28 August 2006

Dependency issues and pain management - "A Busman's Holiday and Other Stories"

Concord Dependency Seminar: Tuesday July 25th 2006

Presenter: Dr Bridin Murnion, Clinical Supervisor, Division of Medicine, and Staff Specialist in Clinical Pharmacology at Royal North Shore Hospital.

Chair: Dr Richard Hallinan

Dr Murnion began by giving us the IASP (International Association for the Study of Pain) definition of pain: "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Pain is always a subjective experience, and for each person what is felt as "pain" is often learnt through experiences in early life. There are many people who are unable verbally to communicate their distress, and yet still need active treatment, including people with dementia, strokes, and intellectual disabilities.

Pain can be present despite no evidence of tissue damage, and we ought to avoid tying its definition to a noxious stimulus. The actual neurological activity produced by a stimulus is not pain until it is reported as such, and it is the subjective report of the patient that must guide our understanding and treatments.

Dr Murnion gave us the AAPM (American Academy of Pain Medicine) definitions of three terms that overlap the worlds of both pain management and dependency medicine "tolerance", "physical dependence" and "addiction":

  1. Tolerance: "A decrease in the effect of a drug over time so that a progressive increase in the amount of that drug is required to achieve the same effect. Tolerance develops to desired and undesired effects at different rates."

  2. Physical dependence: A physiological adaptation to a drug whereby abrupt discontinuation or reversal of the drug, or a sudden reduction in its dose, leads to a withdrawal (abstinence) syndrome. Withdrawal can be terminated by administration of the same or similar drug."

  3. Addiction: A disease that is characterised by aberrant drug-seeking and drug-taking behaviours that may include cravings, compulsive drug use, despite the risk of physical, social and psychological harm. While psychoactive drugs have an addiction liability, psychological, social and genetic factors may play a more important role in the development of addiction than exposure to the drug alone."

Addiction has a complex aetiology whereby a person's biological make-up interacts with psycho-social environment to have a strong bearing on whether use of a substance will lead to continued drug-seeking behaviours. The concept of addiction was contrasted to "pseudo-addiction" in which inappropriate drug-seeking behaviours are directly driven by a person's pain, and in fact resolve when that person is given adequate pain relief.

The similarity was noted to the DSM IV definition of dependence, which listing seven characteristics including tolerance and withdrawal, four of which need to be present to make a diagnosis.

Dr Murnion gave a detailed description of the neurobiology of pain. Pain signals pass from nociceptors in the end-organ tissues along the primary afferent nerve to the dorsal horn in the spinal cord, and thence up the spino-thalamic tract via the peri-aquaductal grey matter (PAG) to the sensory cortex, which identifies where the pain is located. Mu-opioid receptors are located in large numbers in the dorsal horn, and opiates binding here decrease the excitability of the cell membranes. Opiate tolerance occurs partly due to a decrease in the number of opiate receptors and also because of overactivity in the NMDA system (NMDA receptor is a subset of glutamate receptor). Tolerance and hyperalgesia occur via similar mechanisms, and Dr Murnion does not find the idea of opioid-induced hyperalgesia convincing: it is usually better explained by plain old opiate under-dosing.

We were advised to approach chronic pain using a biopsychosocial model: carefully formulate a diagnosis, taking note of any "red flags" that may indicate an aetiology like malignancy requiring a specific treatment as well as management of the pain per se. Details of all current and previous treatments should be obtained and we should develop a thorough understanding of the impact of the pain on the patient's life. Has it affected them in their vocation? What is the impact on their family life and interpersonal relationships? Are they depressed and/or anxious? What are their beliefs about the pain - do they think that it is "harming" their bodies and indicative of ongoing injury? Do they try and avoid activities in the belief that it will increase their pain? What do they expect the various treatments to achieve? Do they have any comorbidities, such as substance use?

We should set treatment goals, which may include a decrease in pain levels, but also psychosocial goals: optimising a person's ability to work, improving mood and personal relationships, and increasing their sense of meaning in their life. Planning will involve avoiding any unhelpful treatments and identifying risk factors for treatment failure.

Treatment options include opioids, paracetamol, NSAIDs, COX-ibs, anti-depressants (the most successful of which are tricyclics) and anti-epileptics. Other options include mobilisation, work rehabilitation, psychological treatments like CBT, and interventional techniques. The latter include dorsal column stimulators, regional nerve blocks and radio-frequency ablation of the medial branch nerves supplying facet joints in both the cervical and lumbo-sacral spines. Dorsal column stimulators have their best evidenced role in neuropathic pain, reflex sympathetic dystrophies, and intractable angina.

The research data on opiate use in chronic non-malignant pain is poor. There is some evidence that oxycodone may have a use in treatment of pain in the knee, back or neck secondary to osetoarthritis. Around 20% patients will suffer significant side effects, such as nausea and vomiting and particularly constipation and somnolence, worse at higher doses. Oxycodone also has some efficacy in treatment of diabetic neuropathy and post-herpetic neuralgia. Some epidemiological studies indicate that those on higher doses of oxycodone for chronic pain are more likely to have several comorbidities including alcohol and benzodiazepine dependence or a positive HIV status.

Up to 50% patients on methadone maintenance treatment (MMT) suffer from chronic pain. Patients on MMT who also have chronic pain are more likely to be on higher doses of methadone. There is some evidence that methadone is particularly effective in treating neuropathic pain. Some patients are reluctant to try methadone as a treatment for chronic pain because of its association with opioid dependency treatment.

Dr Murnion suggested that we adopt a set of "universal precautions", as described by Dr Doug Gourlay, before embarking on any treatment for chronic pain including the prescription opioids. There should be a careful psychological assessment done, including looking at the risk of addictive disorders (personal history, family history, maybe even a spot urine toxicology test). We should explore the patient's goals and define a treatment plan with the patients' consent, setting clear boundaries early on medication use. The use of opioids for chronic pain should always be seen as a 'trial' of opioid therapy, and pain and function should be continually assessed during treatment. Where there are concerns about a patient's psychiatric and drug and alcohol history, seeking support from pain specialists and clinics was encouraged.

