Treatment preferences of opiate-dependent patients

AIMS AND METHOD

To assess the preferences of people attending a substance misusefacility towards the treatment options available for opiatedependency. Interviews were conducted using a card sortingtechnique.

RESULTS

The majority (60%) of the 101 participants believed that detoxificationwas superior to maintenance in preventing illicit heroin use.The preferred treatment options were oral methadone, buprenorphine,drug-free rehabilitation, in-patient detoxification and prescriptionof injectable drugs.

CLINICAL IMPLICATIONS

Both pharmacological and psychosocial options, including in-patient detoxification and rehabilitation, are among the treatmentspreferred by clients of substance misuse services. There isalso a significant demand for both injectable drugs and dihydrocodeine.

Introduction

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Introduction

The involvement of patients is a priority of the Government’sefforts to improve the National Health Service (NHS) (Departmentof Health, 2000a). Current policy states that involving patients leads to ‘more responsive services with better outcomesof care’ (Department of Health, 1999a). Indeed, oneof the six elements of a quality service, according to Appleby (2000), involves being ‘user-led’, i.e. guidedby patients’ views on how services should develop. Thisreflects a general trend in health services in Western democracies(Crawford et al, 2002; Say & Thomson, 2003).

There is limited evidence supporting the notion that involvingservice users leads to more accessible, better-quality services (Beresford & Croft, 1993; Baker et al, 1997; Crawford et al, 2002;Simpson & House, 2002). However, there isno consensus on how best to engage patients in health serviceplanning (McIver, 1991; Baker et al, 1997; Kelson, 1997).The National Service Framework for Mental Health created a workinggroup to develop research tools with service users to assesstheir views on how services can best meet their needs (Departmentof Health, 2000b). There are some reports of the perceptionsof programme directors and clients regarding the effectivenessof methadone treatment (Mavis et al, 1991). However, thereis no substantial report in the medical literature of the treatmentpreferences of the users of addiction services. The objectiveof this study was to assess the preference of people with opiate dependency attending a substance misuse facility for the varioustreatment options.

Method

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Method

Study participants were recruited by the researcher from peopleattending Marina House, the Maudsley Hospital community substancemisuse facility. All participants were interviewed by a trainedpsychiatrist (J.L.) and satisfied DSM-IV research diagnosticcriteria for current opiate or opioid dependence (American Psychiatric Association, 1994).Their socio-demographic andclinical characteristics were elicited using the Maudsley AddictionProfile (Marsden et al, 1998) and Severity of Dependence Scale(Gossop et al, 1995). Opioid drug use was confirmed by the results of urine tests that formed part of the treatment programme.

A modified Q-sort technique was used to obtain patient preferences (Block, 1978; Yalom, 1985). Participants were given cardsstating 17 treatment options (Table 1) with the instruction: ‘Please place these treatments in order from the onethat you think is most likely to stop you using street herointo the one that you think is least helpful’ (intravenousand oral methadone were presented as separate options and wereboth available from the service providers). The participants then placed the cards in order on a table, with the treatmentsthey rated highest furthest away and those ranked lowest nearestto them. The order of preference was recorded. If patientsdid not recognise a particular treatment or had no views onpreference these options were not rated and the cards were placedin a separate pile. Two cards referred to fictitious drugs (‘Hypnazone’and ‘Superval’) to act as tests of reliability.The participants were then asked to remove from their preference list treatments that they had never experienced. The orderof preference for treatments that the person had actualy receivedwas then recorded in the same manner. The orders of preferenceswere compared by giving ‘oral methadone’ an arbitraryscore of 20. Other preferences were ranked in relation to this.Finally, patients were asked: ‘Do you think out-patientdetoxification or maintenance is most likely to stop you using street heroin?’ (detoxification was defined as ‘thedose of drug prescriptions is reduced gradually over 3-6 months’and maintenance was defined as ‘drug prescriptions foras long as you want it’).

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Table 1. Preference rankings of 15 different treatment options

Participants gave written informed consent. Approval to undertakethe study was obtained from the South London and Maudsley NHSTrust research ethics committee.

Results

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Results

None of those recruited met the exclusion criterion of beingunable to give informed consent because of mental illness,illiteracy or poor understanding of English. Two people agreedto take part in the project but did not complete both the interviewand card sort. The 104 people who completed the study had thefollowing background characteristics: 62% male, 76% White European,89% unemployed, mean age 34 (s.e. 0.7) years, age of firstheroin use 20.6 (s.e. 0.6) years, and the mean Severity ofDependence Scale score was 10.3 (s.e. 0.3). In the previousmonth, 55% had injected opiates or other drugs, 65% had usedcocaine or ‘crack’, heroin had been used on an averageof 21 (s.e. 1) days, and the typical daily spending on heroinwas £32 (s.e. £2). Three participants did not rankoral methadone among their treatment options; these resultswere excluded from the analysis as these preferences couldnot be compared with those of other respondents. The preferencesreported in the results are therefore based on 101 respondents. Thirty-five people (34%) believed that maintenance was superiorto detoxification in preventing illicit heroin use. There wasno significant difference between this group and those whobelieved detoxification to be superior, in terms of durationof heroin use: 15.5 (s.e. 1.5) years v. 13.9 (s.e. 0.8) years;P=0.06 (two-tailed t-test).

