Heavy alcohol use and the treatment gap

SMMGP Blog: Heavy alcohol use and the treatment gap

I wrote the blogpost (link above) after putting together the last SMMGP Clinical Update. I’m sure we’re going to see a lot more of these harm reduction medications targeting alcohol use coming through in the next few years.

You can read the Aug-Sep 2013 Clinical Update here. I’m busy writing another one – due out next week.

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The SMMGP Clinical Update – Oct/Nov 2012

This is my 20th Clinical Update – you can access them all here. Or jump to the bottom to learn about SMMGP.

The papers covered this time are:

A record-linkage study of drug-related death and suicide after hospital discharge among drug-treatment clients in Scotland, 1996-2006. Merrall ELC, Bird SM, Hutchinson SJ. Addiction 2012. Published online ahead of print. 

This study showed that there is an increased risk of death in folk who have recently been in hospital and are also registered with substance misuse services in Scotland. Even those who hadn’t stayed overnight showed an increased risk of death.

Opioid dependence during pregnancy: relationships of anxiety and depression symptoms to treatment outcomes. Benningfield MM, Dietrich MS, Jones HE, et al. Addiction 2012;107 Suppl 1:74–82

This was a secondary analysis from the excellent MOTHER study. Women who had just anxiety were more likely to drop out. Women who were just depressed were less likely to leave treatment.

Jones HE, Heil SH, Baewert A, et al. Buprenorphine treatment of opioid-dependent pregnant women: a comprehensive review. Addiction 2012;107 Suppl 1:5–27.

This was a huge review that lays out all the most recent evidence for buprenorphine treatment.

‘Subutex is safe’: Perceptions of risk in using illicit drugs during pregnancy. Leppo A. Int J Drug Policy 2012;23:365–73.

This qualitative study highlights some of the wider issues in women who use during pregnancy: far too often health care professionals get stuck in the ‘biomedical discourse’ without considering other areas.

Heroin users’ experiences of depression: a qualitative study. Cornford CS, Umeh K, Manshani N. Fam Pract 2012;29:586–92.

Another qualitative study from the remarkable Fulcrum Medical Practice in Middlesborough.

Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Grattan A, Sullivan MD, Saunders KW, et al. Ann Fam Med 2012;10:304–11.

Development of dependence following treatment with opioid analgesics for pain relief: a systematic review. Minozzi S, Amato L, Davoli M. Addiction 2012. Published online ahead of print. 

These two papers look at different aspects around the problems of prescription opioid misuse.

The challenges of reducing tobacco use among prisoners. Richmond RL, Butler TG, Indig D, et al. Drug Alcohol Rev 2012;31:625–30.

‘Do more, smoke less!’ Harm reduction in action for smokers with mental health/substance use problems who cannot or will not quit. Baker AL, Callister R, Kelly PJ, et al. Drug Alcohol Rev 2012;31:714–7.

These two papers draw together papers on smoking cessation in some very challenging groups who have high rates of smoking.

Widening access to treatment for alcohol misuse: description and formative evaluation of an innovative web-based service in one primary care trust. Murray E, Linke S, Harwood E, et al. Alcohol Alcohol 2012;47:697–701.

A web-based service that helps address alcohol may seem like a good wheeze but, in practice, there are many problems and barriers to overcome.

Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. MacArthur GJ, Minozzi S, Martin N, et al. BMJ 2012;345:e5945–5.

A solid BMJ systematic review that makes it clear that opiate substitution therapy remains a key intervention to prevent HIV transmission. Yet, globally, only around 6-12% of people who inject drugs will receive it.

Benzodiazepine use and risk of dementia: evidence from the Caerphilly Prospective Study (CaPS). Gallacher J, Elwood P, Pickering J, et al. J Epidemiol Community Health 2012;66:869–73

A UK based cohort that shows that there is a clear association between benzos and dementia. Some aspects of the paper seem to rule out reverse causation but there wasn’t a dose-dependent relationship – so whether benzos are causal is not yet clear.

The SMMGP Clinical Update is a summary of some of the key clinical papers on substance misuse relevant to primary care. Generally, it’s around 3000 words long and I might cover anything from seven to ten papers in that. There is a summary of the methodology and findings of the paper and I make an attempt to put it all into some sort of appropriate context. The team at SMMGP read it through, make helpful comments, and try to filter out any blatant libels. It’s available at www.smmgp.org.uk under the ‘Resource Library’ heading.

If you’ve any interest in substance misuse in primary care then you should join SMMGP – it’s free.

