BACKGROUND AND CLINICAL CONSIDERATIONS

 

In Sweden the intravenous abuse of illegally obtained opiates has been a gradually increasing problem since the mid-sixties, but it has not yet reached American proportions. For a couple of decades amphetamine and other central stimulants were dominating the Swedish drug market. Among the opiates raw opium was the leading drug in the early seventies, to be replaced first by morphine base and since 1975 by heroin. In a recent case-finding survey (Olsson, 1981) it has been estimated that Sweden has 3,000 to 4,000 users of heroin, about half of whom are regular users with a compulsive type of dependence on this drug.

 

The Swedish methadone maintenance treatment (MMT) system, which was set up at our clinic in 1966, has so far remained the only national MMT program and has received applicants from the whole country. Due to the differences in dimensions and intensity between the United States and Sweden, we have felt that we might proceed and develop our treatment program at a slow pace and with a greater amount of caution than was possible when American mega-programs were being organized.

 

Our aim has been to reserve the Swedish MMT program for a certain category of heroin abusers, as defined by a drug career model (Frykholm and Gunne, 1980). We have found that drug abusers tend to make use of treatment facilities in a manner that changes gradually as they move from one stage to another in their drug career. In the early stages they characteristically enter clinics for reasons other than to become permanently drug free. These patients tend to stay in treatment only for a few days, mainly in order to receive substitution medication. When this medication is reduced to a point where they no longer feel comfortable, they typically leave against medical advice. This category of patients might be interested in long-lasting MMT, but we have tried to avoid them by insisting that they should try to live without drugs.

 

Later in the drug career the patients' treatment goals change and they may actually be striving to rid themselves of drugs on a permanent basis. At this stage their visits to the clinic may be prolonged past the acute withdrawal phase and the drug-free periods after discharge indicate an improved pattern. We try not to interfere at this stage either, but rather to leave the patient to his drug-free treatment programs, of which there are many nowadays in Sweden. Unfortunately, there is no reliable information regarding the success rate in those treatment systems, but at least some heroin addicts apparently manage to abandon their drug habit at this stage, with or without treatment.

 

Only when a heroin addict has a history of long-term compulsive abuse with repeated failures to stop, in spite of documented serious attempts to do so, then he becomes eligible for the Swedish MMT program. In order to select drug abusers according to the goals and aims described we have found the original eligibility criteria used by Dole and Nyswander (1965) to be quite useful and have maintained them unaltered over the 15 years our program has been in operation. These criteria are: (1) a history of at least four years of compulsive regular i.v. use of heroin, as documented by earlier hospital records; (2) at least three completed detoxifications, the patient must have remained in the clinic for more than a week after all drugs have been'discontinued; (3) withdrawal signs and urinary opioid excretion on admission; (4) at least 20 years of age; (5) not arrested, not serving sentence; (6) no dominating abuse of non-opiate drugs.

 

EVALUATION RESEARCH

 

The evaluation of an MMT system ideally should contain these four elements:

(1) A comparison of the subjects' situation before vs during (or after) treatment

(2) Comparison between yearly results, to check for the stability of the program

(3) Comparison between treated and untreated (or alternatively treated) assigned by random allocation to control for effects of selection and self-selection

(4) Long-term effects of methadone (which is not covered in the present paper).

 

In an ongoing evaluation study (Gronbladh, 1982) the effects of our MMT program on work, criminality rate and drug abuse is carried out. Table 1 shows the number of weeks our patients have worked two years and one year before they were accepted in the MMT program, together with the corresponding figures for the first and second year in treatment. The total material of 170 cases (131 male, 39 female) was subdivided into those who are still in treatment, those who have been voluntarily discharged, involuntarily discharged, and those who have died while in treatment. The number of weeks of employed increased from 2-8 before treatment to around 33 weeks during the second year of treatment, except in the group which was later discharged involuntarily, due to continued abuse of amphetamines and/or hypnotics.

 

A measurement of the stability of the program is exemplified in Figure 1. When work rehabilitation was measured for seven consecutive years it was found that the percentage of individuals who were working or studying varied between 59-81 percent. In addition, a percentage of able-bodied subjects were reporting to the employment exchange agency as willing to accept any job that might be offered. The sum of these three categories varied between 83 and 91 percent, who were thus able and willing to work. The program stability with regard to work rehabilitation was considered to be satisfactory.

 

EFFECTS OF SELECTION

It has been argued in the Swedish debate about our results that the subjects selected for treatment by our criteria might represent a group which could be on their way out of the drug career anyway and thus perhaps not in need of MMT, which might even prolong their period of dependence on opiates. In order to elucidate this question we carried out a comparative study of two groups, which were both eligible according to our criteria but where one, by random assignment, did not receive MMT. All subjects participating in this study were between ages 20 and 24 and physically healthy when they applied for MMT. The study was carried on until the difference between pairs was significant on a five percent level using sequential analysis according to Bross (1952), which occurred after 34 individuals has been included. Details of the methodology have been given elsewhere (Gunne and GrOnbladh, 1981).

