Methadone comparison with buprenorphine (pure) from Norway.

Tidsskr Nor Laegeforen 2005 125;2:148-151

A randomised clinical trial of methadone vs. buprenorphine to opioid dependants. Kristensen O, Espegren O, Asland R, Jakobsen E, Lie O, Seiler S.

Dear Colleagues,

After decades of denial in Norway, methadone was finally introduced in 1998 and buprenorphine in 2000 for opioid dependence. These researchers set out to compare the effects of the two maintenance therapies in their own drug using population.

There were 50 long term (>10 years) opioid dependent subjects randomised to receive 16mg fixed dose buprenorphine or variable dose methadone (mean daily dose 106mg, range 80-160mg) over 6 months observation. Patient retention rate was 85% in the methadone group and 36% for those prescribed buprenorphine. Opiate positive urine tests were slightly lower in the methadone group (20% vs. 24%). Importantly, the methadone subjects reported less high risk behaviour. For some reason, only the buprenorphine group (or the minority who remained in the trial) reported significant improvements in general health.

This small study should be the last to compare methadone and buprenorphine in this way. Their results were predictable, adding little more than Scandinavian corroboration to 20 years of preceding research. The fixed dose buprenorphine dosing schedule here was probably based on a successful Swedish model (Kakko, 2003) but patients were moved automatically onto second daily double doses after 2 months. This may have caused some of the excess drop-outs. Also, fixed dose schedules are unlikely to be as effective as flexible ones.

Methadone and buprenorphine should both be prescribed in tailored doses according to clinical need, using appropriate increments (eg 5mg for methadone, 0.4mg for buprenorphine). It is likely that some buprenorphine patients in this trial dropped out because they received too little or too much of the drug (32mg is the maximum recommended dose).

There is no longer any doubt that both methadone and buprenorphine are effective for substantial numbers of heroin addicted subjects treated with adequate supervised (and flexible) doses along with psychosocial supports.

From a body of research, including numerous RCT�s, we know that when compared to buprenorphine: (1) methadone generally suits a higher proportion of the total and (2) it reduces the use of other opiates to a greater degree and (3) whilst in treatment, such patients are less likely to be involved in high risk behaviours. Methadone is also considered to be safe in pregnancy and is much cheaper and easier to administer. Thus methadone should probably still be our preferred first option and buprenorphine kept in reserve for particular indications. If there are concerns about patients misusing methadone then take-away doses should be limited until stability has been demonstrated. It may be that long-term users are less likely to fare well on buprenorphine, as shown in this study.

It is unfortunate that decisions for physicians and especially for patients are frequently dictated not by clinical considerations as much as by regulatory constraints. In some countries (and for no logical reason) these are far more onerous and odious for methadone, while others artificially restrict or even ban the use of buprenorphine for addiction treatment, despite almost 20 years of favourable research.

My feeling is that buprenorphine should be available as an option to all patients who report problems taking methadone. Such patients, however, should be carefully monitored since a high proportion relapse (in this case 74% within 6 months) and may need to transfer back to methadone or to consider other alternatives such as detoxification. These authors are not the first to use the term �gold standard� for methadone maintenance treatment.

There is no indication that combination formulation of buprenorphine (with naloxone) will be any more effective than the pure product. Some evidence points towards lowered efficacy (50% higher doses were required in Bell�s pilot study). While some have stated that sublingual naloxone is not relevant clinically, others have found objective changes and significant absorption (10% or more). Naloxone has a rapid serum clearance time (~5 minute half life) but its serum half life following distribution is just over one hour. While one hopes for less diversion with this formulation, Charles (Bob) Schuster writes: "It is unlikely, however, that any formulation can be developed that cannot be altered by �street chemists� into a more abusable form." Dr Bell�s pilot study of seventeen stable subjects had four who did not attend for their random call-backs for medication count, raising the possibility of non-compliance and/or diversion.

Comments by Andrew Byrne ..

References:

Harris DS, Jones RT, Welm S, Upton RA, Lin E, Mendelson J. Buprenorphine and naloxone co-administration in opiate-dependent patients stabilized on sublingual buprenorphine. 2000 Drug and Alcohol Dependence 61:85-94

Berkowitz BA. The relationship of pharmacokinetic to pharmacological activity: morphine, methadone and naloxone. Clin Pharmacokinet. 1976 1;3:219-30

Kakko J, Svanborg KD, Kreek MJ, Heilig M. 1-year retention and social function after buprenorphine-associated relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial. (2003) Lancet 361:662-668

Schuster CR. History and current perspectives on the use of drug formulations to decrease the abuse of prescription drugs. Drug and Alcohol Dependence (2006 in press, pre-publication version, accessed 28/2/06)

Patterns of methadone treatment in NSW: only one in seven is 'long-term'

Drug and Alcohol Dependence 2006 81;1:55-61

Cycling in and out of treatment; participation in methadone treatment in NSW, 1990-2002. Bell J, Burrell T, Indig D, Gilmour S.

Dear Colleagues,

In New South Wales doctors fill out various coloured forms every time a patient starts, stops or transfers opioid maintenance treatment. The Health Department used to release statistics regularly yet little has appeared in recent years. Here, the hard work of Bell et al. pays off with a useful analysis of some of the details of sample cohorts of all patients starting their first treatment episode during February 1990, 1995 and 2000 (n = 477). February was chosen since it is the first 'normal' month after the summer holiday season.

Retention at 3, 6 and 12 months is tabulated for public [free to the patient] and private [typical cost to patient A$40 (~US$30) per week] systems. There was no significant difference between the sectors and retention rates were 64%, 51%, 38% at 3, 6 and 12 months with 12% of the first two cohorts still remaining in their initial episode at 5 years.