 

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The SMMGP Clinical Update

I’m continuing to write the SMMGP Clinical Update on a bi-monthly basis. It’s a summary of some of the key clinical papers on substance misuse relevant to primary care. Generally, it’s around 3000 words long and I might cover anything from seven to ten papers in that. There is a summary of the methodology and findings of the paper and I make an attempt to put it all into some sort of appropriate context. The team at SMMGP read it through, make helpful comments, and try to filter out any blatant libels. It’s available at www.smmgp.org.uk under the ‘Resource Library’ heading. If you’ve an interest in substance misuse in primary care then you should join SMMGP – it’s free.

I’ve been writing this every couple of months since August 2009 so I’ve now racked up quite a few of these – my next one will be my 20th Clinical Update.

The last one was the Aug-Sep 2012 version and covered the following papers:

Prevalence of common chronic respiratory diseases in drug misusers: a cohort study. Palmer F, Jaffray M, Moffat MA, et al. Primary Care Respiratory Journal. Published online: 8 August 2012.

An interesting retrospective study from Scotland looking at this sorely neglected area. And there are few surprises in the findings – even without smoking (and smoking is pretty terrible in this group) respiratory diseases are much more likely.

Persistent cannabis users show neuropsychological decline from childhood to midlife. Meier MH, Caspi A, Ambler A, et al. Proc Natl Acad Sci USA Published online: 27 August 2012.

This is a deeply impressive study based on the New Zealand Dunedin cohort. It goes a long way to settling a fair few questions around harms from cannabis – and adolescents looks particularly vulnerable.

Substance misuse of gabapentin. Smith BH, Higgins C, Baldacchino A, et al. Br J Gen Pract 2012;62:406–7.

A brief report/letter in the BJGP highlights an issue that won’t come as a surprise to many folk working in substance misuse (or particularly prisons). Gabapentin is highly abusable and this report points out some of the issues.

Retrospective accounts of injection initiation in intimate partnerships. Simmons J, Rajan S, McMahon JM. Int J Drug Policy 2012;23:303–11.

This qualitative study does what a good qualitative study should – it’ll really make you step back and consider some of your attitudes. Recommended.

Brief case finding tools for anxiety disorders: Validation of GAD-7 and GAD-2 in addictions treatment. Delgadillo J, Payne S, Gilbody S, et al. Drug Alcohol Depend 2012;125:37–42.

This UK study studied whether or now GAD-7 is actually of any value in an addiction setting.

Involvement of general practitioners in managing alcohol problems: a randomized controlled trial of a tailored improvement programme. van Beurden I, Anderson P, Akkermans RP, et al. Addiction 2012;107:1601–11.

This Dutch study had a bit of a torrid time as they struggled with poor recruitment and not very impressive participation. Some good lessons on how we might go about improving the management of alcohol problems in general practice.

Buprenorphine/naloxone and dental caries: a case report. Suzuki J, Park EM. Am J Addict 2012;21:494–5.

This was just a short case that reported on a woman who developed marked dental caries while on buprenorphine/naloxone. It’s a good opportunity to reflect on the dire state of oral health in many of those with substance misuse issues.

 

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Alcohol and breast cancer – some absolute numbers

This was a meta-analysis of data on light alcohol drinking and breast cancer. The authors reported that they looked at 113 papers which reported breast cancer risk estimates for light drinkers. Only 36% of the reported estimates were adjusted for the main risk factors (age, family history, parity, menopausal status, oral contraceptive/hormonal replacement therapy use). The findings reported in the abstract were:

 A significant increase of the order of 4% in the risk of breast cancer is already present at intakes of up to one alcoholic drink/day.

This fits with the random-effect summary relative risk (RR) of 1.04 (95% CI, 1.02 to 1.07) for the overall analysis. However, when pooling for the 36% of studies that had adjusted for the main risk factors the RR was 1.03 (95% CI, 1.00 to 1.07). Hmm, a 95% confidence interval that includes 1.0 – I’m starting to feel a little anxious about the numbers here.

These epidemiological studies can only show an association. However, alcohol as a causative agent in breast cancer doesn’t seem that unlikely. There is secure evidence that higher consumption of alcohol is associated with an increased risk of breast cancer. There is a plausible mechanism with alcohol affecting oestrogen levels and given that breasts are a highly oestrogen-sensitive tissue. The studies also seem to suggest a dose-response relationship – a further piece of evidence suggesting alcohol is causative.

So, seeing a small effect (and it is small) with light drinking is hardly surprising. On population terms the epidemiologists may be impressed but your average person may wonder at their real risk. It is notable that at no point in this paper, or the press release, or the Daily Telegraph article does anyone attempt to put it in absolute risk terms.

