Effectiveness of Therapies for Heroin Addiction in Retaining Patients in Treatment: Results From the VEdeTTE Study

Abstract

Treatment is effective in reducing heroin use and clinical and social problems among heroin addicts. The effectiveness is related to the duration of treatment. “VEdeTTE” is an Italian longitudinal study funded by the Ministry of Health to evaluate the effectiveness of treatments provided by the National Health Services. The study involved 115 drug treatment centers and 10,454 heroin users. Clinical and personal information were collected at intake through a structured interview. Treatments were recorded using a standardized form. Survival analysis and Cox Proportional Hazard model were used to evaluate treatment retention. Five thousand four hundred and fifty-seven patients who started a treatment in the 18 months of the study were included in the analysis: 43.2% received methadone maintenance therapy (MMT), 10.5% therapeutic community, and 46.3% abstinence-oriented therapy (AOT). The likelihood of remaining in treatment was 0.5 at 179 days. The median daily dose of methadone was 37 mg. Psychotherapy was provided in 7.6% of patients receiving methadone and 4.9% of those in therapeutic community. Type of therapy was the strongest predictor of retention, with AOT showing the lowest retention. In MMT patients, retention improved according to dose. Living alone, psychiatric comorbidity and cocaine use increased the risk of dropout. Psychotherapy associated halved the risk of dropout.

RÉSUMÉ

Le traitement est efficace pour réduire l’usage de l’héroïne, ainsi que les problèmes médicaux ou sociaux des usagers d’héroïne. L’efficacité du traitement est liée à sa durée. Vedette est une étude italienne longitudinale financée par le ministère de la Santé qui a pour objectif d’évaluer les traitements dispensés par les services de santé nationaux. L’étude a concerné 115 centres de traitement de la toxicomanie et 10454 usagers d’héroïne. Des données personnelles et cliniques ont été recueillies au moment de la mise sous traitement au cours d’un entretien structuré. Les données concernant les traitements ont été recueillies à l’aide d’un formulaire standardisé. Une analyse de survie avec modèle de Cox a été effectuée pour évaluer la rétention en traitement. Au total, 5457 patients qui ont commencé un traitement pendant la période d’étude ont été inclus dans l’analyse: 43,2% recevaient un traitement de substitution par méthadone, 46,3% des thérapies orientées vers l’abstinence et 10,5% étaient en communautés thérapeutiques. La dose journalière médiane de méthadone était de 37 mg. 7,6% des patients sous méthadone et 4,9% de ceux en communautés thérapeutiques bénéficiaient d’une psychothérapie. La probabilité de rétention en traitement était de 50% à 179 jours. Le type de thérapie était le facteur prédictif de rétention en traitement le plus fort, les thérapies de sevrage étant associées à la probabilité la plus faible. Chez les patients recevant un traitement de substitution par méthadone, la probabilité de rétention en traitement augmentait avec la dose de méthadone. Vivre seul, une comorbidité psychiatrique et une consommation de cocaïne augmentait le risque d’abandon du traitement. L’association d’une psychothérapie au traitement réduisait de moitié le risque d’abandon du traitement.

RESUMEN

El tratamiento para adicción a opiáceos es efectivo, reduce el uso de la heroína y las consecuencias clínicas y sociales de los adictos. La efectividad del tratamiento depende de la duración del mismo. “VEdeTTE” es un estudio de cohorte italiano financiado por el Ministerio de la Salud con el objetivo de evaluar la eficacia de los tratamientos procurados por el Servicio Público de Salud para la tóxico dependencia. Participaron 115 Centros y 10,454 adictos a la heroína. La información clínica, personal y socio-demográfica de los pacientes fue recogida a través de una entrevista estructurada. La información sobre los tratamientos recibidos fueron relevados mediante instrumentos estandarizados. Para evaluar la retención al tratamiento se utilizaron análisis de sobrevida y el modelo de Cox. Fueron incluidos en el análisis 5,457 pacientes que iniciaron el tratamiento durante el período de 18 meses: el 43.2% recibió un tratamiento de mantenimiento con metadona, el 10.5% un tratamiento de comunidad terapéutica residencial y el 46.3 una terapia orientada a la abstinencia. La probabilidad de restar en tratamiento fue del 0.5 después de 179 días de tratamiento. La dosis mediana de metadona diaria fue de 37 mg. El 7.6% de los pacientes que recibieron metadona y el 4.9% de aquellos enviados en comunidad terapéutica recibieron también un tratamiento psicoterapéutico. El tipo de terapia mostró ser el más fuerte determinante de retención al tratamiento. De las terapias utilizadas, las orientadas a la abstinencia han mostrado la peor retención. Entre los pacientes que recibieron un tratamiento de mantenimiento con metadona, la retención mejora con el aumento de la dosis. Vivir solo, tener comorbilidad psiquiátrica y el uso de cocaína aumentan el riesgo de abandono del tratamiento, mientras que recibir un tratamiento psicoterapéutico lo disminuye.

