- Email: [email protected]
“Should I stay or should I go?” Coming off methadone and buprenorphine treatment
International Journal of Drug Policy 22 (2011) 77–81
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Short report
“Should I stay or should I go?” Coming off methadone and buprenorphine treatment Adam R. Winstock a,b,∗ , Nicholas Lintzeris c,d , Toby Lea e a
National Addiction Centre, Institute of Psychiatry, KCL, London SE5, UK National Drug and Alcohol Research Centre, University of New South Wales, Randwick, New South Wales, 2052, Australia c The Langton Centre, Drug and Alcohol Services, South East Sydney and Illawarra Area Health Service, New South Wales, 2050, Australia d Faculty of Medicine, University of Sydney, New South Wales, 2006, Australia e Drug Health Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, 2050, Australia b
a r t i c l e
i n f o
Article history: Received 17 December 2009 Received in revised form 26 July 2010 Accepted 17 August 2010
Keywords: Maintenance Buprenorphine Detoxification Methadone Opioid substitution treatment Withdrawal
a b s t r a c t Background: This study aimed to investigate patient perspectives regarding coming off maintenance opioid substitution treatment (OST). The study explored previous experiences, current interest and concerns about stopping treatment, and perceptions of how and when coming off treatment should be supported. Methods: A cross-sectional survey was used. Participants were 145 patients receiving OST at public opioid treatment clinics in Sydney, Australia. Results: Sixty-two percent reported high interest in coming off treatment in the next 6 months. High interest was associated with having discussed coming off treatment with a greater number of categories of people (OR = 1.72), not citing concern about heroin relapse (OR = 3.18), and shorter duration of current treatment episode (OR = 0.99). Seventy-one percent reported previous withdrawal attempts and 23% had achieved opioid abstinence for ≥3 months following a previous withdrawal attempt. Attempts most commonly involved jumping off (59%), and doctor-controlled (52%) or self-controlled (48%) gradual reduction. For future attempts respondents were most interested in doctor-controlled (68%) or self-controlled (41%) gradual reduction. Concerns regarding coming off treatment included withdrawal discomfort (68%), increased pain (50%), and relapse to heroin use (48%). Conclusion: While some patients may require lifetime maintenance, the issue of coming off treatment is important to many patients and should be discussed regularly throughout treatment and where appropriate supported by a menu of clinical options. Crown Copyright © 2010 Published by Elsevier B.V. All rights reserved.
Introduction Methadone and buprenorphine are effective pharmacological interventions for the management of opioid dependence (Faggiano, Vigna-Taglianti, Versino, & Lemma, 2003; Mattick, Kimber, Breen, & Davoli, 2008). A large body of research provides strong evidence that longer treatment duration is associated with better long-term drug use and related psychosocial outcomes (Ball & Ross, 1991; Kakko, Svanborg, Kreek, & Heilig, 2003; Mattick, Ali, & Lintzeris, 2009; Sees et al., 2000). Treatment retention has thus become a surrogate marker for treatment success, and in many countries determines how services are evaluated and funded (e.g., National Treatment Agency in UK). That promoting retention is a valid therapeutic aim is further supported by the poor clinical
∗ Corresponding author at: National Addiction Centre, Institute of Psychiatry, KCL, 4 Windsor Walk, London SE5 8AF, UK. Tel.: +44 207 848 0832; fax: +44 207 848 0222. E-mail addresses: [email protected], adam [email protected] (A.R. Winstock).
outcomes, including an increase in mortality rates, seen among patients precipitously discharged from treatment (Zanis & Woody, 1998). Nevertheless, the retention of patients in opioid substitution treatment (OST) is disappointingly low in many programs at around 30–50% at 6 months (Bell, Burrell, Indig, & Gilmour, 2006; Darke et al., 2005; Mattick et al., 2001, 2008), with the majority dropping out of treatment (jumping off) and relapsing to illicit opioid use rather than terminating treatment with a planned withdrawal (Magura & Rosenblum, 2001). Conversely, there is also an increasing group of long-term maintenance patients who remain in treatment for many years, and are considered by themselves and many others to be ‘stuck’ in treatment (Madden, Lea, Bath, & Winstock, 2008). Despite general satisfaction with treatment reported among the majority of OST patients (Ezard et al., 1999; Lea, Sheridan, & Winstock, 2008; Madden et al., 2008; Perez de los Cobos et al., 2004), the emphasis on keeping people in treatment is at odds with the strong wish of many patients to come off treatment (Lenné et al., 2001; Stancliff, Myers, Steiner, & Drucker, 2002). Compounding this are perceptions in the wider community that methadone perpetuates dependence, and should instead be a short-term treat-
0955-3959/$ – see front matter. Crown Copyright © 2010 Published by Elsevier B.V. All rights reserved. doi:10.1016/j.drugpo.2010.08.001
78
A.R. Winstock et al. / International Journal of Drug Policy 22 (2011) 77–81
Table 1 Logistic regression analysis for variables associated with interest in coming off treatment. Interest in coming off treatment in next 6 months Variable
Low (n = 53)
High (n = 90)
OR (95% CI)
p
Age (mean) Gender (% male) Treatment type (% methadone) Months on current treatment episode (mean) No. categories of people discussed coming off treatment with in preceding 6 months (mean) Ever tried to come off treatment (% yes) Ever tried to ‘jump off’ treatment (% yes) Opioid abstinence for 3 months via any method (% yes) Concerned about heroin relapse if come off treatment (% yes) Concerned about withdrawal discomfort if come off treatment (% yes) Concerned about increasing pain if come off treatment (% yes)
35.7 64.2 66.0 46.7 1.4 64.2 34.0 26.4 64.2 67.9 54.7
33.8 55.6 58.9 28.9 2.4 75.6 37.8 24.4 38.9 68.9 46.7
0.98 (0.93–1.04) 1.25 (0.46–3.43) 1.41 (0.55–3.61) 0.99 (0.98–1.00) 1.72 (1.21–2.46) 2.83 (0.79–10.10) 0.73 (0.26–2.02) 0.60 (0.21–1.70) 3.18 (1.32–7.69) 0.92 (0.31–2.73) 1.04 (0.41–2.60)
0.559 0.660 0.474 0.030 0.003 0.108 0.540 0.339 0.010 0.886 0.939
