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.