JOURNAL OF SUBSTANCE USE

2018, VOL. 23, NO. 3, 318–321

https://doi.org/10.1080/14659891.2017.1397210

Outcome of patients who taper off opioid maintenance during in-patient

rehabilitation treatment for opiate use disorder. A controlled multicenter study
Michael Speckaa, Thomas Kuhlmannb, Karin Feugmannc, Wilma Funked, Martina Pietrasc, Yvonne Postd,
Andreas Rhodee, and Norbert Scherbauma
a
LVR-Hospital Essen, Department of Addictive Behavior and Addiction Medicine, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany;
b
Psychosomatische Klinik Bergisch Gladbach, Bergisch Gladbach, Germany; cDiakoniewerk Duisburg, Duisburg, Germany; dKliniken Wied, Mühlental,
Wied, Germany; eFachklinik Release, Ascheberg-Herbern, Germany

ABSTRACT ARTICLE HISTORY

Background: Little is known about the outcome of patients who are accepted into rehabilitation Received 30 May 2017
treatment for opiate users (LRT) while receiving an opioid maintenance drug and who plan to taper Revised 9 October 2017
off during LRT. Method: Patients from four LRT facilities were included if they entered treatment during a Accepted 20 October 2017
3-year period while still receiving their maintenance drug (OMT group). For each OMT patient entering KEYWORDS
LRT, a non-OMT patient from the same facility who had entered treatment immediately before or opiate dependence;
afterwards was selected as control. Analysis included standardized clinical documentation of patient in- patient rehabilitation
characteristics, treatment process, and treatment outcome. Results: The OMT group (n = 227) was similar treatment; opioid
to the control group (n = 156) with regard to sociodemographic and clinical characteristics. A zero detoxification; opioid
dosage was achieved by 37% of OMT patients. LRT was regularly completed by 28% of OMT patients, maintenance treatment
and by 57% of those OMT patients who had reached zero dosage, compared with 49% of controls.
Discussion: Controls represented a preselected group that already had successfully completed detox-
ification. LRT completion rate therefore appears satisfactory for the OMT group and especially for those
who had successfully tapered off opiates during LRT. Opiate taper during LRT is an opportunity to treat
patients who are not ready for are preceding detoxification.

Introduction produce outcomes comparable with drug-free programs

(Meier, Best, & Day, 2007).
In many countries, treatment systems for opiate use disorders
In Germany, evidence-based treatment guidelines for post-
provide some type of long-term in-patient rehabilitation treat-
acute treatment of opiate use disorders describe two main
ment (LRT). These are intensive and highly structured treat-
goals: harm reduction in all life areas and abstinence from
ments for groups or “communities” of patients. LRTs aim at
addictive drugs, especially from heroin (Havemann-Reinecke
helping patients to fully recover from opiate dependence and
et al., 2004). For reaching these goals, maintenance-oriented
to establish a drug-free lifestyle. Programs can differ markedly
and abstinence-oriented treatments are offered. Abstinence-
with regard to therapeutic approach or philosophy, treatment
oriented treatment is often carried out in specialized in-
length, and treatment components (EMCDDA, 2014).
patient clinics or in specialized psychiatric wards. These
One specific aspect of LRTs is whether detoxification, as a
long-term inpatient rehabilitation treatments are mainly
medically supervised intervention to resolve withdrawal symp-
funded by pension insurances. Admission criteria for LRT
toms associated with chronic drug use, is a prerequisite for
are high treatment motivation, high abstinence motivation,
admission to LRT. This is particularly important for patients in
and readiness to abstain from all psychotropic substances
opioid maintenance treatment (OMT). Traditionally, residential
(except caffeine and nicotine) during treatment.
programs based on the therapeutic community approach or on
Traditionally, the separation between OMT and LRT was
the 12-step-approach held unfavorable views on OMT, and it
very strict. Since OMT patients may still experience pro-
was concerned that the use of such medication could impede
tracted somatic and psychiatric withdrawal symptoms after
recovery (Sorensen et al., 2009). In most member states of the
detoxification from opioids (Latowsky, 1996), these symptoms
European Union, residential facilities exist that provide on-site
could possibly increase premature treatment termination dur-
detoxification from opiates (European Monitoring Centre for
ing LRT.
Drugs and Drug Addiction, 2014), but it has rarely been studied
It was therefore proposed to offer slow taper from main-
whether patients who had not detoxified from their maintenance
tenance drugs during LRT for those patients who felt or were
drug at admission show worse outcomes in LRT than opiate-free
considered unable to successfully do so before treatment.
patients. Data from the United Kingdom indicate that those
After German pension insurances had started to grant the
rehabilitation programs that include on-site detoxification
opportunity to temporarily treat patients with opioids when

