Policy and practice briefingsTackling opioid dependence

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Issues

Although the prevalence of opioid dependence among European adults is low and varies considerably between countries, it is associated with a disproportionate amount of drug-related harm that includes infectious diseases and other health problems, mortality, unemployment, crime, homelessness and social exclusion. Heroin use remains a major concern but in many European countries the use of synthetic opioids has also been growing and in a few countries now predominates.

Response options

  • Pharmacological interventions, such as opioid substitution treatment (OST), usually with methadone of buprenorphine. Heroin-assisted treatment may be useful for people who have not responded to other forms of OST.
  • Behavioural and psychosocial interventions to address psychological and social aspects of drug use include brief interventions, structured psychological therapies, motivational interventions, contingency management, and behavioural couples therapy. They are often used in conjunction with pharmacological interventions.
  • Residential rehabilitation involves living in a treatment facility and following a structured, care-planned programme of medical, therapeutic and other activities. This approach is suitable for clients with medium or high levels of need.
  • Self-help and mutual aid groups teach cognitive, behavioural and techniques of self-management without formal professional guidance.
  • Recovery/reintegration support services, for example, employment and housing support.

Effective long-term treatment of opioid dependence often requires multiple treatment episodes and combinations of responses. Harm reduction interventions, mental health and other services, addressing co-occurring mental and physical health problems, will also be important.

European picture

  • Opioid users are the largest group in specialised drug treatment in Europe. However, differences exist between countries. These differences reflect variations in prevalence but also in the orientation of the drug treatment systems.
  • The most common treatment approach is opioid substitution treatment, usually provided in outpatient settings. Methadone (63 %) and buprenorphine (35 %) are the medicines most commonly used for OST in Europe. It is estimated that overall, around 50 % of people with opioid dependence receive some form of substitution treatment but coverage varies greatly between countries.
  • All European countries provide some residential treatment but the level of provision varies greatly.

Summary of the available evidence

Treating opioid dependence

Response option Quality of evidence

Opioid substitution treatment keeps patients in treatment, reduces illicit opioid use, related risk behaviour and mortality, and improves mental health. Its impact may be enhanced by psychosocial support.

higher quality evidence

Methadone and buprenorphine are both recommended as medications for long-term pharmacological maintenance treatments. 

higher quality evidence

Methadone retains more people in the early weeks of treatment than buprenorphine.

higher quality evidence

Heroin-assisted treatment has been found to be effective for chronic opioid users who have not responded to methadone treatment.

higher quality evidence

Methadone or buprenorphine are effective treatment options for people who are dependent on pharmaceutical opioids.

moderate quality evidence

Opioid substitution treatment is strongly recommended over detoxification for opioid-dependent pregnant women. Psychosocial interventions alone do not improve opioid-related or obstetrical outcomes. xpto

moderate quality evidence

When detoxification is indicated, tapered doses of methadone or buprenorphine should be used in combination with psychosocial interventions. 

higher quality evidence

Detoxification with alpha2-adrenergic agonists (e.g. clonidine) is also effective but methadone has fewer adverse effects.

moderate quality evidence

Use of naltrexone for relapse prevention is generally not recommended, except in cases in which relapse would have serious and immediate consequences.

moderate quality evidence

Providing drug users with an incentive-based treatment approach (contingency management) and employment helps improve their social conditions.

moderate quality evidence

Key

  • speedometer at high High quality evidence — one or more up-to-date systematic reviews that include high-quality primary studies with consistent results. The evidence supports the use of the intervention within the context in which it was evaluated.
  • speedometer at medium Moderate quality evidence — one or more up-to-date reviews that include a number of primary studies of at least moderate quality with generally consistent results. The evidence suggests these interventions are likely to be useful in the context in which they have been evaluated but further evaluations are recommended.
  • speedometer at low Low quality evidence — where there are some high or moderate quality primary studies but no reviews available OR there are reviews giving inconsistent results. The evidence is currently limited, but what there is shows promise. This suggests these interventions may be worth considering, particularly in the context of extending services to address new or unmet needs, but should be evaluated.

Implications for policy and practice

Basics

  • The core intervention is OST in combination with psychosocial treatment. This is an effective way to reduce illicit opioid use, transmission of infectious disease, drug overdose and crime.
  • Different medicines are available for substitution treatment. Therapeutic choices need to be based on individual needs, involve a dialogue with patients and be regularly reviewed.
  • Abstinence-oriented psychosocial treatment in residential settings can benefit some opioid-dependent people if they remain in treatment. However, this form of treatment is relatively costly and the relapse-rate is often high, with an increased risk of fatal overdose. Appropriate client selection and management are important as is support in the event of relapse.

Opportunities

  • Optimise service delivery: The quality of treatment delivery is important, in particular, adequate doses of opioid substitution medicines are essential and continuity of treatment is vital. Increasing access to OST should remain a public health priority in those countries where it falls below recommended levels.
  • Where good coverage has been achieved and many of those in OST treatment have now been in care for many years there may be a need to increase the attention given to social reintegration, including employment. Also there may be a need to review what constitutes appropriate individual therapeutic goals for different individuals and to promote recovery where appropriate.

Gaps

  • Treatment services should be alert for the use of opioids other than heroin among treatment entrants and also polysubstance use, including alcohol and tobacco.
  • Better information on unmet need for treatment is required in order to ensure appropriate levels of service availability.

 

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