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SMMGP Clinical Update April 2008

• Papers
• Book Review

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Papers

Characteristics of drug-using patients and treatment provided in primary and secondary settings
E Day et al., Journal of Substance Use Feb 2008 13(1) pp27-35

This was a cross sectional review of all patients (1597) in treatment services in Birmingham in 2003. It aimed to explore the differences in patient groups and treatments offered in primary and secondary care settings.

Results: The primary care sample (36.1%) were significantly more likely to be being prescribed opioid medication whereas benzodiazepines and amphetamines were significantly more likely to be prescribed in specialist services than in primary care. The mean dose for both methadone and buprenorphine was higher in primary care. Secondary care patients were normally older, more likely to be poly drug users and have a greater range of problems. Using the Christo Inventory (CISS) as a basis for judging complexity it was found that 646 patients had a score of 6 or less but that only 46% of these were being treated in primary care. Approximately one third, of patients (338) in secondary care were suitable for primary care based treatment according to the model used. At the same time 47% of primary care case met the initial criteria (CISS score used as basis) for transfer to secondary care.

Conclusions: The differences between primary and secondary care were less than expected. The authors suggested a possible link between higher mean doses in primary care leading to greater stability and explained that in the case of some of the patients treated inappropriately (according to the model) in secondary care it was due to their GP not delivering enhanced services.

SMMGP comment: An interesting study, we feel that it may also have been productive to discuss the usefulness of Christo inventory scores to decide whether someone is appropriate for primary care treatment as there are many variables to this which the inventory does not completely take account of.

Exposure to opioid maintenance therapy treatment reduces long-term mortality
A Gibson et al., Addiction (2008) 103 pp462-468

This was a 10-year longitudinal follow-up study of mortality among participants in a randomised control trial of methadone and buprenorphine maintenance in Australia.

Results: There were no differences found in mortality between methadone and buprenorphine patients. Increased exposure to episodes of opioid treatment of longer than seven days reduced the risk of mortality. More dependent heavier users at baseline had a lower risk of death and also higher exposure to opioid treatment. Older participants randomised to buprenorphine had a significantly improved survival.

Conclusion: Increased exposure to opioid maintenance treatment reduces the risk of death in opioid dependent people.

SMMGP comment: There are potentially useful practice implications of the risks of less heavy end users not accessing treatment and for the treatment of older users.

Adrenocorticotropic hormone and cortisol plasma levels directly correlate with childhood neglect and depression in addicted patients
G Gerra et al., Addiction Biology (2008) 13 pp95-104

Hypothalmic pituitary-adrenal (HPA) axis dysfunction has been reported to be involved in vulnerability to alcohol and drug dependence, possibly underlying both addictive behaviour and depression susceptibility. This study ramdomly selected 82 addicted patients from a Rome clinic (54 heroin 28 cocaine) along with 44 control subjects.

Results: Addicted individuals showed significantly higher neglect and depression scores and adrenocorticotropic hormone (ACTH) and cortisol plasma levels than controls. Depression scores in addicted patients positively correlated with plasma ACTH and cortisol values.

Conclusion: This paper suggests that the possibility of childhood neglect and poor parent child attachment may have a persistent effect on HPA axis function as an adult. This may contribute with other factors to both depressive traits and substance abuse neurobiological vulnerability.

SMMGP comment: An interesting study with potentially useful findings, but of quite a small sample. You can read the whole paper at www.blackwell-synergy.com.

Meta-analysis of depression and substance use and impairment among intravenous drug users (IDU's)
Connor K et al., Addiction 103 pp524-534

This study aimed to evaluate the hypothesised positive association with substance related behaviours. It was a meta-analysis of reports on IDU's published in English in peer-reviewed journals since 1986 that contained data on depression and substance use outcomes.

Results: The studies hypothesis was supported by the analysis except for the predicted association of depression and future drug use and impairment (as opposed to concurrent drug use and impairment). Effect sizes were small and there were moderating effects of gender with greater associations of depression and substance use treatment participation and needle sharing among women and greater association of depression with future drug use and impairment among men. The effect size of moderators was large.

Conclusions: Depression is associated with several substance-related behaviours and select associations are stronger according to gender.

SMMGP comment: A worrying finding in this study is that results showed a significant association with greater substance use treatment participation, particularly for women. The two hypothesised reasons the authors give for this are that depression caused the people to seek help in the first place and that depression acts as a counterweight to other characteristics such as antisocial personality which might otherwise undermine treatment engagement - do not seem to fully explain this association and perhaps this needs to be further examined - maybe it's the treatment!

Diagnosis and management of alcohol use disorders
Andrew J R Parker et al., Clinical review in BMJ 2008; 336:496-501 (1 March)

Alcohol use disorders account for 4% of the global burden of disease and cause 1.8 million deaths each year. The overall economic cost to society is huge-around £20bn each year in the United Kingdom-mostly as a result of lost productivity and alcohol related crime. This excellent review takes us through all the latest developments in screening brief interventions and management in a user friendly and practical way.

Summary points: Most alcohol use disorders go undetected in primary care; the fast alcohol screening test (FAST) is the best screening tool in busy settings; brief interventions are effective for hazardous and harmful drinking; specialist interventions are effective in people with alcohol dependence; and most people with alcohol dependence can undergo medically assisted withdrawal safely at home, after risk assessment.

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Book Review

Contingency management in substance misuse treatment
Stephen T Higgins et al., Guildford Press 2007. Reviewed by Wouter Vanderplasschen in Addiction (103) pp857

This is actually a review of a book review in addiction, but Contingency Management (CM) is to the fore at the moment and this book is described thus by the reviewer: "this excellent and comprehensive state-of-the-art volume edited by and with contributions from leading experts provides convincing evidence for the efficacy and effectiveness of CM across substance abusing populations". It covers various types of CM including money, vouchers and prizes, either as stand alone interventions, or as an adjunct to other treatments. It examines cocaine, opioids, methamphetamine, tobacco and alcohol and provides "ample evidence" for the application of CM across "most of these substances". The reviewer would have liked a specific chapter on poly-drug use, due to CM's lack of effect on multiple drug targets, however the second half of the book dealing with 4 specific populations (homeless, adolescent, mentally ill and pregnant women) highlighted some innovative approaches as well as discussing barriers to application. Usefully it "brings together all of the evidence and gives practical examples in stand alone chapters including many links and references".

The issue of sustainability over time and how this intervention can be applied from a continuing care perspective, is somewhat sidestepped. Also examples and authors are limited to the US and "the main ethical question - i.e. whether drug users should receive additional benefits for abstinence-remains relatively undiscussed". However the reviewer concludes that "this volume is likely to become the standard of reference for any professional, researcher, policy maker or student interested in CM". Therefore it may well be of great interest to members in preparation for when CM is rolled out across England in the near future.

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