29 March 2005

Peer support for dependency problems: 12-step and CBT-based approaches

29th March 2005


Dr Stephen Jurd, Ms Josette Freeman, Dr Alex Wodak, Ms Lyn Roberts.

This session focussed on non-pharmacological management approaches to substance abuse. Stephen Jurd, director of D&A services at RNSH began the session by giving an overview of Alcoholics Anonymous ('AA'). He first presented us with the evidence for a genetic proclivity to alcohol dependence. He defined the dependence syndrome with reference to alcohol. This syndrome includes narrowing of the behavioural repertoire, salience of drinking, increased tolerance to alcohol, subjective awareness of the compulsion to drink, increased frequency and severity of withdrawal symptoms as dependence on alcohol increases and the seeking of relief from withdrawal symptoms by drinking more alcohol. There is also often a rapid return to pre-abstinence levels of drinking after a period of abstinence. He pointed out that controlled drinking for someone with an alcohol dependent syndrome would be very difficult to achieve, and that the two most likely outcomes for heavy drinkers were either a move to abstinence or eventual death from the complications of alcohol overuse.

AA, a 12-step approach, is not just about attending meetings, but a comprehensive philosophy. It does not tell people to "stop drinking" and has no opinion on any outside issues. We were told about the importance of the AA facilitators in encouraging people to attend meetings and connect with people. If people are just told the time and place of a meeting, it is not very likely that they will turn up, so the facilitators ring the prospective attendees to remind them of the upcoming AA events. This demonstrates the emphasis on personal contact that is integral to AA or the 'fellowship'.

Reference was made to the "clichés" used by AA, but Stephen Jurd asserted that if used skilfully they can change people's thinking. Some of these clichés include: "one day at a time", "live and let live", "easy does it", "let it begin with me". The literature that AA produces includes 3 major arms: 1) the AA big book 2) Living Sober, 3) the 12-steps and 12 traditions manual. The "Living Sober" book contains a lot of very practical advice to commonly asked questions such as should I avoid parties? How to I approach sex when I'm not drunk? and what do I do if I can't sleep? The AA groups require regular attendance, and there is usually a group task that is done each session to facilitate the sense of community and aid motivation. There is a group "conscience" whereby particular issues may need to be voted upon and a consensus reached. The 12-steps are the actual AA "program" and the meetings are centred around these 12 steps. Workbooks are available (eg at the Sydney 'Feminist' bookshop). A group member will often have a "sponsor" whose task it is to go through certain steps with the attendee. Sometimes it is required that these steps are written down (step 4). It is up to the attendee as to whether they want their sponsor to be temporary to cover certain steps, or long-term. A sponsor's role can include such things as ringing the person at a certain time each day to see how they are going.

There were questions about whether AA was religious, and though it did originally have Christian roots (the 'Oxford group'), it is now regarded in Australia as having no religious aims or affiliations. The term "God", as mentioned in AA literature, can be taken religiously or in any other way, eg as an acronym for "gathering of drunks" (!). It was noted by Alex Wodak that there is no hard evidence to prove that AA works, but he felt that as AA is a community organisation there should be no onus on it to have to prove its mettle. He believed it would be a difficult thing to assess scientifically, particularly for reasons of confidentiality and privacy. Stephen Jurd pointed out that there are currently about 2 million members of AA worldwide, and that it draws no outside funding yet has continued to exist for many years. He considers this to be suggestive of its merit. He said there is a bit of scant evidence for AA, but you have to scratch around for the data, and it's not "level 1" evidence. (ie double blind randomised control studies.)

Josette Freeman spoke to us about the SMART Recovery programme of which she is the co-ordinator, based at St Vincent's Hospital. They have a grant to establish 20 SMART recovery groups across NSW. SMART ("self management and recovery training") originated in the 1990's in the USA and is based on cognitive behavioural therapy (CBT) principles. The groups are peer-run. One of the principal objectives is to help foster motivation within people so that they are self-propelled towards recovery. The programme cultivates self-help and problem solving skills. People learn how to identify and manage their urges to use their drug of dependence. They work towards achieving a balanced lifestyle. The programme's CBT approach teaches people to challenge unhelpful automatic thoughts that surround their drug use. It is a time-limited commitment of a minimum of five weeks, though some people attend for up to 18 months.