Patients who are opioid dependent often require significantly higher doses of opioids to achieve pain control compared to opioid naive patients, and appear to have a higher incidence of hyperalgesia, being particularly sensitive to thermal stimuli like cold. Treating these patients requires not only an approach to pain management, but a knowledge of how to help avoid potential withdrawal syndromes.

Naltrexone, a competitive antagonist of opioids, and one of two widely used pharmacological treatments for alcohol dependency, is best ceased before any planned surgical procedure, to make management of post-operative discomfort open to opioid options. Its block is theoretically surmountable, and in situations where someone taking naltrexone presents in severe pain, one approach is to try and overcome the antagonism with high doses of opioids, although non-opioids may sometimes provide some response.

Buprenorphine is a partial agonist of opioids, and does have some (albeit limited) analgesic efficacy, so where minor procedures are undertaken on patients on buprenorphine maintenance, an increase in the dose of buprenorphine for pain control may suffice. However, with major surgical procedures and the likelihood of significant post-operative pain, a full opioid agonist should be substituted for buprenorphine pre-procedure.

In the second half of this seminar, Dr Murnion and Dr Hallinan presented case studies. The first was a 35 year old man with chronic low back pain ('CLBP') who developed iatrogenic opioid dependency with erratic and increasing opioid consumption, threatening behaviour in demanding opioids, and eventually, illicit opioid use. It was necessary to report him to the driver licensing authority. His management included attempted weaning off opioids with a ketamine infusion (as an NMDA antagonist), an unsuccessful trial of buprenorphine, his refusal to consider methadone on referral to a drug and alcohol service, and loss to follow up...

"Ellie", a 26 yo woman, was started on MMT after 2 years of increasing opioid seeking after a sinus operation and subsequent severe headaches with vomiting. During 3 years of MMT, her frequent headaches with vomiting meant she was often unable to keep down methadone, managed variously with metoclopramide and methadone intramuscularly, and methadone suppositories, also by medical centres at times with pethidine, morphine injections. At one hospital she developed lockjaw (dystonic reaction) after receiving prochloperazine followed by haloperidol for vomiting.

At another hospital where she presented after vomiting her methadone dose she was refused opioids and given metoclopramide and then droperidol injections to allow her to swallow aspirin: this was followed by a severe dystonic reaction to droperidol: which could have been foreseen from the known reaction to haloperidol.

Some of the issues were how iatrogenic dependency might have been prevented with "universal precautions"; how "opiophobia" in clinicians can lead to poor decisions; and relief of pain with vomiting in MMT.

Ken, 39 yo, was a pain clinic patient on MS Contin after accidents and injuries needing 47 different operations. With a past history of alcohol abuse, injecting drug use, cannabis, 40 cigs daily, he felt the pain clinic treated him as an addict, but he only used illicit drugs when his pain needs were not met. After his pain authority was revoked he started MMT, and only stopped using heroin when stabilised on 285mg/day, anti-inflammatory medications and an antidepressant..

Over years of MMT, he frequently used alcohol up to 200g/day, and intermittently used injected stimulants, benzodiazepines " by the handful", and large amounts of cannabis, especially when he tried to reduce his methadone. He also had low sex drive, had lost muscle, put on fat, and complained of growing breasts, and was found to have low testosterone (probably due to the methadone). He was frustrated being 'trapped' on methadone.

Issues discussed were the need for a thorough reappraisal of his orthopaedic issues, looking at his psychosocial situation, and getting a sympathetic pain clinic review - it was noted that a pain clinic could hardly be blamed for treating this man like an addict, as he was surely one! It was asked "What is the problem, actually?" - maybe he ought simply to accept MMT for life. Finally it was suggested that androgen replacement might help give him more strength, resilience, better mood and improved pain tolerance.

This application of theory to "real" cases concluded an excellent seminar on the interface between dependency and pain management medicine.

Summary by Dr Jenny James and Richard Hallinan

25 August 2006

Adelaide Conference on drugs/alcohol in work place. Summary by Richard Hallinan (part 3 of 4).

Work-related Alcohol and Drug use - A National Forum.

30th June 2006.

The second session of day 2 of the forum tackled the controversial area of "Drug Testing (vs Fitness For Work)"

It began with Dr John Lewis, Head of the Toxicology Unit of Pacific Laboratory Medicine Services speaking on "Urine drug testing in the workplace - The message in the bottle". Dr Lewis, whose experience in toxicology began with greyhound testing, observed that Australians are world leaders, having: in 1900, the worlds highest per capita laudanum/patent opiate consumption; in the 1950s the highest per capita (legal) heroin consumption; in the 1960s highest per capita compound analgesic consumption (and Crown Princes of analgesic nephropathy); and in the noughties, reportedly the worlds highest per capita MDMA consumption.

Drug testing is old, having started with horse racing in the 1930s and having been used regularly in humans first by Vincent Dole in the pioneering methadone programmes in the 1960s, then in the Vietnam war and in the 1970s in the Olympics. However, workplace drug testing is recent, starting with Ronald Reagan's edict in the 1980s "You work for me, no drugs" - NIDA and SAMHSA (Substance Abuse and Mental Health Services Administration) enacted policy and policing of zero tolerance for all Federal Government employees. Dr Lewis pointed out that this was never about occupational health and safety, but was a moral and political prerogative.

Urine is free, accessible, painless (generally) and has no 'matrix' problems, unlike saliva. It is backed up by good research and is medicolegally robust. However, it cannot determine the presence or absence of impairment, nor tell us about dose of drug or time of use. The cutoff levels set for identification of drugs are administrative levels, not indications of impairment.

