Buprenorphine prescription by general practitioners in a French region

Since 1996 French general practitioners (GPs) may prescribe sublingual buprenorphine tablets as maintenance treatment for opiate dependence. The computerised data management of the main French health reimbursement system now allows surveillance of the use of this drug, and how it is prescribed. The purpose of this study is to determine the profile of maintained patients, prescribed doses, associated psychotropic treatments and how practitioners prescribe these treatments. This study analyses the 11186 buprenorphine prescriptions electronically transmitted for reimbursement between September and December 1999 in a specific French region. It was found that the 2078 treated patients consumed a mean of 11.5 mg of buprenorphine per day and 12% of them procured prescriptions from more than two prescribers. 43% of maintained patients had an associated benzodiazepine prescription, mainly flunitrazepam, often on the same prescription form. 61% of patients had regular follow-up, others had occasional consultations (21%) and another 18% had deviant maintenance treatment (more than two prescribers or more than 20 mg per day of daily buprenorphine dose). Benzodiazepine consumption was much higher in the 'deviant group' (71.4%). 85% of buprenorphine prescriptions were made by GPs. 21% of GPs prescribed buprenorphine and 61% of those had only one or two maintained patients. Buprenorphine prescription by French GPs is a procedure with no particular requirements, allowing many patients to easily access maintenance treatments. However, a high risk of abuse exists, which demands extensive investigation and evaluation of these practices.

Comparison of methadone and high dosage buprenorphine users in French care centres

AIMS

In France, maintenance programmes for opiate users were adopted later than in other countries. Two maintenance treatments are available: methadone is only delivered in specialized centres while high dosage (HD) buprenorphine can be prescribed by all general practitioners and in specialized centres. The aim of this study was to compare the socio-demographic profiles, the practices and drug consumption patterns of the two groups attending specialized centres.

METHODOLOGY

The Oppidum Programme (observation of illegal drugs and misuse of psychotropic medications), a multi-centric survey, surveys drug-dependent subjects attending specialized care centres throughout France annually. Data were collected by questionnaire on socio-demographic variables and drug use during the preceding week.

RESULTS

During October 1998, 46 centres took part in the survey. The methadone group (n = 424) was older, with a better economic situation; 16% used cocaine regularly. The HD buprenorphine group (n = 616) consumed more heroin (12% vs. 8%) and engaged in more misuse, such as intravenous use, illicit acquisitions or irregular consumption. These practices were more frequent for patients consuming the drug "outwith protocol" or for patients obtaining the drug from a general practitioner.

CONCLUSION

Our results suggest that patterns of consumption of methadone and buprenorphine are different in several respects: concomitant use of licit or illicit psychoactive substances, route of administration, and illegal acquisition. They also suggest that the behaviours of maintenance treatment users depend less on the nature of the maintenance drug (methadone or high dosage buprenorphine), than the nature of the delivery and monitoring practices.

[Pharmacological modulation of the effects induced by ketamine at subanesthetic doses]

The similarity between ketamine effects and endogenous psychoses has created interest in the capacity of antipsychotic medications to block ketamine effects. In healthy subjects, a sub-anaesthetic single dose of lorazepam, typical neuroleptics, such as haloperidol, and atypical neuroleptics, such as clozapine and olanzapine, failed to block ketamine-induced positive and negative symptoms resembling schizophrenia. However, haloperidol is able to decrease ketamine-induced impairment in executive cognitive functions. Recently, lamotrigine reduced ketamine-induced psychotic symptoms, perceptual alterations, and cognitive impairments. In schizophrenic subjects, single doses of olanzapine do not decrease the effects of ketamine. However, long term treatment with clozapine has been reported to decrease ketamine-induced positive symptoms. Pharmacological modulation of the effects of NMDA receptor antagonists, such as ketamine, may lead to development of novel therapeutic agents for psychiatric illnesses such as schizophrenia.

