Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence. A randomized controlled trial

FRANÇAIS :
Bien que l'efficacité des traitements de maintenance à la méthadone (TTM) pour réduire l'usage d'héroïne et les comportements à risques vis-à-vis du VIH est reconnue, ils demeurent controversés du fait de la délivrance sur une durée inderminée d'un médicament qui lui-même entraîne une dépendance. 179 usagers dépendants des opioïdes ont reçu soit unTTM (91) avec 2 heures par semaine de soutien psychosocial soit un traitement de désintoxication (88) avec 3 heures de soutien psychosocial par semaine, 14 sessions d'éducation et une heure de thérapie de groupe sur la cocaïne. La rétention en traitement, l'abstinence (cocaïne et héroïne), les conduites à risque VIH, les problèmes liés à l'emploi, la famille, les problèmes psychiatriques, vis-à-vis de la loi et la consommation d'alcool ont été comparés dans les 2 groupes. Aucune différence n'a été observée concernant la famille, l'emploi ou la consommation d'alcool. Dans les 2 groupes l'usage illicite d'héroïne a continué, avec cependant une fréquence plus basse. Ces résultats n'apportent pas de preuve en faveur du remplacement des TTM par des désintoxication à long terme.
ENGLISH :
Context: Despite evidence that methadone maintenance treatment (MMT) is effective for opioid dependence, it remains a controversial therapy because of its indefinite provision of a dependence-producing medication. Objective: To compare outcomes of patients with opioid dependence treated with MMT vs an alternative treatment, psychosocially enriched 180-day methadone-assisted detoxification. Design: Randomized controlled trial conducted from May 1995 to April 1999. Setting: Research clinic in an established drug treatment service. Patients: Of 858 volunteers screened, 179 adults with diagnosed opioid dependence were randomized into the study; 154 completed 12 weeks of follow-up. Interventions: Patients were randomized to MMT (n = 91), which required 2 hours of psychosocial therapy per week during the first 6 months; or detoxification (n = 88), which required 3 hours of psychosocial therapy per week, 14 education sessions, and 1 hour of cocaine group therapy, if appropriate, for 6 months, and 6 months of (non-methadone) aftercare services. Main Outcome Measures: Treatment retention, heroin and cocaine abstinence (by self-report and monthly urinalysis), human immunodeficiency virus (HIV) risk behaviors (Risk of AIDS Behavior scale score), and function in 5 problem areas; employment, family, psychiatric, legal, and alcohol use (Addiction Severity Index), compared by intervention group. Results: Methadone maintenance therapy resulted in greater treatment retention (median, 438.5 vs 174.0 days) and lower heroin use rates than did detoxification. Cocaine use was more closely related to study dropout in detoxification than in MMT, Methadone maintenance therapy resulted in a lower rate of drug-related (mean [SD] at 12 months, 2.17 [3.88] vs 3.73 [6.86]) but not sex-related HIV risk behaviors and in a lower severity score for legal status (mean [SD] at 12 months, 0.05 [0.13] vs 0.13 [0.19]). There were no differences between groups in employment or family functioning or alcohol use. in both groups, monthly heroin use rates were 50% or greater, but days of use per month dropped markedly from baseline. Conclusions: Our results confirm the usefulness of MMT in reducing heroin use and HIV risk behaviors. Illicit opioid use continued in both groups, but frequency was reduced. Results do not provide support for diverting resources from MMT into long-term detoxification. (Author' s abstract)