RIASSUNTO

Il trattamento per la dipendenza da oppiacei è efficace nel ridurre l’uso di eroina e le conseguenze cliniche e sociali dell’uso tra i tossicodipendenti. L’efficacia del trattamento dipende dalla sua durata. “VEdeTTE” è uno studio di coorte italiano finanziato dal Ministero della Salute allo scopo di valutare l’efficacia dei trattamenti offerti dai Servizi Pubblici per la dipendenza da sostanze (SerT). Allo studio hanno partecipato 115 SerT e 10,454 tossicodipendenti da eroina. Informazioni sulle condizioni cliniche e socio-demografiche dei soggetti sono state raccolte all’arruolamento tramite intervista. I trattamenti ricevuti dal soggetto sono stati registrati mediante strumenti standardizzati. Per valutare la ritenzione in trattamento sono stati utilizzati l’analisi di sopravvivenza e il modello di Cox. Sono stati inclusi nell’analisi 5,457 pazienti che hanno iniziato un trattamento nei 18 mesi dello studio: tra essi, il 43.2% ha ricevuto un trattamento di mantenimento con metadone, il 10.5% un trattamento di comunità residenziale, ed il 46.3% una terapia orientata all’astinenza. La probabilità di restare in trattamento è 0.5 dopo 179 giorni di trattamento. La dose mediana giornaliera di metadone somministrata è 37 mg. Il 7.6% dei pazienti che hanno ricevuto metadone ed il 4.9% di quelli inviati in comunità terapeutica hanno ricevuto anche un trattamento di psicoterapia. Il tipo di terapia si è rivelato essere il più forte determinante della ritenzione in trattamento, e tra le terapie quelle orientate all’astinenza hanno mostrato la peggiore ritenzione. Nei pazienti che hanno ricevuto trattamenti di mantenimento con metadone, la ritenzione migliora con l’aumentare della dose. Vivere da solo, avere comorbidità psichiatrica e usare cocaina aumentano il rischio di abbandono del trattamento, mentre ricevere un trattamento di psicoterapia dimezza il rischio di abbandono.

Keywords :

• heroin addiction
• treatment retention
• methadone maintenance
• methadone dose
• therapeutic community
• psychotherapy

THE AUTHORS

Giuseppe Salamina, M.D., is a senior epidemiologist, collaborating with Piedmont Centre for Drug addiction Epidemiology and the Italian Centre for Disease Control (CCM), based at the Ministry of Health in Rome, Italy. He works as a coordinator of several programs in different fields of public health, including alcohol and drug addiction. He planned and performed the analysis of data collected in VEdeTTE study, a longitudinal study for the evaluation of effectiveness of treatments for heroin addiction.

Roberto Diecidue, M.D., after many years of field work as clinician in drug addiction treatment community centers, since 2000 he has been working as an epidemiologist at the Department of Epidemiology at the Local Health Authority, ASL TO3, Turin. Drug addiction and mental health are his main fields of investigation.

