1. Changes to opiate treatment programs during Covid – benefits for some, harms for others.

 1 Changes to opiate treatment programs during Covid – benefits for some, harms for others. 

2 Pure versus combination buprenorphine – drug company tactics, ‘smoke and mirrors’. 

3 Harm reduction and diazepam prescribing in opiate programs. 

4 Microdose transfers from methadone to buprenorphine – the ‘Bernese’ method measures up. 

 5 Are we seeing the end of the ‘methadone clinic’? 

6.   The role of OTP clinics in Covid vaccination, diagnosis, prevention, quarantine, home dosing, etc.  

Part the First: Covid changes. 

Covid has taught us many things about many things, including opiate maintenance treatments.  From early in the Covid pandemic most patients were given extra take-home or dispensed doses.  For about a month due to the delta crisis in New South Wales our practice gave no supervised doses but just doses for home consumption from the practice window.  Although substantial numbers of our patients benefited greatly from increased liberties with take-away or dispensed doses of methadone and buprenorphine, a minority have got into trouble, some in a small way, others seriously.  

In our practice we detected about ten percent of our patients, mostly ‘doubling up’ on doses and thus running out before normal return dates.  Others were injecting the medication, selling it or just saving amounts ‘for a rainy day’ (in case the clinic were closed down).  One patient developed serious septic thrombosis from regular inguinal injecting, requiring in-patient treatment for an extended period.  Yet another was reported to be selling doses to others in the practice. 

Daily supervised dosing has been the usual practice in nearly all opiate maintenance research and practice, at least initially.  However, the place of continued supervised dosing has never been systematically investigated to my knowledge.  We found no distinguishing factors in those who ‘stumbled’ when given extra dispensed doses during Covid lock-down periods.  Some were stable, employed, long term patients while others were known to use other drugs including alcohol and had less stable lives generally. 

Detection of irregularities with adherence was made by self-report, venipunctures, requests for supplements or hospitalisations.  Such patients often dictated their own safety measures such as more regular attendance, increased dose supervision and for some, dose adjustments.  Transfer from methadone to buprenorphine was also considered in some cases. 

During the period of zero supervision, several of our patients started taking split doses, finding the benefit of less sedation and longer duration of action.  They were disappointed when dose supervision resumed once the clinic re-opened for regular operation.  The most obvious solution for this is transfer to buprenorphine which is longer acting and usually non-sedating.  This can now be accomplished, even in those on high doses of methadone, using the ‘Bernese’ microdosing technique without the need to reduce methadone doses at all (more about that in a future posting). 

Several groups have tried to measure changes from the Covid provisions in opiate maintenance yet there is still no systematic examination of the outcomes of dose supervision and regular attendance for medication.  A Yale University group headed by addiction psychiatrist Ayana Jordan was working on the subject during the early months of Covid in mid-2020.  A press release waxes about the benefits of increased dispensed doses in American methadone programs (see first reference below).  However, I have read little about the ‘down side’ which we have noted above. Evidence based treatment will always be safest even though it may be inconvenient. 

How COVID pandemic changed methadone treatment for addiction - ABC News (go.com)

Did drug use increase following COVID-19 relaxation of methadone take-out regulations? 2020 was a complicated year - ScienceDirect

Opioid agonist treatment and patient outcomes during the COVID‐19 pandemic in south east Sydney, Australia - Lintzeris - - Drug and Alcohol Review - Wiley Online Library

The impact of COVID-19 on opioid treatment programs in the United States - PubMed (nih.gov)

A pilot randomised controlled trial of brief versus twice weekly versus standard supervised consumption in patients on opiate maintenance treatment - HOLLAND - 2012 - Drug and Alcohol Review - Wiley Online Library

 

 

Written by Andrew Byrne ..

Benzodiazepines in psychiatry and addiction medicine - do they still have a place in chronic care?

Sydney Addiction Seminar

Wednesday 28th November, 2018

“Benzodiazepines in psychiatry and addiction medicine - do they still have a place in chronic care?”

Vladan Starcevic, Paul Haber, Andrew Byrne. Moderator Dr Richard Hallinan.

 

Psychiatrist and Associate Professor Vladan Starcevic spoke about the safety and effectiveness of diazepam and related drugs for anxiety.  He stressed the poor results from almost every treatment tried since the time of Hippocrates for this common and disabling condition.  This changed dramatically with the introduction of benzodiazepines starting with chordiazepoxide (Librium) in 1959.  We were shown numerous trials which included comparisons with tricyclic antidepressants, SSRI’s, SNRI’s and non-drug alternatives (talking therapies, yoga, acupuncture, etc).  The benzodiazepines came out as more effective nearly every time.  The speaker emphasised the low rates of side effects (‘almost none’) as well as the low rates of dependence on the drugs (around 2% in most studies).  It seems that sedation is not considered a side effect of sedatives but a dose related effect, sometimes wanted, as for insomnia, or unwanted for daytime anxiety patients. 

