Methadone maintenance works better than arbitrary reductions

Addiction (2004) 99:718-726

Cost and cost-effectiveness of standard methadone maintenance treatment compared to enriched 180-day methadone detoxification. Masson CL, Barnett PG, Sees KL, Delucchi KL, Rosen A, Wong W, Hall SM.

Dear Colleagues,

The editor of Addiction has long espoused high levels of ethics in submissions to his august journal. Half of the subjects in this study received treatment which is known to be inadequate and inappropriate for unselected heroin addicts, viz: reduction pharmacotherapy [see UK 'Orange' dependency guidelines p59]. I believe that a properly informed and constituted ethics committee would not currently permit such a study without safety net provisions in most countries. A cost analysis of such outcomes is thus a double redundancy since at least one branch of the study used an outmoded treatment model.

Originally published in JAMA in 2000, this study examined outcomes in heroin addicts given access to 'standard' (US) methadone maintenance treatment and compared it with randomised entrants given 6 months reductions with added psychosocial supports. Predictably there were more dropouts and heroin use was higher in the group given methadone reductions. Such problems became most prominent when the doses were reducing, by about 4 months. In a country without freely available needles this may have seen some of the subjects risk viral disease transmission.

It is hard to find justification for this exposure and the results, while statistically impressive, yield little innovative and tell us nothing which was not already determined by the research literature.

Even when inadequate doses are given with minimal additional supports, methadone maintenance has some benefits for most patients. However, such treatment works better still when given according to current recommendations (eg. Strang's UK dependency guidelines; US 'TIP' Guidelines; Australian national guidelines). In addition, methadone maintenance is a relatively cheap intervention when compared with treatment for other chronic mental or physical conditions.

The authors made note of the doses being adequate "by today's standards" yet 100mg appears to have been the maximum, nor do they specify what "standards" they are referring to. This shows how out of touch with treatment practices they are. Most clinics now have a certain proportion of patients taking more than 100mg daily. The original JAMA report by Vincent P. Dole in 1965 described doses of 100mg or more in 16 of the first 24 patients.

There seems little point in discussing the cost effectiveness of two treatments, neither of which meets currently accepted benchmarks. The consequences of giving inadequate doses of methadone (especially NO methadone) are probably as serious and profound as doctors prescribing inadequate doses of lithium, insulin, cortisone, antibiotics or any other useful and potentially life-saving medicine.

This would not be a high point for either the journal nor the researchers since some subjects received less than optimal therapy and little or nothing was added to the scientific knowledge base.

comments by Andrew Byrne ..

References

Masson CL, Barnett PG, Sees KL, Delucchi KL, Rosen A, Wong W, Hall SM. Cost and cost-effectiveness of standard methadone maintenance treatment compared to enriched 180-day methadone detoxification. Addiction (2004) 99:718-726

Original study: Sees KL, Delucchi KL, Masson C, Rosen A, Clark HW, Robillard H, Banys P, Hall SM. Methadone Maintenance vs. 180-Day Psychosocially Enriched Detoxification for Treatment of Opioid Dependence : A Randomized Controlled Trial. JAMA (2000) 283:1303-1310