22 November 2005

Dependency issues in Aboriginal people

Tue 22 Nov 2005

Dr John Daniels, director of health services and research
at Redfern Aboriginal Medical Service (AMS).

Mr Maurice Shipp, public health co-ordinator at Redfern AMS.

Case Histories: Dr Yianni Faros and Michael Englert, nurse unit manager, AMS.

This meeting began with an overview of the link between indigenous culture and health. Regardless of lifestyle choice in either a more traditional setting or westernised urban area, Aboriginal people are a separate cultural group linked by a sense of belonging to a specific locality or extended family. The three widely accepted components of Aboriginal cultural identity were outlined. These are self-identity as an Aboriginal person, being the descendant of an Aboriginal person and being accepted by a particular Aboriginal community as belonging to that community. Maurice Shipp emphasised how the latter point underlines the seamless continuity between the individual person and their community. He discussed how the traditional kinship systems continue to have a powerful influence over contemporary family structures. An example of this would be how the children of two brothers may call each other brother and sister, rather than cousin, and that a person could therefore have several mothers and fathers. For an Aboriginal person, their mother's sister is their mother, but their father's sister is not their mother, but their aunt. Various rights and obligations may be expressed by these relationships and, with regard to any one individual, involve many members of the family and community.

It was pointed out that all of the world's indigenous peoples have a legally enforceable power to obtain and protect their human rights, via the Universal declaration of Human Rights to which Australia is a signatory. However, there are significant anomalies between the Articles within this Declaration and the current situation of Aboriginal and Torres Strait Islander (ATSI) people.

Maurice Shipp talked about various aspects of Aboriginal culture that are shared by different Aboriginal groups. These commonalities include a "world view" that expresses itself in religion, art, dance, music, language and kinship, and individuals within different Aboriginal communities will share these links, though they may differ from one community to another. However, common to all Aboriginal communities is the regard that is given to custodianship, in which all aspects of Aboriginal knowledge are sacred. Certain types of knowledge may only be permitted to be transmitted by certain people. Within particular communities young people may be picked to go through law, even as young as thirteen. Kinship within community is central to Aboriginal conceptions of identity and Maurice Shipp emphasised that Aboriginal people know who their families are. Even cousins, "sixth removed" by western definition, are regarded as close. Historical continuity is another commonality linking all Aboriginal people together, and Australia's indigenous people have at least a 60,000 year history here, ie something like 2400 generations of family living in Australia of which 2392 passed before European settlement. This gives a very deep sense of attachment to family and land; a powerful sense of ancestry. Another commonality between Aboriginal communities is the preservation and renewal of culture, the emotional and spiritual development that has continued to evolve up to and including this present day.

It was pointed out that there are about 70 different Aboriginal language groups in NSW and about 600 nationally. There are even more dialects, around 1,500. They are all absolutely distinct from one another and stem from different root structures. They are grammatically very complex and difficult to learn. For example, the beginning, middle or end of a word may change according to its context, and the meaning of words change according to who is talking to who. There are several languages still spoken in their full context particularly in remote Australia, and urban Aboriginal people often pepper their speech with Aboriginal words from their particular community group. This Aboriginal English is formally recognised by linguists as a distinct form of English and is an important means of expressing Aboriginal identity. It has a distinctive range of accents, incorporates local Aboriginal words, and shows unique grammatical features.

Dr John Daniels outlined some of Australia's shame in his summary of current mortality facts pertaining to Aboriginal people. The life expectancy of Aboriginal men is only 56 years, almost 21 years less than their non-indigenous Australian counterparts. For Aboriginal women the life expectancy is 63 years, about 19 years less than their non-indigenous counterparts. Dr Daniels contrasted the causes of death for Aboriginal people versus non-Aboriginal people.