Some myths were busted such as the canard that antidepressants are not habit forming, do not develop tolerance and do not have any withdrawals (further supportive studies were cited).  The saga of the use and alleged abuse of fluoxetine (Prozac) was quoted.  Professor Starcevic almost sounded like an advertisement for benzodiazepines yet he is clearly expert in the field and quoted rigorous studies to support his views.  He also serves on a number of international committees on the treatment of anxiety and related disorders.  We have all seen the pendulum swing from Valium and related drugs being the panacea to the pariah.  Despite this prescribers all know the great benefits which can be had by using careful assessments, judicious prescribing with psychosocial supports for stress cases who can be very vulnerable and for whom there are few effective alternatives. 

 

This led into a talk by Prof Haber of some aspects of pharmacology of GABA receptors and the respective places in the neurone where barbiturates, alcohol, benzodiazepines, etc, were thought to act … and how flumazanil can block the process of hyper-polarisation when chloride ions are allowed into the cell making it less likely to depolarise.  Then Prof Haber reminded us of the origin of the suffix ‘PAM’ attached to so many of the benzodiazepines - and said it might be the only thing some audience members might remember from the whole evening.  Positive Allosteric Modulators (PAM) of the neurone.  We were shown slides from PBS to demonstrate the enormous popularity of sedatives in Australia since the benzodiazepines replaced the barbiturates from about 1960 onwards. 

 

I spoke next about our negative experience using the zero-tolerance approach.  This had resulted in many patients relapsing after periods of benzodiazepine reductions or abstinence, often associated with high potency products such as alprazolam, clonazepam or flunitrazepam (Xanax, Rivotril, Hypnodorm).  These were sometimes prescribed but most commonly were obtained from the street market.  We selected some long-term patients who were clearly benzodiazepine dependent and allowed a limited daily dose, initially under supervision.  This was most usually diazepam in doses from 2mg to 15mg daily. 

American treatment guidelines point out that just because a patient in on OTP they should not be denied benefits of benzodiazepines for anxiety, panic disorder, insomnia or epilepsy.  And those with dependency need to have this addressed.  Yet this should not simply mean “Valium on demand”. 

I was asked whether I was treating dependence or psychiatric symptoms of stress and anxiety: which is almost like the question of which came first, the chicken or the egg?  Just as methadone maintenance patients may comprise pain management cases as well as some recreational drug users, the matter becomes academic once the patient gets to a certain point in their opiate consumption.  It is now widely agreed that whether one started drug use in a medical setting or the illicit market, opiate dependency treatment should be the same. 

Withdrawal symptoms from both opiates and benzodiazepines usually involve dysaesthesia, anxiety and/or insomnia.  Hence it is not surprising that for some OTP patients, the consumption of opiates and benzodiazepines is closely aligned and equally important to them. 

We have long used the principles of ‘universal precautions’ which assumes that all patients are potentially dependent and should be treated as such, with some dose supervision, some counselling and occasional urine toxicology testing.  Equally, all patients may be genuine anxiety disorder sufferers and thus deserve consideration of pharmacotherapy for that just like any other medical or psychiatric patient. 

This is my Covid warning email sent to family members on 26th Jan 2020 ...

Subject: Corona virus alert is serious and we should all be taking note.

I have followed this and it is a REAL worry, not only for China but for us as well. 

At this early stage we don’t know that much … but that this disease is a very serious form of respiratory infection which can spread from droplets just like colds and influenza. 

We would be crazy to eat in a busy restaurant in Hurstville just at the moment.  Or to travel to China at all, probably. 

We should all have and wear face masks whenever in public transport or enclosed public spaces.  I have a small supply at the surgery but any chemist should supply (but Gold Cross Pharmacy in Redfern have run out already!!). 

So please take this threat seriously and get take-away food, avoid public transport if possible and WEAR a mask when out of the house. 

In a few more days our entire lives could be changed by both the disease and our authorities’ response to it.  Already China has restricted travel to and from large parts of the country.  Wuhan is at a crossroads in central China and twice in the past has been the capital of China.  Similar things happened with the Great Plague in 1349 … but much slower … see: https://en.wikipedia.org/wiki/Black_Death . 

I wish I could say, like global warming, that this was all a hoax … but I strongly fear it is for ‘very real’.  AB ..