s New York Pain Conference | I2P: Information to Pharmacists - Archive
Publication Date 24/05/2010         Volume. 2 No. 5   
Information to Pharmacists

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Newslflash updates for June 2010

Newsflash Updates

Regular updates from the global world of pharmacy.
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Feature Contribution

Do the Maths - 1200 Graduates a Year and Increasing

Neil Johnston

Pharmacists graduating within Australia must have a reasonable assurance that on graduation they will have some form of a job available for them, after due diligence and reasonable effort on their part to get themselves recruited.
The current maths do not stack up - 5000 pharmacies to accommodate 1200 graduates nationally, and increasing.
Who is responsible for the planning for graduates?

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GPs were the ‘gatekeepers’ to the health system. Will they remain so?

James Ellerson

It’s often hard to tell which party is in favour of what outcome when reading some of the media coverage on doctor, pharmacy, nurse practitioner prescribing issues. Here are a few examples to ponder:

• the Guild is opposed to pharmacist prescribing

• pharmacists and nurse practitioners are to be given limited prescribing rights

• most GPs do not actually consult with a patient before issuing a repeat script.

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Is eHealth critical to navigating the world of primary care?

Dr Ian Colclough

Primary health care reform is firmly on the political agenda. For reforms to succeed they must be underpinned by the successful deployment of ehealth; absolutely.
The last decade has witnessed a major lost opportunity for ehealth in Primary Care. Many hundreds of millions of dollars have been wasted on unrealistically ambitious and poorly managed ehealth projects; many of which have failed.
Aptly named Primary Health Care Organisations (PHCO), recently inappropriately renamed ‘Medicare Locals’, will be the centre point of the reform process. Consequently a palpable sense of urgency has developed around ehealth as its central role in the health reform process becomes increasingly apparent to politicians and bureaucrats.

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PSA Future of Pharmacy-Technicians to manage dispensing

Neil Johnston

Comment has been recently made in pharmacy media on the PSA Issues Paper on the “Future of Pharmacy in Australia” in respect of the upskilling of dispensing technicians to dispense without pharmacist oversight.
Comments offered on this aspect included reduced job opportunities for pharmacists, pressure to lower dispensing fees, opportunity to develop clinical services e.g. the ability to perform HMR’s.
No doubt more comment will follow as the paper is digested and potential flow-on impacts are thought through.
Writers will be participating through the pages of the i2P e-magazine to hopefully help build the future version of this PSA paper.

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Health: The Pollies are playing us as well as Orianthi plays the guitar.

Chris Wright

Our politicians are spinning like fury as we head towards the election and despite the fact their gift for spin doesn’t match Orianthi Panagaris’ gift for playing guitar they are getting away with electoral blue murder.
As for “fixing” the health system, the rhetoric is never matched by performance. After all, it is questionable that “fixing” health actually translates to votes, simply because the money required to make an impact is too great an amount compared to the votes gained…besides “fixing” is subjective anyway.

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What is it with pharmacy?

Garry Boyd

The colleges are churning out Pharmacists at a rate that would embarrass the most discerning “people-smuggler”……..

Apologies for the errant humor leading to an election.
Some 1,200 bright-eyed and bushy-tailed fine and mostly young pharmacists are hitting the job market and will somehow try to squeeze into 5,000 pharmacies.
Worse, a similar number will follow them fairly smartly.

What’s it all about, I wonder?

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Looking for answers

Barry Urquhart

Everyone, it seems, is looking for answers. For most there are none “out there”. Those who ask the right questions generally find the right answers “within”.

Solutions abound, looking for problems. Few can define and even fewer recognise the nature and presence of specific problems. Resources are being liberally allocated to furnishing, deploying or paying for preset solutions. Disappointment and dissatisfaction seem inevitable.

Experts are readily accessible. Expertise is harder to find. The business landscape appears to be lush with new green shoots, yet barren. Much like the desert and the Lake Eyre regions of central Australia.

The climates of regions throughout the world are changing. Temperatures are rising. Record cold snaps are also being recorded. Extended dry spells are evident, offset by deluges of flooding proportions.

Prognostications by some economists conclude “boom times” have arrived or are on the near horizon. Many consumers have obviously not heard or read of the confidence building forecasts. They are constraining purchases and outlays. Retailers, particularly smaller entities, are confused, and are finding trading is tough.