Yawning

YAWNING IS A COMMON PHYSIOLOGICAL EVENT THAT CAN BE DIVIDED INTO THREE DISTINCT PHASES: a long inspiratory phase, a brief acme and a rapid expiration. The aim of yawning is not yet well defined. However this semi-voluntary event increases vigilance and aims to alert when drowsiness occurs. Yawning probably has an important role for social communication as well. Yawning can be responsible for pain, luxation or even transient ischaemic attack. Abnormal yawning is present in various pathologies: migraine, Parkinson's disease, tumours, psychiatric diseases, infections or iatrogenic pathologies. The neuro-pharmacology of yawning is complex and knowledge of its mechanisms is incomplete. While under the control of several neurotransmitters, yawning is largely affected by dopamine. Dopamine may activate oxytocin production in the paraventricular nucleus of the hypothalamus. Oxytocin may then activate cholinergic transmission in the hippocampus and, finally, acetylcholine might induce yawning via the muscarinic receptors of the effectors. This is an over-simplification; many other molecules can modulate yawning, such as nitric oxide, glutamate, GABA, serotonin, ACTH, MSH, sexual hormones and opium derivate peptides. Dopamine involvement in yawning could have practical applications in the study of new drugs or the exploration of neurological diseases such as migraine or psychosis. 2001 Harcourt Publishers Ltd

Neurobiology and clinical pharmacology of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a brain disorder with recognizable periods of onset, course, familial occurrence, epidemiology, phenomenology, and treatment response. Several manifestations of pathophysiology are beginning to be defined, although they may represent intermediate pathophysiology rather than primary etiology. Positron emission tomography studies have consistently identified hypermetabolism in the orbitofrontal cortex, caudate nucleus, and, sometimes, anterior cingulate cortex. Neuropsychologic testing frequently identifies abnormalities in visuospatial function. Abnormal levels of cerebrospinal fluid neurotransmitters and neuromodulators are identifiable in untreated patients with OCD and return toward normal levels after effective treatment. The most consistent pathophysiologic finding in OCD points toward an abnormality in serotonin neurotransmission. Therapeutic response to selective serotonin reuptake inhibitors and the absence of improvement with norepinephrine reuptake inhibitors and dopamine antagonists argue strongly for a role of serotonin in the pathophysiology and treatment of OCD. Despite this clear indication from treatment trials, probes and manipulations of the serotonin system and its specific receptors have not provided a useful understanding of specific abnormalities. Clomipramine or potent selective serotonin reuptake inhibitors are the pharmacotherapy of choice for OCD, with a more limited role reserved for monoamine oxidase inhibitors. If one selective serotonin reuptake inhibitor is ineffective, others may be beneficial, in addition to the different proserotonergic and nonserotonergic augmentation strategies that could be useful in treatment of resistant OCD patients. Nondrug therapies are also important in OCD: behavioral therapy is frequently helpful and neurosurgery is sometimes helpful when other treatments fail.

A double blind parallel group placebo controlled comparison of sedative and mnesic effects of etifoxine and lorazepam in healthy subjects [corrected]

This paper describes the psychomotor and mnesic effects of single oral doses of etifoxine (50 and 100 mg) and lorazepam (2 mg) in healthy subjects. Forty-eight healthy subjects were included in this randomized double blind, placebo controlled parallel group study [corrected]. The effects of drugs were assessed by using a battery of subjective and objective tests that explored mood and vigilance (Visual Analog Scale), attention (Barrage test), psychomotor performance (Choice Reaction Time) and memory (digit span, immediate and delayed free recall of a word list). Whereas vigilance, psychomotor performance and free recall were significantly impaired by lorazepam, neither dosage of etifoxine (50 and 100 mg) produced such effects. These results suggest that 50 and 100 mg single dose of etifoxine do not induce amnesia and sedation as compared to lorazepam.

Antipsychotic-associated weight gain and clinical outcome parameters

Weight gain has been observed with many of the antipsychotics, including the atypical antipsychotics. The assessment of whether, and to what degree, a drug causes changes in body weight is not straightforward, since clinical studies performed during a drug development program are not designed to measure changes in body weight. Even when weight change data are obtained from adverse event data or from part of the vital signs measured during a study, assessment is not standardized. Nevertheless, evidence points to the fact that weight gain with the atypical antipsychotics is becoming an increasing problem. This review examines whether antipsychotic-associated weight gain, when it occurs, is associated with clinical outcome parameters.

