Cocaine deaths/Take-away doses. 6th April 2004

Concord Dependency Seminar. Tues 6th April. Cocaine; take-away doses.

Session 1 "At their peril: Cocaine-related deaths in NSW."

Prof Shane Darke, National Drug and Alcohol Research Centre

Session 2 "Forum on takeaway doses."

Prof James Bell, The Langton Centre.

Chair Dr Gary Swift

Shane Darke spoke on his findings from coroner's records in NSW from 1993 to 2002 of nearly 150 deaths in which cocaine was a cause of death (86%) or a contributing factor. He contrasted the use of cocaine in Australia and America. Ours is very Sydney-based and mostly injected. In the US, cocaine is ubiquitous and it is usually smoked as ‘crack’ or ‘freebase’. He told us that of all sudden deaths in New York, 25% had cocaine in the body. This may make it a contributing factor in some cases, but it may equally be that it reflects the widespread use of cocaine in those dying from other causes.

We were told of the different ‘cliques’ of users: snorting, non-dependent ‘middle class’ users to injecting addicts who may swap from one drug to another (speed, coke, heroin, pills, etc). The mixing of drugs and alcohol was the major risk factor in 146 deaths reported from NSW, 96% being poly-drug overdoses. Heroin was the most common accompanying drug (79% as morphine), with alcohol coming second (36%). The medium alcohol level was 0.07%. Others had a variety of other drugs such as cannabis, etc. The actual cause of death appears more complex than with opioids where respiratory depression and hypoxia kill victims, usually within an hour or two. Stimulants are more varied in their effects on the nervous and cardiovascular systems with cardiac and cerebrovascular accidents (stroke) most common reported causes of death.
The time of death found weekends over-represented but there was no strong ‘payday peak’ as with heroin deaths. The place of death was a home in 53% of cases with a higher proportion of inner city deaths occurring in hotels. Over a third of all cocaine related deaths in NSW occurred in Kings Cross or Surry Hills postal areas (2010, 2011). Only three deaths occurred outside of Sydney. This does not accord at all with heroin deaths which were much more widespread in suburban Sydney as well as in nearly all rural areas. [It does, however, fit well with a common manner of drug spread early in an epidemic as described by Frischer and others.]

Half of the overdose victims in Darke’s study were in paid employment with half of them in professional positions. This is in contrast to heroin deaths which mostly occur in the unskilled and unemployed. Nearly all cocaine deaths occurred in males. The mean age was almost 35 which we were told may reflect an on-going pathogenic process such as arteriosclerosis in some cases or in a lack of resistance as drug users approach middle age.

Despite giving some very helpful pointers, Professor Darke said that as a researcher, regarding clinical matters he would defer to his audience. Questions from the large audience centred around just what we as clinicians can do. Education of our patients was the most obvious answer amongst the many other less obvious manoeuvres. Should we advise our own patients to use the Kings Cross injecting room? Should we recommend non-injecting routes of administration? It would seem that basic therapeutic tenets should be strengthened - ‘engagement’ with the drug user, specific drug ‘education‘, sympathetic enquiry into coexisting psychosocial disorders, etc, etc. For those on methadone or other dependency treatment, these need to be optimised in the usual ways and if necessary, a second opinion sought.

In the second half of the Concord Seminar, Associate Professor James Bell gave a talk on the issues surrounding take-away provision for methadone and buprenorphine in New South Wales. He discussed the 'anguish' in delicate decisions regarding how we all entrust take-away doses to patients.

We were reminded about the clinical methadone audit performed in 2001. Dr Bell said that such information was not likely to be released by the current authorities but that he personally understood that those who provided the data (pharmacists, doctors, nurses, patients, etc) were entitled to expect some feedback on the audit. Some doctors have apparently received critical feed-back, but no averages, ranges or recommended figures have been released. Dr Bell said that one figure from his own research showed 12 month retention rates which were 37% and were the same in private and public sectors.

During some discussion with the audience it was agreed that official Guidelines had numerous benefits in dependency practice. (1) They assist doctor say ‘no’ when patients may be unfairly demanding. (2) They save time in preventing undue and lengthy arguments over numbers and timing of such doses, so that, as Dr Bell pointed out, we can spend more time on ‘caring’. (3) They demarcate unambiguous boundaries or limits. (4) They assist busy GPs who may be inexperienced in dependency matters by providing a simple ‘recipe’ for governing take away provisions based on times in treatment, defined stability and in some cases, dose levels (exceptions may be tolerated at 40mg daily or less according to the current methadone take-away guidelines which were promulgated in November 2004).

It was agreed by the speaker and the audience that buprenorphine was a safer drug for take-home doses and that the new guidelines should reflect that fact. This was also a finding of the buprenorphine forum held in October 2002.

Dr Bell pointed out that to free up places for new patients, there needs to be regular movement of patients from the public to the private sector. Currently, one of the few incentives would seem to be the provision of more take-away doses. It is still not clear if this ‘works’ as many public patients are long term. However, NSW is unique in looking after such folk who are often indigent or homeless, sometimes indefinitely, in the public sector without cost to the individual. One wonders what happens to such folk in other states when money for pharmacies and/or the exigencies of private practice, appointments etc may preclude continued maintenance pharmacotherapy.

Andrew Byrne pointed out that most long-term stable patients in the NSW private sector are currently treated perfectly adequately with four take-away doses weekly (eg. Mon, Wed, Fri attendance). Such patients need to clearly document their stability on a regular basis and it is always the prescriber’s responsibility to elicit and record such details. This includes attendance history, work record, family responsibilities, vein condition, urine testing, etc. For experienced doctors, this should involve no anguish, just good clinical acumen and routine practices which most doctors are used to.

Finally, it was pointed out that regular buprenorphine take-away doses are currently permitted for certain stable patients in NSW under certain conditions… as well as for emergencies and pregnancy. Despite this, most doctors in the room had not authorised such doses, possibly due to a lack of communication, hence the utility of seminars such as this … and thanks go to Professor Bell for his participation.

summaries by Richard Hallinan and Andrew Byrne.

contact: 75 Redfern St, Redfern, 2016. (02) 9319 5524