18 May 2006

Atlanta AATOD 2006 conference report

"Treating people with dignity"

April 22-26 2006, Hyatt Regency Hotel, Atlanta, Georgia

This year's AATOD meeting seemed more bland than usual with fewer scientific papers but more emphasis on areas of special need such as social equality, dignity, criminal justice, housing, recovery, etc. Few of the scientific sessions had patient representatives involved.
There were education sessions for health care professionals as well as patient representatives on the Saturday and Sunday prior to the conference proper. There was also a European session, as usual, on the Sunday afternoon, including Swiss, French, Italian, Slovakian, Bulgarian, Ukrainian and other representatives.

Monday 24th:

With fog in Washington (is that an omen?) and airline delays I missed the early sessions on Monday. Afternoon workshops included "Medical Aspects of Methadone: What Counselors Need to Know about the Medication". Judith Martin spoke clearly about the intrinsic benefits of methadone and the need to emphasise to patients why they 'should prefer it' to heroin (or other opioid).
In a parallel session we had James Carleton speaking about his experience with the Rhode Island penal system where there is one large jail for men and two smaller ones for women. When inmates had been on methadone prior to incarceration, this could be continued whilst in holding cells, but only for a limited period. We were told that primary medical care of inmates was quite separate and only those who were already on treatment were able to receive the methadone, albeit on reducing doses, on the authority or their original legal prescription. When pressed, Dr Carleton said that 30 to 60 and sometimes to 90 days treatment could be arranged in that state's lock-ups.
A perceptive participant asked whether a person who developed or redeveloped an opioid habit in jail could be treated by his team in this way. He told us that the prison administration would probably not physically allow such a person to attend for methadone treatment, but that indeed drugs were available in Rhode Island jails. Very recently there had been an overdose leading to hosptialization of the inmate, with a stay in intensive care, presumably at the jail's expense. It would appear that all around the world a drug-free jail is just about as realistic as a drug-free society. Yet US jails allowing methadone are still exceptional (see Tuesday plenary on the subject below).
Andrew Rosenblum from New York spoke about opioid prescription abuse in OTP patients in 70 centers across the country. Data were presented from the past 12 months on over 8000 subjects enrolled in OTP's across the country. The findings show a dramatic difference between whose whose primary drug of choice was heroin or prescribed analgesics. Big-city and metropolitan residents were far more likely to be heroin users while small town people were more often pill takers in their study. The former were 75% injecting while only one third of the pill takers reported injecting. Most of the latter (~80%) reported accessing their drugs primarily from 'dealers', while other sources were from friends, doctors prescription, emergency room, theft and internet or forged prescription (~3%). The prescription drug users were twice as likely to be in work and half as likely to be on public benefits. They were also younger (32 vs. 37) than heroin users and 97% were Caucasian (cf. 54% for heroin users in treatment). Pill takers were also more likely to report chronic pain (>6 months >5/10 severity pain). Prescription drug users were predictably more likely than heroin users to have used more than one drug.
Paul Bowman, NAMA advocate from Massachusetts was billed to speak to "Patient and Provider Groups: Methods and Models". This was one of only a few sessions with consumer input.
There was also a presentation by Randy Seewald on methadone and overdose prevention. Research shows that just being in treatment (of any kind) reduces overdose likelihood. The antagonist naloxone is being distributed in some areas with instructions on emergency resuscitation. Apparently it is available without prescription in Italy. In what seems to be an American habit, in some states naloxone supply has been 'waivered' from medical malpractice action, despite no evidence of its benefits over potential harms in drug overdose treatment by non-medically trained drug users and their associates. Consistent experience from legal injecting rooms shows that only a small minority of 'early diagnosed' observed and confirmed overdoses require naloxone, and that just supportive treatment is sufficient for most.
This New York research group was brave enough to use the "harm reduction" term in their slides, in opposition to the American federal policy against this wording, despite the issue being 'routine' or even 'motherhood' in many countries. They further reminded their audience of the intrusive and unnecessary regulation on methadone prescription.

Tuesday 25th:

The morning plenary was on treatment in the penal system, chaired by Paul Samuels, a long time advocate for rational approaches to the field of addictions and crime.
We heard at length from the Atlanta District Attorney, Paul Howard, about the incarceration statistics, progress with the need for treatment and prevention programs.
Our host lawyer said that for those outside the deep south should take something back home and offered us a local expression: 'lazy as a rigid mule'.
On any one day, 4-7% of prisoners in New York City are getting high on drugs. When he was commissioner in Pennsylvania, the rate was allegedly 10% which dropped to 1% after a concerted effort at interdiction.
Various parts of the country are now moving to allow limited methadone treatment in jails. These include San Francisco; Orange County, Seattle; Orlando, Florida; New York City (not up-state where most prisoners are housed); Rhode Island.
Timothy Ryan spoke eloquently about their implementation of a system of methadone in Florida which gave methadone to existing patients under certain strict rules. He pointed out that one needs to tread lightly as there are 'no absolutes in this area'. I countered afterward to him privately that surely giving correct treatment to all inmates is an appropriate absolute goal. And since drug use is such a high priority issue and methadone treatment is so cheap and effective, there is no excuse for denying such treatment to prisoners on any basis except to punish them twice (like solitary cells and interstate transfers). As Commissioner Martin Horn from New York pointed out to the audience, they work for the Department of Corrections, not the department of punishment.