ment prior to prolonged abstinence (Magura & Rosenblum, 2001; McLellan, Carise, & Kleber, 2003). Following on from work done with Australian methadone maintenance treatment populations in 1999 (Lenné et al., 2001), this study was designed to explore patients’ experience of coming off methadone and buprenorphine treatment, to investigate their concerns regarding stopping treatment, and perceptions of when and how withdrawal should be supported. Methods This paper reports on a cross-sectional survey of 145 patients receiving methadone (61%, n = 89) or buprenorphine (39%, n = 56) maintenance at 3 publicly-funded, specialist, OST clinics in Sydney, Australia, who completed an anonymous, self-compete questionnaire. Two-hundred and thirty questionnaires were distributed (63% response rate) to patients during clinical appointments with their prescribing doctors (AW or NL) or by other clinic staff while in attendance at the clinic during a 3-month period in 2008. No remuneration was offered and all participants provided informed consent. The questionnaire was designed by two of the researchers (AW, NL), and piloted with seven patients. Minor revisions were made following this process. Data were analysed using SPSS 15.0 for Windows. Ethical approval was obtained from the Human Research Ethics Committee of Sydney South West Area Health Service. Results Participants The mean age of the sample was 35 years (SD = 8.3) and 59% were male. The majority of participants (83%, n = 120) were dosed at a public clinic, 13% (n = 19) at a community pharmacy, and 4% (n = 6) did not report where they were dosed. The mean daily dose for participants prescribed methadone was 71.4 mg (SD = 42.3, range: 5–200 mg); and for participants prescribed buprenorphine or buprenorphine-naloxone, 13.4 mg (SD = 7.4, range: 0.8–32 mg). Participants prescribed methadone had been on their current treatment episode for significantly longer than participants on buprenorphine (33 months (range: 1 month–25 years) vs 17 months (range: 3 weeks–20 years) [medians]; Mann–Whitney U = 1604.5, p = 0.002) and had been on their current dose for significantly longer (10 weeks vs 4 weeks [medians]; Mann–Whitney U = 1602.5, p = 0.006). In the preceding 3 months, 41% of participants on buprenorphine had reduced their dose compared to 18% of participants on methadone, while 39% of participants on buprenorphine had stayed on the same dose compared to 52% of participants on methadone (2 = 8.72, df = 2; p = 0.013).
Interest in coming off treatment Sixty-two percent of participants reported a high level of interest in coming off treatment in the next 6 months (34% ‘extremely interested’ [n = 50]; 28% ‘very interested’ [n = 40]). Fifteen percent (n = 22) were ‘moderately interested’, 9% (n = 13) ‘slightly interested’, and a minority (12%, n = 18) reported ‘no interest’. A logistic regression analysis was conducted to determine variables associated with a high level of interest in coming off treatment in the next 6 months (very interested, extremely interested). High interest was associated with having discussed coming off treatment with a greater number of categories of people in the preceding 6 months (OR = 1.72, p = 0.003), not citing concern about heroin relapse (OR = 3.18, p = 0.01), and shorter duration of current treatment episode (OR = 0.99, p = 0.03) (see Table 1). Discussions about coming off treatment Most participants (85%, n = 123) had discussed coming off treatment with a health care provider or other significant person in the preceding 6 months, including 65% with their prescribing doctor, 49% with a family member/friend, 46% with their case manager, 23% with their GP, 12% with a corrections worker, and 5% with a child protection worker. Having discussed coming off treatment in the preceding 6 months was not significantly associated with medication type or duration of current treatment episode (±2 years). When asked about the minimum period of time that a person should have abstained from heroin before attempting withdrawal from OST, 37% of participants reported a minimum period of at least 12 months, 25% reported at least 6 months, 16% at least 3 months, and 9% at least 1 month. Lifetime attempts of coming off treatment Seventy-one percent (n = 103) of participants reported having ever attempted to come off methadone and/or buprenorphine treatment, utilising a variety of methods (see Table 2). Twentythree percent (n = 34) had achieved abstinence from heroin and other opioids for at least 3 months using at least one of these methods. The most commonly used methods were jumping off (i.e., dropping out; reported among 59%) and gradual reduction (either doctor-controlled [52%] or self-controlled [48%]). Future attempts of coming off treatment Participants were asked to endorse, from a list provided, three methods of coming off treatment they would be most interested in trying on their next withdrawal attempt (see Table 3). Gradual reduction was the method most favoured by participants (doctorcontrolled [68%], self-controlled [41%]).
A.R. Winstock et al. / International Journal of Drug Policy 22 (2011) 77–81
79
Table 2 Methods employed by participants in attempts to come off treatment. Description of method
Jumped off (terminate treatment precipitously) Doctor-controlled gradual reduction Self-controlled gradual reduction Other medication for outpatient detoxification Switch to buprenorphine (from methadone) Counselling Inpatient detoxification Residential rehabilitation (≥1 month) Narcotics Anonymous (NA) Rapid Naltrexone detoxification
n
%
n
61 54 49 27 23 22 20 15 15 9
59 52 48 26 22 21 19 15 15 9
9 14 13 8 8 6 5 9 6 3
Table 3 Methods of coming off treatment participants were most interested in employing on their next attempt at coming off treatment. Description of methoda
Doctor-controlled gradual reduction Self-controlled gradual reduction Switch to buprenorphine (from methadone)b Counselling Other medication for outpatient detoxification Inpatient detoxification Rapid naltrexone detoxification Residential rehabilitation (≥1 month) Narcotics Anonymous (NA) Jump off
Opioid abstinence for ≥3 months using this method
Ever tried (n = 103)
Participants (n = 145) n
%
99 59 24
68 41 27
25 24
17 17
20 15 15 11 11
14 10 10 8 8
a Interest in each method was not significantly associated with current treatment type. b This item expressed as % of participants currently on methadone treatment (n = 89).
