Transcript Developments in Community Drug Treatment

Developments in Community - Based
Drug Treatments
Lesley Peters
[email protected]
Overview
1. Facts and figures
2. Best practice evidence base
3. New developments
Extent of problem drug use
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Prison
130 000 annual
through flow (HM Prison
Service, 2003)
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79 700 prison
population (NOMS Oct
2006)
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70 000 problem drug
users annually
39 000 problem drug
users at any one time
(HM Prison Service, 2003)
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Community
288 000 problem
drug users (Best, 2005)
120 000 in treatment
(NTA, 2006)
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181 000 in contact
with drug services
2005/06 (NTA, 2006)
Main drug of misuse
From NDTMS data 2005/2006 (NTA 2006)
 heroin 66%
 crack cocaine / cocaine 11%
 methadone / other opiates 10%
 (cannabis 8%)
Also in Tier 3 services
 benzodiazepines - poly drug use
 amphetamine - some primary users
Community based treatments 1
Opiate substitution treatment
 methadone
 buprenorphine
Opiate detoxification
 methadone
 buprenorphine
 lofexidine
Relapse prevention
 naltrexone
Community based treatments 2
Crack cocaine
 psychosocial interventions
 complementary therapies
Benzodiazepines
 inter-service variation in prescribing policies
 diazepam reductions/de facto maintenance
Amphetamine
 some dexamphetamine prescribing
 otherwise as for crack
Evidence for methadone maintenance
Randomised controlled trials
(Dole 1969, Gunne 1981, Newman 1979, Strain 1993,
Vanichseni 1991, Yancovitz 1991)
Cochrane review (Mattick et al 2003)
TOPS (Hubbard et al 1989)
NTORS (Gossop et al 1997,2001, 2003)
Meta-analysis (Marsch 1998)
Evidence for methadone maintenance
 increased treatment retention
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reduced illicit heroin use
reduced crime and imprisonment
reduced injection related risk behaviour
reduced HIV infection
reduced mortality
improved psycho-social well-being
increased employment
Current guidance on methadone dose
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Department of Health clinical guidelines (1999)
NTA Models of Care (2002)
NTA Research into Practice briefing on MMT
(2004)
‘consistent finding of greater benefit from
maintaining individuals on a daily dose between
60mg and 120mg’
(higher doses in exceptional cases)
Evidence in relation to methadone dose
Cochrane review of effectiveness of MMT at
different dosages (Faggiano et al 2003)
21 studies - 11 RCTs, 10 CPS
low: 1 - 39 mg
med: 40 - 59 mg
high: 60 - 109 mg
methadone doses 60 – 100mg more effective
than lower doses at
- retaining patients
- reducing heroin & (?) cocaine use during
treatment
Effects of increasing methadone dose
individuals on < 60 mg 2x as likely to leave
treatment as those on 60 - 79 mg & 4x as
likely as those on > 80 mg
(Caplehorn & Bell, 1991)
likelihood of using heroin in treatment
reduced by 2% for every 1mg increase in
methadone dose. Odds of using heroin on
40mg, 2.2 x those on 80mg
(Caplehorn et al 1993)
NTORS
MMT - higher doses & retention in treatment
predictive of reduced heroin use
each milligram increase in methadone dose
associated with 2% reduction in likelihood of
regular heroin use
(NTORS 2 year follow up, Gossop et al, 2001)
Optimising methadone maintenance
More effective MMT
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higher doses
maintenance orientation
high quality counselling
medical services
good therapeutic relationship between client &
keyworker
low staff turn over
higher retention rates
(Ball & Ross 1991)
Buprenorphine in maintenance treatment 1
Cochrane review, Mattick et al, 2003
 comparing buprenorphine to placebo or to
methadone maintenance
 ‘buprenorphine is an effective intervention for
use in maintenance treatment of heroin
dependence, but it is not more effective than
methadone at adequate doses’
Buprenorphine in maintenance treatment 2
Cochrane review, Mattick et al, 2005
 comparing buprenorphine with methadone in
flexible dosing regimes
 methadone 20 -120mg
 buprenorphine 2 - 16mg
 methadone maintenance better retention
rates
 no difference in opiate use
Recommended dose for buprenorphine
maintenance 12 - 24mg daily
Opioid detoxification 1
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Methadone at tapered doses for the management
of opioid withdrawal, Cochrane Review, (Amato
et al, 2005)
No difference between methadone and other
pharmacotherapies
Opioid detoxification 2
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Buprenorphine for the management of opioid
withdrawal, Cochrane Review, Gowing et al,
2006
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‘Buprenorphine is more effective than
clonidine for the management of opioid
withdrawal. There appears to be no
significant difference between buprenorphine
and methadone in terms of completion of
treatment, but withdrawal symptoms may
resolve more quickly with buprenorphine.’
