13 February 2007

No Justice for Youth Justice - anyone but Louise Casey

The Guardian has reported that Blair fancies Louise Casey to head up the Youth Justice Board - using it as a platform from which to take forward his Antisocial Behaviour Agenda after he is deposed in May.

This would be a worrying development - and one that everyonce concerned about youth justice should hope does not come to pass. Louise Casey has led something of a charmed life since leaving the world of the London homelessness sector. While she headed up the rough sleepers strategy, there were repeated, well substantiated allegations that rough sleeper counts were manipulated to 'prove' a reduction in rough sleepers. Approaches such as changing the count criteria, temporary opening of shelters on the nights before counts, food and quiz nights - all these and more were reported as ways of pushing the count down.

Unfortunately, few organisations had the confidence or resources to speak out: those that did were threatened with having their funding cut. those that made supportive comments and kept schtum about the manipulated counts were awarded new contracts.

Such strategies have endured since she moved on to the Antisocial Behaviour Unit. But rather than trying to reduce homelessness, Casey has done a 180 degree turn and is now endorsing policies that put people out of housing and on to the streets. In moves that would, one would hope, appall old stable mates at Shelter, Casey has taken forward an agenda which has seen people removed from housing and put directly on to the streets. Centuries of property right and hard-wons gains like tenancies have been overturned by new civil powers incorporated in to anti-social behaviour legislation.

If past experience is anything to go by, Casey, is appointed to the Youth Justice Board, would put punitive measures to the fore: in a 2004 interview she made her stance clear: "Not to challenge behaviour is a very British thing, and we have at times felt sorry for the minority of perpetrators. We think the way to deal with them is by feeling sorry for them and providing more and more services to them in the hope that maybe then their behaviour becomes checked. What is missing is the community saying we have had enough, we have rights too and we have a right to a decent honest way of life with our kids being able to be brought up in peace." [http://www.together.gov.uk/article.asp?c=32&aid=1093]

In the same interview, Casey dismissed concern about ASBOs, saying "I think the criticisms recently have been in the minority. If you read the newspaper coverage of ASBOs, it is immensely positive, and I now find it interesting that even publications like the Guardian are struggling to find holes in them."

This attitude sums up both the Government's and Casey's approach - that if it's well received by the media and popularist it should carry on. In practice there are far bigger holes - such as those reported by the Youth Justice Board:

"Nearly half of the young people whose case files were reviewed, and the vast majority of young people who were the subjects of
in-depth interviews, had been returned to court for failure to comply with their order. The majority had ‘breached’ their ASBO
on more than one occasion. Eighteen young people were sentenced for breach of an ASBO as the sole offence: for one young person,
the outcome was a custodial sentence." [http://www.yjb.gov.uk/publications/Scripts/fileDownload.asp?file=ASBO+Summary%2Epdf]

One suspects that, should she take over at the Youth Justice Board, such criticism would be a thing of the past.

More recently, the Runnymede trust noted that there had been a failing on the part of those delivering, enforcing and monitoring ASBOs to monitor ethnicity - as such this is a failing under the Race Relations Amendment Act and ultimately the responsibility of the Antisocial Behaviour Unit for failing to instruct that such monitoring should take place.
[ http://www.runnymedetrust.org/publications/pdfs/Final%20Report%20Equal%20Respect.pdf]

There has been a growing level of concern about the misuse of ASBOs, and the high breach rate. The Home Office has been reluctant to release accurate figures, despite requests under the Freedom of Information Act from Asboconcern and others.

But despite this we know that:

British Institute for Brain Injured Children (BIBIC) found that up to 35 percent of asbos imposed on young people are given to children with a diagnosed mental disorder or accepted learning difficulty. This represents approximately 1100 cases since asbos were introduced.

As at October 2006, the Home Office had still refused to release breach rates for ASBOs despite repeat requests. Figures up to the end of December 2004 showed a breach rate of 40%.

But reports from some councils (e.g. Westminster) showed a breach rate of 60%.

