Important Conference comes to the South West

Those marvellous people at SMMGP (and if you don't access their web site regularly with all its resources, you should) have chosen the South West to host their Third annual (one day)conference. The theme this year is to be "End of The Line, or Part of The Journey? - How to Optimise Patient Choice and Opportunity". This will be an important event for the hitherto neglected South West, and will appeal to GP and all practice staff, as well as Shared Care workers, patients, carers and all those involved in services. It's at The Bristol Marriott on Friday September 26th - stick it in your diaries NOW! it's a day of CPD, and a chance for us all to get together to show the rest of the UK how things should be done! You can go to the SMMGP conference and events page by clicking here and scroll down to the Bristol event....but look at all the others as well.....

Addiction and The Family

Here is an interesting looking local conference: "Addiction and The Family" - a one day event in Bristol at The Marriot Royal Hotel on Friday November 21st. Speakers include the eminent pioneers of Family Therapy and SBNT, Professors Orford, Copello and Velleman, as well as Prof Moira Plant included in a stellar cast. Details available from Jan.Green@uwe.ac.uk

Personal News

Your scribe is about to undergo a seismic change in his work: I will continue as the RCGP Drug Training Lead in the South West, but have resigned from 30 years as a GP, 15 years in Clouds House and 5 years as Trust Specialist to the Wiltshire SDAS, to take up a new challenge in Somerset.

This means that Clouds House needs a new doctor - if any of you would be interested, please contact them kirby.gregory@actiononaddiction.org.uk - they are marvellous people to work for and the work is fascinating.

The New Drug Strategy

Well it is here - the "new thinking" from the DoH. The Daily Mail hacks have already subverted the key messages with cheery messages for their readers that promise to get the junkies off their backsides by removing their benefits if they "fail" their treatment.... oh dear.

Anyway, give it a read, you can be linked over to the documents by clicking here.

Should Heroin Be Prescribed?

This debate is featured in the BMJ Jan 12 2008, you may like to give it a read. Notwithstanding the considerable cost, and the complexities of supervised injecting and diversion, the experience from studies in Switzerland and Holland have revealed a range of benefits to justify a limited place in our already limited range of treatment options.

Professor Neil McKeganey, never one to shirk controversy in the addiction treatment policy arena, gave his characteristically forthright view that we should not be contemplating this option: “If you can not stop addicts committing crimes to fund their drug habits, then, so the argument goes, the next best thing is to provide them with the drugs thatt are the reason they are committing crimes in the first place. The logic may seem faultless, but at the back of your mind is the nagging question – is this treatment, or is it social problem prescribing?”

My own view is that it is probably both, and in the spirit of harm reduction, I would defend a limited place for diamorphine prescribing, albeit not by me. But my “nagging doubt” is that this is a further step down the road of the medicalisation of drug dependency – a further tacit acquiescence to addiction being some sort of disease that actually reinforces the misguided belief that drugs are needed - rather than their use being a symptom of a more fundamental malaise.

But give it a read – it is thought provoking.

Why We Do What We Do

Compliments of the season folks. Like many of you I am sure, I spent my time seeing the New Year in, reading the latest copy of “Addiction”. There was a very interesting commentary titled “Why we do what we do” in which the author questioned the “received wisdom” of frequent attendances being required of drug users on maintenance prescribing, and I reproduce some of it here:

“….Perhaps the issue is not so much about whether required clinic attendance is good or bad for patients, but about why we do things the way we do. Could it be that at some level we recognize that requiring frequent clinic attendance is a burden on our patients but we make these requirements for other than research-based reasons? Perhaps we do not trust our patients enough, perhaps with good reason, or perhaps traditional treatment approaches are overly reflective of societal expectations more than based on scientific rationale. Even if we clinicians consider these matters consciously, we are unlikely to engage patients in the process. We do not say to our patients that we understand it is a burden to attend clinic, but that it is necessary because society wants us to adhere to certain expectations in order to improve outcomes, ostensibly to exert control, or for whatever reason. In the final analysis, we can only do what ‘Big Brother’ lets us do according to regulatory mandates. In that context, the real message is that we believe addicts are sick and need help but they are also sinners and must suffer a little, whether by required clinic attendance or supervised dosing or providing urine samples: but that ‘suffering’ may not he entirely bad. While the first principle of medicine is that the patient’s best interests are paramount, sometimes the needs of the greater society conflict with the physician’s judgement about what is best for the individual patient. This is particularly pertinent to addiction, which affects not only the individual, but society as a whole. In such cases it is perhaps also our responsibility to convey to our patients that giving consideration to societal needs is an integral part of their recovery, because in the end they will have to live as a member of that same society with its structured mandates, laws and expectations.”

I confess that this made me feel very uncomfortable – it seems to suggest that frequent attendances are “regulatory mandates” and are primarily designed to control and importune our patients rather than be in the interests of their health. And what is more, that this is allowable because the requirement is (allegedly) helping to shape the patient from social deviancy to social conformity. Does anyone agree?

On the QT

High doses of methadone can cause sudden death from acute ventricular tachyarrythmias... or at least that is the impression that some research seems to imply. This is known by some cynics as "Krantz Syndrome" after the author of one of the most influential pieces of research on the subject (click here for abstract).

Krantz's postulate is that some people have naturally prolonged QT intervals on their ECG, which is associated with "Torsade des Pointes" arrythmias. In his study, methadone patients further increased the QT interval, but his patients were complex medical subjects, most of whom were being treated for intractable pain and not regular addiction patients at all. In his first report of 17 cases from US and Canadian pain centres, none of whom died, 15 had pre-existing risk factors for arrhythmias. Also, the mean dose was a ‘stratospheric’ 400mg. Other researchers have confirmed the findings, again in very high doses of methadone not normally used in addiction work. Krantz himself concluded that routine ECG examinations in normal addiction patients was not indicated.

However, the BNF and the new guidelines suggest that in methadone maintenance where the dose of methadone rises above 100mg daily, an ECG should be performed. What you do with patients whose QT is prolonged (>440 msec in males or >470 msec in females) is not stated - but clearly other drugs that can also affect either the QT interval or methadone metabolism, should be avoided.

I suspect that this advice will be officially debunked in the future, but for the time being, that is the advice. You have been told!