GSMS Presidential Address 2007 - Dr Richard Watson

Helping Drug Users; Without Getting Struck Off Dr Richard Watson Glasgow Southern Medical Society

Bob Dylan

OPIUM POPPIES

PROBLEMS WITH METHADONE • Maintains dependence, though perhaps not addiction. • Few patients leave treatment. • Diversion of methadone. • Expense. • Patient choice - some do not want it.

RAPID OPIATE DETOXIFICATION RAPID ANTAGONIST INDUCTION ROD/RAI The Asturian Technique

NALTREXONE • Blocks opiate receptors. • Can be given three times a week. • Give under supervision. • 6 month relapse rate 40% vs 80% without it. • ? implant

Effective Interventions Unit / GGHB • Systematic review recommends increased use of naltrexone. • Methadone Review encourages “moving patients on” from MMT.

DETOXIFICATION • Residential programme very expensive. • Community based programmes have a low success rate. • Rapid detox using naltrexone plus or minus anaesthesia been practised for many years on in-patients.

THE ASTURIAN METHOD • At home - need a responsible carer. • Exclude patients dependent on alcohol or benzodiazepines. • Other exclusions - pregnancy, significant other disease.

FIRST DOSE • S/c octreotide 200mcg • clonidine 450mcg • famotidine 40mg • midazolam 22.5mg • ondansetron 12mg • clorazepate 50mg

45 MINUTES LATER • Asleep, but shaken awake. • Metoclopramide 10mg. • Naltrexone 50mg

1 hour 45 minutes • Again shaken awake. • hyoscine 20mg • clonidine 300mcg • metoclopramide 10mg • 30-60 minutes later withdrawals begin.

ATTEND THE NEXT DAY • Continue naltrexone, orally or with implant. • Some may stop naltrexone and not relapse. • None of my patients able to attend the following day.

ROD/RAI • 3000 in Asturias, 99.8% attended the following day. • Four in Cambuslang. All stopped naltrexone soon. • Two seem free of opiates several years later.

Reference • Carreno JE, Bobes J, Brewer C, Alvarez, CE, San Narciso GI, Bascaran MT, and Sanchez del Rio J. 24- hour opiate detoxification and naltrexone induction at home - the “Asturian method”: a report on 1368 procedures. Addiction Biology (2002) 7, 243-250.

FINAL VERSION Drug misuse Opioid detoxification National Clinical Practice Guideline Number 52

Legal Drugs • Tobacco • Alcohol

ALCOHOL “An Inn has one entrance and three exits: to hospital, to asylum and to prison.” (Croatian proverb)

Alcohol-related mortality

www.sign.ac.uk;

How Long Is Long Enough? • Addiction is a chronic disease and not a voluntary disorder (9) • “180 Day Psychosocially Enhanced Detoxification” no good.(10) • Death Rates go up on discharge from MMT (7,11)

References • 1 Barnett P. G. “The cost-effectiveness of methadone maintenance as a health care intervention.” Addiction. 1999, 94(4), 479-488. • 2 Hulse G.K. et al “the quantification of mortality resulting from the regular use of illicit opiates.” Addiction. 1999, 94(2), 221-229. • 3 Donoghhoe M. C. Opioid overdose. Trends, risk factors and priorities for action. WHO, 1998. • 4 Best D. et al. Overdosing on Opiates. Drug and Alcohol Findings. 2000. 4, 4- 20. • 5 Mattick R. “Are detoxification programmes effective?” Lancet. 1996, 347, 97- 100. • 6 Desmond D.P. et al. Deaths among heroin users in and out methadone maintenance. In: Effective Medical Treatment of Heroin Addiction. National Institute of Health (NIH) Consensus Conference, November 17-19,1997, Bethesda Md. Available at: http://odp.od.nih.gov /consensus/cons/108/108_abstract.pdf:73-78

References 7 Gronbladh L. et al. Mortality in Heroin Addiction: Impact of Methadone Treatment. Acta Psychiatrica Scandanavica. 1990. 82(3), 223-227. 8 Caplehorn J.R.M. et al. Retention in methadone maintenance and addicts risk of fatal heroin overdose. Addiction. 1994. 89, 203-207. 9 McLellan et al. Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance, and Outcome Evaluation. Journal of the American Medical Association 2000. 284, 1689-1695. 10 Sees K, et al. Methadone maintenance versus 180-Day Psychosocially Enriched Detoxification: A Randomised Controlled Trial. JAMA: March 2000: 283 (10) • Magura S & Rosenblum A. Leaving Methadone Treatment: Lessons Learned, Lessons Forgotten, Lessons Ignored. Mount Sinai Journal of Medicine: Jan 2001. 68 62-74

References • 12 Hutchison SJ et al. One year follow up of opiate injectors treated with oral methadone in a GP-centred programme. Addiction. 2000. 95 (7) 1055-1068 • 13 Ward, Mattick and Hall. Methadone Maintenance Treatment and Opioid Replacement Therapies. 1998. Harwood Academic Publishers

GSMS Presidential Address 2007 - Dr Richard Watson

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