In recent times we have worked with clients from a broad spectrum of sectors producing formats, templates and frameworks which enable them to “look within”.

Real riches are being rediscovered, refined and celebrated. Positive and embracing corporate cultures, are being revisited and pride inculcated, because of what made entities great and competitively advantaged in the first instance.
Distinctive symbols and myths are being recognised, valued and applied for internal cohesion, self motivation and for external profiling.
The article text which features later in this transmission unveils and outlines encouraging lessons and principles on the role and nature of a positive corporate culture.

I commend it to the former executives, the players and besieged supporters of the once high achieving, now disgraced Melbourne Storm Rugby League team.
Barry Urquhart

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NAPE begs more questions than answers- for the moment

Neil Johnston

The ideal of having quality continuing pharmacy education, delivered in digestible “bite-sized” chunks plus convenience of delivery at an economical cost has been a dream for pharmacists for as long as I can remember.
With the advent of the new Australian Pharmacy Board there will be requirement for all pharmacists to undertake suitable education to maintain their registration.
While there are many acceptable education streams coming from the Pharmaceutical Society of Australia (PSA), the Pharmacy Guild of Australia (PGA) and the Australian College of Pharmacy Practice (ACPP), there is not a high degree of planning to anticipate all pharmacist needs.
For example, the delivery of professional services for a fee – there is no identifiable pathway enabling individual pharmacists to develop a professional practice that could be incorporated into a community pharmacy, a primary health care organisation, a medical centre or other suitable location.

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Hmmm, I’m not convinced

Garry Boyd

A Woolworths “spokesman” (they are all still so very alpha at Woolies) has come out (excuse the expression) and declared the loss of interest in not only their “pharmacy” type trademarks but the industry of pharmacy itself.
980218 Pharmacist at Woolworths and 980219 PHARMACIST @ WOOLWORTHS, both previously registered trade marks, have been cancelled.

Comments: 3

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Naturopathy and my Doctor.

Chris Wright

To my pleasant surprise the family doctor offered a choice to address a painful problem highlighted by scans.
Acupuncture or an anti-inflammatory drug?
Acupuncture any day thank you, without the fries.

Comments: 2

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Better patient advice loses out to costly prescription errors

Staff Writer

A University of Otago study which shows pharmacists spend too much time seeking clarification for minor prescription errors has prompted a call for greater awareness among doctors and prescribers of this time-wasting problem.

Lead author and School of Pharmacy Senior Lecturer Dr Rhiannon Braund says the study of 20 Dunedin pharmacies found that in most cases unnecessary minor bureaucratic errors were the reason for pharmacists needing to confirm the intent of prescribers - usually doctors.

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Study shows Australian quality of life varies widely

Staff Writer

A survey of 5000 Australians conducted by the University of Technology Sydney has shown middle aged people express the lowest level in quality of life compared with people in their early 20s or mid 60’s.

The finding which throws the ‘life begins at 40’ cliché into serious doubt is among a number of revelations gained from the study.
Findings of the research will be discussed in a public lecture held at the UTS Great Hall on Tuesday 25 May 2010. Details for the lecture which is open to the public for free can be obtained from the UTS web site www.uts.edu.au/new/speaks/2010/May/2505.htm

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Public participation heats up on climate change

Staff Writer

Australians believe that climate change is here to stay, but their expectations about the severity of change fall well short of what scientists predict.
This is one of the key findings from a three-year study led by The Australian National University. The Climate Change and the Public Sphere project has interviewed more than 100 randomly selected citizens from the ACT and Goulburn about their views on climate change in various, increasingly severe, situations and how they are likely to react to it in the future.

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Killed by cold: heart and stroke deaths peak in winter

Staff Writer

* Perth and Sydney lead the country in winter heart-related deaths

* Tasmanians cope best with the cold

* Brisbane not far behind Sydney for winter deaths

* Darwin fares the best because it doesn't get so cold

Rates of cardiovascular disease increase dramatically in Australian winters because many people don't know how to rug up against the cold, a Queensland University of Technology (QUT) seasonal researcher has found.

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Traumatic brain injury linked to sleep disturbance

Staff Writer

A Monash University study has shown that sleep disturbances and depression symptoms are common among people who have suffered Traumatic Brain Injury (TBI).
The team of researchers from the School of Psychology and Psychiatry measured in a laboratory setting the sleep of 23 patients with TBI with 23 healthy people who had not suffered trauma.
Study leader, Associate Professor Shantha Rajaratnam said patients with TBI showed increased sleep disturbance and reported poorer sleep quality, and higher anxiety and depressive symptoms than healthy volunteers.

