Fw: Three fine French papers on methadone/buprenorphine (community, pregnancy, HIV).

Preston Peet ptpeet at nyc.rr.com
Wed Jan 14 04:17:34 EST 2004

It's not really about ibogaine, but it is about treatment modalities.

----- Original Message ----- 
From: "Andrew Byrne" <ajbyrne at ozemail.com.au>
To: "Andrew Byrne" <ajbyrne at ozemail.com.au>
Sent: Tuesday, January 13, 2004 10:41 PM
Subject: Three fine French papers on methadone/buprenorphine (community,
pregnancy, HIV).

> Illicit drug use and injection practices among drug users on methadone
> and buprenorphine maintenance treatment in France. Guichard A, Lert F,
> Calderon C, Gaigi H, Maguet O, Soletti J, Brodeur J-M, Richard L,
> Zunzunegui M-V. Addiction (2003) 98: 1585-1597
> The November Addiction starts with a rather gauche exercise by Griffith
> Edwards et al. in which a hand-picked group of sub-editors, chosen for
> ‘their insight into Addiction’s ways of working’, are asked their
> suggestions for future directions in publication. It will come as no
> surprise to the reader that it is to be more of the same. While these
> distinguished folk come up with numerous worthy suggestions, the
> ‘uncomfortable’ issues are not raised to any level of prominence. These
> include the standard of opioid treatments; heroin prescription trials;
> controlled drinking; injecting centres; views direct from ‘consumers’;
> urine testing protocols; rapid opioid detoxification; naltrexone
> implants; medicinal uses of cannabis; the effects of criminal sanctions
> on the use of drugs, aka ‘drug law reform’; harm reduction philosophy
> and practice.
> The authors congratulate themselves in advance by writing “the exercise
> has fulfilled its intentions”. They then concede that at some time in
> the future such an exercise may be repeated ‘with a wider sample’ and
> from ‘a younger generation’. We can only hope.
> In spite of its current management, Addiction still attracts leading
> researchers, publishing key items of interest. An important item in this
> journal comes from France where in a three-city study, 340 addicts in
> maintenance treatment for at least 6 months were interviewed regarding
> illicit drug use, treatment characteristics and demographics. There were
> 200 on methadone while 140 were prescribed buprenorphine. About half the
> methadone patients and 80% of buprenorphine patients were treated in
> general practice, the remainder in specialist dependency treatment units.
> The authors write that in France methadone can only be started in formal
> dependency treatment units. After stabilization, patients may attend
> pharmacies and receive up to a week’s supply of methadone on a GP
> prescription. In contrast, buprenorphine tablets (‘pure’, sub-lingual)
> can be prescribed for up to 28 days by any physician. Thus the latter
> has had a rather broader uptake even though both were introduced around
> the same time in France. This is especially so in regions without
> specialist units. The authors state that buprenorphine was generally
> considered the ‘first line’ drug in France.
> This study found that methadone patients had been using drugs for longer
> and had been in treatment slightly longer than the buprenorphine
> recipients.
> Mean daily dose for methadone was 67mg (SD 30) and for buprenorphine
> 10mg (SD 9).
> The important finding of this study was a low rate of illicit drug use
> of around 35% of subjects (18% heroin, 25% cocaine, 7% crack). There was
> little significant difference between patients being cared for in
> specialist clinics or by GPs. It was noteworthy that 40% of the
> buprenorphine patients had injected their own substitution drug (ever)
> while only 15% of the methadone patients had done so. In addition, the
> higher dose buprenorphine cases were more likely to have injected, a
> trend which was not seen with the methadone patients.
> About 80% of methadone patients received a prescription for two weeks or
> less. Two thirds of buprenorphine prescriptions were for 3 weeks or more.
> About half of the subjects had a jail history. About 90% of patients had
> been tested for HCV and HIV. Around 50% were HCV positive while 22% HIV
> positive. These figures may relate to the late introduction of harm
> reduction measures in France compared with experience elsewhere (eg.
> Australia and Hong Kong). It is partly as a result of increasing HIV and
> overdoses that France took the bold step of making buprenorphine so
> widely available.
> My ‘theory’ on the buprenorphine injecting is that a proportion of
> patients who do not do well initially on buprenorphine doses may
> increase their dose, still without suppressing cravings. Such unstable
> and unhappy patients may tend to inject their buprenorphine, thus
> defeating one of the main purposes of the treatment. Whether relapse to
> heroin use or buprenorphine injecting, such behaviour should indicate a
> consideration of transfer to methadone or another agonist drug such as
> long acting morphine if available.
> With arbitrary regulations in some jurisdictions these options are not
> always available in the same treatment settings. This would be unlikely
> to occur in other fields, rather like banning some doctors or
> pharmacists from using certain antibiotics. The principles governing
> methadone treatment should be parallel to those for buprenorphine with
> emphasis on real risks and benefits, not implied or theoretical ones.
> Historical regulatory anomalies should be removed in the interests of
> all involved since agonist treatments are evidence based, cost-effective
> and can be simply delivered using existing resources and facilities.
> Fortunately, all Australian jurisdictions now permit (limited) take-away
> provisions for buprenorphine, including New South Wales (up to two per
> week as well as for emergencies and travel in suitably approved
> patients). South Australia allows up to 5 dispensed doses per week in
> stable patients who have been in treatment for over 18 months. Such
> dosing encourages retention and is recommended by the new Australian
> treatment guidelines. Intriguingly, both France and the US allow
> unlimited unsupervised doses even though these have not been researched
> to any degree. Such are the anomalies of our field.
> This Addiction edition also has some largely reassuring information on
> buprenorphine in pregnancy with 13 cases reported from France. The
> authors state that no teratogenic effects have been reported, and that
> their cases had variable neonatal abstinence syndrome but of shorter
> duration than with methadone. Two cases (15%) had some motor
> abnormalities which did not resolve completely at follow-up.
> [Kayemba-Kay’s S et al.]
> Another important recent comparative description is: Carrieri M-P, Reya
> D, Loundoua A, Lepeuc G, Sobeld A, Obadia Y .Evaluation of buprenorphine
> maintenance treatment in a French cohort of HIV-infected injecting drug
> users. Drug Alc Depend (2003) 72; 1:13-21
> comments by Andrew Byrne ..
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> Dr Andrew Byrne,
> Medical Practitioner, Dependency Medicine,
> 75 Redfern Street, Redfern,
> New South Wales, 2016, Australia
> Email - ajbyrneATozemail.com.au
> Tel (61 - 2) 9319 5524 Fax 9318 0631
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> My grandfather Harry Gracie's letters from 1924 trip to Mayo Clinic:
> http://bpresent.com/harry/code/mayo.htm
> Opera reviews (Met & Syd): send email request to receive.
> author of: "Addict in the Family" and
> "Methadone in the Treatment of Narcotic Addiction"
> http://www.csdp.org/addict/
> http://www.drugpolicy.org/library/byrne_contents_methadone2.cfm
> Photo (ugly):
> http://www.opiateaddictionrx.info/aboutus/aboutus06.html#

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