Injecting rooms need support from experts, not alarmist doubts.

The case for piloting supervised injecting centres in the United Kingdom is strong. Wright NMJ, Tompkins CNE. BMJ 2004 328:100-102

Dear Colleagues,

With continuing high rates of drug related deaths in the UK, the BMJ is
right to again give prominence to the issue. The report by Wright and
Tompkins [ref 1] clearly demonstrates that there are new and promising
ways to address the current UK epidemic of overdose deaths from street
drugs, including medically supervised injecting facilities. Overseas
experience with injecting centres over 15 years has been uniformly
positive. Over one million injections occur each year in such centres
where deaths and serious complications almost unknown. Nearly all such
injections would otherwise take place in less savoury and thus less safe
environs. Such services also bring large number of addicts into contact
with health care workers, some for the fist time.

It is thus disappointing that in their following commentary [ref 2],
rather than unequivocally supporting such moves, Strang and Fortson
raise the canard of the differences between prescribed heroin for
dependency and injecting facilities (which they pejoratively call
'fixing rooms').

As a leading dependency expert, Strang knows the reassuring reports of
such centres in Europe, Australia and, most recently, Canada. The
concept has worked effectively elsewhere [ref 3], including apparently
unofficial experience in London. Strang and Fortson give no realistic
alternative strategy for the UK's high rates of overdose, HIV and
hepatitis C. They write that heroin prescription would only ever be a
'tertiary service', while injecting rooms a primary one.

These authors compare injecting centres to pubs, adding to the confusion
they are trying to address. Licensed premises, like Swiss heroin
prescription trials, supply the patrons' drug of choice in a safe
environment, while injecting centres only provide the supervised
environment for consumption of illicit drugs. Injecting centres are
perhaps more like patrolled beaches where people do risky, even
foolhardy things, while professional life-guards move into action if
needed in a non-judgemental manner.

Strang and co-author cannot know how insensitive their petty
reservations on injecting rooms must sound to grieving relatives when
every overdose death is potentially preventable. Rather than refuting
them, these authors raise old issues such as injecting rooms 'fostering
.. more .. drug use', drug dealing and operational protocols after over
a decade of positive experience. Their perfunctory dealing with 'harm
reduction' in the first sentence belies its being the foundation of good
medical and public health practice since the time of Hippocrates. It is
also official government health policy in some countries and has
prevented an HIV epidemic in Australia and Hong Kong.

Like heroin prescription, on current evidence we probably need a small
number of injecting rooms in drug 'hot-spots', as well as simultaneous
improved access to traditional drug treatments, detox services, harm
reduction measures and education.

Yours faithfully,

Andrew Byrne ..

References:

[1] Wright NMJ, Tompkins CNE. Supervised injecting centres. BMJ (2004)
328:100-102
http://bmj.bmjjournals.com/cgi/content/full/328/7431/100

[2] Strang J, Fortson R. Supervised fixing rooms, supervised injectable
maintenance clinics-understanding the difference. BMJ (2004) 328:102-103
http://bmj.bmjjournals.com/cgi/content/full/328/7431/102

[3] Burton, B. Supervised drug injecting room trial considered a
success. BMJ (2003) 327:122
http://bmj.com/cgi/content/full/327/7407/122-a


Extracts:
BMJ 2004 328:100-102 (10 January)

Wright NMJ, Tompkins CNE.

The case for piloting supervised injecting centres in the United Kingdom
is strong.

Medically supervised injecting centres are "legally sanctioned and
supervised facilities designed to reduce the health and public order
problems associated with illegal injection drug use." Their purpose is
to enable the consumption of pre-obtained drugs under hygienic, low risk
conditions. They differ from illegal "shooting galleries," where
users pay to inject on site. Worldwide, medically supervised injecting
centres (also referred to as health rooms, supervised injecting rooms,
drug consumption rooms, and safer injecting rooms or facilities) are
receiving renewed attention. In 2001, the first medically supervised
injecting centre in recent times was opened in Sydney, Australia.




