Successful discharges from opiate substitution therapy dose reduction to zero

Transcription

1 Successful discharges from opiate substitution therapy dose reduction to zero Robert Cohen Consultant Addiction Psychiatrist CGL Luton 9 November 017

2 Introduction The UK Drug Strategy (017) aims to achieve a society in which every individual is supported to live a life free from drugs The 010 UK Drugs Strategy stated that for too many people currently on a substitute prescription, what should be the first step on the journey to recovery risks ending there.

3 Introduction An ACMD review (015) noted that patients prescribed mg methadone were more likely to succeed than patients prescribed lower doses 6.7% of opiate users were discharged drug-free in (NDTMS 017)

4 Purpose of this study There is little recent data observing the process in treatment by which patients reduce the dose of methadone to 0 This study addresses this gap

5 Setting for the study Clinical data from patients of the Luton Drug Service (LDS) Service for residents of Luton, a town 30 miles from London, pop 00,000 approx Secondary care provider of opiate substitution therapy Psychosocial interventions Recovery activities (housing, accommodation etc) CCS, who ran LDS, unsuccessful when contract re-tendered in 016 Change, Grow, Live Ltd (CGL) started to provide this service from 1 April 017 Data presented here all derived from LDS

6 Methods Retrospective case note study List of patients who were successfully discharged from treatment in the year , as given to the commissioners Data from patients with a diagnosis of the opiate dependence syndrome (ICD-10 code F11.) treated with OST Date of starting in treatment with LDS All prescriptions for OST Sequential prescriptions for each patient from start of treatment to end Medication, dose, start date and end date As data collected in the course of routine clinical practice, Trust Senior Research Fellow advised that this study could be regarded as service evaluation and did not require Research Ethics Committee approval. Data nevertheless anonymised

7 Results 800 patients in treatment (approx) 500 patients on OST (approx) 8 patients successfully discharged 8 patients had reduction of methadone or buprenorphine to 0 Data available for 6 patients Buprenorphine daily dose (mg) Data from a patient who was on OST with buprenorphine 0/06/015 0/07/015 0/08/015 0/09/015 0/10/015 0/11/015 0/1/015 0/01/016 0/0/016 0/03/016

8 Breakdown of successful discharges COMPLETED Stopped OST above 10mg 8 Not treated with OST Naltrexone 3 Prison Recall 1 Other 1o drug Respite House Alcohol Stable to rehab 1 Cannabis Transfer to GP Cocaine Still using 1 Diazepam Disengagement 9 Data error 3

9 6 patients reaching zero 9 (34%) were female Age range 5-55 years, no sex differences 1 patients received methadone, 5 patients received buprenorphine

10 Time to dose zero Number of years the patient was in treatment before reaching 0

11 Time to dose zero Number of years the patient was in treatment before reaching 0

12 Years to zero % not returned in 1 year Mean (range) highest methadone dose (mg) Mean (range) time from start of treatment to start of reduction (weeks) Mean (range) time from start of treatment to reduction to zero (weeks) (0-65) (0-13) (6-199) (60-100) (73-541) (33-67) The maximum daily dose for patients treated with buprenorphine was 6mg

13 Phases of treatment /06/015 0/07/015 0/08/015 0/09/015 0/10/015 0/11/015 0/1/015 0/01/016 0/0/016 0/03/016 Buprenorphine daily dose (mg)

14 Phases of treatment /06/015 0/07/015 0/08/015 0/09/015 0/10/015 0/11/015 0/1/015 0/01/016 0/0/016 0/03/016 Stabilisation phase Reduction phase Buprenorphine daily dose (mg)

15 Years to zero % not returned in 1 year Mean (range) highest methadone dose (mg) Mean (range) time from start of treatment to start of reduction (weeks) Mean (range) time from start of treatment to reduction to zero (weeks) (0-65) (0-13) (6-199) (60-100) (73-541) (33-67) The maximum daily dose for patients treated with buprenorphine was 6mg

16 Conclusions For patients treated with OST, there seem to be modes of reaching zero A short period, lasting from a few weeks to 3 years, but mainly under 1 year, with a maximum dose of methadone between 0 and 65mg A long period, lasting at least 6 years, where the patient is treated with higher doses of methadone (maximum mg)

17 Other studies Milby (JNMD 1988;76:409) conducted an early meta-analytic paper of reduction to zero; patients were more successful if they reached zero and then had post-methadone pharmacotherapy (eg clonidine) The literature at that time did not allow clear distinction between acute opiate detoxification with methadone and slow detox Calsyn (006) studying patients on indefinite agonist treatment found none of 30 trial patients completing reduction Nosyk et al (01) found that the advised higher doses (eg methadone dose between mg daily) are associated with a 44% lower likelihood of reaching zero

18 Summary Completed reduction of OST to 0 is not common It occurs in distinct clinical patterns It does not necessarily require the high doses of methadone / buprenorphine advised in current guidelines

19 Thanks to Debbie Liverpool, Service Manager, LDS Rehan Tariq, Deputy Service Manager, LDS Paula Waddingham, Trust Senior Research Fellow, CCS David Vickers, Medical Director, CCS

20 Contact details Robert Cohen CGL Luton Victoria House -1 Victoria Street Luton LU1 UA Tel: