Colin Brewer, Research Director, The Stapleford Centre, London UK.

1. REALLY HIGH RATES OF EARLY ABSTINENCE AND TREATMENT RETENTION AFTER OPIATE DETOXIFICATION, USING ORAL NALTREXONE AND NETWORK-COMMUNITY REINFORCEMENT THERAPY IN GREECE Colin Brewer, Research Director, The Stapleford Centre, London UK. Manos Koukides, Counsellor, Life Care NGO, Greece. MatinaLagoudaki, Psychologist, Life Care NGO, Greece

2. PROBLEM 1 • On an ‘intention-to-treat’ (ITT) basis, drop-out and/or relapse during conventional opiate detoxification and in the first month following it are typically rather high and medium-to-longer-term success rates typically rather low, eg: • Strang et al 2003. only 27% of patients entering the ‘centre of excellence’ stayed the full 28 days and thus regained normal tolerance. • Keen et al Only 13% of patients from a reputable British residential unit were regarded as ‘successful’.

3. PROBLEM 2 • Definitions of ‘detox’ and ‘completion’ vary enormously, eg: • Completing a gradual taper of methadone (MET) or buprenorphine (BPN) plus two or three ‘drug-free’ days. • But ‘drug-free’ days just means that no opiates were prescribed on those days or that urines tested during this period were opiate-free. • It does not mean that withdrawal symptoms had stopped. • Indeed, in some studies, withdrawal peaked 1-2 days after the last MET dose.

4. A civilized detox certainly helps. • De Jong, Roozen et al 2007. Carefully selected, well-prepared, state-funded and intensively-supported patients benefited from the virtually 100% completion-rates typical of rapid detoxification under anaesthesia or sedation. • Followed by supervised NTX using Community-Reinforcement/Network Therapy. • However, only 32% (on an ITT basis) were opiate-free 16 months later. • Possibly because; about 60% of patients who had successfully detoxified and initiated supervised oral NTX had discontinued NTX within the first 4-6 weeks

5. THE FIRST MONTH IS CRITICAL • Persisting withdrawal discomfort – patients know it is instantly relieved by relapse. • Persisting addictive mindset and habits need much more than a month to change but if they don’t get through the first month, change is unlikely. • People doing the NTX supervising have to learn new habits too. If they don’t learn quickly (eg how to detect cheating) relapse is more likely. • Often not much change in levels of temptation from old user friends if patients return home. • Rule of thumb: 66% of relapses happen in the first 6 weeks. That’s why even short-acting implants are so helpful.

6. The Merimna Programme • Civilised in-patient detox with good symptom relief minimises fear of detox and makes abstinence more attractive (or less unattractive) • Implants not available in Greece, only tablets. • So, involvement and preparation including family members even before detox and specific instruction in NTX supervision. • At least weekly follow-up sessions for 1 year with counsellors familiar with NTX. Standard range of psychosocial approaches – and included in treatment price. • Urine testing – though not always possible or systematic.

7. RETROSPECTIVE CASENOTE STUDY • 229 fairly typical non-coerced patients. (m:208; f:21. age 20-24, 27%; 25-31, 50%: 52% employed full-time, 8.7% part-time or student: 48% education to 14 or less.) • Only 29 (12.6%) clearly relapsed or dropped out during the first month). • 134 patients (58.5%) attended most sessions and were opiate-negative throughout the planned period (usually 12 months) and continued to collect NTX prescriptions.

8. SEX SAMPLE

9. AGE

10. EDUCATIONAL LEVEL

11. EMPLOYMENT STATUS (present)

12. PREVIOUS ATTEMPTS TO WITHDRAW FROM HEROIN.

13. Some results…

14. URINE TESTING • In 14%, no urine tests were done at any stage (usually for geographical reasons) but attendance was good - at least 75% of planned appointments during the first 3 months. • In 3.5%, urine not tested during first 3 months but attendance good during that period and later urine tests negative for opiates. • 3.5% had opiate-positive urines during the first 1-3 months but consistently negative ones later.

15. So that overall... • About 65% of patients seem to have been opiate free at around 12 months – which is not at all bad. • This rises to about 70% if we assume that a third of the 14% who weren’t tested but attended regularly for 3 months stayed clean for the rest of the year. • Very few patients dropped-out between detoxification being agreed and the planned admission for detoxification and NTX induction (usually not much more than a week) so that this is close to an ‘intention to treat’ study.

16. However.... • Patients come from all over Greece – and beyond. • So counselling happens at many different locations. • Counsellors are human – and thus variable. • Attitudes to urine testing vary. • Counsellor attitudes to NTX taking generally positive but also vary.

17. Some problems with counsellors.... • Ideally, NTX should be given in a foolproof way at some counselling sessions. Acceptance usually confirms abstinence from opiates. Refusal certainly raises suspicions. • Some counsellors are not keen on this because they see it as the family’s job (or a medical task). Giving it themselves might imply lack of trust in the family (or patient). • If parents were temporarily unable to supervise, many counsellors would not be happy to act as a substitute. • Implants would obviously solve these problems.

18. Urine testing is rarely done during counselling sessions but is usually ordered on a random basis. • Generally done at least monthly, more if necessary. (Op, BDZ, Can, Coc) • Counsellors in remote locations are encouraged to test samples on-site with test-sticks. • Cannabis use may be a factor in drop-out.

19. CONCLUSION • These apparently above-average outcomes probably reflect the good design of the programme, the competence and therapeutic ideology of those who administer it and the persistence of strong family structures in Greece.