25 March 2018

Buprenorphine alone or with naloxone: Which is safer? Subutex versus Suboxone

Buprenorphine alone or with naloxone:  Which is safer?  Kelty E, Cumming C, Troeung L, Hulse G. Journal of Psychopharmacology (2018) in press. 1-9
Dear Colleagues,
After a ten year chronological comparison of 3500 patients prescribed either pure buprenorphine or the combination product with naloxone these authors found few differences in hospital admissions or death rates while in treatment.  However there was a significant increase in mortality post-treatment in those who were prescribed the combination product (odds ratio 1.59).  There were also higher all-cause hospital admission rates in those prescribed the combination product but slightly lower rates for those with skin infection diagnosis.  These extended to the post treatment period and the authors conclude that: “The addition of naloxone does not appear to improve the safety profile of buprenorphine”. 
These Western Australian researchers had access to Health Department prescribing records which were then compared with hospital admission rates and mortality over a ten year period, month by month, in 3500 patients starting in 2001.  The combination product was introduced in the middle of the study period and it quickly became about 90% of the market, allowing a useful comparison.  The 90% transition rate was partly because in WA take-away doses of the pure drug were banned coercively.  There may have been an exemption for pregnant women for whom the pure drug remains the recommended product. 
So here finally we have a study comparing pure buprenorphine with the combination product, although not a randomised controlled trial.  To my knowledge, despite the claims for benefit, there has been little rigorous comparative research before widespread replacement of the pure product with the combination.  The opioid antagonist naloxone was added to an existing sub-lingual product with the intention that it would be safer by being less attractive to inject.  As with other approved medicines, there is no obligation to do comparative research before TGA/FDA approval.  Indeed, all of the early research was on the pure product including the MOTHER study in 2009.  The only real support for the combination product meantime has been some indication that it was marginally less desirable on the black market, attracting a slightly lower reported price.  Yet it would seem self evident that a pure drug would be more desirable to drug seekers than a combination, regardless of the constituents.  Two studies indicated the need for higher doses when the combination drug was used (Fudala and Bell). 
In a small pilot study Bell and colleagues found that after transitioning to the combination product most seemed to do quite well on a number of indices.  However, they also found that subjects appeared to require substantially higher doses (>50% on average) when naloxone was added.  Fudala et al. found substantially more cravings in a large multi-centre RCT in the combination group using fixed doses.  There have been no confirmatory studies to my best knowledge. 
Western Australia has always been a good location for serious D&A research, Perth being a wealthy metropolis with good public health facilities in a relatively isolated position.  And with earnest, experienced and one-time well funded researchers. 
Kelty et al. point out that significant amounts of naloxone are in fact absorbed and that this is known to up-regulate the opioid receptors, possibly making some patients more vulnerable to overdose even after ceasing treatment.  It is also possible that this was the cause of the Sydney patients seemingly requiring higher doses in Bell’s old study. 
A good investigative journalist might make a good story over the profit motive, drug ‘evergreening’ and such, but I leave all this to others.  Suffice it to say that currently our government through the PBS is paying high prices whereas in France the pure product has been used since 1994 and is sold to the government suppliers as a cheap generic (and by an Australian company I believe!). 
Notes by Andrew Byrne ..
Bell J, Byron G, Gibson A, Morris A. A pilot study of buprenorphine-naloxone combination tablet (Suboxone®) in treatment of opioid dependence. Drug Alcohol Rev 2004 23;3:311-318
Fudala PJ, Bridge TP, Herbert S, Williford WO, Chiang CN, Jones K, Collins J, Raisch D, Casadonte P, Goldsmith RJ, Ling W, Malkerneker U, McNicholas L, Renner J, Stine S, Tusel D. Office-Based Treatment of Opiate Addiction with a Sublingual-Tablet Formulation of Buprenorphine and Naloxone. NEJM (2003) 349:949-958

2 October 2017

Large study shows torsade risk remote and ECG non-predictive in methadone maintenance.

