China’s efforts at post-treatment rehab for heroin use disorder
In China, opioid use is a salient issue with over three quarters of the 1.14 million people with a drug use disorder reporting heroin as their primary substance
Despite legally mandated provision of two-year compulsory treatment and three-year community rehabilitation programs, lack of proper training, psychosocial treatment availability, and evaluation of these programs has limited their utility for helping people with opioid use disorders achieve abstinence and reenter society.
WHAT PROBLEM DOES THIS STUDY ADDRESS?
This comprehensive psychosocial intervention (CPI) sought to integrate therapies such as cognitive behavioral therapy (CBT) and motivational interviewing (MI) into existing community resources in Shanghai, China. Using a randomized controlled trial design, the authors then examined efficacy of this intervention at reducing drug use and improving mental health and quality of life.
HOW WAS THIS STUDY CONDUCTED?
This study enrolled 180 patients from three communities in Shanghai, China, that had recently completed two years of compulsory treatment and were thus eligible to begin three years of community rehabilitation. All patients met criteria for DSM-IV heroin dependence before starting compulsory treatment. Participants were randomized to CPI (n = 90) or usual community care (UCC, n = 90).
The main purpose of CPI was to prevent relapse and improve mental health and quality of life through CBT, MI, case management, and urine testing. CPI included individual intervention sessions for 60-minutes once per week and 90 minute small group intervention meetings held once every 2 months. UCC consisted of monthly visits by a social worker and urine tests. Participants were assessed at baseline and at the end of the intervention (one year later).
WHAT DID THIS STUDY FIND?
There was no difference in self-reported drug use or in urine toxicology results between the two groups.
Rates of relapse, defined as meeting criteria for heroin dependence, were 25.9% and 22.7% for CPI and UCC, respectively. Patients with longer lifetime heroin use (odds ratio [OR]: 1.25), longer lifetime amphetamine use (OR: 5.6), and history of injection drug use (OR: 2.8) were more likely to relapse. For example, relapse was 1.25 times more likely for patients with longer lifetime heroin use.
Regarding mental health status at the end of the intervention, participants in both groups showed improvement over time though the CPI group had significantly lower (i.e., better) scores for somatization (i.e., psychological distress presented as physical symptoms), obsessive-compulsive, anxiety, phobia-anxiety, paranoia, and psychoticism as compared to UCC. For quality of life, the CPI group had higher (i.e., better) scores in physical role limitation and emotional role limitation as compared to UCC.
While the CPI intervention did not result in better substance use outcomes than usual care, there was some advantage for mental health and quality of life.
While not traditional measures of success for a substance use program, it may be important to recognize these other areas that are associated with broader recovery. Not only does quality life tend to improve over time following treatment, but quality of life satisfaction may predict continuous abstinence. When evaluating addiction programs, these measures can provide additional insight into their benefit.
WHY IS THIS STUDY IMPORTANT
While providing community rehabilitation is an important first step, the services provided must be useful and effective. In 2010, 216,000 patients with opioid use disorders were registered in compulsory treatment facilities in China while only 84,000 were registered in community rehabilitation programs which is considered the next phase in substance use treatment cascade in this setting. Currently, these 3-year programs include regular urine testing, drug-related education, and job services.
Before expanding services to meet demand, proper evaluation through experimental methods (as seen in the current study) is needed to determine which interventions are most successful at reducing risk of relapse and helping people maintain their recovery.
The CPI intervention did not result in improved substance use outcomes for former opioid dependent individuals in China. However, relapse rates were very low at the end of the intervention (roughly 75% in both conditions had not relapse).
This may indicate:
- that community rehabilitation programs, though not necessarily CPI, are useful for reducing relapse following treatment
- longer exposure to the prior treatment works in reducing relapse
- perceived threat of readmission to compulsory treatment may keep patients motivated to remain in treatment and stay abstinent
Other examples from the U.S. show that the mixture of positive and negative consequence for abstinence/substance use can help people maintain abstinence. In the Physician Health Program where 75 to 85% of recovering physicians remain abstinent, the threat of losing their medical license and disruption to their career may act as a deterrent to use and keep participants engaged in the long-term monitoring and treatment supports. However, it is hard to develop and implement these long-term recovery management paradigms in general clinical practices due to lack of reimbursement and funding from insurance.
Compulsory drug rehabilitation is a controversial human rights issue. Twelve United Nations agencies including the World Health Organization issued a joint statement calling for the close of these facilities in favor of voluntary, evidence-based treatment. Please see here for an argument in favor of compulsory treatment for opioid dependence and here for an argument against it.
- Since participants in both groups were drawn from the same communities, there is a possibility of the UCC participants being exposed to skills and principles learned from CPI through interaction with the CPI participants.
- More information is needed regarding the impact of drop-out. It is unknown if those who dropped out of the CPI group are similar to those completed the intervention (and same for UCC). Comparisons of clinical characteristics of those who dropped out between CPI and UCC are also needed.
Since there appears to be a benefit for mental health and quality of life with the psychosocial model, future research should focus on how to best integrate these techniques in the community setting.
Additionally, with extraordinary low rates of relapse in this setting (i.e., following compulsory treatment), research into the active ingredients and mechanisms through which these kinds of programs are able to achieve these very low relapse rates are needed and could inform program development in the U.S. and other countries.
- For individuals & families seeking recovery: Engaging in a community-based program following formal treatment for opioid use disorder in China may result in low relapse rates and mental health and quality of life improvements.
- For scientists: These rates of relapse to heroin dependence were remarkably low in this Chinese sample. Research into the active ingredients and mechanisms through which these kinds of programs are able to achieve these very low relapse rates is needed. This could help inform clinical program development in the United States and other countries.
- For policy makers: With proper monitoring and evaluation, community programs such as the ones mandated in China may be a powerful recovery resource that can prevent relapse and thereby reduce overdose deaths.
- For treatment professionals and treatment systems: Depending on the services provided, referring patients to community programs may be beneficial to their recovery process. Both conditions included ongoing meetings with a counselor or social worker which may be a part of this model’s success. This is consistent with ongoing recovery management models which advocate for the use of continuing contact, monitoring of abstinence/remission status, and early re-intervention when needed (see here and here).
Zhong, N., Yuan, Y., Chen, H., Jiang, H., Du, J., Sun, H., . . . Zhao, M. (2015). Effects of a Randomized Comprehensive Psychosocial Intervention Based on Cognitive Behavioral Therapy Theory and Motivational Interviewing Techniques for Community Rehabilitation of Patients With Opioid Use Disorders in Shanghai, China. J Addict Med. doi: 10.1097/adm.0000000000000139