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!

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...

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.

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.

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.

APSAD 2010 Day 1

I'm here in Canberra at the APSAD conference 2010. What a fantastic effort by local organising committee.

Prof Lloyd Sansom's keynote talk on the Australian Pharmaceutical Benefits Scheme (PBS), whilst not directly on an AOD topic, was a fascinating explanation on the process of evaluating medications for subsidy on the PBS. This is a process which was quite arcane for many of us working in the health sector and I was delighted to have some light shed on the matter. Equally interesting was the fact that nobody asked a question about what I thought would be the elephant in the room - namely the possibility of PBS listing for opiate replacement pharmacotherapies. I'm sure the topic will arise in other forums.

The 2nd keynote was from Prof Michael Farrell on the risk issues for prisoners following release from prison. The key take home messages were (1) to question whether it is appropriate to lock up drug users at the rates that we do and (2) the key period for risk of death is the 2 to 3 weeks after release from prisons.

The concurrent session were chock full of interesting topics. Well done to the Addiction Medicine Registrars for presenting their work -  particularly fascinating was the presentation of the difficult diagnostic case of Non Convulsive Status Epilepticus secondary to alprazolam withdrawal - thanks Adam Pastor for the presentation.

Day 2 tomorrow...

Treatment works!

Yesterday I had a win!

A patient I have been seeing for several years had reduced off opiate substitution pharmacotherapy. I'm not normally so happy to hear of someone stopping treatment, as addiction is of course a chronic, relapsing condition. In this case, however, I'm chalking it up as a success.

I first started seeing this patient (lets call her Ms X for sheer originality, and to keep all identities well hidden) at a time of crisis for her. She had been on/off pharmacotherapy for some time but had been struggling trying to stay in treatment and dosing. This was in large due to her partner who was a drug dealer, and supplied her with various drugs in order to keep her dependent on him. He had just been arrested for dealing and was looking at a substantial period of incarceration, and she was left sick, in withdrawal, and homeless.

Ms X was from a country town, where her parents still live. She had a young son from a previous relationship whose care she had given over to her parents. At the time I met her, she had not seen her son for close to a year, although she had maintained enough of a connection with her parents to keep in phone contact.

Ms X restarted opiate substitution pharmacotherapy, and we linked her in with a case manager as well as some psychological therapies. After a short period of time in crisis accommodation, she found some more stable (although still transitional) housing through one of the housing services. With support, she gets free of illicit drugs.

After a few months, she moved back to the country town to live close to her parents and her son. This period of time close to the support of her family and away from her old drug using haunts was pivotal in getting her well. She started a new relationship with a non drug using person, and now has her son back in her care.

A few months ago, her new partner was transferred by his work place to Melbourne. She is living with him in the suburbs. She has not used illicit drugs for 2 years. Her son goes to the local school. Opiate pharmacotherapy becomes an inconvenience and an embarrassment for her in her local community. We therefore work out a gradual dose reduction schedule to get her off treatment - she completed this reduction 4 weeks ago.

I saw her yesterday 1 month off treatment and still drug free. The withdrawals from stopping treatment have now resolved, and she reports no cravings or thoughts of drug use. She sees a counsellor for ongoing relapse prevention regularly. She has plans to return to study part time next year.

I have a real sense of optimism for her future success.

It's a win, and I'll take those where I can.