s Final Concord seminar (ever): life beyond maintenance ... | I2P: Information to Pharmacists - Archive
Publication Date 01/07/2014         Volume. 6 No. 6   
Information to Pharmacists

Editorial

From the desk of the editor

Welcome to the July 2014 homepage edition of i2P (Information to Pharmacists) E-Magazine.
At the commencement of 2014 i2P focused on the need for the entire profession of pharmacy and its associated industry supports to undergo a renewal and regeneration.
We are now half-way through this year and it is quite apparent that pharmacy leaders do not yet have a cohesive and clear sense of direction.
Maybe the new initiative by Woolworths to deliver clinical service through young pharmacists and nurses may sharpen their focus.
If not, community pharmacy can look forward to losing a substantial and profitable market share of the clinical services market.
Who would you blame when that happens?
But I have to admit there is some effort, even though the results are but meagre.
In this edition of i2P we focus on the need for research about community pharmacy, the lack of activity from practicing pharmacists and when some research is delivered, a disconnect appears in its interpretation and implementation.

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News Flash

Newsflash Updates for July 2014

Newsflash Updates

Regular weekly updates that supplement the regular monthly homepage edition of i2P. 
Access and click on the title links that are illustrated

Comments: 1

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Feature Contribution

Woolworths Pharmacy - Getting One Stage Closer

Neil Johnston

It started with “tablet” computers deployed on shelves inside the retailer Coles, specifically to provide information to consumers relating to pain management and the sale of strong analgesics.
This development was reported in i2P under the title Coles Pharmacy Expansion and the Arid PGA Landscape”
In that article we reported that qualified information was a missing link that had come out of Coles market research as the reason to why it had not succeeded in dominating the pain market.
Of course, Woolworths was working on the same problem at the same time and had come up with a better solution - real people with good information.

Comments: 5

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Intensive Exposition without crossing over with a supermarket

Fiona Sartoretto Verna AIAPP

Editor's Note: The understanding of a pharmacy's presentation through the research that goes into the design of fixtures and fittings that highlight displays, is a never-ending component of pharmacy marketing.
Over the past decade, Australian pharmacy shop presentations have fallen behind in standards of excellence.
It does not take rocket science - you just have to open your eyes.
Recently, our two major supermarkets, Woolworths and Coles, have entered into the field of drug and condition information provision - right into the heartland of Australian Pharmacy.

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The sure way to drive business away

Gerald Quigley

I attended the Pregnancy, Baby and Children’s Expo in Brisbane recently.
What an eye and ear opening event that was!
Young Mums, mature Mums, partners of all ages, grandparents and friends……...many asking about health issues and seeking reassurances that they were doing the right thing.

Comments: 1

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‘Marketing Based Medicine’ – how bad is it?

Baz Bardoe

It should be the scandal of the century.
It potentially affects the health of almost everyone.
Healthcare providers and consumers alike should be up in arms. But apart from coverage in a few credible news sources the problem of ‘Marketing Based Medicine,’ as psychiatrist Dr Peter Parry terms it, hasn’t as yet generated the kind of universal outrage one might expect.

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Community Pharmacy Research - Are You Involved?

Mark Coleman

Government funding is always scarce and restricted.
If you are ever going to be a recipient of government funds you will need to fortify any application with evidence.
From a government perspective, this minimises risk.
I must admit that while I see evidence of research projects being managed by the PGA, I rarely see community pharmacists individually and actively engaged in the type of research that would further their own aims and objectives (and survival).

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Organisational Amnesia and the Lack of a Curator Inhibits Cultural Progress

Neil Johnston

Most of us leave a tremendous impact on pharmacies we work for (as proprietors, managers, contractors or employees)—in ways we’re not even aware of.
But organisational memories are often all too short, and without a central way to record that impact and capture the knowledge and individual contributions, they become lost to time.
It is ironic that technology has provided us with phenomenal tools for communication and connection, but much of it has also sped up our work lives and made knowledge and memory at work much more ephemeral.