CONTACT Norbert Scherbaum norbert.scherbaum@uni-due.de LVR-Hospital Essen, Department of Addictive Behavior and Addiction Medicine, Faculty of
Medicine, University of Duisburg-Essen, Virchowstraße 174, 44147 Essen, Germany.
© 2017 Taylor & Francis Group, LLC
 JOURNAL OF SUBSTANCE USE 319

in LRT, few facilities took this opportunity, mostly with only a control group. Treatment course and outcome of all included
small number of patients, in order to gather experience with patients could be observed for at least 6 months.
this approach (Kuhlmann, 2012, 2014). Data were extracted from the standardized documentation
The current multicenter study aims at evaluating of this forms that are mandatory for LRT facilities if treatment is
comparatively new approach within the existing treatment funded by the pension funds. They contain sociodemo-
system. Rehabilitation clinics that offer opioid tapering during graphic, economic, and health information, for example,
LRT, in addition to completely drug-free treatment, partici- about existing partnerships and family, former education,
pated in a research project to document baseline character- recent employment, legal problems, somatic and psychiatric
istics and treatment outcomes of both patient groups. diagnoses, and previous treatments. In addition, treatment
files were analyzed with regard to duration of treatment,
course of tapering off the maintenance drug (if applicable),
Methods
and information about LRT outcomes. Anonymous data were
Participating facilities were part of a network of LRT clinics transmitted to a standardized form and sent to the University
offering treatment for OMT patients not yet detoxified from of Duisburg-Essen for statistical analyses.
their maintenance dug. All clinics had at least 3 years of
experience with admitting OMT patients into LRT. Facilities
were located in medium sized or small towns in the German Results
federal states Nordrhein-Westfalen and Rheinland-Pfalz. The
network cooperates with the Addiction Research Group at the Sample description
LVR-Klinik Essen, Hospital of the University of Duisburg- The number of patients from each clinic varied between 38 and
Essen, which provided assistance in study planning and car- 170. The total sample comprised 383 patients, 227 from the
ried out data analyses. OMT group, and 156 from the control group. The different
Access to LRT in Germany is arranged by drug counseling group sizes resulted from the fact that one clinic mainly treated
services. After the pension insurance has accepted an applica- maintenance patients (91 out of 108 included patients).
tion for LRT, opiate users enter comprehensive in-patient Patient characteristics within each group are displayed in
withdrawal treatment (which includes a patient’s preparation Table 1. Mean age was 36.1 years (SD 9.1) in the OMT group
for follow-up treatment) and immediately transfer to LRT
afterwards. If an LRT without preceding detoxification is
Table 1. Patient characteristics at admission.
planned, this has to be approved by the pension insurance
Maintenance Control Group
in advance. These patients do not undergo comprehensive in- (n = 227) (n = 156) comparisonc
patient withdrawal treatment and have to be prepared for LRT Female 36.6% 40.4% ns
by out-patient services. Age (mean, SD) 36.1 (9.1) 35.2 (8.8) ns
Treatment here was provided according to the German Additional Substance Use Disorder ns
(SUD)
guidelines for postacute treatment of opiate use disorders None 10.1% 10.3% ns
(Havemann-Reinecke et al., 2004). Key treatment element is One 16.7% 21.2% ns
>1, or polySUD 73.1% 68.6% ns
the therapeutic community. Within this community, patients Age at start of opiate addiction 19.8 (5.3) 20.4 (6.0) ns
should learn a more realistic perception of their own deficits (mean, SD)
and abilities, learn to reflect the norms and values guiding Years of opiate addiction (mean, SD) 16.3 (9.2) 14.8 (8.8) ns
Psychiatric (non-SUD) diagnosesa ns
their behavior, to act responsibly, to sustain conflicts and None 49.8% 54.5% ns
unpleasant feelings, to solve conflicts by themselves, and to Schizophrenia etc. (ICD F2) 8.4% 12.2% ns
Affective Disorder (ICD F3) 15.9% 24.4% ns
take the initiative for behavior changes. Treatment elements Anxiety Disorder (ICD F4) 8.8% 6.4% ns
include, among others, single and group therapy sessions, Personality Disorder (ICD F6) 21.1% 29.5% ns
ergo therapy, family therapy, social skills training, health Hyperkinetic Disorder (ICDF9) 4.8% 1.9% ns
Other 5.3% 1.9% ns
counseling, sports, relaxation training, and recreational Mandatory LRTb 48.8% 51.2% ns
groups. In response to individual problem profiles, additional Lifetime incarcerations 56.5% 60.8% p < 0.01
Premature termination of previous
interventions could be offered, such as relapse prevention LRTs
training, assertiveness training, or interventions for mental More than one 17.7% 22.5% ns
health problems such as nicotine dependence, chronic anxi- One 26.2% 25.2% ns
Regular completions only 16.4% 15.5% ns
ety, or traumatic experiences. One facility offered treatment No previous LRT 39.6% 36.8% ns
exclusively for women. History of OMT
Currently in OMT 100% 0% –
All patients who received maintenance drugs were OMT last 6 weeks before admission 100% 43.2% –
included if they had started LRT after March 2012 and before No OMT during lifetime 0% 19.6% –
July 2015. They constituted the “maintenance group.” The No complete schooling 28.2% 30.8% ns
No complete vocational training 36.0% 36.2% ns
control group consisted of patients who had started treatment Fully able to work 78.3% 78.9% ns
immediately before or after (depending on which was closer) Currently employed 13.5% 12.8% ns
Current partnership 27.7% 28.8% ns
a respective patient from the “maintenance group.” In one a
Multiple entries possible.
facility, the majority of patients were still on maintenance b
Prison sentence suspended in case of treatment uptake.
medication at admission to LRT. For this facility, all other c
Mantel-Haenszel test for binary variables, analysis of variance for interval scaled
patients treated during the study period constituted the variables, each with “clinic” as stratum.
320 M. SPECKA ET AL.
and 35.2(8.8) in the control group (group comparison,