In SMART, members are encouraged to do a cost/benefit analysis of their drug use. Relapses are looked at by the group and studied to see what has lead up to them. Analysing relapses is seen as part of the group's learning curve. Looking at the here and now is important, and meetings encourage people to study what has worked and not worked for them during the past week. Facilitators are encouraged to network with each other and share ideas about the running of their groups. SMART can complement adjunctive pharmacotherapies being used to treat substance misuse. It is not a substitution or competitor to the 12-step programme and members can attend both programmes if they wish. Group attendees may use different drugs of dependence, like alcohol and opiates, so in this sense the groups are "mixed". Josette described SMART as being an abstinence programme with latitude. The programme has not been evaluated, though discussions regarding this are currently happening with NDARC.

Alex Wodak commented that SMART, like AA, is a community resource and therefore shouldn't have to be evidence-based, though a positive evaluation would encourage health professionals to refer to it. Josette explained that for a client to be suitable for SMART, they must want to go. She said it offers an alternative to those people who don't like the 12-step approach, including the 'higher power' and 'disease concept', thus opening up more options for those with drug and alcohol dependency problems.

Lyn Roberts spoke to us about the therapeutic community model of treatment. She is manager of WHOS MTAR. This acronym stands for 'we help ourselves' and 'methadone to abstinence residential'. It is a residential service for those wishing to withdraw from methadone maintenance therapy. The methadone reduction regime is managed by external GPs as well as being externally dosed at the Langton Centre. There is a recommended protocol of dose reduction of methadone, but clients have the right to delay the reduction. Lyn Roberts stressed that conceptually it is important to understand that MTAR is not a "detox", but clients are undergoing their reduction while they are going through their rehabilitation program. Therapeutic community staff primarily utilise facilitation as a means of engagement as opposed to traditional medical models of treatment. Clients are referred to as residents, not patients, with the expectation that they will take responsibility for their own recovery. They are encouraged to support staff with the orientation of new clients, and the maintenance of the program schedule. They celebrate achievement of goals. MTAR came about after networking with USA TCs, but the Australian approach is modified and more flexible than a traditional American TC. Clients are not required to do as many functions as in a traditional TC and if a client prematurely discharges themselves, they are allowed back into the program within a 3 day time span if assessed as appropriate for readmission. Peer support is an integral part of the TC model and utilises privileges as part of its programme. Insight is gained through group and one-on-one interaction. Clients have access to harm minimisation programmes at MTAR eg educational sessions on hep C and HIV, drug overdose, infection control, etc. There is provision for safe injecting equipment and safe sex supplies throughout all WHOS facilities including MTAR. The recommended length of stay is 4-6 months. Lyn explained that MTAR is in the process of doing follow-up studies on its clients, but felt already that the high retention rates of clients in the programme provided some evidence of its success.

Summary written by Dr Jenny James, Aboriginal Medical Service, Daruk, NSW.

16 March 2005

Buprenorphine diversion prevalent in Victoria, rare in other states

Buprenorphine diversion and injection in Melbourne, Australia: an emerging issue? Jenkinson RA, Clark NC, Fry CL, Dobbin M. Addiction (2005) 100;2:197-205

Dear Colleagues,

When prescribed according to established guidelines, buprenorphine is very effective in retaining addicted subjects in treatment and in suppressing heroin use. This paper looks at buprenorphine from the 'grey' market perspective when supply does not meet demand by interviewing attendees at city needle exchanges in Melbourne.

We are told that of 156 subjects 57% had 'ever' used buprenorphine (53% in the previous 6 months). Of those reporting buprenorphine use, 37% reported obtaining the drug illicitly (i.e. not from their own prescription) at least once during that period with one quarter (26%) reporting 'mostly' using illicitly obtained buprenorphine (ie. not on their own prescription).

Of the 156, 37% had 'ever' injected buprenorphine (33% in the previous 6 months). Around half of these injectors had obtained sublingual tablets from illicit sources at least once and in one third of cases reported 'mostly using illicitly obtained buprenorphine'. Injectors were more likely to be poly drug users, to be in treatment (mostly bup), to be unemployed and to have a prison history (50%).

