Addiction: April 2001

Editorial and debate on injectable methadone by Zador. Addiction (2001) 96:547-553.

Zador's perfectly sensible description on the prescribing of injectable methadone by British doctors is challenged by others on some of the most spurious grounds. Both Malcolm Lader and Jerome Jaffe state that it is medico-legally fraught, being non-evidence based medicine. But they ignore the 'out' that this treatment may be the only reasonable alternative for certain heroin dependent folk in whom other treatments have proven unsuccessful or unacceptable. In such a case it may be possible be prove medical negligence by NOT continuing such apparently effective treatment. This may also be the case in a small number of previous trial subjects in Queensland who were given this treatment some years ago. Much treatment given by doctors currently is not strictly evidence based, such as antibiotics for 'bronchitis'.

Jaffe goes through several possible reasons why such prescribing is not appropriate (cost, political acceptability, evidence base) yet he accepts that research might show that it could be so! He even uses the old peccadillo about supplying alcohol to alcoholics and tobacco to smokers 'all paid for indefinitely by the taxpayers'. Of course these drugs ARE CURRENTLY made available by all our governments at reasonable cost to all addicts, and to the very great benefit of the public purse through taxes. It is unusual for this respected researcher to inject such irrelevancies into this otherwise very serious discussion.

Jaffe writes for three pages, his arguments sounding more like those of a politician or a journalist-with-a-mission. He implies that the issue is enormously complex which is simply not the case. This prescribing is either defensible as good medical practice, or it is not. If it MIGHT be, we need more research. Simple!

The limited research that does exist is virtually all encouraging. Prescribing injectables to addicts appears to 'work' in a similar manner to oral methadone, and it may do so in some patients who fare poorly with existing treatments, thus enshrining it as ethical, if of uncertain application.

The article by Strang and Sheridan on relative dosing practices between private and public sectors in England is also of interest (Addiction (2001) 96:567-576).

These authors have conducted yet another elegant and useful study documenting the poor quality of care received by English dependent patients on methadone under the NHS. It is possible that private doctors also are guilty of giving poor treatment but these surveys did not question concurrent prescription of stimulants, or if they did we are not enlightened on the findings. Some private practices are notorious for multiple, gross over-prescribing, including stimulants and one was even the subject of an episode of "The Bill" a few years back.

Since supervised consumption, even in new patients, is exceptional in England, it is not possible to know how much methadone in private of public sector was actually consumed. It is certain, however, that some public sector patients received markedly inadequate doses.

As they point out, there are weaknesses to the study, but one strength is that it is clearly shows that the mean dose of oral methadone in public patients is around 50mg daily, a finding which is consistent with other British reports. As Strang's own guidelines point out, effective doses are usually in the range of 60mg to 120mg daily with only a small proportion of patients requiring more or less than this range. Even allowing for some patients on reducing doses, a mean dose of 50mg would imply that more than half of these patients may be receiving inadequate and therefore ineffective doses. This regrettable situation is still not acknowledged by the authors despite the unfolding tragedy which is dependency treatment in England and Wales in recent years.

Editorial by Juan Negrete, Montreal. Addiction (2001) 96:543-5

This is intriguingly slanted piece heaps scorn on the large proportion of the professional community which perceives benefits in harm reduction principles. The author fails to carefully define what he means by harm reduction which makes his article almost worthless.

It outlines an unscientific and near hysterical viewpoint on harm reduction, a policy most now consider close to 'motherhood' and which has been shown to save countless lives in its various implementations.

Juan Negrete criticises supporters of harm reduction in a most unflattering manner. He says that harm reductionists' aims towards improving methadone treatment only make it easier to get by removing barriers. But he fails to accept that like every other medical intervention, methadone treatment and any variations on its implementation, are subject to rigorous evaluation and hence improvements should only follow normal research findings, not the arbitrary views of any individual parties.

Negrete roundly criticises the Swiss heroin trial, but accepts that if benefits were found, he would review his opinion. How elegantly he contradicts himself, since only by running such a trial could benefits be demonstrated? And they were! The outcomes clearly showed that among 1146 treatment refractory patients there were very high retention rates and low mortality rates along with benefits regarding employment and housing. It is inescapable that this treatment attracted large numbers of otherwise 'treatment-refractory' patients into treatment and kept them alive over the three years of the trial. Is preventing death a 'benefit to patients'?