Methadone and the QTc Interval: Paucity of Clinically Significant Factors in a Retrospective Cohort. Bart G, Wyman Z, Wang Q, Hodges JS, Karim R, Bart BA. J Addiction Medicine pre-publication 2017. 
Dear Colleagues,
Dr Bart and co-authors have examined the medical records of around 1000 admissions to methadone maintenance nearly all of whom had at least one ECG on or off methadone (or both).  They then compared clinical cardiac events and mortality over 7000 patient years from the major health facility in Minneapolis.  There was an average increase in QTc of 13 milliseconds in those on methadone at the time of the ECG, consistent with other studies.  This was associated with a very low rate of cardiac events of 2.5 per 1000 and QTc intervals were not predictive.  Sudden cardiac death (SCD) rate was lower than age-adjusted community rates (0.4 versus 1.75 per 1000 based on CDC state statistics).  This parallels numerous other reports attesting to the general protective value of being on methadone treatment (see Krantz ref below on cardiac protection).  No case of torsade des pointes was identified by the present authors over 15 years.
This study gives great reassurance in the cardiac safety of methadone maintenance treatment.  The authors also suggest that the requirement for ECG in methadone patients should be reviewed since it does not appear to serve any practical purpose.  A Cochrane review also found no evidence to support QTc screening. 
Concerns over the supposed dangers of QTc prolongation have been over-played, partly by commercial factors favouring the only licensed alternative to methadone maintenance.  Of about 150 torsades cases reported in the literature since 2002 only one was fatal to my best knowledge. 
A paper by Mori Krantz from Denver in 2002 claimed to have found an extraordinary number of tachycardia cases from Colorado methadone clinics and a pain management service in Canada.  Torsade des pointes was reported as a side effect of methadone yet Krantz’s findings have never been replicated elsewhere, even in large samples of closely studied patients over 30 years of research literature.  In the present series by Bart and colleagues not one case was identified in 7000 patient-years.  About 150 anecdotal reports in the literature since 2002 shows this rare event occurs mostly in high-dose, complex methadone patients who were taking other medications, were over 40 years of age and with a higher rate in female patients.  My own practice with approximately 3000 patient-years has identified one single torsade case (non-fatal).  Alcohol and pre-existing heart disease were also associations in this aging population.  Krantz’s claim that methadone was associated with large numbers of otherwise unexplained deaths has also never been supported by the literature (Byrne, Stimmel. Lancet 2009*). 
Notes FYI by Andrew Byrne, Sydney, Australia.  http://methadone-research.blogspot.com/
Krantz on cardiac concerns from the following year (no mention of the balancing protections above): Krantz MJ, Lewkowiez L, Hays H, Woodroffe MA, D. Robertson AD, Mehler PS. Torsade de Pointes Associated with Very-High-Dose Methadone. Ann Intern Med. 2002 137:501-504 http://www.annals.org/cgi/reprint/137/6/501
*Byrne A, Stimmel B. Methadone and QTc prolongation. Lancet 2007 369:366  http://www.thelancet.com/journals/lancet/article/PIIS0140673607601810/fulltext