BMJ 2004 328:102-103 (10 January)
Strang J, Fortson R.

Supervised fixing rooms, supervised injectable maintenance
Clinics - understanding the difference.

John Strang (psychiatrist), Rudi Fortson (barrister)

Harm reduction policies and practices (where anything goes, if it
actually reduces harm) have fundamentally altered our approach to the
drugs problem. Two innovations were recently considered by the Home
Affairs Select Committee-supervised injecting centres and supervised
injectable maintenance clinics-but with unhelpful confusion between the
two. They have different target populations, potential benefits, and
legal obstacles.




http://bmj.com/

Three fine French papers on methadone/buprenorphine (community, pregnancy, HIV).

Illicit drug use and injection practices among drug users on methadone and buprenorphine maintenance treatment in France. Guichard A, Lert F, Calderon C, Gaigi H, Maguet O, Soletti J, Brodeur J-M, Richard L, Zunzunegui M-V. Addiction (2003) 98: 1585-1597

The November Addiction starts with a rather gauche exercise by Griffith Edwards et al. in which a hand-picked group of sub-editors, chosen for ‘their insight into Addiction’s ways of working’, are asked their suggestions for future directions in publication. It will come as no surprise to the reader that it is to be more of the same. While these distinguished folk come up with numerous worthy suggestions, the ‘uncomfortable’ issues are not raised to any level of prominence. These include the standard of opioid treatments; heroin prescription trials; controlled drinking; injecting centres; views direct from ‘consumers’; urine testing protocols; rapid opioid detoxification; naltrexone implants; medicinal uses of cannabis; the effects of criminal sanctions on the use of drugs, aka ‘drug law reform’; harm reduction philosophy and practice.

The authors congratulate themselves in advance by writing “the exercise has fulfilled its intentions”. They then concede that at some time in the future such an exercise may be repeated ‘with a wider sample’ and from ‘a younger generation’. We can only hope.

In spite of its current management, Addiction still attracts leading researchers, publishing key items of interest. An important item in this journal comes from France where in a three-city study, 340 addicts in maintenance treatment for at least 6 months were interviewed regarding illicit drug use, treatment characteristics and demographics. There were 200 on methadone while 140 were prescribed buprenorphine. About half the methadone patients and 80% of buprenorphine patients were treated in general practice, the remainder in specialist dependency treatment units.

The authors write that in France methadone can only be started in formal dependency treatment units. After stabilization, patients may attend pharmacies and receive up to a week’s supply of methadone on a GP prescription. In contrast, buprenorphine tablets (‘pure’, sub-lingual) can be prescribed for up to 28 days by any physician. Thus the latter has had a rather broader uptake even though both were introduced around the same time in France. This is especially so in regions without specialist units. The authors state that buprenorphine was generally considered the ‘first line’ drug in France.

This study found that methadone patients had been using drugs for longer and had been in treatment slightly longer than the buprenorphine recipients.

Mean daily dose for methadone was 67mg (SD 30) and for buprenorphine 10mg (SD 9).
The important finding of this study was a low rate of illicit drug use of around 35% of subjects (18% heroin, 25% cocaine, 7% crack). There was little significant difference between patients being cared for in specialist clinics or by GPs. It was noteworthy that 40% of the buprenorphine patients had injected their own substitution drug (ever) while only 15% of the methadone patients had done so. In addition, the higher dose buprenorphine cases were more likely to have injected, a trend which was not seen with the methadone patients.

About 80% of methadone patients received a prescription for two weeks or less. Two thirds of buprenorphine prescriptions were for 3 weeks or more.

About half of the subjects had a jail history. About 90% of patients had been tested for HCV and HIV. Around 50% were HCV positive while 22% HIV positive. These figures may relate to the late introduction of harm reduction measures in France compared with experience elsewhere (eg. Australia and Hong Kong). It is partly as a result of increasing HIV and overdoses that France took the bold step of making buprenorphine so widely available.