In Australia the procedures surrounding urine testing (but not their interpretation or legal meaning) are governed by the Australian Standard AS4308, which Dr Lewis has been at the forefront of developing. It is important to ask whether labs are accredited to AS4308. There is a "loose association of drug screeners" LAD which work with accredited labs. The AS4308 does not lay down procedures for all drugs, for instance it covers amphetamine type substances ATS (previously called sympathomimetic amines), cannabinoids, and opiates (morphine, 6-acetylmorphine and codeine) but not opioids (such as methadone, oxycodone).

In considering the reliability of tests, especially on site testing, one must distinguish between accuracy (the trueness of the value around a cutoff figure) and precision (the ability of the test to achieve a consistent result every time). Ideally, a test is both accurate and precise, sadly often they are neither.

Dr Lewis gave examples where things go wrong - in bad hands testing results can be horrendous, and this extends to their interpretation. It is important to consult with experts.
One worker was sacked because of having a high urinary creatinine, which is an utter nonsense. Creatinine is essentially a measure of hydration, reflecting also muscle mass (likely to be low in thin Asian women, for instance). In another case, a person in a residential rehabilitation programme was disciplined after putting in positive urine tests for alcohol. However, the urine alcohol was 0.3, which would imply death in most people. On scrutiny, she was found to be diabetic, and sugar in her urine was fermenting to alcohol by the time it reached the lab.

The rights of employees are dealt with under the Privacy Act, which recognises, on balance, the appropriateness of drug testing for some people some of the time. A person tested has rights: to privacy in producing the urine test; to have the specimens correctly labelled and a referee sample provided; not to be accused of drug use on the basis of a urine test; and to challenge test a result.

Discussion followed of the reasons for the AS4308 setting (and most jurisdictions using) a cutoff concentration of 50 ng/mL for EIA for cannabinoids. This cutoff provides a good correlation with the GCMS confirmatory test for carboxy-THC 15: it is in this sense administratively reliable. It does not say anything about impairment, although correlates reasonably well with recent use. A negative test virtually excludes recent cannabis use.

A higher level of 100 ng/mL has also been used, and eliminates any possibility of a false positive test because of passive inhalation, however it will miss many cases of recent cannabis use.

Dr Lewis moved onto the possible benefits and limitations of saliva testing. Some of the issues:

  • the possibility that saliva might correlate better with recent use and impairment;

  • highly variable blood to saliva ratios from 1:2 to 1:5);

  • the impairment caused by a drug such as methamphetamine can be most profound during withdrawal rather than intoxication - "and who is calling for an alco-hangover test", one person asked later. . most accidents caused by THC happened 2-4 hours after use of the drug, which was typically not detected in urine for 4-6 hours after a single consumption.

Dr Kyle Dyer, University of Western Australia, while noting that urine testing remains gold standard for various reasons, is hopeful of the eventual benefits of saliva testing. The evidence is currently limited, much of it produced by the testing industry rather than independent and objective researchers. Saliva concentrations are (variably) proportional to blood concentrations, and therefore a potentially better measure of free unbound drug (what actually gets into the brain), therefore of impairment (although unable to take into account tolerance to the drug). Most drugs, being bases, are passively diffused into saliva, the rate of this is affected by salivary pH. This was already a potential confounder, as the pH of 'stimulated' saliva is 7-8, compared with 'unstimulated' saliva (pH normally 5-5.7). Go stimulate your saliva. Saliva production averages 0.6 mls/minute (0.5-1.5 L/day) with a turnover time of about 10 minutes. Other methods for masking saliva tests were already being touted on the internet.

THC does not passively diffuse into saliva (there may be an active transporter). THC also 'sticks' in the mouth after smoking, also after passive smoking, which may cause a positive test. In general the window periods for detection for THC are short after low dose infrequent use, and earlier for saliva than urine.

Dr Dyer also has hopes for the benefits of saliva testing as a convenient and reliable indicator of plasma methadone concentrations for optimising methadone treatment.

Professor Steve Allsop, Director and Project Officer of the National Drug Research Institute spoke on "Testing the magic bullet. The potential and limitations of drug testing in the workplace.

In a time of changing mores (acceptability of workplace drug use; changes in prevalence and intensity of use), the things that will encourage responses to workplace substance use are a belief that there are real risks, and a responsibility to do something about it, and that there exist effective responses. He suggested we should target high prevalence areas, high harm drugs, and actual workplace risks. Thus, sorting alcohol problems in the workplace may have spin-off effects for other drugs.

Crucially, we should "resist bold claims where evidence is lacking".

In developing strategies, we need to remember the triangle of risk factors for substance use: the individual, the drug, and the environment, and act across all three of these. Connectedness with schools, communities and families reduces take-up of drug use. Substance use is an outcome of individual resilience, culture, and work structures (especially availability, supervision). Drug testing only targets the individual - it may have unintended and negative consequences (for example, removing all truckies with amphetamine type substances in urine tests might lead to higher workloads and increasing use of inexperienced drivers).

Professor Allsop said he would personally refuse a random drug test: if police need a warrant to search his house, they should certainly require one to test his body. In the case of Random Breath Testing, an impairment test would be best, but breath testing has the benefit of being practical. However he warned against using measures removed from the criteria we are interested in.

In the USA, the Council for Scientific Affairs (CAS) had officially pronounced that there is no association of drug screening tests with impairment. There was also little evidence of any benefit of drug testing. An example was pre-employment testing as a predictor of later workplace performance (including dropout): one study showed drug use was associated with poorer later workplace performance, but so too were black race and female gender. Another found a negative association for earlier school leaving age. Should these too be grounds for exclusion from work?

Declining levels of substances in the blood, and hangovers, may be higher risks than higher blood levels. There are quality assurance problems: false positives, handling and lab errors, also problems concerning over the counter (OTC) and prescription drugs. Should employers be privy to information about people's use of such substances?