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Blood Thinners May Prevent Malaria

Staff Writer

New treatments for malaria are possible after Walter and Eliza Hall Institute scientists found that molecules similar to the blood-thinning drug heparin can stop malaria from infecting red blood cells.
Malaria is an infection of red blood cells that is transmitted by mosquitoes.
The most common form of malaria is caused by the parasite Plasmodium falciparum which burrows into red blood cells where it rapidly multiplies, leading to massive numbers of parasites in the blood stream that can cause severe disease and death.

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PAC 10- A Focus on Pharmacy Practice Change

Staff Writer

Pharmacy practice must shift its primary mission from supplying medicines to helping people make the best use of medicines in order to meet the needs of the public and ensure its survival as a health profession.
This is the view of leading US pharmacy expert Professor William A. Zellmer who will present on the topic of The Imperative for Change in Pharmacy Practice at PAC10 in October this year.

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Drug Company Battles with NZ Pharmacy Guild

Staff Writer

In a recent news item reported in the New Zealand Stuff.co.nz highlights a drug recall problem that had significant associated costs involving community pharmacy participation.
It is a problem that could occur within Australia and is currently before the courts in New Zealand.
The problem does reflect on the existing culture within the pharmacy profession where for too long pharmacists have virtually donated their services in instances where there should have been an expectation of payment for a professional service.
PGA (Australia) could monitor the legal process in New Zealand and adopt a protocol, if the result proves favourable to pharmacy.
The story (found online here) follows below:

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Hmmm, I’m not convinced

Garry Boyd

A Woolworths “spokesman” (they are all still so very alpha at Woolies) has come out (excuse the expression) and declared the loss of interest in not only their “pharmacy” type trademarks but the industry of pharmacy itself.
980218 Pharmacist at Woolworths and 980219 PHARMACIST @ WOOLWORTHS, both previously registered trade marks, have been cancelled.

Comments: 3

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Sunlight shines on clean energy future

Staff Writer

Dr Zhiguo Yi and Professor Ray Withers have found a simple inorganic compound can efficiently oxidise water to release oxygen.
The production of clean energy and the treatment of waste water are set to become easier thanks to ANU researchers.
The scientists – Dr Zhiguo Yi and Professor Ray L Withers of the Research School of Chemistry at ANU, along with colleagues from Japan and China – have demonstrated that a simple inorganic compound, silver orthophosphate, can efficiently be used to oxidise water with only the power of light.
The oxidisation process can be used to convert solar energy to clean energy or break down contaminants in water.
The research is published in Nature Materials.

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The Ascendancy of Warwick Plunkett

Neil Johnston

Prior to negotiations commencing for the Fifth Community Pharmacy Agreement (5CPA) the Pharmaceutical Society of Australia (PSA) and the Pharmacy Guild of Australia agreed that the two organisations would present a unified front in their dealings with government.

That did not happen and many details of the 5CPA were completed in secrecy and without the appropriate input by the PSA.

Explanations were later offered by the PGA, but they rang a little hollow and were certainly outside of the spirit of a unified front.

Certainly, on the surface it appears that the PGA did not honour an agreement and was prepared to discount their formal agreement to the extent that it seemed not to exist at all.

The news item reporting the rift between the two organisations follows and Mark Coleman has been asked to provide a commentary at the foot of this news item.

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New York Pain Conference

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.

Pain and addiction conference, Beth Israel Medical Center. Friday 19th and Sat 20th March 2010.

“Emerging Practices in Pain and Chemical Dependency - 2010 Update on Opioid Therapy” 

Times have changed since I attended a Darwinian progenitor of this pain conference in New York in 1996.  The present conference was held at the Times Square Marquis Marriott Hotel, starting promptly at 7.30am.  The conference room was crowded with perhaps 300 attending.  I sat in the front row, near convenor Dr Russell Portenoy, pain expert from Beth Israel Medical Center.  Also present at the front were Ricardo Cruciani, expert on cardiac effects in methadone pain patients; Joyce Lowinson, editor of the big text on dependency; Herman Joseph; Mary Jeanne Kreek; Charles Inturrisi and Howard Heit.  The latter is a close research colleague of Canadian pain and dependency expert Doug Gourlay.

