Dissolving the Mind-Brain Barrier. New York psych conferenceproceedings May 04.
American Psychiatric Association, 2004 Annual Meeting. Psychotherapy andPsychopharmacotherapy. Dissolving the Mind-Brain Barrier. New York. 157thannual Meeting, 1-6 May 2004.
Dear Colleagues,
Despite not having attended this meeting, I have had an opportunity toreview the enormous 'proceedings summary' for this conference which wasgiven to me by one of the large group of Australian psychiatrists whoattended in springtime New York. It consisted of 370 pages of very smallprint! Like all big scientific conferences these days, nobody could attendall the parallel sessions and it is hard to imagine that they could not havebeen pared down for relevance, quality and length. Regarding addictionrelated presentations there was a mixture and these also varied in quality.In our field we are used to being left to the end of days, following theother more 'mainstream' topics.
Even some of the general lectures/workshop titles were very esoteric.'Music and the mind: Beethoven'; 9/11 Research: Reviews; 'Surviving JockCulture'; 'Why does the human brain become addicted'; 'The brain in love';'Better Sex: Naturally'; 'Postwar mental health services'; 'Leash on life:Human attachment to animals'; 'Detection of Malingering'; 'Juvenile Justice. Jazz and Blues'; 'Sexual satisfaction . in Orthodox Jewish Women'; 'Thesissy duckling . gender variance'; 'Psychotherapy in Asian women'; 'Gaynessand God'; 'Modafinil treatment of chronic shift work sleep disorder'; 'Foodand drug cravings: metaphor or common mechanism?' . I could go on . Yogatechniques, show biz, teaching, forensic psychiatry, twin studies,topiramate for alcoholism, terrorism, PTSD, AA, ADD, etc, etc, etc.
From the program, there was still plenty for the 'bread-and-butter'psychiatry issues of anxiety, depression and psychoses, as behoves such alarge conference. We forget just how 'big' psychiatry is in the UnitedStates. While it is exceptional for Australians to have a psychiatrist, itis almost compulsory for middle class Americans.
Regarding addiction, there were a number of papers, many authored by wellknown researchers and clinicians but on a surprisingly limited range ofsubjects. These mostly revolved around the newfound availability ofbuprenorphine for maintenance of opioid addiction in office based practice.When properly used, such work can be enormously professionally rewarding .and prescribing opioids to addicts is something American doctors have beenlargely banned from doing since the 1920s. Also, uniquely in the US,pharmacists are barred from administering methadone in the treatment ofaddiction. Buprenorphine (mostly in combination with naloxone) has beenmade available on a 'waiver' prescription system under the Drug AddictionTreatment Act of 2000 from certified doctors as outpatient management. Thisis without the normal addiction clinic requirements for supervisedadministration, counselling, urine testing, etc. Medication can beprescribed for up to six months on one prescription, including repeats or'refills'.
There were also numerous papers on cocaine and cannabis, with uniquelyAmerican flavours, and thus often of limited relevance to normal medicalpractice in other countries.
Nowhere was there mention of the current uncomfortable conundrum of doctorssometimes prescribing the second best drug for arbitrary regulatory reasons.Methadone is the recommended maintenance drug for pregnant addicts, yet itis not available in some states and is very limited in the others.Methadone is also more effective than buprenorphine for those with hightolerance. Trials often show better outcomes for methadone so it should bethe first line drug in some or even most patients. One could understandthis being omitted by the authors in the section sponsored by drugcompanies. Yet it is not mentioned in the many other free papers, as far asI could determine.
Many of the most prominent personalities of drug research in the US wererepresented here, including names like Ling, Kosten, Kleber, Galanter,McNicholas, Volkow, Rounseville, Portnoy, Tsuang, O'Brien, Millman, McLellanand Bankole Johnson.
Some of their views were controversial, others questionable, such as theclaim that methadone should be avoided in HIV cases because of its supposednegative effect on the immune system. The myths of buprenorphine beingeasier to withdraw from and having less dependence features were alsoresurrected by some contributors. Buprenorphine withdrawals have no bettersuccess than methadone withdrawals. Nobody ever mentions the ratherimportant fact that there are simply no long-term safety data onbuprenorphine, especially in combination with naloxone. Indeed, themanufacturer seems not to be sponsoring any such research currently.
It was gratifying to find so many papers on nicotine dependence. In my viewpsychiatrists have a much wider community responsibility than immediatepatient care. It is tragic that is has taken so long for them to realisewhat psychiatrist Marie Nyswander wrote about 50 years ago . that treatingaddicts with psychotherapy was fraught with frustration without usingmaintenance pharmacotherapy for appropriate cases. And with such therapy itcan be enormously rewarding for doctor and patient as addicts put theiroften considerable talents towards normal life issues rather than constantlyprocuring drugs.
There were only small contributions from overseas including adolescentpsychiatry (one from ANU and another from the UK). There was also areference in Walter Ling's insightful paper on treating chronic pain inmaintenance patients. He quoted some important work from Adelaideresearchers on the subject of induced hyperalgesia in such patients and theneed for different approaches for the future as there will be so many moresuch patients. Australia has contributed much to the field of psychiatry(eg. a Melbourne doctor first devised lithium treatment).
It is a shame that more prominence was not given to a RCT by Bankole Johnsonin which he measured quality of life in alcoholics given topiramate, a newdrug used for cravings and/or relapse prevention. There was a significantpositive effect. So now we have at least four drugs in this class:naltrexone, acamprosate, ondansetron and topiramate. The latter two couldonly be used off-label in Australia and thus should probably only beprescribed in specialist or research settings. The first two should befamiliar to all Australia doctors who come into contact with alcoholics -and who doesn't?
Comments by Andrew Byrne ..
