Injecting rooms need support from experts, not alarmist doubts.

The case for piloting supervised injecting centres in the United Kingdom is strong. Wright NMJ, Tompkins CNE. BMJ 2004 328:100-102

Dear Colleagues,

With continuing high rates of drug related deaths in the UK, the BMJ is
right to again give prominence to the issue. The report by Wright and
Tompkins [ref 1] clearly demonstrates that there are new and promising
ways to address the current UK epidemic of overdose deaths from street
drugs, including medically supervised injecting facilities. Overseas
experience with injecting centres over 15 years has been uniformly
positive. Over one million injections occur each year in such centres
where deaths and serious complications almost unknown. Nearly all such
injections would otherwise take place in less savoury and thus less safe
environs. Such services also bring large number of addicts into contact
with health care workers, some for the fist time.

It is thus disappointing that in their following commentary [ref 2],
rather than unequivocally supporting such moves, Strang and Fortson
raise the canard of the differences between prescribed heroin for
dependency and injecting facilities (which they pejoratively call
'fixing rooms').

As a leading dependency expert, Strang knows the reassuring reports of
such centres in Europe, Australia and, most recently, Canada. The
concept has worked effectively elsewhere [ref 3], including apparently
unofficial experience in London. Strang and Fortson give no realistic
alternative strategy for the UK's high rates of overdose, HIV and
hepatitis C. They write that heroin prescription would only ever be a
'tertiary service', while injecting rooms a primary one.

These authors compare injecting centres to pubs, adding to the confusion
they are trying to address. Licensed premises, like Swiss heroin
prescription trials, supply the patrons' drug of choice in a safe
environment, while injecting centres only provide the supervised
environment for consumption of illicit drugs. Injecting centres are
perhaps more like patrolled beaches where people do risky, even
foolhardy things, while professional life-guards move into action if
needed in a non-judgemental manner.

Strang and co-author cannot know how insensitive their petty
reservations on injecting rooms must sound to grieving relatives when
every overdose death is potentially preventable. Rather than refuting
them, these authors raise old issues such as injecting rooms 'fostering
.. more .. drug use', drug dealing and operational protocols after over
a decade of positive experience. Their perfunctory dealing with 'harm
reduction' in the first sentence belies its being the foundation of good
medical and public health practice since the time of Hippocrates. It is
also official government health policy in some countries and has
prevented an HIV epidemic in Australia and Hong Kong.

Like heroin prescription, on current evidence we probably need a small
number of injecting rooms in drug 'hot-spots', as well as simultaneous
improved access to traditional drug treatments, detox services, harm
reduction measures and education.

Yours faithfully,

Andrew Byrne ..

References:

[1] Wright NMJ, Tompkins CNE. Supervised injecting centres. BMJ (2004)
328:100-102
http://bmj.bmjjournals.com/cgi/content/full/328/7431/100

[2] Strang J, Fortson R. Supervised fixing rooms, supervised injectable
maintenance clinics-understanding the difference. BMJ (2004) 328:102-103
http://bmj.bmjjournals.com/cgi/content/full/328/7431/102

[3] Burton, B. Supervised drug injecting room trial considered a
success. BMJ (2003) 327:122
http://bmj.com/cgi/content/full/327/7407/122-a


Extracts:
BMJ 2004 328:100-102 (10 January)

Wright NMJ, Tompkins CNE.

The case for piloting supervised injecting centres in the United Kingdom
is strong.

Medically supervised injecting centres are "legally sanctioned and
supervised facilities designed to reduce the health and public order
problems associated with illegal injection drug use." Their purpose is
to enable the consumption of pre-obtained drugs under hygienic, low risk
conditions. They differ from illegal "shooting galleries," where
users pay to inject on site. Worldwide, medically supervised injecting
centres (also referred to as health rooms, supervised injecting rooms,
drug consumption rooms, and safer injecting rooms or facilities) are
receiving renewed attention. In 2001, the first medically supervised
injecting centre in recent times was opened in Sydney, Australia.




BMJ 2004 328:102-103 (10 January)
Strang J, Fortson R.

Supervised fixing rooms, supervised injectable maintenance
Clinics - understanding the difference.

John Strang (psychiatrist), Rudi Fortson (barrister)

Harm reduction policies and practices (where anything goes, if it
actually reduces harm) have fundamentally altered our approach to the
drugs problem. Two innovations were recently considered by the Home
Affairs Select Committee-supervised injecting centres and supervised
injectable maintenance clinics-but with unhelpful confusion between the
two. They have different target populations, potential benefits, and
legal obstacles.




http://bmj.com/

Antipodean tabloid teacup tempest.

‘Addiction’: November 2004. A few seasonal observations.