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Each speaker gave a list of potential conflicts of interest including sponsorship from drug companies. One quipped that in the past this declaration was considered a badge of honour. Nowadays however, we were told, it was more a matter of shame! It is interesting to consider the different situations of speakers with one single declared conflict of interest over those with many. “Render unto Caesar …”.

Howard Heit gave the second key-note dissertation entitled ‘Understanding risk in terms of chemical dependency: abuse, addiction and diversion during pain treatment’. In it he quoted his recent article with Dr Doug Gourlay (‘Universal Precautions Revisited’ 2009) with its ‘ten point rules’ for assessing risk of dependency. He called them his Ten Commandments. These carefully codify what should normally be done in good practice: history and physical; differential diagnosis; patient education and consent (oral/written); treatment trial; clinical review … and finally: careful documentation of each step. These are part of the clinical interaction which can help reveal features of substance use instability as well as the benefits or otherwise of current pain treatment.

Dr Heit also covered pseudo-addiction in the pain patient (usually diagnosed in retrospect).  He reminded us that all medical interventions need an ‘exit strategy’, outlining a way of contracting with the patient what might occur if all else failed in the therapeutic relationship.  He spoke about a “golden moment” in the patient’s ‘growth’ when they realised they are through playing games and are addicted.  This acceptance of addiction and associated lack of control can be very moving.  A Sydney colleague once described this, saying the patient always had a tear in the eye as it was related.  We were reminded about the continuum between chronic pain and addiction and the need to treat according to individual need, utilising all the means at our disposal after non-opioid measures have failed … including dose supervision, urine testing, drug diary, counselling, adjuvant prescribing (eg. antidepressants, anxiolytics) etc. 

Dr Ricardo Cruciani gave a talk about choice of opioid and matching patient to appropriate treatment.  He placed opioid prescribing into its proper clinical context along with other physical, surgical, psychological, life-style and alternative pharmacological approaches.  He advised that in the absence of clear evidence opioid treatment is still considered effective and ‘conventional’ in many clinical settings.  We were reminded of the risks of all such prescribing: abuse, addiction, diversion and overdose.  Dr Cruciani broached the rising incidence of deaths involving methadone which was explained by Herman Joseph in question time as being related to the recent expansion of its use in pain patients.  The long half life of methadone has particular benefits in pain management but also requires that physicians be wary of dose escalations which can be toxic. 

Dr Cruciani also gave one of the three morning break-out sessions entitled “Methadone Cardiac Toxicity”.  I was disappointed that he used such a ‘loaded’ title when methadone has still not been scientifically proven to have any clinical cardiac toxicity and may indeed be cardio-protective.  Methadone is associated with electrical changes to the QT interval which are nearly always asymptomatic.  Dr Cruciani gave a roll-out of the literature with more about the ‘unknowns’ that the ‘knowns’.  He repeated that more research needed to be done but did not seem to be aware of the 2009 publication from Norway which has discounted the worrying conclusions he quoted from the studies of Chugh and Fanoe.  These both concluded that torsade may be very common, yet  Anchersen’s comprehensive national study did not find one single confirmed arrhythmia case out of 90 deceased methadone patients in a 7 year period in Norway.  Dr Cruciani correctly emphasised how little we know about torsade de pointes tachycardia and the (supposed) toxicity of methadone.  I believe that this is largely due to the small number of cases ever seen in normal dependency or pain practice.  I continue to meet doctors who have worked full-time in this area for decades without seeing a single case of syncope due to torsade de pointes.  Two experienced colleagues responded separately from Melbourne this month - one had just seen his first case, an older female patient, the other had seen none in 20 years. 

Rather than having cardiac toxicity, it is quite possible that methadone treatment (at least for addiction) promotes cardiac health as pointed out eloquently by Mori Krantz in his paper with Stewart Leavitt from 2001.  This involves a likely lower risk of endocarditis, dyslipidaemia interventions, blood pressure treatment and smoking cessation which are all thought to be better in those taking methadone than in those using street drugs.  There is also some indication of lower rates of myocardial infarction in MMT subjects.  Dr Lisa Borg’s work has shown that higher doses of methadone can reduce cocaine use while the work of Forest Tennant has implied that in some cases alcohol use may diminish in those prescribed methadone.  Both of these could be expected to cause less cardiac irritability and lowered chance of torsade, quite contrary to the prevailing scare campaign. 