My ‘theory’ on the buprenorphine injecting is that a proportion of patients who do not do well initially on buprenorphine doses may increase their dose, still without suppressing cravings. Such unstable and unhappy patients may tend to inject their buprenorphine, thus defeating one of the main purposes of the treatment. Whether relapse to heroin use or buprenorphine injecting, such behaviour should indicate a consideration of transfer to methadone or another agonist drug such as long acting morphine if available.

With arbitrary regulations in some jurisdictions these options are not always available in the same treatment settings. This would be unlikely to occur in other fields, rather like banning some doctors or pharmacists from using certain antibiotics. The principles governing methadone treatment should be parallel to those for buprenorphine with emphasis on real risks and benefits, not implied or theoretical ones. Historical regulatory anomalies should be removed in the interests of all involved since agonist treatments are evidence based, cost-effective and can be simply delivered using existing resources and facilities. Fortunately, all Australian jurisdictions now permit (limited) take-away provisions for buprenorphine, including New South Wales (up to two per week as well as for emergencies and travel in suitably approved patients). South Australia allows up to 5 dispensed doses per week in stable patients who have been in treatment for over 18 months. Such dosing encourages retention and is recommended by the new Australian treatment guidelines. Intriguingly, both France and the US allow unlimited unsupervised doses even though these have not been researched to any degree. Such are the anomalies of our field.

This Addiction edition also has some largely reassuring information on buprenorphine in pregnancy with 13 cases reported from France. The authors state that no teratogenic effects have been reported, and that their cases had variable neonatal abstinence syndrome but of shorter duration than with methadone. Two cases (15%) had some motor abnormalities which did not resolve completely at follow-up. [Kayemba-Kay’s S et al.]

Another important recent comparative description is: Carrieri M-P, Reya D, Loundoua A, Lepeuc G, Sobeld A, Obadia Y .Evaluation of buprenorphine maintenance treatment in a French cohort of HIV-infected injecting drug users. Drug Alc Depend (2003) 72; 1:13-21

comments by Andrew Byrne ..

Do cannabis withdrawals need drug therapy? Controlled trial from America.

Pharmacotherapy for Marijuana Dependence: A Double-blind, Placebo-controlled Pilot Study of Divalproex Sodium. Levin FR, McDowell D, Evans SM, Nunes E, Akerele E, Donovan S, Vosburg SK. American J Addiction 2004 13:21-32

Dear Colleagues,

Negative research findings can be just as important as positive ones. This is especially so in well conducted placebo-controlled, randomised intervention trials. A recently published trial from the group at Columbia University in Manhattan has shown no significant effects using a mood-stabilising anti-convulsant, divalproex, in cannabis withdrawal subjects.

Despite finding no effect from the drug treated group, for some reason these veteran researchers do not say as much in their abstract. One has to read this sentence in the abstract to glean the important message of the article: “Regardless of treatment group, patients reported a significant reduction in their frequency and amount of marijuana use as well as a reduction in irritability.”

These researchers stress their positive findings, corroborating other reports regarding cannabis: (1) There are many members of western communities who perceive that they have cannabis dependency, (2) many such citizens are interested in treatment options, (3) such subjects will attend and comply well with recommended treatment and (4) most will reduce (or cease) their drug consumption during such interventions, regardless of their nature.

Any drug used to counteract cravings or withdrawals must have a safety profile which is in measure with the safety profile of the drug of dependence being treated. As well as such safety, such a drug must also be effective. This trial shows convincingly that divalproex, although a drug with some promise for cocaine withdrawals, is not a useful drug for symptoms of cannabis withdrawal. Cannabis is a harmful drug, causing dependence in a proportion of users and causing damage to the upper respiratory tract if smoked. The scope for harm appears to be low for most users, and is much lower than the harm which occurs in the ‘average’ tobacco smoker.

