Effectiveness of community treatments for heroin and crack cocaine addiction in England: a prospective, in-treatment cohort study

National Addiction Centre, Institute of Psychiatry (King's College London), London, UK.
The Lancet (Impact Factor: 45.22). 10/2009; 374(9697):1262-70. DOI: 10.1016/S0140-6736(09)61420-3
Source: PubMed


Addiction to heroin and crack cocaine is debilitating and persistent, but such disorders are treatable. We present the first effectiveness study of the main community interventions for addiction to heroin and crack cocaine in England, using data from the National Drug Treatment Monitoring System (NDTMS).
The study cohort consisted of all adults with a heroin or crack cocaine addiction, or both, who started pharmacological treatment (n=18 428 patients) or psychosocial treatment (n=2647) between Jan 1 and Nov 30, 2008, received at least 6 months' treatment or were discharged by the study endpoint (May 31, 2009), and had outcome data submitted to the NDTMS. Effectiveness was assessed from change in days of heroin or crack cocaine use, or both in the 28 days before the start of treatment and in the 28 days before review.
14 656 clients-74% of the cohort eligible for analysis at review with available data-were analysed at the study endpoint. During the 28 days before review, 37% (5016/13 542) of heroin users abstained from heroin and 52% (3941/7636) of crack cocaine users abstained from crack cocaine. A higher proportion of users of heroin only abstained than did users of both heroin and crack cocaine (42% [2465/5863] vs 33% [2551/7679]; OR 1.46, 95% CI 1.36-1.56), and more users of crack cocaine only abstained than did users of both drugs (57% [295/522] vs 51% [3646/7114]; 1.24, 1.03-1.48). Overall heroin use reduced by 14.5 days (95% CI 14.3-14.7) and crack cocaine use by 7.7 days (7.5-7.9). For clients given pharmacological treatment, reduction in days of heroin use was smaller for users of both heroin and crack cocaine than for users of heroin alone (p<0.0001), but this differential effectiveness was not recorded for psychosocial treatment in heroin or crack cocaine users compared with users of both drugs.
The first 6 months of pharmacological or psychosocial treatment is associated with reduced heroin and crack cocaine use, but the effectiveness of pharmacological treatment is less pronounced for users of both drugs. New strategies are needed to treat individuals with combined heroin and crack cocaine addiction.
National Treatment Agency for Substance Misuse.

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    • "Instead of a focus on abstinence, taking incremental steps toward reducing use and being safe in drug use is seen as an important part of the change process (Tatarsky, 2007). Those who use harm reduction as a treatment goal seek to integrate clients' needs, support systems, functioning, and own change goals (Marlatt, 2002; Marsden et al., 2009; Seiger, 2014). "
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    • "Developing a criterion for 'treatment success' based on change from baseline is complex, as it would result in differing criteria for success across study populations and may not yield an outcome that is clinically meaningful despite its statistical significance. For example, in a large population of treated cocaine users in the UK, Marsden and colleagues (Marsden et al., 2009) calculated the reliable change index (Jacobson and Truax, 1991), which they determined to be roughly 12 days of cocaine use or less per month—a definition of 'successful outcome' which would seem unacceptable to most clinicians. "
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    • "Hence, our data refer only to the context of crack consume. Finally, despite the high rates of relapse (50%) (Siegal et al., 2002) impacting effectiveness of treatment for crack cocaine users, (Marsden et al., 2009) very few studies addressed the biological impact of crack cocaine dependence. Thus, this exploratory work may help to better understand the physiological mechanisms related to crack cocaine withdrawal. "
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