24 November 2006

APSAD Conference - day three. Nov 8 2006 and various observations

APSAD Annual Scientific Conference. Cairns, Queensland.

Wed 8th November 2006.

This year�s conference was held in a purpose built conference centre, two to four city blocks from the main hotels. This had some good and bad points. Personally, I found it awkward but the walk probably did me good. The venue was comfortable if somewhat sterile - it was rather like being in an airport, without the exotic destinations. The conference rooms all had purpose built power-point connections controlled simply by the use of a mouse on the lectern which was ideal once one got the hang of it. Everything was electronically signposted and sessions timed down to the minute.

All credit to Professor Peter D'Abbs and his committee of locals who did a splendid job without the benefits of the mighty workforce available in the major capitals.

This year, there was no further debate on the contentious heroin �shortage� dating from December 2000. However, Lisa Maher did a noble job of trying to tease out the changes regarding hepatitis C seroconversions among injectors recruited from three city sites including outreach services. She found dramatic reductions (~50%) in heroin use and corresponding increases in cocaine use with higher risk taking behaviours after December 2000. There was a trend to higher rates of hepatitis C following the change in heroin availability.

On the same subject, in a letter to this month�s Addiction journal, Degenhardt and Hall back away from ascribing law enforcement as a major factor in Australia�s heroin shortage in 2001, based on Canadian evidence of �massive decreases in three markers of heroin use� there concurrently (Wood, 2006). While Degenhardt and Hall now state that supply reduction from producer countries may have played a larger role, they still do not address competition from Chinese markets (see below for evidence of the popularity of opiates in that country) and cling tenuously to their thesis: "... that the Australian heroin shortage may have been one of those rare occasions in which law enforcement activities contributed to reduced drug supply."

Aside from recent research, Maher, Hall and Degenhardt may learn more about the heroin shortage�s origin by reading William Burrough�s classic short story "The Junky�s Christmas".

We commenced the third a final day of the conference with a witty talk by David Crosbie on the ins and outs of alcohol policy: what can and cannot be done, as well as some things which ought to be done but probably won�t be. Professor Norman Giesbrecht then gave a perspective from Canada on a variety of community based initiatives. He pointed out that when following proven strategies with a sound design they were likely to be effective. However his final observation was that vast harm can be avoided by major policy shifts, dwarfing the effect of the smaller community based �boutique� projects. However, the latter can sometimes give direction for the larger policy shifts.

Dr Aramrattana gave us the discomforting news from Thailand that a �war on drugs� in 2003 involved a couple of dozen deaths officially but possibly hundreds (or even thousands) more unofficially. There were 200,000 drug users given compulsory treatment at that time of whom 1500 were surveyed with rather rosie sounding results. He seemed to have mixed messages and perhaps this reflects what is happening on the ground. It would appear that despite this draconian policy, Thailand still has a substantial drug problem.

Next we had a series of six more parallel presentations and workshops. Dr Mark Hardy, GP from Sydney�s St George area, did a fine job of demonstrating how new Medicare item numbers for Enhanced Primary Care (EPC) suit chronic conditions and ensure that doctors who treat addicted patients should be better recompensed than ever before. He felt that there is still under-utilisation of Health Care Plans, Team Care Arrangements, Case Conferences, Home Medicines Reviews and the like (see new mental health items). In some states, pharmacotherapy patients sign a treatment agreement which enshrines a goal of 3-monthly comprehensive multidisciplinary case management which is covered by two current Medicare items, initial and follow-up (between them, over $200 rebate). There is a pharmacist, practice nurse and prescriber at the minimum and most patients have other carers (eg. hepatologist, psychiatrist, physiotherapist, dentist, etc).

The next conference strand most importantly brought us up to date with China and its belated but monumental and pragmatic moves to address opiate addiction using hundreds of methadone clinics (195 are due to open in 2007). Dr Zhang Ruimin from Yunnan province was unable to attend but his presentation was given by Dr Nick Walsh quoting over 1000 health care workers with detailed education in pharmacotherapies [see my story on the first methadone clinic in Beijing just one year ago]. It is not all good news as drug use, prison and compulsory detoxification were outlined from China, Vietnam and Indonesia by other speakers.

Other sessions were held on policing, policy and problems in the indigenous community, including a description of NSW Monaro region�s opiate and stimulant approaches. The afternoon sessions covered party drugs, injecting complications, consumer perspectives, youth and "future challenges".