Five years from admission, 45% of original entrants were still registered for maintenance treatment and 75% of these had been continuous or had one break in treatment. 25% had between 3 and 9 treatment episodes.

Overall about two thirds of discharged patients re-entered treatment, the majority within 2 years from discharge. Those more likely to be re-admitted to treatment were young patients as well as those who had a short initial treatment episode (< 3 months). Overall the number discharged after 'successful dose reductions' was 68 (17%) and these patients had been in treatment an average of 2 years at discharge.

The initial cohort from 1990 had an average treatment period of 4.8 years during 2.6 episodes over the 12 year follow-up possible in this study.

Also, 67% dropped out for unspecified reasons. The rest reportedly 'transferred' (8%), were discharged involuntarily (1.5%) or died (1%). Another 69 patients remained in their initial treatment episode (14% of original total).

There were 342 subjects commencing treatment in private clinics while 135 started in public settings (only exceptionally are new entrants started in pharmacies in NSW).

This is a fine demonstration of the natural history of citizens' opiate use as well as their interaction with a mature and flexible medical maintenance service (available in hospitals, pharmacies, private clinics, public clinics and all jails). It is also consistent with Thorley's old review: "over a seven year period, something over a third of dependent subjects will cease opiate use and a very small number will have moved to intermittent use. Approximately 2% will die each year, and after seven years, around 5% will be in prison and 80% will be divided almost equally into a group attending drug clinics and [therefore] in receipt of a legal prescription, and a group not attending clinics and in the community".

Comments by Andrew Byrne ..

Thorley A. Longitudinal Studies of Drug Dependence. In: Drug Problems in Britain: A review of ten years. Eds: Edwards G, Busch C. 1981, Academic Press. p162

Bell J, Burrell T, Indig D, Gilmour S. Cycling in and out of treatment; participation in methadone treatment in NSW, 1990-2002. Drug and Alcohol Dependence 2006 81;1:55-61

Cannabis and psychosis: some references for readers

Dear Colleagues,

This very "debate" proves that if cannabis causes psychosis, it does not cause very much of it, very often (see references below). According to widely published expert Professor Fergusson of Christchurch, the jury is still �out� on causation, but there probably is a small group whose numbers are hard to measure considering schizophrenia is relatively common and cannabis smoking is rife in our society.

Stringent laws against cannabis have never been shown to reduce the use of cannabis or its complications. Even in places like Jamaica and Nimbin (NSW) where cannabis is used rather heavily, no evidence has ever been produced that schizophrenia is more commonly diagnosed. Comparisons of areas with decriminalisation such as Canberra, Adelaide and Amsterdam against places using severe law enforcement (eg. Bali and San Francisco) has never shown either higher rates of cannabis use, nor higher rates of psychosis to my best knowledge.

An important finding in recent years is that the younger one starts using cannabis (or probably any other drug), the more likely one is to develop serious and perhaps permanent complications. A strong reliance on law enforcement in drug control may well encourage more children to become involved as happened in the American alcohol prohibition period last century.

I hope these references are useful for readers.

References

Reinarman C, Cohen PDA, Kaal HL. The Limited Relevance of Drug Policy: Cannabis in Amsterdam and in San Francisco. Am J Public Health. (2004) 94:836 842

Fergusson DM, Horwood LJ, Swain-Campbell N. Cannabis use and psychological adjustment in adolescence and young adulthood. Addiction (2002) 97:1123-35

Lynskey MT, Heath AC, Bucholz KK, Slutske WS, Madden PAF, Nelson EC, Statham DJ, Martin NG. Escalation of Drug Use in Early-Onset Cannabis Users vs Co-twin Controls. JAMA (2003) 289:427-433

van Os J, Bak M, Hanssen M, Bijl V, de Graaf R, Verdoux H. Cannabis Use and Psychosis: A Longitudinal Population-based Study. Am J Epidemiol 2002; 156:319-327

Rey JM, Sawyer MG, Rafael B, Patton GC, Lynskey M. Mental health of teenagers who use cannabis: Results of an Australian survey The British Journal of Psychiatry (2002) 180: 216-221

Comments by Andrew Byrne ..

RCT of buprenorphine versus methadone in pregnancy reassuring

Addiction 2006 101;2:275-281

Methadone versus buprenorphine in pregnant addicts: a double-blind, double-dummy comparison study. Fischer G, Ortner R, Rohrmeister K, Jagsch R, Baewert A, Langer M, Aschauer H.

Dear Colleagues,

This small but meaningful study from Vienna gives us further confidence in the safety and effectiveness of (pure) buprenorphine in pregnancy when compared with traditional methadone treatment. These authors performed a randomised, double dummy trial using flexible dosing, daily attendance and psychosocial supports for 18 patients.

They used flexible doses of 8-24mg buprenorphine and 40-100mg methadone in women at 24-29 weeks of pregnancy.

There was a still birth at 38 weeks in a woman who had been abusing opioids, cocaine and benzodiazepines. Another had a late spontaneous abortion at 28 weeks. Both were methadone subjects. Another two patients were withdrawn from the study due to non-compliance (one buprenorphine and one methadone patient).

Of the remaining subjects who went to term, neonatal abstinence syndrome (NAS) was equal across the two groups. Only about 50% of babies needed treatment for NAS (for an average of 5 days in both groups). The signs were noted slightly earlier in the methadone subjects (60 hours; versus 72 hours after birth for buprenorphine). Intercurrent drug use, determined from urine toxicology, was significantly less in the methadone subjects. Retention rates were not significantly different, possibly owing to the low numbers.

