Does case management work? Journal article.

Rosen A, Teesson M. Does case management work? The evidence and the abuse of evidence-based medicine. ANZJ Psych 2001 35;6:731-746

Dear Colleagues,

This paper is long and complex, but its essence seems to be that to in order to be effective, 'case management' needs to be used for high risk subjects and only when implemented by professionals in the field. As a working definition, case management might be termed: "active and assertive community treatment" or better still: "patient care co-ordinated by a single professional using a multi-disciplinary approach". With minor changes, this is believed to apply to dependency matters just as it does to community psychiatry where most of the current evaluative research has been done. More than twelve randomised controlled studies comparing case management with 'standard therapy', from a variety of countries - including Australia - contributed to a Cochrane database on the subject.

Some have considered case management (CM) as a 'motherhood' subject, ineligible of criticism or modification. So much so that I once considered it an imaginary concept, like Falstaff's "honour" monologue. But as long as it is seen in concert with good quality medical care it is a useful way of examining and implementing psychosocial supports.

If not by name, case management comes naturally to GPs since this is just what they do as a matter of course. Hospital specialists and clinic based health workers may have more clearly demarcated duties and thus be less likely to address a patient 'holistically'. It is still possible, however, for any health professional to take the time to examine various aspects of the patient's life and coordinate an approach to address those areas needing attention. It is sometimes straightforward but at other times the high risk areas need to be teased out of a difficult presentation by subjects who may be 'in denial' or unable to recognise the issues themselves due to the circumstances.

Of fundamental importance is the aspect of medical treatment and its quality in relation to the current evidence base. Addiction treatment is in these respects possibly even clearer than in community mental health. There is some debate as to who is responsible for appropriate medical care. Courts generally find that it is the doctor who is responsible for inadequate medical care. It might be argued, however, that other health care workers are almost equally responsible in matters of diagnosis and treatment, despite sometimes their having no training in therapeutics. The doctor may not always be involved in the first instance. Thus to this point others must take the responsibility for assessments and treatment given (or not given). In the community it is normally the patient who decides when to go to the doctor (or the dentist, or the hairdresser for that matter). But in the health care system, there often needs to be a key worker who does significantly more than a travel clerk booking a ticket on request.

comments by Andrew Byrne ..

References:

Pringle JL, Edmondston LA et al. The Role of Wrap Around Services in Retention and Outcome in Substance Abuse Treatment: Finding From the Wrap Around Service Impact Study. Addictive Disorders Their Treat (2002) 1;4:109-118

Addiction journal goes 'troppo con molto prezzo'.

Dear Colleagues,

The (UK) Society for the Study of Addiction has sent out a somewhat apologetic note with the normal subscription notice this month. Under the name of Christine Godfrey, SSA President, we are informed of the excellent news that all members, for the yearly rate of 75 pounds or US$150 will now receive 4 copies of Addiction Biology in addition to the 12 issues of Addiction and special 'supplements' each year. For an additional 12 pounds, we are told that members can also have on-line access. For us in the distant antipodes, where mails take up to six weeks, this on-line bonus is indeed welcome.

The management is to be congratulated for these moves. That said, similar promises have been made in the past. In March 1998 Addiction's blue cover proudly announced "available online". But it wasn't. Not to me, anyway. I know as I tried all year unsuccessfully punching passwords and down-loading software to make it all happen. To this day, the cover bears that same caption 'AVAILABLE ONLINE'. Apparently it can be down-loaded by enterprising librarians and other institutional subscribers. My library did not seem able to do so.

Another enticing piece nearly 5 years ago, in May 1997 was entitled: "Join the Society for the Study of Addiction" ... "A World Wide Web site is under development and it is proposed in the near future to set up an Internet bulletin board for members to exchange ideas and request information. These are exciting times for the Society ... ". [Vol 92(5) p636]. I should have contained my excitement since recent editions still state the same! "A World Wide Web site is under development and it is proposed in the near future ...". [Vol 96 (10) p1530]. One is tempted to wonder whether the Society is really serious about encouraging debate.

