Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy.

The number of patients in buprenorphine opioid substitution therapy (BOST) or methadone opioid substitution therapy (MOST) programs is increasing. If these patients require surgery, it is generally agreed that methadone should be continued perioperatively. While some also recommend that buprenorphine is continued, concerns that it may limit the analgesic effectiveness of full mu-opioid agonists have led others to suggest that it should cease before surgery. However, no good evidence exists for either course of action. Therefore, we undertook a retrospective cohort study comparing pain relief and opioid requirements in the first 24 hours after surgery in 22 BOST and 29 MOST patients prescribed patient-controlled analgesia. There were no significant differences in pain scores (rest and movement), incidence of nausea or vomiting requiring treatment, or sedation between the BOST and MOST patient groups overall, or between those patients within each of these groups who had and had not received their methadone or buprenorphine the day after surgery. There were also no significant differences in patient-controlled analgesia requirements between BOST and MOST patient groups overall, or between patients who did or did not receive MOST on the day after surgery. BOST patients who were not given their usual buprenorphine the day after surgery used significantly more patient-controlled analgesia opioid (P=0.02) compared with those who had received their dose. These results confirm that continuation of buprenorphine perioperatively is appropriate.

Changes in alcohol history taking and management of alcohol dependence by interns at The Royal Adelaide Hospital.

OBJECTIVE: The objective of this study is to determine whether the presence of a drug and alcohol unit and comprehensive medical education have made a difference to the detection and management of alcohol-related problems in a general teaching hospital. METHODS: Data were obtained from hospital case notes before and after the introduction of the drug and alcohol unit and medical education. Samples of general admissions and admissions with an alcohol diagnosis were obtained. The outcome measures included alcohol history taking, quantification of alcohol consumption and management of alcohol dependence. RESULTS: It was found that for the general admission sample, interns were more likely to take an alcohol history, both in the accident and emergency (A&E) department and on the ward, in 1994 compared to 1988. The difference in the A&E department was statistically significant (P = 0.009). In the A&E department in 1994 there was a greater prevalence of alcohol history taking for male patients (odds ratio (OR) 10.09, 95% confidence interval (CI) 1.89 to 53.70, P = 0.007) compared with female patients (OR = 1.81, 95% CI 0.38 to 8.57, P = 0.045). There were no differences in alcohol history taking by interns in the samples of alcohol-related admissions. There were no statistically significant differences in the prevalence of documenting alcohol histories quantitatively in either sample. The use of alcohol withdrawal charts, ordering diazepam for alcohol withdrawal and ordering drugs which conformed to the hospital formulary all increased significantly by 1994. The prevalence of ordering thiamine and consulting the drug and alcohol unit both decreased slightly by 1994, but not significantly. CONCLUSION: Improvements have been found in the detection and management of alcohol use since the introduction of the Drug and Alcohol Unit and medical education, but there is still room for further improvement and particular areas where greater attention is needed are identified.

Heroin addiction: the science and ethics of the new treatment pluralism.

As approaches to treating heroin addiction grow in number, their ethics and their meaningful contribution to the science in this field need more careful consideration.

Correlates of retention on the South Australian Methadone Program 1981-91.

OBJECTIVES: To investigate correlates of retention on the South Australian Methadone Program during 1981-91. DESIGN: Retrospective study of a nonstratified random sample of 229 HIV-negative clients who received methadone between January 1981 and June 1991. Data were collected from clinical records of the 229 HIV-negative clients and also from the 40 clients known to be infected with HIV during the decade. RESULTS: Being HIV positive, receiving larger maximum doses of methadone, receiving methadone from a private pharmacy and enrolling later in the decade were all associated with longer retention times on the program. CONCLUSIONS: This study supports the findings of previous studies, that maximum dose of methadone is crucial to retention in methadone programs, But even allowing for maximum dose, obtaining methadone from a private pharmacy was also strongly associated with retention on the program. The more 'humane' clinic policy later in the decade is likely to have increased retention and reduced illicit drug use also.

Prevalence of hepatitis C infection in pregnant women in South Australia.

OBJECTIVES: To estimate the prevalence of hepatitis C virus (HCV) seropositivity and known risk factors for HCV infection in a group of pregnant women. DESIGN: Cross-sectional survey. SETTING: Lyell McEwin Health Service, Elizabeth, South Australia (a general public hospital with an annual average of about 2000 deliveries). SUBJECTS: 1537 consecutive women who delivered at the Lyell McEwin Health Service from February 1995 to December 1995. OUTCOME MEASURES: Presence of HCV antibodies; and associations between HCV-antibody status and known risk factors. RESULTS: 17 women (1.1%) were HCV-seropositive. Risk factors significantly more prevalent among HCV-seropositive patients were: a history of injecting drug use, a past or present sexual partner who had injected drugs, having a tattoo and having been incarcerated. The proportions who had received a blood transfusion, had acquired a sexually transmitted disease or were positive for hepatitis B virus surface antigen were not significantly different between seropositive and seronegative women. Multivariate analysis showed that only injecting drug use remained a strong independent predictor of HCV-seropositivity (odds ratio [OR], 50.1; P < 0.001), while having a tattoo approached significance (OR, 3.5; P = 0.07). CONCLUSION: As only 1.1% of this sample of women were HCV-seropositive, screening of all pregnant women does not seem warranted. Testing on the basis of a history of risk factors, such as injecting drug use and having a tattoo, would detect undiagnosed HCV infections more efficiently.

