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Practice Profile

Opiate Maintenance Therapy for Dual Heroin–Cocaine Abusers

Evidence Ratings for Outcomes:

Effective - One Meta-Analysis Drugs & Substance Abuse - Heroin/opioids
No Effects - One Meta-Analysis Drugs & Substance Abuse - Cocaine/crack cocaine

Practice Description

Practice Goals
Opiate maintenance therapy (OMT) is a medication-assisted treatment for opioid dependence. OMT works as a pharmacologic intervention for patients in drug treatment and detoxification programs for dependence to opioids, such as heroin. The overall goals of OMT are to help opioid-addicted patients alleviate withdrawal symptoms, reduce or suppress opiate cravings, and bring about a biochemical balance in the body to reduce the illicit use of opioids.
Target Population
OMT is targeted at individuals with opioid dependence problems. Opioids include narcotics such as heroin, morphine, and oxycodone.
Practice Components
Opioids essentially work as sedatives and can cause feelings of euphoria in users. Some forms of opioids, such as morphine, are prescribed to patients as painkillers. Opioids cause a release of excess dopamine in the body, and users can become dependent because they need opiates to continuously occupy the opioid receptor in the brain. OMT works by occupying this receptor and blocking the euphoric high that usually comes from illicit opioid drug use, thereby discouraging abuse and reducing the desire to seek drugs (Mattick et al. 2009).
There are various forms of OMT, such as methadone, buprenorphine, and Levo-Alpha-Acetymethadol (LAAM). Dosage is determined by several factors related to the patient, such as opioid tolerance level, history of opioid use, age, and current medical status.
Additional Information
Some research has found that cocaine use is present in about half of patients receiving OMT for opioid dependence (Castells et al. 2009; Feri, Bruneau, and Stewart 2003). Pharmacologically, opioids and cocaine are very different types of drugs. As stated above, opioids work as sedatives and are commonly prescribed as painkillers. Cocaine acts as a stimulant, causing a sudden rush and high in users. Dual use of the drugs can occur simultaneously (such as injecting heroin and cocaine at the same time (i.e., a “speedball”]), or separately (such as injecting cocaine immediately before or after heroin use). It is not well understood why individuals would use both drugs, which cause such different reactions, at the same time. One study, based on mostly anecdotal information, suggests that possible reasons for dual use include that the combination of both drugs feels different or better than the feeling from heroin or cocaine alone; or that the combination is used for self-medication (Leri, Bruneau, and Stewart 2003).
Although OMT is available to treat opioid dependence, currently there are no federally approved medications to treat cocaine addiction. There is research to suggest that cocaine use has been associated with poorer outcomes of OMT with regard to reducing the illicit use of opioids (Castells et al. 2009). Therefore, it may be important to address cocaine use among opioid-dependent patients receiving OMT, so the effectiveness of the intervention is not diminished.
To explore this issue, the studies included in the meta-analysis by Castells and colleagues (2009)–which was assessed for this review–specifically examined the effectiveness of OMT on heroin abstinence and cocaine abstinence of heroin- dependent individuals with a comorbid cocaine use disorder.

Meta-Analysis Outcomes

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Effective - One Meta-Analysis Drugs & Substance Abuse - Heroin/opioids
Castells and colleagues (2009) looked at three randomized controlled trials (that yielded five different findings), which analyzed the effect of high- versus low-dose opiate maintenance therapy (OMT) on heroin abstinence for dual heroin–cocaine dependence. The three OMTs investigated in the studies were methadone, buprenorphine, and LAAM (Levo-Alpha-Acetymethadol). The results showed a significant difference between the higher doses of OMT compared with the lower doses of OMT (risk ratio=2.24). The results suggested that higher OMT doses were associated with a 124 percent increase in the likelihood of achieving sustained heroin abstinence for dual heroin–cocaine dependence compared with lower OMT doses.
No Effects - One Meta-Analysis Drugs & Substance Abuse - Cocaine/crack cocaine
Looking at the same three randomized studies, Castells and colleagues (2009) found no significant differences on sustained cocaine abstinence for dual heroin–cocaine dependence when comparing high and low doses of OMT. For additional findings from the meta-analysis, please see Other Information.
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Meta-Analysis Methodology

