3 March 2004

Anxiety symptoms in methadone patients. Trial shows no effect from buspirone.

A Randomized, Placebo-controlled trial of Buspirone for the Treatment of Anxiety in Opioid-dependent Individuals. McRae AL, Sonne SC, Brady KT, Durkalski V, Palesch Y. American Journal on Addictions 2004 13;1:53-63

Dear Colleagues,

This study identified 130 of 297 methadone maintained patients who exhibited symptoms of anxiety, of whom 62 met criteria for treatment with non-benzodiazepine sedative buspirone (‘Buspar’). By randomising subjects to receiving placebo or active drug they found no significant difference in outcomes in a 3 month trial period. The groups were treated using average methadone doses between 85 and 103mg daily (range 20-200mg) which should be adequate according to most clinical recommendations. Up to 60mg buspirone daily was prescribed in increasing doses. Riboflavin was used as placebo which allowed a check for compliance.

Although no significant differences were found in the buspirone group, this study shows the frequency of anxiety and depressive symptoms in the addict population. It also showed that there may be some improvement in depressive symptoms with buspirone although it is not an antidepressant.

The connection between drugs and anxiety/depression is very complex. In some the symptoms may precede drug use while in others it may stem from the dependency and life situation. Alcohol is probably the most common drug used for anxiety but in some it becomes a problem, causing acute intoxication, dependency and other mischief. Benzodiazepines have major disadvantages which are now clearly spelled out by the drug manufacturers such that they advise against them for longer-term conditions like chronic anxiety, and contraindicate them altogether in patients who are prone to dependency.

Thus some doctors are reluctant to prescribe benzodiazepines even when they might still be clinically indicated and in whom they have been used as self-medication. Some methadone patients appear to do well with maintenance diazepam where they have been unsuccessful at dose reductions, but this needs to be supervised. The total daily dose and degree of supervision depends on the individual but more research is needed to document whether such prescribing is safe and effective, and when it can safely be diminished. Some anxious patients say that heroin is the best ‘treatment’ they have had! Hence we are starting at some serious disadvantage with such patients. Methadone dose should always be optimised in such patients by considering post-dose examinations, blood methadone levels, dose adjustments or even dose splitting.

Comments by Andrew Byrne ..

Does dependency treatment reduce homicide rates? Probably, implies BMJ study.

This BMJ summary and article should remind us of the utility, cost effectiveness and simple humanity of basic drug and alcohol treatment. See final sentence of this BMJ news summary …
"Tackling drug and alcohol misuse could reduce 'stranger' homicides".

"Stranger homicides" are most commonly committed by young men, and drugs and alcohol make the offence more likely. Shaw and colleagues (p 734) analysed 1594 homicides in England and Wales between 1996 and 1999. They found that 358 (22%) homicides were stranger homicides, and the largest single cause was fights. Perpetrators of stranger homicides were more likely to have a history of drug and alcohol misuse than to have a mental illness or to have been under mental health care. The policy of care in the community does not increase the risk of stranger homicide by people with mental illness, say the authors; measures directed at curtailing alcohol and drug misuse have more potential for prevention.

For full item, see http://bmj.bmjjournals.com/cgi/content/full/bmj;328/7442/734

What's in a name: 'patient' vs 'client'? Consumer views.

Does Anyone Care about Names? How Attendees at Substance Misuse Services Like to Be Addressed by Health Professionals. Keaney F, Strang J et al. European Addiction Research 2004 10;2:75-79

Dear Colleagues,

At last somebody has asked drug addicts/users in treatment what they would like to be called. “Patients” is the consensus, at least in London. According to these authors, the use of ‘client’ to refer to a patient dates back to at least 1970, when the nursing faculty at Wichita State University considered the term ‘patient’ inappropriate for the healthy seeking health-maintenance advice or going for an annual physical examination. The authors quote Wing: “The recent trend to refer to people seeking health care as “clients” implies to me a component of human interaction that I would expect in the business world rather than in a trusting helping relationship”. ‘Patients’ also have a status and traditional rights which pre-date modern consumer laws.

In a survey of 150 mixed dependency patients, ‘service user’ was the least popular term, identified as the preferred term by only 5% of subjects. “Patient” was preferred by 66% of alcoholics, 52% of opioid users but only 47% of smokers in treatment. “Client”was only preferred by 24% of alcoholics, 46% of illicit drug users and 41% of smokers in treatment.

While only a minority considered that they personally had a ‘mental illness’ (38%), most considered that ‘substance misuse problems’ formed a category of mental health illness (59%). The authors state: ‘Commonly used pejorative terms such as ‘alki’ or ‘junkie’ prejudice appropriate care and add to stigmatisation’.

Thus the majority here preferred the term ‘patient’, going against current trends in dependency treatment services for the wider use of the term ‘client’.

They conclude: “In a culture of ‘user involvement’ in substance misuse, the results of this study should prompt reconsideration and revision of our verbal and written communications with patients”.

Comments by Andrew Byrne ..

BMJ report on alcohol increase in UK.

Dear Colleagues,

New South Wales could take a lesson from this report which advises
strategies against the increasing availability and reducing real price
of alcohol. The twin forces of increased business and increased taxation
need to be balanced by public health factors. Report from BMJ free on
the 'net.

BMJ 2004;328:542 6 March
News roundup.

