Reducing OD Deaths by Peers

A new article describes for a small pilot cohort in SF a program to train heroin dependent individuals to administer CPR and provides them with pre-filled naloxone syringes and the education to use them. The article points out that naloxone is non-"abusable," and that among the lay community CPR training has been deemed reasonable (though largely ineffective because so few folks in the community at large witness cardiac arrests). OD events were self-reported "but were corroborated by one or more witnesses. . . " In a six-month period naloxone was used by the study-population in 15 of 20 cases of observed OD; no deaths were reported, and the subjects claimed to have lessened their own use of heroin. The limitations of the study are acknowledged - but one has to wonder: what could possibly argue AGAINST such training and distribution of naloxone? One plausible reason to hesitate (not discussed in this paper) might be fear of legal liability if individuals die and blame is attributed to the training and the trainers.

Surely there's some way to deal with that issue - if medical intervention in general were to be withheld from patients in need as long as the threat of liability existed, no one would get care for anything. Article appears in J of Urban Health (Bull. of NYAM), 2005, KH Seal et al.

U.S. NEEDS HUMILITY - much to learn from Islamic Republic of Iran!

In the Islamic Republic of Iran the Deputy Minister for Health recently (March 7, 05, Ref 7b-151095) distributed to academic, scientific and clinical leaders throughout the country an "Executive Order" of the Judiciary Branch Ref. 1-83-14434, Jan. 24, 05). In essence, the Head of the Judiciary reminds everyone that harm reduction measures such as needle/syringe exchange and methadone maintenance have been determined to be a "means of combating HIV and Hepatitis infections among drug addicts."

It concludes, "Therefore no judicial authorities should impede the implementation of such needed and fruitful programs." It defies comprehension that evidence-based policies and practices, whose necessity is absolutely clear to the Iranian Government and most nations of the world, continue to be denied and vilified by the US Government, which eschews even the semantics of "harm reduction" and thus condemns to death countless people at home and abroad. A little humility would seem the key prerequisite if America is to join the great majority of nations that have accepted the fact that the world really is not flat, that harm reduction is effective, and that "just say no" is not going to succeed as the cornerstone of anti-drug efforts.

COMMENTS ON ARTICLE ON BUPRENORPHINE

The Article appeared in Acta Neuropsychiatrica 16, 246-274, 2004. A few comments: It is stated that Suboxone, which combines naloxone with buprenorphine, "means that withdrawal symptoms are precipitated in those who are dependent on full opioid agonists such as heroin and methadone," but does not state whether and to what extent withdrawal is precipitated when injected by individuals taking no opiate other than Suboxone and/or Subutex.

Secondly, "there is a strong argument for insisting that buprenorphine be given routinely by daily supervised consumption except in exceptional circumstances... The importance of supervised consumption is illustrated by a survey of several hundred opiate users in France (where supervised consumption is not typical), which found a quarter to be injecting only buprenorphine, and a third to be polydrug users who were injecting buprenorphine sometimes."

In the U.S. it is legal at the first encounter to prescribe a month's supply - and with a prescription permitting multiple refills for additional months. While no data on actual practice appear to have been published, the appeal of buprenorphine over methadone seems to be related in large measure to the fact that it can be prescribed for unsupervised use; also, the enormous benefit associated with provision of buprenorphine treatment in the office-based practice setting would be incompatible with daily supervised administration.

tolerance

It's common knowledge (for 40 yrs) that methadone (and all other opiates) in constant admninistration leads to tolerance - i.e., same dose no longer produces narcotic effect. Not same for all of the many pharmacological effect (e.g., tolerance often slow and incomplete for constipation and tendendency towards excess sweating), but definitely accepted for euphorigenic and respiratory depressant actions. Furthermore, the higher the daily dose, the higher the tolerance - until at doses of methadone above 100-120mg (for most people) it's virtually impossible to achieve and exceed tolerance level and depress respiration, ease pain, create euphoria, etc. (used to be called "blockade").

So . . . is someone at say 120mg methadone daily over long period at greater risk from IV diazepine use/misuse than someone who is methadone- and opiate-naive? (forget chronic issues such as compromised liver functioning, which is usually due not to current methadone treatment but years of heroin injecting). And if so, why and how? One is either tolerant to the maintenance dose or not - and if one is, then there should be no opiate effect regardless what other non-opiates (like diazepines, or alcohol, or barbiturates) are taken, and in what quantity.

When we have the answer to this question, the next will be whether and how the same question is answered with regard to the buprenorphine (Subutex) patient, and the impact, if any, of the combination Suboxone; if there's tolerance to the maintenance dose of buprenorphine, then why and how would concomitant injecting of benzodiazepines be more likely to cause OD - if it does - what with the tolerance to the maintenance dose of B, the ceiling effect of B, and the added "protection" of naloxone?

Seem to be mighty important questions, given the widespread assumption of Buprenorphine "safety" and the fact that there are lots (forgive the vague term) of buprenorphine deaths in France, apparently always associated with concomitant injecting of buprenorphine and diazepines.

rnewman

GPs providing addiction treatment

Last week in London the Royal College of Family Medicine sponsored a conference on addiction treatment - attended by some 600 people, most of whom were generalist, community-based physicians. To an American, it was amazing to see physicians discussing their experiences with treating a chronic medical condition which they are barred by law from managing in the US. Basically, the issues were the same as those that might arise in any medical conference, discussing any illness: patient compliance, when specialist support is indicated, dealing with concomitant illness, etc. If individual generalist practitioners can treat opiate addiction in UK (and, incidentally, in France, Germany, Canada, Ireland, Croatia, Australia . . . . ), how come it's illegal in America?

Correction: for the past 2 years physicians in US have been able to obtain authorization to prescribe buprenorphine - but only a tiny proportion of the medical profession does so. Why?