8 November 2007

Drug and Alcohol Dependence, December 2007. Some interesting titles.

Alcoholic monkeys, clinic accreditation, ‘antagonists’ fail opiate and cocaine users (again), methadone success in US prisoners, buprenorphine/benzo interactions and hep C.


Dear Readers,

Some of you have written to enquire after my health. In fact my internet silence in recent weeks is due to the wasteful, costly and time consuming exercise of practice accreditation. Most health care providers are now subject to this exaction, yet few such interventions could be less productive than for addiction treatment providers in New South Wales. We are routinely assessed by well meaning people who have never written a prescription. Imagine a pharmacy or fire brigade being accredited by non-pharmacists or non-fire officers?! And there is no determination as to whether the right patients are getting the right dose of the right drug! That is a state Health Department responsibility, we are told, yet there is only one single inspector for the entire state! Sadly many addiction patients in NSW receive relatively poor care. Some receive inadequate doses and no access to take-away doses, contrary to the Federal treatment guidelines’ advice that such dosing improves outcomes significantly where used appropriately.

So getting back to a list of meaty scientific titles has been a great pleasure, this time the December edition of Drug and Alcohol Dependence, the largest circulation American addiction publication.

It is nice to see familiar names coming up in the research literature. Some one has never met, others one may have met at conferences, others still have become real friends over the years. In this edition alone we find Cicero, Grabowski, Mitchell TB, Lintzeris, Ciraulo, Strang, Schwartz RP, Dolan, Dore, Westcott, Wodak, Vlahov, Inciardi, Degenhardt, Grulich, Kaldor, Kippax, McCance-Katz, Comer and Nunes. This is a breathtaking array of scientific talent and it is quite something that they would all be represented in a single edition of a medical journal.

Several titles immediately caught my eye so I glanced at their abstracts. Hence I would advise those interested to obtain the full article where appropriate. As ever, there are repetitive themes popular with funding authorities despite usually come up with the same outcomes. Many do not learn from history and keep trying the same thing, hoping for different results. Albert Einstein said this was a form of madness.

Various medications have been tried in cocaine users but researchers seem to ignore the fact that most cocaine users are in for a good time. As such, they are unlikely to continue with a drug which gives them a ‘bad time’ (reserpine makes many normal people feel ill, so why give it to cocaine users?). Likewise the same group from the University of Cincinnati, tried tiagabine in yet another costly RCT with no significant difference (placebo does not give much of a predictable ‘good time’ either!).

Next we learn of yet another study showing that oral naltrexone does not work for relapse prevention in heroin users. Yet this new observational study, with some ethical issues to my mind, shows one marginally interesting finding. The failure rate of 70% in those who ‘tested the block’ (relapsed while still taking the naltrexone) was even worse in those who had waited for the block to wear off where a 90% drop-out rate was found. Is this a joke? Or are 70-90% failure rates encouraging enough to warrant more research?

Next we have a report of what should be the very last RCT of methadone treatment, this time in pre-release prisoners in Baltimore. Jail inmates have never been considered quite the same as others regarding medical and psychiatric needs in many parts of the world, including China, Russia, Cuba and America. So now we know that methadone also ‘works’ in pre-release prisoners. And even American prisoners … surprise, surprise! This was introduced into NSW prisons over 20 years ago, initially as a pre-release measure like in this trial. It has consistently produced enormous benefits for the entire community at very modest cost. Along with some other quite backward things in our state, this is one innovation we can be proud of and which is now being slowly copied around the world.

Next we have a fascinating item in which mature monkeys were found to enjoy alcohol with flavouring and to cut down their voluntary intake significantly when accompaniments were altered. Shades of ice-pops and mixers. Hence there seem to be some parallels between us and our close animal cousins. Again, no real surprise here, but gratifying confirmation that humans are not completely unique freaks in the animal kingdom in our desire to be ‘high’.