After faintly praising methadone treatment, Negrete says that maintenance therapies are 'irreversible' and he implies that they prevent addicts attaining drug free status. But people come off methadone successfully all the time! His emotive terminology reveals his clear unhappiness with the field: "harm reduction ideologues"; "compulsive toxicophilia" (is this English?); "drug reward slavery"; [addicts are] "much diminished human beings"; "primitive self-centredness of their pursuit"; "well meaning harm reduction workers who do not assign much importance to the problem of addiction". These are not the usual terms of clear scientific writing and if applied to those dependent on legal drugs would be considered offensive and outrageous by many such people.

 

It is surprising to find such items in 'Addiction', the world's oldest scientific journal on dependency.

Comments by Andrew Byrne ..

"Confessions of an English Opium-Eater" (Thomas de Quincey)

Written in 1821, this is an intense and pertinent portrayal of narcotic dependence from the addict's viewpoint. De Quincey addresses the constant conflict between intoxication and abstinence. Similar sentiments are related by our patients today, but rarely with as much eloquence and insight as Thomas De Quincey. This classic work is essential reading for all involved in drug and alcohol studies and who admire beautiful language.

With so many patients now on maintenance programs (mostly methadone), and illicit opioids still ubiquitous, it is timely to re-examine this work, probably the oldest account of its kind in English.

The 'Confessions' presents us with several episodes in the author's life. He recounts privileged public school days, subsequent hostile truancy, still later poverty in London squats and, some years afterward, a comfortable country existence. But this story is not just biographical. The disparate scenes each place his drug-taking into vivid context.

As a 36-year-old addict, the writer states that his drug of choice was laudanum (tincture of opium), a medicine first prescribed him for recurrent dyspepsia aged 28. It was then that he also discovered its pleasurable qualities. He consumed up to 320 grains of opium daily, equal to around 20g of raw opium, a large, but not unbelievable quantity. Though he claims to have given up opium, history tells us that he continued heavy use for another 35 years. He did not live long enough to 'enjoy' the discovery of heroin and the hypodermic needle.

The original 'Confessions' was published as a series of articles in the "London Magazine" in 1821. Some parts had been written previously, and the series may have been pieced together hastily out of financial necessity. The author pleads for patience, explaining that his prose follows his own train of thought so closely that it sometimes may appear wandering or disjointed. The American author, William Burroughs suffered the same 'malady', (and possibly for the same reason) but, far from craving his readers' indulgence, he has capitalized on it and has made it his trade-mark.

De Quincey apologises needlessly for his narrative style. Seemingly embroidered or wordy descriptions are well balanced by other elegantly succinct poetic portraits.

"Thou only givest these gifts to man; and thou hast the keys of Paradise, oh, just, subtle, and mighty opium!" Every page of this work contains language of beauty, humanity and frequently, humour.

The subject of this book was taboo at the time of writing, and the very title would have shocked its public. It was then widely believed that Europeans could not become addicted to opium.

As well as 'Preliminary Confessions', he writes chapters on the pleasures and the pains of opium. He affirms his belief in the unique healing powers of the drug, and the benefits of doctor's prescriptions which contain opium. De Quincey reveals that he used opium only intermittently for several years, before developing a daily proclivity. He took it regularly before going to the Covent Garden opera. A proportion of today's narcotic users employ the drug to enhance other pleasurable activities.

Based on personal knowledge as well as information from apothecaries he patronized, De Quincey correctly deduces that opium addiction was extremely widespread in Regency England. He expresses some remorse over his addiction, but devotes much space to explaining his extenuating personal circumstances. Unlike simple pleasure seekers, the reader is told, he took it initially for medical reasons. He also compares it with the pernicious effects of alcohol. He identifies some other prominent opium users: first mentioned is the poet laureate and playwright, Thomas Shadwell (1642-92), a confirmed addict. Of his own contemporaries, he identifies Samuel Taylor Coleridge, William Wilberforce, Dr Abernethy, and several others in public life.