Again, these researchers have provided further evidence of the safety and effectiveness of buprenorphine in pregnancy. With a lack of adverse reports and widespread use in many countries, we can probably now prescribe buprenorphine with more confidence for pregnant women in whom methadone has proven unsatisfactory. It is still not 'first line' in my view, but an excellent alternative when indicated. It also is an indirect reminder that the combination drug should never be used in pregnancy or during lactation (and probably ought not to be used in women who are at risk of becoming pregnant since safety data are absent).

Comments by Andrew Byrne ..

The use of combination buprenorphine naloxone in clinical practice

Email/Medline exercises examining use of combination buprenorphine naloxone in clinical practice.

Dear Colleagues,

The combination buprenorphine product is due for release in Australia in April, as 2mg and 8mg buprenorphine with 0.5mg and 2mg naloxone. Australian states and territories have been using the pure product (0.4mg, 2mg and 8mg sublingual tablets) for almost 6 years and it now accounts for between 10 and 50% of the opioid maintenance 'markets'.

There have been claims that the combination is clinically equi-potent and that it is subject to significantly less abuse. While sublingual naloxone is only partially absorbed (~10%) it may still have side effects in the longer term. It might also be the reason why some patients request a higher dose when taking the combination product (see Bell et al 2004 in which a mean increase of about 50% was required). While research on (pure) buprenorphine is extensive and consistent for addiction, work on the naloxone combination is scanty and conflicting. We need to consider that some of the prescribed combination drug will be injected (in Wellington, NZ, more than 50% of addicts presenting for treatment in 1992 were reportedly doing so). This will predictably cause toxic reactions in some users for which we need to be cognisant.

For these reasons we performed a literature search of naloxone using Medline and find that it is not always benign when used intravenously. Below we list some citations which seem relevant (note that none relates directly to maintenance treatments). We also sent an email request to American colleagues on their experience after nearly 4 years of clinical use of the drug using office based (non-supervised) prescription in that country. This is a summary of the findings.

Methods:

An email request was sent to 184 US colleagues (see wording below). The recipients were drug and alcohol workers who had indicated an interest in the field and who received regular journal summaries sent by email from our surgery. Some details of respondents and responses are tabulated here, along with some selected quotes. The recipients included substantial numbers of university professors, clinicians, drug users, advocates, policy makers and researchers, many of whom responded.

Results:

There were 44 responses received, 5 being from 'secondary' recipients making crude response rate of 24% in the busy weeks between Thanksgiving and Christmas, 2005. Of those who felt that they could comment on the issue, 16 responses came from New York, 5 from Massachusetts, 3 from California, 3 from Maryland, and one each for Connecticut, Illinois, Maine, Minnesota, New Jersey, Vermont and Puerto Rico (omits those unable to comment).

Twenty five of the 44 (57%) reported that they were personally aware of at least one case of diversion and 9 of these (20%) cited the existence of a black market with 5 (11%) quoting a street price. There was one report of primary buprenorphine addiction. A further 10 (23%) stated that they had not seen any diversion in their own practices. Two respondents no longer worked in the field. Another 7 could not answer the question from their own experience.

Analysis:

Most replies were brief but some were quite detailed. Some of the most definitive replies came from Puerto Rico and the North East of the USA. The most worrying replies came from two experienced respondents who stated that virtually all of their detox and/or maintenance patients (in three different states) had tried buprenorphine on the street in the weeks before admission. [See below for sample replies].

Conclusion and discussion:

It appears that despite reportedly low uptake of buprenorphine in America generally, in some regions doctors are prescribing the drug to the extent that a secondary 'grey' market is being reported (Cicero, 2005). Some of the street drugs reported may be 'Temgesic' obtained from Canada, Mexico, the internet or elsewhere. However, the majority would appear to be the local 2mg and 8mg combination tablets from the reports detailing the type of drug diverted. While pure buprenorphine is now available in many countries, the combination drug is currently only used widely in the US. It is also used in medical trials elsewhere (eg. Australia and ?Finland ?New Zealand - see Bell 2004).

The use of buprenorphine and buprenorphine-naloxone combination tablets in an office setting without dose supervision was introduced into the United States in unique and difficult circumstances (see Jaffe 2003) and in spite of very little published research on the intervention (Fudala 2003). Events subsequent to marketing do not appear to have been well monitored/reported as I have yet to find any meaningful data relating to the extent, safety and effectiveness of the intervention in America. There are indications of diversion (Cicero, NEJM, 2005) but these appear to be in isolated areas.

The email survey we have performed has serious limitations, being restricted to a sample of correspondents who have self-identified as being interested in dependency medicine. A true random sample of American prescribers would give more rigorous results. We believe that such a study should be performed as a matter of urgency to ascertain if indeed buprenorphine or buprenorphine-naloxone products are being diverted to a street market at a rate which is of concern.

In my view, until more is known, non-supervised opiate maintenance treatment should generally be used in the context of increasing access to take-away doses ['take-homes' or 'carries' in US parlance] in a structured, 'stepped' or 'streamed' treatment setting. This should be based on traditional indicators of stability and progress in treatment. Another use would be in research trials comparing office based treatment with existing clinic treatment. Extended unsupervised periods (more than ~3 days) have been shown to be satisfactory for 6, 13 and up to 27 doses at a time in highly selected long-term patients after stabilisation in a clinic setting (Senay; Schwartz; Novick; Rhoades).

Appended: [1] wording of email request, [2] selections of responses, [3] references.

[1] Quoted request in buprenorphine diversion survey.

Subject: 'Use and abuse of buprenorphine (Subutex/Suboxone) query'.

Dear Colleague,

Can you let me know if you have any knowledge of the mis-use or 'diversion' of these drugs in the American community since their widespread use began about 4 years ago. They appear to be very safe and well tolerated yet we have little information to date.