So despite the claims made for Antisocial Behaviour Orders and the Respect Agenda, they have, to date, been a collection of media friendly, populist measures. But the Home Office has obfuscated on the evidence, and failed to look beyond the headlines. It hasn't looked at the level of breaches for people receiving orders. It has stigmatised and criminalised children with mental disorders. It has legitimised "naming and shaming" of children as social policy. It has taken people with dependencies and made them homeless. And it has prohibited vulnerable people from carrying harm reduction equipment such as condoms.

Louise Casey has been the leading light and champion of these measures and as such is not fit to lead as essential a body as the Youth Justice Board.

05 February 2007

Getting us hooked on Suboxone

We at KFx Towers like a good pharmaceutical success story as much as the next person. So the news that Schering Plough received an EU-wide licence for Suboxone before Christmas must have been good news for the good people at said company. Indeed, so happy were they at their success, that they decided to make their new medicine available at knock-down prices, so that more people could start on this new treatment. We understand in some areas that Suboxone is being made available more cheaply than Subutex, which shows how much they care about the little people....

Only the truly and despicably cynical would think anything else, but we've had several emails about Suboxone so we thought an article would be in order.

Suboxone is a 'cocktail' of Buprenorphine (Subutex (r)) and Naloxone. The idea is that Naloxone is badly absorbed sublingually, but the amount reaching the brain is very high if the drug is taken intranasally or injected. 100% bioavailability is achieved if Naloxone is injected, and levels as high as 100% are claimed for snorting, but this may not be the same in street settings.

If a patient takes their suboxone sublingually, as directed, they should only get the subutex. But if they are tempted to snort or inject the tablets, then they will get the subutex, but also a dose of Naloxone. This should, the theory goes, act as an opiate blocker, making it ineffective to inject it.

The very pretty Suboxone website explains it thus:

"The naloxone component in SUBOXONE is included to help discourage diversion and misuse. Naloxone has very limited bioavailability when administered sublingually, as intended. However, if SUBOXONE is crushed and injected, the naloxone will precipitate opioid withdrawal. In the absence of an opioid, the antagonist has no effect."

But if we pause for attention and recap some important facts, the situation is less clear.

The NIDA took a leading role in the development of Suboxone: they reported
"the medication buprenorphine/naloxone (marketed as Suboxone), developed by NIDA in collaboration with the pharmaceutical industry for the treatment of opioid addiction..."1

The US department of Justice goes further, explaining "In fact, Suboxone was designed specifically to meet FDA requirements for a more diversion-proof drug for use in opiate addiction therapy."2

But ironically the NDIC reports ongoing abuse of Suboxone, saying
"Suboxone also can be diverted and abused; however, it is more likely to be abused by individuals who are addicted to low doses of opiates since it can precipitate withdrawal symptoms in high doses. The naloxone in Suboxone guards against abuse by causing withdrawal symptoms in abusers who crush and either inject or snort the drug; however, law enforcement and pharmacist reporting indicates that Suboxone is being abused successfully when snorted.

Using buprenorphine and heroin in combination does not produce increased effects, but if buprenorphine and methadone are abused together, the effects of both drugs are enhanced. Consequently, diverted buprenorphine may be attractive to patients currently using methadone for opiate addiction therapy."3

All this talk of precipitating withdrawals can get confusing. So what's really going on?

1) the ratio of buprenorphine to Naloxone is 4:1 - a very low level of Naloxone.

2) Buprenorphine is a partial opiate antagonist - it will block heroin from reaching opiate receptors reasonably well. But it is a less effective antagonist than, for example, Naloxone

3) Buprenorphine can and does cause respiratory suppression; especially when injected in large doses, and especially if mixed with benzodiazepines.

4) If a user has heroin in their system, and they use a dose of buprenorphine, this may produce withdrawal symptoms. The severity of these symptoms will depend on the levels of heroin in the system, the amount of buprenorphine used and the quantity of buprenorphine used.

5) but if a person has no opiates in their system (i.e. in withdrawal) and they take buprenorphine, they will get the opiate agonist effects of the buprenorphine, as in relief from withdrawal and mild opiate effects.