'Government must take unpopular decisions to reduce alcohol consumption.'

London Owen Dyer

Britain "has reached a point where it is necessary and urgent to call
time on runaway alcohol consumption," a report on drinking trends says.
The report, by the Academy of Medical Sciences, calls on the government
to take immediate measures not only to stop the rise in alcohol
consumption but to cut drinking to 1970 levels, a reduction of 33%.

Evidence from recent years in Europe indicates that the increased burden
of health problems related to alcohol has fallen disproportionately on
young people. A 2001 report by the chief medical officer said that the
number of deaths from cirrhosis among men aged 25 to 44 years rose from
49 in 1970 to 470 in 2000, an increase of 959%.

The report’s concrete recommendations include raising taxes on alcohol,
reducing travellers’ alcohol allowances in the European Union, reviewing
advertising practices, and reducing the blood alcohol limit for drivers
from 0.08% to 0.05%.

Calling Time is accessible on the academy’s website at www.acmedsci.ac.uk


1 March 2004

Addiction Biology summaries: naltrexone, dextromoramide, detox and more.

Addiction Biology March 2004 edition.

Dear Colleagues,

This journal contains a bumper crop of research, practicalities and history lessons. The two lead items are invited reviews which initially seem rather esoteric, being about cellular changes in the bone marrow and brain cells of alcoholics. However, on closer reading, the first authors delineate the evolving evidence of very specific changes in red cells due to alcohol's first metabolite, acetaldehyde. The second item is on genetic alterations in neuronal cells following exposure to alcohol. While neither is even remotely practical presently, both are more than distant 'shots in the dark' at causation of the 'permanent' changes which occur in the alcohol dependent state.

There are three items on naltrexone, none a scientific trial, sorry to say. One is a useful report from London of a hepatitis B/C seroconversion case which seemed to run a benign course in spite of being concurrently on naltrexone, which was continued, albeit under close supervision and observation. It would seem that this report, plus the passage of time should reduce fears of naltrexone-related hepatitis. Such fears are largely based on a small number of cases of high-dose naltrexone-treated bulimia cases with elevated transaminases reported some years ago.

These would now seem to be of less immediate concern to opioid treatment at usual doses of 50mg daily orally. The positive results often reported by naltrexone 'enthusiasts' are not always borne out in independent studies. The group from Perth has largely upbeat things to report about their experience with naltrexone implants and maintenance of 'adequate' serum levels of the drug. But their methodology lacks a prospective scientific protocol. The evolving slow-release subcutaneous pellets appear not to have been standardised nor independently validated prior to their use in this private medical practice. It is also disappointing that the authors do not define their selection criteria for long-term naltrexone implant treatment in opioid dependency cases.

This edition of Addiction Biology also contains abstracts presented at the annual meeting of the (centenarian) Society for the Study of Addiction. They reveal the cornucopia of treatment possibilities under the remnants of the "British system" of controlled drug prescription. This belies the real world of tragically limited interventions available in the field through the National Health System for drug and alcohol dependent patients in England - and long waiting lists to see addiction specialists. Most glaring is the reportedly grossly inadequate doses and lack of supervision given to methadone maintenance patients in most centres and in general practice.

Abstracts report on buprenorphine uptake - which is increasing steadily in England (11% of all maintenance prescriptions in 2002 - up from 5% in 2001) but is still unavailable in some areas, partly due to the high cost. A report on buprenorphine in 11 pregnancies mirrors other small reports of good outcomes with shorter and milder neonatal withdrawals (cf. G. Fischer). Transfer from up to 70mg methadone to buprenorphine was satisfactorily accomplished in 28 hospitalised patients using lofexidine (Glasper, Bearn et al). Benzodiazepine use in opioid maintenance as well as in withdrawals is examined in two papers from London. Oxazepam (Serepax) is tested against diazepam for prevention of seizures in alcohol withdrawal, and found wanting, possibly due to its shorter action. Cannabis use is surveyed in a large number of multiple sclerosis patients, finding widespread use for symptom relief (one in five) and only minor side effects. A retrospective analysis of ADD diagnoses in addiction cases showed a high prevalence, suggesting the need for further evaluation of this factor in research into the aetiology of addiction. Dextromoramide (Palfium) is sometimes used for opioid maintenance when other drugs are unsuitable (Holland, Australia, UK). The need for an equivalence table is broached by Strang and colleagues, also pointing out the difficulties in such attempts. Using 13 cases (mean dose 233mg, range 40-800mg daily) who were forced to transfer due to the drug becoming unavailable for commercial reasons, Strang and colleagues found a ratio of 1:1.35 equivalence to 24 hour morphine. They also describe a single case taking 1800mg dextromoramide daily plus large amounts of temazepam. The patient transferred in hospital and stabilized on 900mg methadone daily, a very large dose by any means, being over ten times the mean daily dose in New South Wales and about 25 times the mean dose reportedly used in the UK! Yet even higher doses of methadone (up to 1200mg) have been reported. If one takes methadone to morphine (24 hour total) equivalence as 1:4, then this equates to a dextromoramide to morphine ratio of 1:2 by my reckoning.

Such large opioid doses were first described by Thomas de Quincey in his book Confessions of an English Opium-Eater (32 grains daily, as laudanum) (My review available here).

comments by Andrew Byrne ..