s Does methadone cause QT problems or is it often viral? | I2P: Information to Pharmacists - Archive
Publication Date 01/12/2009         Volume. 1 No. 7   
Information to Pharmacists

Editorial

From the desk of the editor

Welcome to the December 2009 edition of i2p - Information to Pharmacists E-Magazine.
When i2P first began in February 2000, it was decided that a fortnightly publication might prove to be the optimum publishing cycle.
This thought was soon dispelled as it was found that having sufficient content to maintain this cycle became a problem.
Oh for those quieter times!
The cycle then became monthly and has been maintained up to now.
The problem is now coping with the volume of news and opinion that is generated on a daily basis.
Very much the reverse of the year 2000 - a statement for our time and how the pace of pharmacy life has increased.

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Recent Comments

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For some pharmacists the truth will be ‘inconvenient’. WHY is it so??

James Ellerson

Sir Winston Churchill said “Truth is incontrovertible, malice may attack it and ignorance may deride it, but, in the end, there it is.”
Elvis Presley said “Truth is like the sun. You can shut it out for a time, but it ain't goin' away.”

At the PAC 2009 Conference John Menadue’s forthright messages made it abundantly clear that the sun was shining very brightly indeed.
Here are the ‘message sticks’ that resonated with me:

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About that "Un-Invitation"

Dr John Dunlop (PGDipPharm, MPharm, DPharm(Auck), FACPP, FNZCP, FPSNZ, MCAPA)

It was interesting reading John Menadue’s speech given at the Pharmacy Australia Congress in Sydney in October.
It was even more interesting to read of the UN-invitation by the Queensland branch of the College of Pharmacy Practice and Management, the stance taken by the Pharmacy Guild of Australia and the Pharmaceutical Society, to support only pharmacy activities provided from within a community pharmacy.
How draconian is that?
Research has demonstrated, as has the low uptake of new professional services from within a community pharmacy, that the existing community pharmacy model is not compatible with the implementation of these new professional opportunities.
The two major arguments put forward are ‘lack of time’ and ‘lack of funding’.

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A Green Pharmacy is Gold

Neil Retallick

Simon Divecha, Director of GreenMode, a consultancy that assist business and people to find their carbon and sustainable advantages spoke at the recent Pharmacy 2009 Conference.
Simon has assisted businesses including BP Solar, Origin Energy, Lend Lease, ANZ and IAG.
His challenge to community pharmacy is to identify and take advantage of the opportunities that exist for businesses that have such close relationships with their local communities.

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What are we doing to ourselves?

Heidi Mahon

Over the last months, I've noticed the position taken by both the Guild as well as individual pharmacists on our on-line forums.

In his recent address Mr John Menadue poses the question - are pharmacists the most change-resistant health profession?

And if so, what is our future likely to hold?
What can we do about it?

Personally, I have to agree with him - if we as a group - and not just the Guild, DON'T take innovation as a prerequisite for how we practice our profession, then in 20 years time, what will we have left?

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Picture - the wood for the trees

Pat Gallagher

Another year has gone by and what have we done with technology in the health sector?
A good question that deserves a long and detailed review as a written dissertation by somebody learned and influential in health informatics, government, consulting or from the many agencies, departments and committees engaged in delivering e-health service to the Australian public; notably as a value proposition for the tax payers in the greater voting public cohort.

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Advancing Self Care

Neil Johnston

Imagine a pharmacy that had a range of eye catching kiosks that utilised easy to use touch screen technology.
Not passive kiosks, but kiosks that are interactive with customers/patients to efficiently provide a perceived need.
It’s not a new idea, but the marketing of health care through kiosks certainly represents an organised method of transferring information to customers/patients and assisting them to make good health decisions.
One current form of kiosk that is beginning to take hold in Europe and the US is the vision kiosk.

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Wind Farm will Power Sydney's Desalination Plant

Staff Writer

Source: AAP NewsWire

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Communications Technology - a nudge from the big end of town

Staff Writer

National Health IT assumed prominence recently when the National Business Council of Australia wrote directly to prime minister, Kevin Rudd, urging him to create a focus on communications technology and to invest appropriate funds.
I wonder if they were aware of the organisational performance 0f NEHTA and their inability to date, to actually deliver suitable infrastructure and systems.
And with $'s millions already wasted by NEHTA I am sure there is hesitancy by government to spend even more, given the dismal track record to date.
Health communications is stuck in a deep groove.
But it is interesting to note that the Business Council of Australia see productivity and investment opportunities in health if only the primary health players could integrate better and talk to one another.
Shared health communications underpins this potential benefit as the many writers for i2P have continually pointed out.
With the big end of town taking more interest, maybe government and health professionals can align themselves more fluidly.
A read of David More's blog article from a NEHTA insider in this edition of i2P, leaves you still wondering how an alignment can take place without removing the NEHTA structure completely.