Support needs for coming off treatment Participants indicated a variety of supports they would utilise while attempting to come off treatment, if they were available (see Table 4). More than one-third of participants indicated they ‘probably would use’ withdrawal medications (36%) or individual counselling (34%) as adjuncts to support withdrawal. Concerns about coming off treatment Participants were also asked to report if they had any concerns about coming off treatment in the next 6 months to 2 years. Primary
% of those that tried this method 15 26 27 30 35 27 25 60 40 33
concerns were fear of withdrawal discomfort (68%, n = 99), fear of increased pain (50%, n = 72), return to heroin use (48%, n = 69), “life becoming a mess” (34%, n = 50), return to crime (30%, n = 44), loss of contact with clinic (17%, n = 24). Only 5 subjects (3%) identified concerns about overdose. Concerns about coming off treatment were not associated with treatment type or duration of current treatment episode (±2 years). Discussion The main finding of this study is the high level of interest in coming off treatment among the majority of patients on OST, consistent with previous research (Lenné et al., 2001; Stancliff et al., 2002). With only 12% reporting no interest in coming off treatment in the next 6 months, these findings highlight a disparity between the aims of service providers (enhanced treatment retention) and many patients in treatment (treatment cessation). Of the various methods utilised by patients to come off treatment, it was worrying that the most commonly tried approach was ‘jumping off’. Compared to other approaches, jumping off was the least successful method in achieving a 3-month period of abstinence and was the least popular approach among participants considering future attempts. Whether the high prevalence of use of this method was due to the failure of services to support the requests of individual patients to terminate treatment or as a result of other circumstances (e.g., personal crisis or geographical move) was not explored. Approaches that had been most successful during previous attempts were cited as the preferred approaches for future attempts and were broadly consistent with those generally recommended in clinical guidelines (Department of Health (England), 2007; Henry-Edwards et al., 2003; Lintzeris et al., 2006). Self-reported abstinence rates of between 25 and 30% abstinence
Table 4 Supports participants reported they would use when attempting to come off treatment, if available (n = 145). Description of supporta
Withdrawal medications (e.g., clonidine, benzodiazepines) Individual counselling by case manager/other counsellor at my usual clinic Written information (e.g., booklet) Involvement of my GP Regular urine testing to support continued dose reduction Support from other users who have come off successfully Referral to inpatient detoxification unit (for 1–2 weeks) Information DVD Involvement of family/carer Group support or counselling programmes Referral to counsellor at other agency/service Narcotics Anonymous (NA) Referral to residential rehabilitation program (weeks or months) a
Interest in each support was not significantly associated with current treatment type.
Perhaps would use
Probably would use
n
%
n
%
28 32 33 31 25 27 25 35 31 34 26 18 26
19 22 23 21 17 19 17 24 21 23 18 12 18
52 50 42 42 39 35 33 31 29 23 23 20 14
36 34 29 29 27 24 23 21 20 16 16 14 10
80
A.R. Winstock et al. / International Journal of Drug Policy 22 (2011) 77–81
from opioids at 3 months achieved with these approaches is similar to that identified in previous research (Kornor & Waal, 2005; Milby, 1988). Despite the majority of participants reporting an interest in coming off treatment, most also identified concerns, particularly regarding the risk of a return to heroin use, increased pain and withdrawal discomfort. Fear of withdrawal is likely to exist on a spectrum from mild anxiety to ‘morbid almost pathological fear’ (Eklund, Hiltunen, Melin, & Borg, 1997; Milby, 1988). Studies have highlighted the significant role of patient expectation in modulating perceptions of withdrawal distress, and that the experience of withdrawal for many patients may be less severe than they expected (Eklund et al., 1997). This suggests a role for improved education about withdrawal from OST, as well as further research exploring the utility of blind dose reduction for some patients. Although half of the participants cited fears of increasing pain, this could reflect concerns about the unmasking of chronic pain or concerns over the pain of withdrawal itself (Karasz et al., 2004). For patients with chronic pain, pre-emptive discussions about alternative pain management strategies (e.g. CBT, physiotherapy, NSAIDs) and appropriate referrals should be considered as part of withdrawal planning. Limitations The use of convenience sampling limits the generalisability of the findings. While it was not possible to compare responders with non-responders, the treatment characteristics of survey respondents are consistent with larger studies of this population (Madden et al., 2008; Winstock, Lea, & Sheridan, 2008). The findings may have limited applicability to those in treatment in different countries where variations in treatment delivery such as availability, cost, dose and access will exert significant influence upon retention and overall satisfaction with treatment (Hiltunen & Eklund, 2002). Finally, motivations for wishing to come off treatment were not explored, and it is likely there were many. In this respect, future research would benefit from exploring the relationship between wishing to come off treatment and a number of probable influences such as negative attitudes towards treatment and its delivery, stigma, side effects and pressures from significant others (Koester, Anderson, & Hoffer, 1999). It may be useful to explore whether improving feedback about the positive gains made in treatment and addressing related health concerns reduces the proportion of patients who wish to leave treatment. Conclusions Treatment services need to recognise that being opioid free is a key objective of many patients, and that ‘jumping off’ continues to be the most common form of treatment cessation. There is evidence that fear of being stuck on methadone, and the failure of services to address withdrawal concerns may contribute to patients seeking short-term treatment episodes, and avoiding higher methadone doses (Lintzeris, Pritchard, & Sciacchitano, 2007), which in turn may compromise the goals of maintenance treatment. The issue of treatment duration and approaches to coming off treatment should be included in individual care plans at the commencement of treatment. Such an approach would identify the necessary conditions that a patient should achieve before attempting withdrawal (e.g., stable substance use, employment, relationships, housing, comorbidities) and that they are provided with a menu of treatment and support options for when a patient determines that they are ready to come off. Although treatment retention remains a key parameter by which the effectiveness of OST is benchmarked, effec-
tive pathways out of treatment are also required. Failure of service providers to address patient treatment goals will leave a significant proportion of patients facing the unpleasant and typically unsuccessful option of ‘jumping off’.
Acknowledgements We would like to thank the study participants, staff at participating opioid treatment clinics in Sydney South West Area Health Service, Stewart Savage for data entry, and Professor Paul Haber for his helpful comments on the manuscript. This project was funded by Drug Health Services, Sydney South West Area Health Service. Conflict of interest: AW and NL have received honoraria for providing professional education and untied educational grants from Reckitt Benckiser, manufacturer of buprenorphine.