23 May 2017

Medical post-card from New York in April 2017

Butler Library, Columbia University
Dear Colleagues,
New York has had an early spring but all talk is about the new President and his almost daily tweets.  In medical circles, however the opioid overdose crisis across America is top news yet solutions are hard to find and some (like methadone in general practice) are unmentionable.  After three years of investigations I believe I now know why methamphetamine is less of a problem on the US East Coast and it seems to be due to cocaine being so cheap being less than five dollars per cap in some areas.  For the same financial reasons benzodiazepines are less of a problem due to their high price in America.  With national health schemes Valium and other stronger sedatives are relatively easy to obtain at low cost in France, Israel, Australia, etc.  Ergo a larger abuse problem. 
Safer injecting facilities are now being pushed for in public health forums but by few in authority in America.  Naloxone without prescription is now commonplace which is gratifying ... yet by definition it requires the presence of another person at the scene of the overdose to save a life.  Opioid maintenance TREATMENT can ensure a way to stabilize the opioid epidemic yet such treatment is very hard or impossible to access in much of the United States due to the restrictions on methadone programs and the high cost of buprenorphine.  It is a mystery to me why methadone is not available from private American physicians, nor why American pharmacists are banned from administering methadone in addiction programs.  In a meeting at Rockefeller University I was told the reason was the lack of a profit motive as the drug is old and out of patent in its pure form (about 50 cents per dose). I was pleased to be able to get a world authority on buprenorphine, Dr Doug Kramer into the Journal Club of a world authority on methadone, Professor Mary Jeanne Kreek for a lively discussion including the history of FDA approvals and initial dose recommendations. 
A new publication in the British Medical Journal (including an American editorial) attests to the dramatic reduction in mortality, both overdose and all-cause mortality, in those taking opioid maintenance treatment when compared with opioid dependent citizens who are out of treatment.  The metanalysis across several countries shows substantial reductions in deaths, something which has been shown in smaller studies for over 20 years.  See: http://www.bmj.com/content/357/bmj.j1947 (free access for both editorial and article on the subject).  The acute need for action is talked about daily in the US media yet nobody seems to talk about the elephant(s) in the room which are a lack of treatment availability and drug company culpability for pushing profitable opioid analgesics for so long.  As a maintenance treatment, buprenorphine is excellent for those who can afford it and those with lesser habits and the ability to tolerate the induction requirements (being in or near withdrawal before starting).  The lack of a community methadone program is costing America dearly.  One recent report quoted 50,000 deaths in one single year which out-numbers victims or war, cancer, accidents and suicides. 
An interesting side issue is that American states which legalised 'medicinal' cannabis in recent years have significantly lower overdose rates and the initial figures are now being confirmed in longer term statistics.  While one can speculate on the reasons, the 'normalisation' and decriminalisation of cannabis which has been spearheaded by the Drug Policy Alliance, funded by George Soros must now be given credit for saving hundreds or even thousands of lives.  This organisation has been directed by Ethan Nadelmann who stepped down in April after 20 years at the helm.  His send-off was a moving event with supporters, colleagues and friends including Ira Glasser, Stanton Peele, Joyce Lowinson, Ernie Drucker, Clovis Thorn, asha bandele, Chris Soda, Ellen Flenniken, Dr Robert Newman, Tony Newman, Tony Pappa, and many others including Chief Prosecutor from Albany, David Soares and his wife.  I was happy to be able to represent Australia at such an auspicious gathering in Chelsea overlooking the Hudson River. 
Hepatitis C remains a festering issue between outrageous drug prices and limited funding.  The New York based activist group V.O.C.A.L. has long been advocating strongly for State and Federal subsidies for such treatments to be more widely available.  We are very fortunate in Australia that our PBS struck a very favourable deal with the suppliers, allowing universal access to five new direct acting anti-viral (DAA) drugs (the maximum yearly outlay was capped regardless of the number of prescriptions written).  After just over twelve months, an estimated 38,000 patients have been treated ... which is 15% or more of all the cases in Australia.  This makes hepatitis C eradication possible within the next several years.  Only tiny Iceland has done a similar effort, with its reported 1200 HCV cases.
I had very fruitful discussions with senior colleagues at Columbia University and at Rockefeller University regarding the possible safe use of benzodiazepines in stable OTP patients as well as our own recent experience with treating hepatitis C.  It appears that cirrhosis based on viral hepatitis may be partly reversible, contrary to the popular wisdom and I was able to give some examples from Australia.  We have had ~30 viral clearances out of ~30 patients on Direct Acting Antivirals (DAA) over the past 14  months.  This compares with about 45 out of 55 successful treatments on interferon and ribavirin (plus protease inhibitors more recently) over about 9 years (and it was NOT all easy going). 
My last days in Manhattan included some touristy things such as Katz's Deli (a disappointment), Barney Greengrass Deli (a high point), Hello Dolly with Bette Midler ($59 seats in back row sold on day of performance only) and the 50th Anniversary concert at the Metropolitan Opera House.  Details and photos on request (or on my other blogs soon). 
With best regards,
Andrew Byrne ..  

12 February 2017

Lower mortality and better retention in OTP patients prescribed benzos.

Bakker A, Streel E. Benzodiazepine maintenance in opiate substitution treatment: Good or bad? A retrospective primary care case-note review. Journal of Psychopharmacology 2016 1-5
Dear Colleagues,
Finally we have some strong evidence that prescribing benzodiazepines for patients on opiate maintenance treatment is not only safe and effective but in some cases may be obligatory, under careful supervision with adequate psychosocial supports. 
Dr Bakker in London has done us the great service of publishing the data he has extracted from his own general practice from over 20 years of caring for drug dependent patients.  His practice is based on sound harm reduction principles, prescribing long acting, low potency benzodiazepines such as diazepam or clonazepam using graduated supervision for dependent patients.  In this he bucked the trend based on what he considered good medical practice, albeit non-evidence based (like much prescribing practice). 
Bakker reports on 278 OTP patients since 1998 (1289 patient/treatment years) comprising a high proportion of socio-economically deprived citizens, two thirds being male.  Regarding prescription for benzodiazepines (bzd) from the practice, patients were classified ‘never prescribed bzd’, ‘occasional prescription bzd’ and ‘maintenance bzd.  Further, he examined those still in treatment against those who had departed (96% still in UK, 4% gone overseas, lost to follow-up).  From comprehensive statistics kept by the British NHS Bakker was able to derive accurate mortality figures for these six groups with surprising results for retention and mortality. 
Never              Occasional       Maintenance
Current pats:   223t/y              301t/y              765t/y  
Mortality:        1.79p100ty      0.33p100ty     1.31p100ty
Retention        34 months       51 months       72 months      
Ex-patients:     267t/y              320t/y              305t/y
Mortality:        2.24 p100t/y    0.63 p100t/y   5.90 p100t/y
Excess mort:    125%               191%               450%
T/y = treatment years
Contrary to some expectations, retention was highest in the group prescribed maintenance benzodiazepines.  Furthermore, mortality was lower than in the group never prescribed sedatives and the lowest mortality was intriguingly in those occasionally prescribed sedatives.  However, the most meaningful, and very worrying statistic is the high mortality in maintenance patients who transferred elsewhere for their treatment (more than 4 fold those remaining in treatment at Dr Bakker’s practice in London).  The authors report that following health authority directives very few maintenance prescribers in the UK allow benzodiazepine prescription in parallel as Dr Bakker’s practice does.  Hence the likely inference that these patients had legal supplies of benzodiazepines curtailed on transferring elsewhere for their OTP treatment. 
Another important finding was that the death rates were lowest, and very significantly lower, in those prescribed benzos occasionally, both in-house patients and in those transferred elsewhere. 
This report is not a randomised controlled trial, nor was it prospective, yet it involves large numbers of patients in a normal medical population over a long period with very few lost to follow-up (4%).  Hence the findings are very meaningful for those involved in comparable practice providing opiate maintenance with methadone and/or buprenorphine in a community setting. 
From this paper is it apparent that withdrawing benzodiazepines may increase mortality substantially.  Hence, official guidelines and clinical recommendations which warn against benzodiazepine prescription may be contributing to excess deaths rather than preventing them.  In my experience most OTP prescribers have a small number of patients who are prescribed benzodiazepines, some long-term.  Yet up to 70% of our patients have had problems with sedatives and so to ignore this and advise: ‘just say no’ may not be the proper approach.  However, prescribing is well beyond the comfort zone for many in our field without formal protocols. 
It is my view that all dependent patients should be able to access benzodiazepines under some clinical framework although this should not be open-ended, just like methadone.  There should be dose supervision initially ranging to normal unsupervised prescription for those who are socially integrated but unable or unwilling to cease sedative use.  Those abusing alcohol should be excluded until they can demonstrate abstinence.  Trial dose reductions should be negotiated periodically, as with methadone.  In our own practice we use diazepam and we aim to a dose of 4-15mg daily which is satisfactory for the great majority after initial reductions. 
Notes by Andrew Byrne ..
Bakker article PDF:
References: Franklyn AM, Eibl JK, Gauthier G, Pellegrini D, Lightfoot NK, Marsh DC. The impact of benzodiazepine use in patients enrolled in opioid agonist therapy in Northern and rural Ontario. Harm Reduction Journal 2017 14:6
Weizman T, Gelkopf M, Melamed Y, Adelson M, Bleich A. 2003 Treatment of benzodiazepine dependence in methadone maintenance treatment patients: A comparison of two therapeutic modalities and the role of psychiatric comorbidity. Aust N Z J Psychiatry 37: 458–463
Lader M. Benzodiazepines revisited—will we ever learn? Addiction 2011 106:2086-2109
Liebrenz M, Boesch L, Stohler R, Caflisch C. Agonist substitution-a treatment alternative for high-dose benzodiazepine-dependent patients? Addiction 2010 105;11:1870–1874

27 April 2016

Postcard from New York April 2016

Medical postcard from New York, April 2016
Dear Colleagues,
I can report that spring has sprung in New York.  After a cold start, April has seen a wonderful transition from winter bareness to a colour-wheel of splendid blossoms, bulbs and canopy greenery.  Easter was early this year and so were the cherry blossoms which are at their peak over a week before the advertised dates of the Brooklyn festival (‘Sakura Matsuri’). 
I have been afforded the usual generous welcome for Australians by numerous New York institutions where, by contrast with the general public in America, I am usually speaking to “the converted”.  Public health experts, criminologists and addiction medicine workers now mostly know the facts.  Most are also aware of the 15-year-long highly successful Portuguese experiment in decriminalisation.  Likewise the failure of the ‘Rockefeller’ drug laws where severe penalties had no impact on drug usage, but caused vast disruption to the lives of a generation of non-violent ‘criminals’ (and fuelled a profitable gaol-building industry). 
At my talk at Columbia University I was pleased to note that most were already aware of the interesting finding that allowing alcohol in homeless refuges appears to decrease the overall average amount of alcohol consumed.  The first work on this dates from the 1990s.  Marlatt in Seattle also found that this was time-related and that after a year in such lodgings the average amount consumed decreased by around 50%, not to mention reduced use of medical and legal services (references on request).  The findings have been replicated in Canada and Holland where alcohol in limited quantities was actually provided by staff in several hostels with ‘managed alcohol programs’ in place and with similar positive findings and few problems.  We were also told that New York City also has a ‘Housing First’ initiative, whereby residents may bring alcohol into their lodgings.  It is a mystery to me why Australia has not yet trialled this logical and humanitarian measure for severe alcoholics who are homeless. 
Constant coverage this month of the Presidential election has presently pushed the alarming rates of opioid overdose deaths off the front pages.  Despite this crisis affecting a broad spectrum of American society, little sensible appears in the media or from politicians about this well-researched area.  Any student of public health could describe the measures needed to prevent most of these deaths yet nothing seems to happen.  Even the death of high-profile personalities brings only sympathy, even from the President, but no moves to address the crisis logically.  The death of Prince might also have some association with opioid use. 
I learned that over 30 million Americans live in southern states centred on Mississippi where there is a worsening crisis of opiate use and HIV with a lack of access to opiate maintenance treatments.  Most of the predicted HIV cases are from lower socio-economic groups and many have not even been tested as yet.  Needle services are rare or absent.  The few methadone clinics in the affected areas are mostly at or near capacity.  Buprenorphine is only available at substantial expense from a small number of licensed physicians.  There is a recurring theme in America (and to some extent in Australia) that many people with dependency and mental health issues are missing out on treatment. 
Naloxone has been touted as an answer yet it can only help when there is a second party present at the overdose scene - lone users, without other measures, will always be at risk of death without other measures.  At a Columbia University meeting I was shown a nasal insufflation product which can now be purchased in some states without prescription for around $40.  It would be instructive to know the effect of just spraying pure water up the nose of an overdose victim, quite apart from the reversal effect from naloxone.  This has not been systematically tested; and since there is no injecting centre in America it would be difficult to do so.  Many public health experts believe, however, that sufficient evidence is available in the present urgent circumstances for widespread naloxone availability to be implemented.  My information is that injecting centres only rarely use naloxone in the great majority of overdose cases (which are all ‘early’ overdoses and quite unlike most which are treated by paramedics or hospitals). 
One might think that after 50 years of opiate research in America that there would be some voice calling for normalization of opiate maintenance into medical and pharmacy practice, as happens in most other western countries.  Yet I have not read one letter to the editor, one op-ed opinion piece, one quoted lawmaker or journalist calling for expansion of opiate maintenance treatment in America.  I asked a professor of addiction medicine in a faculty meeting why she does not write such a piece.  She said that as the ‘mother of methadone that is the one thing I cannot do’.  I just do not follow this logic.  Equally, despite frequent stories in the media about the epidemic of drug use, there is little discussion of injecting centres or other harm-reduction measures. 
Apologies if this reads like a stuck record … yet the wealth and knowledge in America which put a human on the moon could surely see the less fortunate looked after in a more humane manner.  There are many in America doing good works.  President Obama has extended health care enormously.  Let’s hope that the next President can better that. 
Best wishes from the Big Apple. 

30 January 2016

When alcohol abstinence fails supervised serving may reduce harms. "MAP" or wet rooms.