These authors (or the journal’s editors) use the lay term marijuana for some reason, only rarely using the correct scientific term, cannabis, in their text.

There is also a problem with the formal DSM criteria for cannabis dependency in the USA. The definitions (304.30 and 305.20) involve (1) the time spent acquiring the drug, (2) interference with family, schooling, work or 'recreation' (sic!) and (3) legal consequences of possession and consumption of the drug. Thus some of the subjects in this trial, if given access to cheap, unadulterated cannabis as in Holland, may not have satisfied the same criteria and thus been categorized as having cannabis ‘problems’ rather than cannabis ‘dependency’.

Levin FR, McDowell D, Evans SM, Nunes E, Akerele E, Donovan S, Vosburg SK. Pharmacotherapy for Marijuana Dependence: A Double-blind, Placebo-controlled Pilot Study of Divalproex Sodium. American J Addiction (2004)13:21-32

comments by Andrew Byrne ..

Australian contribution to 'alcohol markers' supplement of "Addiction".

Traditional markers of excessive alcohol use. Conigrave KM, Davies P, Haber P, Whitfield JB. Addiction (2003) 98 (Suppl.2) 31-43

Dear Colleagues,

This is an excellent Australian contribution to the important issue of documenting alcohol use in a quantitative way. Although the markers are over a generation old, their scientific basis is often forgotten. This article gives us the ‘how and why’ on the liver-related blood tests: ALT (alanine amino-transferase); AST (aspartate amino-transferase) and GGT (gamma glutamyl-transaminase) [collectively called “transaminases”] and the red blood cell volume (‘mean corpuscular volume’ ‘MCV’ or red cell size). These are all commonly used both as screening tools as well as prognostic indicators in established liver disease.

The authors use a Medline search of the thousands of studies on alcohol related disease in order to systematically examine the specificity and sensitivity of each test.
Simple blood tests will also show the INR (clotting index or ratio) and platelet count (thrombocytes) which are just as ‘traditional’ and most usually affected in severe alcohol use with associated liver disease. Thus they might be seen as ‘secondary’ markers of excessive alcohol use and are not covered by these authors.

As well as self-report on clinical interview, other items in this ‘Addiction Supplement’ cover numerous other aspects of tests pointing towards alcohol use and liver disease. These include carbohydrate deficient transferrin, serum sialic acid, beta hexosamine, ethyl glucuronide and 5-hydroxytryptophol … as well as the direct measurement of ethyl alcohol itself in serum, urine and other body fluids (Robert Swift, p73).

I often tell students that the raw GGT tells us how many standard drinks that the individual patient consumes in a month. Try it yourself! Divide the GGT by 31 and ask your next few patients their average consumption. It is often closer to the truth than comfort for the drinking patient, although it is unhelpful in established cirrhosis. Like other ‘rules-of-thumb’ this could also be misleading and so must be taken in context with history, physical examination and other clinical factors (palmar erythema, spider nævi, bruising, jaundice, etc). Either way, such discussions could be an interesting and productive starting point for a serious discussion about drinking levels.

Highly recommended reading from these experienced Sydney University experts.

comments by Andrew Byrne ..

Alternatives to methadone show improvements always possible.

Evaluation of levo-alpha-acetylmethdol (LAAM) as an alternative treatment for methadone maintenance patients who regularly experience withdrawal: a pharmacokinetic and pharmacodynamic analysis. Newcombe DA, Bochnera F, White JM, Somogyi AA. Drug and Alcohol Dependence (2004) 76; 1: 63-72

Dear Colleagues,

The Adelaide University Department of Experimental Pharmacology continues to impress with detailed scientific work which contains practical lessons for clinical practice.