Addiction once devoted a column to ME! But rather than robust academic discourse it was a clumsy attempt at 'ad hominem' sarcasm following a critical letter on 'decrimalization'. In fact it was hard to understand the meaning of the swagger by Susan Savva in 'News and Notes', but she was clearly enjoying herself at my expense [Vol 95 p1875-6]. Interestingly, the British government seems not to agree with her line of argument as they are now making minor cannabis possession a non-arrestable offence.

On even more serious matters, I have written to the editor, sub-editors and other esteemed members at various times in recent years about the pressing need to improve the quality of methadone and other treatments in the UK and Australia. I pointed out that the Journal had not broached this issue, nor what might be done about it. I was politely told that this issue was being looked into and that a piece was proposed.

All I have seen to date has been a somewhat pompous and contradictory editorial on the possible mischief attended by harm reduction, "quo vadis", by a savant from Montreal. It stated magnanimously that when given properly, methadone treatment 'worked' and was not questioned by leaders in the field. The author then proceeded to question agonist treatments (!). Two recent letters-in-reply were politely critical ... personally, I find it hard to be polite about curbs on simple measures which save lives.

Despite all, I will probably be renewing my subscription to this venerable organ which is nearly into its hundredth year.

comments by Andrew Byrne ..

Comparison of urine toxicology with self-report.

Chermack ST, Roll J, Reilly M, Davis L, Kilaru U, Grabowski J. Comparison of patient self-report and urinalysis results obtained under naturalistic methadone maintenance conditions. D&A Dependence (2000) 59:43-49

Dear Colleagues,

'Confidential' comparisons of urine testing with self-report outside the clinical setting have shown close accuracy (Darke 1998). However, when responses are given to clinicians in the naturalistic setting, as this study finds, they are less likely to be as accurate, at least this is so in the clinic setting where treatment termination based on such results is possible. It is the experience of most who work in the behavioural area that self report is less accurate than objective findings. This probably applies to weight reduction programs, ("the scales are wrong, doctor"), smoking cessation, etc. Urine toxicology always introduces some tension, just like the scales, but it should never cause treatment to be terminated and *taken alone* such testing should not cause patients' treatment schedules to be altered. The most serious consequence of a positive test should be a counselling visit in which 'punishment' should not be an issue.

Despite the lack of surprise in these overall results, it is always gratifying to have ones own experiences documented in a careful scientific study.

These results are hard to generalise to other practices since the patients were all male, ex-service personel, aged 50.4 years (mean) and three quarters were African American.

These authors use exhaustive statistical analysis comparing urine tests results (EMIT tests for opiates and cocaine) and a structured ASI (addiction severity index) including questions on drug use in the previous 30 days. These showed a degree of concordance, but not nearly as much as previous reports of confidential studies where the information was assured to be kept private from treating doctors. What a remarkable state of affairs when patients are apparently afraid for their own doctor to know more about their case!

Comments by Andrew Byrne ..

Addiction: April 2001

Editorial and debate on injectable methadone by Zador. Addiction (2001) 96:547-553.

Zador's perfectly sensible description on the prescribing of injectable methadone by British doctors is challenged by others on some of the most spurious grounds. Both Malcolm Lader and Jerome Jaffe state that it is medico-legally fraught, being non-evidence based medicine. But they ignore the 'out' that this treatment may be the only reasonable alternative for certain heroin dependent folk in whom other treatments have proven unsuccessful or unacceptable. In such a case it may be possible be prove medical negligence by NOT continuing such apparently effective treatment. This may also be the case in a small number of previous trial subjects in Queensland who were given this treatment some years ago. Much treatment given by doctors currently is not strictly evidence based, such as antibiotics for 'bronchitis'.

