Catherine McGregor

Symptoms and sleep patterns during inpatient treatment of methamphetamine withdrawal: a comparison of mirtazapine and modafinil with treatment as usual.

The safety and tolerability of modafinil (400 mg/day, n = 14) and mirtazapine (60 mg/day, n = 13) in inpatient methamphetamine withdrawal treatment were compared to a historical comparison group receiving treatment as usual (pericyazine, 2.5-10 mg/day, n = 22). Modafinil and mirtazapine were well tolerated, producing minimal positive subjective effects and no discontinuation effects in this open-label study. Side effects were mild and transient. Aches and pains were most commonly reported by participants receiving mirtazapine, whereas headache was reported by modafinil-treated participants. Modafinil-treated participants had a milder withdrawal syndrome as measured by the Amphetamine Cessation Symptom Assessment and less sleep disturbance in comparison to mirtazapine. Pericyazine was associated with a more severe withdrawal syndrome in comparison to mirtazapine and modafinil. Both modafinil and mirtazapine were safe and well tolerated in methamphetamine withdrawal treatment. However, these early findings of efficacy in symptom amelioration should be replicated in an adequately powered, randomized, placebo-controlled double-blind design.

A comparison of antagonist-precipitated withdrawal under anesthesia to standard inpatient withdrawal as a precursor to maintenance naltrexone treatment in heroin users: outcomes at 6 and 12 months

To compare two methods of heroin withdrawal, 51 heroin users were randomised to undergo a 1 day precipitated withdrawal procedure using naloxone under anaesthetic. About 50 participants were randomised to receive the current standard inpatient withdrawal treatment using clonidine plus symptomatic medication. Following withdrawal, both groups were offered 9 months of naltrexone treatment and supportive counselling. Outcome measures were: commencement of naltrexone, retention in treatment and heroin use at 6 and 12 months. Significantly more of the precipitated withdrawal group completed withdrawal, commenced naltrexone and stayed in treatment for the first 3 months. Overall, there was a significant reduction in both self-reported heroin use and morphine concentration in hair over the 12 month study period, with participants in the precipitated withdrawal group showing significantly lower morphine concentration at 6 months. Being younger and having a lower level of dependence were predictors of abstinence at 6 and 12 months. The advantage of precipitated withdrawal under anesthesia did not persist beyond 3 months with respect to retention in naltrexone treatment or beyond 6 months with respect to heroin use. Long-term follow-up is crucial in assessing the effects of treatment interventions for heroin dependence.

Accidental Fatalities Among Heroin Users in South Australia, 1994-1997: Toxicological Findings and Circumstances of Death

A total of 101 accidental deaths were identified among heroin users in South Australia for the period 1994-1997. Mean age at death was 29.9 years. Cases typically involved a single, unemployed, Caucasian male in his late twenties with a history of heroin and other drug use. Two or more drug types were detected in 80% of cases. The total number of substance types identified increased significantly with age. In comparison to younger fatalities, alcohol and benzodiazepines were identified in more of those 27 years of age and over. Thirteen deaths occurred within four weeks of release from prison and in nine cases tricyclic anti-depressants were found. The majority of deaths occurred in a private home and in the presence (or near proximity) of others. Identified risk factors included: being male; being a long-term heroin user; recent release from prison; use of tricyclic antidepressants and/or other central nervous system depressants.

In-patient benzodiazepine withdrawal: comparison of fixed and symptom-triggered taper methods

Fixed and symptom-triggered taper methods during in-patient benzodiazepine withdrawal treatment were compared using a randomized controlled design. Forty-four benzodiazepine users seeking in-patient withdrawal treatment at two substance use treatment clinics in Adelaide, Australia were recruited. Measurements included the Severity of Dependence Scale and the SF-36. A scale comprising six items from the Clinical Institute Withdrawal Assessment Scale--Benzodiazepines (CIWA-B) was used to measure withdrawal symptoms. Participants were randomized to receive a fixed diazepam tapering regime or diazepam only in response to withdrawal symptoms (symptom-triggered group). Results showed that there were no significant differences between treatment groups in terms of withdrawal severity, duration of in-patient treatment, amount of diazepam administered, treatment attrition and benzodiazepine use at follow-up. Both groups showed a reduction in benzodiazepine dosage of 86% over the first 8 days which was maintained at 1 month post-discharge. Although there were improvements in some subscales of the SF-36 between baseline and follow-up, values were significantly below age-matched norms at both time-points. This study showed that benzodiazepine users entering treatment have relatively poor health and that symptom-triggered taper methods incorporating flexible dosing and flexible treatment duration are as effective as fixed dose taper methods for in-patient benzodiazepine withdrawal treatment.