References Ball, J. A., & Ross, A. (1991). The effectiveness of methadone maintenance treatment. New York: Springer-Verlag. Bell, J., Burrell, T., Indig, D., & Gilmour, S. (2006). Cycling in and out of treatment: Participation in methadone treatment in NSW, 1990–2002. Drug and Alcohol Dependence, 81, 55–61. Darke, S., Ross, J., Teesson, M., Ali, R., Cooke, R., Ritter, A., et al. (2005). Factors associated with 12 months continuous heroin abstinence: Findings from the Australian Treatment Outcome Study (ATOS). Journal of Substance Abuse Treatment, 28, 255–263. Department of Health (England). (2007). Drug misuse and dependence: UK guidelines on clinical management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive. Eklund, C., Hiltunen, A. J., Melin, L., & Borg, S. (1997). Abstinence fear in methadone maintenance withdrawal: A possible obstacle for getting off methadone. Substance Use and Misuse, 32, 779–792. Ezard, N., Lintzeris, N., Odgers, P., Koutroulis, G., Muhleisen, P., Stowe, A., et al. (1999). An evaluation of community methadone services in Victoria, Australia: Results of a client survey. Drug and Alcohol Review, 18, 417–423. Faggiano, F., Vigna-Taglianti, F., Versino, E., & Lemma, P. (2003). Methadone maintenance at different dosages for opioid dependence. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD002208. doi:10.1002/14651858.CD002208. Henry-Edwards, S., Gowing, L., White, J., Ali, R., Bell, J., Brough, R., et al. (2003). Clinical guidelines and procedures for the use of methadone in the maintenance treatment of opioid dependence. Canberra: Australian Government National Drug Strategy. Hiltunen, A. J., & Eklund, C. (2002). Withdrawal from methadone maintenance treatment. Reasons for not trying to quit methadone. European Addiction Research, 8, 38–44. Kakko, J., Svanborg, K., Kreek, M., & Heilig, M. (2003). 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: A randomised, placebo-controlled trial. Lancet, 361, 662–668. Karasz, A., Zallman, L., Berg, K., Gourevitch, M., Selwyn, P., & Arnsten, J. H. (2004). The experience of chronic severe pain in patients undergoing methadone maintenance treatment. Journal of Pain & Symptom Management, 28, 517–525. Koester, S., Anderson, K., & Hoffer, L. (1999). Active heroin injectors’ perceptions and use of methadone maintenance treatment: Cynical performance or selfprescribed risk reduction? Substance Use and Misuse, 34, 2135–2153. Kornor, H., & Waal, H. (2005). From opioid maintenance to abstinence: A literature review. Drug and Alcohol Review, 24, 267–274. Lea, T., Sheridan, J., & Winstock, A. (2008). Consumer satisfaction with opioid treatment services at community pharmacies in Australia. Pharmacy World & Science, 30, 940–946. Lenné, M., Lintzeris, N., Breen, C., Harris, S., Hawken, L., Mattick, R., et al. (2001). Withdrawal from methadone maintenance treatment: Prognosis and participant perspectives. Australian and New Zealand Journal of Public Health, 25, 121–125. Lintzeris, N., Clark, N., Winstock, A., Dunlop, A., Muhleisen, P., Gowing, L., et al. (2006). National clinical guidelines and procedures for the use of buprenorphine in the treatment of opioid dependence. Canberra: Australian Government National Drug Strategy. Lintzeris, N., Pritchard, E., & Sciacchitano, L. (2007). Investigation of methadone dosing in Victoria: Factors influencing dosing levels. Melbourne: Turning Point Alcohol and Drug Centre. Madden, A., Lea, T., Bath, N., & Winstock, A. R. (2008). Satisfaction guaranteed? What clients on methadone and buprenorphine think about their treatment. Drug and Alcohol Review, 27, 671–678. Magura, S., & Rosenblum, A. (2001). Leaving methadone treatment: Lessons learned, lessons forgotten, lessons ignored. Mount Sinai Journal of Medicine, 68, 62–74. Mattick, R. P., Ali, R., & Lintzeris, N. (Eds.). (2009). Pharmacotherapies for the treatment of opioid dependence: Efficacy, cost-effectiveness, and implementation guidelines. New York: Informa Healthcare.
A.R. Winstock et al. / International Journal of Drug Policy 22 (2011) 77–81 Mattick, R. P., Digiusto, E., Doran, C. M., OBrien, S., Shanahan, M., Kimber, J., et al. (2001). National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD): Report of results and recommendations. Monograph Series No. 52. Sydney: National Drug and Alcohol Research Centre, University of New South Wales. Mattick, R. P., Kimber, J., Breen, C., & Davoli, M. (2008). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD002207. doi:10.1002/14651858.CD002207.pub3. McLellan, A. T., Carise, D., & Kleber, H. D. (2003). Can the national addiction treatment infrastructure support the public’s demand for quality care? Journal of Substance Abuse Treatment, 25, 117–121. Milby, J. B. (1988). Methadone maintenance to abstinence: How many make it? Journal of Nervous and Mental Disease, 176, 409–422.
81
Perez de los Cobos, J. P., Fidel, G., Escuder, G., Haro, G., Sanchez, N., Pascual, C., et al. (2004). A satisfaction survey of opioid-dependent clients at methadone treatment centres in Spain. Drug and Alcohol Dependence, 73, 307– 313. Sees, K. L., Delucchi, K. L., Masson, C., Rosen, A., Clark, H. W., Robillard, H., et al. (2000). Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: A randomized controlled trial. JAMA, 283, 1303–1310. Stancliff, S., Myers, E., Steiner, S., & Drucker, E. (2002). Beliefs about methadone in an inner-city methadone clinic. J Urban Health, 79, 571–577. Winstock, A. R., Lea, T., & Sheridan, J. (2008). Patients’ help-seeking behaviours for health problems associated with methadone and buprenorphine treatment. Drug and Alcohol Review, 27, 393–397. Zanis, D. A., & Woody, G. E. (1998). One-year mortality rates following methadone treatment discharge. Drug and Alcohol Dependence, 52, 257–260.