The morning workshops included the interactions between pharmacotherapy providers and homeless mental patients who are incarcerated; culturally sensitive treatments; older patients in drug treatments; child protection issues and linkages between recovery community and pharmacotherapy providers. Beth Israel New York is the oldest and largest methadone treatment service in the country having over 7,000 patients of whom 20% are over the age of 55 (max 84 years) while in clinics generally the proportion is about 6% and growing each year. There were already 2% over 75 years. The issues addressed included multiple medications for other illnesses more common in older age - this includes possible drug interactions. Arthritis can make 'child-resistant' bottle lids into 'adult-resistant' which may be the bane of life for some, needing attention. Also eye sight issues and mental state may require simpler labelling in some cases. Nursing homes, hospice care, third party drug collections by registered family members or associates, social services and legal issues were addressed. Just as there may be a place for adolescent dependency services, a clinic for older adults may have advantages so a trial is being run in New York presently.

On the Tuesday afternoon we were presented with the so-called Matrix model of evidence based stimulant abuser treatment (despite there being no scientific evidence of its effects over other treatments or placebo/no treatment as far as I am aware). There was another session on details of implementing drug treatments in the prison system. There were also talks on recovery, technology transfer (is this modern term for education?) and the role of the family, work mates and others beyond the drug dependent subject. A web site for family members is being developed by the daughter of a patient.

Poster displays:

As seems to be the trend, rather than just having poster displays passively available in the 'intermissions', there was a designated 'author session' on Tuesday afternoon which was very well attended. There was the full range of dependency issues, including domestic violence, abstinence based treatments, buprenorphine, viral diseases, PTSD, jails, policy, mothers and drugs, alcohol co-morbidity, childhood methadone overdoses, internet data gathering, methadone mortality, client surveys, office based treatments, oxycodone use and abuse.
I will mention two outstanding posters, the first from a Canadian group from Alberta who describe their completely logical system of treatment involving shared care between community physician, specialist clinic, pharmacist and their liaison. Importantly, the Canadian pharmacists are involved in administering methadone to those who need it while also 'dispensing' take-home doses when ordered for suitable stable cases.
Next was an excellent if depressing description of how clinics across the US are addressing hepatitis C virus infection (HCV) by Sheila Strauss and NDRI colleague Janetta Astone. They have on-going studies of staff awareness and other aspects of HCV in dependency clinics. After piloting their survey in a number of clinics around the country including Florida, there is still much room for improvement. Little or no education is given in 16% of clinics and no testing in 30% in their sample. Yet we are told that there are 4 million HCV patients in the country (and one million with HIV) and the largest single group are potentially attending government registered and accredited clinics and thus are ideally placed for education, testing and referral.

Wednesday 26th:

Morning sessions included motivational interviewing, women in jails, drug interactions with dependency medications, measuring cost effectiveness and lastly, suicide, depression and overdose in pharmacotherapy patients.
The final plenary session was given by General Barry McCaffrey, popular drug advisor for the Clinton White House. He gave a most captivating and realistic presentation, starting with some facts on drug use in America. About one million Americans were regular heroin users and about 3.4 million had used the drug ('lifetime exposure'). Another 2.8 million had abused a prescribed ('synthetic') opiate which he labelled "the new heroin". He pointed out that it was a growing and changing problem. McCaffrey punctuated his comments with dramatic and clearly well-sourced statistics. An untreated heroin addict costs society about US$48,000. In jail, they might 'cost' $27,000 annually, but that the average prison stay is only measured in weeks, even in America. The USA, we were told, incarcerates more of it population than almost any other country (Russia and South Africa are the exceptions).
The much decorated general then reminded his audience that this was the ideal opportunity to introduce mandated treatment as in the drug court program which has been so successful in many jurisdictions. He said that there were 241,000 patients on methadone treatment in the US currently. He quoted MMT as being associated with 70% less heroin use, 57% less crime committed and 24% increase in employment rates (these figures are probably quite conservative in my view). He has no hesitation in saying that 'coercion works' (as with drug courts and contingency measures). That same week, Mexico announced that it was introducing decriminalization of all drugs for personal use, like Portugal did some years ago. Along with freeing access to treatment, this would seem a more logical approach than the traditional prohibition tactics instigated by the US after the second world war.
McCaffrey, who did not frame the current laws and has done much to counter their negative effects, quoted the famous line from 'Trainspotting': "If you have got heroin, who needs friends?!" He also gave a hilarious scenario of a person lost in a hot air balloon who found himself lost in a fog 30 feet above a man tending a garden ... "Can you tell me where I am?" ... "You are in a hot air balloon, 30 feet in the air!" ... "Thanks very much, I see you are a scientist!". (Gulp!) "However did you know?" ... "Well, what you have told me is technically correct ... but is of no use whatever, to anyone!" ... "Well, it seems you must be a government policy officer" ... "However could you tell?" ... "You do not have your feet on the ground, your head is in the clouds and despite your best efforts, you have no idea where you have been, where you are, nor where you are going". [my memory may be imperfect]

Comments by Andrew Byrne ..

8 May 2006

Combination Therapy for Alcohol Dependence

From: JAMA Vol. 295 No. 17, May 3, 2006

Dr Byrne has suggested the following is an important research study. He will consider doing a more formal summary of it in future to ascertain its relevance to regular medical practice and alcohol dependent citizens seeking treatment. We still need to accept that the more effective options we have, the more subjects we can help.

"The efficacies of medication and behavioral therapies, alone or in combination, for treating alcohol dependence were assessed in the multicenter randomized Combined Pharmacotherapies and Behavioral Interventions (COMBINE) study, in which study participants were randomly assigned to 1 of 9 treatment groups. Anton and colleagues report that patients in all groups had an increased number of days of abstinence. However, patients receiving naltrexone, CBI, or both along with medical management had more days of abstinence and fewer heavy drinking days than patients in other treatment groups."

Link to abstract (full text is available for JAMA subscribers only).