The Medical Post
May 2, 2016
OPINION by: JAN KLIMAS
Time to confront iatrogenic opioid addiction
Canada has been grappling for decades in a largely ineffective attempt to keep heroin out of our borders. Now the unsafe prescribing of opioids has organized crime groups turning their attention to ‘customers’ whose addiction started in the doctor’s office.
Physicians are going to have to face the tough conversations that involve two of the hardest words in a doctor’s vocabulary: ‘enough’ and ‘no.
The full article is now online, and has appeared in the Doctor Daily e-newsletter on Monday, May 2, 2016.
April 4: Methadone is a medication used in treatment of people with dependence from heroin or other opioids. Many people who take it drink too much alcohol. We don’t know whether it’s because or in spite of taking this medication. We wanted to know the impact of enrolment in methadone treatment on the onset of heavy drinking among people who use heroin.
Our approach: We analysed information from thousands of interviews from long-term, community-based studies of people who inject drugs in Vancouver, Canada, between December 1, 2005 and May 31, 2014.
What have we found: In total, 357 people who use heroin were included in this study. Of these, 58% enrolled in methadone at some point between 2005-2014, and 32% reported starting to drink heavily. Those who started the treatment said they drank less compared to those who did not start it. It didn’t even make them start drinking faster than those who did not start taking methadone. People who started drinking heavily when they enrolled in methadone were younger than those who did not start drinking heavily. They also used more cannabis.
What does this mean: It is clear that many people in the methadone treatment have problems with alcohol. It seems that they do not drink because they take this medication which may even appear to decrease the initiation of heavy drinking. Our findings suggest younger age and cannabis use may predict heavy drinking. These findings could help inform on-going discussions about the effects of opioid agonist therapy on alcohol consumption among people who use heroin.
This blog is based on article was Accepted for publication in the European Addiction Research Journal on January 31, 2016. The full title of the article is: The Impact of Enrolment in Methadone Maintenance Therapy on Initiation of Heavy Drinking among People who Use Heroin. The authors of the article are following:
The year was 1996 and Ireland was recovering from a recent heroin epidemic. Methadone, a medical replacement drug for heroin, was jut making its way into specialised clinics in Dublin.
Professor Gerard Bury and colleagues had a revolutionary idea that people who use drugs can receive agonist drugs, like methadone, from their family doctors.
The opioid agonist treatment has substantially changed the course of the drug use epidemic. Yet, many continue to die and suffer from chronic diseases. In Ireland, everybody who’s prescribed this medication has to be registered with the Central Treatment List.
In this new study, we wanted to revisit a group of people who were the first to receive their agonist medication, i.e., methadone in the primary care in Ireland.
At follow-up in 2013, 27 (27.6%) of the 98 people had died in Ireland and had relevant entries in the Register of Deaths, 19 (19.4%) were currently in OAT and the status of the remaining 52 (53%) was ‘alive,’ as per the Irish death registry.
The 52 patients ‘alive’ had left the Central Treatment List, but no further information was available on their status.
“Our inability to establish the interval data for the retention in treatment is a significant study limitation, but the overall retention of 19 out of the surviving 71 patients is comparable to previous research.”
The deceased died of multiple causes; only six had a single cause. Drug toxicity, overdose, or both, were the most common causes of death.
Jan Klimas, Anna Keane, Walter Cullen, Fergus O’Kelly, and Gerard Bury (2015) Seventeen year mortality in a cohort of patients attending opioid agonist treatment in Ireland. European Journal of General Practice (http://dx.doi.org/10.3109/13814788.2015.1109076)
What is the future of addiction medicine? What is the future addiction specialist going to look like? Nobody knows what the future is going to look like, but the delegates of the 25th CSAM annual conference imagined answers to these questions in Banff, Alberta at the Banff Centre on Tunnel Mountain. As a first comer to the conference, I had a lot to learn and a lot to write down. Read more below.
Seven high-profile experts explored trends at home and abroad and the scientific topics impacting the future of addiction treatment delivery in their keynote plenaries.
1. Prescription Abuse (Dr. Roger Weiss)
Dr Weiss updated he delegates on the progress of the Prescription Opioid Addiction Treatment Study (POATS). The outcomes of the first phase of the trial were disastrously low, in contrast with the buprenorphine that was 7 times more effective after 4 weeks. Who did well? If you’d ever been in a treatment, or used not-as-prescribed prescription opioids, or the OxyContin was your most frequently used opioid – that was a bad sign. Older people did better. Interestingly, depression was also a good sign. What initiates the addiction is not necessarily what maintains the addiction.