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Academics on the payroll: the advertising you don't see

Staff Writer

This article was first published in The Conversation and was written by Wendy Lipworth, University of Sydney and Ian Kerridge, University of Sydney
In the endless drive to get people’s attention, advertising is going ‘native’, creeping in to places formerly reserved for editorial content. In this Native Advertising series we find out what it looks like, if readers can tell the difference, and more importantly, whether they care.
i2P has republished the article as it supports our own independent and ongoing investigations on how drug companies are involved in marketing-based medicine rather than evidence-based medicine.

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I’ve been thinking about admitting wrong.

Mark Neuenschwander

Editor's Note: This is an early article by Mark Neuenschwander we have republished after the soul-searching surrounding a recent Australian dispensing error involving methotrexate.
Hmm. There’s more than one way you could take that, huh? Like Someday when I get around to it (I’m not sure) I may admit that I was wrong about something. Actually, I’ve been thinking about the concept of admitting wrong. So don’t get your hopes up. No juicy confessions this month except that I wish it were easier for me to admit when I have been wrong or made a mistake.
Brian Goldman, an ER physician from Toronto, is host of the award-winning White Coat, Black Art on CBC Radio and slated to deliver the keynote at The unSUMMIT for Bedside Barcoding in Anaheim this May. His TED lecture, entitled, “Doctors make mistakes. Can we talk about it?” had already been viewed by 386,072 others before I watched it last week.

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Dispensing errors – a ripple effect of damage

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

Most readers will be aware of recent publicity relating to dispensing errors and in particular to deaths caused by methotrexate being incorrectly packed in dose administration aids.
The Pharmacy Board of Australia (PBA), in its Communique of 13 June 2014, described a methotrexate packing error leading to the death of a patient and noted “extra vigilance is required to be exercised by pharmacists with these drugs”.
This same case was reported by A Current Affair (ACA) in its program on Friday 20 June
http://aca.ninemsn.com.au/article/8863098/prescription-drug-warning

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Take a vacation from your vocation

Harvey Mackay

Have you ever had one of those days when all you could think was, “Gosh, do I need a vacation.”
Of course you have – because all work and no play aren’t good for anyone.
A vacation doesn’t have to be two weeks on a tropical island, or even a long weekend at the beach. 
A vacation just means taking a break from your everyday activities. 
A change of pace. 
It doesn’t matter where.
Everyone needs a vacation to rejuvenate mentally and physically. 
But did you also know that you can help boost our economy by taking some days off? 
Call it your personal stimulus package.

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Explainer: what is peer review?

Staff Writer

This article was first published in the Conversation. It caught our eye because "peer review" it is one of the standards for evidence-based medicines that has also been corrupted by global pharma.
The article is republished by i2P as part of its ongoing investigation into scientific fraud and was writtenby Andre Spicer, City University London and Thomas Roulet, University of Oxford
We’ve all heard the phrase “peer review” as giving credence to research and scholarly papers, but what does it actually mean?
How does it work?
Peer review is one of the gold standards of science. It’s a process where scientists (“peers”) evaluate the quality of other scientists' work. By doing this, they aim to ensure the work is rigorous, coherent, uses past research and adds to what we already knew.
Most scientific journals, conferences and grant applications have some sort of peer review system. In most cases it is “double blind” peer review. This means evaluators do not know the author(s), and the author(s) do not know the identity of the evaluators.
The intention behind this system is to ensure evaluation is not biased.
The more prestigious the journal, conference, or grant, the more demanding will be the review process, and the more likely the rejection. This prestige is why these papers tend to be more read and more cited.

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Dentists from the dark side?

Loretta Marron OAM BSc

While dining out with an elderly friend, I noticed that he kept his false tooth plate in his shirt pocket. He had recently had seven amalgam-filled teeth removed, because he believed that their toxins were making him sick; but his new plate was uncomfortable. He had been treated by an 'holistic dentist'. Claiming to offer a "safe and healthier alternative" to conventional dentistry, are they committed to our overall health and wellbeing or are they promoting unjustified fear, unnecessarily extracting teeth and wasting our money?