It is to his credit that Dr Cruciani has consistently said that there is still no evidence to alter existing practice.  However, he leaves the door open to further research which might do so … and that caution needs to be exercised regarding the risk of torsade tachycardia.  It was just a shame that he did not separate the two clear clinical groups: the young, ‘uncomplicated’ opioid users or pain subjects who have virtually no risk of this complication … as contrasted with an older, more complex group in which torsade risk is a reality, albeit very low.  Reddy’s study from Texas has shown prospectively that methadone is safe in cancer patients even though QT intervals are often raised even before patients were prescribed the methadone.  All clinicians who prescribe methadone will have to learn to deal with this problem as our patients get older and other life-saving drugs are co-prescribed (most notably anti-virals and anti-fungals).  However presently, few will encounter more than one or two in a clinical lifetime so collaboration is essential to elucidate the best ways to deal with torsade de pointes cases. 

I asked Dr Cruciani a loaded question regarding the use of methadone in over a million patients under close supervision and whether the almost complete absence of confirmed torsade deaths and paucity of non-fatal torsade reports were not better than the prospective evidence he and his ‘expert panel’ were calling for.  Dr Cruciani seemed annoyed at the question and alluded to my suggestion of ignoring the cardiac risk until it was proven.  I had stated that doctors who were ignorant of the issue probably give their patients better quality treatment than those who worry over it, thereby restricting doses or using a less effective drug in cases where there is a choice. 

Dr Cruciani said that he would not advise anyone to ignore this issue.  The evidence is now overwhelming that the minor but important issue of possible cardiac toxicity of methadone has been fanned along by ignorance, the long-standing prejudice against methadone and also strong commercial considerations.  My view is to treat all patients individually.  The risk of torsade - and many other rare but serious events - can be stratified and possibly prevented using simple clinical details.  Screening ECG was recommended by only one of 13 citations given (Krantz 2009 did; Krantz 2007 did not: ‘for high risk patients’).  A compulsory ECG in the present state of knowledge (or ignorance) is more likely to harm the patient than help them in my view.  The largest literature review by Justo found that 85-100% of torsade cases had predisposing factors such as hypokalemia, structural heart disease, older age, QT prolonging drugs, drugs slowing methadone metabolism, female sex, older age, HIV status, alcohol use/withdrawal, stimulant use, inter alia. 

We then had two interesting talks which probably only had peripheral relevance to doctors and patients in the fields of addiction and pain management.  Firstly Mary Jeanne Kreek spoke about genetic aspects of addiction and the work her lab has been doing for over twenty years.  While she gave an excellent summary of the natural history of addiction, I venture to say that, while fascinating academically and promising for the future, few if any of their recent scientific papers on this subject have been of direct benefit to patients or public health.  Dr. Kreek also provided some interesting insights about the early days at Rockefeller University working with Drs Dole and Nyswander.  Dr Kreek omitted to mention that it was in fact Dr Robert Halliday in Vancouver who first used methadone for opioid addiction between 1959 and 1964.  There were, however, major conceptual differences (Newman, 2009). 

Dr Charles Inturissi then spoke about ‘hyperalgesia’ in those taking opioids short and long term.  Once again, apart from the obvious situations of withdrawal and break-through pain, the relevance of such albeit interesting findings of ‘priming’, conditioning and increased pain sensitivity in some at certain periods seemed a long way from the clinical setting.  If patients are still in significant discomfort they deserve consideration of a higher dose of additional medication/modality for relief of those symptoms.  Much of clinical medicine involves relatively simple ‘trial and error’ strategies while the complex diagnostics/therapeutics are more the exception than the rule in my experience. 

A lunch time talk by FDA official Mark Caverly quipped about the space shuttle having a supply of opioids which had passed their expiry date and needed to be destroyed. This normally requires a visit from an FDA official but an exception was made and the expired drugs were put into a fatal orbit and was witnessed by Hubble telescope to burn up on re-entry to the atmosphere (laughter from lunchtime audience).  It is a interesting that nobody even considered that perhaps American law would not extend to outer space!  On a more serious note, we were told that the FDA did not visit doctor’s offices very often - and when they did they did so “to help”. There are American doctors in jail for what in many other countries would have been considered a relatively minor infringements of technical regulations on prescribing.  As he also pointed out (and as it is in Australia too), the standard of health care is regulated by the States and FDA and national legislation only has overarching responsibilities under the Controlled Substance Act of 1970 (‘TGA’ in Australia). 

