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!

Those marvellous people at Exchange Supplies have posted all the presentations for the 2007 National Conference for Injecting Drug Users on their website. You can read abstracts, see the slides and even hear the speeches in their entirety - this was an excellent conference from an excellent organisation, who we have to thank for giving us all access to the presentations without even having to attend. Click here to be taken to the webpage.

Drug use in Australia

I have not long returned from a visit to Australia, where I attended an interesting conference on methamphetamine. We haven't seen much use in the UK yet, and I wonder whether the Fleet Street prophets of doom will be right with their gloomy predictions - my suspicion is that "Ice" will not become the problem here that it has been in Oz, South East Asia or California - why? well fascinatingly the demographics and the harms with Ice are very similar to Crack - in Australia there is little Crack because there are no traditional smuggling routes and cocaine there is very expensive - in the UK our patients have pretty much open access to Crack or amphetamine and market forces have directed the vast majority of stimulant use to Crack. It is my belief that if we had similar access to methamphetamine, then the amphetamine users might opt for it, but the Crack users would stick with their rocks - but that is just my theory.

Another interesting Australian experience which again arises from traditional smuggling routes is that their heroin is the white water soluble product that is processed in SE Asia and China - so their injecting users are spared the task of cooking up their smack with citric etc as our patients do with the brown Afghan product.

Some Australian commentators have been critical of British heroin treatment, citing low methadone doses and not enough supervision - and I was interested by the comments of one Australian drugs worker who described her country's habit of putting people on daily supervised consumption for ever with virtually no other support, and herding them all into centralised dosing clinics as "a sheepdip" - an interesting antipodean metaphor!

The New DoH Guidelines are out now!

Yes folks, they have finally arrived, and you can click here to be whizzed over to the NTA Thought Police where you can download your very own copy of your new bible! It is actually a very useful document, so don't just stick on the library shelf to gather dust, read it! and feedback any comments that you have, but you can click here to read the SMMGP quick guide and commentary to all the changes in a special "Network" issue.

The NTA is currently touring England's regions and delivering key messages and important changes in the new guidance - I attended the one in the South West and very good it was too. I saw many of you there, but for those who missed it, you can view their slides here:

Key Messages

Clinical Guidelines

Nice Guidance

Implementation

Weights and Measures

Drug users confuse us with many things, but I particularly struggle with their weights and measures, because they insist on using both metric and imperial measures, and dress it all up in confusing jargon as well. So I am indebted to friends who have given me a Tutorial, and I pass this on to you. When dealing in heroin, cocaine and Crack cocaine, the following measures apply:

28g = 1 oz , 7g = ¼ oz , 3.5g=1/8 oz, and a “teenth” (ie. 1/16 oz) should contain 1.75g, but is usually more like 1.5g {NOTE for dealers: a “Nine Bar” is 9oz (250g), and there are 4 Nine Bars to 1 kilogram (36oz)}

So, a typical £10 deal, bag, or wrap of “product” will contain 0.15-0.4g of drug (note the wide range of purity). (Also note that you cannot equate ANY amount of heroin with an “equivalent” dose of methadone for reasons of purity and the variability of individual physiology). So a typical heroin habit that costs, say, £30- £70 per day will involve doses ranging from 0.5g to 1.5g a day, which is…. errrr…. a teenth.

Cocaine and Crack: A dealer will begin with a large amount of powder cocaine, say 1 kilo, or a Nine Bar. Nine Bars of good powder cocaine cost £8000 wholesale. This can then be “re-pressed” (cut or diluted) with a pharmaceutical inert powder called Mannitol, costing £50 for 1kg. An ounce of good powder cocaine might cost £1100, but re-pressed powder cocaine might be £800. Most cocaine sold in ounces or less will have been re-pressed.

Crack cocaine is the free base of (powder) cocaine hydrochloride. “Freebase” Coke is essentially Crack that has been “washed up” (the manufacturing process) using ammonia and ends up weighing less than the original powder weight. Traditional street Crack however is a gain in weight due to the addition of bi-carb, hence the high profit for dealers. The purer the gram of coke, the more weight is returned. 1oz of powder (cost £800) can be turned into £1400 of Rocks if sold in £10 amounts. This can be injected, broken down using frightening amounts of citric, but really its designed to be smoked

Cannabis: The best value in dealing comes from buying Grass in kilos I am told – apparently you can double your money.