OVERDOSE AMONG HEROIN USERS: EVALUATION OF AN INTERVENTION IN SOUTH AUSTRALIA

An evidence-based intervention addressing overdose among heroin users was developed and evaluated in South Australia. The intervention comprised three strands: information materials, peer educator training and achievement of structural change through the establishment of partnerships with user groups, police and ambulance services. Liaison with police and ambulance services resulted in new guidelines being developed for police attendance at overdoses. Pre- and six months post-intervention surveys showed an increase in awareness of risk factors associated with overdose including the concomitant use of other central nervous system depressants with heroin and using heroin while alone. Amongst respondents exposed to the intervention, more rang an ambulance to the most recent witnessed overdose and indicated less fear of police involvement if an ambulance was called. It is concluded that heroin users will respond to appropriate, targeted health education messages developed in conjunction with the user community and implemented using an intersectoral approach.

Twenty-four hour ambulatory monitoring of tremor, sweating, skin temperature and locomotor activity in the alcohol withdrawal syndrome

An ambulatory monitor has been used to determine the characteristic patterns of tremor, sweating, skin temperature and locomotor activity in subjects undergoing alcohol withdrawal. Twenty-four hour records were obtained from six male subjects who had been consuming an average of 345 g of alcohol per day prior to cessation and from a group of agematched controls. Consistent with earlier research and clinical observation, tremor, sweating and locomotor activity were elevated in withdrawal subjects. Sweating was greatest in the period from approximately 00.00 h to 06.00 h, as was skin temperature. Tremor and activity levels decreased during this period, but were considerably higher in withdrawal subjects. The data suggest that 24-h monitoring of alcohol withdrawal using objective methods provides a more sensitive assessment technique than the standard clinical approaches. The technique may be of value in other dysautonomic states.

Antagonist‐precipitated heroin withdrawal under anaesthetic prior to maintenance naltrexone treatment: determinants of withdrawal severity

This study sought to characterize antagonist-precipitated heroin withdrawal during and immediately following anaesthesia and to identify the determinants of withdrawal severity and duration in 48 dependent heroin users. Objective withdrawal signs decreased significantly with each naloxone bolus administered under anaesthetic. The cost (amount) of the final heroin administration and the number of hours between last heroin use and commencement of anaesthesia were significant, independent predictors of the severity of withdrawal symptomatology. While 83% (40/48) of participants completed withdrawal according to objective criteria and commenced maintenance naltrexone treatment, almost half (22/48) were unable to commence naltrexone on the day of the procedure due to residual withdrawal signs. Fourteen of these 22 participants subsequently commenced naltrexone (median number of days between admission and commencement of naltrexone was 2, range 1 - 6) while eight left treatment prior to initiation of naltrexone. Significantly fewer of those with more severe withdrawal signs during anaesthesia commenced naltrexone (40% vs. 60%). While the severity and duration of withdrawal symptomatology may be moderated by encouraging participants to reduce (or cease) heroin use close to the time of withdrawal, for a substantial proportion of participants in this study, heroin withdrawal by this antagonist-precipitated procedure was neither rapid nor painless. [Ali R, Thomas P, White J, McGregor C, Danz,C, Gowing L, Stegink A, Athanasos P. Antagonist-precipitated heroin withdrawal under anaesthetic prior to maintenance naltrexone treatment: determinants of withdrawal severity.

Heroin overdose: Responding to the epidemic

Objective: To develop and evaluate an evidence-based intervention addressing overdose among heroin users in South Australia.Methods: The intervention comprised three strands: information materials, a peer education initiative, and structural change through the establishment of partnerships with user groups, police and ambulance services.Results: Liaison with police and ambulance services resulted in new guidelines being developed for police attendance at overdoses. A pre-intervention survey provided an evidence base for the development of the intervention materials and process, as well as a baseline against which the intervention could be evaluated. An evaluation survey conducted six months after the intervention launch showed that 47% of participants had been exposed to the intervention. More of the respondents exposed to the intervention rang an ambulance to their most recent witnessed overdose, and indicated less fear of police involvement if an ambulance was called. In comparison to the pre-interventi...