A new recruiting strategy to allow estimates of response rates in studies with people who inject drugs.

A new method of recruiting people who inject drugs was employed in Adelaide in 1994 to attempt to obtain a response rate and demographic information about those who declined to participate. Numbered invitation cards were distributed to injecting drug users (IDUs). Those choosing not to participate were asked to complete 4 questions on the card and return them. 22.7%. Of all cards distributed resulted in an enquiry about the study and only 1.4% of the cards were returned from those who chose not to participate. This recruiting strategy is as successful as other strategies with the added advantage of estimating response rates.

HIV infection among male prisoners in South Australia, 1989 to 1994.

The prevalence of human immunodeficiency virus (HIV) in male prisoners in South Australia from July 1989 to June 1994 was ascertained from a repeated cross-sectional study. We also compared the criminological and demographic characteristics and histories of drug use of 39 HIV-infected prisoners and a randomly selected sample of 86 uninfected prisoners admitted at the same time. The numbers of HIV-infected prisoners in prison in any month ranged from 4 to 12. Prevalence among the total prison population ranged from 0.4 per cent to 1.4 per cent, and among the subpopulation of injecting drug users from 1.25 per cent to 4.36 per cent. Many HIV-infected prisoners continued after their diagnosis to have lifestyles that resulted in imprisonment. Infected prisoners were significantly older, had spent longer in prison and were more likely to be users of heroin (OR = 13.1) and methadone (OR = 25.4) than controls. Infection with HIV among South Australian prisoners has been continuous since at least the mid-1980s. The recidivism among many of the infected prisoners contributes to the variation in prevalence but also raises concerns about their management. Greater effort to minimise the recidivism of the HIV-infected prisoners could reduce the prevalence of HIV in the prison population.

The syringe in the machine.

This paper is a report on focus-group discussions with Western Australian and South Australian injecting drug users and South Australian drug workers, about the feasibility of and issues surrounding the introduction of needle-and-syringe vending machines in Australia. Injecting drug users and workers supported the idea of introducing vending machines in Australia to complement existing services that provide sterile injecting equipment. The participants emphasised that the machines should be provided in addition to existing services. Possible adverse effects of their introduction included concerns for the safety of minors who are not drug users. The potential benefits to public health includes further reducing that proportion of the sharing of injecting equipment that is related to unavailability of sterile equipment (usually at times when other services do not operate).

Poststructuralism and other 'species' in public health--a 'Darwinian' view.

The concepts and methods of poststructuralism are emerging as useful tools to increase our understanding of public health. This paper discusses poststructuralism within the context of a metaphoric 'evolutionary ecology' of knowledge (an epistemecology). It argues that claims for the importance of any programs (such as poststructuralism) are problematic. Using evolutionary and ecological metaphors, it suggests that public health may benefit from its advocates fostering the recombination of elements of knowledge to produce epistemes which adapt us congruently to the general and specific goals of public health, which should include a primary aim of minimising suffering. Choosing to act in an ethical way in regard to our construction and use of knowledge may be one way of achieving those aims. The term 'ethical fitness' is a way of conceptualising an evolving epistemic ethic.

HIV infection among injecting drug users in the South Australian methadone program.

OBJECTIVE: To investigate risk factors for infection with HIV among injecting drug users (IDUs) in South Australia. DESIGN: Retrospective case-control study comparing HIV-infected and uninfected IDUs who had received methadone at any time between January 1981 and June 1991. RESULTS: Most HIV-infected clients were diagnosed between 1985 and 1987. Men were more likely to be infected than women. A history of imprisonment was associated with a higher risk of infection on univariate but not multivariate analysis. Infected IDUs on average were three years younger than noninfected IDUs when they first injected drugs. CONCLUSIONS: Prevention programs should target young drug injectors. Prisons are important places to institute prevention programs.

Jabs in the dark: injecting equipment found in prisons, and the risks of viral transmission.

Injecting drug users in prisons may reuse and share contaminated injecting equipment, increasing their risk of infection with blood-borne viruses. We examined 58 syringes found in three metropolitan Adelaide prisons during a one-year period: 95 per cent were one millilitre volume; blood was visible in 24 per cent; 58 per cent indicated repeated use; 33 per cent were wrapped in plastic; and 26 per cent had detachable needles, allowing more blood to be trapped in the dead space between the syringe barrel and needle than with the fixed-needle variety. The nature and condition of some of these syringes suggested they might transmit contaminated blood. The ineffectiveness of present approaches to keeping injecting equipment out of prisons demands a more enlightened approach to harm minimisation. With doubts cast on the efficacy of bleach, education should be supported by practical means to reduce transmission of viruses. Provision of sterile injecting equipment is a possible option.