Background Treatment for heroin addiction is effective in reducing heroin use, clinical and social problems and mortality risk. The effectiveness is related to the duration of treatment. “VEdeTTE” is an Italian cohort study funded by the Ministry of Health to evaluate the effectiveness of treatments provided by the National Health Services. The aim of this work is to evaluate the impact of treatment for opiate dependence on retention and overdose mortality. Methods The study involved 115 Drug Treatment Centres and 10,454 heroin users. Clinical and personal information were collected at intake through a structured interview. Treatments were recorded using a standardized form. Survival analysis and Cox Proportional Hazard models were used to evaluate treatment retention and all causes and overdose mortality. Results Forty-three percent of patients who started a treatment in the study period received methadone maintenance, 10.5% therapeutic community, and 46% abstinence oriented therapies. 50% of patients were under treatment at 179 days. The median daily dose of methadone was 37 mg. Psychotherapy was provided in 7.6% of patients receiving methadone and 4.9% of those in therapeutic community. Type of therapy was the strongest predictor of retention, with AOT showing the lowest retention. Retention improved according to methadone dose. Psychotherapy associated halved the risk of drop-out. Participants spent 78% of person-years in treatment and 22% out of treatment. 37 all causes deaths occurred in treatment and 63 out of treatment. The standardised mortality ratio was 3.9 (95%CI: 2.8-5.4) in treatment, and 21.4 (95%CI: 16.7-27.4) out of treatment. Ten overdose deaths occurred in treatment and 31 out of treatment. Retention in any treatment provides effective protection against overdose mortality (HR=0.09; 95% CI:0.04 to 0.19. The initial period after treatment is at the greatest risk for fatal overdose: 2.3% in the first month and 0.8% thereafter, with an HR=27 and 7 respectively compared to heroin users in treatment. Conclusions Appropriate treatment, high doses of MMT and association with psychotherapy are effective in improving retention among heroin addicts. Any treatment for heroin dependence reduces mortality, particularly for overdose. However, the considerable excess mortality risk in the period immediately following treatment implies that treatments lasting for less than one month are increasing the number of drug related overdose deaths by 7 per 10,000 episodes, and should be a cause of great public health concern and scrutiny.
Effectiveness of treatment for heroin addiction in retaining patients and reducing mortality: results from the VEdeTTE Cohort Study
VIGNA-TAGLIANTI, Federica;
2007-01-01
Abstract
Background Treatment for heroin addiction is effective in reducing heroin use, clinical and social problems and mortality risk. The effectiveness is related to the duration of treatment. “VEdeTTE” is an Italian cohort study funded by the Ministry of Health to evaluate the effectiveness of treatments provided by the National Health Services. The aim of this work is to evaluate the impact of treatment for opiate dependence on retention and overdose mortality. Methods The study involved 115 Drug Treatment Centres and 10,454 heroin users. Clinical and personal information were collected at intake through a structured interview. Treatments were recorded using a standardized form. Survival analysis and Cox Proportional Hazard models were used to evaluate treatment retention and all causes and overdose mortality. Results Forty-three percent of patients who started a treatment in the study period received methadone maintenance, 10.5% therapeutic community, and 46% abstinence oriented therapies. 50% of patients were under treatment at 179 days. The median daily dose of methadone was 37 mg. Psychotherapy was provided in 7.6% of patients receiving methadone and 4.9% of those in therapeutic community. Type of therapy was the strongest predictor of retention, with AOT showing the lowest retention. Retention improved according to methadone dose. Psychotherapy associated halved the risk of drop-out. Participants spent 78% of person-years in treatment and 22% out of treatment. 37 all causes deaths occurred in treatment and 63 out of treatment. The standardised mortality ratio was 3.9 (95%CI: 2.8-5.4) in treatment, and 21.4 (95%CI: 16.7-27.4) out of treatment. Ten overdose deaths occurred in treatment and 31 out of treatment. Retention in any treatment provides effective protection against overdose mortality (HR=0.09; 95% CI:0.04 to 0.19. The initial period after treatment is at the greatest risk for fatal overdose: 2.3% in the first month and 0.8% thereafter, with an HR=27 and 7 respectively compared to heroin users in treatment. Conclusions Appropriate treatment, high doses of MMT and association with psychotherapy are effective in improving retention among heroin addicts. Any treatment for heroin dependence reduces mortality, particularly for overdose. However, the considerable excess mortality risk in the period immediately following treatment implies that treatments lasting for less than one month are increasing the number of drug related overdose deaths by 7 per 10,000 episodes, and should be a cause of great public health concern and scrutiny.
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