N-methyl-D-aspartate receptors and information processing: human choice reaction time under a subanaesthetic dose of ketamine

Ketamine is an N-methyl-D-aspartate antagonist that induces cognitive dysfunctions. The purpose of the present study was to investigate the effects of a subanesthetic dose of ketamine on human information processing, using the additive factor method. During perfusion of a subanesthetic dose of ketamine (0.5 mg/kg over 60 min) or a placebo (randomized double-blind, cross-over design), eight adults (aged 22-33, mean=27) performed a two-choice visual reaction time (RT) task. Signal intensity, stimulus-response mapping, and foreperiod duration were manipulated. The effects of these three variables were found to be additive on RT, indicating that three independent stages - namely, stimulus preprocessing, response selection and motor selection- were manipulated. Ketamine altered RT performance in a specific way: it interacted with foreperiod duration but its effect was additive with those of signal intensity and stimulus-response mapping. These results show that ketamine specifically affects the stage of motor adjustment, which suggests that the glutamatergic system plays an important role in motor processes.

Observation of psychoactive substance consumption: methods and results of the French OPPIDUM programme

This study presents a French programme designed to observe and evaluate psychoactive substance dependence and abuse. Annual surveys lasting 4 weeks are performed with drug users in drug centres. Its usefulness is discussed using examples from the study: potential for antidepressant dependence (amineptine), monitoring benzodiazepine use and consumption associated with maintenance treatments. Flunitrazepam is the most consumed benzodiazepine and often got by deal (29%). There are important differences between buprenorphine consumption in a maintenance treatment context (9/10) and beyond this context (1/10). The main methodology problems encountered are representativeness and validity of data. The limits of the programme and its role in the French health care system are discussed.

Recent evolution in opiate dependence in France during generalisation of maintenance treatments

Two maintenance drugs had been used in France since 1996, methadone and high-dosage buprenorphine. This study aimed to examine changes in drug use from observations gathered between 1995 and 1997, within the framework of the French program for the monitoring of drug dependence (OPPIDUM). This annual survey studies psychoactive substances consumed by drug addicts attending specialised drug care centres. During the last three surveys, 16 centres collected a total of 1597 patient-files. This study shows an increase in the number of patients undergoing maintenance treatment (from 14 to 69%), a reduction in the number of intravenous drug users (from 55 to 22%) and a reduction in consumption of psychoactive substances. However, poly-drug addiction behaviour continues and high-dose buprenorphine subjects frequently use the substance intravenously and in association with benzodiazepines.

Pharmacokinetics of sabeluzole and dextromethorphan oxidation capacity in patients with severe hepatic dysfunction and healthy volunteers

AIMS

The primary objective of this study was to determine how the pharmacokinetics of sabeluzole, an investigational drug with specific effects on memory and learning abilities, are affected by chronic liver disease. Since sabeluzole is metabolised by CYP2D6, a secondary objective was to study the correlation between CYP2D6 activity (as assessed by the dextromethorphan dextrorphan metabolic ratio) and hepatic dysfunction.

METHODS

The single-dose pharmacokinetics of sabeluzole (10 mg) was compared in 10 healthy Caucasian subjects and 10 patients with severe hepatic dysfunction. The urinary dextromethorphan/dextrorphan (DMP/DRP) metabolic ratio was determined after intake of 20 mg dextromethorphan (NODEX capsules).

RESULTS

The terminal half-life of sabeluzole was significantly prolonged in subjects with severe hepatic dysfunction vs healthy subjects (respectively 39.3 +/- 11.5 h; 17.5 +/- 10.2 h (mean +/- s.d.)). The areas under the curve (AUC) were significantly higher in subjects with severe hepatic dysfunction than in healthy volunteers (681 +/- 200 ng ml(-1) h vs 331 +/- 282 ng ml(-1) h). There was a significant correlation between the AUC(0,infinity) and the DMP/DRP metabolic ratio in healthy volunteers and subjects with severe hepatic dysfunction. AUC was greater and elimination of sabeluzole slower in poor metabolizers compared with extensive metabolizers.

