Developments in Community - Based Drug Treatments

Lesley Peters

lesley.peters@manchester.ac.uk

Overview

1. Facts and figures

2. Best practice evidence base

3. New developments

Extent of problem drug use

Prison 130 000 annual

through flow (HM Prison Service, 2003)

79 700 prison population (NOMS Oct 2006)

70 000 problem drug users annually

39 000 problem drug users at any one time(HM Prison Service, 2003)

Community 288 000 problem

drug users (Best, 2005)

120 000 in treatment(NTA, 2006)

181 000 in contact 181 000 in contact with drug services with drug services 2005/06 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    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

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 CPSlow: 1 - 39 mg

med: 40 - 59 mg

high: 60 - 109 mgmethadone 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 treatmentpredictive 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 MMTMore effective MMT

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

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

Buprenorphine for the management of opioid withdrawal, Cochrane Review, Gowing et al, 2006

‘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

naltrexone and behavioural treatment significantly reduced probability of re-incarceration (Kirchmayer et al. 2002)

oral naltrexone effective treatment if retention rate adequate (Johansson et al, 2006)

Treatment of cocaine dependence

Cochrane reviews - all negative

antidepressants

dopamine agonists

carbamazepine

auricular acupuncture

psychosocial interventions most promising

Psychological therapies 1

evidence base for MMT based on studies which included counselling

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 drugmisusing 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 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

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

Dackis et al, 2005Modafinil 33% abstinent for > 3 consecutive weeksPlacebo 13%

New treatments for cocaine dependenceDisulfiram 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

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

target high risk situations

train users, peer group, carers in administration of naloxone and general overdose training

distribute to users, friends and family

named patient basis

Mini-jet naloxone400 micrograms per 1 ml

Mini-jet naloxone400 micrograms per 1 ml

Watch this space !