Effectiveness of community treatments for heroin and crack cocaine addiction in England: a prospective, in-treatment cohort study

doi:10.1016/S0140-6736(09)61420-3

The Lancet

Volume 374, Issue 9697, 10–16 October 2009, Pages 1262-1270

https://doi.org/10.1016/S0140-6736(09)61420-3 Get rights and content

Summary

Background

Addiction to heroin and crack cocaine is debilitating and persistent, but such disorders are treatable. We present the first effectiveness study of the main community interventions for addiction to heroin and crack cocaine in England, using data from the National Drug Treatment Monitoring System (NDTMS).

Methods

The study cohort consisted of all adults with a heroin or crack cocaine addiction, or both, who started pharmacological treatment (n=18 428 patients) or psychosocial treatment (n=2647) between Jan 1 and Nov 30, 2008, received at least 6 months' treatment or were discharged by the study endpoint (May 31, 2009), and had outcome data submitted to the NDTMS. Effectiveness was assessed from change in days of heroin or crack cocaine use, or both in the 28 days before the start of treatment and in the 28 days before review.

Findings

14 656 clients—74% of the cohort eligible for analysis at review with available data—were analysed at the study endpoint. During the 28 days before review, 37% (5016/13 542) of heroin users abstained from heroin and 52% (3941/7636) of crack cocaine users abstained from crack cocaine. A higher proportion of users of heroin only abstained than did users of both heroin and crack cocaine (42% [2465/5863] vs 33% [2551/7679]; OR 1·46, 95% CI 1·36–1·56), and more users of crack cocaine only abstained than did users of both drugs (57% [295/522] vs 51% [3646/7114]; 1·24, 1·03–1·48). Overall heroin use reduced by 14·5 days (95% CI 14·3–14·7) and crack cocaine use by 7·7 days (7·5–7·9). For clients given pharmacological treatment, reduction in days of heroin use was smaller for users of both heroin and crack cocaine than for users of heroin alone (p<0·0001), but this differential effectiveness was not recorded for psychosocial treatment in heroin or crack cocaine users compared with users of both drugs.

Interpretation

The first 6 months of pharmacological or psychosocial treatment is associated with reduced heroin and crack cocaine use, but the effectiveness of pharmacological treatment is less pronounced for users of both drugs. New strategies are needed to treat individuals with combined heroin and crack cocaine addiction.

Funding

National Treatment Agency for Substance Misuse.

Introduction

Illicit drug addiction is characterised by compulsive drug use despite health and social harms.1, 2 Untreated, this disorder is persistent and debilitating.3, 4 In England, illicit opioids (predominantly street heroin; we use “heroin” throughout to include heroin and the very small number of other illicit opioids) and crack cocaine (a colloquial name for the smokeable base form of cocaine) have an aggressive addiction liability and cause most social costs associated with drug misuse.5, 6 In 2006–07, for every 1000 people aged 15–64 years in England, an estimated 8·1 were heroin users and 5·4 were crack cocaine users.⁷ During 2007–08, 29% of clients who were admitted to a treatment programme for drug use disorders were using both drugs.⁸ Results from US and Australian studies assessing treatments for illicit drug use suggest that individuals concurrently using heroin and crack cocaine have worse outcomes than do primary users of either drug.9, 10

During treatment, monitoring of changes in drug use and other problem behaviours is useful for clinicians to assess effectiveness of treatment. This information then contributes to evidence-based clinical practice and assessment of public health policy. However, internationally, treatment system monitoring efforts for drug addiction are rare.

The National Treatment Agency for Substance Misuse (NTA) in England was established by government as a special health authority within the National Health Service (NHS), with the aim of improving the capacity and effectiveness of treatment for drug use disorders. The NTA coordinates the National Drug Treatment Monitoring System (NDTMS) to compile information about all individuals seeking structured treatment in England and to track their progress. With the exception of a few private clinics, all active providers of community structured drug treatment (about 1000 agencies) report to the system, and more than 98% of clients consent to their data being used for performance monitoring. Data from service providers are collected by nine regional NDTMS teams, and centrally aggregated for analysis. A minimum set of identifiable information is included (client's initials, sex, date of birth, and local treatment area) to avoid double-counting individuals concurrently receiving treatment from different agencies.

Since 2001, after a substantial increase in drug treatment funding in England, the government has sought to assess the effect of services delivered by NHS and non-governmental organisations. However, long-term effectiveness studies are scarce and, up to now, the best available outcome data for England are derived from one 5-year prospective study in 1995 of 1000 individuals enrolled in opioid substitution or residential treatment.¹¹ Originally, NDTMS used treatment waiting times, numbers of clients receiving structured interventions, and retention rates as proxy indicators of efficiency and effectiveness. However, in October, 2007, the NTA incorporated the newly developed instrument—the Treatment Outcomes Profile (TOP)—to assess effectiveness directly. 20 items are used to record a set of core data for the past 28 days about the number of days of use of opioids, cocaine, amphetamines, cannabis, and alcohol; injection-related health-risk behaviour; the client's subjective ratings of physical health, psychological health, and quality of life; and the client's reports of criminal behaviours and indicators of social functioning.¹² The TOP is designed to help review clients' progress towards attaining personal treatment goals. These core data are reported to NDTMS at the start of treatment, at subsequent reviews during treatment, and at discharge.