Circulatory diseases account for 27% of Aboriginal deaths, and this compares with 36% for non-Aboriginal. Aboriginal people between the ages of 25 and 44 have ten times the death rate from circulatory disease. External causes of death (self-harm assault, murder) account for 20% of all ATSI deaths, and for non-indigenous people this figure is 6%. Neoplasms account for 14% of Aboriginal deaths, compared to 29% in non-indigenous people. It was emphasised that Aboriginal health data is very similar between rural and urban communities, and that life expectancy is also the same. Disease patterns are also largely similar, with some variations between remote and urban settings noted for particular diseases. Trends in these patterns can only be assessed over a very long time-frame, and whilst the current situation is a national emergency, Dr Daniels did point out that better access to health promotion and health care services are at least positive influences.

There was some discussion of the current situation with regard to blood-borne viruses in Aboriginal people. There are 190 notifications of HIV nationally in Aboriginal people, and 68% of these are in men. Two-thirds of the positive people live in Sydney and there have been about 19 notifications per annum since 1995. The overall prevalence of the HIV is therefore similar to that seen in the non-indigenous population, however whilst Aboriginal people are not over-represented nationally in HIV statistics, this obscures the experience of Aboriginal communities and health service providers in the focal outbreaks that have occurred. Dr Daniels gave an example of this when mentioning a cluster that occurred in Redfern in 1984. It is also important to understand that the pattern of occurrence of HIV in indigenous people is different. Heterosexual transmission is three times higher among Aboriginal people than non-Aboriginal people and 32% of people who are positive are women (compared to 11% for non-indigenous women.) 14% of Aboriginal people who are HIV positive are IVDU compared to only 3% in the non-indigenous population. Between 1995-2004 there were 22 cases where IVDU was the sole method of transmission, and an additional 12 cases where IVDU was a co-risk factor with sexual transmission.

Collection of data on incidence and prevalence of hepatitis C in Aboriginal communities needs to be improved, as many reports don't comment on Aboriginal status. However, Dr Daniels told us that there is almost certainly a higher prevalence of hepatitis C in the Aboriginal community, and that we are yet to see the real burden of disease.

The session finished with some excellent case presentations by Dr Yianni Faros with commentary also from Michael Englert (see below). Optimism for the future was inspired by the creative and thorough way in which the Redfern team deliver health care to the ATSI people who visit their dependency service.

Summary written by Dr Jenny James. Daruk AMS.

Case Studies

Dr Yianni Faros presented three case studies from the Aboriginal Medical Centre at Redfern.

The first was a 29yo man with a history of IDU since his teens, and large heroin habit, whose buprenorphine treatment was unsuccessful owing to poor attendance. Despite accepting only low dose methadone, which he supplemented with heroin, his attendance improved. He later experienced symptoms of withdrawal and received inadequate analgesia when hospitalised for gunshot wounds, due to loss of this illicit opiate intake, his partner bringing in Buscopan for his symptoms. He and his partner perceived suspicion and hostility by hospital staff which they attributed to racism and his being "already on methadone".

The next case was a 34yo woman, homeless with two children, yet also looking after the children of her sister. She had been injecting for ten years and had a $250 per day heroin habit. After being stabilised on methadone, she changed to buprenorphine because of the stigma of methadone. With a coordinated team approach to her care, over 4 years she established housing away from area of drug use, dosing at a community pharmacy, developed improved parenting skills through contact with local community health centre, received instruction in financial planning skills, hepatitis B immunization and hepatitis C assessment, formed a new stable relationship, and managed to move back to the area she grew up in and remain abstinent.

The last case study was a 29yo man with bipolar disorder, renal impairment secondary to lithium toxicity and $200/day heroin dependency. After unsuccessful methadone treatment, he received buprenorphine with variable periods of abstinence following. Written reports were provided for Section 32 applications in relation to outstanding warrants, and he spent reduced time involved with the Justice System. A drop-in service was negotiated for care after many failed attempts for psychiatry appointments. After four years, his drug use was down to once a week, he was compliant with psychiatric medications, and was talking of getting a job as a gardener.

These case studies illustrated points of particular relevance to Aboriginal people, such as the importance of unpressured, respectful communication, the importance of extended family ties, and the value of coordinated approaches to health based in culture and community. There were also lessons applying to all people on opioid replacement treatment, such as the need for adequate analgesia, and the differing sorts of treatment retention and compliance issues with methadone and buprenorphine.