There is no evidence of the cost-effective of drug testing. Too much emphasis on drug testing would parallel giving all resources to the police, rather than concentrating on the triple harm reduction goals of reducing demand, giving effective treatment, and interdiction. It might also undermine other responses, as the greatest benefits were to be had by keeping workers on side. Among other possible harms, people might respond by moving away from long half-life substances (such as cannabis) to short long half-life substances (such as cocaine or alcohol

There are lessons to be learned from OH+S (hard hats and steel cap boots are now associated with manliness) and public health (successful measures in reducing smoking have been based, not on testing, but on developing awareness of the risks to others - similarly with alcohol and RBT).

It was suggested from the floor that workplace drug testing is all about reducing financial risk and above all legal liability, an idea with which Professor Allsop agrees, although he noted that it is also embraced because of moralistic reasons; because of a belief that testing will promote changed behaviour; in response to statutory requirements, and sometimes because of the momentum of a "me too" effect. Dr Dyer suggested drug testing is a useful scapegoat: it is easy to blame the urine test for subsequent actions.

Is there value is determining "levels of impairment"? This requires measurement of baseline proficiency. Performance testing is still in its infancy. Experienced cannabis users do better on field sobriety tests than less experienced cannabis users. Dr Allsop suggested there is no acceptable level of impairment, and turned the question to one of where we best invest our efforts. There is a trade-off between level of evidence, level of intrusion and level of risk. The crucial issue is what members of the community are prepared to tolerate, and efforts were needed to ensure community support. He contrasted the community support for RBT with the general lack of support for speed cameras.

In later discussion, Professor Steve Allsop put his view on prohibition of cannabis: was it effective? NO; was it harmful? YES Did he support legalisation? NO. He believes it is unlikely that we could control that the cannabis industry (through regulation and taxation) as effectively as we do the tobacco and alcohol industries.

The following is an extract from the NCETA Information and Data Sheet Nr 4. Drug Testing as a response to Alcohol and Other Drug Issues in the Workplace

"... random testing can lead to an atmosphere of guilt and mistrust, which in turn can substantially impact on employee morale and motivation. This is especially the case if a positive test results in dismissal. When this occurs, employees may not see testing as a legitimate occupational health and safety or productivity issue. Rather, they may view testing as a disciplinary measure that extends employer control beyond the workplace into their private lives."

The transcripts of these presentations will be available from NCETA in the Proceedings of the Forum. For more details contact NCETA on 08 8201 7535 or nceta@flinders.edu.au or www.nceta.flinders.edu.au.

The forum presentations can be viewed at: www.nceta.flinders.edu.au/events/twenty_four_seven.html#Presentations

Summary by Richard Hallinan

21 August 2006

Adelaide Conference on drugs/alcohol in work place. Summary by Richard Hallinan (part 2 of 4).

Work-related Alcohol and Drug use - A National Forum.

29th June 2006.

Session 3 chaired by Dr Neal Blewett.

New NCETA research shows alcohol is the Number One workplace substance use issue, and first good evidence of workplace-related harms from illicit drug use.

Session 3 on Day 1 of the National Centre for Education and Training on Addiction forum on Work-related Alcohol and Drug Use, chaired by Dr Neal Blewett, presented new NCETA research findings on "Patterns and Problems" for alcohol and illicit drugs, based on analysis of the 2004 National Drug Strategy Household Survey.

Professor Ann Roche reminded us of the National Health and Medical Research Council's revised alcohol guidelines for levels of risk ("low, risky, high risk") both for chronic harms and also acute harms (like memory loss, blackouts). Previous guidelines tended to reflect the orientation of treatment services to the chronic harms.

For alcohol, important findings were

  • older people, and those not working, are more likely to abstain from alcohol.

  • where only small numbers of people were at risk for chronic harms, large numbers of people sometimes put themselves at risk of acute harms.

  • workers in their twenties and early thirties are at particularly high risk for acute harms.

  • as are: women in their late teens; women managers and supervisors (?keeping up with men, despite lower defined safe limits based on gender); people working in the hospitality industry (?owing to their youth, availability of alcohol); and tradespersons.

There were disturbing statistics:

  • 7% of people surveyed had attended work/study under the influence of alcohol in the previous year (9% of males, 3% of females); this figure was 13% of 14-19 year olds.

  • "risky" drinkers (whether acute or chronic) took the most time off work for "all causes" ie whether attributed directly to alcohol or to other causes.

  • 10% of absenteeism overall was related to alcohol, but this rose to 50% of absenteeism among low risk drinkers, who are in the large majority.

  • risky drinking is associated with psychological distress, although the causational direction is unclear - it might be bi-directional association.

Some critical propositions came from these data:

  • alcohol is the Number One workplace substance use issue;

  • harms are caused mostly by regular and intoxication, rather than dependency as such;

  • workplace culture plays a large role in alcohol related harms;

  • risk comes from how, where and with whom you drink.

Dr Petra Bywood presented evidence of high prevalence of use of illicit substances in the Australian workforce - overall 37% lifetime use (58% in the 20-39 age group ) and 15% in the last 12 months. The NCETA research looked at 3 outcomes: working under the influence of drugs, absenteeism due to drug use, and absenteeism due to illness or injury (not necessarily in the workplace)

Painkillers and cannabis are the most available illicit substances; cannabis, amphetamines and MDMA are the most commonly used (lifetime use 33%, 9%, 7% respectively). Males use illicit drugs more commonly than females (20% vs 13% in last 12 months) and use declined after age 30. Tradespersons have the highest, and managers and professionals the lowest, rates of use overall. Low illicit drug use was reported in defence and rail transport.