2. Marihuana and Anxiety (Dr. Matthew Hill)
Dr Hill introduced the insights from the basic science field. Why people use cannabis? 84% say it helps them relax; to help reduce feelings of stress, tension and anxiety. The endocanabinoids tends to keep the amygdala quiet when it should be quiet. They act as natural regulators of the amygdala. Anxiety may be related to impairment in the endocannabinoid signalling. Dr Hill’s 2014 talk on the same topic has been recorded and posted online.
3. State of the Science for Technology-Based Approaches to Substance Use: Directions for the future (Dr. Sarah E. Lord)
Internet Electronic Therapy was the focus of the first afternoon plenary. Dr Lord described some of the tools that are out there, gave examples of them and validation data. Brief intervention and CBT-4-CBT were among them. The space of phone applications industry is far ahead of the science.
4. Integrative Addiction Medicine (Dr. G. Bunt)
The weather conditions worsened in Banff so much that Dr Bunt slipped and fell down on the way to the lecture hall (see Figure 1).
5. Brain Plasticity and Addiction (Dr. Bryan Kolb)
Dr Kolb kicked off the Saturday conference programme. Brain changes constantly. Anything you learn is going to occur because the brain changes. Play and stress too modify pre-frontal cortex. Interaction of brain and psychoactive drugs keeps fascinating scientists.
6. Clinical considerations for behavioural addictionsin the settings of DSM-5 and ICD-11 (Dr. Marc Potenza). During the first part of this millennium the perspectives on addiction changed, especially the behavioural addictions. How are they different or similar to substance use disorders? Many are strongly associated with behavioural addictions, e.g., heavy alcohol use and gambling. In addition to the high rates of co-occurrence, there are similar clinical courses, similar clinical characteristics, similar biologies and similar treatments for behavioural addictions.
7. The Alberta Addiction & Mental Health Review: Current challenges & lessons learned (Dr. David Swann).
Investment into addiction treatment is only a fraction of the Alberta’s budget – 0.1%. The current government of Alberta isn’t doing evidence-based policy but policing evidence. Racism is alive and well in Alberta. Lack of understanding led to the fiasco of the primary care reform in Alberta. It has an ambiguous direction on harm reduction. Dr Swann concluded his talk with 30 questions for the audience.
|Figure 1. Banff centre snow
November 5th, the national conference of the Association for Medical Education and Research in Addiction – AMERSA 39th – took place in Washington, DC. With 75% of the 225 delegates being new to the conference, the conference dynamics enlivened. As a rather small association with only 1 FTE, it is doing great in attracting so many new delegates. To see what lectures they got to hear, read my notes from the Keynote speeches below.
There is no room for prosecutors in the delivery room
Dr Paltrow questioned who gets the rights when it comes to pregnant drug users. While the laws in many US states try to protect the unborn child, in reality it is the judge, the county and the attorney who gets the rights. Is this the protection of the unborn or of the system? Dr Paltrow’s mother smoked during pregnancy:
“Maybe if my mom wasn’t smoking throughout her pregnancy, I might have been a for-profit lawyer.”
To reduce the stigmatisation of pregnant women with substance use disorders, make sure to “use the word use” – not Abuse, neither drug-dependent newborn. If you are asked to drug test when you shouldn’t, it is a moral obligation to do civil disobedience. The medical education should include teaching the risks that clinicians carry when they report pregnant women who use drugs.
What is appropriate counselling?
Dr Carroll posed some really important questions, such as –
How do we really get to good long-term outcomes? Is Medical Management (MM approach) that good? The intensity of MM done in trials is probably not scalable in clinical practice. We shouldn’t give up on the research evaluating psychosocial treatments. Let’s give the therapies a fighting chance, shall we? We’ve just gotta find a way to do better as therapists. Many trials report that people do not finish the treatment. We have to reach to underserved and vulnerable populations. We have to realise that people in buprenorphine treatment are different – they don’t seek counselling. CBT (Cognitive Behavioural Therapy) retains people in treatment 3x better than treatment as usual. Usual treatment does not teach people skills.
Betty Ford Award Plenary Session at the AMERSA 39th Annual National Conference
How AMERSA was saved? When Betty Ford learned in 1985 that the association is near extinction due to only $200 left in the kitty, she offered a $10.000 cheque from the royalties of her new biography and personal account. This year, Dr Caetano received award named after her. His Border project, and two other projects, found how the Mexican Americans and the Puerto Ricans drank much more than the other groups of US Hispanics. Women of this origin drank the most of all national groups in this country.
“No matter what is the dimension of drinking, the diversity is there.”
If you’re in Miami, it’s not gonna be helpful to know the national data. The local authorities need to know.
If you enjoyed reading about this year’s conference, you may like to read my notes from the previous year, 38th meeting in San Francisco, CA, November 4th, 2014.