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Short report
“Should I stay or should I go?” Coming off methadone and buprenorphine treatment Adam R. Winstock a,b,∗ , Nicholas Lintzeris c,d , Toby Lea e a
National Addiction Centre, Institute of Psychiatry, KCL, London SE5, UK National Drug and Alcohol Research Centre, University of New South Wales, Randwick, New South Wales, 2052, Australia c The Langton Centre, Drug and Alcohol Services, South East Sydney and Illawarra Area Health Service, New South Wales, 2050, Australia d Faculty of Medicine, University of Sydney, New South Wales, 2006, Australia e Drug Health Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, 2050, Australia b
a r t i c l e
i n f o
Article history: Received 17 December 2009 Received in revised form 26 July 2010 Accepted 17 August 2010
Keywords: Maintenance Buprenorphine Detoxification Methadone Opioid substitution treatment Withdrawal
a b s t r a c t Background: This study aimed to investigate patient perspectives regarding coming off maintenance opioid substitution treatment (OST). The study explored previous experiences, current interest and concerns about stopping treatment, and perceptions of how and when coming off treatment should be supported. Methods: A cross-sectional survey was used. Participants were 145 patients receiving OST at public opioid treatment clinics in Sydney, Australia. Results: Sixty-two percent reported high interest in coming off treatment in the next 6 months. High interest was associated with having discussed coming off treatment with a greater number of categories of people (OR = 1.72), not citing concern about heroin relapse (OR = 3.18), and shorter duration of current treatment episode (OR = 0.99). Seventy-one percent reported previous withdrawal attempts and 23% had achieved opioid abstinence for ≥3 months following a previous withdrawal attempt. Attempts most commonly involved jumping off (59%), and doctor-controlled (52%) or self-controlled (48%) gradual reduction. For future attempts respondents were most interested in doctor-controlled (68%) or self-controlled (41%) gradual reduction. Concerns regarding coming off treatment included withdrawal discomfort (68%), increased pain (50%), and relapse to heroin use (48%). Conclusion: While some patients may require lifetime maintenance, the issue of coming off treatment is important to many patients and should be discussed regularly throughout treatment and where appropriate supported by a menu of clinical options. Crown Copyright © 2010 Published by Elsevier B.V. All rights reserved.
Introduction Methadone and buprenorphine are effective pharmacological interventions for the management of opioid dependence (Faggiano, Vigna-Taglianti, Versino, & Lemma, 2003; Mattick, Kimber, Breen, & Davoli, 2008). A large body of research provides strong evidence that longer treatment duration is associated with better long-term drug use and related psychosocial outcomes (Ball & Ross, 1991; Kakko, Svanborg, Kreek, & Heilig, 2003; Mattick, Ali, & Lintzeris, 2009; Sees et al., 2000). Treatment retention has thus become a surrogate marker for treatment success, and in many countries determines how services are evaluated and funded (e.g., National Treatment Agency in UK). That promoting retention is a valid therapeutic aim is further supported by the poor clinical
∗ Corresponding author at: National Addiction Centre, Institute of Psychiatry, KCL, 4 Windsor Walk, London SE5 8AF, UK. Tel.: +44 207 848 0832; fax: +44 207 848 0222. E-mail addresses: [email protected], adam [email protected] (A.R. Winstock).
outcomes, including an increase in mortality rates, seen among patients precipitously discharged from treatment (Zanis & Woody, 1998). Nevertheless, the retention of patients in opioid substitution treatment (OST) is disappointingly low in many programs at around 30–50% at 6 months (Bell, Burrell, Indig, & Gilmour, 2006; Darke et al., 2005; Mattick et al., 2001, 2008), with the majority dropping out of treatment (jumping off) and relapsing to illicit opioid use rather than terminating treatment with a planned withdrawal (Magura & Rosenblum, 2001). Conversely, there is also an increasing group of long-term maintenance patients who remain in treatment for many years, and are considered by themselves and many others to be ‘stuck’ in treatment (Madden, Lea, Bath, & Winstock, 2008). Despite general satisfaction with treatment reported among the majority of OST patients (Ezard et al., 1999; Lea, Sheridan, & Winstock, 2008; Madden et al., 2008; Perez de los Cobos et al., 2004), the emphasis on keeping people in treatment is at odds with the strong wish of many patients to come off treatment (Lenné et al., 2001; Stancliff, Myers, Steiner, & Drucker, 2002). Compounding this are perceptions in the wider community that methadone perpetuates dependence, and should instead be a short-term treat-
0955-3959/$ – see front matter. Crown Copyright © 2010 Published by Elsevier B.V. All rights reserved. doi:10.1016/j.drugpo.2010.08.001
78
A.R. Winstock et al. / International Journal of Drug Policy 22 (2011) 77–81
Table 1 Logistic regression analysis for variables associated with interest in coming off treatment. Interest in coming off treatment in next 6 months Variable
Low (n = 53)
High (n = 90)
OR (95% CI)
p
Age (mean) Gender (% male) Treatment type (% methadone) Months on current treatment episode (mean) No. categories of people discussed coming off treatment with in preceding 6 months (mean) Ever tried to come off treatment (% yes) Ever tried to ‘jump off’ treatment (% yes) Opioid abstinence for 3 months via any method (% yes) Concerned about heroin relapse if come off treatment (% yes) Concerned about withdrawal discomfort if come off treatment (% yes) Concerned about increasing pain if come off treatment (% yes)
35.7 64.2 66.0 46.7 1.4 64.2 34.0 26.4 64.2 67.9 54.7
33.8 55.6 58.9 28.9 2.4 75.6 37.8 24.4 38.9 68.9 46.7
0.98 (0.93–1.04) 1.25 (0.46–3.43) 1.41 (0.55–3.61) 0.99 (0.98–1.00) 1.72 (1.21–2.46) 2.83 (0.79–10.10) 0.73 (0.26–2.02) 0.60 (0.21–1.70) 3.18 (1.32–7.69) 0.92 (0.31–2.73) 1.04 (0.41–2.60)
0.559 0.660 0.474 0.030 0.003 0.108 0.540 0.339 0.010 0.886 0.939