CONCLUSIONS

These results suggest that a) sabeluzole dose should be reduced in patients with severe hepatic dysfunction and b) the AUC of sabeluzole is linked to individual CYP2D6 activity.

Quality of life in patients with glioblastoma multiforme participating in a randomized study of brachytherapy as a boost treatment

OBJECT

Until recently the assessment of outcome in patients treated for glioma has emphasized length of survival with the evaluation of quality of life (QOL) limited to unidimensional, mostly physical, measures. The authors report the multidimensional assessment of QOL as part of a randomized clinical trial of brachytherapy as a boost in the initial treatment of patients with glioblastoma multiforme.

METHODS

A questionnaire previously developed by the senior authors and psychometrically validated was completed by patients on randomized entry into the study and at follow-up review every 3 months thereafter. The questionnaire was presented in a linear-analog self-assessment format. Karnofsky Performance Scale (KPS) scores were also recorded on each occasion. No differences were found between patients in either arm of the study (conventional radiation therapy consisting of 50 Gy in 25 fractions or conventional radiation plus a brachytherapy boost of a minimum peripheral tumor dose of 60 Gy) in KPS and QOL scores during the 1st year of follow-up review. However, there was a statistically significant deterioration in patients' overall KPS scores during the 1st year of follow up compared with baseline scores. Of QOL items evaluated, statistically significant deteriorations were found in self care, speech, and concentration, and on subscale analyses, cognitive functioning and physical experience (symptoms) deteriorated significantly during the 1st year of follow up, compared with baseline values. The correlation between QOL and KPS scores was low.

CONCLUSIONS

Future studies in patients harboring malignant gliomas must incorporate measures assessing QOL because traditional measures focusing on physical or neurological functioning give an incomplete assessment of the patient's experience.

[Public health networks: practical aspects and contribution to clinical research. Round table no. 2. XV]

A public health network involves several and different health professionals who work in synergy to achieve a common objective: to improve the management of a given disease. Per se, this objective could not be achieved by each of these professionals if working separately. In practice, existing public health networks ensue from very different legal frameworks and come up against various impediments. They have been developed mainly for the management of chronic and serious diseases (e.g. asthma, diabetes, virus C hepatitis, Parkinson's disease, drug abuse). Public health networks can be a very valuable source of data for clinical and epidemiological research, mainly because patients are followed up over a very long period and information coming from various health professionals (general practitioners, specialists, nurses, etc.) is centralized and recorded in a common database. It can also be useful for pharmacovigilance purposes (assessment of Type A and delayed reactions). In any case, the relative interest of such networks should be regularly assessed by an ad hoc methodology, e.g. an experimental or pseudo-experimental design vs. a reference. Despite the fact that there are relatively few operational networks, they can be of great interest for clinical research.

Effects of lorazepam on emotional reactivity, performance, and vigilance in subjects with high or low anxiety

This study examined the hypothesis that low doses of lorazepam modify emotional response. In accord with the results of prior studies that suggest a differential effect of benzodiazepines according to the subjects' anxiety level, the authors tested the effect of lorazepam (0.5 mg twice daily) on 2 groups of 32 subjects: those with high anxiety (HA) and those with low anxiety (LA). These groups were formed a priori on the basis of their scores on the Cattell Anxiety Scale and the Hamilton Rating Scale for Anxiety. The two groups were evaluated for psychomotor function and vigilance (visual analog scales [VAS], digit-symbol substitution test [DSST], and choice reaction time [CRT]), as well as emotional reactivity. Six emotions (fear, anger, disgust, sadness, joy, and neutral state) were induced by the presentation of six movie excerpts, and subjects' emotional responses were measured using the Differential Emotions Scale. The results suggest that at the doses studied, lorazepam led to an increase in negative emotions and a decrease in positive emotions, compared with placebo. This shift of emotional reactivity toward more negative emotions was slightly stronger with the HA than with the LA subjects. However, no reliable differences in the levels of performance and vigilance (CRT, DSST, and VAS) were observed as a function of either treatment or subject group. These findings suggest a possible relationship between benzodiazepine effects and subjects' anxiety level.

