One of the problems with treatment outcome research is that it’s typically not really recovery research. Often treatment outcome studies for opiate addiction will focus on opioid replacement, measuring reduction of harms over time using baseline measurements against eventual outcomes. If they compare treatment types then ORT is often compared against detox, which is arguably not so much a treatment as an procedure. If all you do is offer detox, or it’s the only part of the package the client will take, then the outcomes are not only bound to be terrible, they are bound to be fraught with danger. Detox is not enough.
I’ve heard it said that if recovery is the train journey on the sleeper from Edinburgh to London, then treatment is the taxi ride to the station. Detox is calling the taxi. That sort of puts it into perspective.
I came across two studies (see below) on the same cohort of patients from Ireland where outcomes following detox were examined. They admitted 149 opiate dependent patients seeking detox to the studies. All were on a six-week inpatient treatment programme, though it’s not clear what psychosocial interventions were offered. Five died in the follow up period up, but they managed to follow up 76% of available patients, a remarkable rate given that follow-ups were 2-4 years later.
Lapse and relapse
Following discharge 94% reported lapse and 91% reported relapse. Much of this happened in the first month (a significant amount within a week). Injectors, younger people, those with a history of being in prison and those with previous detox attempts were more at risk.
What interested me was the association between relapse and treatment completion and intensity. Not completing methadone detox, leaving treatment early (58% were ‘unplanned discharge’) and failure to go to aftercare were all risk factors for early relapse. 92% of relapsers went back to treatment in the interim period with two thirds electing to go onto methadone, but about half giving detox another shot over the time of the study. Two to three years after treatment about a quarter had achieved their goal of abstinence.
The authors are right to be cautious about deaths following detox:
The five deaths that occurred highlight the risks associated with this disorder and the potential hazards of pursuing abstinence. It is this risk of death; especially in the first month after completion of detoxification, that sets opiate addiction apart from other addictive disorders. Patients accessing this treatment option must be made fully aware of the risks of overdose prior to treatment entry.
Though surely those risks could be mitigated in an aggressive manner. The researchers also acknowledge that treatment re-entry was swift for most patients following relapse – an essential feature in risk management.
This study was from patients treated in the 1990s and we have more evidence around what protects people from relapse now, particularly around the value of building community recovery capital through social networking with mutual aid and other recovery resources. Even ten years ago though the authors (in the medium term follow up paper) were able to conclude:
Abstinence remains an attainable goal. As the principal influence on outcome was treatment adherence, inpatient services should seek to enhance rates of programme completion. After-care should be provided to patients.
Compare that to the recommendation in the recent German study:
Until a curative medication or a safe curative procedure is developed, many of the patients may have to remain in [ORT] treatment for the duration of their lives to avoid relapses, increased criminality, subsequent overdoses, and death during the post treatment period
I wonder if we could better these outcomes by giving longer treatment, assertive linkage to mutual aid, harm reduction advice at intervals during treatment and on discharge (overdose prevention, resuscitation, take home naloxone etc.), and evidenced-based psychological interventions during treatment. Having an inpatient unit full of opiate dependent patients detoxing simultaneously (if that’s what happened) is not a recipe for a smooth ride. I wonder if connecting to a therapeutic community post-detox or other longer term residential or intensive community rehab would help.
Hopefully we are moving away from thinking of addiction treatment as a medical intervention and moving towards a mixed model of treatment. David Best, interviewed by Bill White (and quoted most recently at Addiction & Recovery News) gets this right:
We also still cling to a model that is about pathology management, which has two implications, the first being that we don’t focus enough on strengths and the second that we reinforce a model that sees addiction (and recovery) as incorporated rather than as being socially mediated and managed…
The interesting issue for me is much less about what particular therapies and modalities we offer and more about whether we can inspire belief that recovery is possible, establish a partnership between the client and the worker to facilitate that change, mobilise recovery supports within the client’s natural environment, and link the client to those community resources.
Smyth BP, Barry J, Keenan E, & Ducray K (2010). Lapse and relapse following inpatient treatment of opiate dependence. Irish medical journal, 103 (6), 176-9 PMID: 20669601
SMYTH, B. (2005). In-patient treatment of opiate dependence: medium-term follow-up outcomes The British Journal of Psychiatry, 187 (4), 360-365 DOI: 10.1192/bjp.187.4.360