Best regards for the holiday season.

Andrew Byrne .. (Sydney, Australia)

[2] Quotes

The following are selected quotes [most direct quotes, some paraphrased for clarity] of responses received:

no significant reports of misuse or diversion ... <snip> ... few serious adverse events reported

someone on the street sold him two 8mg bup/nal tablets (50 cents per mg).

I'm certainly not aware of any, but you folks might know better.

We see virtually none of it at either my clinics in [W Coast]

'remarkably little'

'expensive' [on street]

all my patients have tried bup on the street ... at $25 for 8mg ... plenty of docs give a month's supply of 32mg at the first visit and hasta luego.

regarding safety and illicit bup use in the United States. ... We are generating many anececdotal stories...

Most diversion seems to be ... from a someone for cash to abate withdrawal symptoms.

there is an illicit market for these drugs with an 8mg tab going for as much as $50.

Several .. patients .. [say] .. suboxone is available at street black market very early since its approval. ... patients have poor compliance ... almost all need supervision of medicine ... in stabilization ...

there is some diversion in NY but it is very small ... diverted buprenorphine was reported in a shelter and use by heroin addicted shelter residents

ONE of our patients in [Tri-state area] got a subutex from a "friend" and put themselves in withdrawal

there has been evidence of diversion of Buprenorphine ...mostly anecdotal.

It didn't do nothin' for me doc!

only heard of one case of street use.

'unpopular with addicts, not just due to naloxone'.

no real abuse or problems thus far.

[bup] has a bad street reputation for getting high ... [but] ... a good reputation if an addict wants to stop withdrawal.

Increasingly patients are telling me of instances where they have purchased a few pills

'little evidence of clear diversion'

one of [20 treated patients] diverted his medication, and that was to his wife

I have to get my medication from the street. The doctors here are charging ridiculous prices ... [I pay] $30 for 3 x 8mg suboxones which .. last for 2-3 weeks.

rumours .. from patient advocate group members, regarding the [New England] area. There is no question that diversion occurs...but it has not hit the papers, yet.

I've had patients report they have used bup (suboxone) provided by others

$30 for 8mg Boston

one patient ... taking extra doses of his suboxone

we ... do unscheduled "call backs" for pill counts [for] detection of diversion ... .

anecdotal reports from needle exchange customers who have used or plan to use street-acquired buprenorphine

addicted unable to get bupe elsewhere

some anecdotal reports suggesting that the little diversion ... for the purpose of trying out the treatment.

[3] References:

Cicero TJ, Inciardi JA. Potential for Abuse of Buprenorphine in Office-Based Treatment of Opioid Dependence. NEJM (2005) 353;17:1863-5

Jaffe JH, O'Keeffe C. From morphine clinics to buprenorphine: regulating opioid agonist treatment of addiction in the United States. Drug and Alcohol Dependence 2003 70 (supp) 2:

Osterwalder JJ. Naloxone -- for intoxications with intravenous heroin and heroin mixtures: harmless or hazardous? A prospective clinical study. Clin Toxicol 1996; 34: 409-416.

Hsu W, Rao RB, Nelson LS. Naloxone hazards overstated. Clin Toxicol 1997; 35: 215-217

Andree RA. Sudden death following naloxone administration. Anesth Analg 1980; 59: 782-784.

Jasinski DR, Martin WR, Haertzen CA. The human pharmacology and abuse potential of N-allylnoroxymorphone (naloxone). J Pharmacol Exp Ther 1967; 157: 420-426.

Schwartz JA, Koenigsberg MD. Naloxone-induced pulmonary edema. Ann Emerg Med 1987; 16: 1294-1296.

Kanof PD, Handelsman L, Aronson MJ, et al. Clinical characteristics of naloxone-precipitated withdrawal in human opioid-dependent subjects. J Pharmacol Exp Ther 1992; 260: 355-363.

Bell J, Byron G, Gibson A, Morris A. A pilot study of buprenorphine-naloxone combination tablet (Suboxone®) in treatment of opioid dependence. Drug Alcohol Rev (2004) 23;3:311-318

Fudala PJ, Bridge TP, Herbert S, Williford WO, Chiang CN et al. Office-Based Treatment of Opiate Addiction with a Sublingual-Tablet Formulation of Buprenorphine and Naloxone. NEJM (2003) 349:949-958

Senay EC, Barthwell A, Marks R, Bokos PJ. Medical Maintenance: An Interim Report. Journal of Addictive Diseases. 1994;13(3):65-9.

Schwartz RP, Brooner RK, Bontoya ID, Currens M, Hayes M. A 12-year Follow-Up of a Methadone Medical Maintenance Program. American Journal on Addictions 1999 8;4:293-299

Novick DM, Joseph H, Salsitz EA, Kalin MF, Keefe JB, Miller EL, Richman BL. Outcomes of Treatment of Socially Rehabilitated Methadone Maintenance Patients in Physician's Offices (Medical Maintenance). J Gen Intern Med. 1994;9:127-30.

Barsan WG, Olinger CP, Adams HP, et al. Use of high dose naloxone in acute stroke: Possible side-effects. Crit Care Med 1989; 17: 762-767.

Reisine T, Pasternak G. Opioid analgesics and antagonists. In: Hardman JG, Limbird LE, Molinoff PB, et al, editors. Goodman & Gilman's the pharmacological basis of therapeutics. 9th edition. New York: McGraw Hill, 1996: 549-551.

Gaddis GM, Watson WA. Naloxone-associated patient violence: an overlooked toxicity? Ann Pharmacother 1992; 26: 196-198.

Neal JM. Complications of naloxone. Ann Emerg Med 1988; 17: 765-766.

