Therapeutic Guidelines Addiction

One of the issues that happens for people who have addiction is an experience of stigma and discrimination, and that in itself causes harm.

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Hi, and welcome to the Australian Prescriber Therapeutic Guidelines Podcast. I'm Dr Justin Coleman, a GP in Brisbane, and also a medical educator with the RACGP, and today we're talking all things addictive. Hopefully this podcast is going to be addictive and, to help me make it so, I have with me Dr Hester Wilson. Hester’s a GP and an addiction specialist, and she’s chair of the special interest group in addiction for the RACGP. But more importantly, for the purposes of this podcast, she is a member of the Therapeutic Guidelines Expert Group for their first ever publication of a guideline to addiction. Welcome, Hester.

Thanks, Justin.

It's wonderful to have you along. Addiction covers two things. The main thing we would think about with Therapeutic Guidelines is psychoactive substances. So there we're talking alcohol, tobacco, and all sorts of licit and illicit substances. And then we also have specific repetitive rewarding and reinforcing behaviours. There, in particular, we're talking about gambling and also gaming. So we'll come to those things later, but let's start with the overview of substance use and addictive behaviour. I guess as a GP, my take-home message is ‘get to know your patient, develop that relationship’ because they're going to be there for a long time and you'll be walking the walk with them. What are the key features for you in addiction medicine, Hester?

Yeah, I totally agree with you, Justin, that the therapeutic alliance that we have with our patients and, in general practice, we have this incredible longitudinal relationship that we have with our patients over time. So we know them. We know their communities. We know their families. We know the other health and welfare and wellbeing, work-life issues that are coming up for them. We also know that our patients in the general practice setting do want us to ask about addiction. They do want us to ask about lifestyle issues, whether it be alcohol or smoking or other drugs or gambling, other behaviours. They kind of expect it and sometimes we can be a bit anxious about doing that, but we are trusted and they want us to ask. Really importantly, it's being open to that and asking about it in a way that suggests that this is every day, this is what we do. It's a health-based approach and we're open to supporting our patients for better health outcomes.

I guess when we're asking those questions, we have to be careful about how we ask them, Hester.

Yeah, so true. One of the issues that happens for people who have addiction is an experience of stigma and discrimination, and that in itself causes harm. It stops people coming to treatment. It stops them talking about what's happening for them. It prevents them from staying in treatment. And so, they have worse outcomes. In itself, stigma and discrimination can actually cause ill health. So really important when we think about “How do I ask this in a way that invites my patients to speak to me?” Understand that people may not tell us all the story because of the shame and their past adverse experiences that they've had with health services. The other really important part with this I think is it doesn't mean that you go, "Oh, anything goes," but really our approach is around, "I am looking to support you to be safe and to be well."

Yeah. So recognising the seriousness of it, but without being judgemental about it. Let's start with something I find it sometimes hard to be non-judgemental about, and that's a very common scenario, which is your cigarette smoker. Happily, there are fewer of them in Australia these days, although we're not quite sure where the vaping is going to take our younger population in a few years time. So for cutting down and quitting smoking, medication is certainly recommended, and that includes people who only smoke a few cigarettes, but particularly those if they start within 30 minutes of waking up, then they probably do have a dependence and they are going to need some sort of drug therapy.

The issue of how we measure cigarettes and nicotine dependency is really important—that it is the first cigarette of the day that is such a good surrogate marker for dependency. People can be incredibly efficient smokers, only smoke five a day, but if they're starting on getting up, they've got their cigarette there by the bed, and they're starting that first one of the day. But if they're only having five, it means they're super-efficient and they're likely to be quite nicotine dependent.

I guess we have nicotine replacement therapy, which is the first therapy really that was around when I was even a med student, but back then it was a slap on a patch and hope for the best. These days, there is a recommendation to combine that patch with another form of nicotine replacement therapy as well, what we call that combination.

Yeah, totally. So having the long-acting, which is your patch, and the short-acting, which is the lozenge, the chewing gum, the inhalator. The way to do it is yes, slap on the patch, but then when people feel the craving to have a cigarette, to use the short-acting as well and the outcomes are better when you combine the two. The other thing is you may think about putting on two patches. For people who are highly dependent, it may be that they need a higher base dose. People are always really worried about the amount of nicotine that you get in a patch and worried about smoking and having a patch on at the same time. Don't worry about that. And so, if somebody is highly nicotine dependent, then two patches is actually better than one.

Justin, you were talking before about the fact that the smoking incidence and prevalence has gone down, but we are left with a group of people who are very highly dependent, who've had multiple failures that are trying to change their smoking, and for them you might say, "Slap on a patch, try the gum. If you still keep smoking, that's okay. What we're going to look at is how long from waking have you been able to avoid having a cigarette, how many are you having in the day," and doing a cut down to stop and then understanding that success looks like less, not nothing, and they can move towards stopping completely in the future.