Relapse prevention: naltrexone
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naltrexone and behavioural treatment
significantly reduced probability of reincarceration (Kirchmayer et al. 2002)
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oral naltrexone effective treatment if retention
rate adequate (Johansson et al, 2006)
Treatment of cocaine dependence
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Cochrane reviews - all negative
antidepressants
dopamine agonists
carbamazepine
auricular acupuncture
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psychosocial interventions most promising
Psychological therapies 1
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evidence base for MMT based on studies
which included counselling
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improved MMT outcomes with addition of a
range of psychosocial interventions e.g.
medical/psychiatric care, social work, family
therapy, employment counselling (McLellan et al,
1993)
Psychological therapies 2
Effectiveness of psychological therapies in drug
misusing clients (Wanigaratne et al, 2005)
Opiates
 substitution treatment plus any psychosocial
intervention
Stimulants
 CBT / relapse prevention / motivational
interviewing
New Guidelines
NICE clinical guidelines (due July 2007)
 Drug Misuse: opiate detoxification of drug
misusers in the community and prison settings
 Drug Misuse: psychosocial management of drug
misusers in the community and prison settings
NICE Technology Appraisals (due March 2007)
 Methadone and buprenorphine for the treatment
of opiate drug misuse
 Naltrexone as a treatment for relapse prevention
in drug misuse
Treatment Effectiveness
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NTA Treatment Effectiveness strategy launched
June 2005
improving client’s journey through treatment
improving local drug treatment systems
- waiting times - 3 weeks for voluntary referral
- retention targets - 12 week target
- care planning
- wrap around services - housing, education, employment
- drug free routes
Buprenorphine / naloxone combination
Suboxone
buprenorphine : naloxone 4:1
• 4 week double blind
study
• open label study, take
home doses, opiate free
urines 35% to 67% over
6 months
Fudala et al, 2003
Sustained release buprenorphine
• Subcutaneous injection 58mg buprenorphine
• lasted upto 6 weeks
• reduced withdrawal, reduced craving, blocked effect of opiates
Sobel et al, 2004
Depot naltrexone
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subcutaneous implants
intramuscular injection
- monthly injections
- positive results alcohol and heroin
dependence
- increased retention; 60%+ in heroin
users
(Garbutt et al, 2005; Comer et al,2006)
New treatments for cocaine dependence
Modafinil and Behavioral Therapy
Modafinil 33% abstinent for > 3 consecutive weeks
Dackis et al, 2005
Placebo 13%
New treatments for cocaine dependence
Disulfiram and CBT
Carroll et al, 2004
Cocaine vaccine
•TA - CD
• generates antibodies
• cocaine - antibody
complex too large to
cross blood brain barrier
• cocaine antibodies
persist for months
• ethical debates
Martell et al, 2005
Take Home Naloxone 1
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opiate antagonist
reverses respiratory depression of heroin
overdose
given by injection
naloxone may be ‘given by anyone for the
purpose of saving life in an emergency’
Medicines for Human Use (Prescribing) (Miscellaneous
Amendments) Order 2005
Take Home Naloxone 2
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target high risk situations
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train users, peer group, carers in administration
of naloxone and general overdose training
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distribute to users, friends and family
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named patient basis
Mini-jet naloxone
400 micrograms per 1 ml
Mini-jet naloxone
400 micrograms per 1 ml
Watch this space !