In this study 16 volunteer methadone patients were transferred to LAAM (L-acetyl methadol, a chemical cousin of methadone, no longer in clinical use) for 3 months and then returned to methadone. While half the patients were chosen as stable or ‘holders’, the rest ‘non-holders’ based on ‘self report’, presumably of illicit drug use and/or withdrawal symptoms. The non-holders had a mean methadone dose of 83mg daily, the ‘holders’ 73mg, at the start of the study (an Adelaide study reported 63mg in 1996). Doses after the study were only very slightly higher with adjustments as clinically indicated during the 6 month period.

It is a disadvantage of pure experimental pharmacology studies using clinical subjects in treatment that one cannot easily determine whether treatment given was consistent with current guidelines (eg. Strang’s UK ‘orange’ guidelines). It is unlikely that a dose of 30mg in a ‘non-holder’ would be based on such prescribing guidelines which recommend about 60mg as a minimum effective dose to abolish withdrawals in most patients. Yet one such patient was included in this trial.

The researchers performed numerous clinical measures including pupils size, respiration rates, blood levels over 24 hours, but the most important findings were patient self report of satisfaction with the treatment (described here as 'holders').

Even with a randomised protocol it may not be possible to know if the improvements reported are due to the LAAM or the actual experimental “fuss” involved. But it does demonstrate that ‘non-holders’ can become ‘holders’ if alternative doses, drugs and/or other therapeutic interventions are considered in the therapeutic milieu. This same benefit can be seen with alternative prescribing in diverse branches of medicine such as arthritis, migraine and diabetes where sometimes a change in medication can lead to improvements for unknown and unpredictable reasons. The ‘placebo effect’ is probably responsible for some such reported benefits, yet actual differences must play a role as well.

Vincent P. Dole, who first devised methadone maintenance treatment, often reminds us that methadone is just another prescribed drug for a medical condition. When given in sufficient doses with adequate supervision and psychosocial supports, the results should be predictable and gratifying for both doctor and patient. But a proportion cannot or will not take methadone so, without an alternative, they drop out of ‘mono-therapy’.

It would be interesting to know how these researchers would approach a similar study, using 2 parallel groups of diabetics who were ‘stable’ and ‘unstable’ with regards to sugar levels. Often ‘real world’ clinical medicine is simpler than all of this science and utilises two principles: (1) patient choice and (2) trial and error (doctor’s choice) ... starting with the safest, cheapest or most popular drug, eg methadone and then only reverting to LAAM, buprenorphine, long acting morphine, naltrexone, etc in those who do not respond to the traditional drug in ‘full’ or adequate doses. And such simple measures, with adequate psychosocial supports, very often yield excellent results with up to 95% of subjects reportedly able to cease injecting behaviours, according to Dole.

While not directly related to this study, it is regrettable that LAAM, being a second day administered drug, was over-used in the United States for the convenience of clinics rather than for genuine clinical indications. The withdrawal of Vioxx for arthritis has some similarities (see also this week‘s JAMA for discussions of post marketing surveillance http://jama.ama-assn.org/). Both Vioxx and LAAM were found to have a very rare but potentially serious side effect (on heart conduction regards LAAM) and both are now completely withdrawn from the market in most countries. This was probably done to protect drug companies from legal liabilities without an independent examination of the risks and benefits in clinical uses. The drugs would probably still be indicated as valuable ‘second-line’ agents where methadone or other first line agents were found to be ineffective or to have unacceptable side effects. Even thalidomide has some limited uses despite its disadvantages. In most cases LAAM would be much safer than injected street heroin!

Comments by Andrew Byrne ..

To crush or not to crush - buprenorphine tablet administration

Drug and Alcohol Review (2003) 22;4:471-2

Muhleisen P, Spence J, Nielsen S. Crushing buprenorphine tablets.