Next year's program is being finalised presently. We will start on Tues Jan 31 with Dr Adam Winstock speaking about drugs, alcohol and driving. "Do we have to inform authorities about such matters?" (eg. RTA as well as DOCS, Medical/Nursing Boards, etc?).

9 November 2005

APSAD annual scientific conference, 2005

9th November 2005

APSAD annual scientific conference. Melbourne, Victoria, Australia. Day three.

The third day of the East Melbourne addiction meeting started with an up-date by Keith Humphreys on the place of Alcoholics Anonymous and other self-help groups in managing addictions. He quoted the estimated staggering numbers of such groups as AA, NA, Alanon, Alateen, Cocaine Anon, etc, across the world. While accepting that scientific proof of the benefits of such social interventions are not possible, he stated that numerous high quality studies showed that health budgets saved large sums from those who chose to use self-help rather than traditional medical services such as counselling, cognitive behavioural approaches and pharmacotherapies. He also quoted one of the most convincing studies from 1981 in which not one patient who was 'passively' referred to AA actually attended a meeting. This compared with 100% who had a personal telephone referral from an AA sponsor. This is consistent with my own experience in simply recommending AA by handing a leaflet with dates, time and addresses of local meetings.

The next talk was by Annie Madden who spoke eloquently about ethics of research on subjects with drug and alcohol issues. Ms Madden was commended for her work in various capacities with and for drug users in NSW and Canberra over many years. This was backed up later by Adam Winstock who praised the Intravenous League for their cooperation and assistance in some of his novel research on drug diversion in South West Sydney. In this parallel session he and his colleague Tony Jackson showed that in their diverse Health Service cohort both methadone and buprenorphine were diverted for numerous reasons. Their findings indicated that about 5 per 1000 doses of buprenorphine were diverted. This was more commonly reported from those treated in community pharmacies where time and other factors make effective direct supervision less practicable. He said that one public clinic stated that they have had absolutely NO diversion yet his confidential questionnaire showed that the clinic had dozens of such instances reported by patients. Dr Winstock takes a non-judgemental line in addressing diversion, treating each case individually and working on the issues leading to the apparent misuse of the prescribed medication. He reminded us of two ways buprenorphine can be diverted, (1) obscuring the drug within the mouth and (2) secreting it elsewhere during administration. These were reported to be equally prevalent in western Sydney. 'Cracking' the tablets to coarse granules was probably an effective strategy both in aiding absorption and preventing diversion. However if tablets are pulverised to powder this can defeat both aims by creating either a milky solution which is swallowed or else forming a paste which is not absorbed at all well either. [In our own service we usually break the tablets in two and to observe them 'in situ' at least twice before they have gone.]

The reasons respondents gave for diverting their medication included: (1) to take later in the day (2) to inject (3) to sell (4) to take a lower dose (5) to store (or 'squirrel' as Dr Bell terms it). Dr Winstock speculated on the 'big picture' reasons for such diversion as being: (1) the continued shortage of treatment positions (2) constraints on such treatment (3) desire for lower maintenance doses (4) as a replacement for street heroin (ie for illicit purposes). Overall he felt that diversion itself was prima facie evidence for a breakdown in the therapeutic relationship, rather than just a lack of understanding of motivations behind it. He pointed out that especially since the 'heroin drought' buprenorphine and methadone can be excellent value on the streets, being cheap and longer acting.

Another important contribution on day three was Winstock's other paper described three means of starting buprenorphine in an attempt to avoid early drop-outs. His own elegant longitudinal study showed in a variety of community patients, those who were given over 17mg in the first three days of treatment had almost twice the chances of still being in treatment at 6 months as those given 17mg or less (54% vs. 29%). He also found heavy heroin users had higher drop-out rates. We were told that whether methadone or buprenorphine, the first few weeks are crucial since inadequate dosing may be the reason for some to drop-out. The risk of early toxicity with methadone is far lower when using buprenorphine . hence his and others' suggestion at this conference that we move away from the 'start low - go slow' approach and move to a 'new paradigm' for a 'new drug'. His preference was for 8mg on the first morning with an option for an extra 2-8mg later that day if desired. Some follow on day 2 with 12mg or more if cravings, insomnia or drug use persist. In our surgery we usually start with 4mg and repeat later in the day if needed (which it often is).

