Utilization and outcomes of detoxification and maintenance treatment for opioid dependence in publicly-funded facilities in California, USA: 1991–2012

doi:10.1016/j.drugalcdep.2014.07.020

Drug and Alcohol Dependence

Volume 143, 1 October 2014, Pages 149-157

https://doi.org/10.1016/j.drugalcdep.2014.07.020 Get rights and content

Abstract

Background

California treats the largest population of opioid dependent individuals in the USA and is among a small group of states that applies regulations for opioid treatment that are more stringent than existing federal regulations. We aim to characterize changes in patient characteristics and treatment utilization over time, and identify determinants of successful completion of detoxification and MMT retention in repeated attempts.

Methods

State-wide administrative data was obtained from California Outcome Measurement System during the period: January 1st, 1991–March 31st, 2012. Short-term detoxification treatment and long-term maintenance treatment, primarily with methadone, was available to study participants. Mixed effects regression models were used to define determinants of successful completion of the detoxification treatment protocol (as classified by treatment staff) and duration of maintenance treatment.

Results

The study sample consisted of 237,709 unique individuals and 885,971 treatment episodes; 837% were detoxification treatment episodes in 1994, dropping to 40.5% in 2010. Among individuals accessing only detoxification, the adjusted odds of success declined with each successive attempt (vs. 1st attempt: 2nd: OR: 0.679; 95% CI (0.610, 0.755); 3rd: 0.557 (0.484, 0.641); 4th: 0.526 (0.445, 0.622); 5th: 0.407 (0.334, 0.497); ≥6th: 0.339 (0.288, 0.399). For those ever accessing maintenance treatment, later subsequent attempts were longer in duration, and those with two or more prior attempts at detoxification had marginally longer subsequent maintenance episodes (hazard ratio: 0.97; 95% CI: 0.95, 0.99). Finally, only 10.9% of all detoxification episodes were followed by admission into maintenance treatment within 14 days.

Conclusions

This study has revealed high rates of detoxification treatment for opioid dependence in California throughout the study period, and decreasing odds of success in repeated attempts at detoxification.

Introduction

The most populous state in the USA, California treats the largest population of opioid dependent individuals (Substance Abuse and Mental Health Services Administration (SAMHSA, 2011) and is among a small group of states that applies regulations for opioid treatment that are more stringent than existing federal regulations. Specifically, to qualify for admission to methadone maintenance treatment (MMT) federal regulations require fulfilment of diagnostic criteria and documentation of at least a one-year history of opioid dependence. In contrast, California regulations require a two-year documented history and, in addition to fulfilment of diagnostic criteria, two failed attempts at detoxification. Further, federal regulations do not limit the duration of detoxification treatment whereas California regulations limit it to 21 days. Individual and programmatic exceptions for long-term detoxification (up to 180 days) and immediate access to maintenance treatment (as opposed to requiring two failed detoxification attempts) are available in California and are believed to be widely applied. Finally, federal regulations specify that no patient may be admitted to the same detoxification program more than twice in a one-year period without a patient-specific federal waiver. Although California regulations do not limit the number of admissions for detoxification, the state additionally requires at least seven days between detoxification treatment episodes (Stephenson, 2008).

Limited-term treatment for opioid-dependence is inconsistent with the disease's known chronic, recurrent course (McLellan et al., 2000). Systematic reviews of detoxification for opioid dependence have noted high rates of relapse, and suggest that the goal of detoxification should not be to provide treatment per se but rather to remove or reduce dependence on heroin in a controlled fashion (Amato et al., 2004, SAMHSA, 2006). Critically, opioid-dependent individuals are exposed to substantially elevated risk of mortality when out of treatment. In a systematic review of heroin users in either detoxification or maintenance-oriented treatment, the relative risk of mortality out-of-treatment was estimated to be 24 times greater than during treatment (Degenhardt et al., 2011). Further, a population-level study of opioid substitution treatment clients in Australia found the risk of mortality peaks in the two weeks following initiation, and discontinuation of treatment (Degenhardt et al., 2009).

California's opioid dependence treatment guidelines acknowledge the limitations of detoxification and the caveat that it should not be considered treatment for opioid dependence (Stephenson, 2008), yet it remains state-wide policy. As of March 2010, California featured 146 state-certified opioid treatment programs; 930% offered only methadone detoxification, while 70% offered MMT (compared to 313% nationally; SAMHSA, 2010).

To be clear, MMT is the most effective form of treatment for opioid dependence (SAMHSA, 2010). Prolonged retention in methadone treatment typically results in decreases in illicit drug use, HIV risk behaviors, and acquisitive crime (Amato et al., 2005). While programmatic restrictions have had mixed results (Ball and Ross, 1991, McCarthy and Borders, 1985, Peles et al., 2006), higher daily doses (Faggiano et al., 2003, Nosyk et al., 2009) are known predictors of positive outcome, and retention improves in subsequent treatment attempts (Nosyk et al., 2009). Further, MMT can provide positive synergies with the treatment and prevention of HIV and Hepatitis C Virus (Volkow and Montaner, 2011, Alter and Liang, 2012).