The Treatment Outcomes Profile

Have you heard of this? do you care? well as a GP it wont affect you much yet - but I have a sneaking suspicion that it may in the future. The "TOP" (the unfortunate clash of acronyms has clearly not bothered the NTA whose knowledge of gynaecology I would imagine is scant) is a simple new scoring tool to assess patient progress in treatment. Like the NDTMS data set, it is (at the moment) the job of your Shared Care worker to complete. So why would a GP need to know about this? well I can imagine some PCTs making the completion of these three monthly forms part of your LES, particulalrly if you are a more advanced GP who might start a patient on treatment before the Shared Care worker is involved - or you might be required to fill them in if you are supporting a patient's abstinence and the Shared Care worker has withdrawn.

But fear not, the form is easy and quick to fill in - and should provide some pragmatic and useful data on the value of treatment....Well MOST of the data is useful - but one question asks "How many "Spliffs" does the patient smoke a day!!! for Heaven's sake! are we talking Fat Ones? Four Skinners? A Camberwell Carrot??!!

I don't think that any GPs yet need to be involved in this new bureaucracy - but if you happen to be the sort of proactive, anally retentive sort who wants to know everything that is going on, then click here and you will be beamed over to the NTA documentation and you can read all about it.

Afghan Heroin production soars

Apparently the amount of Afghan land under poppy cultivation has grown by 21% in the past year - whatever our beleagured troops are doing in that tragic country, clearly any efforts to reduce this trade has been unsuccessful. But to tell an Afghan farmer not to produce one of the few things that has a chance of making any money, seems a bit fatuous anyway - it is in effect punishing him for meeting the demands of our own people. As Simon Jenkins said in The Guardian this week, the ONLY hope for reducing the problems of heroin consumption in the West are to reduce the demand by more investment in treatment and in addressing social exclusion. Attempts to curtail supply have never worked, anywhere, ever.

In the meantime I guess that this increase in heroin supply will be translated into our practices in the year ahead in terms of stronger purity for the same cost - we shall see.

25% Rise in Drug Related Deaths in Scotland

This news from Scotland is depressing:

Scotland you will remember was at the vanguard of introducing supervised methadone consumption in response to its appalling rate of drug related (and methadone related) deaths in the late 80's - the fall in deaths that followed was further evidence of the value of high quality methadone prescribing. And it was Scotland's heroin users who discovered the value of buprenorphine as well in the great Scottish Temgesic "scandal" which led to the CD Classification of buprenorphine and later, in a poetic twist of irony, to buprenorphine receiving a licence for the treatment of opiate dependency. And it is Scotland where high doses of methadone are championed, and where just last year, some Chief Police Officers were calling for a return to abstinence treatments because of the "failure" of methadone programmes! what a confused state of affairs. It is remarkable that since Dole and Nyswander first wrote about methadone treatment in JAMA in 1965, every single study published has reinforced the message of the life saving effects of high quality substitute prescribing - I hope that Scotland does not loose sight of that message - whatever is going on in Caledonia to increase the rate of drug related deaths now is evidence (if we ever needed it) of the need for more treatment, not less.

http://www.drugscope.org.uk/newsandevents/currentnewspages/Scotland_DRD_rise.htm

Suboxone on FP10MDA

There was a minor cock up when this drug was put on sale in the UK - there was some sort of legal reason why it should not be prescribable on "Blue Scripts", making interval prescribing impossible. Soon after there was an unofficial dictat sent out to pharmacists for them to accept Blue Scripts (and be paid for doing so), but now I am happy to tell you that the situation is resolved and it's official, Suboxone MAY BE PRESCRIBED ON FP10MDA - hurrah.

Of course this drug's major selling point over buprenorphine (without naloxone included) is that it is less likely to be diverted because it has no appeal for injecting - so ironically, you might be more inclined to take the patient off supervision more quickly and onto less frequent collections to save the poor old PCT's cash.... and the latest edition of "Addiction" (102) has a study by Prof Bell showing that unsupervised Suboxone is every bit as effective at retaining patients in treatment as supervised buprenorphine - something to ponder.....

"After The War on Drugs"

Our friends at Transform have produced a new document that you may be interested in. Titled: "After the War on Drugs: Tools for the debate" is a guide to making the case for drug policy reform designed to:

• Re-frame the debate, moving it beyond stale ideological arguments into substantive, rational engagement




• Provide the language and analysis to challenge the prohibitionist status quo, and to make the case for evidenced based alternatives

You can access it from Transform's Blog here.

As I write, I have just spent a day attending to casualties of this "war" - including one chap who was released from prison with no methadone, no benefits and no home to go to. He stole a tent to keep out of the rain, is stealing to buy food, and has had two near-fatal overdoses in ten days. If he survives long enough he may live to be sent back to prison again. I am not sure who the winners are in this war, but there seem to be plenty of loosers.

Dalrymple says that Heroin Detox is "No worse than Flu"

For years, Theodore Dalrymple's writings on all things medical have been enjoyable for their dry wit and keen observations - but when he writes about heroin users he seems to me to loose his normal compassion and humanity. Maybe he has some personal "agenda".... but anyway....