I was told that on the Wednesday afternoon John Strang from London gave a witty talk to RACP Addiction Chapter members taking off Donald Rumsfeld: "There are things we know that we know, and things that we know we don't know ... ". It is a shame that Strang still does not directly address the public health disaster he so clearly describes from England regarding pharmacotherapies. Furthermore, he might propose some way out of the mire which has led to some of the worst drug statistics in the European Union.

There were various �add-ons� to this conference such as a Sunday afternoon detailing session sponsored by Reckitt Benckiser, culminating in a panel �Hypothetical� to focus on expansion of treatment and changing the paradigm "unsupervised treatment" hosted by Dr Norman Swan of the ABC. There was also a separate �drug trends� meeting on the Sunday with Chapter, APSAD general and council meetings as well as a �wind-down� on the Wednesday evening.

Comments by Andrew Byrne ..


Wood E, Stoltz J-A, Li K, Montaner JSG, Kerr T. Changes in Canadian heroin supply coinciding with the Australian heroin shortage. Addiction 2006 101:689-695

21 November 2006

Dependency issues in gaols, juvenile justice and drug courts

21 November 2006

Dr Gilbert Whitton began by giving us an overview of the prison population in Australia, currently at 24,000 and rising by 5% per year, 50% of prisoners being recidivist and 20% aboriginal. Based on the 2001 Inmate Health Survey, there are high rates of intellectual disability, and mental illness especially depression. Histories of sexual abuse and of head injury are common. Specific figures are not available for ADHD or personality disorders in NSW prisons, but these are prevalent as are substance use disorders. Eighty percent of prisoners are smokers (though 80% of them report that they are interested in stopping); one third of women and half of men have used alcohol at hazardous levels. Cannabis is the most common illicit substance of dependence, followed by amphetamines and then heroin. Hepatitis C prevalence rose from 34% to 40% between 1996 and 2001.

Among police detainees, 20% are affected by amphetamines, 20% by benzodiazepines and 10% by heroin at the time of arrest. Three quarters of prison sentences are linked to drugs in some way, and 60% had offended while under the influence of drugs and/or alcohol.

Between arrest and reaching the facilities of the Department of Correctional Services (after sentencing or on remand) the responsibility for a prisoner's health rests with the NSW Police. This applies in the holding cells of a police station, court cells (such as Sydney Central Court or in the Sydney Police Centre).

Justice Health is actually part of the NSW Health Department, not the Department of Correctional Services. A prisoner's medical records are therefore protected by the same confidentiality provisions as any one else's, and do not form a part of the prison records.

Seven percent of the methadone population in NSW are in prison at any one time, though the turnover is higher, about 100/month. The risk of overdose is much higher on release from prison: 15 times higher if the person is released not on MMT, three times higher if released on MMT. Unfortunately, the Department of Correctional Services cannot offer methadone or buprenorphine at every prison in NSW, often for logistical reasons such as the legal requirement need to have two people present for dosing, one of whom must be a nurse.

The Department of Juvenile Justice has its counterpart in Adolescent Health, part of Justice Health. Dr Whitton described the increasing activities of the Adolescent Health service, covering smoking is a high priority. There is a black market in cigarettes as these are prohibited in Juvenile Justice facilities. Methadone or buprenorphine treatment requires a second medical opinion for those under 18 years.

An old saw about people in prisons is: "If the drugs came before the crime, there is hope, but if the crime came first there's little hope". Dr Whitton gave evidence of very early histories of alcohol and cannabis use in the teenage prison population.

Sue Jefferies, who previously worked in the prison medical service joined the Drug Court in 1999. She informed us of how Drug Court operates under the Drug Court Act which allows convicted offenders to be diverted into programmes to reduce substance dependency and related crime. The aims are to reduce incarceration and the need to use substances, and to increase involvement in treatment.

Eligibility criteria are:

1. DSM IV for opioid dependency.

2. a prison sentence must be likely.

3. non violent crimes only considered.

4. if there is a previous history of violence, especially driving related, a risk assessment is required.

5. the person must live in a designated area - currently western Sydney.

6. no current serious mental illness.

A typical programme involves parole, attendance at groups, counselling, substitution treatment, for a minimum of a year.

