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.

My thoughts on Ben Cousins and his retirement from football

I admit it, I was one of the many glued to the television watching the Ben Cousins documentary.

As I listened to his narrative, I couldn't help but reflect on the interactions I have on a day to day basis with people who struggle with addiction but are not in fame's spotlight. His words rang true in many ways, but I feel that there are still aspects of his condition that he has yet to face.

Ben Cousins certainly speaks like someone who has been in therapy and dealing with treatment services for a long time. The repetition of the statement "addiction is a chronic, relapsing condition" is certainly a concept that treatment services work hard to impart to people - it is a health condition that can be managed with ongoing treatment, but we don't have a cure for. He clearly has an intellectual appreciation for what addiction is; time will tell how well he translates the information he has been given into real life changes.

Growing up in Western Australia, and being a West Coast Eagles supporter for many years, I remember clearly the draft when Ben was picked up under the Father/Son provisions inot the Eagles squad. From the beginning he was a high profile draft pick, with the media waxing lyrical about his football talent and the sheer good fortune of the Eagles recruiter that his father Brian played for the WAFL. What is the real impact of throwing that much adulation (not to mention the money) toa 17 year old?

In part 2 of the documentary, the story of recovery is closely linked to the story of returning to footy. Being an AFL player is what has given Ben Cousin's meaning in his life. The striving and the adrenalin of the competition is something that obviously lifts him and gives hims a rush.The structure and discipline of training clearly helps to impose structure on his life in general. What does a person do when the thing that gives life meaning is no longer there? There is bound to be a period of grieving and a sense of loss - how will he respond to this?

One of the concepts I discuss with the patients I see who see me for addiction related issues is readiness to stop using. When the drug is taken out of someone's life (removing all the rituals that go with obtaining and using the drug, all the social contacts that are held together by drug use, the pleasant sensations of euphoria or relaxation or absence of pain related to drug use) it leaves a whole, a gap. Filling that gap with positive things is a key element in the prevention of relapse into drug use. To my eyes, Ben filled the gap by working harder on his footy - take away the footy and what else will take its place? What will he do with the time that he used to train in? If he doesn't have the rush of getting out on the paddock on game day, what else in his life will give the rush and buzz? When the AFL isn't looking over his shoulders monitoring him for drug use, will he let his guard drop?

This is a critical time in his recovery. I wish him well in his recovery and with building good things in his life.

...the system (by which I mean Medicare)...

Since I last comented on this blog, Medicare in its wisdom has indeed allocated item numbers to the specialty of Addiction Medicine.

For any chance reader unfamiliar with the Australian system, a Medicare item number is a description linked payment that the goverment insurer (Medicare) will pay for a type of interaction a health provider has with a patient.

With a significant lack of consultation, or maybe a consultation with the wrong parties (still trying to work that out), the government decided to allocate 2 items for the specialty - an item for new patients and an item for reviews. There are no collaborative care or team care items, no items linked to referrals to allied health professionals, no group therapy items, no care plan items... Basically the items in no way match the style of practice which most Addiction Medicine SPecialists actually practice. I don't know any one of my colleagues who doesn't work with psychologists, social workers, AOD nurses and counsellors as part of their standard practice.

Needless to say, we are attempting to negotiate further on this matter. First of all, we need to get this pesky little thing called a Federal Election out of the way so we know which team we will be negotiating with...

I'll keep you posted...

Addiction Medicine a medical specialty

Well it has finally happened... in December 2009, the health minister has recognised Addiction Medicine as a medical specialty. What will this mean to those of us practising in the field? Time alone will tell, but I certainly hope that it will help to attract and retain doctors in work within drug & alcohol treatment services.

The next step in the process will be discussions on Medicare rebates. The challenge will be for the disparate collection of doctors that make up Addiction Medicine to come to some sort of agreement about what the models of billing "should" be...

Watch this space...