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Meta-Analysis Snapshot
 Literature Coverage DatesNumber of StudiesNumber of Study Participants
Meta-Analysis 11997 - 200530

Meta-Analysis 1
Castells and colleagues (2009) conducted a meta-analysis to look at the efficacy of opiate maintenance therapy (OMT) for dual heroin and cocaine dependence. They conducted a comprehensive search of databases such as PubMed and PsycINFO. To be included in the review, studies had to be randomized controlled clinical trials with parallel comparison groups. The studies had to assess the efficacy of an OMT strategy or adjunctive interventions for opiate-dependent patients with a comorbid cocaine use disorder. Studies were included if they compared OMT against either a placebo or another OMT intervention. The review included 37 articles, which enrolled 3,029 patients.
The primary outcomes of interest were the proportion of patients achieving heroin abstinence and the proportion achieving sustained cocaine abstinence. Sustained abstinence was defined as continuous heroin or cocaine abstinence determined by means of urine screens. Originally, data on the efficacy of OMT was to be examined with the following comparisons: high-dose OMT versus placebo, low-dose OMT versus placebo, and high-dose OMT versus low-dose. However, the comprehensive search did not yield any studies that compared the efficacy of OMT against a placebo control group; therefore, the primary comparison of interest is high-dose versus low-dose OMT. Three studies examined high- versus lose-dose OMT. The opiates investigated in this study included methadone, buprenorphine, and Levo-Alpha-Acetymethadol (LAAM). Low doses of OMT were defined as below 50 mg/day for methadone, 6 mg/day for buprenorphine, and 12 mg/week for LAAM.
The relative risk and standardized mean difference (SMD) were calculated for dichotomous outcomes (such as achievement of sustained heroin and cocaine abstinence). The Hedges’ g method was used for calculating SMD with individual study weights calculated as the inverse of the variance. Weighted averages and confidence intervals were calculated using a random effects model.
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There is no cost information available for this practice.
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Other Information

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The meta-analysis by Castells and colleagues (2009) included additional tests—called moderator analyses—to see if any factors strengthened the likelihood that opiate maintenance therapy (OMT) improved outcomes for dual heroin–cocaine abusers. When examining studies that compared the efficacy of equivalent doses of methadone and buprenorphine, the results showed that methadone was more effective than buprenorphine in achieving sustained heroin and cocaine abstinence. Methadone was also associated with a decrease in cocaine use and treatment retention. Heroin use was lower with methadone, but not significantly different than buprenorphine. Thus, the results suggest methadone is more efficacious than buprenorphine for dual heroin–cocaine abusers. The moderator analysis also examined the use of psychological interventions in conjunction with OMT for dual abusers. One intervention is contingency management (CM), which is designed to reinforce either cocaine abstinence alone or simultaneous heroin and cocaine abstinence, usually through the use of vouchers, prizes, or opportunities to work for pay. When CM reinforced only cocaine abstinence, there were higher rates of sustained cocaine abstinence, and decreased use of cocaine and heroin, but there was no impact on sustained heroin abstinence. When CM reinforced abstinence from both heroin and cocaine, there was no significant effect on sustained cocaine or heroin abstinence, and only a small effect on cocaine use (there was no effect on heroin use). Finally, when CM was combined with cognitive behavioral therapy, there was a large impact on cocaine abstinence (although no impact on other outcomes). Thus, OMT combined with psychological interventions such as CM, which reinforce cocaine abstinence (rather than both heroin and cocaine abstinence) can improve cocaine use of dual abusers, but CM that reinforces abstinence from both heroin and cocaine does not improve use of both drugs.
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Evidence-Base (Meta-Analyses Reviewed)

