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Systematic review

Use of biological samples in rehabilitation of persons receiving opioid maintenance treatment: a systematic review

  • Year: September 2016
  • By: Norwegian Institute of Public Health
  • Authors Hov L, Mosdøl A, Ding Y, Strømme H, Vist GE.
  • ISBN (digital): 978-82-8082-767-8

This systematic review summarises the effects of using biological samples in the rehabilitation of persons that receives opioid maintenance treatment. Biological sample can be of urine, saliva, hair or sweat. These are analysed for traces of drugs and medication.

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Key message

Opioid maintenance treatment is the most common form of treatment for people with opioid dependence in Norway. In opioid maintenance treatment, the persons are offered a suitable replacement drug for the opiate they are dependent of. The treatment is often lifelong and involves that they must give samples of biological material regularly.  This systematic review summarises the effects of using biological samples in the rehabilitation of persons that receives opioid maintenance treatment. Biological sample can be of urine, saliva, hair or sweat. These are analysed for traces of drugs and medication.

We only found one relevant study. All the persons participated in the same opioid maintenance treatment program. One group submitted observed urine samples regularly; the other group did not provide such samples. Two times during the study period, all participants had to submit an unannounced observed urine sample.

We found that:

  • The evidence is too uncertain to conclude if submitting regular observed urine samples influence use of illicit drugs or satisfaction with the treatment than if no such test are submitted.
  • There is a lack of evidence concerning whether use of biological samples influence retention in treatment, or have any effect on rehabilitation measures, criminality and self-reported use of illicit drugs.
  • There is a lack of evidence on use of other biological samples than urine.

Summary

Background

Opioid maintenance treatment (OMT) is the most common form of treatment for people with opioid dependence. In opioid maintenance treatment, the persons are offered a suitable replacement drug for the opiate they are dependent on. Persons who receive opioid maintenance treatment show improved survival, reduced damage to health, and better quality of life compared with treatment without use of opioid agonist drugs. The treatment is often lifelong and constitutes a major interference in everyday life, partly because of frequent supervised administration of opioid agonist and supervised urine tests. In Norway, persons in treatment regularly submit observed urine samples that are analysed for traces of drugs. Other relevant biological samples can be samples of saliva, hair or sweat.

Objective

This systematic review summaries the effects of using biological samples in rehabilitation of persons receiving opioid maintenance treatment for opioid dependence.  

Method

We have searched for primary studies in MEDLINE, Embase, PsycINFO, CENTRAL (Wiley) and CINAHL until 12th April 2016. In addition, we searched the reference lists in the studies we examined in full text. Two people examined independently 3772 titles and abstracts, assessed nine papers in full text and included one study. The population in this systematic review is individuals with opioid dependency undergoing opioid maintenance treatment. The intervention is no use of biological samples compared with use of biological samples in the rehabilitation of persons receiving opioid maintenance treatment, with the effect measured as retention in treatment, use of illicit drugs, rehabilitation measures (employment, education), criminality and self-reported use of illicit drugs. We searched for randomized controlled trials, controlled studies with before and after measurements, interrupted time series with at least three measurement points before and three after the intervention, and with a clearly defined point in time when the intervention started. Two persons independently assessed the risk of bias. The project leader retrieved data from the studies, analysed and assessed our confidence in the evidence; and another investigator double-checked the information. We used GRADE (Grading of Recommendation Assessment, Development and evaluation) to assess our confidence in the effect estimate. The confidence can be rated as high, medium, low or very low.

Results

We included one randomised controlled trial with totally 431 persons included, executed in US, 35 years ago. All persons participated in the same OMT-program over a one-year period. One group submitted observed urine samples weekly, and the other group submitted no such samples. All of the participants had to submit an unannounced observed urine sample after four and eight months. We assessed that the study had an unclear risk of bias.

Our confidence in the effect estimates was very low. This implies that the true effect can be very different from the estimate of effect that we present. About the same number of persons in each group submitted clean urine samples after four and eight months, with respectively a RR of 1,08 after 4 months (95% CI 0,89-1,31) and a RR of 1,00 after 8 months (95% CI 0,81-1,24). Based on a questionnaire, there were no significant differences in total score for satisfaction with the treatment after 6 months.

Discussion

We did not find sufficient evidence to answer our research question. Based on one study, published 35 years ago, we have very low confidence in the evidence of likely effects. Very low confidence in effect implies that evidence is inadequate to provide an estimate of the likely effect. A decision concerning whether the OMT-program should continue with the use of regular urine tests/other biological samples as today must be based on other considerations than the probable effect.

Conclusion

We found insufficient evidence to answer whether use of biological samples in rehabilitation of people in opioid maintenance treatment gives better, inferior or equal effect of treatment than not using such tests.