Monday 15th November 2004
Day One
Dear Colleagues,
Health Minister McGinty, despite being the local member for Fremantle, was not able to attend to open the conference so his upper house Parliamentary Secretary said a few brief but very pertinent words in his absence as she declared the conference open.
Aboriginal elder Mr Wilkes spoke about his Nunga people and their land as well as some negative interactions with drugs and alcohol. His grandson, also Mr Wilkes, then played the didgeridoo, albeit with permission from the traditional owners of the pipe far to the north. Both were widely appreciated and complimented by the first key-note speaker Dr Tracy Westerman. She spoke eloquently and effectively about the cultural differences with Koori/Nunga and other indigenous family structures from the European. Her talk came as a breathe of fresh air from a caring, insightful and productive professional who spoke her part with conviction - minus 'attitude'. She also had a team of like-minded psychologists who were involved in spreading the word about interventions, local control and the use of beneficial, self sustaining programs to address drug and alcohol abuse in indigenous communities across the country.
Next the Professor Michael Farrell from London revealed some worrying but sadly unsurprising statistics from London. He showed some slides of depressed neighbourhoods in his once great city. Sorry inhabitants, poor living conditions and the availability of very cheap alcohol were a shock to some in the audience. He gave some figures for tobacco, alcohol and illicit drug use amongst such folk. Despite being worldly and knowledgeable about the field, he stopped short of definitive advice on how to address the multiple problems he described.
The day progressed with 6 'strands' of parallel lectures/workshops covering a multitude of topics.
Initially I heard Robyn Richmond speak about her randomised controlled trial of smoking interventions in schizophrenic patients. Her rigorous evaluation showed significant benefits in the early phase but with waning effects by 12 months. She also addressed smoking in prison populations in another session and described the outcomes of the new GP anti-smoking guidelines. There were also talks on hepatitis C rates and injecting behaviours, indigenous issues, rehabilitation and peer support, co-morbidity and South-east Asian perspectives.
In the afternoon we heard from Dr Tim Mitchell about a new titanium canister being trialled in London to dispense methadone take-away doses by remote control. The tamper-proof unit has an electronic dispenser which only responds to an optical recognition such as a finger-print. The pharmacist would also have a 'key' using finger prints as well to refill the thing. He pointed out that it only monitors methadone usage and does not prevent the patient on-selling or injecting the drug. I am still surprised as to why we use liquid methadone for take-away doses rather than tablets. Liquids can be an invitation to injecting for some unstable or unhappy patients. This would seem like an English response to their situation, being unable to address the abysmal quality of MMT. But there is a risk that this system could stigmatize our patients even more than they are already.
Pier Paolo Pani from Italy went to some trouble next to document his efforts to define which patients are more likely to do well with methadone and (pure) buprenorphine respectively. Even from their wide experience in Italy and his close attention to numerous clinical factors, it still came down to personal preference or trial and error in most cases. Leslie Amass repeated some of her figures from the Sunday meeting, emphasising the bio-equivalence of Suboxone and Subutex and the obvious advantages of take-home doses. I was surprised that despite an enormous experience in the US over the past few years (up to 50,000 individual patients) that there have been no further published studies to support the continuing safety and effectiveness of the combination product, especially whether it can be diverted to the black or 'grey' markets. Professor Walter Ling spoke about opioids and pain, alluding to the possible development of non-addictive drugs which were still effective for pain management. This has long been a 'wish' for those in the field and each drug company claim of a lower addiction potential has been followed by disappointment (including heroin itself!). He cited evidence for the existence and relevance of the 'orphan' receptor which may compliment the mu and other opioid receptors in the brain.
Don Weatherburn gave a talk about reduced detected crime amongst those in the criminal justice system who chose to go onto methadone treatment. The reductions did not seem dramatic but he assured us that they were significant, elaborating details of unreported crimes and low clear-up rates as low as 6% for some types.
Michael Tedeschi gave a fascinating talk on his findings in a survey of patients and prescribers on their reasons for preferring buprenorphine or methadone. Doctors were more impressed with the safety angle while patients were more interested in the convenience of a longer acting drug which is more flexible that methadone in some respects. Some also cited the illusory 'less addictive' nature of buprenorphine, despite a lack of evidence that it is more likely to result in abstinence than methadone or traditional detoxification from heroin. Side effects seem less with buprenorphine in a proportion of those who responded.
Jane Maxwell spoke of her experience with mortality in methadone patients in Texas.
Sue Hailstone described a NSW Health Department initiative aimed at detecting and dealing with doctors who prescribed more than the 'guideline' maximum 4 take-away doses weekly from an audit conducted in May 2001. While the follow-up audit showed better compliance, there was still no attempt to determine if actual clinical practice had improved as a result of the audit. I understand that some experienced doctors left the field at the time, possibly partly as a result of the intrusive nature of this intervention.
A senior Victorian doctor questioned the whole subject when 'guidelines' are 'just that'. 'Mandatory guidelines' is something of an oxymoron. The NSW authorities no longer have the means to vet individual clinical requests to go outside these maximums and doctors are caught in the uncomfortable position of either giving inappropriate treatment or breaking these rules in their patients' interests. It is gratifying that the new draft guidelines do not apply the same restrictions to those taking less than 40mg daily.
Many areas are still sadly lacking in on-going education for front-line health workers to raise the standard of care of patients with alcohol and drug problems.
Next we heard from Suzanne Fraser and Kylie Valentine on their new project comparing the take-away policies in Australia's two most populous states. Their pilot interviews quoted many interesting views from patients on the (obvious) benefits of dispensed doses. One went along the lines: "Urgh . I might not trust myself with doses for a whole week, but a few days of take-aways make all the difference!" The Victorian and NSW studies will make interesting reading in due course.
All in all a fascinating and productive day hosted by the Perth-based APSAD team.