Few people reported going to work under the influence of illicit drugs (overall 2.5%) but rates were higher in some industries (eg hospitality, construction, forestry) and generally in young men. Absenteeism due to illicit drug use was much lower than for alcohol, and again was highest in young men. Illness/injury related absenteeism was also higher in people who used illicit drugs. In summary, this research has provided some of the first good evidence of both direct and indirect harms of illicit drugs in relation to reduced productivity and increased health and safety risks.

Dr Ken Pidd, presented an overview of the key issues and interventions for alcohol and other drug issues in the workplace.

Some key issues are:

  • the identification of groups at high risk: by occupations (tradespersons) and industries (eg hospitality); by gender (males in most age groups) and by age (especially 14-19 year olds); and combinations of these - eg female managers, supervisors and hospitality workers.

  • the duty of care to young people, especially in managing the transition from school to workplace;

  • the importance of a culture where might supervisors traditionally discourage drinking at work but encourage it after work.

  • A characterisation of high risk would be "highly stressed, bored, poorly supervised workers in a confrontational environment with few guidelines".

People are twice as likely to go to work under the influence of alcohol than illicit drugs, yet both are uncommon by contrast with taking days of work due to alcohol use (3.5% in previous 3 months) or illicit drugs (a third as common). Most absenteeism is related to low levels of alcohol use in large numbers of people.

Three overlapping patterns of substance use need to be differentiated in planning interventions: intoxication, regular use, and dependence, with the latter representing a spectrum proportional to the difficulty of abstaining. Two contrasting types of interventions are problem solving (tertiary level care, late) and prevention (with an emphasis on education and risk factors in the workplace).

The elements of comprehensive interventions are:

  1. Workplace policy (should be clear, identify what to do and who should do it, acknowledge the role of workplace environment);

  2. Education & training.

  3. Counselling/treatment (good evidence base)

  4. Employee assistance programs EAP (providing ready access to assessment counselling and referral)

  5. Testing (expensive, poor evidence for benefit, may be largely misdirected ie to illicit drugs)

  6. Health promotion (focusing on general health and well being including drug and alcohol use)

  7. Brief interventions (especially effective in non-dependent and low dependent users).

The NCETA research findings are available in an excellent series of five Workplace Drug and Alcohol Information and Data Sheets.

  1. Workers' Patterns of Alcohol Consumption

  2. Workers Alcohol Use and Absenteeism

  3. Responding to Alcohol and Other Drug Issues in the Workplace

  4. Drug Testing as a response to Alcohol and Other Drug Issues in the Workplace

  5. Illicit Drugs in the Australian Workforce: Prevalence and Patterns of Use

The following is from the information sheet on Drug Testing, which will dealt with in the next part of these summaries.

"A further limitation to testing is the predominant emphasis on illicit drugs. The vast majority of workplace tests are conducted to detect the use of illicit drugs, not alcohol. Recent prevalence data indicate that while 84% of Australians are current drinkers, only 15% are current illicit drug users. ..... Thus, the greatest risk to safety and productivity is likely to come from the much larger numbers of employees who engage in unsafe or risky patterns of alcohol consumption."

The transcripts of these presentations will be available from NCETA in the Proceedings of the Forum. For more details contact NCETA on 08 8201 7535 or nceta@flinders.edu.au or www.nceta.flinders.edu.au.

The forum presentations can be viewed at: www.nceta.flinders.edu.au/events/twenty_four_seven.html#Presentations

Summary by Richard Hallinan

16 August 2006

Community buprenorphine combination study: no control group and limited outcomes

N Engl J Med 2006 355:365-74

Counseling plus Buprenorphine-Naloxone Maintenance Therapy for Opioid Dependence. Fiellin DA, Pantalon MV, Chawarski MC, Moore BA, Sullivan LE, O�Connor PG, Schottenfeld RS.

Dear Colleagues,

Starting in August 2000, these authors prescribed a new and still largely untested buprenorphine combination treatment in three different randomised protocols to 166 community patients who had been on a methadone waiting list. There was no control group given established optimal dependency treatment (supervised �mono�-maintenance therapy).

About a third of subjects had not been on methadone previously (mean age 36; mean 8 years of dependence).

Rather than choosing quite disparate protocols to better contrast different outcomes, these researchers chose two similar levels of counselling (20 vs. 40 minutes per week) and two frequencies of dispensing (1 or 3 times weekly attendance). With these relatively minor differences, the researchers predictably found no significant differences in outcomes, including retention and illicit drug use. This raises the question of why this study was performed.

Unlike nearly all previous American research, there was no direct supervision of doses, even in new or unstable cases. However, the medication was dispensed in a �smart� bottle with a lid which recorded times of opening on a microprocessor. The authors report �adherence� (n�e �compliance�) at 70% � 20% and it would come as no surprise that indeed those with better compliance were more likely to have better drug use outcomes. The sub-optimal maximum dose here of 24mg (usually 32mg) may have limited outcomes to some degree.

In assessing retention rates, we should consider that trial subjects had (1) a comprehensive approach to treatment, (2) gratis treatment, (3) exclusions for those with depression, alcohol/benzo dependence, pregnancy and mental illness and (4) very limited effective alternative treatment options before, during and after the trial. Despite these factors, the 6 month retention rates were nonetheless modest at 39 to 48% (or even less, if we include all drop-outs from entry - see below). These are lower than reports of White (79% at 6 months) or Fudala (55-59% at 6 months).

These researchers also show that even when excluding high risk groups, and after numerous drop-outs, a further 10% fared so poorly in treatment that they needed �protective� transfer to methadone maintenance (with all its uniquely American rigours). Under this provision, after reaching the maximum dose of 24mg daily, patients with three consecutive opiate positive urine tests were automatically advised transfer to methadone. We are not told the subsequent progress of these late failures of buprenorphine combination treatment.