In Australia, as in most of the research reports, buprenorphine is generally given under supervision of the nurse or pharmacist. As with methadone, there is more supervision for new and unstable patients with take-away dosing permitted to some degree for stable patients after periods in treatment. For example in South Australia up to 5 days may be dispensed in a week with 2 supervised doses after 18 months in stable treatment. In NSW up to two doses may be given per week for those needing daily doses under certain conditions, and for emergencies, travel, etc. Reports from France show that a proportion of doses there are also given under supervision although this is not by regulation but just �good practice�. The issue of whether tablets should be given whole, bisected or crushed is debated.

A report in this month's Drug and Alcohol Review covers this area from a practical perspective from a team which has been using the drug for over 5 years (originally running a trial). This group in Melbourne initially crushed tablets for some patients who they suspected were diverting the drug. Others requested crushed tablets to reduce administration time. Then the Victorian Health authorities, who are not known for their liberal attitudes, nor strong evidence base, advised all buprenorphine to be 'substantially broken or crushed'. Too fine crushing, however, is reported by these authors to sometimes result in a 'powder' which may be swallowed and thus remain largely unabsorbed. Thus crushing can cause problems in the attempt to avoid them.

These authors quote reports of about a quarter of buprenorphine patients attempting to inject their drug on at least one occasion but only less than 5% continuing to do so when they could. This is probably not too different from rates of injecting of methadone syrup.

"Merely crushing doses does not stop diversion or injecting..." <snip>

"Adequate supervision is still the basis of good treatment in this field, and is not replaced by dose-crushing. All professionals involved in the treatment should be diligent in their responsibilities in ensuring that the treatment is safe and effective. Clients who continue to misuse their buprenorphine could be considered unsuitable for treatment with this more expensive and time-consuming drug and an option to minimize potential harm to the client and the treatment itself is to suggest transfer to dosing with methadone, which is still the gold standard opioid substitution treatment."

My personal feeling is that the drug was approved by the TGA in the current tablet forms and most patients should receive the doses in that form. The tablets should only be crushed for good clinical reasons, and then only with the consent and understanding of the patients involved. Otherwise it could be seen as another paternalistic manoeuvre perpetuating the 'them and us' attitude so prevalent in drug clinics around the world.

comments by Andrew Byrne ..

60 year follow-up of Boston drinkers.

Vaillant GE. A 60-year follow-up of alcoholic men. Addiction 2003 98:1043-1051

Dear Colleagues,

In a staggering feat, veteran alcohol researcher George Vaillant has followed the classic Boston study groups of Glueck & Glueck for up to 60 years from enrolment. These two groups included over 700 citizens either from poor inner city areas or from Harvard University undergraduates, most born in the 1920s. There are significant findings on the natural histories of alcohol abuse, dependence, abstinence and controlled drinking in relation to other medical problems, employment, self-help and mortality. Most importantly there is information on the onset of alcohol problems since the subjects were chosen young and at random. There is some bias since alcoholics are less likely to comply with such research but the differences in responses were not significant in this case.

There is more in this paper than could be included in a brief review. However, the main finding given by Vaillant in his abstract is that despite major differences in the groups in terms of IQ, social background and ethnicity, the main outcomes were very similar in four important domains by age 70. As also found by Drew, chronic alcohol dependence was rare in the older age groups. Controlled drinking was exceptional (1%). Just over half the subjects had died in both groups and around 10% were abusing alcohol (but not dependent) with most of the remainder abstinent.

‘Surprisingly, in both samples, alcohol abuse could persist for decades without remission, death or progression to dependency.’ [of 29 college alcohol abusers 13 surviv(ed) to age 80]. But there were some differences between the groups: ‘The average age of onset of alcohol abuse was a decade later for the college men (40 vs. 30) than it was for the core city men.’

I felt very proud when I completed a ten year follow-up of opiate dependent patients a few years ago. But my achievement is dwarfed by this monumental piece of work in the case of alcohol since Vaillant has now carefully examined outcomes over more than an average adult lifetime of three score years and ten.

comments by Andrew Byrne ..

Oral lofexidine versus naloxone injections for detox. American Journal of Addiction.