6) Naloxone is less effective at blocking or reversing buprenorphine than it is heroin. The literature says that a higher dose of Naloxone will be required, and attention given to maintaining breathing as Naloxone alone might be inadequate.

7) the amount of buprenorphine reaching the brain via snorting is around 49% compared with 29% sublingually, meaning that if someone were titrated and tolerant to a sublingual dose, they would be getting almost a 1/5th more drug by snorting. The time to reach peak levels would also drop from around 200 mins sublingually, to 30mins nasally, according to sources at Schering Plough.

So let's put all these pieces together.

If crushed and snorted, the subutex in suboxone is reportedly still effective. It is possible that the low doses of Naloxone, combined with the higher effective dose of burprenorphine and the relative poor blockading of Naloxone against burprenorphine make snorting the drug effective.

Schering Plough say "Currently no studies have been carried out looking at the effects of nasal snorting of Suboxone tablets." So it would be curious for them to claim that it cannot be effectively snorted.

If injected then all the subutex and all the Naloxone reaches the brain. If the user has heroin still in the system this will precipitate rapid and marked withdrawal symptoms. In fairness, this is likely to have happened even if the naloxone was not present, as the buprenorphine alone would have precipitated withdrawal.

But if the user has no other opiates in their system and inject crushed suboxone, what happens? Well it won't precipitate withdrawal if there's no opiates in place, that's for sure. So for someone not dependent or already in withdrawal, there won't be a sudden reversal into unpleasant symptoms.

It may be that nothing will happen - the naltrexone component will block the buprenorphine from working.

What could also happen is that the nNaloxone partially blocks the subutex - but not wholly. And so by taking a large dose of suboxone by injection, the person could still overdose, as the low dose of Naloxone would be a poor antagonist in such an overdose.7

The risk of buprenorphine-induced overdose would go up if use were taking place alongside benzo use.

So suboxone appears to be of limited value in preventing snorting, and of questionable benefit in preventing injecting. It will still be good for preventing use on top - but then if used properly no better than Subutex alone.

In which case why the big sell on Suboxone? If it isn't being driven by its clinical superiority, what's the appeal?

Firstly, this drug was developed to meet the demands of the US drug treatment and enforcement bodies. By complying with their demands, Schering Plough have a drugs which is the only one to receive federal approval for the treatment of heroin addiction - which is a huge cash-cow however you look at it;

But it should also be noted that away from the US, the patent period for Subutex has expired 4 leaving the way open for cheaper competitors.

To get an idea of the impact of this, the NHS pricing tariffs demonstrate the difference in costs between generic methadone, generic buprenorphine, and branded Subutex:

buprenorphine: 50x 20mg sublingual tablets £5.33
subutex 7 x 2mg £6.72
methadone 1 x 50mls 75p

Given these price differences it would be imperative that Schering Plough get a newer Patented product on the market and quickly - and the advent of Suboxone appears to meet that need.

Thanks to EU wide approval 6
Suboxone is now in a privileged position to become the prescribed drug of choice, regardless of cost or relative effectiveness. And by providing subsidised early "trials" which won't be randomised or controlled, Schering Plough can accrue claims to effectiveness which wouldn't survive rigorous academic scrutiny.

So on balance, and until we have independent and rigorous evidence to the contrary, Suboxone is more expensive than generic buprenorphine, can still be snorted, and won't induce withdrawal when injected unless the person already has opiates in their system. Further, it will still leave people at risk of overdose when injected, as the Naloxone won't effectively or fully reverse the buprenorphine.

Now why exactly is your rep pushing your patients on to Suboxone???
Don't you think you should ask?
Let us know what they say.

KFx 2007
[thanks to Kate for getting me started on this one]

DOI - Doh!

New drug doing the rounds (again)

While the media was frothing over the reclassification of methamphetamine, four people were admitted to hospital in Bedfordshire following ingestion of an unknown substance.

The Media were quick to report this as being due to a "new drug" called DOI or D09.