Federica Vigna-Taglianti, M.D., specialized in Hygiene, Preventive Medicine and Public Health at the University of Turin, and trained in Epidemiology at the London School of Hygiene and Tropical Medicine. She currently works at the Piedmont Centre for Drug Addiction Epidemiology as an epidemiologist and at the University of Novara as a researcher. Her research interests concern the evaluation of effectiveness of treatments and programs for tobacco, alcohol, and drugs addiction and abuse, with specific focus on adolescent health and gender differences. She also collaborates to the conduction of systematic reviews on behalf of the Cochrane Collaboration Drugs and Alcohol Group. She participated to the conduction of several European Studies, such as GENAIR, HYENA, and EU-Dap, and to the VEdeTTE Italian cohort of heroin addicts.

Paolo Jarre, M.D., specialized in internal medicine and systemic psychotherapy. He is working in the field of addiction medicine since 1983 and he is the Director of the Drug Addiction Department of the western area of Piedmont region, which includes eight facilities for outpatient (illegal substances, alcohol, tobacco use disorders, overeating disorders, gambling), two day-treatment services, one specialized therapeutic community (gambling, cocaine, and alcohol disorders), and other facilities in the field of harm reduction (a residential unit for AIDS patients, two street units, one drop-in center). Since 2005 he is national coordinator of the “Scientific Committee of the Drug Abuse and Addiction Professionals”; and since 2006 he is member of the Scientific Committee of the “Osservatorio droghe” at the Ministry of Welfare.

Patrizia Schifano is a statistician, involved in public health research since 1993. She works at the Department of Epidemiology of the Local Health Authority Rome E, Italy. In the last years she has been mainly involved in the epidemiology of drug dependence and social inequalities in health fields.

Anna Maria Bargagli, is a biologist working at the Department of Epidemiology of the Local Health Authority Rome E, Italy. Trained in epidemiology and biostatistics, she has been involved in opioid treatment evaluation research for many years. Her areas of interest also include the epidemiology of tobacco use and the evaluation of smoking cessation programs.

Marina Davoli, M.D., M.Sc., is an epidemiologist at the Department of Epidemiology of the Local Health Authority Rome E, Italy. Her professional interest is in epidemiology with particular interest in evaluation of health care interventions. She is the coordinating editor of the Cochrane Drugs and Alcohol Review Group.

Dr Laura Amato received her Medical Degree from the University of Rome in 1979. She then undertook postdoctoral studies in psychiatry at the University of Rome, and was awarded a Masters Degree in Drug Addiction Medicine from the University of Rome in 1993. From 1982 to 2000 she was a practicing psychiatrist at the Lazio Drug Unit and since July 2000 has been within the Department of Epidemiology, Lazio Region, Italy. Since 2004, Dr Amato has been the managing editor of the Cochrane Review Group on Drugs and Alcohol

Carlo A. Perucci, M.D., is the director of the Department of Epidemiology of the Local Health Authority Rome E, Italy. His main area of work has been epidemiological research in the field of AIDS and drug dependence and, more recently, outcome research. He has coordinated multisite international epidemiological studies with WHO and EU. He has published more than 500 papers in scientific journals.

Fabrizio Faggiano, M.D., associate professor of Public Health at the Avogadro University of Novara. He is the director of the Piedmont Centre for Drug Addiction Epidemiology and is a member of the editorial board of the Cochrane Drug and Alcohol Review Group. He is also the project leader of the EU-DAP, European Drug Addiction Prevention trial, an evaluation study aimed at estimate the effect of a school-based program for the prevention of alcohol, tobacco, and drugs use

Notes

1 Treatment can be briefly and usefully defined as a planned, goal directed, temporally structured change process, of necessary quality, appropriateness and conditions (endogenous and exogenous; micro to macro levels)), which is bounded (culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual-help-based (AA,NA, etc.), and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users—of whatever types and heterogeneities—which are not also used with nonsubstance users. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) treatment-driven model there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence driven models. Editor's note

2 The reader is referred to Hills's criteria for causation which were developed in order to help assist researchers and clinicians determine if risk factors were causes of a particular disease or outcomes or merely associated, (Hill, 1965). The environment and disease: associations or causation? Proceedings of the Royal Society of Medicine 58: 295–300.). Editor's note.

3 The reader is referred to the “natural recovery” literature which documents cessation of use of a range of psychoactive drugs without professional-based, tradition-based, or mutual-help-based (AA,,NA,.). Editor's note.