Safe inductions into treatment

Tue 8th June 2004

Presenter:
Dr Jon Currie

Dr Jon Currie spoke with his usual punchy enthusiasm about the far reaching and diverse treatments being offered at Westmead Hospital for drug and alcohol addictions. He stressed the important 'divide' between maintenance and abstinence which, at any one time in any individual patient, are mutually exclusive.

We were told of the earnest desire of many opioid dependent patients to be abstinent. However, many such folk still feel 'empty and alone' in the 'un-opiated' state. This appears to be quite distinct from actual withdrawals which can last for up to many weeks. We were told that the fastest and possibly safest way to determine just who can and who cannot cope with abstinence is with rapid detox rather than the usual method of gradual reductions over months on methadone or buprenorphine. As Dr Currie reminded us, it is while on lower doses of maintenance opioids that drug users are most vulnerable to risk-taking behaviour, including overdose.

At a time when many dependency units are still only offering one or two specific treatments, Dr Currie's team seem to have made a number of interventions almost 'routine', despite their novelty. These include naltrexone, topiramate, ondansetron, flumazepil, acamprosate as well as some other 'off-label' uses in novel settings or in unusual combinations. Some interventions were based directly on the scientific evidence while others we were told were from the 'first principles of therapeutics'. His description of flumazenil infusions for those with benzodiazepine dependency was most instructive, noting not a single fit in over 50 cases so treated.

Along with Sydney Hospital, the Westmead unit was charged by the NSW Health Department with the initial Australian research on rapid opioid detox. To their credit, they have since moved ahead with numerous refinements and related treatments. Rapid opiate detoxification (which Dr Currie uniquely says is NOT detoxification but 'antagonist induction') has been done using full anaesthetic as well as under sedation using midazolam and propofol. Dr Currie states that full general anaesthesia is only rarely needed for such cases. The naltrexone is now given as a diluted suspension, initially in very small increments, gradually increasing to the standard 50mg daily. Octreotide is used to prevent the hyper-secretion of the bowel during the withdrawal process. We were told that the intestinal wall has high numbers of opiate receptors which also respond to the withdrawal process by overactivity, hence the diarrhoea so commonly reported during withdrawals. Ondansetron (Zofran) as tablet, syrup or injection is very effective for preventing nausea and vomiting, as also used in chemotherapy cases.

A modification of this procedure is being used by Currie's team to move patients from high dose methadone onto buprenorphine as an alternative to gradual reductions and the associated risks. We await formal reports of their findings, risks and benefits.

Few people can have more incisively and imaginatively applied the meagre literature to clinical dependency practice, and it is to be hoped that Dr Currie's work in the notoriously underfunded public sector will be recognised with the resources to allow the results to reach a wider audience via a peer reviewed forum. We still need more longer-term outcome evidence before recommending rapid detox and/or naltrexone in opioid dependent people. The passage of time and a lack of such publications will make some less confident in such treatments. There has now been 20 years of experience by serious researchers and 'enthusiasts' alike yet little convincing evidence regarding safety and effectiveness to date.

comments by Andrew Byrne ..