Ward S, Corall IM. Hypertension after naloxone. Anaesthesia 1983; 38: 1000-1001.

Azar I, Turndorf H. Severe hypertension and multiple atrial premature contractions following naloxone administration. Anesth Analg 1979; 58: 524-525.

Flacke JW, Flacke WE, Williams GD. Acute pulmonary edema following naloxone reversal of high-dose morphine anesthesia. Anesthesiology 1977; 47: 376-378.

Brimacombe J, Archdeacon J, Newell S, Martin J. Two cases of naloxone-induced pulmonary oedema -- the possible use of phentolamine in management. Anaesth Intensive Care 1991; 19: 578-580.

Harrington LW. Acute pulmonary edema following use of naloxone: a case study. Crit Care Nurse 1988; 8: 69-73.

This report was written by Andrew Byrne. With thanks to all those who generously gave their time in responding to my email request on this issue.

Rapid detox trial shows no long term benefit

Drug and Alcohol Dependence 2006 81;2:109-116

Opioid antagonist detoxification under anaesthesia versus traditional clonidine detoxification combined with an additional week of psychosocial support: A randomised clinical trial. Favrat B, Zimmermann G et al.

Dear Colleagues,
February's D&A Dependence journal has a feast of items including a randomised trial of rapid versus traditional detox from Switzerland. While there is a trend for more rapid detox patients to be abstinent at 3 months, by 6 and 12 months there is no difference and the relapse rate is over 95% for both groups. This is consistent with a similar trial from Adelaide some years ago.

But this item tells us more about rapid detox than just abstinence outcomes. Of the 70 "mono-dependence" patients who sought detoxification in the trial only 26 out of 36 (72%) randomised to rapid detox actually took the procedure, despite it being free and performed in a general hospital. And of the remaining 34 who were randomised to 'classical clonidine' detoxification, only 21 were included in the trial (62%). In each group between 4 and 8 patients just did not turn up on the appointed day while a similar number were excluded because they showed up non-opiates in the pre-treatment urine screen and this trial excluded those using drug other than opiates.

The compliance with oral naltrexone was shown to be very poor despite being offered to all patients. In the clonidine group only 2 started naltrexone, compared to 24/36 in the anaesthesia-assisted patients. Yet the drug was so unpopular that it was only taken for an average of 10.8 days in this latter group, where the company recommends 6 months.

There was a death in the rapid detox group at the 3 month follow-up. The authors state this was probably not related to the treatment, however the treatment obviously did not help this subject. We now know that the choice of detoxification is a risk in itself, regardless of how it is achieved. However, in these low-risk, 'mono-addicted' subjects, rapid detox had no benefit except in the short term. It is invasive, costly and in this as other reports, there is a mortality (see ABC link below in which 80 deaths have apparently been reported from a single 'naltrexone' clinic).

Comments by Andrew Byrne ..

The ABC had a very revealing naltrexone item on the 7.30 Report on Friday 13th. See http://www.abc.net.au/7.30/content/2006/s1547424.htm

Developments in buprenorphine, methadone and hepatitis in France

Dear Colleagues,

"Le Flyer" is a French dependency newsletter (circ 10,000, also on internet www.rvh-synergie.org/) edited by the director of an addiction centre in Paris. The latest issue (no.23) has a provocative editorial predicting that 2006 will be a year of big changes for drug treatments in France.

We are told that a company called 'Arrow' specialising in generics will market a new brand of buprenorphine while the current French supplier, Schering Plough, intends to introduce a quick dissolving tablet or wafer. This has been talked about for several years by Reckitts staffers and would be most welcomed in Australia too. The editorial also predicts the introduction of the combination product with naloxone - which they term 'non-injectable' - at the risk of 'a bad quarter hour' - meaning withdrawals, I presume, in translation.

The proposal appears to be the same as in the US where the current guidelines recommend using pure buprenorphine for initiation but that continuing maintenance be done with the combination product (except in pregnant women or those who are sensitive to the combination). It is hard to imagine how the French authorities will convince doctors and patients to move from pure buprenorphine to a combination after so many years of apparently successful experience with the treatment using 'Subutex' in the community.

There is a press release on "H�patite C: Xavier Bertrand (French Health Minister) souhaite que les patients soient majoritairement pris en charge en ville. PARIS, 8 d�cembre 2005 (APM)" [this calls for hepatitis treatment to be largely undertaken in the community in the future.]

"Le Flyer" also covers a comprehensive report by a committee of French experts on the prevention of both hepatitis B and C. It is pointed out that methadone has a better track record in several respects (reducing needle sharing; less illicit drug use; better retention). They therefore recommend that methadone become the treatment of first choice for people who are sero-negative (to keep them that way, I suppose is their logic). In my own view, it is also the treatment of choice for those who are sero-positive to prevent them passing it on.

In France buprenorphine can be prescribed in a community setting where methadone maintenance treatment (MMT) can only be commenced in a specialist clinic (as in New South Wales). This does not prevent gradual increases in methadone numbers in France or Australia since once stable, GPs can take over prescribing of methadone, just as might occur with insulin, warfarin, etc. In the US, methadone 'slots' are frozen by the number of clinics and the ban on GPs or pharmacies being involved. This is all the more tragic since America still has such a large unmet need for addiction services while these are relatively cheap and simple treatments with major benefits for individuals and society.

I have been sent some interesting old papers from the 1970s regarding the combination methadone and naloxone. Although it never really 'caught on', this may have seemed a logical concept considering methadone can be so toxic in overdose. One of the comparative studies showed that the addition of naloxone caused a significant reduction in the initial methadone peak on serial blood levels (the paper was way ahead of its time!). I wonder if this could explain the dose increases requested by nearly all 17 subjects in Bell's study when changed from pure buprenorphine to the combination product.