Nick Lintzeris then told us about his study from London (with Ridge, Gossop, Strang and Witton) looking at a large number of maintenance treatment starts (or re-starts) as to preference, experience of and actual prescription for four drugs: methadone, buprenorphine, lofexidine and dihydrocodeine. He suggested that lofexidine 'is hardly used any more in England' and that 'it is virtually the same as clonidine, except much more expensive'. He showed many comparative figures, reflecting much work from his team, but which overall showed that most patients eventually got what they had expressed a preference for initially. Because of the longer duration of action of (pure) buprenorphine, sufficient dose can be given to last 24 hours without causing the sedation which sometimes occurs with methadone. This gives rise to the 'clear-headed' reports from some patients. However, he also reminded us that many patients feel better on methadone, hence the need for individual choices, the only real other issue being pregnancy where buprenorphine is relatively contraindicated and the combination drugs completely contraindicated.

Nico Clark gave an illuminating talk on transferring in-patients from high dose methadone (between 40 and 100mg) to buprenorphine using clonidine and Valium. While all were patients wishing to try buprenorphine, several had to return to methadone dissatisfied within 2 weeks of the transfer. A significant proportion were only slightly uncomfortable and some had no withdrawal symptoms at all. The methadone was stopped for a full 24 hours and where possible for 48 hours while close observations were done in the detoxification centre being used.

Suzi Nielsen spoke about the Melbourne experience with buprenorphine and benzodiazepines. It was one of several descriptions during the conference which all seemed to be quite consistent. A majority of opioid maintenance patients (up to two thirds) have used benzodiazepines in the past 6 months and about 10-20% are dependent at any one time. One strategy was given from the Adelaide group presented by Kate Morefield on how to deal with this problem. Following on the work of Rickells, they tested a protocol to put long-term dependent patients onto 40 weeks stepped reduction doses of long acting benzodiazepine, in this case clonazepam. They used 5 weeks slow reductions by 25%, followed by 5 weeks plateau doses which was repeated in steps. The final reductions were more individually tailored. The drug was to be taken supervised on the same regimen as the opioid, from the same dispensary. Matched benzo users in parallel and "usual" treatment were used as controls and at the end of 12 months, despite numerous relapses, far less benzodiazepine (about 75% less) was being consumed by the trial patients. Such interventions are unlikely to eliminate benzo use but should enable substantial reduction in overall use of the drug, consistent with harm reduction principles. It is probably the responsibility of maintenance prescribers to address benzodiazepine use in their patients - yet many clinics and pharmacies still do not have a protocol of dispensing or administering for such dual dependencies. Poisons regulations are not attuned to this in some states. Community pharmacy may not be ideal for such treatment in new or unstable patients where there is a choice of a specialist clinic. It may be that a subsidised PBS item number for 'administration' of a small quantity of diazepam could solve the major conundrum that when we prescribe less than 50 tablets it costs our patients more money.