In the first session after lunch (of salad, poached chicken, followed by blanc-mange) Dr Steven Passik spoke about numerous new medications which are either in development or recently released which contain constituents which are aimed at less abuse.  In each case he referred to certain benefits, most of which consisted of quite modest trends, that there were fewer subjects likely to misuse particular medications, the prototype being combination buprenorphine utilising naloxone (originally used and discredited and withdrawn in the early 1990s in New Zealand). 

Dr Passik mentioned a combination of morphine with naltrexone (Embeda, approved by FDA in 2009).  This hardly sounded possible until he revealed that the antagonist was contained in a vitreous bead in the center of the pill which would normally not be absorbed but would pass intact through the gut.  The theory is that if drug mis-users crushed the pill indiscriminately they could get a rude shock if injecting anything containing naltrexone which is a long acting opioid antagonist.  In certain circumstances it could also be quite dangerous, inducing persistent vomiting and dehydration (this was not discussed). 

Another combination in the final stages of approval was hydromorphone in a viscous gel which it was believed would discourage injecting.  Another method was to use the ‘push-pull’ osmotic controlled delivery system which also delayed absorption according to the membrane put around a tablet which may also have some short acting component for pain control.  Oxycodone provided in waxy micro-particles is another as yet investigational product under trial at present (“Deter-Ex”).  Yet another is the ‘Oros’ technology which has an internal membrane for slow delivery of drugs such as methylphenidate (already approved) and hydromorphone (under investigation). 

Niacin (vitamin B3) can also be added to other drugs to induce an unpleasant flushing (‘niacin reaction’) if taken at certain high dose levels.  This raises the issue that adding just about anything to an opioid will make is less attractive to drug users, just like adding anything to neat alcohol will do likewise for an undiscerning alcoholic. 

Dr Passik was at pains to point out that for every combination and anti-abuse device developed, there were those intent on thwarting the attempts.  He detailed various ways including differential dissolution in water or alcohol, chemically manipulating them or simply crushing tablets intended to be swallowed whole. 

Dr Passik did not touch on the issue that these medications are invariably far more expensive than morphine, methadone, aspirin, acetaminophen or most of the NSAIDs (eg. ibuprofen).  This is related to the new opportunities for drug companies to re-patent old drugs and secure higher prices for what are essentially cheap drugs with modest development costs compared to brand new drugs. 

As with all these mixtures, the manufacturers have not considered that the most likely person to abuse such a drug is an existing buprenorphine pharmacotherapy patient who could probably inject the combination with impunity as happened in New Zealand in 1991 as documented carefully in Robinson’s famous paper in D&A Dependence (1993 33;1:81-6). 

In question time Dr Passik was asked (by me) if there were any other areas of medicine in which a second drug of no immediate benefit to the patient was added to known effective medications in this way.  He said that he was not, but that compulsory treatment for tuberculosis might have some parallels.  He did not cite the old use of naloxone with methadone invented in the 1970s and reported at one of the very first methadone conferences.  This was quickly dropped as a ‘useless precaution’ (see Barber of Seville, Rossini 1813). 

Yet another of these ethicals was reportedly released for use in America in March 2010: a waxy new Oxycontin formulation. 

In parallel to the research on diversion potential, there is not much carefully controlled comparative research to show equivalence of efficacy of these new formulations, nor was this required by the FDA in all cases, such as Suboxone.  The only small pilot study (n=17) showed that changing to the mixed product required a 50% increase in dose for the average patient when compared to the pure product, Subutex.  This has never been replicated in other studies to my knowledge.  Dr Russell Portenoy had detailed to the audience the importance of differentiating the concepts of efficacy and effectiveness.  “Efficacy” is the ability of the drug when administered to obtain the desired effects whereas “effectiveness” goes further and determines if the benefits outweigh the costs and side effects in the field. 

Saturday’s opening plenary was by Dr Martin Cheatle from Philadelphia who spoke with clarity about the prevalence of chronic non-cancer pain and the consequences of inadequate treatment.  These included delayed healing, depression, stress, suicide and addiction.  Up to 50 million Americans may suffer from this at some time and as many as 40% reporting inadequate pain relief from treatment received.  The conflicting pressures in primary care were broached, initially the essential nature of opioid prescription for serious pain, yet the reported increase in non-medical use of opioid drugs increasing four-fold from 1990 to 2002, up to 2.5 million citizens being involved. 