Comments by Andrew Byrne ..

More about the Byrne Surgery practice

Extract from a recent publication (Drug and Alcohol Dependence) relating to methadone dose levels and metabolism.

The study practice has been treating drug and alcohol dependent patients for 15 years (Byrne and Wodak, 1996). Patients are referred by local doctors or other drug services and at any one time up to 150 patients are treated with opioid pharmacotherapy. Most patients live or work in the area and attend the practice for supervised dispensing for which they pay a fee, others attending public or private clinics, or pharmacies, for dosing.

There is no maximum methadone dose, although doses above 200 mg/day must be approved by a committee of the New South Wales Department of Health. Mean methadone doses calculated periodically in recent years at this practice have ranged between 89 and 107 mg/day.

Patients are seen regularly by a doctor for counselling and dose review, one- to four-weekly as their stability in treatment is demonstrated, and a doctor is available to see patients whenever the clinic is open. Dose changes are made in consultation with the patient, in response to any symptoms of opiate withdrawal, mood disturbance, continuing use of illicit opioids, or other prescribed and non-prescribed substances including alcohol, benzodiazepines and cannabis.

The practice uses an enzyme immunoassay (Microgenics CEDIA®, Fremont, CA, USA) for urine toxicology, which includes a test for opiates, sensitive to 300 ng/ml of morphine/monoacetyl morphine and having similar sensitivity for metabolites of morphine (glucuronides), for codeine and a range of other opiates. In our experience, the opiate screen remains positive for up to five days after heroin use. If the opiate screen is positive, specific thin paper chromatography is performed which has a sensitivity of 300-500 ng/ml for morphine/monoacetyl morphine.

Supervised urinary drug toxicology is performed every one to four weeks depending on the patient's progress in treatment. Patients newly in treatment are tested more frequently while those patients with consistent evidence of abstinence from illicit drugs over a period of time are tested less frequently. The testing protocol is random but is varied by the doctor or dispensing nurse on duty in response to clinical indicators of drug use (such as intoxicated presentations) and prior urine toxicology results. Urine testing is encouraged but not compulsory, and patients receiving takeaway doses are seldom asked to provide urine specimens on days when they would not otherwise attend the practice. Positive urine drug screens do not lead to forced withdrawal regimens or withholding of treatment, and do not disqualify a patient from receiving take-away doses, but are indicators for more intensive supervision including more frequent urine tests. Typically several negative opiate screens are required before a patient qualifies for less frequent urine tests.

Taken from: Hallinan R, Ray J, Byrne A, Agho K, Attia J. Therapeutic thresholds in methadone maintenance treatment: A receiver operating characteristic analysis. Drug and Alcohol Dependence 2006 81;2:129-136

Drugs, alcohol and driving: Do we have to inform authorities about such matters?

Tue 31 Jan 2006

Presenter:
Dr Adam Winstock, who also presented on this subject at the recent APSAD conference in November in Melbourne.

A whistlestop tour through the epidemiology of self-reported recent substance-affected driving in Australia showed prevalence to range from 3-9%, varying depending on such factors as substance availability, availability of other transport, and the age group and cultural mores. Preferred substances vary greatly, MDMA, cannabis and alcohol being most commonly used by clubbers, and stimulants by truck drivers. Illicit opioids are generally the least commonly used by drivers. Not surprisingly, young men are the group most likely to engage in substance-affected driving.
The risk of substance affected driving is not only due to intoxication, but also to more subtle effects such as altered judgement and risk perception, and post-use effects such as the alcohol 'hangover'. Other important factors include the behaviour of passengers (even when the designated driver is not substance affected), driver inexperience, road and vehicle conditions. Such factors tend to aggregate, as in ......a group of drunken teenage males in a rickety car hooning on a dirt road on a dark and stormy night.....
The legal concept of the 'culpability' of certain substances was defined: "If drugs contribute to road accidents then drivers found culpable for crashes will be more likely to have drugs in their bodies than drivers deemed non culpable". Culpability is clearly demonstrated with benzodiazepines and alcohol, but not for cannabis, opioids and stimulants.
The 'culpability' of alcohol is striking, with a dose-related risk of accidents with rising blood alcohol level (BAL). Permissible blood alcohol concentrations vary from zero (Bulgaria, Turkey), 0.02 = 20 mg/L (Sweden) and 0.08 = 80mg/L (UK, Austria, Spain). Dr Winstock deplored this high permitted level in the UK.
Driving under the influence of alcohol is strongly associated with other alcohol related problems, particularly dependence with rate of accidents being 0.5/year for all drivers, 2.5 for binge drinkers and over 3/year for those with alcohol dependence. Further, there is an overrepresentation of alcohol dependent drivers who are caught with very high BAL .
Driving simulator studies show impairment of driving skills by cannabis, however there is a wide variation between individuals. The impairment appears to be less in true on-road conditions, possibly because cannabis affected drivers are capable of adapting by driving more carefully. There is some evidence that chronic use of cannabis causes impairment of driving unrelated to current intoxication.
Gamma hydroxybutyrate (GHB), like alcohol, produces dose-related psychomotor impairment. It is especially prone to cause gross impairment (including vomiting and amnesia) owing to the narrow 'therapeutic window' of its desired effects. Testing for this drug is difficult as it may be detected in small amounts in the body as a normal metabolic product. We were told that it is used therapeutically in some countries for alcohol withdrawal management.
Stimulants such as amphetamines may possibly improve some aspects of driving by increasing vigilance and stamina, and reducing fatigue. However judgement may be impaired at higher doses, with over-confidence, risky or reckless behaviour. Depending on the dose and a person's reaction to the substance, stimulants may have other risks, including altered vision from dilated pupils, the possibility of perceptual disturbance or paranoia. MDMA has been shown to increase the rate of accidents on a driving simulator (De Waard 2002).
Given that Attention Deficit Disorder (ADD) is itself a risk for driving accidents, it is an interesting question whether people with this condition ought to be provided with stimulant drugs that might in some cases improve their safety on the road.
With prescription medicines, both the underlying condition as well as the effects of the medicine need to be considered, as well as interactions with other substances. An example is opioids, where the stabilised opioid-tolerant person will generally show no signs of psychomotor impairment from their medication. However there may be increased impairment when combined with alcohol or other sedative-hypnotics, and one needs also to consider any associated personality or other psychiatric disorders.
In Germany, it was reported, a patient on opioid replacement is considered impaired until proven otherwise and facilities exist for formal testing. In New South Wales, the situation is rather complicated, and Dr Winstock took us step by step through his experience of trying to achieve clarity about legal and professional responsibilities of the health professionals. A useful website for understanding these is Austroad's Information for Health Professionals section.
In general it is, in the first instance, a driver's responsibility to report to the relevant Drivers Licensing Authority (DLA) any medical condition which may impair their ability to drive. In NSW, for example, the DLA is the Roads and Traffic Authority.
If a patient is "unable to appreciate the impact of their condition, or to take notice of the health professional's recommendations due to cognitive impairment or if driving continues despite appropriate counselling and is likely to endanger the public, the health professional should consider reporting directly to the Driver Licensing Authority" and "in the Australian Capital Territory, New South Wales, Queensland, Tasmania and Victoria ..... health professionals who make such ....without the patients consent but in good faith that a patient is unfit to drive, are protected from civil and criminal liability ".
This leaves the health professional with flexibility and at the same time a grey area of legal responsibility. It was pointed out that a family doctor may have very detailed knowledge of a person's psychosocial situation which may help making differentiated judgements but might also involve a conflict between the interests of their patient and society at large.
In general situations involving imminent risk and involving commercial drivers call for more decisive action from health professionals.
In determining whether to report someone to the Driver Licensing Authority, Dr Winstock advised considering:

• the risks associated with disclosure without the individual's consent or knowledge, balanced against the implications of non-disclosure;


• whether the circumstances indicate a serious and imminent treat to the health, life or safety of any person.

He reminded us of the formula: Risk = (likelihood of the event) x (the severity of consequences).
Unfortunately, anomalies do arise. Dr Winstock was advised by a NSW Roads and Traffic Authority spokesperson that a driver need only self-report a medical condition that was chronic, therefore the commencement of methadone treatment need not automatically be notified. However, if a person stayed on methadone treatment for over 12 months, notification would be appropriate. This is exactly the opposite of what an experienced clinician would advise - a patient early in methadone treatment should be advised not to drive until the dose is stabilised, a person stable on methadone maintenance can be expected to be perfectly fit to drive. In cases where illicit use compromises driving safety (regardless of the treatment status of the patient) notification by the patient should be recommended.
Dr Winstock's algorithm "What should do we do in practice ?" is based on the need to protect ourselves, the patient and the community where a driver has an impairment to driving.

1. Give feedback to the patient on the legal and financial obligations and implications for them, as well as your own legal/professional responsibility.


2. Invite the patient to notify the DLA, or inform them of your intention before you do so yourself.


3. Document your advice, including that you have told patient what they should do.


4. Request feedback and document patient's reported action/inaction re-driving at next appointment.


5. Assess immediate risk if patients continue to drive.


6. Document and seek second opinion from colleague/DLA.


7. Advise patient that unless they notify the DLA you will.

The case studies illustrated how these principles might be applied in practice.
In the first case, a patient on methadone maintenance developed psychotic depression and was commenced on risperidone and citalopram. The patient was notified to the DLA, and a subsequent medical report was that her akathisia did not affect her psychomotor skills and she was fit to drive. However, another doctor started her on large doses of diazepam for the akathisia. Interest centred on the inappropriateness of using diazepam for akathisia, but also the question of how a doctor best determine whether there was any impairment from this combination of medications. Suggestions included examination 3-4 hours after supervised methadone and diazepam dosing.
A second case study dealt with a patient on methadone maintenance known to use benzodiazepines who was observed to stop on the wrong side of the road then reverse across double lines to park on the correct side. He claimed that he did not usually drive as he was unlicensed and his car unregistered. Although the patient showed no signs of benzodiazepine intoxication, the behaviour could reasonably be described as disinhibited, and the responsible doctor chose to deal with this by giving very firm warnings, including a future possible notification of police or the Department of Community Services (responsible for the safety of children in NSW). Debate centred on whether the doctor should have confiscated the car keys, immediately informed the police, notified the DLA (even though it has no powers over unlicensed drivers) and the question of how best to follow up the patient for compliance with acceptable standards.
In another case a patient using a cocktail of medications including sedative hypnotics, tricyclic antidepressants, opioids and a major tranquilliser, was offered inpatient management of her problems. She agreed to be admitted but insisted she had first to drive home to cook dinner. In the face of this woman's signs of current intoxication, the doctor acted firmly to take her car keys (which the patient accepted in good spirit), justified by the immediate and serious risk to her and the public.
This led to discussion of possible protocols such as requiring anyone entering an alcohol detoxification treatment to agree to notify the DLA of their impairment. It was pointed out that draconian measures by health professionals could push a person out of the therapeutic relationship, losing the opportunity for constructive engagement.
Finally, some public health challenges including road side drug testing were discussed:

• Legal status of drugs is unrelated to driving risk.


• Nor does the mere presence of drugs imply impairment.


