Detoxification treatment for heroin dependents adolescents
Review question
We reviewed the evidence on the effect of detoxification treatment compared with pharmacological maintenance treatment or psychosocial intervention in achieving abstinence on adolescents heroin dependents.
Background
Substance abuse among adolescents (13 to 18 years old) is a serious and growing problem. It is important to identify effective treatments for those who are opioid dependent. For adults, pharmacotherapy is a necessary and acceptable part of effective treatment. Detoxification agents are used to reduce withdrawal symptoms during managed withdrawal but the rate of completion of detoxification tends to be low, and rates of relapse are high. Withdrawal symptoms, particularly drug craving, may continue for weeks and even months after detoxification. The period of recovery from dependence is typically influenced by a range of psychological, social and treatment- related factors. Detoxification treatments include methadone, buprenorphine, and alpha2-adrenergic agonists.
Study characteristics
The review authors searched the literature for randomised controlled trials investigating pharmacological interventions with or without psychosocial intervention aimed at detoxification in adolescents. They found only two trials, both conducted in the USA; one compared 28-day treatment with buprenorphine, using tablets placed under the tongue, to wearing a clonidine patch in 36 opiate dependent adolescents who were treated as outpatients. The other trial compared maintenance treatment versus detoxification treatment: buprenorphine-naloxone maintenance versus buprenorphine detoxification.
Key results
The trial comparing buprenorphine with clonidine reported a trend in favour of buprenorphine in reducing the drop-out rate but no difference between treatments in the duration and severity of withdrawal symptoms. More participants in the buprenorphine group went on to long-term naltrexone treatment. Side effects were not reported. In the second trial comparing buprenorphine maintenance versus buprenorphine for detoxification, for drop out the results were in favour of maintenance treatment, At one-year follow- up, self-reported opioid use was clearly less in the maintenance group and more adolescents were enrolled in other addiction programs. Conducting trials with young people may be difficult for both practical and ethical reasons.
Quality of the evidence
This review was limited by the very few number of trials retrieved and the quality of the evidence was moderate for the comparison between buprenorphine and clonidine and low for the comparison between buprenorphine detoxification and buprenorphine maintenance. The evidence is current to January 2014.
It is difficult to draw conclusions on the basis of two trials with few participants. Furthermore, the two studies included did not consider the efficacy of methadone that is still the most frequent drug utilised for the treatment of opioid withdrawal. One possible reason for the lack of evidence could be the difficulty in conducting trials with young people due to practical and ethical reasons.
The scientific literature examining effective treatments for opioid dependent adults clearly indicates that pharmacotherapy is a necessary and acceptable component of effective treatments for opioid dependence. Nevertheless, no studies have been published that systematically assess the effectiveness of the pharmacological detoxification among adolescents.
To assess the effectiveness of any detoxification treatment alone or in combination with psychosocial intervention compared with no intervention, other pharmacological intervention or psychosocial interventions on completion of treatment, reducing the use of substances and improving health and social status.
We searched the Cochrane Central Register of Controlled Trials (2014, Issue 1), PubMed (January 1966 to January 2014), EMBASE (January 1980 to January 2014), CINHAL (January 1982 to January 2014), Web of Science (1991-January 2014) and reference lists of articles.
Randomised controlled clinical trials comparing any pharmacological interventions alone or associated with psychosocial intervention aimed at detoxification with no intervention, placebo, other pharmacological intervention or psychosocial intervention in adolescents (13 to 18 years).
We used standard methodological procedures recommended by The Cochrane Collaboration
Two trials involving 190 participants were included. One trial compared buprenorphine with clonidine for detoxification. No difference was found for drop out: risk ratio (RR) 0.45 (95% confidence interval (CI): 0.20 to 1.04) and acceptability of treatment: withdrawal score mean difference (MD): 3.97 (95% CI -1.38 to 9.32). More participants in the buprenorphine group initiated naltrexone treatment: RR 11.00 (95% CI 1.58 to 76.55), quality of evidence moderate.
The other trial compared maintenance treatment versus detoxification treatment: buprenorphine-naloxone maintenance versus buprenorphine detoxification. For drop out the results were in favour of maintenance treatment: RR 2.67 (95% CI 1.85, 3.86), as well as for results at follow-up RR 1.36 [95% CI 1.05to 1.76); no differences for use of opiate, quality of evidence low.