From these figures it would appear that for the previous 6 months for the 156 subjects, 31 (20%) had used illicit buprenorphine and 24 (15%) had injected illicitly obtained buprenorphine. Hence a quarter of the subjects involved in diversion had obtained illicit buprenorphine and NOT used it by injection. Thus Jenkinson, Clark, Fry, and Dobbin have demonstrated clearly that the mooted combination buprenorphine product (with naloxone to discourage injecting) cannot address this major aspect of diversion (illicit oral use). In addition, despite nearly 100% 'supervised' administration of this sublingual product there still appears to have been widespread 'leakage' to the community near these 5 needle programs. Take-home doses are apparently only allowed in exceptional circumstances in Victoria.

It is reassuring that 58% of these subjects who attended a needle exchange had been involved in some treatment in the previous 6 months. However, it may concern Victorian authorities that only 38% remained in treatment at the time of the questionnaire, implying that two thirds of these high-risk users had dropped out. Of those still in treatment, two thirds were taking buprenorphine, one third methadone and 3% drug-free treatment ('counselling').

This survey shows that even when there is widespread availability of buprenorphine from pharmacies, as in Melbourne, there is still a market for the diverted drug. This must be at least partly consumer driven and might reflect inadequate dose levels prescribed locally, inadequate dispensary opening hours, travelling, fees and/or other constraints in accessing prescribed buprenorphine.

From a purely public health perspective, this report might be seen as demonstrating a reduction in dependence on illicit, unhygienic and impure heroin for a pharmaceutical with quality control, labelling and predictability. However, some of the tablets may have been diverted after being in the oral cavity and thus could represent a serious infection risk. This might be termed a 'secondary treatment program' as in the concept of secondary needle programs which were reported recently. As with needles, it is still disappointing that the tablets were not available legally to those who needed them, when they need them (eg. before work for unskilled people starting at 7am; in lunch hours; evening doses for those doing overtime). While buprenorphine can last for 48 hours or longer in some situations, for new patients, reductions, pregnancy (not approved as yet) and fast metabolisers (half life as short as 9 hours in some - ref on request) it is not realistic to expect such people to work and function normally without having their daily medication first.

In response to the high rates of diversion, the authors remind us of the challenge to busy community pharmacists to strictly supervise the sub-lingual administration of the drug which can take over ten minutes in some cases. They even suggest the possibility of formal clinic treatment for some patients or else transferring to methadone to prevent diversion (a liquid is much easier to supervise).

The authors inform us that of the other five Australian jurisdictions for which comparable figures were taken for recent buprenorphine injecting, each was less than 5% (cf. 33% for this Melbourne sample). This is all the more remarkable since both Queensland and South Australia have allowed take-away dosing in parallel to methadone for stable patients for a number of years (up to 4 per week for those NOT on second daily dosing already). I understand that, apart from Perth, WA, the reported figures for subsequent years have not risen significantly. I have asked the Sydney injecting room staff about buprenorphine injecting and they say it is almost unheard of with heroin and cocaine making up the bulk (~95%) of their patients' dealings, in 'oscillating' proportions. Some Kings Cross police I have interviewed had never heard of the drug. Currently, there are about 2500 patients taking buprenorphine in New South Wales (pop ~ 6 million).

Congratulations to these authors for their vital seminal work. Thanks also to RAJ for her helpful suggestions and corrections for an earlier draft of this summary.

Comments by Andrew Byrne ..


Jenkinson RA, Clark NC, Fry CL, Dobbin M. Buprenorphine diversion and injection in Melbourne, Australia: an emerging issue? Addiction (2005) 100;2:197-205

10 March 2005

Internet drugs 'more expensive' than from pharmacy ... but no doctor needed

Sydney Morning Herald 3/3/05. "Online sales of mind-altering drugs surges: UN."

In a slightly confusing article on drugs AFP reports on the International Narcotic Control Board's chief Hamid Ghodse and his 'panel' warning about increased supply of narcotics and other psychoactive drugs from the internet.

Ghodse mentions the serious worry of children having access to internet supplies. But he then appears to contradict himself regarding how to address the situation. He states that policing was difficult (or impossible) as internet supply companies 'can easily be relocated' across borders to avoid tighter laws. But his final quote is to call for governments to 'act urgently'. This is usually 'code' for increasing restrictions and raising penalties which he has already pointed out only serve to drive suppliers off-shore. Can he mean the opposite?

On a seemingly separate issue, the report then moves to Afghan opium production which is nearing peak levels again (4600 tons per year).