We present results of the first analysis of the effectiveness of the national treatment system in England. We assess change in drug use for clients receiving community pharmacological and psychosocial interventions operating in all NHS regions in England. To accord with the priorities of the national drugs strategy,¹³ the focus is on change in heroin and crack cocaine use during treatment. This study does not assess residential programmes since they use different methods of analysis. We postulated that pharmacological and psychosocial treatments would be associated with reduced heroin and crack cocaine use, but that this improvement would be attenuated for clients using both drugs.

Section snippets

Treatment system for drug use disorders in England

A range of structured community interventions is available in each locality (primary care trust), and individuals receive one or more interventions tailored to their specific needs and delivered according to national clinical guidelines14, 15, 16 in a community or residential setting. A specified key worker—sometimes a physician or psychologist, but usually a psychiatric nurse, social worker, or trained non-medical drugs worker—takes the lead role in coordination of the client's care. Through

Results

21 075 clients were eligible to form the study cohort. Table 1 shows their characteristics at admission. The proportions of black (African, Caribbean, or other) and white (British, Irish, or other) clients receiving the pharmacological and psychosocial interventions differed substantially, as would be expected from research documenting differences in use of heroin and crack cocaine between these population groups.²⁴

The figure shows the flow of clients through the study. The cohort used 816

Discussion

We recorded high proportions of treatment retention from the first 28 days of treatment to the study endpoint. At review, by which time clients had completed a mean of 19 weeks' treatment, more than a third of heroin users were abstaining from heroin and more than half of crack cocaine users were abstaining from crack cocaine; a higher proportion of users of either heroin and crack cocaine abstained than did users of both drugs. From before admission to review, we reported an overall reduction