While maintenance opioid treatments have an enormous research base, nearly every rigorous study involved a pure drug (eg. methadone, buprenorphine, LAAM, morphine, heroin) given under direct supervision (at least initially). Thus the use of non-supervised dispensing and a combination drug were two aspects which were experimental in 2000 (as they largely remain in 2006). Thus one must question what these researchers hoped to achieve beyond a prominent peer reviewed publication of an untested treatment against itself of very limited scientific value.

It is also an ethical conundrum that these patients were prescribed a documentedly inferior drug having all been recruited from a waiting list for simple, traditional methadone treatment which is the gold standard. In a �normal� world (eg. Canada, New Zealand, Italy, Switzerland, Scotland, etc) these patients would have been given the option of methadone initially or alternatively, they might have been offered the study protocols in community practice compared to traditional clinic treatment.

In the 6 years since the trial started, the opiate of choice in many American cities has changed from heroin to morphine (which might please drug company shareholders). Buprenorphine may be more of less effective for this group. It is generally believed that buprenorphine is less effective for those with high level opiate use, yet this has never been scientifically tested to my knowledge.

During the 3� year recruitment two thirds of subjects were lost through being excluded, dropping out, etc. This left only one third finally accepted into the trial based in primary care (166 of 497). Hence, treatment retention is really substantially lower than reported if we include those assessed as opioid dependent but never actually starting treatment (208 of 497 lost contact or declined to enroll). This is something Prof James Bell has reiterated from his own trial work: what a small proportion of dependency patients actually prove to be suitable for non-supervised buprenorphine treatment.

The genesis of this study is unclear. It does not address the question about dose equivalence of the new combination buprenorphine, nor does it examine traditional supervised maintenance treatment against fully dispensed (un-supervised) treatment. These are crucial questions which nobody seems prepared to address scientifically (and which one might think would have been answered before approval).

Regarding the different levels of counselling, the first comparison of �bare bones� methadone dispensing with full service management was done in 1973 by Senay and Jaffe in Chicago, finding no significant differences (although some interesting trends were reported).

The improved results of any treatment due to adjuvant supports, both physical and mental, have been known about since the time of Hippocrates. In dependency treatments, McLellan (1993) and Yancovitz (1991) used quite different methods to provide evidence that added supports can make small but significant differences in outcomes.

Comments by Andrew Byrne ..

Yancovitz SR, Des Jarlais DC, Peyser NP, Drew E, Friedmann P, Trigg HL, Robinson JW. A randomised trial of an interim methadone maintenance clinic. (1991) American Journal of Public Health 81:1185-91

Schwartz RP, Highfield DA, Jaffe JH, et al. A Randomized Controlled Trial of Interim Methadone Maintenance. Arch Gen Psychiatry 2006 63:102-109

Senay EC, Jaffe JH, diMenza S, Renault PF. A 48-week study of methadone, methadyl acetate, and minimal services. In: Fisher S. and Freedman AM, eds, Opiate Dependence: Origins and Treatment. New York: Halsted 1973 185-201

Kraft MK, Bothbard AB, Hadley TR, McLellan AT, Asch DA. Are Supplementary Services Provided During Methadone Maintenance Really Cost-Effective? Am J Psychiatry (1997) 154;9:1214-19.

McLellan AT, Arndt IO, Metzger DS, Woody GE, O'Brien CP. The Effects of Psychosocial Services in Substance Abuse Treatment. JAMA. 1993;269:1953-1959.

Fiellin DA, Pantalon MV, Chawarski MC, Moore BA, Sullivan LE, O�Connor PG, Schottenfeld RS. Counseling plus Buprenorphine�Naloxone Maintenance Therapy for Opioid Dependence. N Engl J Med 2006 355:365-74

Fudala PJ, Bridge TP, Herbert S, Williford WO, Chiang CN, Jones K, Collins J, Raisch D, Casadonte P, Goldsmith RJ, Ling W, Malkerneker U, McNicholas L, Renner J, Stine S, Tusel D. Office-Based Treatment of Opiate Addiction with a Sublingual-Tablet Formulation of Buprenorphine and Naloxone. NEJM (2003) 349:949-958

15 August 2006

Adelaide Conference on drugs/alcohol in work place. Summary by Richard Hallinan.

Work-related Alcohol and Drug use - A National Forum.

29th June 2006.

Keynote speaker Bob Hawke

Adelaide was host to this important Forum on 29-30 June, in which the National Centre for Education and Training on Addiction (NCETA) and the Alcohol and other Drugs Council of Australia (ADCA) brought together workers, employers, researchers and alcohol and other drugs (AOD) professionals to look at the role of work - and the workplace - in how we use alcohol and other drugs, and the workplace's role in prevention of AOD related problems. The AOD field has probably never seen a gathering of such diverse parties and interests.

This series of four summaries covers most of the sessions of the Forum. While every attempt has been made to be accurate and objective, these summaries reflect necessarily the impressions (and possibly some misunderstandings) of one audience member. The present tense is generally used for reported speech. [Some comments of the writer are noted in brackets RH].

After the official opening by Christopher Pyne MP (Parliamentary Secretary to the Minister for Health and Ageing), three keynote speakers gave a social commentator's, then workers', and employers' perspectives on the issues involved.

Professor Barbara Pocock, of the University of South Australia, spoke on the impact of work in our lives. Her thesis is that Australian workers are on a work/life collision course. Australians have an apparent increasing appetite for work. Along with increased traveling time and work intensity, common family time is being squeezed or lost. Most new jobs are part time and casual, with lack of tenure, respect, predictability of earnings and hours, retirement savings, and limited job security. With this has come a contraction in those at home caring. We rank 17th out of 20 OECD countries in terms of the generosity of public support for childcare, paid leave for parents and child benefits.

