Objective: To evaluate the effectiveness of tapered methadone compared with other detoxification treatments and placebo in managing opioid withdrawal on completion of detoxification and relapse rate. Abuse of opioid drugs and dependence on them causes major health and social issues that include transmission of HIV and hepatitis C with injection, increased crime and costs for health care and law enforcement, family disruption and lost productivity. Addicts, particularly those aged 15 to 34 years, are also at higher risk of death. Managed withdrawal (or detoxification) is used as the first step in treatment. Withdrawal symptoms include anxiety, chills, muscle pain (myalgia) and weakness, tremor, lethargy and drowsiness, restlessness and irritability, nausea and vomiting and diarrhoea. Persisting sleep disturbances and drug craving can continue for weeks and months after detoxification and often lead to a return to opioid use. The number of addicts who complete detoxification tends to be low, and rates of relapse are high. For a tapered dose treatment to reduce withdrawal symptoms, illicit opioids are replaced by methadone or another agent using decreasing doses up to 30 days under medical supervision. The review authors searched the medical literature and identified 23 controlled trials involving 2467 adult opioid users in various countries. Trial participants were randomised to receive methadone or another pharmacological treatment. The other treatments were adrenergic agonists such as lofexidine, partial opioid agonists such as buprenorphine, opioid agonists such as LAAM (levo-AZÂ±-acetyl-methadol) and the anxiolytics chlordiazepoxide and buspirone. In the two studies that compared methadone with placebo, withdrawal symptoms were more severe and more people dropped out in the placebo group. The studies included in this review confirmed that slow tapering with temporary substitution of long- acting opioids, could reduce withdrawal severity. Nevertheless, the majority of patients relapsed to heroin use. The medications used in the included studies were similar in terms of overall effectiveness, although symptoms experienced by participants differed according to the medication used and the program adopted. The programs varied widely with regard to the assessment of outcome measures. Seventeen of the included trials were conducted in inpatient settings.

/pdf/methadone-at-tapered-doses-for-the-management-of-opioid-3tlmdp72sr.pdf

Methadone at tapered doses for the management of opioid withdrawal

We systematically reviewed randomized controlled trials of interventions to improve the health of people during imprisonment or in the year after release. We searched 14 biomedical and social science databases in 2014, and identified 95 studies. Most studies involved only men or a majority of men (70/83 studies in which gender was specified); only 16 studies focused on adolescents. Most studies were conducted in the United States (n = 57). The risk of bias for outcomes in almost all studies was unclear or high (n = 91). In 59 studies, interventions led to improved mental health, substance use, infectious diseases, or health service utilization outcomes; in 42 of these studies, outcomes were measured in the community after release. Improving the health of people who experience imprisonment requires knowledge generation and knowledge translation, including implementation of effective interventions.

A Systematic Review of Randomized Controlled Trials of Interventions to Improve the Health of Persons During Imprisonment and in the Year After Release

We conducted a systematic review to examine the substance use and recidivism outcomes of prison-based substance use interventions. We searched public health, criminology, and psychology databases, and conducted forward and backward snowballing methods to identify additional studies. Studies were included if they were published between January 1, 2000 and June 30, 2017; were published in English; and reported substance use and/or recidivism outcomes of prison-based substance use interventions. Studies were reviewed for methodological rigor using the Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies. Our search returned 49 studies: 6 were methodologically strong, 20 were moderate, and 23 were weak. Results suggest therapeutic communities are effective in reducing recidivism and, to a lesser extent substance use after release. There is also evidence to suggest that opioid maintenance treatment is effective in reducing the risk of drug use after release from prison for opioid users. Furthermore, care after release from prison appears to enhance treatment effects for both types of interventions. Results provide evidence that policymakers can use to make informed decisions on best-practice approaches when addressing prisoner substance dependence and improving long-term outcomes. This comprehensive review highlights the difficulties of conducting quality research in the prison setting and suggests innovative study design for future research.

Substance use and recidivism outcomes for prison-based drug and alcohol interventions

BACKGROUND: The review represents one in a family of four reviews focusing on a range of different interventions for drug-using offenders. This specific review considers pharmacological interventions aimed at reducing drug use or criminal activity, or both, for illicit drug-using offenders. 

OBJECTIVES: To assess the effectiveness of pharmacological interventions for drug-using offenders in reducing criminal activity or drug use, or both. 

SEARCH METHODS: We searched Fourteen electronic bibliographic databases up to May 2014 and five additional Web resources (between 2004 and November 2011). We contacted experts in the field for further information. 