People can be breached for non-compliance, being sent back to prison for a period of time - for practical reasons a 3 day spell may be stored up and added to other 'penalities' all to be served in one episode. Urine toxicology is performed 3 times a week. Actual titres of cannabinoids are used, and in consultation with a toxicologist conclusions are drawn about recent cannabis use. Some leniency is shown at first, but abstinence may be required. This fascinating area of differential or quantitative urine toxicology will be looked at in a Concord seminar next year.

Since 1999 there have been 1200 people inrolled in the programme. There are 270 out of prison having completed the programme successfully, and another 370 returned to serve their sentence.

The Drug Court is distinct from the MERIT programme, which is a pre-sentence programme for 'bailable' offences, administered by parole officers. It is a 3 month programme, but the same principles are used, including participation in groups, counselling and goals monitored by strict urine testing.

Health professionals do not refer people to the Drug Court, but Sue Jefferies is keen that GPs and addiction specialists are involved to ensure a smooth transition at the end of the programme.

A compulsory drug treatment programme has also commenced in NSW.

Several case studies were presented in the second half:

A seventeen year old was given symptomatic withdrawal management and eventually started on methadone. The rate of induction reflected both the need for a safe protocol which the doctor may have to write up without medical review being feasible for a week or two, and the low risk of illicit opiate access in prison. A sad observation was that this person was arrested after spending many weeks trying unsuccessfully to get onto buprenorphine maintenance. With early treatment perhaps he could have been kept out of gaol.

The case entitled "I had a liver autopsy in gaol but they stopped the interferon, dunno why" raised the question about how to get medical records (such as liver biopsy and hepatitis treatment results) from a person's time in prison. Stephanie Smith, Public Health Nurse at Mulawa Correctional Centre and a regular Concord participant, advised us of the contact numbers to obtain medical records of people released from custody: Phone 9289 5011/5012/5013; Fax 9289 5014. "It usually takes a few days for the files to get to records, which is located at Silverwater, so if they are recently released you are best off contacting the clinic directly."

"I don't want to go to gaol, they'll make me the pretty boy for sure". The issue of male rape in prison is a real one. Apparently one judge responded to a pre-sentence plea for the risk of rape to be considered with the comment: "Show me the evidence" (books and official reports have since been written on the subject). We heard about an ex-prisoner's advice to threats of rape when arriving in prison. A young cell-mate who had yelled out defiantly in response to threats of rape was the only one who got targeted. The usual advice is "keep your mouth shut". Many rapists are actually homophobic, and the rape is all about power.

Men who have been raped are often afraid or ashamed to report it. They may present to the clinic with complaints about their bowels instead.

"In gaol they used to punch me in the gut to spew my methadone so they could shoot it up". We were advised that this sort of thing is quite real. Another graphic example of the need to 'get stoned' in prison: woman may strap a tampon to their back of teeth and swallow it before dosing to absorb the methadone from the stomach. The product can be filtered through a kitchen scour. Diversion of buprenorphine is likewise a big problem, and sometimes requires a transfer to methadone.

One question showed some ignorance about typical prison conditions: Do people get a cell to themselves? The answer given was a definite "NO".

Summary compiled by Gilbert Whitton, Sue Jefferies and Richard Hallinan.

Sent from Byrne Surgery http://www.redfernclinic.com/

Next year's program is being finalised presently. It will start with a talk on stimulant problems by Dr Alex Wodak of St Vincent's Hospital on Tuesday Jan 30th 2007.

Cairns APSAD Conference 2006 summary: day two

APSAD Annual Scientific Conference. Cairns, Queensland.

Tues 7th November 2006.

The day started with a spirited talk by Shane Kawenata Bradbrook on tobacco use from a Maori perspective. His �Maori Smokefree Coalition� had a major input into a global treaty to address the epidemic, winning a number of international legal cases in which tobacco had been promoted using grossly inappropriate means. He spoke logically and passionately about the desire to rid his country of tobacco, reminding us that his people (and other non-American indigenous people) had always lived without tobacco before European colonisation.

