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ProfNicholasLintzerisMBBS,PhD,FAChAMDirectorD&AServices,SESLHD,NSW
DivisionAddic@onMedicine,UniversityofSydney
NewDevelopmentsinDrugandAlcoholTreatmentsRelevanttotheCorrec@onalHealthcareSeJng
Overview
• D&AIssues&Correc@ons• Newtreatments&implica@onsincorrec@onalseJngs
– Extendedreleasebuprenorphinetreatment– Othersubs@tu@ontreatmentapproaches:cannabinoids,amphetamines
– Depotnaltrexoneforalcoholandopioiddependence– Takehomenaloxoneforoverdosepreven@on
Impactofsubstanceuseonincarcera@on
• 51%ofmenand35%ofwomeniden@fiedalcoholand/ordrugsasthecauseoftheirlife@meoffendingcareer• 71%ofprisonentrantshadusedillicitdrugsinyearpriortoincarcera@on,with
60%repor@ngahistoryofinjec@ngdruguse• 29%ofoffendersa^ributedtheirmostseriouscurrentoffencetodrugand/or
alcoholintoxica@on• 70%ofjuveniledetaineesintoxicatedat@meoftheiroffence
• Typesofcrime– Alcoholisinvolvedinapproximatelyhalfofallviolentcrime.Homicideand
assaultoffencesweremorelikelytobea^ributedtoalcoholintoxica@on.– Property,fraudandmul@pleoffenceswerelikelytobea^ributedtoillegaldrugs
• 55%ofreleasedprisonersinAustraliareturntocustodywithre-offendingstronglylinkedtodrug/alcoholdependencyandsocialdisadvantage.
Co-morbidi@esandsubstanceuse
• Substanceuseassociatedwith– Psychiatriccomorbidity:depression,anxiety,PTSD– Physicalhealthproblems:chronicpain,liverdisease– Cogni@veimpairment:studiesinD&Atreatmentgroupindicate40-60%haveseverecogni@veimpairment
– Homelessness– Violence,childtrauma
DIVERSIONINTOD&ATREATMENTINTHECOMMUNITY
Primarydrugofconcernindiversionepisodes
“Diversionisagrowthindustry”
D&Atreatmentinprisons• “Psycho-educa@onprograms”• “Therapeu@cprograms”• Medica@onassistedtreatment
• Subs@tu@ontreatment
• Maybelinkedtourinedrugtes@ng• Maybelinkedtopost-release
SUBSTITUTIONTREATMENT
OpioidSubs@tu@onTreatment(OST)
OSTinAustralia
OSTinAustralia
OSTinAustralia
OSTinprisons:TheevidenceSystema@creview:Hedrichetal2012
• Inprison:OSTassociatedwith– Reducedheroinuse,reducedinjec@ng&sharingequipmentinprison
• Pre-releaseOSTassociatedwith:– Reducedmortality– Increasedtreatmentreten@onincommunity– Post-releaseheroinuse– 20%reduc@oninre-incarcera@onifremainintreatment
OSTinprisons• 87%ofallOSTinprisons=methadone• 9/10OSTpa@entsmale;youngerthancommunity• Verylimitedaccessinsomestates
Suboxone®inprisons
• ConcernswithSuboxoneFilm– Requiresdailysuperviseddosing:difficulttoco-ordinateinprisonseJngs
– Sublingualformula@on:‘easy’todivert• 30%pa@entsreportedselling/sharingtheirSuboxoneinprison,44%hadusednon-prescribedmedicines(Whiteetal2016)
– InNSW:pa@entsenteringprisononSuboxonetransferredtomethadone.
• Greatersideeffects,higherODrisk• Difficulttotransfer‘back’tobuprenorphinewhenreleasedintocommunity.
ExtendedreleasebuprenorphinepreparaCons
• Probuphine®6monthimplant• BraeburnCAM20381-weekand4-weekdepotinjec@ons
• IndiviorRBP60004-weekdepotinjec@on
CAM2038SCBPNdepotinjec@onBraeburn/Camurus
• 1weekand4weeksubcutaneousinjec@ons• Severaldosestrengthsallowing@tra@onofdoses
• RCTcomparingtoSLBPNunderwayinUSA• SafetystudyunderwayacrossAustralia(Sydney,Newcastle,Adelaide),Europe&Asia
• AimingforUSFDAlicence?2017
RBP-6000SCdepotinjec@onIndivior
• OnceamonthSCdepotinjec@onavailablein2doses:300mgand100mg
• PreliminaryRCTfindingsindicatebe^erthanplacebo
• Requirescoldstorage(S8medica@on)• ?AimingforUSFDAregistra@on
Medica@onassistedtreatmentofmethamphetaminedependence
• >20yrhistoryofa^emptedsubs@tu@ontreatmentofs@mulantdependencewithdexamphetamine:mixedresults
• Lisdexamfetamine(LDX),apro-drugofdexamphetamine(licensedforADHD,bingeea@ng)– Drugisnotac@veun@lmetabolisedinliver(less
abusepoten@althandexamphetamine)– Longertherapeu@cac@on:once-a-day-dosing
Lisdexamfetamine:ProofofconceptstudyEzardN,DunlopA,CliffordB,BrunoR,CarrA,LintzerisN
• NSWpilotstudySydney(StVH)&Newcastle
• N=13MAdependentpa@ents
• Doseranging&safetystudy
LisdexamfetamineMul@siteRCTEzard,Ali,Dunlop,Lintzerisetal
• NHMRCProjectGrant• 12-weekrandomisedplacebo-controlledtrial• N=180par@cipantsacross3sites(Sydney,Newcastle,Adelaide)
• Allpar@cipantsalsogetcasemanagementandcounselling(CBT)
• Mainoutcomes:methamphetamineuse,health,crime,psychosocialfunc@oning
• Duetocommencerecruitmentearly2017.