adjusted for clinic not significant). The overall proportion of
female patients was 36.6% versus 40.4% (Mantel-Haenszel test
with clinic as stratum not significant).
About 90% of patients had received one or more diagnoses
of a substance-related disorder (SUD) in addition to opioid
dependence. Substances were cocaine (n = 66), alcohol
(n = 67), cannabis (n = 71), sedatives (n = 47), and stimulants
(n = 22), and/or the diagnosis was “multiple substance depen-
dence” (n = 207). Opiate dependency had started during
adolescence or young adulthood. Since then about 15 years
had passed, on average. A large proportion of patients had no
vocational qualifications, and while nearly 4 out of 5 patients
were classified as being able to work, only 1 out of 8 was
currently employed.
None of clinical, sociodemographic, or treatment history
characteristics investigated here showed a marked or a statis-
tically significant difference between groups.
Methadone taper
Tapering off the maintenance drug was started 1–2 days after
admission in two clinics, and about 2 weeks after admission in
the other two clinics. In individual cases, taper started later than
usual. Buprenorphine was the maintenance drug for 21.1%,
racemic methadone for 48%, and levomethadone for 30.8%.
Using a 1:5 ratio for calculating equivalence doses between
buprenorphine and racemic methadone (Schottenfeld, Pakes,
Oliveto, Ziedonis, & Kosten, 1997), and a 1:2 ratio for levo-
methadone versus racemic methadone, the median initial dose
was 40 mg racemic methadone (-equivalent) for the total group
and also in each clinic. Methadone (-equivalent) was reduced by
1.3 mg/d, on average (SD 1.6). This rate varied from 1.0 to 1.7
between clinics.
Premature termination of LRT already before the start of
dose reduction was documented in 15% (n = 34) of patients in
the maintenance group, 4.4% (n = 10) were found mentally or
physically too unstable for complete detoxification and
received their maintenance drug throughout LRT, 2.5%
(n = 6) were transferred to other clinics, and 40.5% (n = 92)
terminated LRT during dose reduction. Therefore, 37.4%
(n = 85) reached a zero dose (range 22.1% to 57.9% between
clinics). There was no statistically significant difference
between detoxification drop-outs versus completers with
respect to when tapering off had started (analysis of variance
with treatment center as additional factor).
Outcome of LRT
In the maintenance group, 27.8% of patients regularly com-
pleted treatment, compared with 48.7% in the control group.
The overall completion rates were not biased by different
sample sizes between facilities: when weighted by the number
of patients per clinic, completion rates were 27.0% in the
maintenance group and 45.8% in the control group. The
spread of completion rates between groups varied from 7%
to 27% between clinics. A Mantel-Haenszel test with clinic as
stratum showed a statistically significant (p < 0.001) associa-
tion between group membership and treatment completion
and no significant interaction effect between clinic and group
membership (p = 0.30). Of those patients who had reached
zero dosage, 57.6% regularly completed LRT, 5.8% prema-
turely terminated LRT during the first week after having
reached zero dose, 9.4% during the second week, and 27.2%
after more than 2 weeks. Of those patients whose detoxifica-
tion was stopped or dismissed, 83.3% (10 out of 12) regularly
completed LRT.
Main reasons for irregular termination of treatment were
patient drop-out against medical advice (44.9% of the main-
tenance group, 28.2% of the control group), and discharge on
disciplinary grounds, for example, because of uncontrollable
substance use (26% versus 20.5%).
Discussion
To our knowledge, the present study is the first that empirically
investigated the outcome of patients who enter abstinence-
oriented LRT facilities while still receiving their opioid main-
tenance drug. The study included patients who were admitted to
long-term residential treatment (LRT) while on opioid main-
tenance and also opiate-free patients (mostly after previous
inpatient detoxification treatment). The LRT completion rate
in the opiate-free group (48.7%) was higher than expected from
literature (29–37%, Havemann-Reinecke et al., 2004, or 20–71%,
Ravndal, Vaglum, & Lauritzen, 2005), and the completion rate
of successfully detoxified patients (57.8%) was even higher.
Groups were very similar in terms of opiate use history,
psychiatric comorbidity, legal problems, and experience
with previous LRT. Nevertheless, patients opiate-free at
admission necessarily were a positively selected group
from those opiate users who had been accepted to LRT
and had entered in-patient withdrawal treatment: they had
already successfully completed opiate detoxification, while
those applicants for LRT who were not able to complete
detoxification do not show up in the studied group of
opiate-free LRT patients This kind of selection is severe:
typically, less than half of in-patient detoxification treat-
ment patients reach a detoxified state (Specka, Buchholz,
Kuhlmann, Rist, & Scherbaum, 2011). In contrast, the group
of initially opioid-maintained patients was a mixture of
those who had the ability to achieve an opiate-free status
and those who had not. The 37% rate for complete opiate
withdrawal within the maintenance group was lower than
for opioid-maintained patients who enter specialized in-
patient detoxification treatment with the intention to trans-
fer to drug-free treatment afterward (54.8%; data from a
German multicentre study, Specka et al., 2011), but it was
similar to the rate of successful transitions from detoxifica-
tion into drug-free treatment (35.4%).
In addition to direct comparisons within the study sample
and with findings from other studies, the outcome of the
initially opioid-maintained group can be evaluated with
respect to the particular difficulties expected for this group.
Patients themselves and/or their treatment providers con-
cerned large difficulties to reach and maintain an opiate-free
status. Dose reduction of the maintenance drug until absti-
nence must not be underestimated as some kind of mild,
protracted detoxification. It rather implies a considerable