I did mention vaping before, and I guess it really is a double-edged sword. My fear and the fear of a lot of GPs is that the rise of the acceptability of vaping might lead to increased nicotine addiction, but then, of course, it may be it has a place also in those who are already smoking cigarettes to switch to vaping. Where do you see that balance?

Yeah. Look, I think this dichotomy is vaping is good, vaping is bad, is unhelpful; somewhere in the middle. We want to have policies and structures that prevent and support our young people to not become the next generation of nicotine-dependent people, but we also have a group of people who are at real risk from their smoking. Giving up smoking is really tricky, and e-cigarettes may well be a harm minimisation for that group. The trickiness is walking that middle line. We want e-cigarettes to be seen as the thing that middle-aged, overweight, grumpy people do when they're trying to stop smoking rather than a cool thing that young people take up because it's hip and fun.

Well put. Let's move to my favourite addiction, which is, of course, a tipple of alcohol. For mild alcohol withdrawal, which is probably what we see the most as GPs and people are going to get genuine withdrawal but want to be managed at home and it probably is quite appropriate to manage that subset at home. But I guess the guidelines are going to talk about who is safe to manage at home and who we really should be referring off or getting assessed in a hospital setting.

Absolutely. It's a really important thing for us as GPs to establish is somebody withdrawing? Are they having withdrawal symptoms? Are they mild? Can we manage them at home? Justin, you're absolutely right, if we can manage people at home, brilliant. They're in their setting. They're supported. But if they are at risk of severe medical complications, they do need to be in the hospital setting. So that would be people at risk of seizures or delirium tremens or confusion, other significant health issues that put them at risk. The guidelines go through this in quite some detail to help GPs delineate that. It's a really important thing to assess.

Medication's been around for yonks. The good old diazepam has still got its place, I think, in that home setting.

Absolutely, it does. You're looking at for some people, they may not need any diazepam at all. They might need just a little bit at night because their sleep is disturbed. But once again, in the guidelines, basically no more than 40 mg day one and cut it down to stop by 5 to 7 days. Most people, when I'm seeing people doing it at home, many of them only need 10 or 20 mg day one, and we cut it down from there. But bottom line for this is don't write a script for 50 times 5 mg diazepam and give it to the person to take away and say, "There you go, sort it out." It doesn't work. It's got to be in this supervised supported setting. Quite often if I'm doing a withdrawal at home, I'll get the person to go to the pharmacy daily to pick up their medicines because it's a really nice way to support them. There's another healthcare professional who's supporting them as well, and it really helps them to manage that cut down to cease over that short period of time.

Certainly for the long-term management of alcohol dependence, there are medications which are around and possibly even underused. And then I guess, is there anything on the horizon research-wise?

Yeah. So the three tablets that we have are acamprosate, naltrexone and disulfiram. They do have a place. I think particularly naltrexone and acamprosate are under prescribed, and sometimes GPs are a bit anxious because they don't know these medications. They're super safe. One thing I would say is don't start them when people are going through the withdrawal period because they don't treat withdrawal. They're about relapse prevention and helping with cravings. Disulfiram or Antabuse is a much older medication and it can be useful in a subset of people, but it wouldn't be my go-to very often. More often than not, I'm talking to people and I'm saying, "I'm just keeping this one in the back pocket just in case it's one that we want to go to," but it can be quite effective in a small group.

There's some research looking at the place of psychedelics in this space to help people change their alcohol and maintain that. Ketamine as well. Transcranial magnetic stimulation, deep brain stimulation, don't know quite where they're going to take us, but there is some interesting research being done in this space. I guess though for me one of the really important things is looking at what does the drinking mean? What part does it play in that person's life? Understanding that it is a chronic illness and it's around the psychological and social supports and lifestyle changes that help people to, once they've actually stopped, to maintain that change, and that's super important as well.

Thank you. I'm talking, of course, with Dr Hester Wilson. Moving on to opioid dependence. I was a methadone and buprenorphine prescriber in the past, but the big change seems to me, and it seems to be a brilliant change really, is the rise and rise of subcutaneous long-acting buprenorphine, which I think has great value-add for the people using it.

Totally. The wonderful thing about the long-acting injection—there's two varieties. One of them comes weekly and also monthly and the other one comes monthly. So the great thing about it is that the person has the injection, it's kind of set and forget. Very stable levels of buprenorphine in the bloodstream. The wonderful thing about buprenorphine is it has a high affinity. If people use opioids on top, it doesn't do anything. It's blocked. So they have good levels. They're well supported. They're well stabilised and they don't have to worry. They don't have to come in and be dosed and have supervised dosing. It's just once a month they just come and get a shot.