Managed Alcohol Programs - (MAP). Slow progress of effective hostel protocol to save money, suffering and dignity of our most marginalised citizens. 
Dear Colleagues,
I have been writing these summaries for many years but there is little more dramatic I can think of than the findings of three published studies and numerous other reports of allowing alcohol to alcoholics in refuges under strict supervision with psychosocial supports.  I wrote enthusiastically about a Canadian study by Tiina Podymow in 2006 ( http://www.redfernclinic.com/c/2006/01/supplying-alcohol-to-alcoholics-may_9924.php4 ).  The other two are from 2009 and 2012, both from Seattle (see refs below). 
Essentially these interventions allow limited quantities of alcohol such as one standard drink per hour in previously ‘dry’ hostels. Thus there is a supervised supply from trained staff inside the establishments from opening at 5 or 6pm up to 10pm or later. 
The published findings of events before and after implementation of the ‘managed alcohol program’ show substantial and significant improvements.  Both medical and police interactions dropped while overall alcohol consumption also dropped.  The authors of some of the studies quantify the benefits using estimates of the costs of police and medical services, each showing very dramatic savings per individual. 
These subjects were all hostel residents who had had multiple attempts at abstinence, detoxification, meetings and medical interventions without success.  Hence for some of these high-end alcohol users “managed alcohol” may be a better goal than enforced abstinence in return for the bed for the night.  The may also be some parallels with the use of nicotine replacement therapies, opiate maintenance treatments and other harm reduction strategies.  Outright overnight bans on alcohol in these hostels may be a well meaning policy which has paradoxically increased harms to those it was intended to help. 
The very fact that the trials were able to be performed is impressive.  It is my belief that these publications are so persuasive that a randomised trial is warranted on a large scale, such are the potential benefits to the alcoholic drinkers, their families and society at large. 
The take-home message from the three reports is that when abstinence based interventions for chronic alcoholics are unsuccessful, further pursuit of abstinence, even temporarily may lead to unwanted consequences which are expensive, painful and time consuming.  And they are avoidable. 
One possibly reason for the findings might be that residents facing overnight lock-up may drink very heavily in the period immediately before entering the hostel.  Such binge drinking is known to be associated with complications from falls and injuries, chest infections, nerve/skin damage from pressure necrosis, liver disease, ulcers, etcetera. 
In 2011 Time Magazine was so impressed that they ran an enthusiastic article (The ‘Wet House’ Where Alcoholics Can Keep Drinking - link below).  This was based on an original story in the New York Times (link below). 
Next time you hear of someone’s operation being postponed due to lack of hospital bed, recovery services or operating theatre time, it is possible that the services are being used by a person in the position above suffering some urgent but preventable medical or surgical complication requiring your local hospital services.  This may also apply to casualty waiting times, blood transfusion services, ambulance, rehabilitation and more.  Likewise, when the police are tied up with local issues of this nature they could be attending to other important policing matters. 
Notes by Andrew Byrne .. http://methadone-research.blogspot.com/
Since writing this I have become aware that Prof Kate Dolan has done a lot of work in this area and has provided much needed summaries of the English and Canadian experience with detailed suggestions for Managed Alcohol Programs in Sydney (refs below). 
Podymow T, Turnbull J, Coyle D, Yetisir E, Wells G. Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol. CMAJ 2006 174;1:45-49        http://www.cmaj.ca/content/174/1/45.full
Larimer ME, Malone DK … (et al.) Marlatt GA. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009 Apr 1;301(13):1349-57      http://www.ncbi.nlm.nih.gov/pubmed/19336710
Collins SE, Malone DK, et al. WG, Marlatt GA, Larimer ME. Project-based Housing First for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories. Am J Public Health. 2012 Mar;102(3):511-9        http://www.ncbi.nlm.nih.gov/pubmed/22390516
Happy Hour? ‘Wet Houses’ Allow Alcoholics to Drink, With Surprising Results. Time Magazine            http://healthland.time.com/2011/04/27/happy-hour-wet-houses-allow-alcoholics-to-drink-with-surprising-results/
The Wet House Where Alcoholics Can Keep Drinking            http://www.nytimes.com/2011/05/01/magazine/mag-01YouAreHere-t.html?_r=1
Feasibility of a Managed Alcohol Program for Sydney.
Introduction to Professor Kate Dolan’s work in this area:
British Columbia’s North-West remote areas.
Ottawas MAP

I acknowledge the traditional owners and custodians of this land on which I walk and work, the Gadigal people of the Eora nation, and pay my respects to elders both past and present.

12 September 2015

BMJ article: increasing overdoses but they ignore known solutions (+ Hari TED talk).

