9 September 2004

Book reviews may reveal as much about reviewers as their books.

“Addiction”, August 2004. Posted 10 Sept 04

Dear Colleagues,

I enjoy reading book reviews, partly because I rarely get around to reading the works themselves. Editor Griffith Edwards, author of numerous books himself, often undertakes such reviews in Addiction. He sometimes declares, but apparently does not act on his conflict of interest as an author of books on alcoholism, a field in which he is a peerless authority. In the reviews, he often reveals as much about himself as his subject. When authors’ views depart from his own, he often praises aspects of the work and then turns to indecorous and pointed criticism. For example, this month ina review of what promises to be a fascinating new book on drugs in China by some (we are told) eminently qualified authors (Dikotter, Laamann and Xun): “Unfortunately, at the same time it is a text marred by serious weaknesses.The intention is early declared of debunking ‘narcophobic discourse’ and that phrase is wearily repeated page after page. The authors go on to state that their aim ‘is to provide a critical analysis of narcophobic discourse and an in-depth examination of the social costs of government attempts to police the bloodstream of the nation’ - what is to be made of that strange image is unclear.” writes Edwards of this historical work. Then: “… it is evident that these writers have no intention of weighing the evidence dispassionately or seeing two sides of any question.”

What Edwards surprisingly omits from his review is that indeed 20th century China is probably one of the few shining examples of prohibition actually having the desired effect (law enforcement leading to near elimination drug use). But this was only achieved at the cost of civil liberties to an unprecedented degree in human history (and hence the belabouring of the ‘anti-narcotic’ sentiments by these authors, I imagine). Rather than discussing the merits of such rather major issues, or historical lessons for others, Edwards heaps scorn on these authors for what he perceives as theirpainting ‘opium as good’ and ‘narcophobia’ as bad (Edwards seems to espouse the exact opposite).

Opium, like most traditional drugs, can be both ‘good’ and ‘bad’ in different circumstances. Edwards knows that. Despite lacking a scientific basis, the blanket prohibition philosophy Edwards appears to support has proven to be counter-productive in most countries. Current prohibitions in our own society are associated with continued and often increasing and widespread availability of drugs to our citizens, most worrying, to the very young, poor and vulnerable. Edwards knows that. In addition, such policies deny medical uses of appropriate drugs in some instances (eg. cannabis,amphetamine, heroin). Edwards knows that. Yet he still sings the same old tune that appears to place confidence in the current prohibitions. The world is moving on, albeit slowly, and, while nobody I know has seriously suggested placing drugs on the supermarket shelves, there are better means to effective drug control than those existing in most countries currently.

According to London press reports, cannabis is now virtually decriminalised in the UK, an issue Edwards has yet to address to my knowledge. Portugal has apparently decriminalised all psychoactive drugs. The Dutch and Swiss now prescribe heroin to a small proportion of their addicts, as does the UK. Germany now has federal laws legalizing injecting rooms. South Australia decriminalized cannabis almost 30 years ago. Canberra, Darwin, Belgium, Holland … the list goes on. The lack of serious commentary in Addiction on these major issues does not reflect well on the journal’s management.

Edwards and co-authors have also written in reviews that the American prohibition period needs closer attention for its positive side, citing respected academic historian Ian Tyrrell. Can they be serious? Did the trains run on time? An underlying implication is that if we just tried a little harder that prohibition (of psychoactive drugs and/or alcohol) mightjust ‘work’. When I sent a mild letter pointing to these inconsistencies, Addiction used their “Iguana” chat column* to attempt to patronise and humiliate me, even suggesting that I take some tablets and lie down! Therewas no offer of genuine debate on the issues ‘between people of goodwill’ (to quote Edwards). Just a reminder that the editor’s decision is final. On another occasion: “I hope, however, you will think me in no waydiscourteous if I say that I do not see it as useful to re-open correspondence with you about …”. [Meaning, on this occasion, that a lead article ‘Additional methadone increases craving for heroin …’ remainsunchallenged despite the serious implications.]

In the review on drugs in China, as a further example which some may interpret as intolerance or a lack of equipoise, Edwards is extremely critical of some possible minor errors which would detract little from the authors’ overall message about drugs in China. Morphine is implied to be ‘semi-synthetic’; penicillin introduction in the 1940’s “took care of its [opium’s] medical uses”; tobacco is described as a stimulant. None of these seem like hanging offences to me and the meanings are reasonably clear, even if not all necessarily pin-point accurate from these non-medical authors.

In the July edition, Edwards also featured himself in one of a pair of book reviews on alcohol history in, respectively, Canada and the United States. Edwards spends over a third of his review commenting upon the appropriateness or otherwise of a media announcer deigning to write a historical work. He castigates the poor amateur on ‘getting caught up with the history of prohibition’ upon which Edwards then launches into his own opinions again: ‘Prohibition is an experience from which America has had difficulty moving on, but a book that reinforces such perseveration is not a recommended guide.’ After lambasting the authors over three more alleged errors, he goes out below the belt saying that ‘The validity of such claims should be checked out before being put into a newscast.’ This review is sadly unhelpful in informing us on the book’s general merits.