Presentations on hepatitis C reminded us that 90% of such infections occur in drug users and it is the responsibility of every maintenance prescriber to address this disease. Greg Dore and his group described early results of a multicentre trial of the treatment of 'acute' (or at least recently acquired) HCV using 24 weeks pegylated interferon. The treatment looks promising in HCV but may not be effective in HIV co-infected patients. Nick Walsh and Turning Point team are up-beat about a dependency clinic as a 'one stop shop' for addressing blood borne viruses (BBV). Their abstract described the use of a peer counsellor to facilitate regular in-house blood testing to monitor the need for vaccination (HBV, HAV) and/or referral for biopsy. They also dispense anti-virals at the clinic. In the same bracket Ian Chaussivert points to the enormity of the problem by describing early numbers from their 'clinic within a clinic' started in January. Out of an estimated 550 HCV carriers who have been in contact with their service, up to 200 may benefit from treatment. In the first 5 months, they assessed 32 patients and two have commenced therapy while 4 await biopsy. While these models may be very useful for New South Wales where a large proportion of patients are treated in clinics, other strategies are needed for other states and territories where community pharmacies deliver most opioid maintenance treatment. A more traditional medical referral system requires that doctors ensure that their maintenance prescription patients have blood tests ordered and referred as appropriate. A useful model might be Pap smears for cervical cancer which are now standard practice. Ian Kronborg and colleagues related a slightly larger pilot study of 23 methadone patients prescribed 'standard' antiviral treatment of 24 or 48 weeks (40% genotype 1, 55% genotype 3, 16% already with cirrhosis). We await further results after the full 50 outcomes have been tabulated.

I apologise if these summaries seem to be biased towards my own 'medical' interests. In fact many other fascinating subjects were covered in this conference. These included stimulant use and abuse, performance enhancing drugs, policy issues, injecting rooms, Aboriginal health, ethics, drugs and driving, alcohol "Interlock" ignition lock program, designer party drugs, withdrawal practices, drugs in pregnancy, specialist College policies, pain management and more.

It was disappointing that despite just receiving Commonwealth funding of up to 2 million dollars, those utilising naltrexone implants and performing rapid detoxification did not present any of their experimental findings. We could sure use funding like that in Redfern where our patients often have to pay $2000 or more per year out of their own pockets for pharmacy dispensing of their medication.

Melbourne is a beautiful city and it is a good time of year to visit. It was a frustration to have to stay indoors for the conference. I hope most delegates from out of town managed to enjoy some of the city's pleasures aside from the meeting. Congratulations to the conference organisers and presenters. The ever-present Walter Ling from California has said that he believes our annual APSAD conference is probably the worlds second largest and certainly most diverse dependency 'talkfest' (after the AATOD meeting which is held every 18 months in North America - next is April 2006 in Atlanta).

Comments by Andrew Byrne ..

8 November 2005

APSAD 2005 Conference - Melbourne 7-9 November

8th November 2005

APSAD Conference 2005. 'Australian Professional Society on Alcohol and other Drugs' scientific meeting

The 2005 APSAD conference has all the hallmarks of a great meeting. While I missed day one, having been in China, evidently there was a full program of diverse subjects covered by well qualified folk. I understand that there was a 'full and frank' discussion in a large plenary session on the origins of the Australian 'heroin drought' (so-called - and it may NOT be JUST Australia involved). One view was that 'new' law-and-order initiatives had meant drugs were less available in Australia. Another was that other factors such as poor seasons in the opium growing countries as well as increased consumer demand from an expanding Asian market led to less heroin for the relatively small Australian market. Much has been written since 2001 and many statistics examined and interpreted. It is agreed by all that the price of heroin increased dramatically and purity dropped while annual overdose deaths dropped from over 800 to under 300 in Australia overall. We should remember that even with capital punishment possible for traffickers, compulsory detoxification for users and a shortage (or absence) of effective treatment options, opium and heroin are readily available in most countries in Asia, showing that 'Tough on Drugs' is probably more a slogan than a policy. It is a shame that so many criminology experts are salaried and thus under certain constraints not to 'rock boats'.

Tuesday's proceedings started with Tim Rhodes discussing issues from the UK on 'The social structure production of drug-related harm'. He suggested that we go further than simple harm reduction techniques and examine the whole "risk environment" including political, social, economic and geographic factors in drug use. He then brought together much of what we know about the origins and exacerbators of drug dependency in our societies including poverty, homelessness, depression, etc.

Rajita Sinha then spoke on 'the role of stress and cues in addiction - how does it relate to clinical practice?' She reminded us of the role of stress in relapse in drug and alcohol addiction. Her talk was largely based on the American abstinence model. She showed some PET scans, quoting Dr N. Volkow's demonstration of the physiological basis of stress and certain specific changes in the brain's reward circuits. Hippocrates described similar sentiments over 2000 years ago, needing little electro-science but just his own learning and experience. Her two video clips of two recent patients describing why they relapsed were hardly novel for the gathered audience. She said that the patients, recorded in September this year, had given permission for the use of their recorded interviews.

