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BOBBY P. SMYTH, JOE BARRY, ALISON LANE, MARY COTTER, MARY O’NEILL, CAROLINE QUINN, and EAMON KEENAN
In-patient treatment of opiate dependence: medium-term follow-up outcomes
The British Journal of Psychiatry 2005; 187: 360-365 [Abstract] [Full text] [PDF]
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[Read eLetter] Study does not confirm therapeutic effect
Richard Braithwaite   (18 November 2005)

Study does not confirm therapeutic effect 18 November 2005
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Richard Braithwaite,
Staff Grade Psychiatrist
Isle of Wight Healthcare NHS Trust

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Re: Study does not confirm therapeutic effect

richard.braithwaite{at}iow.nhs.uk Richard Braithwaite

I read Smyth et al's cohort study with interest, having not long ago completed a senior house officer post in a substance misuse service providing a six- week inpatient programme for patients with opiate dependence. The relative lack of evidence for the efficacy of such a programme led me to question my practice during this post, especially given the huge financial costs of inpatient care.

Unfortunately, despite its relatively long period of follow-up, Smyth et al's study does little to add to our knowledge base, other than to provide insight into the demographics of Dublin's opiate misusing population. The lack of a control group not only makes it impossible to determine an effect size, as admitted by the authors, but precludes the authors' conclusion that treatment adherence positively influences outcome. Their results show that treatment adherence is significantly associated with attainment of abstinence, but this result is hardly surprising and cannot confirm direction of effect. One would surely expect those motivated enough to comply with the expectations of the establishment by completing a six- week residential placement and by attending regular outpatient appointments to be the very same individuals who succeed in beating their addictions.

Furthermore, Smyth et al's results are misleading in that the 27% of the sample who were lost to follow-up were not included in the main statistical analysis. Thus the authors' assertion that 23% of patients were abstinent at follow-up cannot be upheld; only 17% of the sample who were still alive at follow-up were confirmed abstinent at that point in time.

I agree with the authors that abstinence remains an attainable goal, but it is by no means clear that an expensive and intensive paramedical intervention helps individuals to achieve that goal. Indeed, with a success rate of just 17%, substance misuse services providing residential programmes need to reconsider the wisdom of their current financial outlay.