He revised and enlarged the confessions 35 years later, as if to prove opiate addiction and longevity are not mutually exclusive. Most modern editions give some passages from the revisions, but wisely keep the original as a discrete work. The revisions are longer than the entire original work. Although some central issues are clarified in the revisions, other tangential ones are drawn out and examined in excruciating detail.

De Quincey remains one of the great wordsmiths, and this well-forged story gives a personal aspect to one of mankind's most ancient activities, the pursuit of pleasure from drugs. [De Quincey, T. Confessions of an English Opium-Eater. Penguin English Library 1972, edited with an introduction by Alethea Hayter. First published in the "London Magazine", 1821]

Hulse et al. omit deaths in naltrexone report.

re: Hulse GK, Basso MR. Reassessing naltrexone maintenance as a treatment for illicit heroin users. Drug Alcohol Review 1999 18:263-269

Comment letter published D&A Review 2000 19;3:347

[Note: no reply published from original authors]
Dear Editor,

I support the authors' contention that naltrexone be judged using the same criteria as other treatments to enable fair comparisons of outcomes.

It is self-evident that stricter acceptance criteria will yield lower apparent 'success' rates, but that these will not alter actual patient outcomes. Clinical trials are rarely directly comparable so one of the tasks of clinicians is to determine the significance of each addition to the scientific literature. For dependency treatments this is not difficult since the aims of treatment are relatively straightforward and can be verified by simple means.

Hulse and Basso have reported detailed outcomes of a naltrexone treatment trial using two criteria for reporting six month follow-up details. Despite using tables and text to illuminate these outcomes, they place these results out of clinical context by omitting the two deaths which were previously reported from this cohort [Hulse G. Naltrexone - Defining a framework for use. Australian Professional Society on Alcohol and other Drugs (APSAD) Newsletter 'Summer' 1998, p4].

Mortality is the most fundamental end point in any treatment trial. To ignore, omit or mis-state deaths or other end points makes interpretation of data impossible and is inappropriate in balanced scientific writing.

A comparison of methadone and naltrexone in dependency management should be rigorous and impartial. After twenty years and over 500 peer-reviewed papers demonstrating the benefits of methadone, there has been only very limited research favouring naltrexone treatment in heroin addicts in the same time period. Few if any accredited addiction treatment services use naltrexone as a first line drug although it shows promise in certain selected groups and is effective in alcoholism.

The authors of all scientific research studies should be scrupulous in all reporting, lest they be seen as advocates for particular causes instead of maintaining the detachment which is essential in ethical research.

Yours faithfully,

Andrew Byrne ..

Another effective anti-craving drug for some alcoholics.

Dear Colleagues, In a most interesting development, researchers in Texas have shown significant improvements in drinking behaviour in some alcoholic patients given modest doses of ondansetron (Zofran). This widely used anti-serotonin, anti-nausea drug was given in a 3 month randomised, double-blind, placebo-controlled trial. Compliance was over 90% as measured by history and urine riboflavin tracer. Side effect profile was low with the only significant problem being constipation in 5% of patients. One death occurred in a patient falling down a flight of stairs, unrelated to the treatment (but possibly related to the condition being treated). Patients reported 'drinks per day', 'drinks per drinking day', 'percentage of days abstinent', and 'total days abstinent'. In older onset alcoholics the results were equivocal (n=160). The younger onset group (<25 years, n=161) are believed to comprise those with a stronger genetic component to their alcoholism and appear to have more psychiatric co-morbidity such as antisocial personality traits. In these patients the reductions in alcohol consumed was substantial and significant [those on 4ug/kg twice daily had a dramatic (p<0.001) response compared to placebo. The 'effect sizes' of the benefit of the twice daily medication were up to 0.41 which was in the 'moderate' range. "Patients with early-onset alcoholism who received ondansetron (1, 4, and 16 µg/kg twice daily) compared with those who were administered placebo, had fewer drinks per day (1.89, 1.56, and 1.87 vs 3.30; P = .03, P = .01, and P = .02, respectively) and drinks per drinking day (4.75, 4.28, and 5.18 vs 6.90; P = .03, P = .004, and P = .03, respectively)."