Dalrymple was plugging his new book on Radio 4 this morning (hear the interview here) but some aggrieved methadone patient was shouting him down constantly so I did not hear the full argument and I have not read the book.... but it seems pointless to say that stopping using heroin is no worse than a dose of flu - and that it is all "psychological" (as if psychological distress didn't matter), because quite clearly people seem to have a great deal of difficulty coming off heroin which is disproportionate to a dose of flu...... But in another sense of course he is right - traversing an opiate detox can be achieved within 2 weeks by 80% of our patients at Clouds - rather less I suspect if we did not medicalise the event - but then we medicalise flu with aspirin and going to bed as well..... and I also agree with him that by medicalising addiction we turn clients into patients, tacitly suggesting that as "sufferers", they are not responsible for their "disease" ... and the ongoing daily dosing of methadone petrifies that mindset.

But I am not greatly bothered by Dalrymple's prejudices, because when people like him talk about heroin addicts, they talk about heroin, rather than talk about why people become unhappy and look for chemical relief in the first place. Returning to the unhappiness that the chemicals null out is what is hard, not relinquishing the chemicals themselves. Perversely, I am rather glad that we do have heroin and alcohol sloshing around our streets.... for every society has always had inequality of opportunity brought about by intellectual, social, mental and family dysfunction, and that inequality brings about enormous unhappiness. Whilst others, dealt a decent set of cards, get on with their lives, there is a big section that is left behind. If comforting chemicals had never existed, noone would know these people or their unhappiness - but because they find temporary solace in drugs and alcohol, and the knock on effects of their habits are health and criminal consequences, whole care systems have been invoked to look after them. Yes, some of them Dalrymple will say, are indeed lazy blackguards - but not many - the rest are lost souls behind a smokescreen of chemicals, who we try to help and care for - and by looking no deeper than the smoke, his simplistic arguments disrespect them.

Part 1 E Modules have moved!

Thanks to my friend Jo Betterton at the SMU, who writes:

The Part One e-modules have gone live on doctors.net.uk today

If people ask you should direct them to doctors.net.uk and everyone can complete them there, GP’s will go through the old route, nurses will go through the new nurse learning section and everyone else is now able to sign in through a new registration system they have built for us, this is signposted on the site and any problems will be dealt with by the doctors.net.uk helpline

If people go to the RCGP website they are directed to go to the Doctors.net.uk and can just click on the link that takes them into the Doctors.net.uk site where they log in and proceed as normal.

People are no longer able to register to start the e-modules on the RCGP website, but have until the end of September to complete them there if they have already started them.

Adult ADHD

This is a diagnosis that I confess to being quite cynical about in the past, but the evidence and the scientific papers that suggest it is a real and treatable condition, are mounting up. I commend a Consensus Statement published by the chaps at BAP last year:

http://www.bap.org.uk/consensus/adult_ADHD.html

Try reading it as the detail is very interesting – and the checklist of signs and symptoms was fascinating, if only because I “Strongly Agreed” with all of them! (But if you know me that might not surprise you.) Particularly of note to me was that ADHD persists into adulthood in most cases, and continues to respond to stimulants, there is a strong inherited tendency, and untreated ADHD in childhood is strongly associated with the later use of illicit drugs and alcohol. So early detection might be one of those rare opportunities at preventing substance misuse, not to mention enhancing education and social functioning. So find out who your local specialists are, and if you suspect ADHD in a child (or an adult), get them assessed.

Cannabis, potency and Psychotic Illness

This debate continues to rage, mostly in the tabloids but perhaps also in the new Labour Cabinet "Chill Out" rooms - and a search of the literature does seem confusing. Addiction (July 2005) published a report from Italy revealing that cannabis seizures over 20 years showed little change in THC concentration, and my chums at Transform whose bias they wear on their sleeves, say that american seizures have only revealed a doubling of potency in recent years (not a "30 fold" increase as some hysterical headline grabbers have claimed).

http://transform-drugs.blogspot.com/2007/04/cannabis-potency-update-ios-digs-in.html

I find my most reliable information source is our patients, and mine all seem to think that Skunk is a great deal stronger than block resin and weed was some years ago. Does that matter? well the association with psychotic illness has been made,

http://journals.cambridge.org/action/displayAbstract;jsessionid=F1921C7E09548430C6B105183E5B437D.tomcat1?fromPage=online&aid=141663

http://www.thelancet.com/journals/lancet

http://www.bris.ac.uk/news/2007/5554.html

and there are a number of disquieting parrallels with addictive practices in the past. For several thousand years the Indians of the Andes chewed Coca leaves with impunity and our Victorian forebears regarded a Laudanum habit as little more than a "weakness of character". But those who profit from supplying these things have learnt that greater concentrations of drug increase compulsion and demand, even tobacco companies enhance the nicotine content of cigarettes - if that were not the case, then Crack and Heroin would have no supply or demand - and we would all be happy with playing Snap, and not pressing buttons on Fruit machines all day. And greater compulsion and demand seem invariably to have harmful consequences.