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These sources were used in the development of the practice profile:

Meta-Analysis 1
Castells, Xavier, Thomas R. Kosten, Dolors Capella, Xavier Vidal, Joan Colom, and Miguel Casas. 2009. “Efficacy of Opiate Maintenance Therapy and Adjunctive Interventions for Opioid Dependence with Comorbid Cocaine Use Disorders: A Systematic Review and Meta-Analysis of Controlled Clinical Trials.” The American Journal of Drug and Alcohol Abuse 35:339–49.
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Additional References

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These sources were used in the development of the practice profile:

Leri, Francesco, Julie Bruneau, and Jane Stewart. 2003. “Understanding Polydrug Use: Review of Heroin and Cocaine Co-Use.” Addiction 98:7–22.

Mattick, Richard P., Courtney Breen, Jo Kimber, and Marina Davoli. 2009. “Methadone Maintenance Therapy Versus No Opioid Replacement Therapy for Opioid Dependence (Review).” Cochrane Database of Systematic Reviews, Issue 3.
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Related Programs

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Following are programs that are related to this practice:

Interim Methadone Maintenance (IM) Promising - One study
A daily treatment program where opiate-addicted adults on waiting lists for comprehensive treatment receive doses of methadone as well as emergency counseling. The program is rated Promising. Participants entered into treatment programs more than the waitlist control group. There was less drug use detected for heroin, but not for cocaine or alcohol; and no difference in crime rates between groups however self-reports of drug spending was less for participants at the 4-month follow-up.

Naltrexone for Federal Probationers Promising - One study
A medication used in the treatment of opioid addiction, which works by antagonizing opioid receptors and blocking the effects of opiates consumed by addicts (usually in the form of heroin). The program is rated Promising. There was significantly less opioid use among the experimental group. The experimental group receiving naltrexone was significantly less likely to be reincarcerated.

Prison-Initiated Methadone Maintenance Treatment Promising - One study
This program offers methadone maintenance to heroin-addicted prisoners and provides referrals to community-based treatment programs to encourage continued treatment during reentry. The program is rated Promising. The counseling + methadone group were significantly more likely to spend more days in treatment compared to the other groups. There were fewer positive urine drug tests for opioids and cocaine for the counseling + methadone group compared to those who received counseling only in prison.

Methadone Maintenance Treatment Effective - More than one study
A medication-assisted treatment for individuals with opioid dependence. The program is rated Effective. The methadone maintenance treatment intervention group had significantly lower HIV drug-risk behaviors (i.e. less reported needle use) than the comparison group who received psychologically enriched 180-day methadone assisted detoxification. The standard and minimal treatment group both reported less heroin use and had fewer positive urine tests at follow-up than the detoxification group.

Buprenorphine Maintenance Treatment Effective - More than one study
Used in the treatment of patients with opioid dependence to alleviate withdrawal symptoms, suppress opiate effects and cravings, and decrease the risk of overdose. The program is rated Effective. The experimental group had more days of participation, treatment retention, decreased drug use, improved well-being and mental health. Participants had significantly reduced opiate cravings.

New South Wales (Australia) Prison Methadone Maintenance Program No Effects - One study
This program aims to reduce recidivism, prevent the spread of blood-borne viral infections (HIV and hepatitis) in prison, and encourage continuation of treatment in the community following release. The program is rated No Effects. Overall, the evidence did not find a significant difference between the prison methadone maintenance treatment group and the control group on measures of mortality, reincarceration, hepatitis C virus seroconversion and treatment retention.
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Practice Snapshot

Age: 32 - 42

Gender: Both

Race/Ethnicity: Other, White

Targeted Population: Alcohol and Other Drug (AOD) Offenders

Settings: Inpatient/Outpatient, Other Community Setting

Practice Type: Alcohol and Drug Therapy/Treatment, Individual Therapy

Unit of Analysis: Persons