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Self reported drinking frequencies were corroborated using serum carbohydrate deficient transferrin (CDT). Taken along with blood alcohol concentrations at visits, this makes the study very scientifically rigorous.


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JAMA also contains an enthusiastic editorial by Dr Henry Kranzler from Connecticut ('Medications for Alcohol Dependence. New Vistas'). He waxes about the significance and importance of these findings in the context of disulfiram, naltrexone and acamprosate treatment. In addition, he mentions that SSRI drugs have a positive effect in the older age onset alcoholics, linking the serotonergic basis for much surrounding cravings, reward pathways and other still ill-understood areas.


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This may be a landmark paper. It allows us to match diagnosis with an effective treatment in a way not previously imaginable in alcohol dependency. The findings are consistent with a smaller study (Sellers, Sobell et al. Ontario, 1994) and animal experiments, according to the authors.


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These new findings place an even greater burden on the medical profession to be equal to the 'therapeutic challenge'. Society stands to gain enormously if these research findings can be widely implemented. It is a great tragedy and a travesty that naltrexone uptake has been so slow when it is so very effective in alcoholism, doubling the rates of abstinence. Many physicians still seem to take the line that there is 'nothing you can do for an alcoholic' and 'they have to help themselves'. comments by Andrew Byrne ..

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Johnson BA, Roache JD, Javors MA, DiClemente CC, Cloninger CR, et al. Ondansetron for Reduction of Drinking Among Biologically Predisposed Alcoholic Patients. A Randomized Controlled Trial. JAMA (2000) 284:963-971

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http://jama.ama-assn.org/issues/v284n8/rfull/joc00147.html


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Kranzler H. Medications for Alcohol Dependence. New Vistas. Editorial. JAMA (2000) 284
http://jama.ama-assn.org/issues/v284n8/ffull/jed00057.html

Could additional methadone increase cravings? 'Addiction' thinks so!

Curran HV, Bolton J, Wanigaratne S, Smyth C. 'Additional methadone increases craving for heroin: a double blind, placebo controlled study of chronic opiate users receiving methadone substitution treatment. Addiction 1999 94(5), 665-674


Rather than a useful contribution to the literature this small study confirms much of what is known about methadone behavioural pharmacology. It has one surprising finding of increased cravings in those given a one third extra methadone dose on one day, blind, with a week 'wash-out' period. This finding, being based on surveys of 18 patients and which, although statistically significant (p=0.03), was based on questions of a like nature concerning heroin craving on a small number of cases in a purely subjective area. This finding has been used in the title as though a highly important new finding despite a lack of further statitsical analysis possible and perhaps desirable on such series. The finding is out of keeping with much of what we know of methadone and the methods require closer scrutiny before being accepted. The reviewers had a difficult task as the findings would be considered controversial and rather outlandish by some.

While this is a little pedantic, I would also dispute the part of the title which states these are patients 'receiving methadone substitution treatment'. The text reveals that the patients were indeed on a treatment with a policy of 'reductions' and eventual abstinence rather than 'methadone substitution' which I use synonymously with 'maintenance'. According to the latest UK dependency guidelines, 'methadone substitution treatment' requires an effective dose of 60mg to 120mg with only exceptional cases needing less or more. These patients were not doing particularly well, judging by the frequent reported use of illicit drugs by the group. The authors state that the patients were chosen on the basis that they were on stable doses, but that the clinic had a policy of reductions to abstinence. In this cohort the average dose was 43mg, about half the level found in good quality methadone treatment services generally (and these include some patients on reductions). Hence these patients were either on inappropriate, ineffective 'methadone substitution' as defined by the UK
Guidelines or they were on reduction treatment with evidence of instability. For these reasons any conclusions as delicate as whether additional methadone could affect cravings over a few hours are based on the most shaky grounds and should be received by the academic community only with great caution.

The authors chose not to develop discussion about the most glaring finding of the study which is that a proportion of English addicts seem to be receiving sub-standard and ineffective treatment in publicly funded clinics. Some would see this as scandalous.