Eric Strain from Johns Hopkins told us of the importance of choices in treatment and that oral supervised methadone was, for about 25 years, the only treatment for opioid addiction. Even in the US, LAAM was used, while dihydrocodeine, heroin prescription and parenteral methadone have been used quietly in certain countries for a generation or more. He said that the past 15 years was 'a golden age' of drug development, stressing that we not lose sight of the three complementary factors in the addicts progress, only one of which is medication. He then went in rapid succession through a series of newer drugs for alcohol, cocaine and opiate addiction. He said that the US funding agencies would only allow research on non-opiates, which for some reason included tramadol, the only 'non-scheduled' opiate on the US market. Tramadol may be a step down from buprenorphine and methadone for progressively lower levels of opiate dependency. While not having the ring of scientific language, it is probably an area worthy of more research.

He then discussed naltrexone, acamprosate and even combinations of the two for alcoholism, quoting all the relevant studies. He did not cover the monumental disinterest of the medical profession in using such drugs (as stressed by the next speaker, also American). Ondansetron and topiramate were also mentioned. In the next 15 minutes he mentioned over a dozen approaches including current mooted FDA approval for rimonabant in obesity treatment. The manufacturers seem reluctant to become involved in drug addiction trials although there is already quite a degree of promise in this cannabinoid receptor blocker. Dr Strain gave some of his own preliminary results in a pilot study of lofexidine for opioid cravings. His results were mixed at best, yet he felt positive about further research. It would be extraordinary that if lofexidine actually reduced cravings that it never developed a black market in England where it has been used freely for many years. At the conference, a UK speaker spoke disparagingly about his experience with lofexidine in opioid addiction.

Next we heard Dr H. Westley Clark describe (at some speed) 'The art and science of knowledge transfer'. Early on he gave a 'plug' for the 'Addiction Technology Transfer Center' and its web site: http://csat.samhsa.gov/ This is one way that his organisation the 'Substance Abuse and Mental Health Services Administration' (SAMHSA) uses to raise clinical standards. He sounded unduly pessimistic, quoting an average of 15 years for advances in research to be implemented clinically (although in some places is seems to take forever!). While his organisation was "committed" to the field, one wonders what all the other medical bodies are doing in the intervening years. We know that with help from drug companies and the media, some advances can be made within weeks (eg. Viagara). His group has produced high quality clinical guidelines for many years. They are available in print and electronically at TIP (Treatment Improvement Protocols or see http://www.kap.samhsa.gov/products/manuals/) which are also available on the SAMHSA web site above (as long as you express an affinity with Uncle Sam). He comes from the only western country where community pharmacists are banned from administering methadone for addiction purposes just as American doctors are banned from prescribing it. Don't they trust their own professionals? He explained that buprenorphine was made available, not by an authority but through a 'waiver' system. It used to be the British 'system' which 'waived the rules', now it seems to be American!

In the course of a wide-ranging talk on recent innovations, Dr Clark also made some intriguing and seemingly inconsistent remarks. He said that in many parts of the USA now, pain killers (mostly taken orally) rather than street heroin (often injected) are the main reason for admission to opioid addiction treatment (as also found in Tasmania and N.T.). Apparently these prescription tablets are prescribed by avaricious or simply naïve doctors - and the tablets readily find a street market from unscrupulous (or perhaps desperate) 'consumers'. Yet in almost the same (very long) breath Dr Clark stated his confidence in the lack of diversion of the buprenorphine combination in the US, although he did not cite any sources. Is it hard to imagine that this drug could be so successful for addicts in treatment and NOT command a place on the black or 'grey' market, especially in America where treatment positions are often either in short supply or else very expensive. We were told elsewhere in the conference that substantial buprenorphine diversion had been reported in the past from Perth, New Zealand, Finland and Scotland - and some speakers even quoted recent street prices for methadone and buprenorphine as if they were high street commodities (which they probably are). Dr Clark also said that out of 600,000 US doctors, only 1000 are addiction specialists and only another 2000 others have expressed an interest in prescribing buprenorphine (by doing a short course in dependency treatment). This he pointed out was woefully inadequate for the needs of his country where less than 1% of doctors are prepared to be involved in addiction treatment.

