Scientific Evidence Module 2

The evidence of effectiveness Most research is on methadone, much less on other medications Has proven effective for the individual Has proven effective for society at large

Large body of evidence JC Ball and A Ross (1991). The effectiveness of Methadone Maintenance Treatment. New York: Springer Verlag M Farrell, J Ward, R Mattick, W Hall, G Stimson, D des Jarlais, M Gossop, J Strang (1994). Methadone Maintenance Treatment in Opiate Dependence: a Review. BMJ 309: A Preston (1996). The Methadone Briefing J Ward, R Mattick, W Hall (1998). Methadone Maintenance Treatment and other Opioid Replacement Therapies. Harwood Academic Publishers, Amsterdam, The Netherlands H Joseph, S Stancliff, J Langrod (2000). Methadone Maintenance Treatment (MMT): A review of Historical and Clinical Issues. In: the Mount Sinai Journal of Medicine Vol.67 Nos 5&6

Effectiveness for the individual Stay alive Achieve abstinence or a stabilised pattern of use Stabilise social live Improve physical health Reduce criminal activity

Effectiveness for society Improve public health Reduce emergencies, hospitalisations Reduce spread of HIV and other infectious diseases Reduce social welfare costs Reduce costs in criminal justice system

What are the cost–benefits of ST? DASA, NYC, 1991 estimated the annual costs of opiate addicts: –Untreated on the street€ –In prison€ –In residential TC€ –In methadone maintenance€ 2.500

Costs-benefits 2 DASA calculated the effects of ST in 2001 in reductions of: 64% in property crimes 54% overall arrests 63% drug offence arrests 65% emergency room visits 59% medical hospitalisations 55% psychiatric hospitalisations

Cost – benefits 3 Collaboration between departments is important because spending in one can yield savings in another: –NTORS (UK,1998): Every €1,5 spent on treatment (health) return €4,5 savings in costs of crime (criminal justice)

Chronic versus acute care Opiate dependence often chronic condition Treatment for many patients needs to be chronic too Effectiveness higher with long term treatment at adequate dosage and provided properly

Source: McLellan, Treatment Research Institute, USA Outcome in hypertension

Source: McLellan, Treatment Research Institute, USA Outcome in addiction

Comprehensive treatment Assessment of co-morbidity Assessment of psycho-social problems Treatment of these issues

Limitations Being stable on agonist medication can cause dependency to treatment and to the doctor Substitution treatment is often not considered as valid as recovery to abstinence It is corrective rather than curative However, these limitations do not outweigh the benefits

Limitations of prescribing There are some side effects (e.g. increased transpiration, constipation, and disturbances of sleep, sex drive and concentration) which affect 20% of patients They are however without medical consequences Methadone helps around 70% of patients Despite the scientific basis, there is no consensus in practice, leading to contradictory or excessively rigid practice Existing oral formulations are not well designed and unpopular

Conclusions As drug addiction is a condition not easy to overcome, it is important to reduce the harm both to society at large and to the individual patient Scientific evidence has shown that good quality substitution treatment available for anybody who needs it can save many other costs in health care, social welfare and the criminal justice system.