Jaffe goes through several possible reasons why such prescribing is not appropriate (cost, political acceptability, evidence base) yet he accepts that research might show that it could be so! He even uses the old peccadillo about supplying alcohol to alcoholics and tobacco to smokers 'all paid for indefinitely by the taxpayers'. Of course these drugs ARE CURRENTLY made available by all our governments at reasonable cost to all addicts, and to the very great benefit of the public purse through taxes. It is unusual for this respected researcher to inject such irrelevancies into this otherwise very serious discussion.

Jaffe writes for three pages, his arguments sounding more like those of a politician or a journalist-with-a-mission. He implies that the issue is enormously complex which is simply not the case. This prescribing is either defensible as good medical practice, or it is not. If it MIGHT be, we need more research. Simple!

The limited research that does exist is virtually all encouraging. Prescribing injectables to addicts appears to 'work' in a similar manner to oral methadone, and it may do so in some patients who fare poorly with existing treatments, thus enshrining it as ethical, if of uncertain application.

The article by Strang and Sheridan on relative dosing practices between private and public sectors in England is also of interest (Addiction (2001) 96:567-576).

These authors have conducted yet another elegant and useful study documenting the poor quality of care received by English dependent patients on methadone under the NHS. It is possible that private doctors also are guilty of giving poor treatment but these surveys did not question concurrent prescription of stimulants, or if they did we are not enlightened on the findings. Some private practices are notorious for multiple, gross over-prescribing, including stimulants and one was even the subject of an episode of "The Bill" a few years back.

Since supervised consumption, even in new patients, is exceptional in England, it is not possible to know how much methadone in private of public sector was actually consumed. It is certain, however, that some public sector patients received markedly inadequate doses.

As they point out, there are weaknesses to the study, but one strength is that it is clearly shows that the mean dose of oral methadone in public patients is around 50mg daily, a finding which is consistent with other British reports. As Strang's own guidelines point out, effective doses are usually in the range of 60mg to 120mg daily with only a small proportion of patients requiring more or less than this range. Even allowing for some patients on reducing doses, a mean dose of 50mg would imply that more than half of these patients may be receiving inadequate and therefore ineffective doses. This regrettable situation is still not acknowledged by the authors despite the unfolding tragedy which is dependency treatment in England and Wales in recent years.

Editorial by Juan Negrete, Montreal. Addiction (2001) 96:543-5

This is intriguingly slanted piece heaps scorn on the large proportion of the professional community which perceives benefits in harm reduction principles. The author fails to carefully define what he means by harm reduction which makes his article almost worthless.

It outlines an unscientific and near hysterical viewpoint on harm reduction, a policy most now consider close to 'motherhood' and which has been shown to save countless lives in its various implementations.

Juan Negrete criticises supporters of harm reduction in a most unflattering manner. He says that harm reductionists' aims towards improving methadone treatment only make it easier to get by removing barriers. But he fails to accept that like every other medical intervention, methadone treatment and any variations on its implementation, are subject to rigorous evaluation and hence improvements should only follow normal research findings, not the arbitrary views of any individual parties.

Negrete roundly criticises the Swiss heroin trial, but accepts that if benefits were found, he would review his opinion. How elegantly he contradicts himself, since only by running such a trial could benefits be demonstrated? And they were! The outcomes clearly showed that among 1146 treatment refractory patients there were very high retention rates and low mortality rates along with benefits regarding employment and housing. It is inescapable that this treatment attracted large numbers of otherwise 'treatment-refractory' patients into treatment and kept them alive over the three years of the trial. Is preventing death a 'benefit to patients'?

After faintly praising methadone treatment, Negrete says that maintenance therapies are 'irreversible' and he implies that they prevent addicts attaining drug free status. But people come off methadone successfully all the time! His emotive terminology reveals his clear unhappiness with the field: "harm reduction ideologues"; "compulsive toxicophilia" (is this English?); "drug reward slavery"; [addicts are] "much diminished human beings"; "primitive self-centredness of their pursuit"; "well meaning harm reduction workers who do not assign much importance to the problem of addiction". These are not the usual terms of clear scientific writing and if applied to those dependent on legal drugs would be considered offensive and outrageous by many such people.