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Planning for Profit in 2015 – Your key to Business Success

Chris Foster

We are now entering a new financial year and it’s a great time to reflect on last year and highlight those things that went well and those that may have impacted negatively in the pursuit of your goals.
It's also a great to spend some time re-evaluating your personal and business short, medium and long term goals in the light of events over the last year.
The achievement of your goals will in many cases be dependent on setting and aspiring to specific financial targets. It's important that recognise that many of your personal goals will require you to generate sufficient business profits to fund those aspirations

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Attracting and Retaining Great People

Barry Urquhart

Welcome to the new financial year in Australia.
For many in business the past year has been described as a challenging period.
Adjectives are a key feature of the English language.  In the business lexicon their use can be, and often is evocative and stimulate creative images.  But they can also contribute to inexact, emotional perceptions.
Throughout the financial pages of newspapers and business magazines adjectives abound.
References to “hot” money draw attention and comment.  The recent wave of funds from Chinese investors, keen to remove their wealth from the jurisdiction and control of government regulations is creating a potential property bubble in Australia.

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Updating Your Values - Extending Your Culture

Neil Johnston

Pharmacy culture is dormant.
Being comprised of values, unless each value is continually addressed, updated or deleted, entire organisations can stagnate (or entire professions such as the pharmacy profession).
Good values offer a strong sense of security, knowing that if you operate within the boundaries of your values, you will succeed in your endeavours.

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Evidence-based medicine is broken. Why we need data and technology to fix it

Staff Writer

The following article is reprinted from The Conversation and forms up part of our library collection on evidence-based medicines.
At i2P we also believe that the current model of evidence is so fractured it will never be able to be repaired.
All that can happen is that health professionals should independently test and verify through their own investigations what evidence exists to prescribe a medicine of any potency.
Health professionals that have patients (such as pharmacists) are ideally placed to observe and record the efficacy for medicines.
All else should confine their criticisms to their evidence of the actual evidence published.
If there are holes in it then share that evidence with the rest of the world.
Otherwise, do not be in such a hurry to criticise professions that have good experience and judgement to make a good choice on behalf of their patients, simply because good evidence has not caught up with reality.

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Laropiprant is the Bad One; Niacin is/was/will always be the Good One

Staff Writer

Orthomolecular Medicine News Service, July 25, 2014
Laropiprant is the Bad One; Niacin is/was/will always be the Good One
by W. Todd Penberthy, PhD

(OMNS July 25, 2014) Niacin has been used for over 60 years in tens of thousands of patients with tremendously favorable therapeutic benefit (Carlson 2005).
In the first-person NY Times best seller, "8 Weeks to a Cure for Cholesterol," the author describes his journey from being a walking heart attack time bomb to a becoming a healthy individual.
He hails high-dose niacin as the one treatment that did more to correct his poor lipid profile than any other (Kowalski 2001).

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Culture Drive & Pharmacy Renewal

Neil Johnston

Deep within all of us we have a core set of values and beliefs that create the standards of behaviour that we align with when we set a particular direction in life.
Directions may change many times over a lifetime, but with life experiences and maturity values may increase in number or gain greater depth.
All of this is embraced under one word – “culture”.
When a business is born it will only develop if it has a sound culture, and the values that comprise that culture are initially inherent in the business founder.
A sound business culture equates to a successful business and that success is often expressed in the term “goodwill” which can be eventually translated to a dollar value.

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Pharmacy 2014 - Pharmacy Management Conference

Neil Johnston

The brave new world of health and wellness is not the enemy of Pharmacy, it is its champion.
Australian futurist, Morris Miselowski, one of the world's leading business visionaries, will present the Opening Keynote address on Pharmacy's Future in the new Health and Wellness Landscape at 2.00pm on Wednesday July 30.
Morris believes the key to better health care could already be in your pocket, with doctors soon set to prescribe iPhone apps, instead of pills.
Technology will revolutionise the health industry - a paradigm shift from healthcare to personal wellness.
Health and wellness applications on smartphones are already big news, and are dramatically changing the way we manage our personal health and everyday wellness.

