Friday, November 4, 2011

So what is the Australian Alcohol and Other Drug Treatment Sector?

I had the interesting experience this week of attempting to explain the Alcohol and Other Drug (AOD) treatment sector to a mental health nurse from Hong Kong who was visiting the clinic I work in on an observational placement... for the record I think I failed.

The general gist of the explanation (not verbatim; my memory isn't that good) was as follows:

Well, you see, there are 2 levels of government that control our treatment delivery in various ways. The federal government and the state/territory governments each have separate sets of legislation as well as bureaucratic and funding structures that regulate AOD treatment. And the regulations and service delivery structures in each of the states differs. The type of treatment and how it is funded and structured depends on which of either the state or federal programs is providing the service.

No, not all the treatment services are provided by government. Many of the treatment services are run by non government organisations (NGOs). Some of the NGOs are charities, other are not for profit organisations. Yes there is some private work, but it's not really a profitable area. So which services tend to be provided by NGOs and which ones are provided by government? Well that actually depends on what state or territory you happen to be in. For example here in Victoria the government has actually opted out of a lot of the service provision in AOD treatment - they still provide some funding but as a service purchaser not a service provider. A lot of the AOD treatment is tendered out to various NGOs. No there isn't really any over-arching governance over the service provision, so really there are a lot of different organisations all doing their own thing. Duplication? Well, I guess so. There would have to be wouldn't there?

Of course the set up is different across the border in New South Wales. They tend to have more treatment services embedded within their area health services and directly provided by state government run health organisations. It's kind of different again in Western Australia and different again in Tasmania, and so on.

The funding for different treatment programs can depend on the type of drug treatment too. Opiate replacement pharmacotherapy is delivered in quite a complex manner (yes, even more complex that what I was talking about before). You see, the medication is provided by the federal government. No-one actually pays for methadone and buprenorphine as such. However, people may have to pay to be on the opiate replacement program but that depends on the state government. The delivery on the opiate replacement is the responsibility of state government, and the approach varies state to state. Here in Victoria the state government funds the training and accreditation of doctors and pharmacists to provide treatment but they don't fund the delivery of treatment much at all. This means that GPs will bill either the federal government through Medicare or bill the patient, and the pharmacies charge a dispensing fee (yes they set their own fees so it can vary greatly). In New South Wales there is a mix of public clinics where opiate replacement is provided by doctors and nurses and pharmacists employed by government and private doctors and pharmacists who charge for their service... etc

I wish I could say that I was observant enough to notice that the poor fellow's eyes were well and truly glazed over at this point, but I have to admit that I kept going for a bit longer and actually started exploring the differences between the AOD sector and the mental health treatment sector. I'm worried that I may have actually committed a crime against humanity.

Friday, July 22, 2011

The dilemma of Pain and Addiction

I read this article in the Wall Street Journal online recently which discussed some of the issues about pain medication in America. The difficulties experiences by doctors in the USA are definitely shared by those of us here in Australia.

The challenges of dealing with people presenting with chronic pain and requesting narcotic analgesics are numerous.

Firstly, pain is subjective. There may be only a partial relationship between the actual severity of the problem (illness or injury) causing the pain and the intensity of the pain itself. A person's experience of pain is also influenced by their beliefs about what the pain stimulus means, their intrinsic ability to cope with stress/distress, learnt responses to pain from past experiences, current emotional state and other psychosocial influences. This can be particularly so in the context of chronic pain.

Secondly, even in the absence of addiction, narcotics may well be a poor treatment choice for treatment of pain. The scientific evidence for the use of narcotics in acute pain is pretty good whereas the evidence for the use of narcotics in treating chronic pain is scant and inconclusive. In many cases narcotics will have a detrimental effect on health as many people who dull their pain with narcotics then opt not to participate in the physical rehabilitation needed to improve injuries or the psychological therapies which could improve quality of life.

Thirdly, the risk of developing an addiction to a narcotic following a significant exposure is estimated at around the 10% "ball park". This means that in a significant number of people that are prescribed narcotics, the doctor will be causing an addiction... and remember "do no harm"

Fourthly, doctors are trained to help people and it can be difficult for a doctor to refuse a narcotic prescription to a patient who wants something to stop pain. We (doctors) are not well trained enough in how to say "no" when we need to.

Fifthly (I did say "numerous"), people with opiate addictions do lie about experiencing pain in order to get narcotics to feed their addictions. Often these same folk exhibit a range of inappropriate drug seeking behaviour and can be aggressive and violent towards hospital or clinic staff, "doctor shop" to multiple prescribers, engage in illegal activities such as theft or forgery.