# “Moo Joose” controversy.
# Addiction treatment compliance.
# Long-acting injectable ‘depot’ buprenorphine.
# Brief interventions on the web; twin study on alcoholism; ketamine brain damage; cannabis psychosis book review.

On the eve of a century of publication, this issue demonstrates the best and worst features of Addiction. The content of individual issues sometimes reveals editorial shortcomings and apparent inconsistencies yet an examination of a whole year’s titles would leave little doubt as to this journal’s editorial policy directions. These are well known to regular readers. On the positive side, the issue maintains an elegantly balanced dual thematic ‘leitmotif’, this month being a combination of modern approaches to alcohol policy and compliance to pharmacotherapy treatment for alcohol and drug problems. Authors represented in November include such luminaries as Anderson, Berridge, Bigelow, Caswell, Curran, Hickman, Kleber, Klingermann, Petry, Rhodes, Saunders, Tsuang and West. It is to Griffith Edwards’ credit that few other scientific journals in the world could boast such a line-up of experts in the one monthly edition. Clearly Addiction has the confidence of those in the research field.

The ‘Moo Joose’ (alcoholic flavoured milk) story is an example of how an important and topical subject should NOT be dealt with. Where there is clearly a divergence of opinion the case should be made with commentaries from the protagonists and experts but here we have only one side of the matter as so often happens in Addiction. Mr Aldred and his Alcohol and Drug Foundation (Queensland) are roundly criticised in the item as having changed their view on this product as a result of influence from the alcohol industry. However, they were not asked by Addiction to provide a comment (personal communication, 14/12/04). Nor, it appears, was the alcohol industry or government.

While many of us may agree with aspects of Munro’s critical report, it is hardly useful to have our own misgivings repeated by experts who have little more information than we do ourselves. And sadly, it is nothing novel for the beverage industry to chalk up another victory regarding alcohol marketing, against the advice of public health experts. The invited commentaries are therefore not balanced, nor are all the facts yet to come in on the matter, as pointed out in one frank review by Virginia Berridge. To her credit, she points out that Munro’s item raises as many questions as it answers. Yet editor Edwards, perhaps in hasty indignation, allows this antipodean tabloid teacup tempest to dominate his ‘scientific’ journal (items 2 to 9). So much for his maxim of encouraging ‘robust debate between people of goodwill’.

‘Moo Joose’ may be novel, and the final outcome possibly instructive but there are also matters of major moment from closer to home needing to be covered. Edwards has still not addressed the scandalously low standard of dependency treatment given by many of his British colleagues to hapless addicts in England. Details of this have been documented in the small print of his own journal many times over the years. I understand from impeccable sources that the average methadone dose prescribed in the UK is around 37mg daily, and further, that the most commonly prescribed daily dose is 30mg! These facts may partially explain why maintenance treatments have such a poor reputation in the UK. The official UK guidelines state that 60mg is the usual effective minimum.

While on this subject, it is hard to understand how Professor Weiss from Harvard could possibly omit methadone compliance and retention in his item (No 10) entitled ‘Adherence to pharmacotherapy in patients with alcohol and opioid dependence’. [Addiction (2004) 99: 1382-92]. Could it be that Addiction does not want to ‘offend’ by mentioning methadone at all? (shades of ‘Don’t mention the war!’).

Perhaps the most interesting item was the evaluation of an injected depot formulation of buprenorphine against placebo comparison. In an experimental in-patient detoxification setting, Sigmon, Bigelow and colleagues found few differences in responses over 6 weeks between those given the active opioid and those given placebo (my more complete summary elsewhere).
Perhaps the wisest commentary is last, the second ‘letter to the editor’ (actually an invited commentary) being from Herbert Kleber who has been around a long time and seen much come and go. Despite accepting some potential benefits, he also expresses concerns about depot and implanted medications, detailing the disadvantages. These include costs, painful administration, infections and a lack of ability to adjust the dose. Some, such as depot injections, do not allow removal but commit the patient to weeks or months of treatment. It reminded me of a Sydney University professor who was given an injection of procaine penicillin, having omitted to mention his life-long allergy. He apparently spent the next fortnight going in and out of anaphylaxis, needing adrenalin and cortisone treatment. I note with concern that in Sigmon’s trial they did not give a test dose of buprenorphine so allergies, although unusual with pure opioids, would not be have been detected until after a depot injecting was given. Depot preparations usually include numerous other chemicals (to delay absorption, preservatives, stabilizers, etc).

An extraordinary item on time-frames in Swiss alcohol and drug clinics tries to tease differences between social times and clock times (Klingermann & Schibili).

Kypri, Saunders and colleagues take alcohol brief interventions to the web, reporting benefits on both drinking and personal problems which declined with time in university students with hazardous drinking.

