Summary of findings for the main comparison. Supervised dosing with a long‐acting medication compared to unsupervised consumption for opioid dependence.
| Supervised versus unsupervised dosing | ||||||
| Patient or population: patients with opioid dependence Settings: outpatients Intervention: supervised dosing with a long‐acting medication Comparison: unsupervised consumption | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect (95% CI) | No of Participants (studies) | Quality of the evidence (GRADE) | Comments | |
| Assumed risk | Corresponding risk | |||||
| Unsupervised | Supervised | |||||
| Retention ‐ retention at the end of treatment (number of participants) Follow‐up: 3‐12 months | Study population | RR 0.99 (0.88 to 1.12) | 716 (4 studies) | ⊕⊕⊝⊝ low1 | ||
| 634 per 1000 | 628 per 1000 (558 to 710) | |||||
| Moderate | ||||||
| 653 per 1000 | 646 per 1000 (575 to 731) | |||||
| Retention ‐ retention at 3 months (number of participants) Follow‐up: mean 3 months | Study population | RR 0.94 (0.84 to 1.05) | 472 (3 studies) | ⊕⊕⊝⊝ low2 | ||
| 707 per 1000 | 664 per 1000 (594 to 742) | |||||
| Moderate | ||||||
| 737 per 1000 | 693 per 1000 (619 to 774) | |||||
| Adverse serious events (any) (number of participants) Follow‐up: mean 7.5 months | Study population | RR 0.63 (0.10 to 3.86) | 363 (2 studies) | ⊕⊝⊝⊝ very low3,4 | ||
| 77 per 1000 | 49 per 1000 (8 to 298) | |||||
| Moderate | ||||||
| 80 per 1000 | 50 per 1000 (8 to 309) | |||||
| Abstinence from unsanctioned opioid use (number of participants with urine drug screen or self‐report use) Follow‐up: mean 3 months | Study population | Not estimable | 293 (1 study) | ⊕⊝⊝⊝ very low4,5 | No difference between supervised and no supervised therapy in self‐reported heroin use at 3 months (67% vs 60%, P = 0.33) | |
| See comment | See comment | |||||
| Moderate | ||||||
| Diversion (number of participants) Follow‐up: mean 3 months | Study population | Not estimable | 293 (1 study) | ⊕⊝⊝⊝ very low4,5 | 5% respondents in the supervised group and 2% in the unsupervised group reported that "they had let another person have their drug", but it is not clear if the data referred to diversion. | |
| See comment | See comment | |||||
| Moderate | ||||||
| Frequency of unsanctioned opioid use at the end of the intervention (number of days) | See comment | See comment | Not estimable | 0 (0 study) |
See comment | No studies assessed this outcome |
|
Mortality ‐
(number of participants) Follow‐up: mean 12 months |
See comment | See comment | Not estimable | 230 (1 study) | ⊕⊕⊝⊝ low4 | It was reported one death from gastric haemorrhage at day 304 post‐enrolment, and one death from pneumonia at day 334 post‐enrolment. In one cohort study (6983 participants), the mortality rate ratio was unrelated to regular supervised methadone consumption. All‐cause mortality was lower in those with regular supervision (crude mortality rate 0.60 versus 0.81 per 100 person‐years), although after adjustment insufficient evidence existed to suggest that regular supervision was protective (mortality rate ratio = 1.23, 95% CI = 0.67–2.27). |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; | ||||||
| GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate. | ||||||
1 Downgraded of two levels because all studies were at high risk for performance bias, one at high risk of detection bias and one at unclear risk for selection bias 2 Downgraded of two levels because all studies were at high risk for performance bias, one at high risk of detection bias and one at unclear risk for selection bias 3 Downgraded of two levels because two studies at high risk for performance and detection bias 4 Downgraded of two levels because OIS not met 5 Downgraded of two levels because the study was at high risk for performance and detection bias