The Effectiveness of Combined Naloxone/Lofexidine in Opiate Detoxification: Results from a Double-blind Randomized and Placebo-controlled Trial. Beswick T, Best D, Bearn J, Gossop M, Rees S, Strang J. American Journal of Addiction 2003 12;4:295-305

Dear Colleagues,

This intriguing trial from a London based group gave frequent injections of naloxone to addicts in a detoxification ward.

The authors state that methadone ‘has been the standard treatment for in-patient opioid detoxification’. This may be the case in England but not necessarily elsewhere. There seems to be an assumption that lofexidine (and/or clonidine) are safe and effective in outcomes of opioid withdrawal episodes. Although there are apparently fewer hypotensive side effects with lofexidine (‘Brit-Lofex), a recent study from England, a generation of experience and the absence of a reported black market would seem to cast some doubt on their efficacy in successful heroin withdrawals. Next comes the rather controversial and little-researched use of naloxone in drug withdrawal. These researchers gave most subjects over 30 hypodermic injections, a behaviour which most of us are actively trying to discourage.

After finding that there were no significant differences in overall outcomes in those randomised to receive the antagonist naloxone, the authors come to the surprising conclusion that more research is needed on this treatment modality for those trying to quit heroin. With the increasing use of buprenorphine for detoxification, it would seem almost outlandish to support the use of injectable, short acting antagonists like naloxone.

About half of the 33 references are from the authors themselves which may indicate their pre-eminence in the field of opioid detoxification.

Comments by Andrew Byrne ..

Article on inheritance of addiction in Iran. One in 15 offspring opioid-dependent.

Ahmadi J, Arabi H, Mansouri Y. Prevalence of substance abuse among offspring of opioid addicts. Addictive Behaviors (2003) 28:591-595

Dear Colleagues,

This fascinating study from Iran tells us some basic facts about drug use and inheritance in that population. With major differences with western experience in drug and alcohol use there, the significance for our own populations is somewhat limited.

The authors interviewed 500 randomly chosen adult offspring of 2000 addicts in treatment in Shiraz, Iran. Evidently the average age of those in treatment is much higher than our patients since 28% of their offspring were over 40 years of age and 80% married (but still living under the one roof, a condition of the survey).

The authors remind us of the ‘old tradition of drug use’ in Persia, including opium which is used for pleasure as well as as a medicine. While all these drugs are currently illegal, and penalties severe, drug use and dependency are still common. Even alcohol, which is ‘both religiously and legally prohibited’ has significant reported use and dependency. In the first degree relatives of opioid addicts there was substantial ‘ever used’, ‘current use’ and ‘dependency’. There was no reported use of cocaine or psychodelics. Stimulants were not mentioned.

In short, the findings were that among the offspring of opioid addicts in Iran, 20% had ‘ever used’ opium or heroin and 6.4% were currently opiate dependent. Tobacco was ‘ever used’ by 36% with 24% being currently dependent by DSM-IV criteria. In 95% of the opioid used was opium and 5% heroin. Males greatly outnumbered females for most forms of drug use by up to 9:1. The survey was evenly split, however.

Alcohol was ‘ever used’ by 18.2% and cannabis products by only 4.2%. Thus over half of the population had used a psychoactive drug (56.4%) excluding caffeine.

These researchers asked the respondents the reason for their drug use. ‘Enjoyment’ was the prime answer (57%). Next came ‘modeling’ (50%) [which I take to be something akin to ‘peer pressure’] and then ‘release of tension’ (34%).

In our own patient population in Redfern we have a median age of 37 years. On cursory exmination, we could identify only twelve patients out of 328 from the past three years who had adult children and only two of these had a known drug dependency history. Hence, while this paper shows distinct differences between drug use in different countries, drug use can certainly run in families as with other habits, partially as a result of genetics and partly environmentally induced (see elegant twin studies from Minneapolis St Paul).

Comments by Andrew Byrne ..