[Maintenance treatment for opioid dependence in care centers: the OPPIDUM program of the Evaluation and Information Centers for Drug Addiction]

The aim of this study was to analyze information concerning multiple drug addiction, illicit behaviors and use of the venous route by maintenance treatment patients included in the October 1998 survey of the OPPIDUM program. Among 1,462 observations, 71% of the subjects were taking maintenance treatments (60% high-dose buprenorphine and 40% methadone). High-dose buprenorphine was taken without medical supervision in 10% of cases. Indicators of abuse were high in this case: multiple drug addiction and intravenous use of buprenorphine (28%). Patients maintained by methadone were older and living in better socio-economic conditions than patients maintained by high-dose buprenorphine. However, in the two groups, the percentage of patients using the intravenous route was the same (15% and 21%). More cocaine was used by the methadone group (16% versus 7%). Thirty-seven percent of the subjects maintained on high-dose buprenorphine were followed by a general practitioner. They appeared to be more unbalanced and in more precarious condition than subjects treated in specialized care centers but they were not representative of the patients maintained by buprenorphine. It would be important to determine why these subjects consult a specialized care center.

Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system approach

OBJECTIVE

To examine the occurrence of critical incidents (CIs) in order to improve quality of care.

DESIGN

Prospective survey.

SETTING

Multidisciplinary, neonatal-pediatric intensive care unit (ICU) of a non-university, teaching children's hospital.

PATIENTS

Four hundred and sixty-seven admissions over a 1-year period.

METHODS

A CI is any event which could have reduced, or did reduce, the safety margin for the patient. Comprehensive, anonymous, non-punitive CI monitoring was undertaken. CI severity with respect to actual patient harm was graded: major (score 3), moderate (2) or minor (1). The system approach incorporates the philosophy that errors are evidence of deficiencies in systems, not in people. We undertook 2-monthly analyses of CIs.

RESULTS

There were 211 CI reports: 30 % major, 25 % moderate, 45 % minor. The CI categories were management/environment 29 %, drugs 29 %, procedures 18 %, respiration 14 %, equipment dysfunction 7 %, nosocomial infections 3 %. The respiratory CIs were the most severe, the drug-related CIs the least severe (score mean, SD: 2.9, 0.26 vs 1.4, 0.76; p < 0.001). However, 20 out of 62 drug-related CIs were potentially life-threatening. Thirteen percent of drug CIs were decimal point errors. Eleven of the 29 respiratory CIs were accidental extubations (2.6/100 ventilator days). CIs were most often precipitated by consultants (32 %), followed by residents (23 %, over-represented in drug CIs, 22/62) and specialized nurses (21 %). Doctors had a greater proportion of major CIs than nurses (p < 0.01). Fifty percent of the CIs were detected by routine checks. The most important method of detection was patient inspection (44 %), alarms accounted for only 10 %. Contributing factors were human errors (63 %), communication failure (14 %), organizational problems (10 %), equipment dysfunction (7 %) and milieu (3 %).

CONCLUSIONS

CIs are very common in pediatric intensive care. Knowledge of them is a precious source for quality improvement through changes in the system.

[Anti-hepatitis B vaccination: after the health authorities' decision]

In 1991, the WHO proposed that the antihepatitis B vaccine be included in national vaccination programs. In France, it was decided in 1994 to move on from a selective immunization scheme aimed at high-risk subjects to a general vaccination policy aimed first at adolescents in school and secondly infants. During this period, several cases of demyelinizing diseases after vaccination led to court actions and were magnified in the popular press, interfering with this new vaccination policy. On October 1, 1988, the French Secretary of Health decided to interrupt the school vaccination programs. This decision, taken as a precautionary measure, had some unexpected consequences. As had been feared by the WHO, there was an overall drop in the public's confidence in the vaccine. Health care professionals highly criticized the spectacular nature of the decision and the absence of scientific argumentation. These events lead us to raise a certain number of questions concerning the use of the public press in the management of health information, the notion of medical responsibility, and the rationality of political decisions in public health.

