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Home > Detoxification: the evidence on setting and intervention.

Keane, Martin (2012) Detoxification: the evidence on setting and intervention. Drugnet Ireland , Issue 41, Spring 2012 , p. 15.

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An expansion in the number of residential detoxification beds has been recommended by the Working Group on Drugs Rehabilitation (2007)1 and endorsed by the National Drugs Strategy (Interim) 2009–2016.2  While the provision of effective detoxification services is acknowledged as a key component of rehabilitation and recovery from substance addiction, it is important to understand the impact of different settings and interventions for detoxification to improve the evidence base and promote best practice. This article summarises the evidence from one systematic review and one randomised controlled trial (RCT) concerning the most effective setting for detoxification and one systematic review that compared different interventions for detoxification.  
 
Evaluating the setting in which detoxification takes place
Day and colleagues3 looked for RCTs comparing inpatient detoxification programmes with other types of opiate withdrawal programmes (outpatient programmes) to ascertain what was more effective. They found only two trials, only one of which, from 1975 and involving 40 patients receiving methadone substitution treatment, satisfied the inclusion criteria. The results of that trial suggested that inpatient detox might be more effective in the short term: 70% of the inpatient group were opioid free on discharge, compared to 37% in the outpatient group. However, all of the inpatients had relapsed within three months of detoxification. The authors’ conclusions and their notes for practitioners state ‘…there is very little available research to guide the clinician about the longer-term outcomes or cost-effectiveness of inpatient or outpatient approaches’. 
 
Day and Strang 4 undertook an RCT on the impact of treatment setting on detoxification. In the trial, 68 opioid-dependent patients (most were in receipt of methadone and all but six were also using heroin) were randomised to an inpatient or an outpatient setting. Participants in both settings received the same structured lofexidine detoxification treatment. More inpatients (51%, 18) than outpatients (36.4%, 12) completed the detox but the difference was not statistically significant. This meant that less than half of the 68 patients randomised to the different detoxification settings managed to complete the treatment. Eleven participants in all were abstinent from all opioids at one-month follow-up, and only eight at six-month follow-up, with no superior differences between the groups. The authors state: ‘The results of [this] trial confirm previous research findings that detoxification is an ineffective stand-alone treatment for opioid dependence.’
 
Evaluating different interventions for detoxification
Amato et al.5 compared the effectiveness of any psychosocial plus any pharmacological intervention with any pharmacological intervention alone for opioid detoxification. Eleven studies including 1,592 participants met the inclusion criteria for the review; these included both RCTs and non-randomised trials. The authors concluded that ‘psychosocial treatments offered in addition to pharmacological detoxification treatments [methadone or buprenorphine] are effective in terms of completion of treatment, use of opiate results at follow-up and clinical attendance’. However, they also state that ‘the evidence is limited due to the small numbers of participants in the trials and differences in assessments from the trials’. On the other hand, they do contend that it may be desirable to combine both psychosocial and pharmacological approaches to make detox more effective.
 
1. Working Group on Drugs Rehabilitation (2007) National Drugs Strategy 2001–2008: rehabilitation. Report of the Working Group on drugs rehabilitation. Dublin: Department of Community, Rural and Gaeltacht Affairs. www.drugsandalcohol.ie/6267
 
2. Department of Community, Rural and Gaeltacht Affairs (2009) National Drugs Strategy (interim) 2009-2016. Dublin: Department of Community, Rural and Gaeltacht Affairs.
 
3. Day E, Ison J and Strang J (2008) Inpatient versus other settings for detoxification for opioid dependence. Cochrane Database of Systematic Reviews. Published online 8 October 2008. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004580.pub2/full
 
4. Day E and Strang J (2011) Outpatient versus inpatient opioid detoxification: A randomised controlled trial. Journal of Substance Abuse Treatment, 40(1): 56–66.
 
5. Amato L, Minozzi S, Davoli M and Vecchi S (2011) Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Cochrane Database of Systematic Reviews. Published online 7 September 2011. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005031.pub4/full 

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