What can you do to reduce the alarming drug overdose death toll?

by Andrew Byrne ..

The press has been full of the disastrous toll from heroin overdoses in recent weeks, especially from Victoria. As doctors, we must face our responsibility to the community to address these matters in any way possible.

The overdose death rate in Australia rose gradually from 30 to 40 per million over a number of years in the mid 1990's. Although official figures are not available, this rate appears to have gone up from 4 deaths per week to almost 14 as reported from Victoria this year. One newspaper described it as "the overdose epidemic Australia had to have". Mostly in metropolitan Melbourne, 2 deaths per day are causing great tragedy to the families who are both ill-prepared and perplexed.

It is clear that every one of these heroin overdoses is preventable.

The means of prevention are a number of well known proven strategies as well as some proposed innovations which have shown promise in trials here and overseas. It is accepted that preventive education of addicts, availability of needles and syringes as well as methadone treatment are all effective in stemming some of the potentially lethal complications of drug use. 'Safe injecting rooms', heroin prescription, rapid detoxification, oral morphine, long acting methadone and buprenorphine are among other strategies which deserve further examination.

Improvements to our emergency services are unlikely to reduce the toll much since, in most areas, they are prompt and effective at saving lives when they are called in time.

Educating drug users about the means to save lives is important. 'Do not inject while alone'. 'Use small quantities initially'. 'Call emergency services immediately if overdose is suspected'. 'Use clean syringes'. 'Do not mix drugs and alcohol'. These are all simple but life-saving messages.

Increasing the accessibility of good quality methadone treatment will certainly reduce the death rates. It is well established that once in treatment, the mortality diminishes significantly. Methadone treatment should be available to all who require it, like any other effective pharmacotherapy. The indications are simple: chronic compulsive opiate use with proven inability to withdraw. For historical reasons this is still restricted in some states and has been banned altogether in the Northern Territory. A recent review in the Journal of the American Medical Association stated that "All persons dependent on opiates should have access to methadone hydrochloride maintenance therapy under legal supervision" [ref 1].

It is likely that bringing addicts out of secluded locations and into 'safe houses' will also spare some lives. Supervision is available and help can be summoned if overdose occurs. Most importantly, these marginalised folk can come into contact with treatment services.

Switzerland and Holland both have official death rates of less than 5 per million compared to our rates of over 40. If we could copy their examples, over 500 young Australian lives could be saved each year. These countries must be 'doing something right'. Injecting is far less common among the young in Holland where the average age of heroin injectors is around 40 years of age. The Swiss introduced 'safe injecting rooms' over 6 years ago. Switzerland has had heroin prescribed for certain groups of resistant addicts for over 5 years. Cannabis is decriminalised in Holland.

Whatever the reasons for our high overdose death rates, we desperately need to investigate all these means for reducing it. The prime reason for NOT having a heroin trial, 'sending the wrong message,' is now out of date. The second reason sometime proffered is that it 'has not worked' overseas. This is intriguing as the reported outcomes of the London, Zurich and Geneva based trials all showed benefits to addicts and society generally and a referendum in Switzerland endorsed the practice of heroin prescription to seriously addicted patients under strict supervision.

Politics, personal prejudice and international pressure must be put aside since Australian lives are too important. We need to approach this epidemic from a scientific standpoint as we did with HIV. If we can match our successes there is very much to gain.

Ref 1: Effective Medical Treatment of Opiate Addiction. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. JAMA 1998 280:1936-1943

Gradual detoxification to 0.5mg buprenorphine 'effective' over 10 days

Diamant K, Fischer G, Schneider C, Lenzinger E, Pezawas L, Shindler S, Eder H. Outpatient Opiate Detoxification Treatment with Buprenorphine. European Addiction Research 1998 4:198-202

There are impressive outcomes reported in this Vienna study of well-motivated heroin addicts doing a structured 10 day out-patient graduated detoxification using buprenorphine sub-lingual tablets.