Health info needs urgent technological injection

Source: Industry Search -24/11/2009

http://www.industrysearch.com.au/Features/Health-info-needs-urgent-technological-injection-4306

Read the BCA letter in full here

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Powering up by osmosis

Staff Writer

An unusual form of renewable energy has emerged recently in a novel format involving the use of fresh water and salt water interaction across a membrane that creates osmotic pressure.
This pressure has been demonstrated to be able to drive a turbine that can produce an electric current.
Osmotic pressure is well known in medicine with adjustments having to be made to eye drop and injection formulas to minimise the pain associated with the administration of these medicine forms.

The process is a more controllable form of natural energy when compared with weather-dependent versions of energy generation (solar, wind, tidal etc) and has a reasonably small and discrete footprint in the environment.
With a bit of imagination it is not too far of a stretch to have the salt water filtered through another form of membrane to create fresh water to be recycled within a closed system.

Norway tries osmotic power to harnessing power of salt

Source: Industry Search

http://www.industrysearch.com.au/News/Norway-tries-osmotic-power-to-harnessing-power-of-salt-42094

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Insuring the Disabled

Staff Writer

Prime Minister Kevin Rudd is to be commended for the initiative in having a look at the feasibility of creating a no fault disability insurance scheme.
Disability can cause disaster to any family structure and can be a constant drain on financial resources that can add to further stresses up to, and involving bankruptcies.
By putting in place a proper financial underpin, each family member is enabled to be productive and self-sustaining. This can create a net gain to the taxation base when viewed globally, to include service providers and industries that can feed off that activity stream.

PM calls for national disability reforms

Source:DPS Guide to Aged Care

http://www.agedcareguide.com.au/news.asp?newsid=4178

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Should patents apply to the natural world?

Staff Writer

I can't but help wonder if the move to be able to patent all things natural is a smart move.
Take for example the Neam tree that grows wild in the northern part of Australia.
The leaves of this tree make a great insect repellent with no known side effects.
An entrepreneurial Australian a few years back, decided to grow these trees and was surprised to have legal documents served on him claiming royalties and damages from some obscure US company that had registered a patent for all things Neam.
Unfortunately, there was no legal defence for the Australian grower.
Now there is an outcry by vested interests because the Australian government has resisted pressures to allow the patenting of human genes.
All sorts of calamities are therefore predicted for the local biotech industries.
But I wonder if these claims will prove to be valid?

Follow the debate in this article:

Ban drives 'biotech industry to its knees'

http://www.news.com.au/story/0,23599,26309574-5011761,00.html?from=public_rss

Source: AAP

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Public Hospitals - Time they were fixed

Staff Writer

Queensland Health struggles through another drama after using instruments that had been used on patients and left unsterilised.
But it's not just Bundaberg Hospital that is sick - the entire Australian hospital system needs a radical overhaul.
The Rudd government had promised to "fix" the problem after taking office, but so far has not made any noticeable progress.
Read about the latest problem.

Qld Health cleaning up after dental sterilisation scare

Source: ABC Online

http://www.abc.net.au/news/stories/2009/11/18/2745842.htm

By Chris O'Brien

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Patient uses initiative to attract nurses

Staff Writer

If anyone has ever been a patient in a hospital and tried the buzzer to get assistance from a nurse, then here is a new innovation to get attention.
Not that the nursing fraternity should shoulder the blame.
It's the politicians and the lack of political will to solve this issue and many others.
Congratulations to the patient and his initiative in dialling triple O.
Read the full story here:

Man rings triple-0 from hospital bed

Source: ABC Online

by Cate Grant

http://www.abc.net.au/news/stories/2009/11/18/2745829.htm

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What's good for climate is good for health

Staff Writer

Health professionals from around the world are slowly waking up to the fact that climate change can induce adverse effects on health.
At i2P we have been carrying messages for just on two years, regarding climate change effects, including research reports from our own writer Con Berbatis, in the hope that official pharmacy would see the need and develop policies and strategies for pharmacists to adopt.
Now, with the formation of the International Climate and Health Council a recognised forum is available to be addressed.
Will pharmacists be given a seat at the table?
Perhaps the Pharmaceutical Society of Australia should find out.

Health Professionals Around The World Launch The International Climate And Health Council

Source: Medical News Today

http://www.medicalnewstoday.com/articles/172330.php?nfid=20247

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Ageing slowly and safely

Staff Writer

The ageing process is relentless with function loss noticeably diminishing over the age of 60.
Supplementation of nutrients holds one key to slowing down some of the processes, in particular the loss of muscle mass and the subsequent aches and pains that follow as the skeletal system is no longer held together in an optimum manner.
This process can be a contributor to falls and more serious damage.
Not being able to adequately stay on your feet as you age, robs you of your independence.
It would seem that a strategy of slowing down slowly might be prudent for the age demographic entering retirement - the "baby-boomers".

