Dear Esteemed Colleagues,
After over a decade of being almost a "one product shop", our addiction practice has moved to try each new form of opiate pharmacotherapy as it was made available. In most cases initial reservations were dispelled by the positive feedback regarding patient acceptability, stability and retention from the new drugs. We have also noted a proportion withdrawing successfully from all opioids. Professor Vincent P. Dole suggests that addiction pharmacotherapy should be considered the same as any other prescription medicine.
Thus the first patients to be considered for any new modalities might best be those who are unhappy with current options (usually moderate-dose methadone 'syrup'). While staff considerations are important, patient considerations should be paramount. Hence despite our reticence, we have tried each new product in patients who seemed appropriate. I now believe that buprenorphine and 'Biodone' (and probably diazepam and naltrexone) should be available in every addiction treatment service dispensary. And they should be available during the same hours, and from the same experienced staff as other supervised pharmacotherapies (and if possible, at the same price). To do otherwise is unduly disruptive to couples or associates who may be on different treatments, of for those changing from one to another. It also adds to the stigmatisation of addiction treatments and may increase congestion.
Staff may feel reluctant to introduce new medications in addiction treatment but they can yield enormous rewards for both patients and staff. I recommend starting with the most frustrating and unhappy cases and one may find that with some manipulation of the medication such folk can become the most devoted and grateful patients, and they often attain stability surprisingly rapidly. We thought that having buprenorphine cases would take longer but in fact it now saves us time. People are more likely to be getting what they need and are thus less likely to be in the 'unstable' category who take up so much of our time.
In our practice (~150 patients) about 75% now choose 'Biodone' sugar-free solution of methadone. About 10% are grateful that we still supply the old 'syrup' being as yet unable to tolerate the sugar-free medicine. And we have about 20 patients on buprenorphine currently, nearly all previously unhappy with methadone. There are also a number on methadone who were very unhappy with buprenorphine, which is no surprise considering personal preferences.
Some say that it is more difficult to dose different medications but I remember the frustrating cases who previously took time to 'gag down' their medicine - as well as those with nausea and vomiting who needed reassessments, anti-emetic injections, supplementary dosing and other time-consuming consultations and procedures. In community pharmacies, hospital wards, ambulance and psychiatric crisis teams, the staff members dispense and administer a variety of different medications without difficulty, sometimes to large numbers of patients.
With some places being still "one product" establishments, I hope that we can "normalize" these pharmacotherapies since what is happening at present is less than satisfactory for a great many patients and is certainly no good for staff morale. My staff and I have found the new options have made our lives easier and more rewarding professionally. I estimate that the proportion we can retain in treatment has increased substantially to perhaps 85%.
Andrew Byrne ..
