months
12 months
Days abstinent
30%
42%
46%
Units per day
26.8
17.9
19.2
Leeds dependence
questionnaire
17
12
11
• LDQ sample question: Do you feel you have to
carry on drinking (drug use) once you have
started?
• <10 low dependence
• 10-20 Moderate to high dependence
• 21-30 High dependence
Medication for alcohol dependence
• Acamprosate: 12 month relative risk or
relapse 0.88 (0.75-0.96)
• Disulfiram: No difference to lapsing, increased
time to first drink and to heavy drinking
• Naltrexone: 12 months relative risk for relapse
to alcohol 0.71 (0.57-0.88)
All three medications are recommended by NICE
One hundred alcoholic doctors (2002)
Followed 100 alcohol dependent doctors for 21 years.
From North West Doctors and Dentists alcohol support group
2002 figures:
Recovered
64 Abstinent 47 died abstinent 14 drinking
normally 3
Not recovered 30: Drinking heavily 6 Died of alcoholism 24
‘Lost’
6
Causes of death overdose of alcohol and drugs, liver failure,
upper GI haemorrhage, inhalation of car fumes, inhalation of
vomit
Methadone Maintenance Evidence
• Evidence of reduction of harm
• Mortality data
• Experimental data
• Evidence for maintenance
• Economic evidence
• Nice guidance: The analysis of maintenance treatment
compared with no treatment resulted in an Incremental
cost effectiveness ratio of £12,600 per additional QALY
gained.
Gunne & Gronbladh (1981) RCT:
Methadone versus no methadone
 34 subjects using heroin by injection
 17 experimental (methadone)
 17 controls (no methadone)
 Controls not allowed to enter MMT for 2 years
 Followed up at 2 years and again at 4 years
Gunne & Gronbladh (1981): Baseline
Experimental Group
(methadone)
Control group
(no methadone)
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U – ongoing daily heroin Use
U
Gunne & Gronbladh (1981): 2 years
Experimental group
(methadone)
Control group
(no methadone)
A
A
A
A
U
U
U
A
A
A
A
A
U
U
U
U
A
A
A
A
U
U
U
U
U
U
U
U
U
U
U
D
U
A – Abstinent
U – on-going daily Use
D – Deceased
D
Gunne & Gronbladh (1981): 4 years
Experimental Group
(methadone)
Control group
(methadone)
Control group
(no methadone)
A
A
A
A
U
U
U
A
A
A
A
A
A
A
U
U
A
A
A
A
A
A
U
D
U
U
U
A
A
A
D
D
U
A – Abstinent
U – on-going daily Use
D – Deceased
D
U.K. Methadone treatment:
benefits in the first month
(Strang, Finch et al, Addiction Research)
7
6.36
6
5
4.7
4
3.5
3
2
2.56
2.2
1.8
1.2
1
pre-entry
1 month
0.5
0.8
0.5
0
heroin
times/wk
heroin
mgX10
cocaine
times/wk
coc mgX10
shoplifting
per week
U.K. Methadone maintenance –
changes in heroin use over time
Source: Finch 2000 MD thesis
Outcomes of drug treatment
• 2009 – Drug Treatment Outcomes Research
Study (UK Home office)
• Recruited ~1800 new presentations for drug
(mainly opiate or cocaine) treatment
• Interviewed at ~4 months then at ~1 year
• About ¾ were still in treatment at the time of
reinterviewing.
• Looked at proportions self reporting using
DTORS findings
• About ¾ were still in treatment at the time of
reinterviewing.
• Drug use dropped substantially
• Crime dropped substantially from 40%
participating in acquisitive crime in past
month to 16% at 1 year
• Health was largely unchanged but risk (sharing
needles or of o.d.) dropped
DTORS - results
• Drug use dropped
substantially
NTA Drug treatment and recovery
statistics
• National Treatment Agency
– Quasi Autonomous Non Governmental
Organisation.
– Tasked with improving availability, capacity and
effectiveness of drug treatment
– Monitors treatment via National Drug Treatment
Monitoring System (NDTMS)
– Monitors individuals via Treatment Outcome
Profile (TOP) forms
– Enables data
Overall outcomes for substance misuse
treatment
• 74,000 started treatment in 2010.
• Total number in treatment was 204,000
• 29,000 left system free from dependency
255,000 entered
treatment 2005-2011
28% left free of
dependency
33% still in treatment
(may have left and reentered)
39% dropped out but
not returned (may be
using, dead or
overcome dependency)
Cocaine treatment
• Commonly
18-24 age
group, high
numbers
through
Offender
Managment
Programmes
Changes at 6 months
Randomised Injectable Opiate Treatment
Trial - (RIOTT)
• Multi-centre open label randomised
controlled trial.
• Comparing injectable Diamorphine, injectable
Methadone and oral Methadone
• Carried out partly in response to Home Office
problems wrt persistent Heroin users
• Open to chronic heroin addicts
‘Usual treatment’
• Methadone Maintenance treatment
“treatment can reduce a individual patient’s
drug use, that treatment is associated with
improved health and employment outcomes
and that treatment can reduce the risk of
serious harms including overdose, crime and
HIV infection” Reuter & Pollack 2006
Current IOT situation
• Gradual reduction of injectable treatment
• Injectable
Methadone 1995 – 8.7%
Diamorphine 1995 – 2%
2003 – 1.9%
2000 - 1%
• Oral
Methadone 1995 – 50K
2003 - 100K
RIOTT Design
Dosing
• Oral Methadone
– Relatively high doses (upper limit 300mg/day)
– Supervised for three months then reducing to 3 days a week
• Injectable Methadone i.v. or i.m.
– Dosing of 200 mg/day + oral 100 mg day
– od dosing
– Supervised throughout
• Injectable Diamorphine i.v. or i.m. or s.c.
– Dosing up to 900mg/day with up to 100mg oral methadone
(300mg/day methadone equivalent)
– bd dosing
– Supervised throughout study.
Outcomes
• Primary
– Self reported heroin use
– Urine drug screening for heroin contaminants for
last 3 months of treatment
• Secondary
–
–
–
–
–
Other drug use
High risk injecting
Health status and psychosocial functioning
Criminality
Pt satisfaction
Results
Responders – 50% or
more samples –ve for
heroin in weeks 14-26
Diamorphine 66%
Inj Methadone 30%
Oral Methadone 20%
Results II
• The number of abstinent participants was not
significantly different however the number of ≤2
positive screens was significant.
Weekly Heroin use
Safety
• 3 serious adverse events directly related to
study
• All overdoses following injectable
administration 1 methadone, 2 Diamorphine
• Treated with O2 and Naloxone
Discussion
• “supervised injectable heroin leads to significantly
lower use of street heroin than Methadone”
• “logistical problem of patients who do not progress
out of treatment”
• “Some reductions in use across three groups despite
previous persistent failure”
• “Injectable Methadone significantly worse than
injectable Diamorphine but not better than oral
Methadone”