Telling people who drink heavily that they need to cut down isn’t controversial but how much can a woman who cuts down on her light drinking expect to benefit? Well, firstly, there is no guarantee that stopping or reducing drinking will reduce risk anyway- no one has ever done that study and they’re not likely too either. But we can do a very rough and ready calculation with the absolute numbers.

How about if we do something as simple as reduce the current age-related risks by 4%?

In women under 49 the absolute risk is estimated as 1 in 50 (2%). A reduction of 4% would put the risk at 1.92%.

That’s an absolute risk reduction of 0.08%.

In women under 39 the absolute risk is estimated as 1 in 215 (0.465%). A reduction of 4% would put the risk at 0.447%.

That’s an absolute risk reduction of 0.018%.

(Age-related risk data from Cancer Research UK.)

Of course, these numbers wouldn’t make quite such impressive headlines. But it’s a pity that the authors, the journal, or the newspaper haven’t made any referral to absolute risk at all.

 

ResearchBlogging.orgSeitz, H., Pelucchi, C., Bagnardi, V., & Vecchia, C. (2012). Epidemiology and Pathophysiology of Alcohol and Breast Cancer: Update 2012 Alcohol and Alcoholism DOI: 10.1093/alcalc/ags011

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Tobacco harm reduction – no smoke without fire

Tobacco harm reduction – no smoke without fire

Posted on Wednesday, November 18, 2009 at northerndoctor.com

Smoking kills millions of people every year and yet the medical community seems pathologically opposed to any measure to tackle the issue other than through the promotion of total abstinence.

Carl Phillips suggests in his paper in the Harm Reduction Journal this month that smoking for just one month is more dangerous than switching to a smokeless nicotine product for a lifetime. Take a moment to take a deep drag on a few breathtaking statistics. Across the world approximately 1.3 billion people use tobacco products and by 2030 it is estimated that 10 million people will die annually from smoking-related diseases and 70% of these deaths will be in developing countries. We’ve known about the harmful effects of smoking for over 50 years and yet over that same period 6 million Britons have died of tobacco-related disease.

It’s no secret that it’s hard to stop smoking. Bandolier published an interesting little analysis of trials which included smokers and heroin addicts. They asked: which is the most addictive? In a rather elegant twist they looked at the cessation rates in the placebo arms of all the relevant trials. Cessation rates for smokers were around 8-9% yet for opiates users were around 43%. No surprises there – smoking is extraordinarily difficult to stop. Even in those that are highly motivated 12 month cessation rates are often no better than 10%. Opposing a harm reduction approach might be doing a grave disservice to those that just find it too tough to stop.

I am intrigued by the concept of tobacco harm reduction – not least because it requires a considerable effort of will to put aside a pathological distrust of Big Tobacco. Some of this post is taken from one I posted over at doc2doc a few months ago. The very first comment on the blogpost at doc2doc sums up the gut reaction of many doctors:

I think we should dismiss this out of hand! This argument is like low tar cigarettes are healthier..so you can smoke more of them. There is no such things as a safe(r) cigarette. The safer cigarette makes no sense given my understanding of how nicotine receptors work, not to say addiction. Do not trust Big Tobacco who have a vested interest in not losing their customers.

End of. Decision made. One suspects that the notion of smokeless nicotine products is simply not endorsable by the scientific orthodoxy in any shape or form. Phillips addresses all the arguments and using a back of a fag packet (though he prefers an envelope) calculation suggests that:

Whatever the explanation for it, the present analysis shows that anti-THR [tobacco harm reduction] activism is deadly. Hiding THR from smokers, waiting for them to decide to quite entirely or waiting for a new anti-smoking magic bullet, causes the deaths of more smokers every month than a lifetime using low-risk nicotine products ever could.

If you are inclined to read the paper then flick to the back first and read the competing interests statement. Not for our Carl a bland ‘nothing to declare’ and instead it reads like a heartfelt plea that we pause, ignore the gut reaction and consider the evidence. It also speaks volumes for the ignominious role of mavericks in the scientific world; they may occasionally be lauded as heroes but more often they will be squeezed out of funding, shunned at the peer-review review stage and ostracised by their own community.

Within the wider medical community tobacco harm reduction remains an exercise in thinking the unthinkable. Doctors recommending it may be vilified and it opens up a researcher to accusations of acting as an industry patsy; labelled as a dull-eyed lackey in the pay of malignant giants. Yet it could save millions of lives and it certainly merits wider debate.