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Generation and Application of Community Pharmacy Research

Neil Johnston

Editor’s Note: We have had a number of articles in this issue relating to pharmacy research.
The PGA has conducted a number of research initiatives over the years, including one recently reported in Pharmacy News that resulted from an analysis of the QCPP Patient Questionnaire.
Pharmacy Guild president, George Tambassis, appears to have authored the article following, and there also appears to be a disconnect between the survey report and its target audience illustrated by one of the respondent comments published.
I have asked Mark Coleman to follow through, elaborate and comment:

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Final Concord seminar (ever): life beyond maintenance ...

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.

Final Concord seminar (ever): life beyond maintenance ...

"The Exit Strategy Part 2: Is there life after methadone?"

Tuesday December 7 2010 saw the final Dependency Seminar at Concord Hospital, which concluded with a presentation of native flowers and thanks to Andrew Byrne, whose energy and organizing skills whose energy and organizing skills kept the Concord Seminars going over more than a decade. The series continues in similar format and new venue, at Royal Prince Alfred Hospital.

Nick Lintzeris and Richard Hallinan presented an overview of published evidence about duration of opioid substitution treatment (OST), withdrawal and reduction regimens, "cycling in and out of treatment", the relative ease of reductions for methadone and buprenorphine and other matters.

Key points:

People come off OST in numerous ways, the most common methods are simply jumping off, and gradual reductions.

The issue of exit from OST should be discussed openly at the time of treatment induction.

There should be a shared understanding of when coming off treatment is likely to be successful, and clear milestones for achieving this.

Abstinence from problematic substance use, and psychosocial stability are generally preconditions for coming off OST.

Psychoeducation is important to allay inappropriate fears about coming off treatment.

Patients need to understand that their body takes time to adjust (reverse neuroadaption to opioids) - it's not just a matter of "the methadone getting out of my system”.

A flexible menu of options for coming of treatment should be offered, as well as after care.

There is no evidence that transfer from methadone to buprenorphine improves the chances of sustainably coming off OST, but it is one of the menu of options.



Summary:

A common complaint about opioid substitution treatment (OST) is that there is "no exit strategy". People talk of liquid handcuffs, and critics claim OST just keeps people addicted forever.

How should the health professionals respond to a request for reductions toward abstinence? Is there any evidence to guide professional practice?

Richard Hallinan began by pointing out that people come off OST all the time, with retention rates varying from 40-70% after 12 months. Some "jump off" treatment, others use shorter or longer tapers of methadone or buprenorphine, or accelerated withdrawal regimens. But many or most of these people return to OST. There is a common pattern of cycling in and out of treatment, particularly with buprenorphine.

RH proposed to discuss "exit" from OST in terms of coming off treatment "sustainably". In the absence of an agreed definition he proposed a working definition: “sustainable exit” means not needing to return to OST.

Sadly, there is very little evidence for how this be best done. Korner and Waal (2005) reviewed the issue of reductions off MMT and found studies heterogenous, poorly described, methods and results extremely various. A total of 1900 people in 14 studies were followed up for 1 to 24 months after reductions off MMT, with reductions ranging over periods up to 7 months, with sustained periods of abstinence achieved by 33%, ranging from 22% to 86%.

Interestingly the 86% figure comes from Andrew Byrne's 9-year follow up published in 2000.

RH proposed some preconditions for sustainably coming off OST. There should be:
• no current injecting drug use nor problematic other substance use (otherwise there is a likelihood of relapse, or "swapping the witch for the bitch", ie substituting other drugs);
• no "chemical coping" with life stresses;
• psychosocial stability, including stable mental health (no uncontrolled mood or anxiety disorders) and stable housing; and
• no uncontrolled chronic pain.

