Foetal withdrawals with buprenorphine; uptake of buprenorphine in America; Australia's heroin 'drought' revisited; Barcelona death rates confirm protective effects from methadone;
Dear Colleagues,
From the plethora of publications on dependency recently I report on a number of items below so that readers may pick what might be relevant to their own practices, starting with a RCT of buprenorphine (pure) in pregnant women and results of foetal withdrawals.
Jones HE, Johnson RE, et al. Buprenorphine versus methadone in the treatment of pregnant opioid-dependent patients: effects on the neonatal abstinence syndrome. Drug and Alcohol Dependence (2005) 79;1:1-10 (Ref 1)
This shows favourable outcomes in 10 women and their babies on buprenorphine compared with 11 on methadone (randomised, double dummy trial). The proportion receiving medication for neonatal abstinence syndrome was lower in the buprenorphine and the doses used were lower (neither significantly due to the small numbers). Hospitalization period was significantly shorter in the buprenorphine treated subjects/offspring. This is yet another report showing the safety of buprenorphine in pregnancy. It is sensible that the combination drug was not used in these women. The best 'evidence' for the safety of buprenorphine in pregnancy comes probably from a lack of reports of serious foetal or maternal problems from France where the drug has been freely available from GPs for a decade.
Sullivan L, Chawarski M, O'Connor PG, Schottenfeld RS, Fiellin DA. The practice of office-based buprenorphine treatment of opioid dependence: is it associated with new patients entering into treatment? Drug and Alcohol Dependence (2005) 79;1:113-116 (Ref 2)
This piece attempts to categorize some characteristics of 96 buprenorphine prescribed addicts in America in comparison with 94 entering methadone maintenance at the same period. While not a piece of controlled research, it does indicate that methadone is more likely to attract previous methadone recipients while buprenorphine attracts a higher proportion who have never had methadone (or other maintenance) treatment.
Degenhardt L, Day C, Dietze P, Pointer S, Conroy E, Collins L. et al. Effects of a sustained heroin shortage in three Australian States. Addiction (2005) 100, 908-920 (Ref 3)
This is the latest and probably most comprehensive description of the so-called heroin 'drought' or shortage starting in early 2001 in Australia. There are detailed figures for crime, treatment entries, street prices, etc from three states. While NSW saw a temporary increase in crime, this was not seen in other states. The most dramatic effect was on overdoses which dropped by up to 75% from their high points around 1999. There appeared to be less injecting as shown by fewer syringes distributed. Treatment places were increased at the same time as the 'drought' began while Sydney's highest overdose area saw the opening of an injecting room which attracted thousands of injectors.
Most interesting are commentaries from 6 or 7 experts, each agreeing that a sustained drug shortage of this nature has never been reported before and that the cause was not an obvious alteration in drug policies (although some mention a 'tough on drug' strategy without documenting any substantial changes in customs, policing, treatment, etc).
Gossop points to police crackdowns in Canada and London resulting in enormous drug seizures and arrests, neither of which had any reported effect on illicit markets. None of the wise commentators speculates on China 'opening up' and causing opiates to be diverted from the relatively much smaller Australian market. The 'drought' began within weeks of the start of the so-called 'Chinese century' in January 2001. Ironically a commentator from the People's Republic writes in critical terms about 'harm reductionists' as though they were a pest to be eradicated. He is apparently proud that China 'has experienced a drug-free society for more than 30 years' without mentioning how this was achieved by the deprivation of civil liberties, travel, etc! And then he has the temerity to suggest that methadone and needle services should only be used as a last resort! Does he mean only when the HIV rates exceed 10% of the population? Or 20%? Hao then quotes a proverb using cats and mice to describe the drug war! His views, which some term 'zero tolerance', are so nauseating that they well plead the contrary case!
Brugal MT, Domingo-Salvany A et al. Evaluating the impact of methadone maintenance programmes on mortality due to overdose and AIDS in a cohort of heroin users in Spain. Addiction (2005) 100:981-989 (Ref 4)
This study followed over 5000 heroin users in a variety of treatment settings in Barcelona over a 6 year period, looking at mortality, HIV and other demographics. In 23,000 patient years of treatment there were just over 1000 deaths, one third from overdose, one third from HIV and another third from 'all other causes'. Only 11 overdose deaths occurred in patients currently receiving methadone treatment (50% were on MMT during the study period - mean dose 71mg daily). Being in methadone treatment conferred a 'protection' reducing the risk of death by a factor of 7. This also reduced the risk of contracting HIV.
Reported death rates dropped from 3.1/100 to 0.6/100 between 1992 and 1999 and the authors state: "the protective effects of methadone treatment was proved to have played a significant role." The overall decline is similar to that reported for France during the late '90s, where the drop in overdose deaths is attributed to massive increase in buprenorphine availability. Further, they estimate "that 86% of the overdoses and 38% of the AIDS deaths occurring among non-methadone users could have been avoided had they been in treatment."
This is not to say that all addicts should be on methadone for life. However, only a very experienced professional, after a complete assessment and probably knowing the patient for a time, should ever recommend a course of abstinence based treatments over supervised medical maintenance with psychosocial supports.
Despite containing possibly some of the most valuable lessons in the 40 years of methadone treatment, Addiction, true to type, gives this Spanish item no particular prominence. No editorial appears on the anniversary this month of this life-saving treatment. Methadone (along with related public health measures) has probably saved Australia from the HIV epidemic suffered in most other comparable countries. It also addresses addictions in a humanitarian manner for those unable or unwilling to go directly down the abstinence pathway. Even Australians who express disapproval of methadone treatment can still share in the multi-million dollar savings they have from its use in this country. Most New South Wales patients who were approved for methadone treatment are now off treatment (over 50,000 approved, ~17,000 currently).
Rehm J, Frick U, Hartwig C, Gutzwiller F, Gschwend P, Uchtenhagen A. Mortality in heroin-assisted treatment in Switzerland 1994-2000. Drug and Alcohol Dependence (2005) 79;2:137-144 (ref 5)
These authors report on the continuing success of the heroin prescription trial in Switzerland. Death rates have declined to rates comparable with other drug treatment subjects at around 1% per year, having been over 2.5% in the 1990s across the spectrum of drug users. This is all the more remarkable, they say, because only 'treatment refractory' subjects were admitted for heroin prescription, and these probably had a much higher expected mortality than the 2.5% estimated for opioid users generally in Switzerland in the 1990s.
Comments by Andrew Byrne ..
References
(1) Jones HE, Johnson RE, et al. Buprenorphine versus methadone in the treatment of pregnant opioid-dependent patients: effects on the neonatal abstinence syndrome. Drug and Alcohol Dependence 2005 79;1:1-10
(2) Sullivan L, Chawarski M, O'Connor PG, Schottenfeld RS, Fiellin DA. The practice of office-based buprenorphine treatment of opioid dependence: is it associated with new patients entering into treatment? Drug and Alcohol Dependence 2005 79;1:113-116
(3) Degenhardt L, Day C, Dietze P, Pointer S, Conroy E, Collins L. et al. Effects of a sustained heroin shortage in three Australian States. Addiction 2005 100, 908-920
(4) Brugal MT, Domingo-Salvany A et al. Evaluating the impact of methadone maintenance programmes on mortality due to overdose and AIDS in a cohort of heroin users in Spain. Addiction 2005 100:981-989
(5) Rehm J, Frick U, Hartwig C, Gutzwiller F, Gschwend P, Uchtenhagen A. Mortality in heroin-assisted treatment in Switzerland 1994-2000. Drug and Alcohol Dependence 2005 79;2:137-144
