Psychosocial treatment for opiate abuse and dependence.

BACKGROUND: Substance dependence is a major social and public health problem; therefore it is a priority to develop effective treatments. The treatment of opioid dependence is complex. Previous Cochrane reviews have explored the efficacy of pharmacotherapy for opiate dependence. This current review focuses on the role of psychosocial interventions alone for the treatment of opiate dependence. There are many different psychosocial interventions offered to opiate addicts, which are widely spread. There is some evidence for the effectiveness of psychosocial interventions, but no systematic review has even been carried out. OBJECTIVES: To assess the efficacy and acceptability of psychosocial interventions alone for treating opiate use disorders. SEARCH STRATEGY: Electronic searches of Cochrane Library, EMBASE, MEDLINE, and LILACS; reference searching; personal communication; conference abstracts; unpublished trials; book chapters on treatment of opioid abuse/ dependence. SELECTION CRITERIA: The inclusion criteria for all randomised-controlled trials were that they should focus on psychosocial interventions alone for treating opioid use disorders. DATA COLLECTION AND ANALYSIS: Reviewers extracted the data independently using relative risks, weighted mean difference and number needed to treat estimated, when possible. The reviewers assumed that people who died or dropped out had no improvement (intention to treat analysis) and tested the sensitivity of the final results to this assumption. MAIN RESULTS: Five studies fit the study criteria. These analysed Contingency Management, Brief Reinforcement Based Intensive Outpatient Therapy coupled with Contingency Management, Cue Exposure therapy, Alternative Program for Methadone Maintenance Treatment Program Drop-outs (MMTP) and Enhanced Outreach-Counselling Program. All the treatments were studied against the control (standard) treatment; therefore it was not possible to identify which type of psychosocial therapy was most effective. The main findings were that both Enhanced Outreach Counselling and Brief Reinforcement Based Intensive Outpatient Therapy coupled with Contingency Management had significantly better outcomes than standard therapy within treatment. This was regarding relapse to opioid use, re-enrollment in treatment and retention in treatment. At 1-month and 3- month follow up the effects of Reinforcement Based Intensive Outpatient Therapy were not sustained. There was no further follow up of the Enhanced Outreach Counselling group. The Alternative Program for MMTP Drop-outs and the behavioural therapies of Cue Exposure and Contingency Management alone were no better than the control (standard) therapy. As the studies were heterogeneous, it was not possible to pool the results and perform a meta-analysis. AUTHORS' CONCLUSIONS: The available evidence has low numbers and is heterogeneous. At present psychosocial treatments alone are not adequately proved treatment modalities or superior to any other type of treatment. It is important to develop a better evidence base for psychosocial interventions to assist in future rationale planning of opioid use drug treatment services. Large-scale randomised trials are required with longer follow up stating methods of randomisation, allocation concealment and blinding. Where possible this should include intention to treat analysis, with power calculations performed prior to the trial. These studies can be designed and delivered to provide usable data for better understanding of this important component of intervention in the field of dependence.

BU-224 produces spinal antinociception as an agonist at imidazoline I2 receptors.

In this electrophysiological study, the effect of BU-224 (2-(4,5-dihydroimidazol-2yl)-quinoline hydrochloride)), a novel high affinity imidazoline I2 receptor ligand, was tested on the responses of nociceptive neurones in the spinal dorsal horn. When applied spinally, akin to an intrathecal application (i.t.), BU-224 (5-250 microg) reduced the nociceptive responses of dorsal horn neurones, producing a dose-dependent inhibition of C-fibre evoked responses, postdischarge and wind-up of the cells. A complete block of the antinociceptive effects was produced when idazoxan (100 microg), with both alpha2-adrenoceptor and imidazoline I2 receptor antagonist actions, was administered i.t. 10 min prior to the maximal dose of BU-224 tested. The nonselective alpha2-adrenoceptor antagonist, yohimbine (150 microg) only partially attenuated the inhibitory effects of BU-224 when administered i.t. 10 min prior. The highly selective alpha2-adrenoceptor antagonist, atipamezole (100 microg) produced no greater reversal than yohimbine under the same conditions. Although BU-224 has been reported to possess high affinity for imidazoline I2 receptors, a minor action at spinal alpha2-adrenoceptor receptors cannot be discounted. These results demonstrate that BU-224 is an agonist and that imidazoline I2 receptors, present in the dorsal horn, might play a role in spinal nociception, although further studies are needed to fully elucidate their functional roles.

Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence.