ment prior to prolonged abstinence (Magura & Rosenblum, 2001; McLellan, Carise, & Kleber, 2003). Following on from work done with Australian methadone maintenance treatment populations in 1999 (Lenné et al., 2001), this study was designed to explore patients’ experience of coming off methadone and buprenorphine treatment, to investigate their concerns regarding stopping treatment, and perceptions of when and how withdrawal should be supported. Methods This paper reports on a cross-sectional survey of 145 patients receiving methadone (61%, n = 89) or buprenorphine (39%, n = 56) maintenance at 3 publicly-funded, specialist, OST clinics in Sydney, Australia, who completed an anonymous, self-compete questionnaire. Two-hundred and thirty questionnaires were distributed (63% response rate) to patients during clinical appointments with their prescribing doctors (AW or NL) or by other clinic staff while in attendance at the clinic during a 3-month period in 2008. No remuneration was offered and all participants provided informed consent. The questionnaire was designed by two of the researchers (AW, NL), and piloted with seven patients. Minor revisions were made following this process. Data were analysed using SPSS 15.0 for Windows. Ethical approval was obtained from the Human Research Ethics Committee of Sydney South West Area Health Service. Results Participants The mean age of the sample was 35 years (SD = 8.3) and 59% were male. The majority of participants (83%, n = 120) were dosed at a public clinic, 13% (n = 19) at a community pharmacy, and 4% (n = 6) did not report where they were dosed. The mean daily dose for participants prescribed methadone was 71.4 mg (SD = 42.3, range: 5–200 mg); and for participants prescribed buprenorphine or buprenorphine-naloxone, 13.4 mg (SD = 7.4, range: 0.8–32 mg). Participants prescribed methadone had been on their current treatment episode for significantly longer than participants on buprenorphine (33 months (range: 1 month–25 years) vs 17 months (range: 3 weeks–20 years) [medians]; Mann–Whitney U = 1604.5, p = 0.002) and had been on their current dose for significantly longer (10 weeks vs 4 weeks [medians]; Mann–Whitney U = 1602.5, p = 0.006). In the preceding 3 months, 41% of participants on buprenorphine had reduced their dose compared to 18% of participants on methadone, while 39% of participants on buprenorphine had stayed on the same dose compared to 52% of participants on methadone (2 = 8.72, df = 2; p = 0.013).
Interest in coming off treatment Sixty-two percent of participants reported a high level of interest in coming off treatment in the next 6 months (34% ‘extremely interested’ [n = 50]; 28% ‘very interested’ [n = 40]). Fifteen percent (n = 22) were ‘moderately interested’, 9% (n = 13) ‘slightly interested’, and a minority (12%, n = 18) reported ‘no interest’. A logistic regression analysis was conducted to determine variables associated with a high level of interest in coming off treatment in the next 6 months (very interested, extremely interested). High interest was associated with having discussed coming off treatment with a greater number of categories of people in the preceding 6 months (OR = 1.72, p = 0.003), not citing concern about heroin relapse (OR = 3.18, p = 0.01), and shorter duration of current treatment episode (OR = 0.99, p = 0.03) (see Table 1). Discussions about coming off treatment Most participants (85%, n = 123) had discussed coming off treatment with a health care provider or other significant person in the preceding 6 months, including 65% with their prescribing doctor, 49% with a family member/friend, 46% with their case manager, 23% with their GP, 12% with a corrections worker, and 5% with a child protection worker. Having discussed coming off treatment in the preceding 6 months was not significantly associated with medication type or duration of current treatment episode (±2 years). When asked about the minimum period of time that a person should have abstained from heroin before attempting withdrawal from OST, 37% of participants reported a minimum period of at least 12 months, 25% reported at least 6 months, 16% at least 3 months, and 9% at least 1 month. Lifetime attempts of coming off treatment Seventy-one percent (n = 103) of participants reported having ever attempted to come off methadone and/or buprenorphine treatment, utilising a variety of methods (see Table 2). Twentythree percent (n = 34) had achieved abstinence from heroin and other opioids for at least 3 months using at least one of these methods. The most commonly used methods were jumping off (i.e., dropping out; reported among 59%) and gradual reduction (either doctor-controlled [52%] or self-controlled [48%]). Future attempts of coming off treatment Participants were asked to endorse, from a list provided, three methods of coming off treatment they would be most interested in trying on their next withdrawal attempt (see Table 3). Gradual reduction was the method most favoured by participants (doctorcontrolled [68%], self-controlled [41%]).
A.R. Winstock et al. / International Journal of Drug Policy 22 (2011) 77–81
79
Table 2 Methods employed by participants in attempts to come off treatment. Description of method
Jumped off (terminate treatment precipitously) Doctor-controlled gradual reduction Self-controlled gradual reduction Other medication for outpatient detoxification Switch to buprenorphine (from methadone) Counselling Inpatient detoxification Residential rehabilitation (≥1 month) Narcotics Anonymous (NA) Rapid Naltrexone detoxification
n
%
n
61 54 49 27 23 22 20 15 15 9
59 52 48 26 22 21 19 15 15 9
9 14 13 8 8 6 5 9 6 3
Table 3 Methods of coming off treatment participants were most interested in employing on their next attempt at coming off treatment. Description of methoda
Doctor-controlled gradual reduction Self-controlled gradual reduction Switch to buprenorphine (from methadone)b Counselling Other medication for outpatient detoxification Inpatient detoxification Rapid naltrexone detoxification Residential rehabilitation (≥1 month) Narcotics Anonymous (NA) Jump off
Opioid abstinence for ≥3 months using this method
Ever tried (n = 103)
Participants (n = 145) n
%
99 59 24
68 41 27
25 24
17 17
20 15 15 11 11
14 10 10 8 8
a Interest in each method was not significantly associated with current treatment type. b This item expressed as % of participants currently on methadone treatment (n = 89).