Robin Room is a frequent author in Addiction’s pages, whether reviews, research or commentary. He writes two alcohol book reviews, one being of a classic text (a suggestion I made to Griffith Edwards some years ago – with a submission on De Quincey’s confessions book* - a suggestion Addiction has finally chosen to act upon, albeit un-attributed). It is hard to write two lengthy reviews about alcohol policy without stating categorically the negative consequences of prohibition (which I was fascinated to learn was also tried, without lasting success, in some jurisdictions in Canada, Norway, Turkey, Soviet Russia and Finland up to 1930 - and also Box Hill insuburban Melbourne I understand). But Room manages to avoid writing about the unpleasantness of the prohibition period(s), despite the substantial loss of life, crime, corruption and under-age drinking attributed toenforced temperance policies. Intriguingly, these terms are not used, nor their consequences addressed. Room knows the best approaches to alcohol harms, including restricted hours of sales, age limits, responsible bartending, scaled taxation, honest labelling, limited advertising, driver breath testing and education, all within community expectations and tolerance. Yet for some reason, he stops short of being definitive on the inappropriateness of blanket prohibition of alcohol, leaving this perilous door yet wide open.
Life goes on. Our 100 year old flagship journal miraculously continues too, and will likely outlive Edwards, Room, Byrne and other current players. So will harm minimisation policies, variations upon which doctors have beenespousing since the time of Hippocrates.

comments by Andrew Byrne ..

*Copies available on request.

1 September 2004

Important and novel findings from Suboxone� study in Sydney

Drug Alcohol Rev (2004) 23;3:311-318

A pilot study of buprenorphine-naloxone combination tablet (Suboxone®) in treatment of opioid dependence. Bell J, Byron G, Gibson A, Morris A.

Dear Colleagues,

These researchers are to be congratulated on one of the first studies of its kind. They report on responses in 17 consenting 'stable' buprenorphine patients who were offered transfer to the combination product containing naloxone which, after the first week, was dispensed once weekly and taken by the patient unsupervised rather than daily dispensing as previously.

Most research I have read on buprenorphine employs the drug for new patients presenting for treatment, measuring illicit drug use and treatment retention. However, very useful clinical evidence is also derived from comparing existing practice with the experimental condition. The combination buprenorphine and naloxone product ('Suboxone®') was approved for unsupervised use in the US over 2 years ago despite most of the existing research being on supervised dosing. We are told that the combination drug is equally effective and has theoretically less prospect for diversion as it contains an antagonist which if injected will cause withdrawals in those dependent on heroin or methadone.

The most surprising finding in this pilot study was that when transferred to the combination drug, nearly all patients required substantially higher doses of buprenorphine. Of the 15 successful cases, 4 needed double or more of the original dose of buprenorphine. One needed triple while the rest required more modest increases averaging about 50% at the transfer time.

"The switch from buprenorphine (Subutex®) to the combination product (Suboxone®) was associated with mild withdrawal symptoms for 24 hours in the first subject. Thereafter, 13 subjects had about a 50% increase in dose when switching (from an average dose of 8.5 mg Subutex® to day 1 Suboxone® average of 12.2 mg); in no cases were there complaints of either intoxication or withdrawal."

The possible 10% quoted absorption of naloxone may be responsible for antagonising the opioid effects, at least temporarily. Three patients reported withdrawals when starting the combination product. One of them chose to withdraw from the study altogether rather than taking increased doses offered. Thus it would appear that the combination drug may not be bio-equivalent and therefore not 'equally effective' as pure buprenorphine, especially for high-dose patients since 32mg is the current maximum recommended dose. Another explanation might be that the subjects in this trial were originally taking inadequate doses of the pure drug. Yet, since they were 'stable' such doses must have been associated with positive outcomes at the time.

Those intent upon eventual abstinence may have been disappointed that after six months in these 'stable' patients the mean buprenorphine dose were still significantly higher than at the start of the trial (up from 9 to 11mg daily [22%]). Apart from the withdrawals, there were some major events with one patient suffering a stroke and another becoming pregnant despite the strict protocol (Suboxone® is contraindicated in pregnancy). It must also be a concern that despite only enrolling stable, employed patients, by the end of the study four of the fifteen were unemployed. In spite of being chosen for their stability, there was still use of illicit drugs in about 6 patients according to urine toxicology reported. At least one patient was using such drugs frequently.

Since doses were dispensed unsupervised, in order to check for compliance, patients agreed to random call-back arrangements. Despite this, four patients (27%) failed to do so, claiming they had work commitments. Yet it appears that they were still permitted to continue with unsupervised medication. This reported finding could mean that some of the four patients had already consumed or even on-sold their medication.

It is puzzling that these patients had not been receiving any take-home doses despite being long-term and 'stable'. Nor do the authors address second daily administration of buprenorphine in these cases as recommended by the manufacturer. They write at length on the benefits of take-away doses and of the difficulties with daily attendance. Indeed, Australian Commonwealth guidelines on opioid maintenance point out that retention rates are reduced when take-away doses are not available. Even the original strict NSW buprenorphine prescribing guidelines allowed stable patients 2 take-away doses weekly with certain conditions. Most Australian jurisdictions now permit up to 5 take-away buprenorphine doses per week with few reports of problems. The use of strict 7-day dosing should be exceptional and dispensed doses used judiciously as an added incentive to normalise the dependent life style.

It is clear that opioid maintenance can be very successful with twice (or even once) weekly supervision. The researchers' final statement is that 'using access to unsupervised dosing to promote abstinence from heroin probably limits the potential benefits of unsupervised administration to a very small proportion of patients.'

comments by Andrew Byrne ..