[Dependence on psychotropic drugs and substitution treatment: recent trends. The OPPIDUM study of the Centers for Evaluation and Information on Drug Dependence (CEIP), October 1997]

The aim of this study was to identify the latest trends in psychotropic drug use and the effect of the increase of maintenance treatments for serious opioid addiction. The results are based on data from OPPIDUM, an annual survey primarily concerned with the consumption of licit and illicit drugs. The study involved 1066 drug addicts recruited during the month of October 1997 from 38 French health centres connected with the Centres for Evaluation and Information on Drug Addiction (CEIP). The most frequently reported drugs were benzodiazepines (n = 323), some of which, especially flunitrazepam (Rohypnol, n = 123), are extremely addictive. The data showed a slight decrease in heroin consumption as well as a marked increase in the use of maintenance treatments. The association between benzodiazepines and buprenorphine (Subutex) should consequently be studied, whether buprenorphine is being used illicitly or prescribed as a maintenance treatment.

[Measurement of anxiety state in women: a short-form scale]

BACKGROUND

Clinical epidemiology and psychosocial studies often take into account the measurement of anxiety. Our objective was to develop and validate a short form scale of anxiety state from the Spielberger's State Trait Anxiety Inventory (STAI-Y), one of the most widely used scales.

METHODS

This study was carried out on French samples of women with different levels of anxiety. The first step was to select from the original 20-items scale, the items susceptible to compose two short forms scales: an 8-items (18-STAI) and a 5-items (15-STAI) one. It was carried out on patients attending cancer genetic clinics (n1 = 160, n2 = 41). The second step was carried out on 3 other samples of women (n3 = 150, n4 = 167, n5 = 105) and measured the psychometric characteristics of the short-form scales obtained previously.

RESULTS

The correlation coefficients between the short-forms and the complete 20-items form were very high (> 0.90) in particular for the 18-STAI (r > 0.95). Both short forms are sensitive to change. The internal consistency measured by Cronbach-alpha was comparable to the original scale. The results obtained with the 18 scale and another 10 items Spielberger's short-form scale are comparable and better than those with the 15 scale.

CONCLUSION

The 18 French short-form scale, balanced with positive and negative items, can be recommended for the measurement of state anxiety when the complete form cannot be used.

[Assessment of the quality of life in the surgery of cancer of the esophagus: critical review of the literature]

The surgery of the oesophageal carcinoma is subjected today to a renewed interest. In the objective to draw recommendations for the clinicians wishing to include quality of life measures in clinical trials, it seemed pertinent to us to critically review existing studies. The review of the literature, presented here, is based on a bibliographic research using Medline database (January 1986-December 1996). A precise methodology was adopted to read the eighteen articles retained and the psychometric instruments used in each study were listed and classified. Nine studies considered the issue of quality of life but failed to measure the outcome or used not validated psychometric instruments and 4 others used only indicators of physical performance. Only five studies assessed quality of life using instruments with known psychometric properties (Quality of Life Index of Spitzer, Rotterdam Symptom Checklist and EORTC QLQ-C30 questionnaire) more often associated to ad hoc dysphagia scales. This review of literature shows that the inclusion of validated quality of life measures in the surgery of oesophageal carcinoma is very recent and that it presents some difficulties inherent to the lack of specific tools. The EORTC QLQ-OES24, specific of oesophageal cancer, being not yet validated in french, the authors recommend the use of the EORTC QLQ-C30 jointly with ad hoc dysphagia scales.

Thermus oshimai sp. nov., isolated from hot springs in Portugal, Iceland, and the Azores, and comment on the concept of a limited geographical distribution of Thermus species

We examined aerobic, thermophilic, gram-negative bacteria that were isolated from hot springs in Portugal and were identified as Thermus strains and placed in phenetic groups on the basis of their phenotypic characteristics. We determined the composition of the peptidoglycan, identified the respiratory quinones, and determined the mean base composition of the DNA, and the levels of DNA-DNA homology were determined by both the filter hybridization and reassociation rate methods. Thermus aquaticus, Thermus brockianus, and Thermus filiformis were not detected in this collection of organisms, although three Thermus thermophilus strains were identified. We propose that the isolates that belonged to phenetic clusters E and F are members of a new species, Thermus oshimai; the type strain of T. oshimai is strain SPS17.