The authors of the study chose 50 motivated heroin or opium addicts and administered up to 10 days out-patient treatment with reducing doses of buprenorphine. Doses were titrated daily depending on the degree of withdrawal symptoms. The maximum dose was on day 2 at 2.6mg. Doses averaged 2mg daily for the first 5 days, then reducing to 1.5mg for 2 days, 1.0mg for 2 days and 0.5mg on the tenth day. For only 20% of cases was it the first formal attempt at withdrawal. Withdrawal symptoms were measured on the WANG scale and were most severe initially but waned substantially despite buprenorphine dose decreases.

Patients were also routinely given an antacid preparation (famotidine or 'Pepcidine') and night time sedation if required (prothipendyl - an antihistaminic sedative).

With 15 patients dropping out, this treatment was acceptable to 35 of the 50 patients (31 male, mean age 27) yielding an overall 70% 'success' rate. Even if only a half of these remained abstinent for the medium term, it could still be considered better outcome than traditional drug free treatment.

Buprenorphine is a semi-synthetic narcotic derived from thebaine. It is long acting (>36 hours) and has opioid agonist as well as antagonist effects, rather like pentazocine (Fortral). It has been available in Australia since 1992 as an injected or sublingual analgesic but it is not yet licensed for maintenance addiction treatment. Such maintenance treatment may require much higher doses, up to 32mg daily, so 0.2mg SL tablets are not suitable. In addition, this drug, as a Schedule 8 can only be used in addicts with prior permission from the health authorities in most Australian states.

A large multi-centre trial of the sub-lingual version has reported preliminary results which apparently confirm overseas experience showing safety and efficacy when compared with methadone maintenance. Buprenorphine also has a number of important advantages over methadone such as a longer duration of action, allowing second daily attendance, a lower potential for acute toxicity as well as a possible antidepressant effect. The researchers pointed out that this drug will not be a replacement for methadone, but may be a useful alternative for those in whom methadone is not suitable.

This drug's wider availability in Australia will greatly enhance our repertoire in dealing with drug addiction. In France it has been available on normal doctors prescription for over 3 years with apparently good results in up to 50,000 patients. In the meantime, less satisfactory drugs such as codeine compounds, propoxyphene, quinine, clonidine and metoclopramide may be used to mitigate some of the symptoms of withdrawal. It is to be hoped that this drug can be marketed in a suitable preparation for addiction as soon as possible.

comments by Andrew Byrne ..

A decade of caring for drug users

[Letter in Br J Gen Pract. 1999 Feb;49(439):146.]
Sir,

Martin et al�s report on treating drug dependent patients in general practice is heartening (October Journal).1 It is a shame that the authorities do not reward such innovative and successful interventions with appropriate payment, encouragement, and replication elsewhere. Oral supervised methadone is well established as an effective management for heroin addiction.

Although it was obviously successful in numerous cases, the research evidence for injected methadone is still rudimentary. Like heroin prescription, it should probably be reserved for patients who have failed at standard treatments such as oral methadone or supported detoxification.

After 14 years of prescribing and dispensing methadone in our general practice in Sydney, we have found that oral methadone suits up to 90% of heroin injectors who present for treatment. There should be no arbitrary limits on daily doses (we use up to 350 mg daily; mean = 85 mg). It is normal practice in most jurisdictions for at least two doses per week (up to 7 in new or unstable patients) to be consumed under supervision. The use of non-supervised methadone may be effective in certain cases but this has not been demonstrated generally in the research literature. It omits a fundamental safeguard for compulsive drug users and also increases the possibility of drug diversion.

Oral methadone �failures� should be candidates for studies of alternatives such as injected methadone, prescribed heroin, rapid detoxification, oral long-acting morphine, or other approaches. There is no reason for this to happen only in specialist units. A general practice with sufficient experience in dependency, as in this case, is perfectly capable of doing the same as, or even better than, existing dependency units.

Andrew Byrne

Reference

1. Martin E, Canavan A, Butler R. A decade of caring for drug users entirely within general practice. Br J Gen Pract 1998; 48: 1679-1682.