Safe inductions into treatment

Tue 8th June 2004

Presenter:
Dr Jon Currie

Dr Jon Currie spoke with his usual punchy enthusiasm about the far reaching and diverse treatments being offered at Westmead Hospital for drug and alcohol addictions. He stressed the important 'divide' between maintenance and abstinence which, at any one time in any individual patient, are mutually exclusive.

We were told of the earnest desire of many opioid dependent patients to be abstinent. However, many such folk still feel 'empty and alone' in the 'un-opiated' state. This appears to be quite distinct from actual withdrawals which can last for up to many weeks. We were told that the fastest and possibly safest way to determine just who can and who cannot cope with abstinence is with rapid detox rather than the usual method of gradual reductions over months on methadone or buprenorphine. As Dr Currie reminded us, it is while on lower doses of maintenance opioids that drug users are most vulnerable to risk-taking behaviour, including overdose.

At a time when many dependency units are still only offering one or two specific treatments, Dr Currie's team seem to have made a number of interventions almost 'routine', despite their novelty. These include naltrexone, topiramate, ondansetron, flumazepil, acamprosate as well as some other 'off-label' uses in novel settings or in unusual combinations. Some interventions were based directly on the scientific evidence while others we were told were from the 'first principles of therapeutics'. His description of flumazenil infusions for those with benzodiazepine dependency was most instructive, noting not a single fit in over 50 cases so treated.

Along with Sydney Hospital, the Westmead unit was charged by the NSW Health Department with the initial Australian research on rapid opioid detox. To their credit, they have since moved ahead with numerous refinements and related treatments. Rapid opiate detoxification (which Dr Currie uniquely says is NOT detoxification but 'antagonist induction') has been done using full anaesthetic as well as under sedation using midazolam and propofol. Dr Currie states that full general anaesthesia is only rarely needed for such cases. The naltrexone is now given as a diluted suspension, initially in very small increments, gradually increasing to the standard 50mg daily. Octreotide is used to prevent the hyper-secretion of the bowel during the withdrawal process. We were told that the intestinal wall has high numbers of opiate receptors which also respond to the withdrawal process by overactivity, hence the diarrhoea so commonly reported during withdrawals. Ondansetron (Zofran) as tablet, syrup or injection is very effective for preventing nausea and vomiting, as also used in chemotherapy cases.

A modification of this procedure is being used by Currie's team to move patients from high dose methadone onto buprenorphine as an alternative to gradual reductions and the associated risks. We await formal reports of their findings, risks and benefits.

Few people can have more incisively and imaginatively applied the meagre literature to clinical dependency practice, and it is to be hoped that Dr Currie's work in the notoriously underfunded public sector will be recognised with the resources to allow the results to reach a wider audience via a peer reviewed forum. We still need more longer-term outcome evidence before recommending rapid detox and/or naltrexone in opioid dependent people. The passage of time and a lack of such publications will make some less confident in such treatments. There has now been 20 years of experience by serious researchers and 'enthusiasts' alike yet little convincing evidence regarding safety and effectiveness to date.

comments by Andrew Byrne ..

Can current addiction services cope with demand? US study.

McLennan AT, Carise D, Kleber HD. Can the national addiction treatment infrastructure support the public’s demand for quality care? Journal of Substance Abuse Treatment (2003) 25:117-121

Dear Colleagues,

This ‘commentary’ teaches us some very important lessons regarding staffing, education and career development in the dependency field. Arising out of an unrelated study, the authors had the opportunity to interview key staff in 175 assorted American dependency treatment agencies. Ten percent were traditional methadone clinics.

The most dramatic finding, almost invalidating the other information being sought, was that within the treatment services examined, staff turnover was extremely high (up to 53% annually). Also, medical and nursing services were under represented with part-time and even volunteer workers in senior positions in many centres. Thus we should be concerned about continuity and consistency of treatment, keeping highly trained and experienced staff in the field and allowing career pathways which can be both rewarding and sustainable. Remarkably, 15% of the agencies identified for the study had either closed down or else ceased to provide addiction services at all! A further 29% had been reorganised under different management, showing yet more starkly how much volatility there is in addiction treatment services.

Drs Kleber and McLennan are highly respected veterans of the dependency research field. What they say in their discussion is both telling and embarrassing for an embattled and threatened rehabilitation ‘industry’ in their country. They found that much time was wasted in these agencies having to collect data required for insurance, city, state and federal requirements. Little if any of this information was used in any way clinically and it took between 2 and 4 hours of staff time to collect. Few agencies used computers. The final comment of these authors goes so far as to compare addiction treatment agencies with the degraded electrical grid which was blamed for the massive recent outages in North America.