Next we had a presentation from veteran criminologist and researcher Don Weatherburn from NSW. He outlined the alarming figures which were presented at the first �Deaths in Custody� report 15 years ago and showed that most have become even worse since, despite enormous efforts and expenditure at federal and state levels. He reminded us that the indigenous community is over-represented 10 fold or more in the prison system and that almost 50% of the crimes involved are alcohol related. He discussed the use of police action to enforce community instigated prohibitions on alcohol, also reminding us that such action must not be too severe and must have community support (eg. no �commando� operations). The overall thesis proposed by Weatherburn was that we need to address alcohol and drugs more seriously as being causal in indigenous detention - and dedicate more resources to specific drug/alcohol interventions - given that the significant investments in addressing the broader social and economic circumstances had not reduced harms associated with indigenous imprisonment to date.

Dr Mark Wenitong spoke about his Aboriginal Woochopperan Health Centre in Cairns, concerning delivery of smoking cessation and other services to both local and remote communities. He reiterated us of the high rates of smoking and drinking as well as the costs. Domestic violence and injuries can result in an air ambulance evacuation and long term hospitalisation, quite apart from the uncostable social disruption for families involved.

Following the opening plenaries there were another 7 sessions on a variety of subjects including detoxification, SMART recovery, prison issues, cannabis (including a trial from Sydney of using lithium) and the so-called heroin drought.

In one session, we were told that 50% of young people in a particular birth cohort had used cannabis and 22% had reported a cannabis use disorder at some time. I found this figure very high and wondered about the definition. We were also told that �The evidence suggests that most young people who use cannabis do so infrequently and that they do not develop a cannabis use disorder�. There were other presentations concerning psychosis and cannabis use, inhalant use and hepatitis C.

These afternoon sessions were all delayed slightly by the running of the Melbourne Cup. We heard in a brief presentation from Professor John Strang of London that the standard of methadone prescribing in England improved in the ten years during which his �Orange� guidelines were circulated to GPs (1999). Findings from comparable surveys in 1995 and 2005 showed a modest increase from around 45mg daily dose to 54mg. This is still a long way from the ideal, believed to be between 80 and 100mg daily. Strang�s own guidelines recommend a minimum effective daily dose of 60mg. In response to my question after the session, he explained findings of 37mg daily in another UK study he performed in 2005 used different methodology so he did not bring it up at the presentation. He agreed with me that the state of clinical standards in the UK were �disastrous�, but �less disastrous than they had been in 1995�.

Professor Strang told us that dose supervision was now more common in England and there was less methadone ampoule and tablet prescribing This may be a good thing overall, yet it is also possible that such treatment suited some patients who may do poorly on standard oral treatment. Along that line, he reported a new initiative prescribing heroin and methadone ampoules to addicts who had failed other forms of treatment in London, Brighton and two other centres in England. They are using the same protocols as the Swiss trials started in 1995.

Strang�s London colleauge, Dr Soraya Mayet spoke about QT intervals being affected by methadone, especially at high dose. She had the whole room debating how often cardiographs should be done, yet an authority on the subject wrote in Lancet recently that routine cardiographs are unnecessary in new patients joining treatment (Krantz 2005). In fact, most reported symptomatic cases either had other risk factors such as cocaine use or else they were on extremely high doses (mean 300mg daily) and/or were pain management patients.

Our own group presented analysis of trough blood R-methadone levels showing that these were lower (1) in high dose patients and (2) in those smoking cannabis, but that there was no significant association with benzodiazepines or alcohol using stepwise regression analysis of 70 cases uncomplicated by other medication use. Causation would have to be determined by further research.

Eight parallel sessions followed afternoon tea, covering worker burnout, injecting rooms, blood borne viruses, tobacco interventions in mental patients, pregnancy and indigenous communities with an optional visit to the Wuchopperen Health Service in Cairns where inhalant use is being addressed.

The conference dinner was a noisy but pleasant affair at the Pacific International ballroom. Everyone seemed to mix and let their hair down. I looked at my watch as security hounded us out - it was midnight!

Comments by Andrew Byrne ..


Krantz MJ, Mehler PS. QTc prolongation: methadone's efficacy-safety paradox. Lancet 2006 368;9535;556-557

17 November 2006

Cairns APSAD Conference 2006 summary: day one

APSAD Annual Scientific Conference. Cairns, Queensland.

Mon 6th November 2006.

The morning started with Christopher Pyne MP, parliamentary secretary to the Minister for Health and Ageing, giving a spirited talk on the public health benefits of alcohol restrictions.

The convenors cleverly commenced with plenary presentations on the least and most dangerous drugs back-to-back with national and international expert speakers.