It seemed odd that this conference had broken with a number of long standing 'conventions', including timing of the James Rankin oration which was ably given again by Ian Webster on the second mornings. He said that either the management had forgotten that he spoke a couple of years ago, or else they were so impressed that they wanted more of the same! He did not disappoint, painting a generous verbal 'picture' of his colleagues, Australia's successes and some gaps needing attention in the dependency landscape.

The poster displays this year were not just a side-show but were given a 90 minute section when their authors stood by and explained their work. This was largely successful but also caused some congestion as so many people were interested (I was reminded of the fowl pavilion at the Easter Show). The prize for lateral thinking should probably go to the enterprising group from Perth who showed that keeping an animal (a bunny rabbit in this case) makes detoxification more manageable and successful. We sometimes forget that for some drug addicts, attending the clinic, self-help group or dispensary is sometimes the most interesting thing they do all day. Hence a chat or a 'pat' may not go astray.

In a session on pharmacotherapies after lunch James Bell described his recent excellent study with Dr Batey from Sydney on the combination buprenorphine product. This may be the first time in the world that the combination product has been prescribed as a weekly dispensed medication in a parallel comparison with traditional daily clinic treatment. It appears that this drug combination was approved in the US, NZ and now Australia despite not one single trial of this kind (Fudala's study did not compare with traditional supervised addiction treatment). After consent and randomisation, patients had 3 months of either 'dispensed' or 'supervised' treatment and after that time were 'streamed' into dispensed or supervised medication. This was done largely according to self report and/or urine testing, although we were told that these two were quite inconsistent at times. The trial, performed in a socially deprived part of inner Sydney, somehow attracted a group of patients with a mean of 12+ years of schooling and were 70% in paid work. Dr Bell said that employment rates in patients presenting to his clinic had been rising over the years even though this seemed surprising to him (and to some of the audience). He described in detail the similarities between the groups for demographic and drug use characteristics. He then gave their findings of psychological testing, pathology results and self reported drug use � with no significant difference in outcomes apart from one aspect of 'stress' (but not 'anxiety', interestingly). Dr Bell reminded us that the main difference between the groups was daily attendance for one and weekly for the other, and that less stress in the weekly group was hardly surprising. Dr Bell agreed with one suggestion from the audience that pure buprenorphine may well have delivered the same results. In response to my question about evidence of diversion, we were told that some diversion was expected and that this had occurred, but it was not quantified any further. Despite enormous interest in the field and heavy sponsorship by the manufacturers, this was the only session which addressed the use of this drug combination which was approved only a couple of months ago by the TGA in Canberra (and is yet to be marketed). I was approached by numerous colleagues on this point and can only suppose that it is because there is so little evidence on the subject, despite the combination drug having been used in America for several years in community practice.

Nick Lintzeris then revisited the serious dangers of buprenorphine in combination with other depressants. He first reminded us that in opiate na�ve individuals, buprenorphine can be very toxic, citing 4 reports of overdoses from the anaesthetic literature. He then said that 27 out of 43 buprenorphine related deaths in the UK had involved benzodiazepines in addition. Following old animal reports (which he reported to APSAD in past years), he has since performed an excellent study on volunteer subjects in London. Some initial problems with ethics approval were overcome by using two separate groups. However, this made direct comparisons less rigorous. Stable maintenance patients were given 50% extra methadone (or placebo) and/or 20 or 40mg diazepam (ie. 4 groups) and then perform detailed psychometric testing, most importantly, at peak (3 hours). His conclusion was that 50% extra methadone given with placebo or even 20mg Valium had little effect on sedation, respiratory rate or other measurable domains. However, 40mg had substantial effects on all factors measured. His conclusion was that despite relative safety when used on its own, buprenorphine in combination with other drugs is unpredictable and can even be lethal.