Antioxidants could help preserve muscle strength

Source: Reuters Health
By Marilynn Larkin

Found at this link

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Are we planning for future skill shortages?

Neil Johnston

National Seniors Agency have published a report indicating that Australia will have a shortfall of 1.4 million workers by 2025.
This shortage will also be reflected in the profession of pharmacy.
It is pointed out that a smart move would be to match an improved workplace to match specific requirements for mature-aged employees and thus retain them for longer periods..
APESMA has recently published an online survey in an endeavour to poll employed pharmacists on the issues that affect them specifically. Obviously, this is a move in the right direction, and much of what they are polling has a direct relationship to mature-aged employees.

So what is community pharmacy doing to retain their senior pharmacists?

Very little, it seems.

i2P asked Mark Coleman to comment and his commentary appears below the news item:

Comments: 1

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Does methadone cause QT problems or is it often viral?

Dr Andrew Byrne & Associates

articles by this author...

A Harm-Minimisation Research Perspective: Dr Byrne (and his associates) advocate for better policies which are proven to reduce risks for drug users and the general community, under a framework in parallel with Australia’s official policy of harm minimisation.

HIV and Long QT syndrome - Cause or coincidence?
Puri R, Roberts-Thomson KC, Young GD. International Journal of Cardiology 2009 133;1:e9-e10

Dear Colleagues,
This may be the first article to formally describe the link between HIV and torsade de pointes tachycardia and at the same time to question the role of methadone.
Their single case report has much in common with others in the literature: the 36 year old female with HIV was taking long term methadone for dependency and presented with recurrent syncope.
The dose was only 70mg daily at the time of the torsade but importantly, had been 190mg daily 18 months previously – at which time ECG showed the QTc to be normal - and there were no cardiac symptoms. The authors proposed that their patient did not have methadone induced QT changes, but HIV-induced long QT (LQT) syndrome.
The QTc was 540ms around the time of the torsade.

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These authors go on to discuss the effects of HIV on the heart. Up to 60% apparently have positive cardiac findings at autopsy and 30% of cases may have asymptomatic prolonged QTc, largely in the absence of ‘culprit’ medications (citing Kocheril 1997). “Minor repolarisation abnormalities in HIV infecteds may therefore become clinically overt in the setting of concomitant predisposing drug therapies.”

The authors state in their introduction: “Methadone use has been associated with prolongation of the QTc and an increased risk of sudden cardiac death.” In fact after 40 years of widespread use there has been no such association with sudden cardiac deaths. Yet this statement well exemplifies the current popular mythology around the subject. Since Krantz and colleagues wrote the original case series (but not the first case) in 2002, there have been no confirmed or strongly suspected deaths due to torsade tachycardia from my reading. The only 2 or 3 deaths were either remote from the period of the torsade and/or else due to another reported cause such as myocardial infarction. French reports from over 30 years ago quote a mortality from ‘torsade de pointes’ of around 16%. Since this was before modern mobile resuscitation and pacing technologies were widespread, the survival rate of 84% might have increased to something over 95%.

It is now clear that ‘torsade de pointes’ tachycardia rarely if ever occurs in new entrants to methadone treatment. The 103 reports in the literature and Justo’s excellent summary of the field in the Addiction journal inform us that simple clinical features can highlight risk and indicate the need for ECG monitoring where appropriate. Almost 50% of the ~100 reported cases in the literature had HIV infection. The author of the original FDA report, Ellen Pearson, has postulated that QT prolongation and torsade are ‘threshold events’ with numerous contributors based on the known risk factors.

The risk factors (not in order) are:

(1) long term methadone maintenance for addiction

(2) female sex

(3) age over 40

(4) doses over 150mg daily

(5) HIV infection

(6) concomitant use of drugs which either increase methadone levels and/or prolong QT interval

(7) metabolic disturbance

(8) structural heart disease

Comments by Andrew Byrne ..

Clinic web page: http://www.redfernclinic.com/c/

Refs:

Kocheril AG, Bokhari SAJ, Batsford WP, et al. Long QTc and torsades de pointes in human immunodeficiency virus disease. Pacing Clin Electrophysiol 1997 20:2810-6

Krantz MJ, Lewkowiez L, Hays H, Woodroffe MA, D. Robertson AD, Mehler PS. Torsade de Pointes Associated with Very-High-Dose Methadone. Ann Intern Med. 2002 137:501-504

Dessertenne PF. La tachycardie ventriculaire a deux foyers opposes variables. Arch Mal Coeur 1966 59:263-72

Pearson EC, Woosley RL. QT prolongation and torsades de pointes among methadone users: reports to the FDA spontaneous reporting system. Pharmcoepidemiol Drug Safety. 2005 14;11:747-753

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