Frank Vocci from the American NIDA (NIH) spoke about mooted pharmacotherapies for cannabis addiction. He quoted figures for �ever used� and recently used, finding that about 50% of all Americans have exposure to the drug. We were told that many of the subjects in treatment trials in the US are young people who are referred from the court system as an alternative to jail. He broached possible novel approaches such as the cannabinoid agonists as well as the French antagonist, rimonabant. Other possibilities are lithium, antidepressants or other drugs to counter withdrawal symptoms as well as reduce cravings in dependent subjects. In questioning our speaker later, I was told that while naltrexone showed some promise in rodent studies, that in humans, the drug seemed to augment the effect of cannabis, a very worrying finding. It may paradoxically be a benefit if smokers can get as �high� by smoking half as much. It would appear that this finding alone has been sufficient to stop further funding of such research by NIH.

I also noted with Dr Vocci that the US buprenorphine post-marketing survey released recently showed that over a third of new patients see no doctor, psychologist, pharmacist, nurse or other health care worker in the first 30 days after their initial prescription for the drug in dependency treatment. Unsupervised maintenance treatment is a paradigm shift indeed. It is not evidence based, yet it is being encouraged by health authorities and professional bodies here and overseas for some reason. At present it must be considered a noble experiment.

Smoking and nicotine dependence was covered next by Professor Wayne Hall from Brisbane. In a logically structured talk he broached the novel area of genetic studies to determine susceptibility to addiction to nicotine and/or available treatment. He quoted some moves to look at �vaccinating� children where appropriate risks were high, yet we were told of major ethical concerns here. While he said that parents would always have the right (and responsibility) to choose, he would not advise such moves under any foreseeable circumstances. At the very end of his talk he reminded us of the use of �snus� oral tobacco in Sweden and its potential for harm reduction (which seems to have been ignored across the world, despite promise of reduced harms).

The strict anti-smoking laws in Queensland required that the few smokers present had to stand in a small roped off area near the convention centre drive-way. Not very dignified, but that�s the law. Luncheon included some delicious crumbed reef fish but the rest of the fare was middling to ordinaire.

No less than seven parallel sessions followed. Alcohol in indigenous communities, dual diagnosis, Europe�s highest overdose rates in the UK being addressed with pilot study of naloxone provision, hepatitis referrals and treatment successes in Sydney as well as monitoring of drug trends in Australia and America.

It seemed incongruous that the Turning Point group from Melbourne presented an integrated system of assessment and treatment for hepatitis C within the clinic. Yet this model would have little use in Victoria which depends almost completely on GPs and pharmacies for pharmacotherapies unlike New South Wales which has a large proportion in clinic settings. Their excellent model should be replicated in some form in each and every such clinic in the interests of public health.

Next we presented our own practice approach using community prescribing and a shared care model with liver clinic referrals, which might just be ideal for Victoria! We found that 75% of Redfern injectors were Hep C positive and 75% of those patients had chronic hepatitis, half of whom had high risk factors for cirrhosis. Out of 250 patients seen over a 3 year period at the practice, 70 were at risk, 50 were referred to a hepatitis shared-care service and 40 attended. To date about 25 have commenced interferon and ribavirin treatment, mostly with excellent responses and modest to moderate side effects. Of 29 biopsies performed, 24 showed at least moderate fibrosis, consistent with recent advice to allow treatment to proceed without a requirement to do liver biopsy.

Louisa Degenhardt gave a learned and teasingly titled plenary talk entitled: �Are we the biggest users of ecstasy in the world, and how worried should we be if we are?� She pointed out that �biggest� could mean greatest overall amount consumed per person, but it could equally mean more frequent, youngest or longest career of drug use. She emphasised the dangers of ecstasy but put them into perspective with regard to the large proportion of young people who use the drug regularly, often with few apparent adverse effects and low mortality compared with heroin, cocaine, tobacco and alcohol.

We were asked to allow a bigger input of consumers in opioid maintenance delivery as now standard practice in other areas of health care. Annie Madden and Joanne Bryant urged mangers to take heed of the needs of addicts in treatment and involving them in decisions affecting them. My own feeling is that until there is wider choice and a little competition, the present stigmatising and monopolistic system will remain in place.