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This pragmatic, parallel-group, open-label, multi-centre, effectiveness superiority randomised, controlled, phase 3 trial was conducted at five National Health Service community-based treatment clinics in England and Scotland. Participants (adults aged ≥ 18 years; all meeting DSM-5 diagnostic criteria for moderate or severe OUD at admission to their current maintenance treatment episode) were randomly assigned (1:1) to receive continued daily SoC (liquid methadone (usual dose range: 60–120 mg) or sublingual/transmucosal buprenorphine (usual dose range: 8–24 mg) for 24 weeks; or monthly BUP-XR (Sublocade;® two injections of 300 mg, then four maintenance injections of 100 mg or 300 mg, with maintenance dose selected by response and preference) for 24 weeks. In the intent-to-treat population (senior statistician blinded to blinded to treatment group allocation), and with a seven-day grace period after randomisation, the primary endpoint was the count of days abstinent from non-medical opioids between days 8–168 (i.e., weeks 2–24; range: 0–161 days). Safety was reported for the intention-to- treat population. Adopting a broad societal perspective inclusive of criminal justice, NHS and personal social service costs, a trial-based cost-utility analysis estimated the Incremental Cost-effectiveness Ratio (ICER) per quality-adjusted life year (QALY) of BUP-XR versus SoC at the National Institute for Health and Care Excellence threshold. The study was registered EudraCT (2018-004460-63) and ClinicalTrials.gov (NCT05164549), and is completed.
Between Aug 9, 2019 and Nov 2, 2021, 314 participants were randomly allocated to receive SoC (n = 156) or BUP-XR (n = 158). Participants were abstinent from opioids for an adjusted mean of 104.37 days (standard error [SE] 9.89; range: 0–161 days) in the SoC group and an adjusted mean of 123.43 days (SE 4.76; range: 24–161 days) in the BUP-XR group (adjusted incident rate ratio [IRR] 1.18, 95% confidence interval [CI] 1.05–1.33; p-value 0.004). The incidence of any adverse event was higher in the BUP-XR group than the SoC group (128 [81.0%] of 158 participants versus 67 [42.9%] of 156 participants, respectively—most commonly rapidly-resolving (mild–moderate range) pain from drug administration in the BUP-XR group (121 [26.9%] of 450 adverse events). There were 11 serious adverse events (7.0%) in the 158 participants in the BUP-XR group, and 18 serious adverse events (11.5%) in the 156 participants in the SoC group—none judged to be related to study treatment. The BUP-XR treatment group had a mean incremental cost of £1033 (95% central range [CR] −1189 to 3225) and was associated with a mean incremental QALY of 0.02 (95% CR 0.00–0.05), and an ICER of £47,540 (0.37 probability of being cost-effective at the £30,000/QALY gained willingness-to-pay threshold). However, BUP-XR dominated the SoC among participants who were rated more severe at study baseline, and among participants in maintenance treatment for more that 28 days at study enrolment.
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People accessing publicly-funded specialist addiction treatment services in England provide written consent to share their information with NDTMS and are informed that NDTMS records may be linked with data from other specifically sanctioned UK government-held databases, including HES [18]. Over 98% of patients provide consent [19], and the nature of this consent states that individuals may opt out at any time from having their records used. Approval to conduct the linkage analysis was granted under regulation 3 of the Health Service (Control of Patient Information) Regulations 2002 [20], following review by the PHE Caldicott Advisory Panel (CAP) (Ref: CAP-2019-06).
Over the past decade in England the rate of alcohol and opioid-related hospitalisation has increased alongside a simultaneous reduction in people accessing specialist addiction treatment. We aimed to determine the hospitalisation patterns of people presenting to addiction treatment with problematic use of alcohol or opioids, and estimate how individual sociodemographic characteristics and hospital admission diagnoses are associated with the rate of hospitalisation, death and successful completion of addiction treatment.
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This is the first study to interrogate national hospitalisation patterns within people presenting to addiction services with problematic use of alcohol or opioids. Having identified high-risk, high-cost individuals with increased hospital usage, and increased odds of death, future work should focus on targeting appropriate interventions, to improve their health outcomes and prevent unnecessary hospital readmission.
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Participants were patients receiving injectable opioid agonist treatment for opioid use disorder. Study visits were completed at baseline prior to receiving treatment, and 3,6,9,12,18, and 24 months after baseline. A multi-level regression approach to growth curve modeling was employed to estimate and explain intra- (within-person) and inter-individual (between-person) variation in cocaine use.
Significant intra and inter-individual variation in cocaine use was identified over 24-months. Treatment engagement was on average associated with reductions in the prior month number of days of cocaine use (range: 0–30)(Estimate (standard error): -0.05(0.02), p = 0.003). On average, men reported less cocaine use compared to women (Estimate (standard error): -5.91(1.57), p=<0.001), and participants reporting ever regularly using cocaine at baseline reported more cocaine use over 24-months compared to participants reporting never regularly using cocaine (Estimate (standard error): 4.72 (1.91), p = 0.013).
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The relationship between past drug use trajectory and long-term relapse risk after rehabilitation among heroin-dependent patients remain understudied. The primary objectives were to identify longitudinal heroin use patterns of heroin-dependent patients, to determine the associative factors with trajectories and to investigate the impact of trajectory groups on relapse after finishing compulsory rehabilitation programs.
A total of 564 heroin-dependent patients were recruited from 4 compulsory rehabilitation facilities in Shanghai, China between 2007 and 2008. The baseline data was linked to participants’ follow-up data on relapse from official records. Group-based trajectory model was used to identify distinctive drug use trajectory groups. The association between the identified group and heroin relapse risk was then analyzed to understand the role of past drug use trajectory on relapse.
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Heroin use trajectories vary among heroin-dependent patients in China. The trajectories of heroin use before compulsory rehabilitation are associated with subsequent long-term relapse risk.

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ArticlesEffectiveness of community treatments for heroin and crack cocaine addiction in England: a prospective, in-treatment cohort study

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Treatment system for drug use disorders in England

Results

Discussion

Lancet

Drug Alcohol Depend

Drug Alcohol Depend

Drug Alcohol Depend

International statistical classification of disease and health-related problems (ICD-10)

Diagnostic and statistical manual of mental disorders

Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation

JAMA

A 33-year follow-up of narcotics addicts

Arch Gen Psychiatry

Local and national estimates of the prevalence of opioid use and/or crack cocaine use (2004/05). In: Singleton N, Murray R, Tinsley L, eds. Measuring different aspects of problem drug use: methodological developments (2nd edn). Home Office online report 16/06

National and regional estimates of the prevalence of opiate use and/or crack cocaine use 2006/07: a summary of key findings. Home Office research report 9: summary

Statistics from the National Drug Treatment Monitoring System (April 1, 2007–March 31, 2008)

The National Treatment Outcome Research Study (NTORS): 4–5 year follow-up results

Addiction

Development of the Treatment Outcomes Profile

Addiction

Drugs: protecting families and communities. The 2008 drug strategy

Drug misuse and dependence: UK guidelines on clinical management

Drug misuse: opioid detoxification (NICE clinical guideline 52)

Drug misuse: psychosocial interventions (NICE clinical guideline 51)

Articles
Effectiveness of community treatments for heroin and crack cocaine addiction in England: a prospective, in-treatment cohort study