Dear Colleagues,
There is no more ‘final’ statistic regarding drug use than overdose deaths.  And in England the official figures go back to Victorian times, then often involving opium, laudanum and other strong drugs including alcohol.  The British Coroner’s Act of 1844 was ahead of its time and even pre-dated the famous Broad Street Pump reports of the London cholera epidemic of 1854.  The latter is sometimes quoted as the first exercise in modern, scientific public health. 
The BMJ has reported increasing overdose deaths in the UK which are little short of disastrous, reflecting experience in America - doubling in a few short years and overtaking other causes of death like a tragic game of leap-frog.  The UK now has about 50 overdose deaths per million of population or 3346 in 2014 of which 952 were from heroin or morphine.  In Portugal it is about a tenth of this rate according to EMCDDA.  
The familiar story of increasing overdoses happened in Portugal before 2001 when a forward thinking and science based experiment was undertaken moving away from prohibition. 
Portugal decriminalised personal drug use 14 years ago, heralding a new era in public health in that small country.  Since the liberalisation experiment the country has gone from a pariah to a paragon of public health outcomes.  HIV, overdose and addiction rates have dropped significantly while resources have been strongly diverted to treatment and social services.  The UK and USA have comparable drug control laws strongly relying on punishment, in stark contrast to Portugal.  
Like seeing refugees on a television screen, overdose deaths only come home to us when they are personalised by a friend, family member or particularly moving portrayal such as the recent footage of a dead young boy on a beach in Turkey.  Why is nobody taking notice of one of the biggest and longest and most successful real-life experiments in drug law reform?  Why are those supporting prohibition so successful in beating a drum which has no scientific or empirical basis?  And their actions are leading to preventable deaths every single day. I recommend a 14 minute talk by Johann Hari about his ‘journey’ investigating addiction*. 
* https://www.youtube.com/watch?v=PY9DcIMGxMs Everything You Think You Know About Addiction Is Wrong. Johann Hari. TED Talks 

I acknowledge the traditional owners and custodians of this land on which I walk and work, the Gadigal people of the Eora nation, and pay my respects to elders both past and present.