We then had an interesting talk from Ann Roche on the Australian workforce in dependency and how only ~75% are happy and satisfied with their jobs. I would have thought that is better job satisfaction than many other trades or professions. By contrast in America, McLellan and Keber found quite the opposite with unhappy workers, �burnout� and short careers in the dependency treatment field. (McLellan AT, Carise D, Kleber HD. Can the national addiction treatment infrastructure support the public's demand for quality care? J Subs Abuse Treat 2003 25:117-121).

Next there were seven more parallel break-out sessions in which mental health, alcohol in the workplace, NGO�s, heroin dependency in pregnancy, state comparisons of methadone treatment and indigenous dependency research partnerships were all covered. There were many useful �messages� such as NGO�s being undervalued in doing work which governments cannot or will not do. We were told that some women avoided methadone in pregnancy for fear of addicting their baby to drugs, despite on-going and very harmful illicit drugs use. Victoria has not solved the problem of diverted drugs by severe restrictions on take-away medication (indeed, they have just freed up access to dispensed drugs for stable patients).

Cairns is a special place and the timing was perfect as a full moon rose on the first night, visible from the entire boardwalk waterfront. The temperature was around 29 degrees for the three days and while there was a slight heat haze, there were no tropical storms, earthquakes nor tsunamis. The silky oaks, bougainvillea and flamboyant trees were in full flower while numerous fragrant tropical species, frangipani, palms, grasses and even mangroves graced the place in abundance.

Comments by Andrew Byrne ..

11 November 2006

Memory - impact (or lack of it) from ecstasy use.

Simon NG, Mattick RP. The impact of regular ecstasy use on memory function.
Addiction 2002 97:1523-29

This interesting study compared regular ecstasy users with cannabis users on
a variety of verbal, spacial and other tests of memory. It is gratifying to
see a realistic comparison after numerous studies, mostly from America, in
which drug users are compared with teetotallers.

Most of the ecstasy using volunteers (average lifetime use ~90 tablets) were
also cannabis users, making the comparison particularly appropriate and the
results therefore more rigorous.

"Conclusion: This study does not show memory impairment in a group of
ecstasy users relative to cannabis using controls. The previously reported
association of life-time exposure to ecstasy and memory was not found. The
findings may indicate a confounding role of cannabis use, as has been
recently reported."

comments by Andrew Byrne ..

3 November 2006

Opioid Maintenance: Back to Basics. Therapeutic lessons from Vioxx and LAAM.

Concord Dependency Seminar: Tuesday September 26th 2006

Presenters: Dr Andrew Byrne, Redfern, NSW. Professor Ernie Drucker, USA.

This seminar provided an overview of opioid use and treatment issues, including patterns of drug use, scientific research and treatment decisions that must be made within the context of the consultation. There was also an overview of topical issues surrounding amphetamine use. In the introduction to this evening, we were reminded that combination buprenorphine has given us one more option for management of opioid dependence and is thus an important addition to treatment possibilities. In the general sense, we should approach prescribing for addiction disorders in the same manner as prescribing for any other medical condition. If we prescribe according to clinical guidelines we will get predictable outcomes, and likewise when we step outside such guidelines as for unusual cases, we should ensure careful documentation and sometimes a second opinion. We should attempt to tease out the evidence based aspects of treatment versus what we do which is non-evidence based. Most therapeutic regimes probably contain elements of both. We should take care to define the problem clearly with the correct diagnosis, and then use a consistent approach to therapeutics.

A fairly typical case history was shown to us, followed by a possible treatment approach and analysis of what was or was not evidence based.

  • 30 year old male with a 7 year history of heroin use, now relapsed.

  • Works as a part-time cook, smokes 20/day and does not drink any alcohol.

  • Only had brief episodes off heroin, eg whilst in jail.

  • Hep C positive, HIV negative, urinalysis positive for morphine.

An approach to initial treatment might include the following:

  • Give counselling re HIV/HCV infection.

  • Arrange urine and blood tests.

  • Initiate MMT - starting dose 30-40mg.

  • Discuss teeth, halitosis, diet.

  • Arrange next appointment for 4 - 7 days later.

We were asked to consider which of these treatment decisions are research based, and which are "sound medical practice". This led on to an overview of scientific research methods in medicine and a reminder of the various forms that they can take. Whilst observational reports do not constitute "Level A" evidence, it was exactly this type of research which first supported methadone maintenance as a treatment. "Negative" evidence (an absence of reported ill effects) is cited to support methadone and, increasingly buprenorphine treatment in pregnancy. We can consult the Cochrane summaries, look for cohort studies and individual randomised controlled trials as well.