 

Figure 2 illustrates the situation before the start of the experiment. Each circle represents an individual (H in the circle stands for regular heroin abuse). To the left are the 17 who will be given methadone, to the right there are 17 who, by random allocation, will not be given this treatment. Table 2 shows that the mean age, number of years of drug abuse, number of treatment periods, and court trials was about the same in both groups. Only the sex distribution differed, the experimental group having six females as compared to two in the control group.

A refusal to accept a patient in our MMT program means that the subject cannot apply again until two years later. For that reason the situation after two years is of interest (before any of the controls had an opportunity to enter the treatment program). Figure 3 shows that after two years 12 of the patients given methadone had abandoned their drug abuse and started work (ten) or studies (two). Five in the treated group still had drug abuse problems, and two of those had even been excluded from MMT due to severe abuse of hypnotics. Among the controls one had become drug free, two were in prison (indicated by P in the circles), and two were dead (black circles). The rest were still abusing heroin and three had incurred drug-related diseases. Two had sepsis, one of them with concomitant endocarditis, and the third in a state of drug intoxication had thrown himself before a subway train and had a foot amputated afterwards.

Figure 4 shows the present situation for these drug addicts. About five years have elapsed since the subjects entered the study (median 5.1 years) and nine of the original controls have now reapplied for treatment and been accepted. Out of the 26 subjects thus admitted into the program, 21 (81 percent) have ceased to abuse drugs and started to work. Five have been excluded from treatment due to repeated abuse of hypnotics, requiring repeated visits to emergency care units for severe coma. Among those subjects who have not received MMT, five are dead (allegedly from overdose), two in prison and one is still drug free.

Table 3 compares the results within the original experimental group of 17 with the outcome of the entire MMT program of 170. It is seen that the percentage of successful cases (free of drug abuse and in treatment plus drug free after voluntary discharge from the program) is quite similar between the two groups. Thus, from the point of view of outcome, the experimental group proved to be a representative sample of the total program.

 

DISCUSSION

 

Our data have shown that the Swedish MMT program has favorable rehabilitative effects, which have remained reasonably stable during the last seven years. When the results were compared to a randomly allocated control group the differences were very marked. Among the controls only six percent had a favorable outcome as opposed to 76 percent rehabilitated in the experimental group. Five of the 17 control subjects died, corresponding to a yearly death rate of six percent. The death rate is 59 times the expected mortality risk for that age group in Sweden (Official Statistics, 1980). Still it must be considered to be only a minimum mortality rate figure, since after two years about half of the controls reapplied and were accepted in treatment. The results show that the Swedish MMT protects against drug-related morbidity and death among heroin addicts.

Recent American outcome research has shown only a marginal or no effect when MMT is compared with drug-free treatment or no treatment (Sells and Simpson, 1979; Burt et al, 1980). This difference between the Swedish and some American treatment operations, probably has to d6 with the selection of cases. Due to our restrictive admission policy the Swedish program is being regarded as a last resort among heroin addicts. Those who are accepted are thus likely to put a maximal effort in their own rehabilitation, a tendency that is further amplified by the therapists' emphasis on patients' employment and work. All this may contribute to the favorable outcome, which seems to be comparable to the pioneering American MMT programs (Dole et al, 1968).

 

ACKNOWLEDGMENTS

 

This study has been supported by a Medical Research Council grant nr 4810. The design of the randomization study was approved by the Swedish Board of Health and Welfare and by the Ethics' Committee of the University of Uppsala.

Swedish Methadone Maintenance Program 213

 

REFERENCES

 

Bross I: Sequential medical plans. Biometrics 1988-205, 1952

Burt MR, Brown BS and DuPont RL: Follow-up of former clients of a large multi-modality drug treatment program. Int J Addict 15:391-408, 1980

Dole VP and Nyswander M: A medical treatment for diacetylmorphine (heroin) addiction. JAMA 193:646-650, 1965

Dole VP, Nyswander M and Warner A: Successful treatment of 750 criminal addicts. JAMA 206:2708-11, 1968

Frykholm B and Gunne L-M: Studies of the drug career. Acta Psychiat Scand 62 (suppl 284):42-51, 1980

Gunne L-M and GrOnbladh L: The Swedish methadone maintenance program: A controlled study. Drug Ale Dep 1981

Olsson B: National case-finding study in Sweden ICAA report. (In press) 1981

Sells B and Simpson D: Bulletin on Narcotics, Vol. XXXI No. 1, 1979