The Role of Wrap Around Services in Retention and Outcome in Substance Abuse Treatment: Finding From the Wrap Around Service Impact Study. Pringle JL, Edmondston LA et al. Addictive Disorders and Their Treatment (2002) 1;4:109-118
Dear Colleagues,
This lead article had the promise to describe one of the most useful studies since McLellan and Woody's work a decade ago on psychosocial supports in addiction treatment. Sadly, such is not the case as we are not even told what specific treatment these patients were receiving, so we cannot generalise to other settings. Also, there was no control group, making the conclusions of limited value.
The authors found unsurprisingly that improved retention and other outcomes in those who used extra support in ten main areas (legal services, nutrition, child care, education, domestic, housing, medical care, mental health services, transport, vocational services). Their almost 'motherhood' conclusion states that the findings "support policies that address clients' broader biopsychosocial needs while substance abuse treatment is provided". This is hardly surprising, but sadly it is the sort of argument used by some in the methadone "industry" and government to support limiting methadone treatment to formal clinics in the US. Yet 'medical' methadone using community dispensing is used successfully overseas as well as in numerous American trials.
Supervised methadone in opioid dependent citizens is the most common and best evaluated treatment. Yet inexplicably, I could not find mention of methadone in the entire 10 pages of this article which looked at outcomes at 3 and 12 months. While a range of treatments should be available to opioid dependent patients, methadone maintenance treatment (MMT) is often chosen treatment by heroin dependent subjects. The availability of MMT and its quality are known to be most important factors in (1) attracting patients, (2) retaining patients in treatment and (3) improving important outcome measures, including viral transmission and mortality from all causes. The outcome of excessive prescribing may be overdose death and inadequate doses may lead to early drop-outs, which can also lead to fatalities. Poor psychosocial services could also have untoward consequences in a proportion, although details have never been examined, but usually only their existance and utilization by trial subjects.
It is unfortunate and extraordinary that these researchers could closely examine one aspect of treatment while ignoring other crucial elements, especially those already known to directly affect outcomes. Methadone dose, administration and additional psychosocial supports have long been known to influence outcomes ... in some cases dramatically. I can see little scientific or clinical relevance for this odd item which seems to lack clinical input, except to almost completely ignore therapeutics which necessarily must occur hand in hand with psychosocial services in those who continue to attend for treatment. It is disappointing that there were apparently no physicians involved in this paper.
We know that even with rudimentary ancillary services, prescribed methadone with sufficient dose levels and supervision is highly efficacious, enabling most subjects to regain their independence rapidly (Yancovits 1991, etc). The remainder clearly need more help and these can be recognised in the clinical setting within weeks of starting treatment. While possibly beyond the scope of this study, those who need most help are, paradoxically, those who drop out of treatment early. While these researchers found that most subjects had a need for at least one wrap around service in the course of treatment, this probably applied to those giving the treatment as well (and those reading the article!).
comments by Andrew Byrne ..