Clearly only a radical re-think of current policies will have any impact. Citizens deserve access to good medical care at affordable prices. At the same time community demand for drugs in non-medical settings such as alcohol, tobacco, cannabis, ecstasy, cocaine, steroids, etc should be met with more enlightened policies than ineffective and expensive bans as at present. This does not mean 'legalising' everything, however!

My calculations of 4600 tons of opium (which may be flawed), based on 20% morphine equivalent approximation, yields 100,000 million standard 10mg doses of morphine. If dependent people used an average of half a gram per day, this comes to just under 200 grams per year. Thus the Afghan crop estimate above could support 50 million addicts. This may, however, include a larger numbers of non-addicted, occasional drug users.

A Sydney TV news bulletin on Sat 5/3/03 dealing with these matters stated that Afghanistan has now eclipsed Burma by 17-fold in opium poppy production. It may be no coincidence that both of these countries lie in close proximity to potentially the world's biggest opium market after Europe and America, China. Places like Australia and New Zealand must look like tiny 'niche' markets in such a world.

comments by Andrew Byrne ..

5 March 2005

Fewer methadone deaths reported from UK. Female drug users at higher risk.

Dear Colleagues,

The March 5 2005 British Medical Journal has a reassuring news report about reductions in most poisoning cases for the year 2003. The exception was for female drug users whose rate had climbed to 346, the highest on record (compared to 1042 men, the lowest since 1997).

Notably, Ms Brock of the Office for National Statistics stated that "...deaths involving methadone fell to their lowest number recorded..." Further: "We do not have information or an indication that people are taking fewer drugs."

They report further that there was an increase in the number of deaths involving antidepressants-from 392 in 2002 to 424 in 2003. These were mostly selective serotonin reuptake inhibitors such as Prozac and related drugs, although these are widely thought of as safer alternatives to older antidepressants.

I commend readers to the BMJ site for
the full article

Comments by Andrew Byrne ..

3 March 2005

January 2005 National Geographic cover article on caffeine

Dear Colleagues,

January 2005 edition of the National Geographic Magazine has a 30 page cover story on caffeine which makes fascinating reading. Caffeine is the world’s most popular drug, even eclipsing tobacco and alcohol.

The history of beverages, nuts and confection containing caffeine makes quite a story, paralleling civilisation itself. Prior to the industrial revolution there was little to be gained in keeping awake after dark. Since caffeine increases alertness, improves reflexes and reduces fatigue, it is an ideal accompaniment to round-the-clock factory work. With few proven side effects at normal doses, it would thus appear to be the ideal drug for the modern era.

After tea, coffee and cocoa, the latest incarnation is in ‘energy drinks’. We are told that “Red Bull” was an Austrian invention which is now copied all around the world. I recall seeing "Jolt" cola when in Japan over ten years ago. Strangely, it is compulsory in many countries to state contents details on the label of most products, but tea, coffee and cola often still remain exempt from this requirement.

We are informed that dark chocolate contains up to three times as much caffeine as milk chocolate and 12mg is a typical dose contained in a small block. The article quotes a cup of brewed tea at 50mg, about the same as a single shot of espresso coffee. A 20oz (US) bottle of Coca-Cola has 57mg caffeine while a small tin of Red Bull contains 80mg.

There is an exhaustive discussion of the benefits versus the potential side effects of the drug, including its use in pregnancy and in children. The author’s conclusion on balance is parallel with the FDA, that the drug is ‘generally recognized as safe’ in doses of up to 300mg daily. However they sound a warning that ‘people who consume caffeine have higher rates of kidney and bladder cancer, fibrocystic breast disease, pancreatic cancer and osteoporosis’ even if these are not necessarily causative. Nervousness, panic attacks and temporary increases in blood pressure are also occasional associations of caffeine consumption.

Other interesting quotes: “The caffeine extracted from coffee beans to make ‘decaf’ is sold to drug and soft drink manufacturers”. “Military studies of subjects who had not slept for 48 hours showed that 600mg of caffeine improved alertness and mood as much as 20mg of amphetamine”. “The robusta coffee beans used in less expensive brands contain almost twice as much caffeine as the arabica beans favored by connoisseurs”. “Going without caffeine for a day and a half increases blood flow in the brain which may explain why people get headaches when they first give it up”. “Cigarette smoking nearly doubles the rate at which the body metabolises caffeine”. “Vietnam is now the world’s second largest coffee producer, yet is largely a nation of tea drinkers”.

comments by Andrew Byrne ..