As to when to start reducing off OST, RH proposed there should usually be 3-6 months since last problematic opioid use, and since last injecting drug use. The journey of reductions doesn't really begin until you achieve a probationary period of abstinence. Every time a person in OST injects, they are resetting the "trip meter" on their journey.

Should the reductions by a fixed or physician determined protocol, or flexible patient determined protocol with room to rest on the way? The small number of published benefit shows no clear benefit for physician regulation.

How fast should reductions be? 10% per 3-4 days (as for example at the residential facility WHOS MTAR: see Concord Summary from 2005), or 10% per week, or per month? Senay et al (1977) randomised MMT patients to 3% or 10% weekly reductions, and those reducing by the slower protocol did clearly better on a number of measures.

Should reductions be linear (straight down) or inverse exponential (landing like an aeroplane)? Strang and Gossop (1990) compared linear with inverse exponential reductions and found no benefit for the latter: perhaps because the reductions were completed within 10 days. One's impression is that most physicians and patients elect smaller dose reductions as their dose gets smaller.

Many people describe having "hit a wall" during attempts at methadone reductions, often after 4 or 5 successful dose reductions, and actually increased their dose again after that.

RH suggested one way of understanding the phenomenon of "hitting a wall" during reductions: consider the pattern of symptom recovery from one reduction, and then imagine what happens when you add more reductions.

Previous studies from the Maudsley showed symptoms peaking at the very end of both 10 and 21 day methadone reductions protocols, and declining slowly (and apparently inverse exponentially!) after that, persisting in a long "tail" up to 40 days (Gossop et al 1987, 1989).

Thus, after early rapid improvement of symptoms from one dose reduction, a person may be tempted to add another reduction, even though the "tail" of symptoms from the previous reduction persists. If enough "tails" accumulate, one is left with significant symptoms with no sign of improvement day to day: "hitting a wall".

Patients need to understand that their body takes time to adjust (reverse neuroadaption to opioids) - it's not just a matter of "the methadone getting out of my system", as many people imagine.

RH suggested reduction of 10% of the current dose (ie inverse exponential), every 3-4/weeks, resting whenever necessary, with the prescriber "pulling on the reins", as patients are often keen to reduce more quickly.

How long would it take to get off methadone at this rate? From 200mg methadone there are about 31 reductions. For example: 200mg - 180 - 165 - 150 - 135 - 120 - 110 - 100 - 90 - 80 - 70 - 62.5 - 55 - 50 - 45 - 40 - 35 - 32.5 - 30 - 27.5 - 25 - 22.5 - 20 - 17.5 - 15 - 12.5 - 10 - 8 - 6 - 4 - 2 - 0.

At 3 weeks between reductions, that’s 93 weeks to come off 200mg. Compare that with reductions from 100mg (24 reductions = 72 weeks) or from 50mg (19 reductions = 57 weeks).

The bottom end reductions take most of the time.

To put that in perspective, RH referred to a study from The Redfern Clinic (Hallinan et al 2006) which found each 50mg of increased methadone dose doubled the odds of not using heroin, the same odds achieved by staying an extra 34 months on MMT at the same dose.

Thus a higher dose may get people on the road to reductions much sooner, more than compensating for the modest increase in time required for reductions.

Of course, at some point people have to jump off (otherwise the frog would never reach the wall). Some people jump at 10mg. One patient of the Byrne surgery continued on 1mg methadone/day for many months.

Is coming off buprenorphine maintenance any easier?

Although there is some evidence for the superiority of buprenorphine for opioid withdrawal management (Gowing et al 2009), there is no published evidence to demonstrate sustainable reductions off maintenance pharmacotherapy are easier or quicker with buprenorphine, nor any evidence that transfer from MMT to buprenorphine with subsequent reductions is more effective than reductions off methadone maintenance (though it is feasible: Breen et al 2003). Top end buprenorphine reductions may be particularly easy where the daily dose exceeds receptor saturation (typically above 16 mg/day).