mental and pharmacological challenge. At the same time, the
function of the maintenance drug for emotional and mental
stability must be taken into account. It may therefore be
assumed that only a minority of the substituted group
would have entered LRT or even succeeded there, if the
opportunity of receiving their maintenance drug within treat-
ment had not been offered.
It is not known whether particular characteristics of the
initially maintained patients lead to their decreased completion
rates, or whether treatment characteristics play a more impor-
tant role. For example, patients entering LRT on their mainte-
nance drug were a minority in three out of four clinics. In
addition, the use of medically prescribed drugs for substance
abuse has traditionally been considered inconsistent with the
Therapeutic Community approach, since intake of medications
which alter mental or emotional states was considered as drug
use which impedes recovery (Sorensen et al., 2009). In compar-
ison, according to data from the United Kingdom, specialized
rehabilitation services for psychotropic drug users that include
detoxification achieved completion rates not lower than drug-
free services (Meier et al., 2007). Clinical experience suggests that
successful medical rehabilitation of opioid-maintained patients
requires realistic expectations on the side of treatment staff and
readiness of staff to react constructively and in a therapeutic way
with the particular problems experienced by these patients dur-
ing and after detoxification (Kuhlmann, 2014). The therapeutic
attitude based on the treatment with drug-free patients and the
internal dynamics within the therapeutic staff (e.g., during times
of organizational changes) have an important impact on ther-
apeutic judgement and how patients are worked with in LRT.
To conclude, results from the present study suggest that
within traditionally drug-free LRT environments, a patient
group that anticipated low success for detoxification and subse-
quent drug-free treatment can be treated with sufficient success,
if offered opioid taper during LRT. Further research might
concern the optimal speed of taper, additional treatment mea-
sures to increase retention, and whether discontinuation of taper
without discontinuation of LRT should be a regular and more
frequently chosen treatment option. If detoxification is an obsta-
cle for some patients to either apply for, or enter, or sustain in
LRT, these patients are withheld from the benefits of treatment,
which possibly can be achieved regardless of whether the patient
is still on a maintenance drug or opiate-free.
Disclosure of potential conflicts of interest
Professor N. Scherbaum received honoraria for the participation in
Advisory Boards and for holding lectures by the companies AbbVie,
Sanofi-Aventis, Mundipharma, Indivior (formely Reckitt-Benckiser)
JOURNAL OF SUBSTANCE USE 321
and Lundbeck in the past three years. Dr. A. Rhode received honoraria
for holding lectures by the company Mundipharma. Dr. T. Kuhlmann,
Dr. M. Specka, Dr. W. Funke, Y. Post, K. Feugmann and M. Pietras have
nothing to declare.
Funding
The present study was supported by a grant by Deutsche
Rentenversicherung Bund, grant number 0421/40-64-50-54 Reha und
Substitution.
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