29 May 2007

Three recent journal items: alleged problems with cannabis, methadone and buprenorphine

Dear Readers,

I try to give credit when it is due. However, at the same time there should be a �gong� for less-than-inspiring articles which make it thru the peer-review process. There are a number of contenders for my wooden spoon award � which I hesitate to write about, lest my words raise their prominence unduly. But in the interest of fairness, I present here a number of publications which would have been returned for rewriting had I been the editor.

Paradoxically, some of the findings, while inadequately clad, are potentially of clinical importance.

�Gong� award number 1:

Pollack HA, Reuter P. The implications of recent findings on the link between cannabis and psychosis. Addiction 2007 102:173-176

This lead editorial lurches from confidence in the American system of drug control to admissions of wholesale failure of the same. There are no �recent findings�, hence there are no useful �implications�. No mention of the Dutch situation or medicinal cannabis. �Don�t mention the war!� (on drugs).

�Gong� award number 2:

Gossop M. Methadone - is it enough? Heroin Addict Relat Clin Probl 2006;8(4):53-64

This is written as if methadone were some carrion being encircled by birds of prey. Despite being an excellent alternative, buprenorphine does not rate a mention in this long, tedious article. After reiterating the proven benefits of methadone, Gossop states: �Supporters of methadone maintenance bring discredit upon themselves and their treatment [sic] by mean-spirited attacks on other forms of treatment.� (no references). My review of this edition includes another fraught article by Krantz on the supposed cardiac risks of QT prolongation in methadone patients (copy on request).

My final �gong� goes to a research item of certain interest but with conclusions which are completely at odds with its data:

Kakko J, Gr�nbladh L, Svanborg KD, von Wachenfeldt J, R�ck C, Rawlings B, Nilsson L-H, Heilig M. A Stepped Care Strategy Using Buprenorphine and Methadone Versus Conventional Methadone Maintenance in Heroin Dependence: A Randomized Controlled Trial. Am J Psychiatry 2007 164;5:797-803

This Swedish report claims to support buprenorphine as the first line drug for addiction despite a 65% failure rate (dropout or transfer). Indeed, the findings showed that those randomised to buprenorphine fared poorly, even though final retention rates in the two groups were the same. Most needed to transfer to methadone to achieve such an outcome. Read the full summary for all the other problems (such as early bup drop-outs; mean bup dose of 29mg; drug company sponsorship).

We are all learning (me especially), and as a prominent author wrote to me, all research is done in its own context. While pure science is always welcome, real-world practice requires that there be a combination of information to advise clinical decisions. The above articles yield very little new in this regard.

Comments by Andrew Byrne ..