Sixthly, there is a substantial black market for diverted opiate medications. In Australia this is particularly problematic as the national subsidy for medications (the PBS) means that folk on social security only pay just over $5 AUD for a prescription for a month's worth of medication but can sell individual tablets for up to $1/mg morphine (receiving $80 for a single 80mg tablet, where 60 tablets cost $5). This presents a real temptation to on sell their medication, resulting in more narcotics on the streets contributing to overdose risk, injecting drug use related risks. etc.

Seventhly, opiates are not completely benign medications. They represent a significant overdose risk as well as increase the risk of other health issues including sleep apnoea, falls, osteopaenia, cardiac problems (eg ST segment prolongation and heart block)...

The challenge for the health sector, not just individual doctors, is to ensure that people who legitimately need treatment are able to receive it; that people with no legitimate need do not get access to it either via prescriptions or the black market; that medications are prescribed safely and responsibly taking into account the potential risks. This involves the development of better prescription monitoring systems that provide real time reporting, and the development and widespread adoption of universal precautions in opiate prescribing in order to reduce the substantial risks that narcotics can represent (the Prescription Opioid Policy put together by the combined efforts of the colleges of physicians, anaesthetists, GPs and psychiatrists discusses this at length).

Monday, March 21, 2011

Medicine in Addiction Coference - Melbourne 2011 - pictorial extra - the debate

Images from Saturday's debate

 Dr Michael Aufgang opening the debate

Magistrate Margaret Harding began on a serious note borrowing on examples from the Drug Diversion Court

A/Prof Adrian Dunlop encouraging the audience to "get drunk" with  glass of red in hand... I'm still trying to sort out the relevance

Dr Matt Frei responding by quoting Homer Simpson

Mr John Ryan calling on Matt Frei to stand and comparing him to Superman... Matt in return comparing  John to Wonder Woman... no costumes please!

Sunday, March 20, 2011

Medicine in Addiction Conference - Melbourne 2011 - Day 3

Today was the third and final day of the inaugural Medicine in Addiction conference in Melbourne. The focus of today's presentations was the complex issues that create challenges in managing patients' substance use.

The first presentation of the day was Dr Glenys Dore speaking on comorbid PTSD substance use disorder. The occurrence of trauma is common in the substance using population, and this population is vulnerable to developing PTSD. There are challenges involved in managing the withdrawal period when the symptoms of PTSD are likely to re-emerge, as well as treating PTSD in the post withdrawal period in order to reduce its impact as a trigger for relapse. Resources such as the National Guidelines on the management of comorbidities can provide some useful strategies. There have been some encouraging results for COPE (Concurrent Prolonged Exposure) therapy involving integrated CBT addressing both substance use and PTSD.

This was followed by a presentation on medical consequences of long term opioid use presented by A/Prof Nick Lintzeris. With greater, long term survival of opiate dependent individuals as well as changing patterns of opioid use (the increase in use of prescribed opiates), there is a growing  population of older people dependent on opiates. This has resulted in increasing rates of the various clinical consequences of long term opiate use. The conditions that were discussed in some detail included hypogonadism from opiate induced androgen deficiency (OPIAD) with all of its sequelae which can adversely affect quality of life and morbidity(poor libido, fatigue, depressed mood...), and increasing rates of central sleep apnoea which leads to increased overdose risk in the older opiate dependent patient.

A/Prof Kate Conigrave spoke on the challenges in providing treatment to indigenous Australians. There are socioeconomic and cultural factors that can make the delivery of any health care, and particularly AOD treatment with all its baggage of guilt and shame, difficult. The levels of grief and loss in indigenous communities is high. Community and family hold a vital importance both as  protective factors and as a triggers for relapse. The Aboriginal Medical Services can be a valuable resource, but as the community can be small there are times when a patient will not feel comfortable in accessing them. Understanding differences in communication styles is an important element in interacting with indigenous patients - visual resources are more helpful than text based resources, and clarifying "sharing" is important in taking substance use history.

Dr Beth Whitehouse from Austin Health (Talbot Hospital) discussed challenges involved in managing substance misuse in patient who have an acquired brain injury. Management often involves a multidisciplinary and multi-service team, and it is important for clear and specific goals to be decided upon. Patients often have poor insight and high impulsivity, and it is important to put practical strategies in place that are tailored to the patient's level of function and circumstances. It is important to provide psychoeducation to patients delivered at a level that they are able to make sense of.

The final session of the conference was a windup of the issues. Professor Michael Farrell, the new director of NDARC, spoke on future directions for the sector. After a sum total of 5 whole days in the job (and in the country), he was asked to sum up where we were at as a sector and predict what our future challenges were likely to be. He did a phenomenal job of summing up the discussions and concerns raised throughout the conference and, more importantly, presented some pertinent questions - As doctors working in this sector what are our goals? What outcomes do we want to see? What is our voice and our message? The delegates were then also left pondering what footy team he was likely to adopt now he is here in Australia (of course the issues came up - the conference was in Melbourne after all).

