16 November 2004

APSAD Conference, Fremantle, Western Australia - Day 2

Tuesday 15th November 2004



Day Two


Dear Colleagues,

The second formal day of proceedings had an emphasis on prisons and law enforcement. Michael Farrell's talk was entitled "Tackling problem drug users before, during and after prison. Dealing with a high risk environment". He reminded us of the problems of suicides in jail as well as deaths in recently released prisoners, citing numerous studies showing the greatly increased risks of overdose in the days after release. It was for this reason that methadone was introduced into all prisons in New South Wales almost 2 decades ago. It appears that methadone treatment is still not routine in British jails and indeed, most other countries' jails, despite the evident need and benefits.

Next we heard from Heino Stoever on drug use in German prisons. He quoted numerous trials of needle/syringe availability, which is known to reduce rates of blood borne diseases. None of the trials had been associated with reported problems such as prisoners threatening other inmates or staff with officially provided syringes. Since one cannot stop drugs entering jails, it would seem illogical to ban needle/syringe provision for their safer use.

Brian Watters launched the new ANCD (Australian National Council on Drugs) compilation of the research on custodial matters. He was remarkably frank about the value of harm reduction measures of all kinds in the prison system, including needle/syringe programs. Copies were available for delegates.

The meeting then split into 6 streams of which I was involved in 'pharmacotherapies'.

Tim Mitchell spoke on the potential advantages of using the active enantiomer ('R') of methadone in preference to the cheaper racemic version ('RS') generally available. He had searched the literature, especially from Germany where this has been used in clinical practice for many years for historical reasons. While there were some negative effects noted from the inactive form, these appeared mild in most people, except at high dose levels. It was shown that the metabolism of the two forms could be quite different and one might induce the metabolism of the other. The best information might be obtained from those who have transferred regularly from the German program to other European locations where doses have to be doubled to yield the same agonist effect.

Ian Kronborg gave in interesting talk on sleep disturbances in methadone maintained patients, pointing out how complex this field has become. There are dozens of specific sleep pathologies recognised and now, a particular one associated with opioid maintenance. All practitioners should remind those with insomnia about regular 'sleep hygiene' as some methadone patients were found to require only simple advice to improve disturbed sleep patterns.

Lula Kamal gave a disturbing account of the reasons English patients had left maintenance treatment in past episodes. Methadone doses had been 'too low' with 'cravings', 'withdrawals' and 'continued heroin use' given as the reasons in many of her confidential questionnaire subjects in London. A question from the audience confirmed that poor quality treatment appears to be rife in London with little patient involvement in decision making about dose levels. It is still a mystery why the mean methadone dose in England remains reportedly below 40mg (where it probably should be double this for optimising benefits) . and no wonder that as a consequence methadone has a bad name amongst patients, doctors, journalists and the community generally. It is most surprising that the major Addiction journals, Colleges, NAC and NHS have not conceded the existence of this parlous state of affairs, nor have they done anything to rectify it. Comparisons with other European countries show an ongoing spate of adverse consequences from overdoses to HIV and hepatitis. The matter is so grave that even quite conservative people are now calling for heroin prescription for addicts.

Richard Hallinan from our own surgery then presented evidence of hypogonadism and sexual dysfunction in opioid treated men. He recommended that practitioners include these issues in clinical assessments and in monitoring of on-going opioid replacement treatment.

In a second paper, Dr Hallinan then described the use of receiver operating characteristic (ROC) analysis to define statistically optimal thresholds for methadone dose and plasma concentrations (100mg daily; 250ng/ml R-methadone; 300-400ng/ml for racemic methadone) in relation to continuing heroin use in MMT. Measuring plasma concentrations apparently did not help to predict continuing heroin use in MMT.

Dr Comer spoke about her work with long acting depot naltrexone for heroin relapse prevention. Her own study from Columbia University used ~200mg and ~400mg doses, measuring blood levels and responses to injected heroin in the 6 weeks following (yes, an American heroin trial!). Some developed skin irritation at the naltrexone injection site and one attempted suicide during the trial. This is consistent with Miotto and Ling's findings and might be associated with an accompanying depression although Comer said that it was not thought to be a result of the treatment.

After lunch we heard a series of speakers on the increasing problems with psychostimulants. Robert Ali implied that following an epidemic of stimulant popularity, there may have been some reductions of late, with some high quality heroin 'flooding' back onto the market. He had done the ground work for a trial of treatment for amphetamine psychosis but now there seemed to be fewer presentations for this diagnosis at the two centres proposed for the trial. Drugs such as benzodiazepines and anti-psychotics were discussed, along with their various advantages and disadvantages including the stigma of a 'schizophrenia' diagnosis and the addictive nature of the 'minor' tranquillizers.

Parallel sessions then addressed alcohol use in the older person, prison issues, general practice, youth and cannabis law reform.

The James Rankin oration was given this year by Jason White in the presence of Professor Rankin himself. We were given a succinct but detailed overview of the subcellular neural mechanisms for the actions of many of the substances people use as well as the treatments we institute. We then heard from Dr Comer again on naltrexone in relapse prevention using the long acting depot form.

Finally, Frank Hansen from the NSW Drug Squad gave the constabulary's view of the stimulant epidemic, followed by the police approach to harm minimization and some difficulties which can arise.

It is impossible to get a completely fair overview of such a large meeting and my apologies to all those who contributed who I have not mentioned. There was a camaraderie in all of the coffee and meal breaks in which sometimes quite disparate people found common ground and enjoyed each others' company. While the company was superlative, the conference dinner was not really worth $75 (food review on application). However, I approve of the principle of individual bar service rather than 'unlimited poor quality grog' which has sometimes been the case in the past.

comments by Andrew Byrne ..