BACKGROUND: Methadone maintenance at proper doses is effective in retaining patients in treatment and suppressing heroin use. Questions remain regarding the efficacy of the psychosocial services that are offered by most maintenance programs. OBJECTIVES: To evaluate the effectiveness of any psychosocial plus any agonist maintenance treatment versus any agonist treatment alone in retaining patients in treatment, reducing the use of substances and improving health and social status. SEARCH STRATEGY: We searched the Cochrane Central Register of Trials (CENTRAL) issue 3, 2003; MEDLINE 1966-2003; EMBASE 1980-2003; PsycINFO 1985-2003; relevant web sites; scan of reference list of relevant articles. There were no language or publication restrictions. SELECTION CRITERIA: RCTs which focus on any psychosocial plus any agonist compared to any agonist maintenance intervention for opiate dependence. People aged less than 18 and pregnant women were excluded. Psychosocial in combination with antagonist maintenance treatment are excluded too. DATA COLLECTION AND ANALYSIS: The trials were independently assessed for inclusion and methodological quality by the reviewers. Data were extracted independently and double checked. MAIN RESULTS: The searching process resulted in the identification of 77 different studies: 12 studies met the inclusion criteria. These studies considered 8 different psychosocial interventions and 1 pharmacological treatment: Methadone Maintenance (MMT). The results show additional benefit in adding any psychosocial treatment to standard methadone maintenance treatment in relation to the use of heroin during the treatment RR 0.69 (95% CI 0.53-0.91); no statistically significant additional benefit was shown in terms of retention in treatment RR 0.94 (95% CI 0.85-1.02); and results at follow-up RR 0.90 (95% CI 0.76-1.07). REVIEWERS' CONCLUSIONS: The present evidence suggests that adding any psychosocial support to Standard MMT significantly improves the non-use of heroin during treatment. Retention in treatment and results at follow-up are also improved, although this findings did not achieve statistical significance. Insufficient evidence is available on other possible relevant outcomes such as Psychiatric symptoms/psychological distress, Quality of life. Limitations to this review are imposed by the heterogeneity of the trials both in the interventions and the assessment of outcomes. Results of studies were sometimes in disagreement and because of lack of detailed information no meta analysis could be performed to analyse the results related to the outcomes more often reported as positive results in the single studies. Duration of the studies was also too short to analyse other relevant outcomes such as mortality. In order to study the possible added value of any psychosocial treatment over an already effective treatment such as standard MMT, only big multi-site studies could be considered which define experimental interventions and outcomes in the most standardized way as possible.

Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification.

BACKGROUND: Different pharmacological approaches aimed at opioid detoxification are effective. Nevertheless a majority of patients relapse to heroin use, and relapses are a substantial problem in the rehabilitation of dependent heroin users. Some studies have suggested that the sorts of symptoms which are most distressing to addicts during detoxification are psychological symptoms rather than physiological symptoms associated with the withdrawal syndrome. OBJECTIVES: To evaluate the effectiveness of any psychosocial plus any pharmacological interventions versus any pharmacological alone for opioid detoxification, in helping patients to complete the treatment, reduce the use of substances and improve health and social status. SEARCH STRATEGY: We searched the Cochrane Central Register of Trials (CENTRAL) issue 3, 2003; MEDLINE 1966-2003; EMBASE 1980-2003; PsycINFO 1985-2003; relevant web sites; scan of reference list of relevant articles. There were no language or publication restrictions. SELECTION CRITERIA: Randomised controlled trials which focus on any psychosocial associated with any pharmacological intervention aimed at opioid detoxification. People less than 18 years of age and pregnant women were excluded. DATA COLLECTION AND ANALYSIS: The trials were independently assessed for inclusion and methodological quality by three reviewers. Data were extracted independently and double checked. MAIN RESULTS: The searching process resulted in the identification of 77 different studies: 8 studies met inclusion criteria. These studies considered 5 different psychosocial interventions and 2 substitution detoxification treatments: Methadone and Buprenorphine. The results show promising benefit from adding any psychosocial treatment to any substitution detoxification treatment in terms of completion of treatment RR 1.68 (95% CI 1.11-2.55), results at follow-up RR 2.43 (95% CI 1.61-3.66), and compliance RR 0.48 (95% CI 0.38-0.59). In respect of the use of heroin during the treatment, the differences were not statistically significant but favoured the combined treatments. REVIEWERS' CONCLUSIONS: Psychosocial treatments offered in addition to pharmacological detoxification treatments are effective in terms of completion of treatment, results at follow-up and compliance. Although a treatment, like detoxification, that exclusively attenuates the severity of opiate withdrawal symptoms can be at best partially effective for a chronic relapsing disorder like opiate dependence, this type of treatment is an essential step prior to longer-term drug-free treatment and it is desirable to develop adjunct psychosocial approaches that might make detoxification more effective. Limitations to this review are imposed by the heterogeneity of the assessment of outcomes. Because of lack of detailed information no meta analysis could be performed to analyse the results related to several outcomes.