15 May 2015

Medical Postcard from New York, April 2015

It was my privilege to again spend a month in Manhattan learning about American developments in alcohol and drugs issues as well as passing on some of the Australian experience. 
My main mission in New York this year concerned our current plague of stimulant use in Australia and whether there were any answers from colleagues in the Big Apple.  One only has to open an Australian newspaper to find another notable crime or accident traced, at least in part, to amphetamine type stimulants, ‘ice’ or ‘crystal meth’.  I have done my best to ascertain how much of the reported mayhem from ‘ice’ is actuality and how much hype.  The authorities certain seem to be taking it seriously with various enquiries under way. 
America had a spate of methamphetamine use about ten years ago but without the reported behavioural consequences we are seeing at home.  A senior Justice Health clinician told me that ‘crystal meth’ problems were starting to become prominent about 6 years ago, perhaps heralding the current reports of adverse consequences in the wider community.  Others have confirmed that acute drug-related psychosis cases presenting to mental health facilities are now commonplace, even more so than the conditions they are trained, funded and able to treat like schizophrenia, bi-polar disorder, depression, phobias, etc. 
In the past month alone three of our practice patients (n=180) were hospitalised due to complications ascribed to stimulant use, two for psychosis and one having had a stroke.  And this was while they were IN TREATMENT.  On the other hand we have numerous patients who seem to do well taking prescribed stimulants for ADHD at the same time as their opiate maintenance.  Sydney’s St Vincent’s Hospital Stimulant Clinic has prescribed dexamphetamine under medical supervision for the past 8 years with a positive experience in selected cases.  We are now doing the same in the private sector on a small scale. 
Several stories have shocked Australians including a report of a Cairns mother killing eight children before stabbing herself (non-fatally) in the chest and neck.  In another case a previously normal man became so paranoid that he chiseled the initials of the person he believed was targeting him into his leg so that “the coroner will know who did the deed after I’ve been killed”. 
In New York I was told by several experts that stimulants just don’t usually cause major behavioural disturbances.  Yet we have reports of previously normal people starting to wield weapons, leap off buildings or become acutely paranoid.  Some senior clinicians in America told me that such reports are likely to be associated with mixed drugs, PCP, alcohol, benzos, etc.  It is hard to reconcile statements from prominent public figures about amphetamine being a “horrendous new drug which is causing such mayhem” when we prescribe it widely amongst school children where there is a lack of such reports.  As Paracelsus noted 500 years ago, a useful medicine at one dose may become a poison at a higher dose. 
Heroin overdose has now become a national emergency in America and several state Governors have enacted crisis provisions.  I read that there are now more heroin overdose deaths than motor accidents, suicide and cancer put together (this may be in certain age groups).  Such is the epidemic that naloxone peer-distribution has been implemented in various situations despite not fulfilling the usual requirements of safety and effectiveness required for other drug interventions.  There are uncertainties about how to give it (IV, IM or nasal insufflation) and how much to give.  The overseas experience of early heroin overdose (such as in injecting centres) shows that naloxone is rarely required.  Physical manoeuvres and oxygen are sufficient in most cases.  Most ambulance and casualty services treat overdose cases much later which is quite a different clinical situation.  It may be that resuscitation education is also worth emphasising in the drug using population and associates.  Despite these limitations, a parallel benefit to the approval of naloxone has been concurrent Good Samaritan rule in some states such as New Jersey and Hawai’i.  If one calls an ambulance to an overdose case one will not be automatically subject to police action as a result. 
The prospect of tens of thousands of doses of naloxone being sold for just a few ampoules actually used must be joy to some drug company shareholders.  One only hopes that any associated side effects or adverse consequences are minimal as the saving of even one life is important.  Future research should determine these matters as well as a cost benefit analysis since there are various other life-saving interventions which could be implemented. 
The Americans are known for their ‘noble experiments’ some of which have paid off, others, such as alcohol prohibition, proved to be unmitigated disasters.  It seems bizarre that with a heroin addiction problem and overdose crisis US authorities still ban methadone treatment in normal medical practice despite it being used successfully in most western countries.  Methadone clinics are also now commonplace in China.  Methadone treatment is known to dramatically reduce opioid overdoses when used under established clinical guidelines.  It is cheap [sic], meaning no profit for Big Pharma … and it requires only a modest amount of medical education and no new infrastructure.  Methadone and buprenorphine treatments also prevent HIV and very probably hepatitis C as well.  So why is it still restricted to registered clinics in America, especially when few new clinics have opened in the last 20 years?  I am an onlooker, respectful of the great works the US has done for medical research, yet I am unable to answer this question. 
There has been a highly publicised report of 140 new cases of HIV transmission in a small rural county on the Indiana/Kentucky border in just a few weeks.  This has prompted the Governor Mike Pence to countenance needle programs for the first time, although only temporarily.  He still says he does not ‘believe’ in needle availability and one wonders if he knows better than health experts who support such services which are commonplace across the rest of the western world.  A two month period of limited needle and syringe ‘exchange’ programs is unlikely to make much difference as the epidemic is already advanced.  Perhaps the Governor should ban the provision of ash trays … which may discourage smokers!  This is the level of his logic (or lack of it). 
In New York I was given a tour of the John Jay College of Criminal Justice in 59th Street.  A more than life-sized bronze statue in flowing robes celebrates John Jay who was America’s first Chief Justice in 1789.  The magnificent new wing with its long atrium, ramps and roof top lawn  is joined tastefully to the old building adjacent with its magnificent classical façade (ref below). 
My medical contacts have taken me back to the origin of methadone treatment at Rockefeller University, Columbia University, Bellevue Hospital, West Midtown Medical Group (methadone, buprenorphine and general practice uniquely under the one roof), Drug Policy Alliance, New School University with NY State Psychological Society, Addictions group.  To name just a few, I was also in touch with Prof Ernest Drucker, Herbert Kleber, Mary Jeanne Kreek, Robert Heimer, Tom Haines, Lynne Paltrow, Robert G. Newman, Terry Furst, Doug Kramer, Andrew Tatarsky, Scott Kellogg, Richard Juman, Joyce Lowinson, Herman Joseph, Ethan Nadelmann, Tony Newman, Tony Papa, gabriel sayegh and asha bandele, who are all key players in our small field of drug and alcohol treatment, research and policy. 
Annual conference of New York State Psychological Society addiction chapter at New School University in 13th Street near 6th Avenue.  Richard Juman gave the oration and introductions while Andrew Tatarsky and Scott Kellogg, both previous presidents of the organisation, spoke on their approach to addictions in a non-abstinence based therapeutic setting.  This setting gave me a balance to the usual chemical approach used by doctors in dependency (aka ‘methadone’) clinics.  I was surprised to learn that the majority of patients for these clinicians were mandated from court decisions. 
Other issues broached on this trip included ‘lethal’ synthetic cannabis (and it IS, unlike the real thing!); new hepatitis C treatments which avoid interferon injections; police victimization of minorities has been a topic with some balance pointing out the difficulties of policing some localities; Puerto Rico has allegedly adopted the policies once used in the Northern Territory, putting addicts onto flights to Chicago for example, with a vague promise of treatment on arrival. 
Another important observation is that most of the colleagues I meet up with in New York are over 60 and some are over 80.  Some younger folk are getting involved but not nearly enough to replace those of us who are bowing out.  Australia still only has a fledgling community of addiction specialists and there is no secure career path for such doctors.  I hope these reflections may be of interest to the reader. 
Written by Andrew Byrne ..