I have tried to compare these results with agencies in New South Wales and believe that things are not as grim here, but there are warning signs. I found similar staffing data in some clinics while in others, there were managers and senior staff who had been in the field for decades, providing excellent care for dependent patients/clients.

comments by Andrew Byrne ..

Methadone in holistic treatment

Reprinted from "Drugs in Society", March/June 2004, Alcohol and Drug Foundation of Queensland.

Dr.Andrew Byrne

Methadone is just a drug. When used appropriately it can obtain predictable, positive outcomes for opioid dependent citizens. As with other drugs, when used improperly, unpredictable things occur, including sudden deaths.

One unique thing about methadone is that everyone seems to have an opinion about it - although few have probably read the research literature on its use and outcomes. These opinions vary according to personal prejudices. Some say it is a cure for society's problems while others say it should be banned, just like heroin. People rarely have such strong opinions about penicillin, cortisone, Prozac or aspirin, each a drug with possible serious consequences, even when used 'properly'. And the clinical research regarding methadone is more comprehensive than for many other drug treatments.

Amongst the injecting population methadone prevents the spread of HIV (and probably also hepatitis C). When used in sufficient doses, it may also reduce the use of alcohol and other drugs such as cocaine. Other benefits include reduced criminality, better employment rates and enhanced home life.

Yet to some of the criticisms one would think there was some hidden scope for harm which has not been recognised by 40 years of careful research. Even Professor John Strang who chaired the authoritative UK treatment guidelines, stated that methadone treatment may have a 'sting in the tail'. Some also praise abstinence as a unique ideal and the only means to a 'pure' and 'worthy' life-style, condemning methadone maintenance as though it should never be used. Despite no supporting body of research evidence, some still support the use of naltrexone in the regular treatment of heroin addiction. Rather than clarifying matters by publishing their own findings, some issue loose statements about a particular form of treatment being 'useful' in 'well motivated' patients, without defining success, motivation or what exactly the treatment was!

In my experience most drug users, like most smokers, would dearly love to be drug-free. They nearly all regret their first drug experience. They express guilt and often go to extraordinary lengths to detoxify, including the use of unproven, dangerous and expensive means such as rapid detox under anaesthesia. Dozens of Australian addicts travelled to Israel for this procedure in the early 1990s, few with long term abstinence and some only to return to an early, unnatural death from overdose, suicide or other cause.

But abstinence is not as elusive as sometimes painted. Most smokers DO give up. Most methadone patients do eventually achieve abstinence, as shown by good research. Only a minority of them remain on continuous treatment for very long periods (>5 years). For some the abstinence is 'solid' and long lasting. For others it is temporary and fraught with problems. Deaths in such folk are tragically common and that is why treatment professionals should never push for early methadone dose reductions until the patient expresses strong commitment and readiness for such a major change in their lives. Frustration with the rigours or expense of daily treatment should not be sufficient motivation on its own for genuine 'change' . although sometimes this may be the final catalyst when other things are 'set'.

So what else do we know about methadone treatment? It is delivered in a manner which is often very unfriendly, expensive and without the supports needed by many addicted patients. Yet it still reports positive outcomes. 'Retention rates' show that people stay on it for extended periods despite these indignities. The 'down-side' of methadone treatment needs to be seen in this context. If it were always given in privacy in the community, many complaints would disappear. Yet much treatment is still given in circumstances which are very 'public'. Patients are handed doses in an open pharmacy with all-and-sundry looking on, sometimes after others have been served first. This is not ideal, nor is it consistent with the spirit of new laws on privacy. It is a mixed blessing that the price of a dose of methadone is about the same now as it was in 1988 at four to five dollars daily. Despite higher costs, increased paperwork and regulations, pharmacists to their great credit have kept prices almost inflation-free. But for this relative drop in income, they have often not been able to invest in dependency treatments specifically and move with the times. There are some notable exceptions where efforts have been made for treatment to be obtained without delay, in private, and with adequate time for professional discussion in the pharmacy or clinic involved.

Do patients need counselling? As for every other form of treatment, the more positive interventions that are included, the better the outcomes. It is known that 'bare-essentials' methadone without counselling can yield reasonable results but that added psychosocial supports improve retention and other outcome statistics. This finding is used by some, especially in the USA, to limit methadone to specialist clinics where added services can be obtained. Due to the large numbers of dependent patients and limited resources, this requirement in turn denies methadone to most addicts who nearly always outnumber clinic treatment spaces available.

