If by 'outcomes', you mean the completion rates for withdrawal, buprenorphine seems to have considerably improved them, especially if combined with clonidine or lofexidine for symptom control, so look at BPN trials as well as methadone. If you mean how many people are still abstinent six months or a year after withdrawal, that doesn't depend on the taper technique. It depends on post-detox management and depot/implanted naltrexone has made it much easier to get through the crucial first month or two when relapse rates are especially high. (Papers by Hulse et al, Kunoe, Lobmaier, Krupitsky for starters.) Patient selection is also important. People who really want to withdraw obviously do better than people who are very ambivalent or frankly reluctant, or are in the 'withdrawal' wing of an RCT of maintenance vs withdrawal. Also - and just as obviously - people with jobs, relationships and lives outside the addict community do better than those without. Anglin's 'Shutting off the methadone' study is an interesting natural experiment following the closing of the only methadone clinic withing a large radius.

Thank you. I will check out Anglin's work. Here in the US we really are seeing two types of maintenance- Intentional taper to abstinence, and non taper sustaining. Typically the latter is in the case of coercive intervention from the legal system or from Department of Children and Families. Anecdotal evidence suggests the long term non-taper do poorly (their lives improve little). I am trying to establish whether this is a product of the coercion,  or  because without a taper they do not develop any of the coping strategies and social tools needed in abstinence-based recovery, or both.

Many people do well on indefinite, long-term MMT and I don't think it stops them from developing general coping strategies but in the nature of things, long-term RCTs are almost impossible to do. That's partly because drop-out rates in abstinence programmes are much higher than in MMT. If they are young, they may well improve with time. If they still have important personality and coping deficits at 30 or 40, no treatment is likely to make them very much better and coping with a coerced withdrawal can destabilise them. I'm keen on making alternatives to MMT  available but it has a lot to be said for it. I've attached a chapter that discusses some of the issues. CB

I can see the point with low-coping and low functioning. However, It seems the impetus to develop appropriate coping skills may also be reduced while on MMT (application of action to affect change)? At the same time, MMT clients general score poorly in long term studies especially in the MH measure, chronic pain, abuse other medications and substances, and may exhibit neurological deficits. MMT clients very rarely achieve abstinence as well which places their outcome on par with abstinence-based treatments (and sometimes worse), it just allows for time in the interim (delay).

At the public policy level, this may useful, but the propensity for gentrification of such treatments is apparent. If we compare PHP (Physician Health) programs, and say, county maintenance outcomes, there are pretty big disparities in outcomes, and in QOL. While this doesn't account for general intellectual and social capital in comparison, it does point to a wide gulf in treatment "deservedness". 

From what I have gathered thus far, MMT is exceedingly useful in treatment retention when other measures (say in-patient care) cannot be offered. It also seems to be good for creating a safer stasis for lower functioning clients, whereby the more dangerous aspects of addiction are arrested. Additionally, from a monetary stance it makes sense, reducing crime, cost of treatment, etc etc.

What I would really like to see (and maybe I'll try to put this together if I cannot find one.) Is a control group of long term MMT clients (say 5 years) as treatment-as-usual and clients of similar social and intellectual function, who were given taper to abstinence, combined with intensive treatment, transitional supports, mutual aid membership, and capitalization of recovery gains through recovery support services.  The five year benchmark for people who receive the latter appears to drop below 20% relapse rate, with no medication, and improved social status, education, and MH outcomes (as well as stable abstinence). Do the MMT clients on on-going medication do as well? There is a lot of conjecture, but I am having trouble being able to find studies which I can compare.

I will check out this chapter. This is an exceedingly cloudy area in addiction science, fraught with politics, measurement issues, operationalized definitions which may not reflect QOL,  general subjectivity of QOL scales and inaccuracies of long term data due to self-selection bias. All this makes for the proverbial apples to oranges comparison.

Thank you for your assistance. 

Re: Your chapter. The RCT difficulty- I feel like the RCT issue could be overcome with moderate suspension of the insistence on psychological measurement  must resemble medical trials. My opinion is that psychology tries to fit itself as a square peg into a round hole by the insistence (fetish) with empirical measurement. To me that misses the larger point of psychology- which is to examine, treat, and understand the subjective psychological experience.

One salient point you made about the "morality" of dosages- that by reducing the overall intake to maintain thresholds, administered responsibly by a third party (or even in the case of self-dosing), which does show effectiveness- has essentially been subject to moral argument rather than scientific ones.

I see this as well. I think most people in the field see this. However, my observational experience with the transformative effects of abstinence-based recovery (when done in full) really moves the discussion into the social and moral realm. Since the "problem is removed" from the lives of the sufferer in 12-Step work (anecdotal), then that would seem to be preferable (and ethical) over giving an addict just enough that they are neither intoxicated nor in withdrawal, which seems somewhat cruel when juxtaposed, to the radical improvements those in abstinence based recovery seem to undergo when done completely. At the same time, one cannot (truly) account for readiness and willingness to change, which is likely the single best determinant of outcomes, no matter what treatment is used.

I can see the basis of the moral argument. We could stop terrorism by implanting a chip in every human and monitoring them, but we don't, and shouldn't, though empirically, it would fix the problem. Thus morality is a consideration. In the end, the basic question still remains- Can we adequately compare, or should we really try to compare the two? After reading your work, I can more clearly define what the inherent problems of such a comparison would be beyond the RCT issue.

I really do like your point about having treatment options which are informed, which allow for the person receiving service to choose  the option which best fits (like family planning and BC). I wish we could do this in substance abuse. Unfortunately, too many people come in for services unwillingly, and thus would choose only the most comfortable choice, which may not be the best for him. I think a lot more work could be done at the intake level of substance abuse which could reduce or eliminate this phenomena. 

Thank you again.