Comment by Andrew Byrne ..

Where is your local GP?

Have you noticed? Your GP has gone. Yes, just not there any more! A community icon for generations, this Australian institution is now in its death throes.

To find the reason, we need go no further than the dentist who charges $50 for you to walk in the door and, more often than not, another $50 to do whatever needs doing in the 15 or 30 minutes you might be there.

A plumber, vet, electrician or builder will charge about the same. The appliance repair person charges even more.

So where do doctors fit into all this? Australians were told over 20 years ago that 'Medicare' would finance doctor's fees and it would be funded out of taxation. Doctors were told that bad debts would be a thing of the past and that they would be paid promptly for their services at 85% of an agreed or 'common' fee. Successive governments of both persuasions have supported Medicare and actively encouraged bulk-billing. To this day the 'phone information line will only give information if you state that you are bulk-billing the patient. There was no arbitrated mechanism for annual fee adjustments and only on government largesse were rebates increased, at ever decreasing increments. Anyone who expected otherwise was foolish indeed.

Differential fees were introduced for doctors who jumped onto the Vocational Register. It offered a temporary relief from financial ruin by paying an extra $2.50 per consultation for bulk billed customers and refunded the extra money to those privately billed.

Doctors' practices were examined more closely than any other worker in the land. How long we spent with individuals of certain ages and sexes ... what tests we ordered ... what drugs we prescribed. All this without our consent ... even those who never bulk billed were drawn in. Now we have ludicrous committees trying to assess our 'work values'. Practice incentives have been thought up by bureaucrats with no detailed knowledge of the supposed deficiencies of general practice. As an example, it was felt that all doctors should do house calls and, along with after hours care, this is written into the agreement to be on the Vocational Register. Are patients not the best arbiters of who is a good doctor? We do it for vets and dentists, knowing little about those fields, but knowing what we want as consumers.

GPs used to work on the same street corner for 40 years and more for two reasons: There was demand for their services ... and they earned a decent income in the process.

Now traditional general practice has become unviable. This has not happened because of the supermarket revolution elsewhere. People are not demanding big medical clinics ... but they are there and they can survive better in a cut-price atmosphere. Alternative pursuits, some very valid additions to practice, can help pay the bills. These are many and varied ... acupuncture, hypnotherapy, laser treatments, drug group counselling sessions and other pursuits.

Who do we have to blame for all this? Ourselves, or our immediate predecessors to be more accurate. Any group which accepts government money must be prepared to die. Like soldiers. That is what happened to nursing homes. A perfectly viable, profitable and expanding industry for an aging population has been stifled to death thanks to government interference. Restricted subsidies and uniform regulations for nursing homes have turned a varied and free environment for our old folk into a uniform, regimented and unfriendly set of small, safe bunkers. Only the seriously rich can expect adequate retirement care.

So to the solution ... if it is not too late. I suggest that GPs do not do anything relating to a new matter for less than about $50. This is comparable with the minimum fee for many other professionals such as plumbers, vets, dentists, decorators, etcetera.

Even if an old patient just wants 'a certificate', they need to be told that they are also expecting the service which backs up that certificate, such as a history, physical and record in the medical notes. They may need their blood pressure measured. It is now widely recognised that visits to the GP for unrelated causes are important points of intervention, including blood pressure, smoking, drinking and diet just to name the most obvious. With the history known there could be Pap tests, thyroid, work related illnesses, chest X rays and a myriad of other areas which may need attention.

If the patient only gets $21 back from Medicare that is not the doctor's business. Most patients assume that doctors make lots of money and that they pay dearly in their taxes to ensure this is the case. They may not know that GPs mostly earn very modest incomes. Most specialists and employed doctors have kept their income parity, having had strong lobbies to look after their interests. GPs lobby groups have consistently acted against the interests of their constituency and continue to do so to this day. The AMA and GPs College have both failed dismally while the latter has facilitated much of the erosion to doctors' independence.

Most workers in the position doctors find themselves today would use strong-arm industrial tactics with no holes barred. Do Australian GPs have the will to take on this fight? If not, it means that the Australian public can bid farewell to the old family doctor forever. What is your strategy?