Australian national opioid treatment guideline publications August 2003.

Commonwealth Department of Health and Aging. Australian national treatment guidelines (full citations and internet address below) published Aug 03

Dear Colleagues,

Below are the web contacts for the Australian National treatment guidelines which were distributed in December 2003 by the Department of Health and Aged Care in Canberra. There are four volumes, a full and abbreviated version for both methadone and naltrexone. The authors are to be congratulated on a 'generic' set of instructions for the basic approaches to maintenance treatments, regardless of where this may be given.

http://www.healthyactive.gov.au/internet/main/publishing.nsf/Content/phd-illicit-methadone-treatment (old 1997 version)

http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-illicit-methadone-cguide-s (abbreviated version 2003)

http://www.health.gov.au/internet/drugstrategy/publishing.nsf/Content/pharmacotherapy
(link to other guidelines available for buprenorphine, naltrexone, methadone, etc)

Australia’s eight different jurisdictions have eight different sets of treatment rules, from quite liberal (South Australia) to almost barbaric (Northern Territory). However, doctors do not normally have the liberty of giving sub-standard treatment because of the jurisdiction they practice in. According to the British Medical Journal, where there is clear research evidence, doctors are normally required to follow it. Hence, as these Guidelines point out, all Australian opioid dependent residents should have access to appropriate dose levels of the right drug in the right setting. Also, in all community treatment settings there should be some level of take-away dosing available for stable patients as this improves compliance and retention rates, according to these Guidelines. In the absence of regular take-away doses one of the most important ‘incentives’ of supervised methadone treatment is lost and patients may feel condemned to almost daily attendance indefinitely (as apparently sometimes happens in Victoria as well as the NSW public sector clinics). If local rules should impinge on appropriate dosing, they should be addressed and overcome in the interests of making treatment safe, effective and humane (for example the ACT rules on daily methadone doses of over 100mg; the Victorian DOH will allow waivers for take-home doses under certain circumstances if doctors apply appropriately).

An area of major difficulty in these and other guidelines remains induction protocol for methadone. Mortality from overdose in the first week has caused a knee-jerk reduction in starting doses from 40mg to 20mg in some settings. However, there has been no evaluation of this rather dramatic change and it may well have caused an increase in treatment drop-outs. Despite the stated wide variations in methadone metabolism in these guidelines, no clinical protocol is given for determining who is a fast metaboliser and thus may need higher doses. In one paper it is stated that due to variable absorption and metabolism of methadone, “the rate of clearance from the body has been reported to vary by a factor of almost 100” [Ward J, Bell J, Mattick RP, Hall W. Methadone Maintenance Therapy for Opioid Dependence. A guide to appropriate use. (1996) CNS Drugs. 6;6:440-449]. Thus increasing doses by only 10mg per week may take many months to reach optimal levels in some folk who may need 200mg or even more to achieve ‘normal’ or therapeutic blood levels.

There is no substitute for careful clinical assessment and gradual dose adjustments for this drug, as with insulin, digoxin or Dilantin in unstable folk at the commencement of treatment. Perhaps somebody should describe a ‘sliding scale’ for methadone inductions. The American Health Department “TIP” protocols allow up to 60mg on the first day in three divided doses under very close clinical supervision. Few clinics can support the clinical supervision necessary for this, hence 40mg is the usual starting dose in many cases in the USA. Most Australian drug services now apparently use a standard 30mg starting dose in the great majority of cases.

I hope this is of assistance for colleagues involved in methadone and buprenorphine treatments. Naltrexone should only be prescribed for opioid dependency in specialist settings, whereas for alcoholism all primary care physicians should be familiar with it.

Andrew Byrne ..

Clinical guidelines and procedures for the use of methadone in the maintenance treatment of opioid dependence - Abbreviated version (pdf file 176Kb) Date Published: 2003 ISBN: 0 642 82263 8
Author: National Drug Strategy Australian Government Department of Health and Ageing.