Support needs for coming off treatment Participants indicated a variety of supports they would utilise while attempting to come off treatment, if they were available (see Table 4). More than one-third of participants indicated they ‘probably would use’ withdrawal medications (36%) or individual counselling (34%) as adjuncts to support withdrawal. Concerns about coming off treatment Participants were also asked to report if they had any concerns about coming off treatment in the next 6 months to 2 years. Primary
% of those that tried this method 15 26 27 30 35 27 25 60 40 33
concerns were fear of withdrawal discomfort (68%, n = 99), fear of increased pain (50%, n = 72), return to heroin use (48%, n = 69), “life becoming a mess” (34%, n = 50), return to crime (30%, n = 44), loss of contact with clinic (17%, n = 24). Only 5 subjects (3%) identified concerns about overdose. Concerns about coming off treatment were not associated with treatment type or duration of current treatment episode (±2 years). Discussion The main finding of this study is the high level of interest in coming off treatment among the majority of patients on OST, consistent with previous research (Lenné et al., 2001; Stancliff et al., 2002). With only 12% reporting no interest in coming off treatment in the next 6 months, these findings highlight a disparity between the aims of service providers (enhanced treatment retention) and many patients in treatment (treatment cessation). Of the various methods utilised by patients to come off treatment, it was worrying that the most commonly tried approach was ‘jumping off’. Compared to other approaches, jumping off was the least successful method in achieving a 3-month period of abstinence and was the least popular approach among participants considering future attempts. Whether the high prevalence of use of this method was due to the failure of services to support the requests of individual patients to terminate treatment or as a result of other circumstances (e.g., personal crisis or geographical move) was not explored. Approaches that had been most successful during previous attempts were cited as the preferred approaches for future attempts and were broadly consistent with those generally recommended in clinical guidelines (Department of Health (England), 2007; Henry-Edwards et al., 2003; Lintzeris et al., 2006). Self-reported abstinence rates of between 25 and 30% abstinence
Table 4 Supports participants reported they would use when attempting to come off treatment, if available (n = 145). Description of supporta
Withdrawal medications (e.g., clonidine, benzodiazepines) Individual counselling by case manager/other counsellor at my usual clinic Written information (e.g., booklet) Involvement of my GP Regular urine testing to support continued dose reduction Support from other users who have come off successfully Referral to inpatient detoxification unit (for 1–2 weeks) Information DVD Involvement of family/carer Group support or counselling programmes Referral to counsellor at other agency/service Narcotics Anonymous (NA) Referral to residential rehabilitation program (weeks or months) a
Interest in each support was not significantly associated with current treatment type.
Perhaps would use
Probably would use
n
%
n
%
28 32 33 31 25 27 25 35 31 34 26 18 26
19 22 23 21 17 19 17 24 21 23 18 12 18
52 50 42 42 39 35 33 31 29 23 23 20 14
36 34 29 29 27 24 23 21 20 16 16 14 10
80
A.R. Winstock et al. / International Journal of Drug Policy 22 (2011) 77–81
from opioids at 3 months achieved with these approaches is similar to that identified in previous research (Kornor & Waal, 2005; Milby, 1988). Despite the majority of participants reporting an interest in coming off treatment, most also identified concerns, particularly regarding the risk of a return to heroin use, increased pain and withdrawal discomfort. Fear of withdrawal is likely to exist on a spectrum from mild anxiety to ‘morbid almost pathological fear’ (Eklund, Hiltunen, Melin, & Borg, 1997; Milby, 1988). Studies have highlighted the significant role of patient expectation in modulating perceptions of withdrawal distress, and that the experience of withdrawal for many patients may be less severe than they expected (Eklund et al., 1997). This suggests a role for improved education about withdrawal from OST, as well as further research exploring the utility of blind dose reduction for some patients. Although half of the participants cited fears of increasing pain, this could reflect concerns about the unmasking of chronic pain or concerns over the pain of withdrawal itself (Karasz et al., 2004). For patients with chronic pain, pre-emptive discussions about alternative pain management strategies (e.g. CBT, physiotherapy, NSAIDs) and appropriate referrals should be considered as part of withdrawal planning. Limitations The use of convenience sampling limits the generalisability of the findings. While it was not possible to compare responders with non-responders, the treatment characteristics of survey respondents are consistent with larger studies of this population (Madden et al., 2008; Winstock, Lea, & Sheridan, 2008). The findings may have limited applicability to those in treatment in different countries where variations in treatment delivery such as availability, cost, dose and access will exert significant influence upon retention and overall satisfaction with treatment (Hiltunen & Eklund, 2002). Finally, motivations for wishing to come off treatment were not explored, and it is likely there were many. In this respect, future research would benefit from exploring the relationship between wishing to come off treatment and a number of probable influences such as negative attitudes towards treatment and its delivery, stigma, side effects and pressures from significant others (Koester, Anderson, & Hoffer, 1999). It may be useful to explore whether improving feedback about the positive gains made in treatment and addressing related health concerns reduces the proportion of patients who wish to leave treatment. Conclusions Treatment services need to recognise that being opioid free is a key objective of many patients, and that ‘jumping off’ continues to be the most common form of treatment cessation. There is evidence that fear of being stuck on methadone, and the failure of services to address withdrawal concerns may contribute to patients seeking short-term treatment episodes, and avoiding higher methadone doses (Lintzeris, Pritchard, & Sciacchitano, 2007), which in turn may compromise the goals of maintenance treatment. The issue of treatment duration and approaches to coming off treatment should be included in individual care plans at the commencement of treatment. Such an approach would identify the necessary conditions that a patient should achieve before attempting withdrawal (e.g., stable substance use, employment, relationships, housing, comorbidities) and that they are provided with a menu of treatment and support options for when a patient determines that they are ready to come off. Although treatment retention remains a key parameter by which the effectiveness of OST is benchmarked, effec-
tive pathways out of treatment are also required. Failure of service providers to address patient treatment goals will leave a significant proportion of patients facing the unpleasant and typically unsuccessful option of ‘jumping off’.
Acknowledgements We would like to thank the study participants, staff at participating opioid treatment clinics in Sydney South West Area Health Service, Stewart Savage for data entry, and Professor Paul Haber for his helpful comments on the manuscript. This project was funded by Drug Health Services, Sydney South West Area Health Service. Conflict of interest: AW and NL have received honoraria for providing professional education and untied educational grants from Reckitt Benckiser, manufacturer of buprenorphine.