Written by Andrew Byrne ..

What can you do to reduce the alarming drug overdose death toll?

by Andrew Byrne ..

The press has been full of the disastrous toll from heroin overdoses in recent weeks, especially from Victoria. As doctors, we must face our responsibility to the community to address these matters in any way possible.

The overdose death rate in Australia rose gradually from 30 to 40 per million over a number of years in the mid 1990's. Although official figures are not available, this rate appears to have gone up from 4 deaths per week to almost 14 as reported from Victoria this year. One newspaper described it as "the overdose epidemic Australia had to have". Mostly in metropolitan Melbourne, 2 deaths per day are causing great tragedy to the families who are both ill-prepared and perplexed.

It is clear that every one of these heroin overdoses is preventable.

The means of prevention are a number of well known proven strategies as well as some proposed innovations which have shown promise in trials here and overseas. It is accepted that preventive education of addicts, availability of needles and syringes as well as methadone treatment are all effective in stemming some of the potentially lethal complications of drug use. 'Safe injecting rooms', heroin prescription, rapid detoxification, oral morphine, long acting methadone and buprenorphine are among other strategies which deserve further examination.

Improvements to our emergency services are unlikely to reduce the toll much since, in most areas, they are prompt and effective at saving lives when they are called in time.

Educating drug users about the means to save lives is important. 'Do not inject while alone'. 'Use small quantities initially'. 'Call emergency services immediately if overdose is suspected'. 'Use clean syringes'. 'Do not mix drugs and alcohol'. These are all simple but life-saving messages.

Increasing the accessibility of good quality methadone treatment will certainly reduce the death rates. It is well established that once in treatment, the mortality diminishes significantly. Methadone treatment should be available to all who require it, like any other effective pharmacotherapy. The indications are simple: chronic compulsive opiate use with proven inability to withdraw. For historical reasons this is still restricted in some states and has been banned altogether in the Northern Territory. A recent review in the Journal of the American Medical Association stated that "All persons dependent on opiates should have access to methadone hydrochloride maintenance therapy under legal supervision" [ref 1].

It is likely that bringing addicts out of secluded locations and into 'safe houses' will also spare some lives. Supervision is available and help can be summoned if overdose occurs. Most importantly, these marginalised folk can come into contact with treatment services.

Switzerland and Holland both have official death rates of less than 5 per million compared to our rates of over 40. If we could copy their examples, over 500 young Australian lives could be saved each year. These countries must be 'doing something right'. Injecting is far less common among the young in Holland where the average age of heroin injectors is around 40 years of age. The Swiss introduced 'safe injecting rooms' over 6 years ago. Switzerland has had heroin prescribed for certain groups of resistant addicts for over 5 years. Cannabis is decriminalised in Holland.

Whatever the reasons for our high overdose death rates, we desperately need to investigate all these means for reducing it. The prime reason for NOT having a heroin trial, 'sending the wrong message,' is now out of date. The second reason sometime proffered is that it 'has not worked' overseas. This is intriguing as the reported outcomes of the London, Zurich and Geneva based trials all showed benefits to addicts and society generally and a referendum in Switzerland endorsed the practice of heroin prescription to seriously addicted patients under strict supervision.

Politics, personal prejudice and international pressure must be put aside since Australian lives are too important. We need to approach this epidemic from a scientific standpoint as we did with HIV. If we can match our successes there is very much to gain.

Ref 1: Effective Medical Treatment of Opiate Addiction. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. JAMA 1998 280:1936-1943

Gradual detoxification to 0.5mg buprenorphine 'effective' over 10 days

Diamant K, Fischer G, Schneider C, Lenzinger E, Pezawas L, Shindler S, Eder H. Outpatient Opiate Detoxification Treatment with Buprenorphine. European Addiction Research 1998 4:198-202

There are impressive outcomes reported in this Vienna study of well-motivated heroin addicts doing a structured 10 day out-patient graduated detoxification using buprenorphine sub-lingual tablets.