The Beds police were a little more cautious saying "Speaking to other party-goers at the scene, officers were told that the two men may have taken a drug called DO1, DOI or DO9."

Importantly, it has not been verified that the people in question had indeed taken DOI, or what they believed to be DOI. No independent toxicology reports have been made available at this time, so the suggestion that the substance involved is DOI is highly speculative.

Having said that, other sources have noted some availability of DOI - especially amongst communities with a keen interest in hallucinogens and stimulants. These sources suggest that there is at least a batch of DOI doing the rounds. This, they speculate, may have been a UK based chemist who has cooked up this batch, or an imported batch from an overseas chemist. This would seem more credible than DOI becoming more popular as a rave drug.

DOI is short for 2,5-dimethoxy-4-iodoamphetamine

It was one of a number of compounds developed by Alexander Shulgin and listed in Pikhal. It binds strongly to various serotonin receptors and has been widely used as a research chemical to help identify the location of these receptors.

It is a powerful and long-lasting hallucinogen. Sources suggest periods of effect as long as sixteen hours, with a similar level of hallucinatory effect to LSD, but with the user also feeling more active.

It has not proved hugely popular as the hallucinogenic effects last a long time, and are not that good compared to other, shorter acting, more readily available compounds.

Dose ranges are small - 1-3mg. People undertaking experimental use in controlled conditions have typically had it in refined, powder form for carefull self-administration - e.g. snorting.

Generally such low-demand research chemicals would be in pure powder form for the user to dose at their own level, knowing exactly how much they were taking.

A source from Milton Keynes says that the DOI taken at these events was in tablet form,as E's would be.

no literature is clear on risks and none mention risk of convulsions, though, as this is an amphetamine-type compound this risk is not inconceivable. This would be especially hazardrous at high doses.

Suspicion is at this time that it could be (a) real DOI and some users have taken massive doses, not knowing its strength or (b) it's poorly made DOI with some additives of unknown type/action or (c) it's not really DOI at all but some unknown compound knocked up and flogged to users at a rave (d) it's MDMA or another E-type compound with DOI or something similar in their too, to increase the trippiness...

If you have anything to add please email so we can keep people informed...

Beds Police
Wikipedia on DOI

[thanks to Carly for bringing this one to my attention]

Testing Times

Consolidation of Drug Testing Companies - profit over privacy?

There's been a flurry of shopping activity in the world of Drug Testing - and it's not for testing on arrest!

Concateno PLC, an AIM listed company with no history in the field of Substance Misuse, has been buying up a motley collection of Drug testing companies. This has included Medscreen (November 2006) Altrix (January 2007) Trichotech (February 2007) effectively meaning that one company now owns the major urine, mouth swabbing and hair testing companies in the UK. Concateno PLC is a cash-shell company, headed by Keith Tozzi, former Group Technical Director of Southern Water, CEO of the British Standards Institute and former Chairman of Mid Kent Water...

Why does this matter? The risk is that, in a profit-driven market, the ethics of drug testing will gradually be eroded. To date, most UK testing companies have taken a responsible approach to drug testing by parents and carers. But the worry is that, as the need to create greater shareholder value grows, so the push towards large sales, more widespread testing and more frequent testing grows too.

Any one selling drug testing products has a vested interest in seeing them routinely rolled out in schools, the workplace, and other non-criminal justice settings. This is where the big money lies.

This is something Altrix has been especially keen on. They "passionately believe..." drug and alcohol misuse...are reaching epidemic proportions," and as such drug testing should be embraced to confront these "threats in society." Hence their willingness, enthusiasm and support for such initiatives as the Drug testing in schools rolled out in Kent. No evidence that it reduces use of course, but massive profits for companies.

It will be interesting to see how well these smaller companies can maintain any kind of ethical stance as they become just another part of a larger company.

As there is virtually a monopoly now on drug testing in the UK, it must surely be time for a review of these last purchases and ensure that they continue to act in the interest of the market and consumers.

BBC coverage of Tricho-tech buyout here