References Ball, J. A., & Ross, A. (1991). The effectiveness of methadone maintenance treatment. New York: Springer-Verlag. Bell, J., Burrell, T., Indig, D., & Gilmour, S. (2006). Cycling in and out of treatment: Participation in methadone treatment in NSW, 1990–2002. Drug and Alcohol Dependence, 81, 55–61. Darke, S., Ross, J., Teesson, M., Ali, R., Cooke, R., Ritter, A., et al. (2005). Factors associated with 12 months continuous heroin abstinence: Findings from the Australian Treatment Outcome Study (ATOS). Journal of Substance Abuse Treatment, 28, 255–263. Department of Health (England). (2007). Drug misuse and dependence: UK guidelines on clinical management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive. Eklund, C., Hiltunen, A. J., Melin, L., & Borg, S. (1997). Abstinence fear in methadone maintenance withdrawal: A possible obstacle for getting off methadone. Substance Use and Misuse, 32, 779–792. Ezard, N., Lintzeris, N., Odgers, P., Koutroulis, G., Muhleisen, P., Stowe, A., et al. (1999). An evaluation of community methadone services in Victoria, Australia: Results of a client survey. Drug and Alcohol Review, 18, 417–423. Faggiano, F., Vigna-Taglianti, F., Versino, E., & Lemma, P. (2003). Methadone maintenance at different dosages for opioid dependence. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD002208. doi:10.1002/14651858.CD002208. Henry-Edwards, S., Gowing, L., White, J., Ali, R., Bell, J., Brough, R., et al. (2003). Clinical guidelines and procedures for the use of methadone in the maintenance treatment of opioid dependence. Canberra: Australian Government National Drug Strategy. Hiltunen, A. J., & Eklund, C. (2002). Withdrawal from methadone maintenance treatment. Reasons for not trying to quit methadone. European Addiction Research, 8, 38–44. Kakko, J., Svanborg, K., Kreek, M., & Heilig, M. (2003). 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: A randomised, placebo-controlled trial. Lancet, 361, 662–668. Karasz, A., Zallman, L., Berg, K., Gourevitch, M., Selwyn, P., & Arnsten, J. H. (2004). The experience of chronic severe pain in patients undergoing methadone maintenance treatment. Journal of Pain & Symptom Management, 28, 517–525. Koester, S., Anderson, K., & Hoffer, L. (1999). Active heroin injectors’ perceptions and use of methadone maintenance treatment: Cynical performance or selfprescribed risk reduction? Substance Use and Misuse, 34, 2135–2153. Kornor, H., & Waal, H. (2005). From opioid maintenance to abstinence: A literature review. Drug and Alcohol Review, 24, 267–274. Lea, T., Sheridan, J., & Winstock, A. (2008). Consumer satisfaction with opioid treatment services at community pharmacies in Australia. Pharmacy World & Science, 30, 940–946. Lenné, M., Lintzeris, N., Breen, C., Harris, S., Hawken, L., Mattick, R., et al. (2001). Withdrawal from methadone maintenance treatment: Prognosis and participant perspectives. Australian and New Zealand Journal of Public Health, 25, 121–125. Lintzeris, N., Clark, N., Winstock, A., Dunlop, A., Muhleisen, P., Gowing, L., et al. (2006). National clinical guidelines and procedures for the use of buprenorphine in the treatment of opioid dependence. Canberra: Australian Government National Drug Strategy. Lintzeris, N., Pritchard, E., & Sciacchitano, L. (2007). Investigation of methadone dosing in Victoria: Factors influencing dosing levels. Melbourne: Turning Point Alcohol and Drug Centre. Madden, A., Lea, T., Bath, N., & Winstock, A. R. (2008). Satisfaction guaranteed? What clients on methadone and buprenorphine think about their treatment. Drug and Alcohol Review, 27, 671–678. Magura, S., & Rosenblum, A. (2001). Leaving methadone treatment: Lessons learned, lessons forgotten, lessons ignored. Mount Sinai Journal of Medicine, 68, 62–74. Mattick, R. P., Ali, R., & Lintzeris, N. (Eds.). (2009). Pharmacotherapies for the treatment of opioid dependence: Efficacy, cost-effectiveness, and implementation guidelines. New York: Informa Healthcare.
A.R. Winstock et al. / International Journal of Drug Policy 22 (2011) 77–81 Mattick, R. P., Digiusto, E., Doran, C. M., OBrien, S., Shanahan, M., Kimber, J., et al. (2001). National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD): Report of results and recommendations. Monograph Series No. 52. Sydney: National Drug and Alcohol Research Centre, University of New South Wales. Mattick, R. P., Kimber, J., Breen, C., & Davoli, M. (2008). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD002207. doi:10.1002/14651858.CD002207.pub3. McLellan, A. T., Carise, D., & Kleber, H. D. (2003). Can the national addiction treatment infrastructure support the public’s demand for quality care? Journal of Substance Abuse Treatment, 25, 117–121. Milby, J. B. (1988). Methadone maintenance to abstinence: How many make it? Journal of Nervous and Mental Disease, 176, 409–422.
81
Perez de los Cobos, J. P., Fidel, G., Escuder, G., Haro, G., Sanchez, N., Pascual, C., et al. (2004). A satisfaction survey of opioid-dependent clients at methadone treatment centres in Spain. Drug and Alcohol Dependence, 73, 307– 313. Sees, K. L., Delucchi, K. L., Masson, C., Rosen, A., Clark, H. W., Robillard, H., et al. (2000). Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: A randomized controlled trial. JAMA, 283, 1303–1310. Stancliff, S., Myers, E., Steiner, S., & Drucker, E. (2002). Beliefs about methadone in an inner-city methadone clinic. J Urban Health, 79, 571–577. Winstock, A. R., Lea, T., & Sheridan, J. (2008). Patients’ help-seeking behaviours for health problems associated with methadone and buprenorphine treatment. Drug and Alcohol Review, 27, 393–397. Zanis, D. A., & Woody, G. E. (1998). One-year mortality rates following methadone treatment discharge. Drug and Alcohol Dependence, 52, 257–260.