Phillips, C. (2009). Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments Harm Reduction Journal, 6 (1) DOI: 10.1186/1477-7517-6-29

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IV heroin – I predict a RIOTT

IV heroin – I predict a RIOTT

Posted on Tuesday, September 15, 2009 at northerndoctor.com

There is almost a sad inevitability about the discussion in the media around the issue of giving heroin to heroin users. When it come to heroin-assisted treatment (HAT) it is inevitable that any reasonable discussion will be drowned out by the clamouring commentariat.

The UK has been using heroin as part of the treatment of users in one form or another since 1926. More recently, there have been studies of HAT in Switzerland, Germany, the Netherlands and Canada which have shown benefits in health, psycho-social adjustment and illicit drug use to socially excluded heroin dependent patients resistant to other treatments.

However, it’s inevitable that ill-informed parallels will be drawn with alcohol, smoking and the funding of almost anything else in the NHS deemed more worthy. It’s even possible to drag in ‘our boys’ fighting the drugs (spot of mission creep here) war in Afghanistan if one wants to work up a proper lather. The RIOTT study (I am assuming the obligatory acronym is an ironic nod to the impact this study will have on Daily Mail readers) isn’t even published yet and already the hysteria begins…

Is it even worth discussing the science amongst this hubbub? It might be better to crawl back under the duvet, let the dust settle and have a more rational discussion when we actually have the results of the UK study.

But there is some science to look at and consider. It is only last month that the New England Journal of Medicine published the results of NAOMI, the North American Opiate Medication Initiative (another tortured acronym) which looked at exactly this issue and it’s probable that RIOTT will have similar results. NAOMI compared oral methadone versus injectable diamorphine. It was open-label and there was no attempt to blind users to their treatment. They had better retention in the diamorphine arm at 88% versus the methadone arm at 54%. The reduction in rates of illicit drugs were 67% in the heroin group and 48% in the methadone group. Overall, the diamorphine arm tended to do better.

There were clear benefits but it wasn’t without issues and there were serious adverse events. There were 18 events in the methadone group (n=111) but none of them were felt to be related to the treatment. In the diamorphine arm (n=115) there were a total of 51 serious adverse events. However, it was reckoned that 27 of these were directly related to the diamorphine and included overdoses and seizures. This has to be put in context: a total of 89,924 doses of diamorphine were self-administered during the course of the study so that’s 0.03% of injections causing an event.

There are some issues around the methodology. Users know what kind of trial they are entering and many will drop-out when they get randomised to methadone rather than injectable. Indeed, this was the case in this study and it raises some issues around bias. The methodology of RIOTT was published in the Harm Reduction Journal in 2006 and is available for free.

The final conclusion of the NEJM paper is a reasonable one:

In this trial, both diacetylmorphine treatment and optimized methadone maintenance treatment resulted in high retention and response rates. Methadone, provided according to best-practice guidelines, should remain the treatment of choice for the majority of patients. However, there will continue to be a subgroup of patients who will not benefit even from optimized methadone maintenance. Prescribed, supervised use of diacetylmor-phine appears to be a safe and effective adjunctive treatment for this severely affected population of patients who would otherwise remain outside the health care system.

It will certainly need to be given in a specialised environment so it is likely to remain a very limited intervention. The headlines have tended to highlight that crime rates fall. How can this be surprising? UK studies have shown reductions in criminal activity across all treatment modalities for years. Part of the reason for this emphasis is presumably to make it as palatable to the public as possible. It’s not enough for it to be a useful option to improve health in a limited group of treatment resistant users. There has to be a fringe benefit to society as well.

There is an excellent paper by the authors of NAOMI commenting on some of the controversies around HAT. Again, it is freely available at the Harm Reduction Journal and will give you as good a background knowledge of the issues around HAT as anything. The authors commented on the media:

Treating heroin addiction with heroin tends to evoke a knee-jerk reaction. Lack of understanding, restrictions on time and resources, and the need for a catchy headline often lead to sensationalism by the media. As previously mentioned, opposition both within Canada and the US also contributed to misleading reports from local, national, and international media. The resulting focus has been on a seeming shift in Canadian drug policy in direct contradiction to the US war on drugs, rather than on the scientific or medical merits of the NAOMI study.

Much hand-wringing will be provoked by these studies for the simple reason that some will perceive that the logical development of this whole debate is that the next step will be de-criminalisation of drugs. It is entirely possible that we are waging a phoney ‘war on drugs’ but that’s really not what these studies are all about.

Oviedo-Joekes E, Brissette S, Marsh DC, Lauzon P, Guh D, Anis A, & Schechter MT (2009). Diacetylmorphine versus methadone for the treatment of opioid addiction. The New England journal of medicine, 361 (8), 777-86 PMID: 19692689

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