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  Cairns APSAD Conference 2006 summary: day two

Posted: November 21, 2006 12:45

APSAD Annual Scientific Conference. Cairns, Queensland.

Tues 7th November 2006.

The day started with a spirited talk by Shane Kawenata Bradbrook on tobacco use from a Maori perspective. His �Maori Smokefree Coalition� had a major input into a global treaty to address the epidemic, winning a number of international legal cases in which tobacco had been promoted using grossly inappropriate means. He spoke logically and passionately about the desire to rid his country of tobacco, reminding us that his people (and other non-American indigenous people) had always lived without tobacco before European colonisation.

Next we had a presentation from veteran criminologist and researcher Don Weatherburn from NSW. He outlined the alarming figures which were presented at the first �Deaths in Custody� report 15 years ago and showed that most have become even worse since, despite enormous efforts and expenditure at federal and state levels. He reminded us that the indigenous community is over-represented 10 fold or more in the prison system and that almost 50% of the crimes involved are alcohol related. He discussed the use of police action to enforce community instigated prohibitions on alcohol, also reminding us that such action must not be too severe and must have community support (eg. no �commando� operations). The overall thesis proposed by Weatherburn was that we need to address alcohol and drugs more seriously as being causal in indigenous detention - and dedicate more resources to specific drug/alcohol interventions - given that the significant investments in addressing the broader social and economic circumstances had not reduced harms associated with indigenous imprisonment to date.

Dr Mark Wenitong spoke about his Aboriginal Woochopperan Health Centre in Cairns, concerning delivery of smoking cessation and other services to both local and remote communities. He reiterated us of the high rates of smoking and drinking as well as the costs. Domestic violence and injuries can result in an air ambulance evacuation and long term hospitalisation, quite apart from the uncostable social disruption for families involved.

Following the opening plenaries there were another 7 sessions on a variety of subjects including detoxification, SMART recovery, prison issues, cannabis (including a trial from Sydney of using lithium) and the so-called heroin drought.

In one session, we were told that 50% of young people in a particular birth cohort had used cannabis and 22% had reported a cannabis use disorder at some time. I found this figure very high and wondered about the definition. We were also told that �The evidence suggests that most young people who use cannabis do so infrequently and that they do not develop a cannabis use disorder�. There were other presentations concerning psychosis and cannabis use, inhalant use and hepatitis C.

These afternoon sessions were all delayed slightly by the running of the Melbourne Cup. We heard in a brief presentation from Professor John Strang of London that the standard of methadone prescribing in England improved in the ten years during which his �Orange� guidelines were circulated to GPs (1999). Findings from comparable surveys in 1995 and 2005 showed a modest increase from around 45mg daily dose to 54mg. This is still a long way from the ideal, believed to be between 80 and 100mg daily. Strang�s own guidelines recommend a minimum effective daily dose of 60mg. In response to my question after the session, he explained findings of 37mg daily in another UK study he performed in 2005 used different methodology so he did not bring it up at the presentation. He agreed with me that the state of clinical standards in the UK were �disastrous�, but �less disastrous than they had been in 1995�.

Professor Strang told us that dose supervision was now more common in England and there was less methadone ampoule and tablet prescribing This may be a good thing overall, yet it is also possible that such treatment suited some patients who may do poorly on standard oral treatment. Along that line, he reported a new initiative prescribing heroin and methadone ampoules to addicts who had failed other forms of treatment in London, Brighton and two other centres in England. They are using the same protocols as the Swiss trials started in 1995.

Strang�s London colleauge, Dr Soraya Mayet spoke about QT intervals being affected by methadone, especially at high dose. She had the whole room debating how often cardiographs should be done, yet an authority on the subject wrote in Lancet recently that routine cardiographs are unnecessary in new patients joining treatment (Krantz 2005). In fact, most reported symptomatic cases either had other risk factors such as cocaine use or else they were on extremely high doses (mean 300mg daily) and/or were pain management patients.

Our own group presented analysis of trough blood R-methadone levels showing that these were lower (1) in high dose patients and (2) in those smoking cannabis, but that there was no significant association with benzodiazepines or alcohol using stepwise regression analysis of 70 cases uncomplicated by other medication use. Causation would have to be determined by further research.

Eight parallel sessions followed afternoon tea, covering worker burnout, injecting rooms, blood borne viruses, tobacco interventions in mental patients, pregnancy and indigenous communities with an optional visit to the Wuchopperen Health Service in Cairns where inhalant use is being addressed.

The conference dinner was a noisy but pleasant affair at the Pacific International ballroom. Everyone seemed to mix and let their hair down. I looked at my watch as security hounded us out - it was midnight!

Comments by Andrew Byrne ..


Krantz MJ, Mehler PS. QTc prolongation: methadone's efficacy-safety paradox. Lancet 2006 368;9535;556-557


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