We will see where this leads - but the lessons of the past seem to be going unheeded as usual.

NCIDU 2007

The Exchange Supplies sponsored National Conference on Injecting Drug Use will this year be on Monday 15th & Tuesday 16th October at Glasgow's Radisson Hotel - you can find the conference programme here:
http://www.exchangesupplies.org/conferences/NCIDU/2007_NCIDU/programme.html

Plenary keynote topics will include: composition of illicit drugs: manufacture, adulterants, purity; developing our understanding of sharing, and how to reduce it; providing needle exchange to young people; insulin use by body-builders; pharmacy needle exchange; and
crack cocaine preparation and injection.

The Draft NEW DoH Guidance for Doctors working with Drug Users

Comrades

I am sure that you have all been eagerly devouring the draft new National Guidelines and helpfully feeding back to the Politburo various tweaks and editions. For your edification I pass on my comments which are in no way expert, are completely my personal opinion and not those of the College, and treat the weighty tome with the sort of superficial dismissiveness which you have probably come to expect from me, but at least I have read it….

Overall I have to say that although I was prepared to hate it – in the main it is quite a good document, but at 204 pages, no way can this be called guidance – it is a text book that is comprehensive and draws upon current evidence as presented to NICE, and various other research from home and overseas.

The priorities are very clearly harm reduction – abstinence is noteworthy for being mentioned in the list of priorities, but only after all other avenues of harm reduction. Indeed reading the document you might well wonder if it is ever permissible to discharge a patient from treatment. I think that guidance that clearly steers us away from punitive practices and discourages the harm aggravation of discharge is absolutely necessary, but it should be balanced by guidance on situations (for instance serial non-attendance) where it is unsafe to continue prescribing.

Governance: you might expect (and you would be right) for a section on governance matters to be pretty turgid – but again it is necessary and welcome. I am dismayed by the number of colleagues who are put into positions where they are “over-extended” and neither supervised nor given proper appraisal by someone who understands their work One day something horrible will happen and the wretched doctor will have my blessing if he calls his employers/PCT into the Dock to stand alongside him – because they share the responsibility for his actions.

“Non Medical Prescribing” – a bit of an insult to nurses and pharmacists to call them “Non Medical” but we know what they mean – this is the way forward Comrades – it is high time that all these over paid Prima Donna doctors got their marching orders….............. oh hang on a minute….

Contingency Management – or “inducements”, are vogue at present – NICE saw the American evidence and were impressed, and that has come over into the draft guidance. Excuse me, but isn’t the USA the country where they deny cannabis smokers university grants, but do not extend the same punishment to rapists and armed robbers? Don’t they have more blacks in prison than are at liberty in the whole of Europe? And aren’t welfare payments roughly 40% of what we dish out in the UK? Call me old fashioned, but it is surely flawed to extrapolate that if American drug users attend appointments with their service because they are offered luncheon vouchers (as opposed to being sent down to San Quentin), that the good old British drug user will be similarly impressed? Maybe Contingency measures will be effective in Blighty, and maybe our paymasters will give us a load of money to support this, but I think that we need British evidence first.

As a document of “best practice” this is mostly pretty good in my view. At times it is very biased toward Specialist Service models and offers little to Primary Care with regard to low intervention/long term stable clients. There are a number of worthy although quite unrealistic statements eg: “Drug misusers in the criminal justice system should neither receive higher priority for their treatment, nor should their legal status deny them access to care equivalent to that available in the community.” I hope that the finished article will take account of the feedback that has been sent, and I hope that nothing else is sneaked in at the last minute……!

You can find the entire document and feedback forms by clicking this link:

http://www.nta.nhs.uk/areas/clinical_guidance/clinical_guidelines/cgl_update0607/consultation.aspx

and the latest NICE Guidance on Psychosocial interventions by clicking:

http://guidance.nice.org.uk/CG51

I've become a Blog

It's a well known fact that to be a drug doctor, you've got to be "down with the kids" - and what better way to demonstrate that, than to host a Blog - a sort of self indulgent depository to commit one's thoughts to, where they can be cherished for posterity - and new members of the group can read the witterings passim of myself and others.

The plan is that in future I will post my ramblings here and simply send out an email announcement with a link, so that you can read them, or not, as you wish.