Commentary on Nosyk et al. (2012): detoxification from methadone maintenance therapy: how important is the exact technique that is used?

Pathways to abstinence from methadone maintenance treatment have been explored in the literature several times over the past 30 years. Milby looked at ‘how many make it’ from methadone maintenance to abstinence in three eras of published research (1970–75, 1976–80 and 1981–85) [1], and found a progressive improvement in overall completion rates across time (from 40 to 76%). Two further groups of authors have subsequently returned to this literature, finding pooled abstinence rates between 22 and 86% [2,3]. Milby attributed the improvement in results over time primarily to ‘the use of new drugs which greatly shorten the detoxification interval and ameliorate withdrawal symptoms’ (i.e. clonidine and lofexidine). Similarly, Kornør & Waal approached their review with the expectation that evidence would be available for another technological advance in detoxification, i.e. buprenorphine treatment, although ultimately found only one study. Subsequently, the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom has provided evidence-based clinical guidance for opioid detoxification, finding no evidence to recommend lofexidine over methadone or buprenorphine, and recommending that the choice of medication used should be guided by the preference of the patient. The study by Nosyk et al. adds a new dimension to this literature [4]. By utilizing a naturalistic approach involving a cohort of patients receiving methadone treatment in an entire province (as opposed to controlled studies conducted at single centres), the authors are able to bring a new perspective to the technical aspects of prescribing most likely to achieve successful abstinence. They highlight the fact that successful completers are likely to have had a longer reduction period, with a more gradual, stepped tapering schedule involving a dose decrease in only 25–50% of the weeks of taper. In so doing they concur with the recommendations of the NICE report [5]. This is useful clinical information for prescribers in opiate substitution programmes. However, the paper also forces us to think beyond a narrow, technical approach to detoxification. Since the initial descriptions of indefinite methadone maintenance therapy for opioid dependence, the concept has led to discomfort in some clinicians, policy makers and members of the general public. Despite a strong evidence base for the benefits of long-term maintenance therapy in terms of reduced use of illicit opiates [6], concerns about the ethics, necessity and expense of indefinite treatment have led to support for the concept of ‘abstinence-oriented’ methadone treatment in contrast to ‘maintenance-oriented’ treatment [3,7]. This debate has recently come to prominence in the United Kingdom with a change of national government and a new Drug Strategy [8]. A political desire to ‘rebalance’ the national treatment system away from the perceived dominance of the maintenance approach initially led to a call for time-limited treatment [9], fuelled by enthusiasm for commissioning of treatment services utilizing ‘payment by results’. In this context, three important points should be made. First, Nosyk and colleagues remind us that very few attempts at detoxification from methadone succeed (13%). The reviews of the literature cited above all found a very high rate of relapse to opioid use after methadone treatment was stopped, with a ‘long-term’ abstinence rate (i.e. 2 years) of approximately 30–40%. Secondly, when an abstinence-orientated approach was compared directly with a maintenance-orientated approach in both a natural experiment [7] and a randomized controlled trial [10], the results favoured the maintenance approach. Finally, the one factor associated most frequently with abstinence in the literature has been ‘therapeutic detoxification’, i.e. voluntary participation in detoxification having met eligibility criteria such as being in treatment for at least 6 months, being compliant with programme regulations and reporting stability across problem areas. In dwelling on the technical aspects of the detoxification process, there is a danger that we miss a fundamental point. People do recover from opioid dependence, and go on to live drug-free, healthy and productive lives [11]. However, research on addiction careers suggests that the exact detoxification technique used has limited impact on the likelihood of success, with ex-users in recovery instead reporting a combination of the pressures and strains of using drugs, key life events (‘turning points’) and the availability of social support as important factors [12,13]. In this respect, the recent articulation of a recovery-orientated approach to methadone maintenance can be useful to guide treatment services [14]. It is possible to provide a high-quality, maintenanceorientated approach utilizing adequate doses of medication while constantly striving to empower patients to achieve their goals in life. The paper by Nosyk and colleagues reminds us that success will be driven ultimately by the patient, and utilization of techniques that mobilize internal resources and build social support for change may have more impact on outcomes of detoxification than the exact medical technique applied [15]. COMMENTARY bs_bs_banner