The authors of the study chose 50 motivated heroin or opium addicts and administered up to 10 days out-patient treatment with reducing doses of buprenorphine. Doses were titrated daily depending on the degree of withdrawal symptoms. The maximum dose was on day 2 at 2.6mg. Doses averaged 2mg daily for the first 5 days, then reducing to 1.5mg for 2 days, 1.0mg for 2 days and 0.5mg on the tenth day. For only 20% of cases was it the first formal attempt at withdrawal. Withdrawal symptoms were measured on the WANG scale and were most severe initially but waned substantially despite buprenorphine dose decreases.

Patients were also routinely given an antacid preparation (famotidine or 'Pepcidine') and night time sedation if required (prothipendyl - an antihistaminic sedative).

With 15 patients dropping out, this treatment was acceptable to 35 of the 50 patients (31 male, mean age 27) yielding an overall 70% 'success' rate. Even if only a half of these remained abstinent for the medium term, it could still be considered better outcome than traditional drug free treatment.

Buprenorphine is a semi-synthetic narcotic derived from thebaine. It is long acting (>36 hours) and has opioid agonist as well as antagonist effects, rather like pentazocine (Fortral). It has been available in Australia since 1992 as an injected or sublingual analgesic but it is not yet licensed for maintenance addiction treatment. Such maintenance treatment may require much higher doses, up to 32mg daily, so 0.2mg SL tablets are not suitable. In addition, this drug, as a Schedule 8 can only be used in addicts with prior permission from the health authorities in most Australian states.

A large multi-centre trial of the sub-lingual version has reported preliminary results which apparently confirm overseas experience showing safety and efficacy when compared with methadone maintenance. Buprenorphine also has a number of important advantages over methadone such as a longer duration of action, allowing second daily attendance, a lower potential for acute toxicity as well as a possible antidepressant effect. The researchers pointed out that this drug will not be a replacement for methadone, but may be a useful alternative for those in whom methadone is not suitable.

This drug's wider availability in Australia will greatly enhance our repertoire in dealing with drug addiction. In France it has been available on normal doctors prescription for over 3 years with apparently good results in up to 50,000 patients. In the meantime, less satisfactory drugs such as codeine compounds, propoxyphene, quinine, clonidine and metoclopramide may be used to mitigate some of the symptoms of withdrawal. It is to be hoped that this drug can be marketed in a suitable preparation for addiction as soon as possible.

comments by Andrew Byrne ..

A decade of caring for drug users

[Letter in Br J Gen Pract. 1999 Feb;49(439):146.]
Sir,

Martin et al�s report on treating drug dependent patients in general practice is heartening (October Journal).1 It is a shame that the authorities do not reward such innovative and successful interventions with appropriate payment, encouragement, and replication elsewhere. Oral supervised methadone is well established as an effective management for heroin addiction.

Although it was obviously successful in numerous cases, the research evidence for injected methadone is still rudimentary. Like heroin prescription, it should probably be reserved for patients who have failed at standard treatments such as oral methadone or supported detoxification.

After 14 years of prescribing and dispensing methadone in our general practice in Sydney, we have found that oral methadone suits up to 90% of heroin injectors who present for treatment. There should be no arbitrary limits on daily doses (we use up to 350 mg daily; mean = 85 mg). It is normal practice in most jurisdictions for at least two doses per week (up to 7 in new or unstable patients) to be consumed under supervision. The use of non-supervised methadone may be effective in certain cases but this has not been demonstrated generally in the research literature. It omits a fundamental safeguard for compulsive drug users and also increases the possibility of drug diversion.

Oral methadone �failures� should be candidates for studies of alternatives such as injected methadone, prescribed heroin, rapid detoxification, oral long-acting morphine, or other approaches. There is no reason for this to happen only in specialist units. A general practice with sufficient experience in dependency, as in this case, is perfectly capable of doing the same as, or even better than, existing dependency units.

Andrew Byrne

Reference

1. Martin E, Canavan A, Butler R. A decade of caring for drug users entirely within general practice. Br J Gen Pract 1998; 48: 1679-1682.

Doctor shopping: dependency and a consistent approach to drug policy issues

The Health Insurance Commission's (HIC) approach to 'doctor shopping' may not be the most effective strategy. The HIC is driven by finances, public opinion and, to some extent, by government policy.

