1. Methods Results ASAT Extract of Objectives COBRA*: 1-Year Retention and Outcome of Methadone and Buprenorphine Maintenance in Different Care Settings in Germany Apelt SM, Bühringer G, Siegert J, Soyka M & Wittchen H-U Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden Background Conclusion References & Publications  Buprenorphine and methadone are two established substitution drugs licensed in many countries for the maintenance treatment of opioid dependence.  Little ist known about how these two treatments work under routine care conditions... ...and particular in different provider formats, such as small, primary care based and large, specialized substitution centres. To describe over a period of 12 months:  Differences in retention rates...  Differences in concomitant drug use...  Differences in therapy outcome......in a nationally representative sample of N=223 substitution physicians and a total of N=2,694 consecutive patients in substitution treatment. Settings were divided into small, primary care based settings ( 40 patients per day). 2,694 patients (223 doctors) 2,223 patients still in treatment (215 doctors) 2,007 patients still in treatment (206 doctors) 1,631 patients still in treatment (194* doctors) 405 patients discontinued therapy, reasons were: 1 – death n = 13 2 – disciplinary reasons n = 58 3 – treatment success (clean) n = 55 4 – change to drug-free therapy n = 86 5 – side effects n = 0 6 – change of residence n = 135 7 – other/unknown n = 58 8 doctors withdrew participation (N = 66 patients) 9 doctors withdrew participation (N = 47 patients) 169 patients discontinued therapy, reasons were: 1 – death n = 5 2 – disciplinary reasons n = 29 3 – treatment success (clean) n = 15 4 – change to drug-free therapy n = 37 5 – side effects n = 0 6 – change of residence n = 52 7 – other/unknown n = 31 12 doctors withdrew participation (N = 120 patients) 256 patients discontinued therapy, reasons were: 1 – death n = 10 2 – disciplinary reasons n = 32 3 – treatment success (clean) n = 30 4 – change to drug-free therapy n = 51 5 – side effects n = 0 6 – change of residence n = 67 7 – other/unknown n = 66 baseline 1st short assessment (6-month-fu) 2nd short assessment (9-month-fu) 12-month follow-up summary documentation available of 2,461 patients Response Rate = 91,35% 830 patients with complete drop-out documentation! Reasons for drop-out were: 1 – death n = 28 2 – disciplinary reasons n = 119 3 – treatment success (clean) n = 100 4 – change to drug-free therapy n = 174 5 – side effects n = 0 6 – change of residence n = 254 7 – other/unknown n = 155  The study confirms an overall effectiveness of agonist maintenance treatments in routine care.  Small-scale, primary care based settings perform as well or better as large-scale substitution centres... ...suggesting that these primary care based settings might be a promising alternative to improve access to maintenance therapy in underserved areas.  Further analyses of possible patient‘ diffences between settings are necessary. Wittchen, H.-U., Apelt, S. M., Soyka, M., Bühringer, G. et al. (2005). Buprenorphine and methadone in the treatment of opioid dependence: methods and design of the COBRA study. International Journal of Methods in Psychiatric Research, 14(1), 14-28 Wittchen, H.-U. (2005). Buprenorphine and Methadone Treatments in Routine Care: Findings from the 12- month COBRA Cohort Study in Germany. Conference Abstract Book, "Safer Options in the Treatment of Opioid Dependence", Day 3, S. 16 Apelt, Sabine M. (2005). Correlates of High-Risk Behavior Among Methadone and Buprenorphine Patients with HIV (COBRA). NIDA 2005 International Forum Abstracts, Page 5 of 52 Apelt, S.M., Siegert, J. & Wittchen, H.-U. (2005). Substitution in Routine Care: Retention Rates after 9 Months of Follow-up (COBRA). WPA-World Congress 2005 Abstract Book, Page 607 Wittchen, H.-U., Apelt, S.M., Mühlig, S. (2005). Die Versorgungslage der Substitutionstherapie. Buchbeitrag in Gerlach, R. & Stöver, H. (Hrsg.) Vom Tabu zur Normalität: 20 Jahre Substitution in Deutschland - Zwischenbilanz und Aufgaben für die Zukunft. Wittchen, H.-U., Apelt, S. M., Christl, B., Hagenau, K. A., Groß, A., Klotsche, J. & Soyka, M. (2004). Die Versorgungspraxis der Substitutionstherapie Opiatabhängiger (COBRA). Suchtmed 6 (1) 80-87 OR 0.41** OR 0.51*** OR 0.58*** OR 0.73** ATTAINMENT OF TREATMENT TARGETS CONCOMITANT DRUG USE 12-MONTH RETENTION BMBF - Suchtforschungsverbund Sachsen – Bayern Allocating Substance Abuse Treatments to Patient Heterogeneity This work has been prepared in the context of the project F8 “Allocation in substitution treatments – COBRA ( PI ) within the Addiction Research Network ASAT (Allocating Substance Abuse Treatments to Patient Heterogeneity).Contact information: e-mail: asatkoordination@mpipsykl.mpg.de (www.asat-verbund.de).www.asat-verbund.de ASAT is sponsored by a federal grant of the Federal Ministry of Education and Research (01 EB 0440 - 0441, 01 EB 0142). First phases of this project have been funded in addition by an unrestricted educational grant of essex pharma GmbH, Munich, Germany. COBRA contact information: COBRA@psychologie.tu-dresden.de baselinefollow-up positive drug screen (in %) small setting large settingsign small setting large settingsign opiates13.618.8 p=0.065 8.814.1 p=0.019 methadone*3.62.3 p=0.670 2.00.0 -- cocaine6.811.5 p=0.035 3.16.2 p=0.041 XTC0.50.4 p=0.934 1.4 p=0.986 amphetamine0.90.4 p=0.463 0.60.3 p=0.647 benzodiazepine21.126.7 p=0.088 16.023.8 p=0.007 THC38.252.4 p=0.000 31.846.2 p=0.000 *without methadone-patients Target week assessment (Feb-Mar/2004) Small setting (<10 p/d) 6- and 9-month Follow-up Monitoring with Drop-out Documentation Medium setting (10-40 p/d) Large setting (>40 p/d) Target week assessment of 12-month Follow-up Representative sample of substitution physicians in Germany (N=3006) Random sample Participation at prestudy (Jun-Sep/2003): N=379 physicians Patients QuestionnaireDoctors Questionnaire Urine Drug Screening Prestudy QuestionnaireMaintenance Staff QuestionnairePrestudy Main Study Follow-Up Patients QuestionnaireDoctors Questionnaire Urine Drug Screening Retention rate (%) weeks after baseline % * Cost-Benefit and Risk Appraisal of Substitution Treatment