addiction treatment outcomes prof michael gossop national addiction centre maudsley...
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Addiction Treatment Outcomes
Prof Michael Gossop
National Addiction Centre
Maudsley Hospital/Institute of Psychiatry
• Why should we be interested in outcomes?
Why should we be interested in outcomes?
• Natural history
Why should we be interested in outcomes?
• Treatment effectiveness
The Clinical Fallacy
•
Heavydrinking
Treatment Outcome
A common but mistaken model of treatment outcomes
•
Heavydrinking
Treatment Outcome
(Pre-treatment problems affect outcomes)
•
Heavydrinking
Treatment Outcome
Therapists respond to presenting problems by providing targeted interventions
•
Heavydrinking
Treatment Outcome
[ - ]
[ + ][ + ]
Presenting problems lead to altered treatment interventionsas well as affecting post-treatment outcomes.
•
Heavydrinking
Treatment Outcome
[ - ]
[ + ][ + ]
Presenting problems lead to altered treatment interventionsas well as affecting post-treatment outcomes.
Psych.factors
Content &Process
Environment
Multidimensionality(multiple outcomes)
• Drug outcomes• Route of drug administration• Alcohol outcomes• Social adjustment (e.g. employment)• Crime• Mental health• Physical health• Mortality
PROBLEMS
DEPENDENCE
Problems and Dependence: two separate dimensions
NTORSThe National Treatment Outcome Research Study
• Prospective cohort study.
• 1075 clients admitted to treatment.
• Treatments representative of 4
national treatment modalities.
• Repeated follow-up over 5 years.
Regular heroin use(NTORS methadone programmes)
0
25
50
75
100
Intake 1 Year 2 Years 5 Years
%
from Gossop et al., 2003)
Regular heroin use(Methadone treatment : TOPS/US)
0
30
60
90
%
Intake 1 Year 2 Years 4-5 Years
Related Outcomes
Regular heroin use(NTORS methadone programmes)
0
25
50
75
100
Intake 1 Year 2 Years 5 Years
%
from Gossop et al., 2003)
Regular non-prescribed methadone use
0
10
20
30
40
Intake 1 Year 2 Years 5 Years
%
Regular benzodiazepine use
0
10
20
30
40
50
Intake 1 Year 2 Years 5 Years
%
Injecting and sharing – methadone programmes
0
10
20
30
40
50
60
70
Intake 1 Year 2 Years 5 Years
%
Sharing Injecting
Causes of death among opiate addicts (Norway)
Overdose
Somatic
Trauma
Mortality RatesPrior to, during, and after maintenance treatment (Norway)
0
1
2
3
4
Pre During Post
%
Anxiety and Depression(5 year outcomes: methadone programmes)
0
0.5
1
1.5
2
2.5
Intake 1 Year 2 Years 5 Years
Mea
n
Time to follow-up
Is bigger better?
Psychiatric symptom scores(Short-term outcomes: methadone programmes)
0
2
4
6
8
Intake 1 Month 6 Months
Mea
n
Predictors of psychiatric symptoms at 6 months
• Pre-treatment symptom scores
• Heroin use at 6 months
• Illicit methadone use
• Benzodiazepine use
• Stimulant use
Unrelated Outcomes
Crack cocaine
Users and non-users at intake
0
20
40
60
80
100
Intake 1 Year 2 Years 5 Years
%
Use at intake Not at intake
Frequency of drinking: methadone programmes
0
10
20
30
Intake 1 Year 2 Years 5 Years
Days
Drinking quantity/day: methadone programmes
0
5
10
15
Intake 1 Year 2 Years 5 Years
Units
Years since 1st injection
and positive hepatitis serostatus (Noble et al.,2000)
0
25
50
75
100
1 2--5 6--9 10--13 14--19 20+
Years of use
%
HCV
HBV
Returning to …...
Related Outcomes
Crime
What is it?
Where does it come from?
Since it came to power in 1997, the New Labour Government created more than three and a half thousand new ways of becoming a criminal.
“The more laws, the less justice”
German proverb
“The more laws, the more offenders”
Thomas Fuller, MD, 1732
Selling a grey squirrel. Importing Polish potatoes.Offering to sell a game bird killed on a Sunday.Allowing an unlicensed concert in a church hall.To enter the hull of the Titanic.
To cause a nuclear explosion.
•
Types of acquisitive crime before admission to treatment
(percent of NTORS cohort)
0
20
40
60
Shoplifting Fraud Burglary Robbery Other theft
%
(from Stewart et al., 2000)
Total crimes reported before admission to treatment (NTORS)
0
5000
10000
15000
20000
25000
Shoplifting Fraud Burglary Robbery Other theft
n
(from Stewart et al., 2000)
Involvement in acquisitive crime during 90 days before admission to treatment (NTORS)
0
25
50
75
No crime Low High
%
(from Stewart et al., 2000)
The majority of the acquisitive crimes were committed by a small minority of the NTORS clients
• Over three quarters (76%) of the total number
of acquisitive crimes were committed by just
10% of the sample.
Acquisitive crime: methadone programmes
0
20
40
60
Intake 1 Year 2 Years 5 Years
%
The association between drug use and acquisitive crime
• Heroin: Odds = 11.4 (4.1-32.0, 95% CI)
• Cocaine Odds = 3.1 (1.9-5.0, 95% CI)
Acquisitive crime: methadone programmes
0
20
40
60
Intake 1 Year 2 Years 5 Years
%
Regular heroin use(NTORS methadone programmes)
0
25
50
75
100
Intake 1 Year 2 Years 5 Years
%
from Gossop et al., 2003)
Acquisitive crime: methadone programmes
0
20
40
60
Intake 1 Year 2 Years 5 Years
%
Measures of Crime
Offending Behaviour
Arrests
Convictions
Criminal convictions (all): NTORS clients
0
10
20
30
40
Intake 1 Year 2 Years 5 Years
%
Criminal convictions (all)NTORS clients: Methadone and Residential
0
10
20
30
40
50
Intake 1 Year 2 Years 5 Years
%
Methadone Residential
Acquisitive crime convictions: NTORS clients
0
10
20
30
40
Intake 1 Year 2 Years 5 Years
%
Drug selling convictions: NTORS clients
0
2.5
5
7.5
10
Intake 1 Year 2 Years 5 Years
%
Exceptions to the general pattern of reductions in crime
• Robbery and serious crime• Women
Violent crime convictions: NTORS clients
0
2.5
5
7.5
10
Intake 1 Year 2 Years 5 Years
%
Addiction disorders within the criminal justice system
Drug use by prisoners in year before custody
0
20
40
60
80
Any drug Heroin Tranq Crack Cocaine Amphet
%
Men Women(from Stewart et al., 2008)
Management of opiate withdrawal syndrome after arrest
Persistence of drug use during imprisonment
Risk of overdose after release of detoxified opiate dependent offenders
from prison