Liu, Tsuang and colleagues provide yet another examination of the huge Vietnam war era twin register to determine genetic influences on the age of onset of alcohol dependence.

There is an item on the long-term effects of ketamine, a sometimes popular illicit psychodelic anaesthetic agent. The authors find that there are some transient and other more long-lived side effects from heavy ketamine use, warning that users and potential users should be aware of such effects on memory and subjective experience. As usual with such items, there is no comparison with subjects who drink alcohol to excess, nor the degree of harms or benefits resulting from the illicit status of the drug in most countries.

David M. Fergusson gives an erudite book review on ‘Marijuana and Madness’, quoting some authoritative reports favouring causation as well as one discounting it. Recent writings on the subject make it clear that cannabis still may actually cause some cases of schizophrenia, but at most it could only account for a very small proportion of the total number of cases (well under 10% and possibly as low as 2%. Thus only with a massive increase in cannabis use could changes in prevalence be detectable in mental health statistics. For a comprehensive review of the current evidence see the current Drug and Alcohol Review which contains several relevant items.

Finally come two informative items pertaining to our most destructive drug, tobacco. Aspects of nicotine replacement and bupropion are examined from a general medical practice angle as well as certain gender differences in treatment response.

This is the second last edition under the editorship of Griffith Edwards. On 1st January 2005 he becomes “Commissioning editor“ - whatever that may mean. We are assured by Robert West, the new editor, that there will be more of the same.

comments by Andrew Byrne FAChAM ..

Victorian survey of methadone patients - not all good.

Ezard N, Lintzeris N, Odgers P, Koutroulis G, Muhleisen P, Stowe A, Lanagan A. An evaluation of community methadone services in Victoria, Australia: results of a client survey. Drug and Alcohol Review (1999) 18:417-423


Dear Colleagues,

This study reveals some interesting and important findings regarding the treatment of heroin dependency patients in Victoria, Australia where most patients attend pharmacies for their dosing with licensed GPs prescribing. It is a credit to the authorities that there has been such an expansion of treatment services to meet the increasing numbers of dependent citizens. It is especially important to document the functioning of methadone dispensing in community pharmacies since this is where most of the expansion of such treatment is occurring around the globe.

However, while changes will have occurred since 1995/6, the authors' positive conclusions still need to be tempered with some reservations about the limitations of current treatment delivery.

As in other states, there is a perception by Victorian dependency patients that pharmacy dosing sometimes lacks confidentiality (46% said it was 'too public') and that there is some discrimination in others being served first (42%). Dosing hours and location (only 66% satisfied) were also problems, especially when looking for work (53% said it 'interfered').

The authors state: "Results of the study were generally encouraging. The majority of clients surveyed stated they were satisfied with their relationship with their prescriber and their pharmacist, and with the methadone programme overall. Overall, our survey indicates that the Victorian community-based methadone service is in general an acceptable model of methadone service delivery for clients in the metropolitan area."

The survey of 195 patients would seem to indicate otherwise, revealing worrying deficiencies with treatment delivery as well as responses to that treatment. Only 72% were satisfied with their treatment and over a third stated that they would not have commenced treatment if they had know more about it, quoting 'hassles' amongst other problems.

Although the average duration of treatment was over 2 years, 40% of patients had received no take-away or dispensed doses at the time of the interview. Only 10% received 2 such doses weekly, and they were more likely to be female. The reason for this uniquely rigid regimen is not given.

The mean dose was 41mg (mode 30mg) with only 15% receiving 60mg or more. Almost half of the patients (44%) were still using heroin regularly by self-report.

These outcomes are consistent with the literature which yields a consensus that doses of methadone should normally be in the range 60mg to 120mg daily with only a small proportion of cases needing less or more than these levels. Hence up to 85% of Victorian patients may have been receiving inadequate doses in 1995/6.

Dr Vincent P. Dole wrote "With adequate dosage of methadone, taken daily, heroin use should be completely eliminated in 95% of all patients." He also recommended a minimum blood methadone level of 0.2mg/l to prevent cravings in such patients.

The lack of dispensed doses in this study is unparalleled in the world to my knowledge and is not based on sound scientific grounds. Like inadequate dosing, it is known to be associated with a significantly lower retention rates (Rhoades 1998). Dispensed doses for the Sabbath are given in many areas and reports have shown no differences from strict 7-day pick-ups (Gelkopf 1999).

comments by Andrew Byrne ..

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Dr Andrew Byrne,

General Practitioner, Drug and Alcohol,

75 Redfern Street,

Redfern,

New South Wales, 2016,

Australia

Tel (61 - 2) 9319 5524 Fax 9318 0631

Email ajbyrne@ozemail.com.au

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



author of: "Methadone in the Treatment of

Narcotic Addiction" and "Addict in the Family"

How much do they spend on drugs? Are all users dealers?