The top preferences in the participants’ initial rankingincluded both pharmacological and psychosocial options. Preferencesfor oral methadone, buprenorphine, drug-free rehabilitation(for 6-18 months) and in-patient detoxification (over 2-4 weeks)were each reported by a majority of participants (Table 1). Preferences for treatments that the participants had personallyexperienced also comprised both pharmacological and psychosocialoptions (Table 2). Whereas all participants had experiencedoral methadone treatment, fewer than half had direct exerienceof many of the other treatment options.

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Table 2. Preference rankings of treatments that participants had personally experienced

Discussion

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Discussion

Although there is considerable interest in involving users inplanning services, little is known about the views of the clientsof substance use facilities. Brown et al (1971) and Cheinet al (1964) reported the views of opiate users on reasonsfor initiating and withdrawing from heroin use. Mavis et al(1991) found that methadone patients in drug-free programmeswere sceptical about the efficacy of methadone, whereas clientsreceiving methadone treatment reported it to be beneficial.These results can be partly explained by patient selection:when patients are given a choice, each service is likely toattract patients who sympathise with that service’s objectivesand methods. There are many dramatic and literary reports onthe experience of addiction, several of which are based ondirect experience (Day & Smith, 2003). However, this paperis one of only a few reports of formal research into users’preference for substance misuse treatment in the UK.

The top four preferences - oral methadone, buprenorphine, rehabilitation and detoxification - are recognised by purchasers as treatmentpriorities (National Treatment Agency for Substance Misuse,2002a). The next three preferences, however, were more controversialtreatments: intravenous methadone, oral dihydrocodeine and i.v.diamorphine. The use of injectables in the treatment of substancemisuse has always been the subject of controversy, and dihydrocodeineis not licensed for use in opiate dependence (Department ofHealth, 1999b; Home Office, 2000). There is Government supportfor the use of prescribed injectables, but services will probablybe reluctant to provide them (National Treatment Agency forSubstance Misuse, 2002b; Luty, 2003).

No evidence was found to support the view that participants’previous experience of treatment might influence their perceptionof effectiveness. Prescribed injectables were ranked lowerin Table 2 than in Table 1, suggesting that injectables wereless desirable in practice than clients might imagine; however,further analysis of the results from Table 1 showed no differencein preferences for treatment between those who had been prescribedinjectables and those who had not. It was notable that bothbenzodiazepines and dihydrocodeine were apparently rated morehighly by those who had experienced treatment with these agents(Table 2) than the overall preferences reported in Table 1.This apparent preference arose because a greater proportionof participants had used these drugs than had experienced rehabilitationor detoxification, and disappeared when the results were analysedseparately for participants who had direct experience of rehabilitationand detoxification. Finally, the responses were analysed separatelyfor participants who had experienced three or more forms oftreatment (including at least one non-drug therapy). The resultswere very similar to the ranking in Table 2, with no treatmentchanging its position by more than one place.

Drug-free rehabilitation and in-patient detoxification wererated highly among the preferences. It was also notable thattwo-thirds of participants believed that detoxification wasbetter than maintenance therapy. This is particularly encouraging,as it indicates that treatment-seeking participants were motivatedto overcome their dependence on both prescribed and illicit drugs. It is perhaps regrettable that evidence shows maintenanceis probably superior to detoxification in preventing illicitopiate use (National Consensus Development Panel, 1998).

Strengths and limitations of the study
The list of treatments was restricted to eight pharmacologicaland seven psychosocial treatments, to avoid presenting participantswith an unmanageable number of options (combining the optionsfrom each group would lead to 56 permutations). Nevertheless,they were still presented with a substantial number of choices(17 including the fictitious drugs). Participants were asked to distinguish between detoxification and maintenance treatments. Unfortunately the study could not determine the preferred combinationof other drugs, regimens and psychosocial support, and thiscould be the subject of further research.

The people in this study were very similar to patients notifiedin 2000-2001 to English regional drug misuse databases, andother research samples, in terms of age, gender, ethnicityand socio-demographic status (Gossop et al, 1995; Government Statistical Office, 2000).Nevertheless, they were people withopiate dependency seeking treatment from a teaching hospitalsubstance misuse facility with a ‘harm reduction’rather than an ‘abstinence’ philosophy, which islikely to attract patients with similar preferences. The resultsmay not be typical of other community samples.

Two fictious agents (‘Hypnazone’ and ‘Superval’) were included in the treatment preference lists to ensure thatparticipants understood the procedure. All but six patientscorrectly identified and excluded these options from theirpreferences. However, another limitation of the study is thereliance on self-report of preferences to a clinician employedat the treatment centre, raising the possibility that patientswould report preferences that they imagined the researcherwould approve of, rather than expressing genuine opinions.

In conclusion, the results suggest that both pharmacologicaland psychosocial treatments are desirable options for peopleseeking treatment of their opiate dependency. These optionsinclude in-patient detoxification and rehabilitation. Thereis also a significant demand for both injectable drugs anddihydrocodeine.

Acknowledgments

Dr M. Farrell was the principal applicant on the ethical committee application. All funding for the project was provided by theprincipal author (J.L.).

References

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