Professor Drucker then spoke about substitution treatments for amphetamine use and parallels with opiates. He told us that the scientific research on amphetamine replacement therapy is now at the same place as studies were with regards to early use of methadone maintenance therapy. There was a show of hands from the audience to indicate that most people had noticed an increased use of amphetamines in their area in the last 5 years. This has been linked to the heroin drought, which has also seen the arrival of Ice in Australia. The drought has been determined by markets and it was noted that if the market is there, the drug will appear. In both England and Europe stimulant use is now far more common than heroin use. The ease with which amphetamines can be made, (they don't have to be grown or refined), predicts an infinite stream of stimulant supplies. As with any addictive substance, there are different patterns of stimulant use, which include a stable controlled use and a more pathological pattern, particularly when amphetamines are combined with Viagra. About 20% of people who use stimulants exhibit a problematic pattern to their use and both amphetamine and �crack� users often seek help sooner than people who use other drugs, sometimes within 6 months of commencing amphetamines or cocaine (for opiates it is 2-4 years typically).

Studies in the 1980s showed there was a negligible HIV incidence among amphetamine users. In the same decade, 4 studies in the BMJ showed that oral amphetamines decreased the intravenous use of amphetamines in those who were addicted. Advantages to oral treatment also included health professionals being able to regularly review the patient, being able to titrate the dose of stimulant, and the patient receiving a drug whose composition was known. Since then, a further 20 or more studies have shown that oral stimulant replacement therapy has reasonable treatment retention rates and a reduction in adverse outcomes, where government policy in Australia has not improved the outlook for amphetamine users at all.

A number of studies have looked at the role of anti-depressants for amphetamine withdrawal and there is currently no evidence to suggest that anti-depressants help. Professor Drucker emphasised the increased danger of combining stimulant use with Viagra use, citing the increased prevalence of HIV in the New York gay community. He pointed out that amphetamine users are desperate to avoid the "crash" as the stimulant effects wear off, and so a sustained release substitution treatment would make good pharmacological sense. The use of stimulants has very deep roots in many different cultures, including medical students cramming for exams and truck drivers on long runs. In Jamaica, people who worked on the land doing hard labour for long hours at a stretch showed a significant level of stimulant use so it can be seen that societal expectations and conditions linked to people's rights should be considered as a necessary part of the solution to increased stimulant use.

Professor Drucker pointed out the irony of the USA having a record number of children now diagnosed with ADHD and currently on stimulants (Ritalin and dexamphetamine) as treatments. This is in a country where it is the Drug Enforcement Agency (DEA) that gives the licences to prescribe opiates and where it is the police who give the drug education in schools. Medical authorities have little say in this, despite being the clinicians called upon when things go wrong. There is evidence that some of those in treatment for ADHD are selling their medication in an amphetamine-hungry market.

In Australia (unlike England) we cannot currently prescribe amphetamines as a replacement therapy, so what do we do? The following were offered as guidelines:

  • be supportive in a non-judgmental way

  • remember that many people use drugs for a while and then stop

  • treat all co-morbid problems

  • offer brief harm reduction interventions eg. sniff/smoke, don't inject

  • always see if there is a safer way of using and/or a longer acting form of the drug

The question arose as to whether the principles outlined in the discussion on amphetamine replacement therapy can be applied to benzodiazepine (BZD) use. It is likely that uncontrolled prescribing of BZD by doctors (in large amounts and with no supervision or counselling) is part of the problem in Australia. Valium is available as a PBS item in quantities of fifty tablets, and whilst the Doctor Shopping Hotline is a useful service for tracking �overusers� it has significant limitations. Limitations include the fact that it doesn't include private prescriptions of BZD, and in a 3 month period will show that a patient has seen 6 or more prescribers of BZD or has received greater than a certain number of scripts. People can have a significant problem with BZD use when using amounts less than this. There was a discussion about experiences of controlled BZD prescribing for BZD addiction and it was acknowledged that it is very labour intensive for the pharmacists who often don't charge for the daily pickup of BZDs by the patient.