Cannabinoidsubs@tu@ontreatment• Sa@vex(nabiximols)
– 49%THC,49%CBD• RCTSa@vexforcannabiswithdrawal(AllsopetalJAMAPsychiatry2014)
• N=51,inpa@enttrial(Sydney,Newcastle)
• UNSW,SESLHD,HNELHD
WhatareTHCandCBD?
• Cannabinoidspresentincannabisplant.• Bindtocannabinoidreceptors(CB1receptorspresentinbrainandperipheralorgans)
• THC:themainintoxicantincannabis• CBD:(Cannabidiol)anxioly@c,reducesparanoia,an@[email protected]@veimpairment.Notintoxica@ng.– Wascommonin‘oldbush’strainsofcannabis,butnowrareinNSWcannabis
PotencyofNSWpoliceseizedcannabis:highTHCandlowCBDSwitetal2013.AnalysisofcannabisseizuresinNSW.PlosOne8(7)
T H C T H C - A T H C T O T A L 0
5
1 0
1 5
2 0
2 5
3 0
3 5
4 0
% C O
N T E N
T
% C O
N T E N
T
C B D C B D - A C B D T o t a l 0
5
1 0
1 5
2 0
2 5
3 0
3 5
4 0 85%ofsamplescontained
<0.1%CBD-totAverageTHCcontent=15%
Cannabidiol(CBD)maymodulatetheeffectsofTHCincannabis
THCandCBD=
THConly=
Sa@vexsubs@tu@ontrialLintzeris,Allsop,Dunlopetal
• NHMRCProjectGrant• 12-weekoutpa@entrandomisedplacebocontrolledtrial• Allclientsalsogetcounselling(CBT)&casemanagement
• Mainoutcomes:cannabisuse,health,psychosocial,safetyandcosteffec@veness
• N=140subjectsacross4sites(SouthEastSydney,WesternSydney,Newcastle)
• Studyrecrui@ngnow…
Naltrexone
• Naltrexoneisanopioidantagonist–blockstheeffectsofopioidsandreducescravingsforalcohol
• OralnaltrexonelicensedfortreatmentalcoholdependenceandopioiddependenceinAustralia
• Lowlevelsofadherencehaspromptedexamina@onoflongac@ngproducts
• Vivitrol®istheonlylicensed/registeredproduct:once-a-monthdepotinjec@on– NotavailableinAustralia
• Examplesoflong-ac@ngNTXinprisonsinterna@onally
Mortalityofprisoners• Opioidoverdoseismaincauseofdeathonreleasefromprisons
• Deathreducedby– OSTinprisonsandonrelease
– Takehomenaloxone
Takehomenaloxone
• Naloxone(Narcan®)isashortac@ngopioidantagonistusedtoreverseopioidOD
• Increasingeffortstogetnaloxonetoopioidusersandtheircarerstohaveintheeventofanopioidoverdose:“takehomenaloxone”
• Onestrategyeffec@velyusedtoreduceODonreleasefromprison:useinUK&Americanprisons
• InAustralia:availableonprescrip@onand‘overthecounter’.ConsidertrialsofTHNonprisonrelease
Implemen@ngTHNinprisons
• Issues(Sondhietal2016)– Poorunderstandingofissuesbystaff&prisoners– Iden@fying‘atrisk’prisoners– Localimplementa@oninprisons– Seniorprisonstaffengagement
• RCTinUK:Parmaretal2016(N=1685)
Inconclusion
• Substanceusecon@nuestoberelatedtomajorityofincarcera@onepisodesinAustralia
• Needeffec@ve&widespreaddiversionprograms• Needeffec@veandwidespreadD&Atreatmentprogramsinprison–equivalenttowhatisavailableinthecommunity
• NewtreatmentapproachesmayincreaseavailabilityoftreatmentsinprisonseJngs