There is no going back to the male breadwinner, yet a gendered distribution of domestic work and care persists. With a shift of community from home and street to workplace, there is erosion of relationships and intimacy, and an increasing tendency to commodify domestic responsibility, with care and love becoming the invisible sacrifice. What happens when women's need to work, and the increasing stress of the workplace, collide with the culture of motherhood: that mother is ever-loving, and always there? While kids understand parents' need to work, most prefer more parental time to more money in the household. One parent at home doesn't make up for the absence of the other.

Professor Pocock asks: will we adapt as a society or leave the individual privately to juggle? She put the case for reforms to accommodate the new worker and family , including an improved leave regime, decasualisation of ��permanent casual�� jobs; quality, accessible, affordable childcare, reduced hours of work and overtime, shared domestic work and unpaid care, and improved family payments system.

Richard Marles, Assistant Secretary of the Australian Council of Trade Unions (ACTU) told us that Australians are the second hardest working people (in job hours, paid and unpaid) in the OECD. At a time of low unemployment the reality is underemployment: with a third of the workforce working part-time, and increasing numbers in precarious and "atypical" employment; as casuals or independent contractors, getting no sick pay, holiday pay or paid parental leave - and this by virtue of workforce trends, rather than legislation or any particular policy decisions.

Work intensification is caused not only by globalisation, but by the trend to the 24-hour day economy - the benefits of both of which Mr Marles lauded. However workers are required to show more and more 'flexibility' and work is being pushed to its limits. This process leads to both long and short hours workers, and tips the scales in favour of employers. He described the unpredictability and precariousness of modern employment (only increased by the "Workchoices" legislation) as amounting to disempowerment, and listed possible health implications: less time spent with partner and children leading to relationship breakdown; less volunteering work in the community; stress being associated with heart disease, decreasing fertility, increased rate of accidents, increased use of drug and alcohol and increased anxiety and depression.

Mr Marles made the critical proposition that stress leads to increased use and abuse of drugs and alcohol, and identified stress, fatigue and bullying as the greatest problems in the workplace.

Chris Harris representing the Australian Chamber of Commerce and Industry (ACCI), reckoned the costs of drug and alcohol misuse as $13.7 billion per year, through absenteeism, decreased output, increased staff turnover, and as a trigger for claims such as sexual harassment, especially alcohol playing a role in the latter .

He outlined the forms of employer's responsibilities, whether statutory (eg laws covering aviation, or rail transport; or more broadly state Occupational Health and Safety (OH+S) legislation; through the need for liability management; or a broader commitment to corporate citizenship. These obligations are tempered by unfair dismissal and privacy laws - for example, it is unusual for summary dismissal to stand up in the courts.

He noted that employers are not drug and alcohol professionals, and have limited knowledge of unfamiliar drugs, including prescription drugs, but also other drugs whose use may reflect changing mores in the community.

An ACCI survey of enterprise agreements showed 70% addressed health and safety issues; 38% drug and alcohol issues (especially in building and construction); and only 2% provided for employee assistance in this respect. Of strategies in evidence in these agreements, behavioural standards were common (eg "must be fit and alert at work") as were provisions for serious misconduct (eg "intoxicated with alcohol or under the influence of illicit drugs"). Workplace drug testing was not widespread, being very industry specific (especially transport and mining). Nor were provisions for counselling, disciplinary measures, or rehabilitation. Few agreements had comprehensive strategies involving all these elements.

Mr Harris stressed that the greatest challenge lies with small and medium sized businesses [incidentally, more likely to be exempted from the restraining provisions of unfair dismissal laws. Although the ACCI does not share the ACTU's gloomy vision of "Workchoices" legislation, enterprise agreements will be a thing of the past for many employees under "Workchoices" and Australian Workplace Agreements. comment RH]

Previous ACTU secretary, and Australian Prime Minister, Bob Hawke was introduced as an authority on workers issues and also architect of the enlightened drug and alcohol policies which have existed in Australia since the middle 1980s. Mr Hawke promptly gave credit to Dr Neal Blewett as a great Health Minister who had championed such initiatives as the National Drug Summits and Strategies. He referred also to his own personal expertise both as a drinker, and an alcohol abstainer for the term of his prime ministership.

Mr Hawke commended to the forum three principles which he had laid down for the nation to work together in the difficult economic times in which he took over the prime ministership, in the national summit of governments, churches, businesses, and unions:

  1. complete sharing of information, to provide a common factual basis for understanding and action;

  2. an understanding of the identity of interests (what is in all our interests); and

  3. the universality of obligation - not just employers telling workers to behave themselves (or vice versa, presumably).

In the discussion that followed, several contentions emerged:

  • workplace drug and alcohol issues can be seen as an individual responsibility or being caused by structural problems in the economy and workplaces.

  • an unhealthy impetus for developments may come from 'push-back', a kind of tit-for-tat between unions and employers.

  • stress and overwork have consequences (mistake rates increasing after working 40-50 hours/week), having healthy workers is better for all, and therefore a need to prioritise keeping workers healthy, for employees to 'own' this issue.

  • there is evidence that it is appropriate to average overtime over 1-2 month periods (but not longer), and that workers are often their own worst enemies when it comes to overtime - also, one in two overtime hours is unpaid.

  • substances may be used in response to stress (especially sedative-hypnotics) but also to improve workplace performance (eg stimulants).

  • Workchoices may lead to a 'race to the bottom' in workers' conditions (ACTU) - but OH+S is protected because enshrined in state law (ACCI).

  • The second session of the day dealt with employees' and employers' obligations.

Tony Beech, Chief Commissioner of the Western Australian Industrial Relations Commission spoke on "Drug Testing at Work - Getting it Right". He described cases where workplace drug testing was tested in the courts - either challenged upon its introduction, or in claim for unfair dismissal.

The first case involved BHP in the mining industry in 1998. The testing programme was upheld by the Commission because BHP had consulted widely, and explained the programme, which was holistic and comprehensive and included education and opportunities for rehabilitation. It set higher levels for cannabinoids in urine on the basis that these might better represent impairment than the lower levels usually used - one implication is that such levels may be challenged in the courts.

