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  APSAD annual scientific conference, 2005

Posted: November 09, 2005 22:41

9th November 2005


APSAD annual scientific conference. Melbourne, Victoria, Australia. Day three.



The third day of the East Melbourne addiction meeting started with an up-date by Keith Humphreys on the place of Alcoholics Anonymous and other self-help groups in managing addictions. He quoted the estimated staggering numbers of such groups as AA, NA, Alanon, Alateen, Cocaine Anon, etc, across the world. While accepting that scientific proof of the benefits of such social interventions are not possible, he stated that numerous high quality studies showed that health budgets saved large sums from those who chose to use self-help rather than traditional medical services such as counselling, cognitive behavioural approaches and pharmacotherapies. He also quoted one of the most convincing studies from 1981 in which not one patient who was 'passively' referred to AA actually attended a meeting. This compared with 100% who had a personal telephone referral from an AA sponsor. This is consistent with my own experience in simply recommending AA by handing a leaflet with dates, time and addresses of local meetings.

The next talk was by Annie Madden who spoke eloquently about ethics of research on subjects with drug and alcohol issues. Ms Madden was commended for her work in various capacities with and for drug users in NSW and Canberra over many years. This was backed up later by Adam Winstock who praised the Intravenous League for their cooperation and assistance in some of his novel research on drug diversion in South West Sydney. In this parallel session he and his colleague Tony Jackson showed that in their diverse Health Service cohort both methadone and buprenorphine were diverted for numerous reasons. Their findings indicated that about 5 per 1000 doses of buprenorphine were diverted. This was more commonly reported from those treated in community pharmacies where time and other factors make effective direct supervision less practicable. He said that one public clinic stated that they have had absolutely NO diversion yet his confidential questionnaire showed that the clinic had dozens of such instances reported by patients. Dr Winstock takes a non-judgemental line in addressing diversion, treating each case individually and working on the issues leading to the apparent misuse of the prescribed medication. He reminded us of two ways buprenorphine can be diverted, (1) obscuring the drug within the mouth and (2) secreting it elsewhere during administration. These were reported to be equally prevalent in western Sydney. 'Cracking' the tablets to coarse granules was probably an effective strategy both in aiding absorption and preventing diversion. However if tablets are pulverised to powder this can defeat both aims by creating either a milky solution which is swallowed or else forming a paste which is not absorbed at all well either. [In our own service we usually break the tablets in two and to observe them 'in situ' at least twice before they have gone.]

The reasons respondents gave for diverting their medication included: (1) to take later in the day (2) to inject (3) to sell (4) to take a lower dose (5) to store (or 'squirrel' as Dr Bell terms it). Dr Winstock speculated on the 'big picture' reasons for such diversion as being: (1) the continued shortage of treatment positions (2) constraints on such treatment (3) desire for lower maintenance doses (4) as a replacement for street heroin (ie for illicit purposes). Overall he felt that diversion itself was prima facie evidence for a breakdown in the therapeutic relationship, rather than just a lack of understanding of motivations behind it. He pointed out that especially since the 'heroin drought' buprenorphine and methadone can be excellent value on the streets, being cheap and longer acting.

Another important contribution on day three was Winstock's other paper described three means of starting buprenorphine in an attempt to avoid early drop-outs. His own elegant longitudinal study showed in a variety of community patients, those who were given over 17mg in the first three days of treatment had almost twice the chances of still being in treatment at 6 months as those given 17mg or less (54% vs. 29%). He also found heavy heroin users had higher drop-out rates. We were told that whether methadone or buprenorphine, the first few weeks are crucial since inadequate dosing may be the reason for some to drop-out. The risk of early toxicity with methadone is far lower when using buprenorphine . hence his and others' suggestion at this conference that we move away from the 'start low - go slow' approach and move to a 'new paradigm' for a 'new drug'. His preference was for 8mg on the first morning with an option for an extra 2-8mg later that day if desired. Some follow on day 2 with 12mg or more if cravings, insomnia or drug use persist. In our surgery we usually start with 4mg and repeat later in the day if needed (which it often is).

Nick Lintzeris then told us about his study from London (with Ridge, Gossop, Strang and Witton) looking at a large number of maintenance treatment starts (or re-starts) as to preference, experience of and actual prescription for four drugs: methadone, buprenorphine, lofexidine and dihydrocodeine. He suggested that lofexidine 'is hardly used any more in England' and that 'it is virtually the same as clonidine, except much more expensive'. He showed many comparative figures, reflecting much work from his team, but which overall showed that most patients eventually got what they had expressed a preference for initially. Because of the longer duration of action of (pure) buprenorphine, sufficient dose can be given to last 24 hours without causing the sedation which sometimes occurs with methadone. This gives rise to the 'clear-headed' reports from some patients. However, he also reminded us that many patients feel better on methadone, hence the need for individual choices, the only real other issue being pregnancy where buprenorphine is relatively contraindicated and the combination drugs completely contraindicated.