The other thing that I think us as prescribers really like is that we know that that medicine is in there. It's not going to be lost or given away or used in ways that it wasn't intended to be used. So there's a safety, a level of safety that is really terrific as well. They're a great medication. I'm very supportive of the other medications as well. Injections don't suit everybody, but it really is a very easy thing to do in the general practice setting.

Yeah. The Therapeutic Guidelines Addiction gathers together a whole bunch of useful information, not only about the drugs themselves, but also about the legal and practical requirements in each, which vary state by state. But we'll move on to cannabis. I did spend time for three years in a remote community where there was a lot of cannabis there and it is a very common drug used, of course, often used with tobacco. What are some take-home messages for GPs?

Yeah. Look, I think you've hit the nail on the head there with the tobacco co-use because that is a really important part to consider. So you've got to treat the nicotine dependency, as well as the cannabis dependency. Many people in our communities use cannabis and it doesn't cause them harm. It's better to actually ingest it rather than to smoke it just because of the lung damage that goes with that. We also have medicinal cannabis. So we're seeing a rise in the use of cannabis for medical reasons. So in many ways, it is a much lower risk medication or substance. There is the risk certainly for young people at risk of psychotic illnesses and that's an issue, and as well if people are using a lot of it the dependency can become something that people want to seek help for. Also, cannabis hyperemesis, which is something that we sometimes do see, and the guidelines have got some really good discussion around how to manage that.

On the island I was living on, we had people sitting for hours in our emergency department with intractable vomiting. So I'm certainly quite familiar with that and it's an awful condition really. Something I'm less familiar with is GHB, gamma hydroxybutyrate. I think that's the first time I've ever said that word. Tell me something about GHB, Hester.

This is a sedative that is used... Look, we do see it quite a bit in Sydney and you'll see the little plastic soy fish containers on the floor in nightclubs at the end of the night. For many people, it's just a bit of fun, doesn't cause any problems. The thing to be aware of is that it has a very narrow therapeutic index. So you get no effect. You feel the intoxicated effect and then you actually pass out. Very, very narrow window. There are a group of people who do become dependent. It'd be quite a difficult thing to manage, particularly the withdrawal. And so, there's quite a lot of information in the guidelines there. But my take-home as a GP is if I'm seeing that, I'm getting my specialist addiction colleagues involved.

We are nearly towards the end of this podcast, but I did want to talk about the non-psychoactive substances part of the addiction guideline, and that is gambling and gaming. Gambling has long been common. In our practice, we've actually started asking about that as a routine question for our annual health check. You'd be surprised how many people bring it up when you ask about it, but not many people seem to seek help for it.

Yeah. Look, gambling has long been an issue in our community. One in 7 people will have issues with their gambling. They may not have developed a gambling use disorder, but it can certainly be causing them harm, so financial harm, relationship harm, physical and mental health harms as well. So it's great that your practice is asking about it because it's certainly something years ago I never asked about but I've actually realised it's a really important behaviour that quite often co-exists with substance use as well. But the great thing in Australia is that we have access to free gambling help services. So for us in general practice, do ask the question, do offer the support, do offer referral because at the moment it can take people years to get to treatment because they're not aware that there is treatment. They feel shamed about the behaviour. It's a hidden behaviour. So it's something that's really important for us to ask. Once again, the guidelines have some good information around how you might ask and how and where to refer.

Yeah. We'll finish on gaming, which is really gambling with a couple of letters cut out of it, but gaming is really referring, I guess, to largely online electronic games where people, more often male than female, but can be both, of course, sit down for large proportions of their day, ignoring life outside. I noticed it's hit the ICD as its own diagnosis and there are three components to it, impaired control over gaming, increasing priority over other life interests and activities, and finally, a continuation or escalation of gaming despite the occurrence of harm. So it's great to see some information for GPs and health professionals about the problems of gaming.

Yeah, totally. I think I should flag that sometimes part of the gaming is actually the gambling aspect. So for example, eSports and the gambling on who's going to win the eSports or the in-game gambling that can happen, so it's gambling as well as gaming. The tricky thing, and I see this in my general practice, is parents coming in concerned about their teenager. Do they have an addiction to gaming? It's a bit of a tricky thing. So at what point does it stop being an enjoyable, engaging activity that they interact with their mates online and is a good thing, and at what point does it start causing harm? And so, that's the tricky area. It is very new as an accepted addiction and we're still looking at what are the best ways to actually treat this. Your addiction psychiatrists, adolescent psychiatrists are the people to go to for support around this. But for us in general practice, quite often it's seeing the families and finding out what the issues are and looking at how we can support them and try and actually engage with the young person as well.

Hester Wilson, you've been a font of wonderful information, but that's all we have time for today, so thanks very much for being on the podcast.

Thank you.

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My guests’ views are their own and don't represent Australian Prescriber, and my views are certainly all mine.