The second day saw yet another talk about opioid regulations (State regulations by Dr Aaron Gibson of the Carbone Cancer Center in Madison, Wisconsin.  He tried to reassure the audience that visits by regulators to doctor’s offices hardly ever happen and they are not in the business of putting doctors in jail.  More than any other country, I understand that America convicts doctors for matters relating to psycho-active drug prescribing.  Many of us have colleagues who have experience it, and often in circumstances which, while always regrettable, are not always the ‘hanging’ offences they are made out to be by the authorities who seem to need to make an example of such souls. 

At another session entitled “Office-Based Buprenorphine Therapy for Opioid Addiction: Lessons for Pain Management” Randy M. Seewald of BIMC gave an enlightened description of her lower Manhattan dependency practice.  Having originally worked in the hospital and methadone clinic system, she found private office practice to be liberating as well as challenging.  One main difference was that in her new ‘middle class’ subjects drug diversion was a minor concern rather than the constant bug-bear it can be in the clinic population.  Although unable to prescribe methadone in parallel with buprenorphine, and despite having ties with the buprenorphine manufacturer, she was frank enough to say that if one could have only one drug, her choice would be for methadone. 

Dr Seewald told us of the high retention rates in her practice … but this corresponded with low rates of successful withdrawal from buprenorphine – she only related one or two cases.  In question time I raised the matter of smaller dose increments than 2mg in the virtually unbisectable Suboxone tablets.  Dr Seewald had used the 2mg Subutex which can be broken in two but 0.4 or 0.2mg sublingual preparations are apparently not available in America (perhaps the company wants patients to remain on their drug for life!).  There was a discussion about the legal but off-label prescribing of Suboxone for pain management which paradoxically in America requires no special licence as it does for addiction patients, even at the same dose levels. 

Comments by Andrew Byrne .. http://methadone-research.blogspot.com/

References:

Krantz MJ. Clinical Concepts- Cardiovascular Health in MMT Patients. Addiction Treatment Forum 2001 No 4 http://www.atforum.com/SiteRoot/pages/current_pastissues/fall2001.shtml#anchor1222388

Reddy S, Fisch M, Bruera E. Oral methadone for cancer pain: no indication of Q-T interval prolongation or torsades de pointes.  Journal of Pain and Symptom Management 2004 28;4:301-303 http://www.redfernclinic.com/c/2009/11/methadone-safe-in-cancer-patients-with.php4

Justo D, Gal-Oz A, Paran Y, Goldin Y, Zeltser D. Methadone-associated Torsades de Pointes (polymorphic ventricular tachycardia) in opioid-dependent patients. Addiction. 2006 101:1333-1338   http://www3.interscience.wiley.com/journal/118730811/abstract

Krantz MJ, Rowan SB, Schmittner J, Bucher Bartelson B. Physician Awareness of the Cardiac Effects of Methadone: Results of a National Survey. Journal of Addictive Diseases 2007 26;4:79-85

Krantz MJ, Martin J, Stimmel B, Mehta D, Haigney MCP. QTc Interval Screening in Methadone Treatment. Ann Intern Med 2009 150;6:387-395  http://www.annals.org/cgi/content/full/0000605-200903170-00103v1

Marmor M, Penn A, Widmer K, Levin R, Maslansky R. Coronary artery disease and opioid use. Am J Cardiol. 2004;93:1295-1297

Gross ER, Hsu AK, Gross GJ. Acute Methadone Treatment Reduces Myocardial Infarct Size via the mu-Opioid Receptor in Rats During Reperfusion. Anesthesia and Analgesia 2009 109;5:1395-1402

Paulus I, Halliday R. Rehabilitation and the Narcotic Addict: Results of a Comparative Methadone Withdrawal Program. CMAJ 1967 96:655-659 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936075/pdf/canmedaj01207-0020.pdf

Halliday R. Management of the Narcotic Addict. 1963 British Columbia Medical Journal 5(10):412-414 http://www.redfernclinic.com/c/2007/11/management-of-narcotic-addict-halliday_4512.php4

Newman RG. "Maintenance" treatment of addiction: To whose credit, and why it matters. International Journal of Drug Policy (2009) 20;1:1-3

http://www.ijdp.org/article/S0955-3959(08)00165-5/fulltext

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