Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence

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Abstract
Methadone maintenance was the first widely used opioid replacement therapy to treat heroin dependence, and it remains the best‐researched treatment for this problem. Despite the widespread use of methadone in maintenance treatment for opioid dependence in many countries, it is a controversial treatment whose effectiveness has been disputed. To evaluate the effects of methadone maintenance treatment (MMT) compared with treatments that did not involve opioid replacement therapy (i.e., detoxification, offer of drug‐free rehabilitation, placebo medication, wait‐list controls) for opioid dependence. We searched the following databases up to Dec 2008: the Cochrane Controlled Trials Register, EMBASE, PubMED, CINAHL, Current Contents, Psychlit, CORK [www. state.vt.su/adap/cork], Alcohol and Drug Council of Australia (ADCA) [www.adca.org.au], Australian Drug Foundation (ADF‐VIC) [www.adf.org.au], Centre for Education and Information on Drugs and Alcohol (CEIDA) [www.ceida.net.au], Australian Bibliographic Network (ABN), and Library of Congress databases, available NIDA monographs and the College on Problems of Drug Dependence Inc. proceedings, the reference lists of all identified studies and published reviews; authors of identified RCTs were asked about other published or unpublished relevant RCTs. All randomised controlled clinical trials of methadone maintenance therapy compared with either placebo maintenance or other non‐pharmacological therapy for the treatment of opioid dependence. Reviewers evaluated the papers separately and independently, rating methodological quality of sequence generation, concealment of allocation and bias. Data were extracted independently for meta‐analysis and double‐entered. Eleven studies met the criteria for inclusion in this review, all were randomised clinical trials, two were double‐blind. There were a total number of 1969 participants. The sequence generation was inadequate in one study, adequate in five studies and unclear in the remaining studies. The allocation of concealment was adequate in three studies and unclear in the remaining studies. Methadone appeared statistically significantly more effective than non‐pharmacological approaches in retaining patients in treatment and in the suppression of heroin use as measured by self report and urine/hair analysis (6 RCTs, RR = 0.66 95% CI 0.56‐0.78), but not statistically different in criminal activity (3 RCTs, RR=0.39; 95%CI: 0.12‐1.25) or mortality (4 RCTs, RR=0.48; 95%CI: 0.10‐2.39). Methadone is an effective maintenance therapy intervention for the treatment of heroin dependence as it retains patients in treatment and decreases heroin use better than treatments that do not utilise opioid replacement therapy. It does not show a statistically significant superior effect on criminal activity or mortality. 美沙冬維持治療與非鴉片類替代療法治療鴉片依賴者之比較 美沙冬(methadone)維持治療是第一個用以治療海洛因(heroin)依賴者，廣泛使用之鴉片類替代療法，此仍是最佳研究的治療議題，雖然許多國家廣泛使用美沙冬於維持治療，整體效力益仍有爭議。 評估美沙冬維持治療(MMT)與其他戒毒、無毒品行為重塑、安慰劑、等待清單控制等不涉鴉片替代療法之鴉片依賴性治療。 我們搜尋以下資料庫至2001年：考科藍藥物與酒精回顧群註冊、考科藍控制試驗驗註冊，MEDLINE, EMBASE, Current Contents, Psychlit, CORK [www.state.vt.su/adap/cork], 澳洲藥物酒精委員會(ADCA) [www.adca.org.au], 澳洲藥物基金會(ADFVIC) [www.adf.org.au], 藥物與酒精教育資訊中心(CEIDA) [www.ceida.net.au]，澳洲書目網絡(ABN)，議會資料庫圖書館，藥物濫用國家研究院專論和藥物依賴問題學會、會刊，所有確知的研究及刊登回顧文章的參考文獻 詢問RCTs作者有關刊登與未刊登的資料。 含括所有美沙冬維持治療鴉片依賴性相較於安慰劑或其他非藥物治療之隨機控制試驗。 回顧者分別及獨立地評估文章，排序分配隱匿性方法學的品質，獨立地取用數據進行統合分析和雙輸入。 6個研究符合收錄回顧標準，全是隨機分配的臨床試驗，2個是雙瞞。合計954位參與者，1試驗分配隱匿方法不足，4個研究描述的不清楚，6個研究符合需求。根據統合分析，美沙冬較非藥物方法具有顯著地統計意義，固定治療患者(3 RCTs, RR = 3.05; 95%CI: 1.75 – 5.35)，抑制海洛因使用(3 RCTs, RR = 0.32; 95%CI: 0.23 – 0.44), 但對犯罪活動不具統計意義(3 RCTs, RR = 0.39; 95%CI: 0.12 – 1.25)。 對於固定接受治療患者及減少海洛因使用，美沙冬是有效的維持治療，優於不使用鴉片替代療法，對犯罪活動沒有統計上的優勢影響。 本摘要由高雄榮民總醫院毛志民翻譯。 此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。 美沙冬維持治療能夠讓依賴海洛因的人們持續接受治療和降低海洛因的使用。美沙冬最普遍用於替代海洛因，醫療運用於維持或戒毒療程，一些非藥物戒毒及行為重塑治療方法也嘗試使用及幫助海洛因戒斷民眾；然而，回顧發現分派於試驗中無用藥組的民眾已經戒斷。因此，除了美沙冬安慰劑試驗或只用美沙冬戒毒外外，沒有以美沙冬維持治療與無用藥組相較，這些試驗顯示美沙冬能降低依賴者使用海洛因，並持續接受治療。 Traitement de maintien à la méthadone versus absence de traitement de substitution des opiacés contre la dépendance aux opiacés Le maintien à la méthadone a été le premier traitement de substitution des opiacés utilisé couramment pour traiter la dépendance à l'héroïne et reste le traitement le mieux étudié pour ce problème. Malgré l'usage répandu de la méthadone dans le...