Coherent long‐term treatment approaches–superior in the treatment of opioid dependence

Abstract

Evans et al. have published an impressive registry-based study from California, including more than 32 000 individuals and 76 000 observation years 1. The aim of the study was to investigate if two commonly used treatments, detoxification and methadone maintenance treatment (MMT), provided differential effects on all-cause and cause-specific mortality among opioid-dependent people. Both treatments, detoxification and MMT, reduced mortality following treatment admission: MMT more so than detoxification treatment alone. The combination of first in-patient detoxification, thereafter directly entering MMT in a (probably planned) sequence produced the best overall results in terms of mortality reductions. Contemporary understanding is that opioid dependence is to be perceived and treated most often from the perspective of chronic medical disorders, thus well-designed provision of treatment would be the ideal and logical response 2-4. In that context, treatment needs to be designed and combined as a long-term and coherent effort in a continuum of care. This is in contrast to shorter-term interventions that aim at ‘total cure’ at the end of a specified treatment episode, as would be the model practised in acute care medicine. Few would argue today that short-term detoxification is an adequate stand-alone treatment, due to the high risk of relapse combined with loss of opioid tolerance 5. Nevertheless, as part of a planned series of interventions, detoxification may have an important role in the treatment of opioid dependence, as shown by Evans et al. [1]. As untreated opioid dependence is a disorder with a very high risk of premature mortality, a main goal is to recruit opioid-dependent people into adequate treatment 6. Hence, treatment providers need to offer evidence-based services that attract opioid-dependent people. A higher risk of mortality was observed among those who had more severe disorder and who had been untreated for the longest periods 1. More ‘aggressive’ engagement of opioid-dependent people into treatment sooner after onset of drug use is recommended. Current evidence points towards opioid maintenance treatment (OMT) as the preferred treatment for opioid dependence 7-9. OMT reduces the risk of overdose and overall mortality while people are in treatment 10, 11, and is ideally a long-term approach. However, OMT is provided in a range of ways globally, and the search is still on to settle how this treatment is to be offered in the most appropriate fashion. As has been shown in the Evans et al. [1] paper, OMT should preferably be provided in a long-term/life-long perspective, to ensure long-term risk reduction, ideally with a detoxification prior to OMT. In California, and for many other treatment providers across the world, it should be seen as a challenge that only a minority (11% in California) of those entering treatment for opioid dependence actually received the combination and sequence of treatments (detoxification followed by OMT) that provided the best outcome in terms of mortality reduction. In contrast, most of the observation time was spent outside treatment, and when treatment was provided the most common mode of treatment was short-term stand-alone detoxification (25%), which offers a horrendously increased risk of mortality immediately following treatment cessation. In addition to finding the right combinations and sequence of treatments the contents of treatments also vary and are indeed of importance. It has been shown that there is a dose–response relationship with positive outcomes such as long-term retention in OMT with increasing amounts of psychosocial services included 12. OMT with an emphasis on integrated psychosocial interventions is key to supporting patients in their recovery process. From Norway, we have reported previously from a national OMT system which performs treatment initiations via specialist treatment centres 10. The results from that setting showed very low rates of mortality during the first 2 weeks of OMT 13, 14. This was in contrast to predominantly primary care and general practitioner-initiated OMT reported previously from the United Kingdom, as well as the current findings from California, which show an elevated risk of overdose mortality during the first weeks of OMT 15. OMT initiation is a challenging medical procedure, and if not managed by skilled and experienced personnel with knowledge of addiction medicine it may be a hazardous undertaking. Ongoing polydrug use along with OMT initiation provides a serious risk for death. We need to investigate further how the sequences of different interventions are best combined to meet the needs of people with chronic disorders, rather than delivery of treatment as stand-alone efforts. Particularly at ‘treatment completion’ or, rather, transitions from one treatment phase to another, we need to emphasize the ideals of long-term continuum of care. Additionally, a range of different treatments are probably required to meet the needs of the heterogeneous opioid-using population. Evaluating treatment outcomes using registries and cohorts from real-life treatment settings will become increasingly important when combinations of interventions are to be evaluated for chronic conditions from a long-term perspective. None.