Golub A, Johnson BD. How much do Manhattan-arrestees spend on drugs? Drug and Alcohol Dependence (2004) 76;3:235-246

Dear Colleagues,

This report analyses responses from over 2000 detailed questionnaires concerning specific sums paid for a variety of drugs in the 30 days prior to being arrested in Manhattan between 1998 and 2002.

The authors state in their results summary: "Among 2000-2002 arrestees, median drug expense in the past 30 days varied widely with frequency of use and drug-user type. Infrequent marijuana-only users spent as little as $5, daily marijuana-only users spent about $600. Arrestees who used both heroin and cocaine spent over $1000. Estimates with the 1998-1999 data were about half as large". "The amounts expended on drugs based upon the most recent episode(s) of drug consumption were almost twice as large as estimates derived from asking arrestees how much they had spent for drugs in the past 30 days."

While corresponding research is rare elsewhere, we do know that most heroin users applying for treatment in Sydney have been injecting (a minority smoke or sniff) almost daily and commonly between A$25 and A$100 (~US$600 - $2400 per month). Cocaine is much more expensive in Australia and is not seen in the form of crack at all. Injected cocaine is nearly always in binge-type use and is apparently uncommon outside of inner Sydney. Since retention in good quality treatment is high, and heroin/cocaine use is known to reduce dramatically while in treatment, the actuarial losses to the illicit market and reductions in law enforcement costs must be substantial, quite apart from humanitarian benefits and lessened viral disease transmission.

On related matters from New York, Davis, Johnson and other colleagues show that in upper, eastern Manhattan almost half of all drug users are also currently involved in some part of drug distribution. Those involved in dealing drugs were more likely to have HIV, higher incomes and to be in current drug treatment, but to have poorer education, housing and employment status than those not involved. While more women than men are involved, men are more likely to be involved in direct selling. [Citation: Davis WR, Johnson BD et al. Gender differences in the distribution of cocaine and heroin in Central Harlem. Drug Alc Dependence (2005) 77:115-127]

Comments by Andrew Byrne ..

Depression symptoms in new patients on methadone and buprenorphine. Randomised trial report.

Dean AJ, Bell J, Christie MJ, Mattick RP. Depressive symptoms during buprenorphine vs. methadone maintenance: findings from a randomised, controlled trial in opioid dependence. Eur Psychiatry. 2004 Dec;19(8):510-3

Dear Colleagues,

This well conducted double blind, randomised study examined psychiatric symptoms used the Beck Depression Inventory (BDI) in a subgroup of consenting patients seeking maintenance treatment for opioid dependence. There were 54 subjects who were each tested at entry and at 3 months into treatment. While we are not told the proportion who had depression, the mean BDI dropped from 22 (�10) to 12 (�10) in methadone patients and 25 (�11) to 13 (�9) in those on buprenorphine. By my calculations, the methadone patients saw a mean reduction of 48% in their severity while for buprenorphine, it dropped by 46%. We are told that the difference between the groups was not significant and that larger studies would be needed to determine if there is actually any difference. In my view, any residual difference would be modest, and other factors would probably prevail in clinical decisions about which drug to prescribe. While a BDI reading of 22 would only indicate a moderate depression individually, these are mean figures with standard deviation of 10 so there must have been a number of severely depressed subjects in each group.

The mean doses (for third month) were 48mg (� 20) for methadone and 9mg (� 4) for buprenorphine. Both would probably be considered lower than optimal although they are higher than in a number of other quoted reports.

Thus the conclusion should be that both methadone and buprenorphine treatments are associated with dramatic reductions in overall depression symptoms in the first three months of maintenance treatment. Some still warrant specific antidepressant treatment and indeed, one in ten had been prescribed such drugs during the study period. This is likely to improve retention and reduce illicit drug and/or alcohol use.

The authors state: "The reasons for improvement include both pharmacological and psychosocial stabilisation and may also reflect poorer retention rates for depressed subjects". This latter seems inconsistent with their finding that 'Baseline BDI scores ... were not predictive of treatment retention'.

It is always gratifying to have ones long-held clinical impressions confirmed by controlled scientific research. While the comparative findings may be novel, the observations about depression are not. Several relevant references are over 20 years old. We should all be reassured to learn that both methadone and buprenorphine treatments are probably equally effective in addressing symptoms of depression. This finding supports the general therapeutic practice (in countries where both drugs are available in normal practice) that methadone is the more common first line drug and buprenorphine is used very successfully for those who are unable or unwilling to take methadone. As with naltrexone (and probably any other drug), doctors who preferentially use buprenorphine will often find limited results with a proportion of patients, notably those with high tolerance, who may later transfer successfully to methadone or other treatments.

comments by Andrew Byrne ..