The conference was closed by Prof Dan Lubman as we all broke for lunch full of anticipation for the next conference...

Saturday, March 19, 2011

Medicine in Addiction Conference - Melbourne 2011 - Day 2

Day 2 of the Medicine in Addiction Conference started off with a session on prescribed medication dependence. Dr Malcolm Dobbin called on data from USA and Canada to paint a picture of increasing use and harms from dependence and misuse of prescribed medications - particularly strong narcotics and benzodiazepines. In some of the data from these jurisditions, prescribed narcotics are 3rd only to alcohol and cannabis of drugs that people are reporting to use recreationally, and this heavy use is reflected in the hospital activity and drug related mortality data. Trends in Australian data show that we are headed rapidly in the same direction. A/Prof Nick Lintzeris discussed some of the evidence around the potentially dependence causing medications that are commonly prescribed and the universal precautions for safe prescribing. In a health system that is focussed on acute care and has little support for psychosocial supports or for realistic drug monitoring systems, it can be challenging to balance access to appropriate treatment with reduction in risk of drug misuse and diversion. Dr Adrian Reynolds, the director of drug treatment services in Tasmania, reported on the Apple Isle's coordinated response to prescribed medication misuse which includes a real time drug reporting system. He gave a strident call to arms for medical folk involved in drug treatment to be involved in lobbying for better directions and choices nationally to improve outcomes.

The second session of the day looked at various medical complications of drug and alcohol use. Prof Paul Haber discussed the aetiology and treatment of alcoholic liver cirrhosis. The key take home message was that it is never to late to stop drinking - even in people with established fibrosis, some reversal of disease can occur following a substantial perion of abstinence. There are some medications used in specialist units that can help manage the problem. Dr Ian Kronborg discussed the difficult issues of sleep in the drug using population. It was unsurprising to hear that benzodiazepines simply don't work in the long term. In spite of claiming not to be an expert, Dr Richard Hallinan gave a broad and detailed overview of sexual dysfunction in the substance using population. The most disturbing question I'm left with is - who is Mrs Palmer and her 5 daughters?

After lunch we broke into groups for the workshop sessions. Dr Sathya Rao challenged us with a discussion of borderline personality disorder and being aware of counter-transference in the management of these patients. Tobie Sacks presented a practical "non drug" approach to dealing with chronic pain. I was unable to attend Ms Catherine Dwyer's workshop on Motivational Interviewing, but feedback received from atendees was very positive. Several people expressed their intention on following up with the website.

The highlight of day 2 would have to be the debate on involuntary treatment. It was refreshing to hear the views from a member of the legal fraternity, especially when those views came from Margaret Harding who is the magistrate presiding over the drug diversion court. A/Prof Adrian Dunlop and Dr Matthew Frei traded some lively banter on the topic, although I wonder about the academic rigor of the debate  with Adrian quaffing wine and advising folk to "get drunk" and Matthew quoting Homer Simpson. There was also the somewhat disturbing image of Matthew as Superman and Mr John Ryan as Wonder Woman. The take home message was that the evidence is poor.

An engaging and entertaining second day. It all winds up tomorrow.

Friday, March 18, 2011

Medicine in Addiction Coference - Melbourne 2011 - Day 1

The inaugural Medicine in Addiction Conference started in Melbourne today. The conference is a collaborative effort between the Royal Australia and New Zealand College of Psychiatrists (section of Addiction Psychiatry), the Royal Australian College of General Practice (special interest faculty of Addiction Medicine) and the Royal Australasian College of Physicians (Chapter of Addiction Medicine), and was driven in a large part by the effort and force of personality of Professor Dan Lubman who chairs the section of Addiction Psychiatry. The conference brings together health professionals (mainly medical) working in the area of the medical treatment of addiction and has practical, clinical focus.

The program for Day 1 predominantly dealt with addiction treatment in a hospital setting. The first session of the day had a focus on the Emergency Department. We started with an overview of the epidemiology of alcohol and drug issues presenting to the ambulance services and then through to ED based on Victorian data presented by  Turning Point's senior research fellow in population health, Dr Belinda Lloyd. Unsurprisingly, alcohol was the substance most associated with hospital presentations, although the typical (and visible) injury related presentations were overshadowed by admissions related to the medical complications of chronic alcohol use. What was particularly interesting was the increase in alcohol related presentations in the older age groups. The public health perspective was followed up by 2 presentations from Emergency Medicine Physicians on clinical presentation to the ED and clinical management. The bulk of substance related presentations occur in the time period from the afternoon through to the early hours of the morning and therefore EDs (being 24 hour services) end up managing the bulk of these issues as the other services like the non-acute mental health and AOD support services are only open office hours. This provides a particular challenge as EDs also tend to have a high proportion of junior and temp staff who may not have particularly well developed skills in dealing with these issues. Comorbid substance use and mental health presentations are particularly challenging - not overly surprising to anyone working in the field. Brisbane addiction psychiatrist, Dr Mark Daglish, then presented the outcomes of an program to provide brief interventions to people using substances in a harmful manner as identified by screening in the ED. When services work together you get better integration of care and improve access to services - again unsurprising, but it is good to see evaluations of projects that work (more information to present to funding bodies and administrators to try and improve service provision).