Claims that 'doctor shopping' has decreased in the time of the HIC's efforts in this area do not prove that these are necessarily causal. We know that historically all drug and alcohol use fluctuates in response to influences from many quarters. I understand that 'doctor shoppers' are currently defined as those who can be identified as attending more than 15 doctors in a year.

The medical profession should only support measures which are medically and scientifically sound. For example, we now have strong support for the provision of clean needles for drug users, correct labelling of alcoholic beverages, tobacco warnings, nicotine patches, methadone and the like.

The consumption of benzodiazepines is a major problem for a small minority of the Australian population. Dr Andrew Parkes of the HIC invited participants to have an input into this matter, but before any consultations, the momentum was already strongly in favour of the current 'voluntary' reporting arrangements. The scientific approach was rejected over a politically saleable scheme with no clear rationale. There is little reason to think that the current measures address any fundamental problem although they could be part of an overall strategy to counter the harms occurring from the use of tranquillizers in our society. The current measures are an invitation to use false Medicare cards, to use black market sources and generally avoid addressing the underlying problem. I am not aware of the involvement of dependency specialists, urine testing, psychiatric intervention or other more logical and medical approaches.

We know that around 700 young Australians died from heroin overdose last year alone and about a third may have been on benzodiazepines which may have contributed to the deaths. These drugs have been shown to be associated with risk-taking behaviour and it is clear that they can affect judgement, memory, balance and sleep patters, even in modest doses. In older patients, it is now proven from numerous studies that therapeutic doses are associated with more than doubling of the rates of falls and hip fractures.

While banning benzodiazepines outright is no solution, the continued NHS subsidy is equally inappropriate. But for political sensitivity, these drugs would be dropped from the 'free-list' immediately. Government funding of sedative use by young people who have no clinical indications for the drugs seems bizarre. Indeed, the easy availability of the drugs due to the NHS scheme has undoubtedly contributed to the current overuse of benzodiazepines. It also gives some ill-founded legitimacy to a treatment for which there is little clinical justification under the current prescribing instructions.

We need to look at why people take these drugs. Surveys on the reasons for episodes of drug use have commonly come up with the reply "because it was there". Some users are undoubtedly recreational drug takers. Some become truly dependent on the drugs, others are binge users and a small number are arguably on therapeutic doses for clinical indications.

When I spoke to the HIC officials about this matter, the department had done virtually no research on the subject, although they have access to an enormous amount of relevant statistical information. I suggested that the department look at the number of 'doctor shoppers' who had ever had a urine drug screen ordered. This simple step defined a group of patients who had mostly volunteered for methadone treatment in the past who were currently attending large numbers of doctors for sedatives. Hence, they could be identified as patients who were already in contact with D&A treatment services, albeit with sub-optimal results.

Although there is no proven treatment for benzodiazepine addiction, doctors should still be involved in the treatment of a dependence for which the profession is at least partly responsible. The principles of 'primum non nocere' apply here as elsewhere in practice. 'Harm reduction' is a closely related concept which has been used to let the general public know what doctors have always done where short-term 'cure' is not feasible.

Public health policies have ensured that in the case of tobacco, alcohol and even opiates that there is a clean source of a safe form of the drug. Tobacco is easily the most dangerous of these although it is probably subject to the least controls. These controlled drugs are only available to adults in safe quantities from certain licences premises at restricted hours. Benzodiazepines should be no different than other drugs on doctor's prescription. A safe supply should be accompanied by an appropriate degree of medical supervision, advice and psychosocial supports.

While there are still many unknowns in addiction studies, it is quite clear from the research that when there is increased availability, longer hours of operation or reduction in price, there is generally an increase in overall consumption. This 'availability theory' is supported by many research studies as well as being based on sound fundamental principles. Serious arguments against it still come from such parties as the tobacco and alcohol industry. Some tobacco industry officials still claim that nicotine is not addictive and that tobacco does not cause lung cancer.

We should press for a more logical approach to drug policy as it impinges on our practices, the health budget and the lives of our patients.

Comments by Andrew Byrne ..