The BHP case provided a precedent for workplace drug testing for that particular setting and context, but not necessarily for others. It illustrates the principle that 'fairness' is a test at law, in this case weighing a "demonstrable need" against civil liberties, and the right to privacy.

Some further issues were the distinction between random and targeted urine testing, the need for employees to examine the reasons for an employee refusing to do a urine test (eg religious, modesty, on principle), the lack of current accepted standards for saliva testing, and the fact that extension of workplace testing will depend on acceptance of the need for it by the wider community, as was the case with random breath testing of motorists.

Ms Lyn Barnett, of Safework South Australia, gave a perspective from an OH+S inspectorate - noting that all Australian states had similar provisions. Obligations on employers fall into 3 types: Acts and Regulations, which are law and must be followed; Approved Codes of Practice, which must be followed unless a better alternative exists; and Guidelines, designed to help employers meet their obligations.

In general employers must

  • provide a safe workplace environment and consult with employees

  • carry out risk management

  • implement and document policies

Employees are obliged to

  • look after themselves and others in the workplace

  • not endanger these by using alcohol and other drugs

  • obey reasonable orders

Risk assessment must always consider how likely harms were to occur, and the degree of those harms. Policies should take account of workplace culture, stress, relationships and the availability of substances.

An medical perspective came from senior occupational physician Dr Ian Gardner, currently Senior Consultant to the Australian Defence Force, under the title: "To Pee or Not to Pee - That is the question". Dr Gardner stressed that the views he expressed were his own, not necessarily those of the ADF.

While there was no debate anymore about the place of alcohol testing, the same could not be said for other drug testing. There is, in his view, little evidence of the relationship between other drugs and workplace harms, and minimal evidence of a relationship between available drug tests and impairment.

There are important concerns regarding privacy, interpretation of tests, chain of custody and punishment resulting from positive tests. Existing tests may miss current intoxication (eg very recent use of amphetamines) and do not detect impairment from fatigue, ill-health, and medications (eg chemotherapy).

Dr Gardner reviewed the limitations of the available evidence for the relationship between other drugs than alcohol and workplace harms. He stressed the importance of "root cause analysis" of industrial accidents, rather than blaming substance use merely by association. In the absence of good evidence, Dr Gardner's position is that there is "a limited place for drug testing in safety critical areas".

Currently available tests of fitness for duty, for example computer based tests of reaction or cognition, are unvalidated, though they are already in use in some industries like mining.

In the discussion that followed, it was pointed out that Blood Alcohol Level BAL of 0.05 though often used as a benchmark or reference point, does not actually define safety or impairment, but is a legal definition reflecting what is socially acceptable at this time. Although it does not prove impairment, it implies it, based on good research evidence. A comment from the floor was that the pharmaceutical industry has considerable expertise from testing its products for causing possible impairment - coming as it were from the opposite direction, of establishing the safety or safe use of these substances.

Many of these issues were taken up in more detail on Day 2 of the Forum.

The transcripts of these presentations will be available from NCETA in the Proceedings of the Forum. For more details contact NCETA on 08 8201 7535 or nceta@flinders.edu.au or www.nceta.flinders.edu.au.

The forum presentations can be viewed at: www.nceta.flinders.edu.au/events/twenty_four_seven.html#Presentations

Summary by Richard Hallinan; with assistance from Marijke Boers

2 August 2006

In Memory of Vincent P. Dole, MD

Vincent P Dole, MD, Dies at Age 93

August 2, 2006

Dr. Dole (an internist) and his late wife, Marie Nyswander, MD (a psychiatrist), began their collaborative research with methadone with a handful of long-term heroin-dependent individuals in 1964. They did so in the face of overt threats of harsh criminal and civil action by federal narcotics agents. Their courageous, pioneering work demonstrated that methadone maintenance is a medical treatment of unparalleled effectiveness - a superlative description that is as applicable today as it was four decades ago. As a result, well over three-quarters of a million people throughout the world are able to lead healthy, productive, self-fulfilling lives - over 200,000 in the United States, an estimated 530,000 in Western Europe, and many tens of thousands more in Eastern Europe, Middle East, Central Asia, Far East, Australia and New Zealand.

After the remarkable transformation they observed in their first few patients, Dr. Dole and Dr. Nyswander went on to provide direct supervision of the first "methadone maintenance treatment program" at Beth Israel Medical Center in New York. In so doing they demonstrated that it was possible to replicate on a large scale the therapeutic success they achieved in the small, controlled, research environment of the Rockefeller Institute (now Rockefeller University). Dr. Dole was also responsible in the early 1970s for convincing the New York City Department of Corrections (at the time headed by Commissioner Ben Malcolm) that detoxification of heroin-dependent inmates in the city�s main detention facility at Rikers Island was imperative to save lives and lessen suffering (there had been a wave of suicides at the time that had been attributed to severe opiate withdrawal). The detoxification program continues to this day, and has become a model for enlightened corrections officials in other countries.

Dr. Dole and Dr. Nyswander�s contributions, however, transcend the life-saving clinical impact on patients and the enormous associated benefits to the community as a whole. They had prescience to hypothesize, years before the discovery of the morphine-like "endorphine system" in the human body, that addiction is a metabolic disorder, a disease, and one that can and must be treated like any other chronic illness. What was at the time brilliant insight on their part is today almost universally accepted by scientists and clinicians alike, and remains the foundation upon which all rational policies and practices in the field rest.

In his mid-80s Dr. Dole traveled to Hamburg to be present at the naming ceremony of the "Marie Nyswander Street"; in less than ten years Germany moved from methadone being illegal to having over 60,000 patients in treatment! His efforts during recent years were devoted to fighting the stigma that, tragically, remains so widespread against the illness of addiction, the patients and the treatment.

Robert G. Newman, MD, M.P.H.