SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Clinical & Policy Updates:
SMMGP Clinical Update September 2007

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Contingency Management

Quite a few new papers have come out on this and it is building up a head of steam. Here is a selection...

Cost-effectiveness of prize-based contingency management in methadone maintenance treatment programs
Sindelar J et al., Addiction 2007 Sep; 102(9): 1463-71

Participants were recruited from six methadone maintenance community treatment programs. The study sample consisted of 388 participants: 190 in the usual care (UC) condition and 198 in the contingency management (CM) condition. Participants were randomised at each site to either the UC or the CM condition based on the presence of stimulants (cocaine, amphetamine or methamphetamine) and opioids in their baseline urine sample. CONCLUSIONS: By comparing this study to a companion study, it was found that adding prize-based CM to usual care may be more cost-effective in methadone maintenance clinics than in counselling-based drug-free clinics.

Abstinence-based incentives in methadone maintenance: interaction with intake stimulant test results
Stitzer ML et al., Experimental clinical psychopharmacology: 2007 Aug; 15(4): 344-50

This study examined the association between baseline urine test result and treatment outcome in 386 stabilized methadone maintenance patients with ongoing stimulant use to determine whether abstinence incentives were differentially effective in those testing stimulant negative versus positive at entry. Compared with those receiving usual care, the addition of abstinence incentives resulted in a significant increase in stimulant-negative urine samples submitted during the study both for those testing negative and for those testing positive These findings suggest that abstinence incentives have significant clinical benefits independent of initial drug use severity among methadone maintenance patients with ongoing stimulant drug use.

Contingency management in cocaine abusers: a dose-effect comparison of goods-based versus cash-based incentives
Vandrey R et al., Experimental clinical psychopharmacology: 2007 Aug; 15(4): 338-43

Recent research suggests that development of a cash-based contingency management approach may improve treatment outcomes while reducing operational costs of the intervention. A trend was observed in this study for greater rates of abstinence in the cash-based versus goods-based (vouchers) incentives at the $50 and $100 magnitudes. Receipt of $100 checks did not increase subsequent rates of cocaine use above those seen in control conditions. Use of cash-based incentives deserves consideration for clinical applications of contingency management.

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Cochrane Reviews

There have been 2 recent reviews which might be of interest to members. However, neither come up with anything absolutely conclusive about their respective topics. The full reviews are available won these links.

Pyschosocial interventions by General Practitioners (a review)
Huibers M et al.,

Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders (Review)
Knapp WP et al.,

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Clinical Misc

Torsades de pointes and self-terminating ventricular fibrillation in a prescription methadone user
Atkinson D, Dunne A, Parker M., Anaesthesia. 2007 Sep; 62(9): 952-5.
An interesting case study

Methadone is known to prolong the QT interval and precipitate torsades de pointes. A 54-year-old prescription methadone user with hypokalaemia was referred to Critical Care with acute confusion and respiratory distress. Alcohol withdrawal was the presumed precipitant. The real precipitant only became evident on analysis of a 24-h ECG (Holter monitor) attached to the patient at the time. The patient had suffered prolonged (10 min) ventricular arrhythmias including torsades de pointes and self-terminating ventricular fibrillation. The patient made a full recovery. Risk factors for acquired long QT syndrome and the treatment of torsades de pointes are discussed.

An in vitro approach to potential methadone metabolic-inhibition interactions
Bomsien S, Skopp G., European Journal of Clinical pharmacology 2007 sept; 63(9):821-827

Amitriptyline, MDMA and zolpidem are likely to slow down conversion of methadone and to increase its area under the curve (AUC). A consideration of the in vitro evidence of drug-methadone interactions should help to improve patient care during methadone maintenance treatment.

Adherence to hepatitis C treatment in recovering heroin users maintained on methadone
Silvestre DL, Clements BJ., European Journal of Gastroenterology & Hepatology. 19(9): 741-747, September 2007

68% of the sample were adherent, and adherent patients were significantly more likely to achieve a sustained response. Patients with and without a prior psychiatric history were similarly adherent, and there was a trend towards reduced adherence in patients without a period of abstinence before initiating HCV treatment. Although occasional drug users were equally adherent as those who were abstinent, patients who relapsed to regular drug use showed a significantly lower level of adherence. Conclusion: the majority of methadone-maintained drug users can adhere to HCV treatment, even those with psychiatric illness and relatively limited pre-treatment drug abstinence. This provides further evidence for an individualized approach to HCV treatment that does not categorically exclude patients with potential barriers such as mental illness and limited drug abstinence.

The 5-Step family intervention in primary care: I. Strengths and limitations according to family members
Orford J et al., Drugs: education, prevention and policy, February 2007; 14(1): 29-47

This is an interesting analysis of a family based drug and alcohol intervention in primary care with broadly positive results. It involved analysing a full and brief version of the intervention which was delivered by a primary care professional. Read the full text on:

Drug user involvement in treatment decisions
Fischer J et al., Joseph Rowntree foundation

This report provides discourse on the extent nature and context of user involvement in the UK. It also examines its effect on treatment outcomes. The whole report is available here


An editorial by Richard Mattick and Wayne Hall in The Lancet (2007 Aug 18; 370(9587) :550-2) noted recent evidence for the efficacy of Codeine in treating opiate dependency. They called for more research in particular from Germany where it is widely used and felt it could be of particular use in a primary care setting and also in developing countries due to its price.

A recent letter in the BMJ by forensic physician, Richard Stevenson, was strongly critical of methadone and elicited some strong replies. Read them on

Remember the new Clinical Guidelines are due to be published on September 28th on the NTA web site. A brief summary will appear in the forthcoming Policy Update.