1-6 May 2004
Psychotherapy and Psychopharmcotherapy. Dissolving the Mind-Brain Barrier. New York. 157th annual Meeting.
Dear Colleagues,
I have had an opportunity to review the enormous 'proceedings summary' for this conference given to me by one of the large group of Australian psychiatrists who attended. It consisted of 370 pages of very small print! Like all big scientific conferences these days, nobody could attend all the parallel sessions and it is hard to imagine that they could not have been pared down for relevance, quality and length. Regarding addiction related presentations there was a mixture and these also varied in quality. In our field we are used to being left to the end of days, following the other more 'mainstream' topics.
Even some of the general lectures/workshop titles were very esoteric. 'Music and the mind: Beethoven'; 9/11 Research: Reviews; 'Surviving Jock Culture'; 'Why does the human brain become addicted'; 'The brain in love'; 'Better Sex: Naturally'; 'Postwar mental health services'; 'Leash on life: Human attachment to animals'; 'Detection of Malingering'; 'Juvenile Justice . Jazz and Blues'; 'Sexual satisfaction . in Orthodox Jewish Women'; 'The sissy duckling . gender variance'; 'Psychotherapy in Asian women'; 'Gayness and God'; 'Modafinil treatment of chronic shift work sleep disorder'; 'Food and drug cravings: metaphor or common mechanism?' . I could go on . Yoga techniques, show biz, teaching, forensic psychiatry, twin studies, topiramate for alcoholism, terrorism, PTSD, AA, ADD, etc, etc, etc.
From the program, there was still plenty for the 'bread-and-butter' psychiatry issues of anxiety, depression and psychoses, as behoves such a large conference. We forget just how 'big' psychiatry is in the United States. While it is exceptional for Australians to have a psychiatrist, it is almost compulsory for middle class Americans.
Regarding addiction, there were a number of papers, many authored by well known researchers and clinicians but on a surprisingly limited range of subjects. These mostly revolved around the newfound availability of buprenorphine for maintenance of opioid addiction in office based practice. When properly used, such work can be enormously professionally rewarding . and prescribing opioids to addicts is something American doctors have been largely banned from doing since the 1920s. Also, uniquely in the US, pharmacists are barred from administering methadone in the treatment of addiction. Buprenorphine (mostly in combination with naloxone) has been made available on a 'waiver' prescription system under the Drug Addiction Treatment Act of 2000 from certified doctors as outpatient management. This is without the normal addiction clinic requirements for supervised administration, counselling, urine testing, etc. Medication can be prescribed for up to six months on one prescription, including repeats or 'refills'.
There were also numerous papers on cocaine and cannabis, with uniquely American flavours, and thus often of limited relevance to normal medical practice in other countries.
Nowhere was there mention of the current uncomfortable conundrum of doctors sometimes prescribing the second best drug for arbitrary regulatory reasons. Methadone is the recommended maintenance drug for pregnant addicts, yet it is not available in some states and is very limited in the others. Methadone is also more effective than buprenorphine for those with high tolerance. Trials often show better outcomes for methadone so it should be the first line drug in some or even most patients. One could understand this being omitted by the authors in the section sponsored by drug companies. Yet it is not mentioned in the many other free papers, as far as I could determine.
Many of the most prominent personalities of drug research in the US were represented here, including names like Ling, Kosten, Kleber, Galanter, McNicholas, Volkow, Rounseville, Portnoy, Tsuang, O'Brien, Millman, McLellan and Bankole Johnson.
Some of their views were controversial, others questionable, such as the claim that methadone should be avoided in HIV cases because of its supposed negative effect on the immune system. The myths of buprenorphine being easier to withdraw from and having less dependence features were also resurrected by some contributors. Buprenorphine withdrawals have no better success than methadone withdrawals. Nobody ever mentions the rather important fact that there are simply no long-term safety data on buprenorphine, especially in combination with naloxone. Indeed, the manufacturer seems not to be sponsoring any such research currently.
It was gratifying to find so many papers on nicotine dependence. In my view psychiatrists have a much wider community responsibility than immediate patient care. It is tragic that is has taken so long for them to realise what psychiatrist Marie Nyswander wrote about 50 years ago . that treating addicts with psychotherapy was fraught with frustration without using maintenance pharmacotherapy for appropriate cases. And with such therapy it can be enormously rewarding for doctor and patient as addicts put their often considerable talents towards normal life issues rather than constantly procuring drugs.
There were only small contributions from overseas including adolescent psychiatry (one from ANU and another from the UK). There was also a reference in Walter Ling's insightful paper on treating chronic pain in maintenance patients. He quoted some important work from Adelaide researchers on the subject of induced hyperalgesia in such patients and the need for different approaches for the future as there will be so many more such patients. Australia has contributed much to the field of psychiatry (eg. a Melbourne doctor first devised lithium treatment).
It is a shame that more prominence was not given to a RCT by Bankole Johnson in which he measured quality of life in alcoholics given topiramate, a new drug used for cravings and/or relapse prevention. There was a significant positive effect. So now we have at least four drugs in this class: naltrexone, acamprosate, ondansetron and topiramate. The latter two could only be used off-label in Australia and thus should probably only be prescribed in specialist or research settings. The first two should be familiar to all Australia doctors who come into contact with alcoholics - and who doesn't?