The next part of this seminar dealt with some of the particulars of opioid replacement therapy and Dr Byrne began by discussing induction onto MMT. Whilst there are some differences in terms of the rate of increases in methadone doses, people are generally started on between 30 and 40mg of methadone. We should be guided by the patient's circumstances as to whether to commence them on methadone or buprenorphine. Whilst research seems to indicate that dose reductions are almost never indicated, we must understand the best way to approach this if a patient requests to "come down". The traditional indicators of stability (including good psychosocial functioning, stable housing, relationships going OK, no current problematic drug use) should be present before decreasing the dose of opioid replacement. There was some discussion of time frames and it was generally agreed that a minimum of 3 months of stability was advisable. Whilst there are no hard and fast rules, it was also suggested by one experienced member of the audience that a patient should probably be out of jail for a minimum of 2 years, as the recidivism rate within the 2 year period is high. Doses should be reduced in small steps (eg. no more than 10% in 3-4 weeks), gradually (the increments of reduction should get smaller the lower the dose becomes), and with a constant lookout for any indicators of instability. With general principals of pharmacotherapy in mind, the aim is to achieve the minimum effective dose. Dr Byrne suggested that no-one should stay on MMT for greater than 1 year without seriously considering a dose reduction. It was recognized that some patients will require replacement opioids for life while a majority of �starters� will successfully withdraw from maintenance treatment.

Reductions down to 40mg of methadone allow a transfer from methadone onto buprenorphine, and it was pointed out that patients can be very grateful for the opening up of this possibility. Patients on very low doses of methadone (say, 20mg), are at risk of overdosing as their tolerance to opiates lessens, so reversion back to illicit opiate use can be particularly dangerous for those on small doses of methadone. With regards to take-away opioid replacement therapy, there is very little research as to whether supervision of doses is useful, though it is generally agreed that some supervision is needed- finding the ideal amount for the patient is the task.

One study in the USA (Rhoades et al. AJPH) did show significant benefits for patients receiving increased take-away ORT (5 vs. 2 per week). Boundaries however must be set, never doing "favours" for particular patients but maintaining consistency with some flexibility.
Frequency of consultations depend on stability of both dose and the patient's life circumstances. The rule of thumb is see the patient often during inductions, then less often when the patient is stable (eg once a month). Dr Byrne told us that about half of his patients attend every fortnight for a medical consultation.

The role of counselling in these situations has been questioned. One old study by Jaffe showed that in two groups of patients both on MMT, one receiving no counselling and social supports, and the other receiving a large amount of counselling and social supports, there was little or no difference in outcomes for the patients. This has been replicated in other studies, but it was pointed out that just giving the methadone with �bare-bones� medical assessments still has a significant �personal� therapeutic input, quite apart from the drug administration. This seems to suggest that by far the most important aspect of clinical care is placing people on supervised opioid replacement therapy. Similarly, there is little evidence to support urinary drug screens in terms of improved outcomes for patients, though UDS have been traditionally done since the very first MMT in 1965. It was generally agreed that UDS do not discourage drug use, yet they are certainly the best indicator of treatment effectiveness both in the individual and across the clinic population.

This seminar ended with a reminder that methadone and buprenorphine are equally effective treatments for opioid dependency. Dr Byrne took us back to Osler's maxims as a reminder of what constitutes good clinical care, whether it be for patients with opioid dependence or otherwise.

  • "Let me take the history.

  • Let the medical student perform the physical exam,

  • Throw the lab results away,

  • And I'll give you the diagnosis."


  • "To study the phenomena of disease without books is to sail on uncharted sea, while to study books without [seeing] patients is not to go to sea at all."

Summary written by Dr Jenny James, Daruk AMS.


Senay EC, Jaffe JH, diMenza S, Renault PF. A 48-week study of methadone, methadyl acetate, and minimal services. In: Fisher S. and Freedman AM, eds, Opiate Dependence: Origins and Treatment. New York: Halsted 1973 185-201
Schwartz RP, Highfield DA, Jaffe JH, et al. A Randomized Controlled Trial of Interim Methadone Maintenance. Arch Gen Psychiatry 2006 63:102-109
Yancovitz SR, Des Jarlais DC, Peyser NP, Drew E, Friedmann P, Trigg HL, Robinson JW. A randomised trial of an interim methadone maintenance clinic. (1991) American Journal of Public Health 81:1185-91
Rhoades HM, Creson D, Elk R, Schmitz J, Grabowski J. Retention, HIV Risk, and Illicit Drug Use during Treatment: Methadone Dose and Visit Frequency. 1998 Am J Public Health 88:34-39