A group from Australia has done a careful study of the chronological march of the hepatitis C epidemic with very little good news to date. Despite harm reduction measures, treatment availability, education, etc, Australia still has a major public health problem with up to 9,000 new cases each year. More effective interventions might reduce this, as with HIV to hundreds or even dozens.

Another item looks at over 1000 gay men and finds that each year, about 5% started at least once weekly amphetamine use with the same proportion taking up at least once weekly MDMA (ecstasy) use. The proportions would have been very different 10 years ago when ecstasy use would probably have been much more popular. But we now live in the ‘ice age’ as Walter Ling calls it, where Pam Lichty calls it the ‘drug for today’ (which it is!). Yet few researchers have really addressed stimulant use in a logical manner, looking unemotionally at the harms and benefits as perceived by the users and to society generally. This is extraordinary when these drugs have been used across the world for generations now. Anabolic steroids probably fit into the same category and because of their often illicit or unprescribed nature, research is extremely limited and thus advice to the many users of these drugs is necessarily perfunctory: ‘say no to drugs’, keep fit, don’t share needles, don’t use too much, use with a friend, use an injecting room, etc.

Lastly there are two items on drug interactions. We have what might be the first serious report of a significant buprenorphine interaction. Some buprenorphine patients developed sedation on anti-retroviral drugs and needed dose reductions. This is just normal therapeutics, but nice to see it formally reported by a clinical experiment rather than happenstance. Lintzeris reports on giving 20mg diazepam or placebo to methadone or buprenorphine patients in a small RCT with variations in the opioid as well. He concludes: ‘High dose diazepam significantly alters subjective drug responses and psychological performance in patients maintained on methadone and buprenorphine’. No great surprise here, either.

Comments by Andrew Byrne ..

http://www.redfernclinic.com/

http://www.sciencedirect.com/science/journal/03768716

Winhusen T, Somoza E, Ciraulo DA, Harrer JM, Goldsmith RJ, Grabowski J, et al. A double-blind, placebo-controlled trial of tiagabine for the treatment of cocaine dependence. Drug and Alcohol Dependence 2007 91;2-3:141-148

Winhusen T, Somoza E, Sarid-Segald O, Goldsmith JR,,,. A double-blind, placebo-controlled trial of reserpine for the treatment of cocaine dependence. Drug and Alcohol Dependence 2007 91;2-3:205-212

Sullivan MA, Garawi F, Bisaga A, Comer SD,,,Nunes EV. Management of relapse in naltrexone maintenance for heroin dependence. Drug and Alcohol Dependence 2007 91;2-3:289-292

Kinlock TW, Gordon MS, Schwartz RP, O’Grady K, Fitzgerald TT, Wilson M. A randomized clinical trial of methadone maintenance for prisoners: Results at 1-month post-release. Drug and Alcohol Dependence 2007 91;2-3:220-227

Katner SN, Von Huben SN, Davis SA, et al. Robust and stable drinking behavior following long-term oral alcohol intake in rhesus macaques. Drug and Alcohol Dependence 2007 91;2-3:236-243

Razali K, Thein HH, Bell J, Cooper-Stanbury M, Dolan K, Dore G et al. Modelling the hepatitis C virus epidemic in Australia. Drug and Alcohol Dependence 2007 91;2-3:228-235

Prestage G, Degenhardt L, Jin F, Grulich A, Imrie J, Kaldor J, Kippax S. Predictors of frequent use of amphetamine type stimulants among HIV-negative gay men in Sydney, Australia. Drug and Alcohol Dependence 2007 91;2-3:260-268

McCance-Katz EF, Moody DE ,,,. Interaction between buprenorphine and atazanavir or atazanavir/ritonavir. Drug and Alcohol Dependence 2007 91 2-3:269-278

Lintzeris N, Mitchell TB, Bond AJ, Nestor L, Strang J. Pharmacodynamics of diazepam co-administered with methadone or buprenorphine under high dose conditions in opioid dependent patients. Drug and Alcohol Dependence 2007 91;2-3:187-194