• Limitations of road side testing, including the number of false negatives.


• Visible, frequent, random testing may maximise exposure to enforcement and testing may alter perception of risk and lead to a positive impact on people's decision whether to drive.

Office tests such as heel-toe, past-pointing, Rombergs and examination for lateral gaze nystagmus are good for alcohol but much less good for other causes of impairment (the latter is a good party trick as well). Dr Winstock briefly described other more sensitive measures of impairment such as head sway measures that may become more widely used in the future.
A telling note was struck when Dr Winstock asked how many participants at the seminar routinely asked about driving in every clinical drug and alcohol assessment. At the end of the seminar participants were left with a heightened awareness of this need and a practical framework for acting to protect themselves, the patient and the public.

Summary by Richard Hallinan, with contributions from Adam Winstock and Andrew Byrne.

Combination buprenorphine widely abused in New Zealand in early 1990s

Drug Alcohol Dependence (1993) 33;1:81-6

The misuse of buprenorphine and a buprenorphine-naloxone combination in Wellington, New Zealand. Robinson GM, Dukes PD, Robinson BJ, Cooke RR, Mahoney GN.

Dear Colleagues,

This 1993 study from Wellington, New Zealand, has relevance to us today with the recent approval of the buprenorphine combination product containing naloxone. According to my reading there have only been two published comparative studies of the combination product in recent years and neither compared unsupervised combination treatment with traditional methadone treatment. Nor did either examine community diversion in any systematic way. After TGA approval and PBS funding process, the States and Territories are responsible for introducing the combination into clinical practice (we are told from April 2006). An absence of good research evidence on the product led me to look into older literature for knowledge about the subject.

To his great credit, Dr Robinson saw an opportunity in 1991 to monitor a naturalistic experiment in Wellington, New Zealand when pure buprenorphine tablets were withdrawn and replaced with a combination product due to reports of abuse. The replacement combination product contained approximately the same quantity of naloxone (the modern version has only one quarter of this proportion). Owing to the widespread abuse of prescribed analgesics (and almost absence of heroin) in New Zealand in the early 1990s, the combination product was introduced in an attempt to make it unpopular with addicts. Although the analgesic tablet was only one tenth of the strength of the common 2mg tablet used for maintenance, it was dispensed in quantities of 50 in a pack (10mg total � 8.5mg naloxone).

What the article does NOT say is that shortly after publication, the combination drug was also withdrawn by the company after the widespread abuse including injecting reported here. After years in the 'therapeutic wilderness', I understand that NZ authorities have licensed the drug(s) again for addiction treatment, presumably with more formal assessments, structure and supervision this time around.

Robinson interviewed a sample of new methadone treatment applicants 12 months apart during which the pure product was withdrawn and replaced with the combination. This revealed the surprising original rate of 81% of patients had abused buprenorphine in the previous 4 weeks. The rate was still 57% 12 months later when only combination product was available in New Zealand (nearly all of these had used the combination drug intravenously). Both figures were corroborated with consistent urine tests, a testimony to Robinson�s thoroughness (it is not easy to get buprenorphine toxicology performed even now). At the same time, between the two surveys it apparently became easier to obtain the prescribed Reckitts' tablets, the proportion stating it was 'easy' rising from 35% to 52%.

Two thirds of patients who had injected the combination product reported no withdrawal reactions. One third reported possible withdrawals after injecting, yet this experience did not appear to discourage injecting generally and the drug was subsequently withdrawn. Thus the combination product appears to have been less popular with addicts but was still widely abused, albeit at lower levels. The lower street price reported may be been due to the naloxone, increased supply or lower demand (or a combination of the three factors).

There is now a burgeoning literature on diversion of prescribed opiates, both from Australia and overseas. Cicero writes in October�s New England Journal of Medicine that, after numerous provisos, �� its [buprenorphine combinations] availability as new product lines led to an almost immediate increase in buprenorphine use for nontherapeutic purposes.�). In recent cross-jurisdictional comparisons, both Ritter et al. from Australia and EMC from Europe found that there was little correlation between �take-away� policy and the extent of methadone or buprenorphine diversion reported across borders.

Clearly one way for us as dependency workers to address the issue of diversion is to ensure addicted citizens have access to appropriate, flexible treatments of high quality, including detoxification, maintenance as well as attention to other medical and social problems.

Comments by Andrew Byrne ..

References:

Fudala PJ, Bridge TP, Herbert S, Williford WO, Chiang CN et al. Office-Based Treatment of Opiate Addiction with a Sublingual-Tablet Formulation of Buprenorphine and Naloxone. NEJM (2003) 349:949-958

Cicero TJ, Inciardi JA. Potential for Abuse of Buprenorphine in Office-Based Treatment of Opioid Dependence. NEJM (2005) 353;17:1863-5

Cicero T, Inciardi J, Mu�oz A. Trends in Abuse of OxyContin� and Other Opioid Analgesics in the United States: 2002-2004. The Journal of Pain 2005 6;10:662-672

Inciadi JA, Surratt HL, Kurtz SP, Burke JJ. The Diversion of Prescription Drugs by Health Care Workers in Cincinnati, Ohio. Substance Use & Misuse 2005 41:255-264

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

Ritter A, Di Natale R. The relationship between take-away methadone policies and methadone diversion. Drug Alcohol Rev (2005) 24;4:347-352

Robinson GM, Dukes PD, Robinson BJ, Cooke RR, Mahoney GN. The misuse of buprenorphine and a buprenorphine-naloxone combination in Wellington, New Zealand. Drug Alcohol Dependence (1993) 33;1:81-6

Prevalence of buprenorphine misuse. EMCDDA2005 (web site accessed 22-1-06)