Inpatient versus other settings for detoxification for opioid dependence

Dependence on opioid drugs, such as heroin, morphine, and codeine, is a serious problem in many societies. Opioids are very difficult to quit using. The first step to quitting is detoxification, which can cause a number of painful symptoms as the drug withdraws from the body. Many people choose an inpatient detoxification program rather than trying to stop using opioids on their own. In an inpatient program, medications such as methadone can ease the symptoms of withdrawal and patients are in a secure, supportive environment with no access to opiates. However, inpatient programs are expensive and can disrupt patients' lives. An increasing number of outpatient programs are available, providing medication and some support while keeping the drug user in the community. In addition to drop-in programs, there are day centres and even residential facilities which are not staffed 24 hours, unlike inpatient programs. The authors of this review looked for research comparing inpatient and other types of opiate withdrawal programs to see which is more effective. They found only one study from 1975, which had 40 participants. The study suggested inpatient therapy might be more effective than outpatient therapy in the short-term, but all of the inpatients relapsed within three months after detoxification. Since they found only one outdated study which included very few patients, the Cochrane review authors could not conclude whether inpatient treatment is more effective than outpatient or other settings. More research must be done to measure the benefits and costs of inpatient detoxification, especially for more severely dependent users.

Authors' conclusions: 

This review demonstrates that there is no good available research to guide the clinician about the outcomes or cost-effectiveness of inpatient or outpatient approaches to opioid detoxification.

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Background: 

There are a complex range of variables that can influence the course and subjective severity of opioid withdrawal. There is a growing evidence for the effectiveness of a range of medically-supported detoxification strategies, but little attention has been paid to the influence of the setting in which the process takes place.

Objectives: 

To evaluate the effectiveness of any inpatient opioid detoxification programme when compared with all other time-limited detoxification programmes on the level of completion of detoxification, the intensity and duration of withdrawal symptoms, the nature and incidence of adverse effects, the level of engagement in further treatment post-detoxification, and the rates of relapse post-detoxification.

Search strategy: 

Electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL - The Cochrane Library Issue 2, 2008); MEDLINE (January 1966-May 2008); EMBASE (January 1988-May 2008); PsycInfo (January 1967-May 2008); CINAHL (January 1982-May 2008). In addition the Current Contents, Biological Abstracts, Science Citation Index and Social Sciences Index were searched.

Selection criteria: 

Randomised controlled clinical trials comparing inpatient opioid detoxification (any drug or psychosocial therapy) with other time-limited detoxification programmes (including residential units that are not staffed 24 hours per day, day-care facilities where the patient is not resident for 24 hours per day, and outpatient or ambulatory programmes, and using any drug or psychosocial therapy).

Data collection and analysis: 

All abstracts were independently inspected by two reviewers (ED & JI) and relevant papers were retrieved and assessed for methodological quality using Cochrane Reviewers' Handbook criteria.

Main results: 

Only one study met the inclusion criteria. This did not explicitly report the number of participants in each group that successfully completed the detoxification process, but the published data allowed us to deduce that 7 out of 10 (70%) in the inpatient detoxification group were opioid-free on discharge, compared with 11 out of 30 (37%) in the outpatient group. There was very limited data about the other outcomes of interest.

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