After morning tea, we launched into session two dealing with managing pain and addiction in the hospital setting. The presentations amusingly borrowed (in part) titles from the Stieg Larsson "girl" novels to reflect the different aspects of treatment - at least those of us who were familiar with the books (unlike the session chair A/Prof Nick Lintzeris) found the titles amusing. Dr Bronwen Evans, anaesthetist and coordinator of acute pain services at Western Health, presented a comprehensive synopsis of her approach to managing perioperative pain in opiate dependent patients, and how she addresses the challenges posed by tolerance and hyperalgesia. Dr Bridin Murnion discussed the issue of general acute pain management in hospital inpatients dependent on opiates, and especially the need for good discharge planning and communication with community based services. Dr Mike McDonough provided some cautionary tales on inappropriate prescribing, particularly involving pethidine.

The third session, directly following lunch, looked at specific addiction psychiatry issues. Dr Grant Christie from New Zealand gave an overview of ADHD and substance use disorder. The evidence indicates that there are some clear benefits in treating children with ADHD, including a lower rate of development of substance use disorder in patients with ADHD who had treatment as a child compared with those who id not have treatment as a child. The evidence for treating adults for ADHD is less convincing. Animal models looking at cocaine seeking in mice exposed to methyl phenidate at various stages in the life cycle showed that juvenile mice exposed to methyl phenidate showed less cocaine seeking as adults, whereas mice exposed as adolescents showed more cocaine seeking as adults and exposure of adult mice did not alter cocaine seeking at all. Prof Shane Thomas discussed problematic gambling and introduced the draft guidelines that are available for consultation. Prof Dan Lubman discussed affect and anhedonia in patients with dependence issues and the impact this has on treatment.

The fourth and final session of the day had a focus on developing new therapies. Prof Andrew Lawrence discussed the neuroscience of target sites for new therapies - to either decrease the drivers for relapse or boost the promoters of abstinence. The animal models were fascinating, although he did acknowledge that you can do things with with rats that you simply cannot do in patients. I, for one, am delighted that the slides will be available after the conference as the speed with which he covered the neuroscience defeated me somewhat, but the future looks bright. Prof Jason White gave an overview of new directions in pharmacotherapies for alcohol and opiates, including baclofen, topiramate, buprenorphine implants and naltrexone depot injections. Dr John Boyle gave a brief run down of aspects of psychological therapies. He also managed to order the chair, Prof Paul Haber, back into his seat, a feat I haven't seen done previously.

All in all a fabulous first day. Hope day two lives up to it.

Sunday, February 20, 2011

Coroner calls for restriction of methadone takeaway doses

The coroner in Victoria has commented on the intrinsic risk of methadone takeaway (unsupervised) doses in her finding in the inquest into the death of a girl who took a methadone dose which was dispensed to her cousin. The statement from the coroner indicates a concern about who should take responsibility for methadone doses and a view that "[leaving] the decision-making and storage arrangements solely in the hands of the addicted person seems to be an approach which is fraught with risk, given the unreliability often associated with persons suffering with substance addiction".

Whilst the coroner has made a valid point in relation to the risks involved in the provision of methadone doses, the resources involved in inspecting medication storage arrangements of each and every patient receiving methadone takeaway doses would be prohibitive and impossible to enforce.

The requirement for checks on stability of patients prior to providing takeaway doses is designed to try an minimise the risk such that only patients who are stable enough in treatment so that their "unreliability" is lessened are eligible for takeaway doses - i.e. only patients who are able to take responsibility for storing takeaway doses appropriately have access to them. If a patient who is stable and has had the importance of appropriate storage of their takeaways explained to them then choses not to store their takeaway doses correctly, they need to be held responsible for that lack of care.

Perhaps instead of a call for greater direct supervision (which would be resource intensive in a sector that already suffers from a shortage of resources) there should be a greater onus on ensuring that the checks for stability are more closely adhered to. This would prevent "unreliable" patients form having takeaway doses.

Patients need to be seen regularly, need to have their dosing at the pharmacy checked up on, need to have random urine screening, need to be checked for injecting sites... It is part of the clinical risk assessment that is vital to the safe provision of service (and in Victoria the stability criteria are clearly documented in the state prescribing policy). Arguably if a prescriber is unable to check on adequate stability for takeaway doses, then that prescriber should not be prescribing takeaway doses.