SELECTION CRITERIA: We included randomised controlled trials assessing the efficacy of any pharmacological intervention a component of which is designed to reduce, eliminate or prevent relapse of drug use or criminal activity, or both, in drug-using offenders. We also report data on the cost and cost-effectiveness of interventions. 

DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as expected by Cochrane. 

MAIN RESULTS: Fourteen trials with 2647 participants met the inclusion criteria. The interventions included in this review report on agonistic pharmacological interventions (buprenorphine, methadone and naltrexone) compared to no intervention, other non-pharmacological treatments (e.g. counselling) and other pharmacological drugs. The methodological trial quality was poorly described, and most studies were rated as 'unclear' by the reviewers. The biggest threats to risk of bias were generated through blinding (performance and detection bias) and incomplete outcome data (attrition bias). Studies could not be combined all together because the comparisons were too different. Only subgroup analysis for type of pharmacological treatment were done. When compared to non-pharmacological, we found low quality evidence that agonist treatments are not effective in reducing drug use or criminal activity, objective results (biological) (two studies, 237 participants (RR 0.72 (95% CI 0.51 to 1.00); subjective (self-report), (three studies, 317 participants (RR 0.61 95% CI 0.31 to 1.18); self-report drug use (three studies, 510 participants (SMD: -0.62 (95% CI -0.85 to -0.39). We found low quality of evidence that antagonist treatment was not effective in reducing drug use (one study, 63 participants (RR 0.69, 95% CI 0.28 to 1.70) but we found moderate quality of evidence that they significantly reduced criminal activity (two studies, 114 participants, (RR 0.40, 95% CI 0.21 to 0.74).Findings on the effects of individual pharmacological interventions on drug use and criminal activity showed mixed results. In the comparison of methadone to buprenorphine, diamorphine and naltrexone, no significant differences were displayed for either treatment for self report dichotomous drug use (two studies, 370 participants (RR 1.04, 95% CI 0.69 to 1.55), continuous measures of drug use (one study, 81 participants, (mean difference (MD) 0.70, 95% CI -5.33 to 6.73); or criminal activity (one study, 116 participants, (RR 1.25, 95% CI 0.83 to 1.88) between methadone and buprenorphine. Similar results were found for comparisons with diamorphine with no significant differences between the drugs for self report dichotomous drug use for arrest (one study, 825 participants, (RR 1.25, 95% CI 1.03 to 1.51) or naltrexone for dichotomous measures of reincarceration (one study, 44 participants, (RR 1.10, 95% CI 0.37 to 3.26), and continuous outcome measure of crime, (MD -0.50, 95% CI -8.04 to 7.04) or self report drug use (MD 4.60, 95% CI -3.54 to 12.74). 

AUTHORS' CONCLUSIONS: When compared to non-pharmacological treatment, agonist treatments did not seem effective in reducing drug use or criminal activity. Antagonist treatments were not effective in reducing drug use but significantly reduced criminal activity. When comparing the drugs to one another we found no significant differences between the drug comparisons (methadone versus buprenorphine, diamorphine and naltrexone) on any of the outcome measures. Caution should be taken when interpreting these findings, as the conclusions are based on a small number of trials, and generalisation of these study findings should be limited mainly to male adult offenders. Additionally, many studies were rated at high risk of bias.

/pdf/pharmacological-interventions-for-drug-using-offenders-27emuvjgg0.pdf

Pharmacological interventions for drug‐using offenders

We summarized and appraised evidence regarding HIV prevention interventions for adults with criminal justice involvement.We included randomized and quasi-randomized controlled trials that evaluated an HIV prevention intervention, enrolled participants with histories of criminal justice involvement, and reported biological or behavioral outcomes. We used Cochrane methods to screen 32 271 citations from 16 databases and gray literature. We included 37 trials enrolling n = 12 629 participants. Interventions were 27 psychosocial, 7 opioid substitution therapy, and 3 HIV-testing programs. Eleven programs significantly reduced sexual risk taking, 4 reduced injection drug risks, and 4 increased testing.Numerous interventions may reduce HIV-related risks among adults with criminal justice involvement. Future research should consider process evaluations, programs involving partners or families, and interventions integrating biomedical, psychosocial, and structural approaches.

HIV Prevention for Adults With Criminal Justice Involvement: A Systematic Review of HIV Risk-Reduction Interventions in Incarceration and Community Settings

Pilot Trial of a Recovery Management Intervention for Heroin Addicts Released from Compulsory Rehabilitation in China

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Pilot Trial of a Recovery Management Intervention for Heroin Addicts Released from Compulsory Rehabilitation in China