Nationally, two key changes in the opioid dependence epidemic and treatment delivery occurred over the past 20 years. First, buprenorphine treatment was introduced into office-based settings in 2003 (US Food and Drug Administration, 2002). By 2008, it was estimated that some 140,000 patients in the US were receiving maintenance treatment using buprenorphine (Kleber, 2008). Second, prescribed opioids (PO) rapidly displaced heroin as the most prevalent opioids abused in America. It is estimated that there are approximately 23 million individuals in the USA with opioid dependence or abuse, 19 million of which abuse POs (SAMHSA, 2009).

It is within this context that we evaluate outcomes for the treatment of opioid dependence in the state of California. Using population-level data on opioid treatment in publicly-funded facilities from 1991 to 2012, we consider repeated attempts at opioid detoxification and MMT over time for a cohort of nearly a quarter-million unique individuals. We focus specifically on characterizing changes in patient characteristics and treatment utilization over time, and identifying determinants of successful completion of detoxification and MMT retention in repeated attempts.

Section snippets

Study population

The study population included all individuals presenting for MMT in publicly-funded drug treatment centers (DTCs) in California from January 1st, 1991 to March 31st, 2012. Information received from all treatment programs receiving state or federal funding are recorded by the California Department of Alcohol and Drug Programs (ADP; California Department of Alcohol and Drug Programs, 2012a, 2005). Each DTC licensed to dispense methadone in California is required to submit data on each client

Study population

Over 21 years of observation, 237,709 unique individuals accounting for 885,971 treatment episodes were captured; 95,427 individuals accessed only detoxification (192,252 episodes, 30.2% of all episodes) and 142,282 individuals accessed MMT (693,719 episodes, 390% of which were MMT episodes). Over 70% of the ‘detoxification only’ cohort initiated treatment before 2002, while 60.1% of the ‘ever maintenance’ cohort initiated treatment post-2002 (Table 1). Those accessing MMT were older, more

Discussion

This study has revealed high, but decreasing rates of detoxification treatment for opioid dependence in California during the study period and decreasing odds of success in repeated attempts at detoxification for those never accessing MMT. Detoxification had a modest positive effect on subsequent MMT retention; however, time to treatment re-entry was similar following successful vs. unsuccessful detoxification episodes, and a low proportion of clients transitioned to MMT following

Role of funding source

Funding for this study was provided by the National Institutes of Health/National Institute on Drug Abuse Grant nos. R01-DA031727 and R01-DA032551, and by the University of California, Los Angeles, Integrated Substance Abuse Programs Center for Advancing Longitudinal Drug Abuse Research (CALDAR; P30-DA016383). The NIH had no further role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Contributors

Authors BN, DU, DH, EW, RR and YH aided in the design of the study and procured the data. Authors LL, EE and BN led the statistical analysis and BN wrote the first draft of the article. All authors contributed to and have approved the final manuscript.

Conflict of interest

All authors declare that they have no conflicts of interest.

Acknowledgments

Bohdan Nosyk is a Michael Smith Foundation for Health Research Scholar. We acknowledge the California Alcohol and Drug Program for use of the CADDS/CalOMS Tx data. This manuscript was supported by funding from funders had no role in the design and conduct of the study; preparation, review, and approval of the manuscript; or decision to submit this manuscript for publication.

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Utilization and outcomes of detoxification and maintenance treatment for opioid dependence in publicly-funded facilities in California, USA: 1991–2012

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study population

Study population

Discussion

Role of funding source

Contributors

Conflict of interest

Acknowledgments

J. Subst. Abuse Treat.

Drug Alcohol Depend.

Drug Alcohol Depend.

Drug Alcohol Depend.

Hepatitis C: the end of the beginning and possibly the beginning of the end

Ann. Intern. Med.

Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification

Cochrane Database Syst. Rev.

Adoption of evidence-based clinical innovations: the case of buprenorphine use by opioid treatment programs

Med. Care Res. Rev.

The Effectiveness of Methadone Maintenance Treatment

Approximate inference in generalized linear mixed models

J. Am. Stat. Assoc.

Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies

Addiction

Methadone maintenance at different dosages for opioid dependence

Cochrane Database Syst. Rev.

The California Treatment Outcome Project Supplement to the Final Report

Methadone maintenance 4 decades later: thousands of lives saved but still controversial

J. Am. Med. Assoc.

Limit setting on drug abuse in methadone maintenance patients

Am. J. Psychiatry

Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation

J. Am. Med. Assoc.

Primary care office-based buprenorphine treatment: comparison of heroin and prescription opioid dependent patients

J. Gen. Intern. Med.