Can methadone be abused? Of course it can, like almost any other drug. But excessive doses of methadone in habituated people are generally said to be rather uninteresting . and methadone is not a 'party' drug. Prescribed patients who take additional methadone can develop severe constipation. They may also sweat excessively and have poor libido. They use little if any other drugs or alcohol and are involved in little extraneous activity such as employment, crime or domestic violence. They usually learn rather quickly that taking excess methadone is not consistent with most other activities. Also, they may learn that taking the correct dose for the individual takes away all cravings and allows normal energy levels, appetites, creativity and other facets of normal human activities. Some experienced clinicians used to describe this as 'blockade' treatment and it is disappointing that none of them ever researched it.

But this is just one part of the task of clinicians to help patients come to terms with being on maintenance medication, and the right dose for their situation. It was once thought that as long as the patient has ceased using heroin that the dose is necessarily sufficient but this may not always be the case. Some still feel depressed and lack energy on a certain dose which abolishes cravings, but may still require slightly more to regain their normal functioning.

It appears that some of the main criticisms against methadone treatment are directly due to inadequate doses being prescribed. Apart from the obvious problems of continued heroin use, this also causes an immediate scope for a black market in methadone, loitering near dispensaries and even the injecting of methadone. The introduction of an alternative, buprenorphine, has also given a new effective option for those who cannot or will not take methadone for their opioid habit. Together, these drug treatments can offer a means away from illicit opiate use, and which is acceptable to a large majority of addicts.

Written by Andrew Byrne

Methadone maintenance works better than arbitrary reductions

Addiction (2004) 99:718-726

Cost and cost-effectiveness of standard methadone maintenance treatment compared to enriched 180-day methadone detoxification. Masson CL, Barnett PG, Sees KL, Delucchi KL, Rosen A, Wong W, Hall SM.

Dear Colleagues,

The editor of Addiction has long espoused high levels of ethics in submissions to his august journal. Half of the subjects in this study received treatment which is known to be inadequate and inappropriate for unselected heroin addicts, viz: reduction pharmacotherapy [see UK 'Orange' dependency guidelines p59]. I believe that a properly informed and constituted ethics committee would not currently permit such a study without safety net provisions in most countries. A cost analysis of such outcomes is thus a double redundancy since at least one branch of the study used an outmoded treatment model.

Originally published in JAMA in 2000, this study examined outcomes in heroin addicts given access to 'standard' (US) methadone maintenance treatment and compared it with randomised entrants given 6 months reductions with added psychosocial supports. Predictably there were more dropouts and heroin use was higher in the group given methadone reductions. Such problems became most prominent when the doses were reducing, by about 4 months. In a country without freely available needles this may have seen some of the subjects risk viral disease transmission.

It is hard to find justification for this exposure and the results, while statistically impressive, yield little innovative and tell us nothing which was not already determined by the research literature.

Even when inadequate doses are given with minimal additional supports, methadone maintenance has some benefits for most patients. However, such treatment works better still when given according to current recommendations (eg. Strang's UK dependency guidelines; US 'TIP' Guidelines; Australian national guidelines). In addition, methadone maintenance is a relatively cheap intervention when compared with treatment for other chronic mental or physical conditions.

The authors made note of the doses being adequate "by today's standards" yet 100mg appears to have been the maximum, nor do they specify what "standards" they are referring to. This shows how out of touch with treatment practices they are. Most clinics now have a certain proportion of patients taking more than 100mg daily. The original JAMA report by Vincent P. Dole in 1965 described doses of 100mg or more in 16 of the first 24 patients.

There seems little point in discussing the cost effectiveness of two treatments, neither of which meets currently accepted benchmarks. The consequences of giving inadequate doses of methadone (especially NO methadone) are probably as serious and profound as doctors prescribing inadequate doses of lithium, insulin, cortisone, antibiotics or any other useful and potentially life-saving medicine.

This would not be a high point for either the journal nor the researchers since some subjects received less than optimal therapy and little or nothing was added to the scientific knowledge base.

comments by Andrew Byrne ..

References

Masson CL, Barnett PG, Sees KL, Delucchi KL, Rosen A, Wong W, Hall SM. Cost and cost-effectiveness of standard methadone maintenance treatment compared to enriched 180-day methadone detoxification. Addiction (2004) 99:718-726

Original study: Sees KL, Delucchi KL, Masson C, Rosen A, Clark HW, Robillard H, Banys P, Hall SM. Methadone Maintenance vs. 180-Day Psychosocially Enriched Detoxification for Treatment of Opioid Dependence : A Randomized Controlled Trial. JAMA (2000) 283:1303-1310