APSAD Annual Scientific Conference. Cairns, Queensland.
Mon 6th November 2006.
The morning started with Christopher Pyne MP, parliamentary secretary to the Minister for Health and Ageing, giving a spirited talk on the public health benefits of alcohol restrictions.
The convenors cleverly commenced with plenary presentations on the least and most dangerous drugs back-to-back with national and international expert speakers.
Frank Vocci from the American NIDA (NIH) spoke about mooted pharmacotherapies for cannabis addiction. He quoted figures for �ever used� and recently used, finding that about 50% of all Americans have exposure to the drug. We were told that many of the subjects in treatment trials in the US are young people who are referred from the court system as an alternative to jail. He broached possible novel approaches such as the cannabinoid agonists as well as the French antagonist, rimonabant. Other possibilities are lithium, antidepressants or other drugs to counter withdrawal symptoms as well as reduce cravings in dependent subjects. In questioning our speaker later, I was told that while naltrexone showed some promise in rodent studies, that in humans, the drug seemed to augment the effect of cannabis, a very worrying finding. It may paradoxically be a benefit if smokers can get as �high� by smoking half as much. It would appear that this finding alone has been sufficient to stop further funding of such research by NIH.
I also noted with Dr Vocci that the US buprenorphine post-marketing survey released recently showed that over a third of new patients see no doctor, psychologist, pharmacist, nurse or other health care worker in the first 30 days after their initial prescription for the drug in dependency treatment. Unsupervised maintenance treatment is a paradigm shift indeed. It is not evidence based, yet it is being encouraged by health authorities and professional bodies here and overseas for some reason. At present it must be considered a noble experiment.
Smoking and nicotine dependence was covered next by Professor Wayne Hall from Brisbane. In a logically structured talk he broached the novel area of genetic studies to determine susceptibility to addiction to nicotine and/or available treatment. He quoted some moves to look at �vaccinating� children where appropriate risks were high, yet we were told of major ethical concerns here. While he said that parents would always have the right (and responsibility) to choose, he would not advise such moves under any foreseeable circumstances. At the very end of his talk he reminded us of the use of �snus� oral tobacco in Sweden and its potential for harm reduction (which seems to have been ignored across the world, despite promise of reduced harms).
The strict anti-smoking laws in Queensland required that the few smokers present had to stand in a small roped off area near the convention centre drive-way. Not very dignified, but that�s the law. Luncheon included some delicious crumbed reef fish but the rest of the fare was middling to ordinaire.
No less than seven parallel sessions followed. Alcohol in indigenous communities, dual diagnosis, Europe�s highest overdose rates in the UK being addressed with pilot study of naloxone provision, hepatitis referrals and treatment successes in Sydney as well as monitoring of drug trends in Australia and America.
It seemed incongruous that the Turning Point group from Melbourne presented an integrated system of assessment and treatment for hepatitis C within the clinic. Yet this model would have little use in Victoria which depends almost completely on GPs and pharmacies for pharmacotherapies unlike New South Wales which has a large proportion in clinic settings. Their excellent model should be replicated in some form in each and every such clinic in the interests of public health.
Next we presented our own practice approach using community prescribing and a shared care model with liver clinic referrals, which might just be ideal for Victoria! We found that 75% of Redfern injectors were Hep C positive and 75% of those patients had chronic hepatitis, half of whom had high risk factors for cirrhosis. Out of 250 patients seen over a 3 year period at the practice, 70 were at risk, 50 were referred to a hepatitis shared-care service and 40 attended. To date about 25 have commenced interferon and ribavirin treatment, mostly with excellent responses and modest to moderate side effects. Of 29 biopsies performed, 24 showed at least moderate fibrosis, consistent with recent advice to allow treatment to proceed without a requirement to do liver biopsy.
Louisa Degenhardt gave a learned and teasingly titled plenary talk entitled: �Are we the biggest users of ecstasy in the world, and how worried should we be if we are?� She pointed out that �biggest� could mean greatest overall amount consumed per person, but it could equally mean more frequent, youngest or longest career of drug use. She emphasised the dangers of ecstasy but put them into perspective with regard to the large proportion of young people who use the drug regularly, often with few apparent adverse effects and low mortality compared with heroin, cocaine, tobacco and alcohol.
We were asked to allow a bigger input of consumers in opioid maintenance delivery as now standard practice in other areas of health care. Annie Madden and Joanne Bryant urged mangers to take heed of the needs of addicts in treatment and involving them in decisions affecting them. My own feeling is that until there is wider choice and a little competition, the present stigmatising and monopolistic system will remain in place.
We then had an interesting talk from Ann Roche on the Australian workforce in dependency and how only ~75% are happy and satisfied with their jobs. I would have thought that is better job satisfaction than many other trades or professions. By contrast in America, McLellan and Keber found quite the opposite with unhappy workers, �burnout� and short careers in the dependency treatment field. (McLellan AT, Carise D, Kleber HD. Can the national addiction treatment infrastructure support the public's demand for quality care? J Subs Abuse Treat 2003 25:117-121).
Next there were seven more parallel break-out sessions in which mental health, alcohol in the workplace, NGO�s, heroin dependency in pregnancy, state comparisons of methadone treatment and indigenous dependency research partnerships were all covered. There were many useful �messages� such as NGO�s being undervalued in doing work which governments cannot or will not do. We were told that some women avoided methadone in pregnancy for fear of addicting their baby to drugs, despite on-going and very harmful illicit drugs use. Victoria has not solved the problem of diverted drugs by severe restrictions on take-away medication (indeed, they have just freed up access to dispensed drugs for stable patients).
Cairns is a special place and the timing was perfect as a full moon rose on the first night, visible from the entire boardwalk waterfront. The temperature was around 29 degrees for the three days and while there was a slight heat haze, there were no tropical storms, earthquakes nor tsunamis. The silky oaks, bougainvillea and flamboyant trees were in full flower while numerous fragrant tropical species, frangipani, palms, grasses and even mangroves graced the place in abundance.