Nico Clark gave an illuminating talk on transferring in-patients from high dose methadone (between 40 and 100mg) to buprenorphine using clonidine and Valium. While all were patients wishing to try buprenorphine, several had to return to methadone dissatisfied within 2 weeks of the transfer. A significant proportion were only slightly uncomfortable and some had no withdrawal symptoms at all. The methadone was stopped for a full 24 hours and where possible for 48 hours while close observations were done in the detoxification centre being used.

Suzi Nielsen spoke about the Melbourne experience with buprenorphine and benzodiazepines. It was one of several descriptions during the conference which all seemed to be quite consistent. A majority of opioid maintenance patients (up to two thirds) have used benzodiazepines in the past 6 months and about 10-20% are dependent at any one time. One strategy was given from the Adelaide group presented by Kate Morefield on how to deal with this problem. Following on the work of Rickells, they tested a protocol to put long-term dependent patients onto 40 weeks stepped reduction doses of long acting benzodiazepine, in this case clonazepam. They used 5 weeks slow reductions by 25%, followed by 5 weeks plateau doses which was repeated in steps. The final reductions were more individually tailored. The drug was to be taken supervised on the same regimen as the opioid, from the same dispensary. Matched benzo users in parallel and "usual" treatment were used as controls and at the end of 12 months, despite numerous relapses, far less benzodiazepine (about 75% less) was being consumed by the trial patients. Such interventions are unlikely to eliminate benzo use but should enable substantial reduction in overall use of the drug, consistent with harm reduction principles. It is probably the responsibility of maintenance prescribers to address benzodiazepine use in their patients - yet many clinics and pharmacies still do not have a protocol of dispensing or administering for such dual dependencies. Poisons regulations are not attuned to this in some states. Community pharmacy may not be ideal for such treatment in new or unstable patients where there is a choice of a specialist clinic. It may be that a subsidised PBS item number for 'administration' of a small quantity of diazepam could solve the major conundrum that when we prescribe less than 50 tablets it costs our patients more money.

Presentations on hepatitis C reminded us that 90% of such infections occur in drug users and it is the responsibility of every maintenance prescriber to address this disease. Greg Dore and his group described early results of a multicentre trial of the treatment of 'acute' (or at least recently acquired) HCV using 24 weeks pegylated interferon. The treatment looks promising in HCV but may not be effective in HIV co-infected patients. Nick Walsh and Turning Point team are up-beat about a dependency clinic as a 'one stop shop' for addressing blood borne viruses (BBV). Their abstract described the use of a peer counsellor to facilitate regular in-house blood testing to monitor the need for vaccination (HBV, HAV) and/or referral for biopsy. They also dispense anti-virals at the clinic. In the same bracket Ian Chaussivert points to the enormity of the problem by describing early numbers from their 'clinic within a clinic' started in January. Out of an estimated 550 HCV carriers who have been in contact with their service, up to 200 may benefit from treatment. In the first 5 months, they assessed 32 patients and two have commenced therapy while 4 await biopsy. While these models may be very useful for New South Wales where a large proportion of patients are treated in clinics, other strategies are needed for other states and territories where community pharmacies deliver most opioid maintenance treatment. A more traditional medical referral system requires that doctors ensure that their maintenance prescription patients have blood tests ordered and referred as appropriate. A useful model might be Pap smears for cervical cancer which are now standard practice. Ian Kronborg and colleagues related a slightly larger pilot study of 23 methadone patients prescribed 'standard' antiviral treatment of 24 or 48 weeks (40% genotype 1, 55% genotype 3, 16% already with cirrhosis). We await further results after the full 50 outcomes have been tabulated.

I apologise if these summaries seem to be biased towards my own 'medical' interests. In fact many other fascinating subjects were covered in this conference. These included stimulant use and abuse, performance enhancing drugs, policy issues, injecting rooms, Aboriginal health, ethics, drugs and driving, alcohol "Interlock" ignition lock program, designer party drugs, withdrawal practices, drugs in pregnancy, specialist College policies, pain management and more.

It was disappointing that despite just receiving Commonwealth funding of up to 2 million dollars, those utilising naltrexone implants and performing rapid detoxification did not present any of their experimental findings. We could sure use funding like that in Redfern where our patients often have to pay $2000 or more per year out of their own pockets for pharmacy dispensing of their medication.

Melbourne is a beautiful city and it is a good time of year to visit. It was a frustration to have to stay indoors for the conference. I hope most delegates from out of town managed to enjoy some of the city's pleasures aside from the meeting. Congratulations to the conference organisers and presenters. The ever-present Walter Ling from California has said that he believes our annual APSAD conference is probably the worlds second largest and certainly most diverse dependency 'talkfest' (after the AATOD meeting which is held every 18 months in North America - next is April 2006 in Atlanta).

Comments by Andrew Byrne ..

 

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