 

It is surprising to find such items in 'Addiction', the world's oldest scientific journal on dependency.

Comments by Andrew Byrne ..

"Confessions of an English Opium-Eater" (Thomas de Quincey)

Written in 1821, this is an intense and pertinent portrayal of narcotic dependence from the addict's viewpoint. De Quincey addresses the constant conflict between intoxication and abstinence. Similar sentiments are related by our patients today, but rarely with as much eloquence and insight as Thomas De Quincey. This classic work is essential reading for all involved in drug and alcohol studies and who admire beautiful language.

With so many patients now on maintenance programs (mostly methadone), and illicit opioids still ubiquitous, it is timely to re-examine this work, probably the oldest account of its kind in English.

The 'Confessions' presents us with several episodes in the author's life. He recounts privileged public school days, subsequent hostile truancy, still later poverty in London squats and, some years afterward, a comfortable country existence. But this story is not just biographical. The disparate scenes each place his drug-taking into vivid context.

As a 36-year-old addict, the writer states that his drug of choice was laudanum (tincture of opium), a medicine first prescribed him for recurrent dyspepsia aged 28. It was then that he also discovered its pleasurable qualities. He consumed up to 320 grains of opium daily, equal to around 20g of raw opium, a large, but not unbelievable quantity. Though he claims to have given up opium, history tells us that he continued heavy use for another 35 years. He did not live long enough to 'enjoy' the discovery of heroin and the hypodermic needle.

The original 'Confessions' was published as a series of articles in the "London Magazine" in 1821. Some parts had been written previously, and the series may have been pieced together hastily out of financial necessity. The author pleads for patience, explaining that his prose follows his own train of thought so closely that it sometimes may appear wandering or disjointed. The American author, William Burroughs suffered the same 'malady', (and possibly for the same reason) but, far from craving his readers' indulgence, he has capitalized on it and has made it his trade-mark.

De Quincey apologises needlessly for his narrative style. Seemingly embroidered or wordy descriptions are well balanced by other elegantly succinct poetic portraits.

"Thou only givest these gifts to man; and thou hast the keys of Paradise, oh, just, subtle, and mighty opium!" Every page of this work contains language of beauty, humanity and frequently, humour.

The subject of this book was taboo at the time of writing, and the very title would have shocked its public. It was then widely believed that Europeans could not become addicted to opium.

As well as 'Preliminary Confessions', he writes chapters on the pleasures and the pains of opium. He affirms his belief in the unique healing powers of the drug, and the benefits of doctor's prescriptions which contain opium. De Quincey reveals that he used opium only intermittently for several years, before developing a daily proclivity. He took it regularly before going to the Covent Garden opera. A proportion of today's narcotic users employ the drug to enhance other pleasurable activities.

Based on personal knowledge as well as information from apothecaries he patronized, De Quincey correctly deduces that opium addiction was extremely widespread in Regency England. He expresses some remorse over his addiction, but devotes much space to explaining his extenuating personal circumstances. Unlike simple pleasure seekers, the reader is told, he took it initially for medical reasons. He also compares it with the pernicious effects of alcohol. He identifies some other prominent opium users: first mentioned is the poet laureate and playwright, Thomas Shadwell (1642-92), a confirmed addict. Of his own contemporaries, he identifies Samuel Taylor Coleridge, William Wilberforce, Dr Abernethy, and several others in public life.

He revised and enlarged the confessions 35 years later, as if to prove opiate addiction and longevity are not mutually exclusive. Most modern editions give some passages from the revisions, but wisely keep the original as a discrete work. The revisions are longer than the entire original work. Although some central issues are clarified in the revisions, other tangential ones are drawn out and examined in excruciating detail.

De Quincey remains one of the great wordsmiths, and this well-forged story gives a personal aspect to one of mankind's most ancient activities, the pursuit of pleasure from drugs. [De Quincey, T. Confessions of an English Opium-Eater. Penguin English Library 1972, edited with an introduction by Alethea Hayter. First published in the "London Magazine", 1821]