RH's advice is: don't transfer from methadone to buprenorphine for the sake of it; don't transfer to buprenorphine if methadone reductions are going well; but if the methadone dose is no longer "holding" 24 hours, there is a reasonable chance buprenorphine will last better. Methadone to buprenorphine transfer doesn't always succeed, and it can be disappointing to end up on 32mg buprenorphine when transferring from 25mg of methadone!


Nick Lintzeris advised us to take much of what RH had said with a grain of salt!

People come off OST every which way, is the long and short of it. His rule of thumb is that 1/3 of people find coming off MMT easy and 1/3 find it very difficult.

Breen et al (2003) found a majority of people on low dose methadone maintenance randomized to buprenorphine based reductions lasting up to 16 weeks managed to reduce to zero, but only 31% were abstinent from opiates a month later. The published evidence for long-term benefit of “rapid opioid detoxification” is equivocal at best (see seminar summary of The Exit Strategy Part 1).

NL pointed out that although many people would like to come off OST, many are daunted by the prospect; as are their care providers. A large cross-sectional study of MMT clients found only 17% had interest, confidence and good prospects for methadone reductions. Clinic staff and doctors were less optimistic about post-withdrawal outcomes than patients. (Lenné et al 2001).

NL also cited a recent study "Should I stay or should I go?" Coming off methadone and buprenorphine treatment. (Winstock et al 2010), showing high levels of interest and low levels of confidence in coming off OST; interest being higher in people who had been on treatment longer. Surprisingly, the most common method previously used was jumping off treatment (though perhaps that is why they were back in treatment). The idea of physician regulated-reductions was more popular among clients than patient-regulated.

But it is true that we have little research to guide us. We were reminded of the historical context: the first days of MMT in which the opioid treatment was seen as replacement in a neurochemical deficiency syndrome, with the expectation that the treatment would be long term, followed by a swing toward low dose and limited duration treatment in the 1990s. As evidence showed inferior results for lower doses and shorter treatments, by the middle years of this decade the swing was back to higher doses and longer treatment.

The fight to establish a person's right to stay on OST, if they need and want to, may have overshadowed considerations about how to end the treatment. It is particularly telling that one of the measures of treatment success in opioid pharmacotherapy is RETENTION in treatment.

NL pointed out that little is known about the long term consequences of opioid pharmacotherapy on physical health, as the patient cohort ages: 16% of OST patients in Australia are over the age of 50, and as they grow older, there will be increasing problems with other medical illnesses, medication interactions, transport and mobility issues, and the cost of continuing supervised dosing.

NL proposed that the issue of an exit from treatment should be discussed openly at the time of treatment induction. There should be a shared understanding of when coming off treatment is likely to be successful, and clear milestones for achieving this.P Psychoeducation is important to allay inappropriate fears about coming off treatment and a flexible menu of options for coming of treatment should be offered, as well as after care. Clearly we need more research on this subject.


There were two cases presented:

Hugh, 47 yo, was already 20 years on MMT, and his last heroin many years ago, though he continued weekly to monthly cocaine use. His highest previous MMT dose was 170mg and current dose 110mg. Previous reductions had stalled at 80mg, several times. He had decided he would never be able to get his dose under 80mg.

Detailed history revealed morning anxiety, butterflies in stomach especially when attending for supervised doses at 8am (take-home doses he consumed at 5am). Anxiety interfered with his work, sometimes feels afraid to go out. Hugh used occasional diazepam to assist with this, mainly on days of supervised dosing. On examination pre-dose Hugh had huge pupils and a pulse of 94. He was visibly anxious.

Hugh was offered a trial of low dose fluvoxamine 25mg mane, increased to 50mg/day with considerable improvement in his anxiety. Advised that methadone reductions would fail while his cocaine use continued, he indeed ceased cocaine use. At time of writing his methadone dose had reached 15 mg by logarithmic reductions over 2 years. Reductions were supported by PRN dispensing of small numbers of diazepam tabs 5mg*4 at a time, though he has now ceased these.