Jason White then gave a summary of his and others' work on methadone metabolism in relation to 2 important genetic markers. He also said that although the observed equivalence ratio of 1:2 of levo methadone to racemic (R,S) methadone seemed relevant to most situation, there may be a subgroup of patients who are sensitive to levels of the inactive enantiomer (dextro or 'S' form) and who may benefit from receiving half the dose of the (double strength) active (or levo, or R) form. This theory should be easy enough to test in practice if the drug could be sourced. Also administering the S form might also be a way to test it. Dr Kreek at Rockefeller tells an amusing if pathetic anecdote of the world's entire supply of inactive (S) methadone being used up by an inexperienced research assistant in a small animal experiment at her lab some years back.

Eric Strain then discussed the 20 year history of consistent buprenorphine research. For some reason his group examined the QT cardiographic changes in some methadone patients, despite it not being a high profile problem after 40 years of experience. While he made passing reference to the serious complication of torsades which has also happened with LAAM and numerous other common medications (Yap, 2000), he did not report that the mean dose level of almost 300mg in those developing such complications (Krantz, 2000), nor the fact that buprenorphine is widely believed to be less effective than methadone in those with high opioid requirements or severe pain management problems.

The rates of two different cut-offs of prolongation of the QT segment in the standard ECG was shown to be more prominent in methadone then buprenorphine cases. While this is reassuring for the legal department of the manufacturers of the latter, it is not clear whether it has any clinical significance. It was disappointing that LAAM was taken off the shelves by its manufacturer supposedly in a response to cardiotoxicity when it should be the clinician who makes the decision balancing risk versus benefit in the individual. The same logic might see methadone withdrawn except that this would probably cause a revolution. Also, there is more than one manufacturer which is healthy for all including consumers.

Paul Cassadonte then told us about his work with long-acting naltrexone injections (Vivitrex) in alcoholism and a more recent trial which included both alcoholics and drug addicts. His group found that monthly injections, while large and in some cases uncomfortable, had substantial positive effects on alcohol-free days and overall alcohol consumption. One wonders if they could be combined with acamprosate tablets to improve results.

The next bracket saw Paul Haber report a controlled comparison of these two latter medications. A session on inhalants was chaired by Jane Maxwell from Texas. Wendy Loxley introduced 5 speakers on early and brief interventions for harm prevention. Other parallel sessions were on prison populations, court diversion, illicit drug market economies and cannabis harms.

The Melbourne organizers should be congratulated on an excellent venue, great service in the 'old lady' hotel Hilton on the Park (next to the MCG) and fine scientific papers from a range of invited and local speakers. Alison Ritter and her colleagues should get a medal for their preparation and hard work.

The conference dinner was another 'first' for this conference, and I hope a 'last'. Rather than a sit-down meal with colleagues, this was held in the tennis centre. Only after serious urging from folk with sore legs they finally produced some chairs for what was otherwise a stand up 'entertainment' starting with the Tivoli lady dancers whose average age was over 70. Initial mirth was not maintained for these proud and ambitious senior citizens. A stand-up comedian and flame thrower (the smoke detectors had to be turned off) did not encourage collegial discussions, reminiscences or new introductions which is what a conference dinner should be all about. Also a loud band producing aggressive, amplified modern music is not my idea of a good night out either. While I approve of paying for drinks individually, I find it most annoying that, with 2 friends, I ordered 3 glasses of white wine without being told that a whole bottle would cost much the same price (which others learned quickly). The food was either finger food or else served in boxes with sauces to dip. In order to consume the boxes, one had to put one's drink down, but there were few tables on which to do so. Glasses which were put down were quickly taken away by attentive staff. All in all a disaster with only the 'fresh air' for us to 'smoke' and retreat from the din within. I vote for a string quartet next time and a sit-down dinner featuring Queensland seafood and tropical fruits for dessert in Cairns.

Comments by Andrew Byrne ..