Discussion centred on the use of fluvoxamine to reduce methadone clearance in rapid metabolisers (with care needed that toxicity doesn't develop). One colleague reported a case of acute opioid withdrawal in a methadone patient who suddenly stopped their fluvoxamine.

The second case was Domel, whose first MMT was at age 26. He was a heroin smoker of 8 years. Though he continued THC heavily, he ceased heroin quickly with methadone dose at 85mg and reduced to 35mg methadone by 1 year into treatment. He transferred to 16 mg buprenorphine, with further reductions to 4mg within 5 months, and to 1.2mg by 10 months. However further reductions were limited by restless and cramped legs when his dose was late, feeling nauseous in the morning before dose, unable to cope if he missed a day's dose.

He reached 0.2 mg/day by 16 months, and 0.1mg (using "Temgesic" tablets) by 24 months into BMT. Despite the cost and inconvenience of continuing treatment, he was not prepared to jump off buprenorphine. At his physician's insistence he finally ceased buprenorphine a year later with assistance of clonidine, paracetamol, ibuprofen, leg and back stretches, and mirtazepine to assist with sleep. He remains opioid abstinent 12 months later.

Discussion centred on the possibility that Domel's symptoms were psychological (which neither he nor his physician believed), the difficulty of low-end reductions, and the unavailability of buprenorphine/naloxone in tablets less than 2mg buprenorphine.



Selected references

Breen CL, Harris SJ, Lintzeris N, Mattick RP, Hawken L, Bell J, Ritter AJ, Lenné
M, Mendoza E. Cessation of methadone maintenance treatment using buprenorphine: transfer from methadone to buprenorphine and subsequent buprenorphine reductions. Drug Alcohol Depend. 2003 Jul 20;71(1):49-55.

Byrne A. Nine-year follow-up of 86 consecutive patients treated with methadone in general practice, Sydney, Australia. Drug Alcohol Rev 2000;19:153 - 8.

Gossop M, Bradley B, Phillips GT. An investigation of withdrawal symptoms shown by opiate addicts during and subsequent to a 21-day in-patient methadone detoxification procedure. Addict Behav. 1987;12(1):1-6.

Gossop M, Griffiths P, Bradley B, Strang J. Opiate withdrawal symptoms in response to 10-day and 21-day methadone withdrawal programmes. Br J Psychiatry. 1989 Mar;154:360-3.

Gowing L, Ali R, White JM. Buprenorphine for the management of opioid withdrawal. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD002025. ..... "Buprenorphine may offer some advantages over methadone, at least in inpatient settings, in terms of quicker resolution of withdrawal symptoms and possibly slightly higher rates of completion of withdrawal."

Hallinan R, Ray J, Byrne A, Agho K, Attia J. Therapeutic thresholds in methadone maintenance treatment: a receiver operating characteristic analysis. Drug Alcohol Depend. 2006 Feb 1;81(2):129-36.

Kornor H, Waal H. From opioid maintenance to abstinence: a literature review. Drug Alcohol Rev. 2005 May;24(3):267-74.

Lenné M, Lintzeris N, Breen C, Harris S, Hawken L, Mattick R, Ritter A. Withdrawal from methadone maintenance treatment: prognosis and participant
perspectives. Aust N Z J Public Health. 2001 Apr;25(2):121-5.

Senay EC, Dorus W, Goldberg F, Thornton W. Withdrawal from methadone maintenance. Rate of withdrawal and expectation. Arch Gen Psychiatry. 1977 Mar;34(3):361-7.

Strang J, Gossop M. Comparison of linear versus inverse exponential methadone reduction curves in the detoxification of opiate addicts. Addict Behav. 1990;15(6):541-7.

Winstock AR, Lintzeris N, Lea T. "Should I stay or should I go?" Coming off methadone and buprenorphine treatment. Int J Drug Policy. 2010 Oct 16. [Epub ahead of print]

http://dependencyseminars.blogspot.com/2010_10_01_archive.html

http://www.redfernclinic.com/c/2005/03/peer-support-for-dependency-problems-12_5218.php4

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