Claims that 'doctor shopping' has decreased in the time of the HIC's efforts in this area do not prove that these are necessarily causal. We know that historically all drug and alcohol use fluctuates in response to influences from many quarters. I understand that 'doctor shoppers' are currently defined as those who can be identified as attending more than 15 doctors in a year.
The medical profession should only support measures which are medically and scientifically sound. For example, we now have strong support for the provision of clean needles for drug users, correct labelling of alcoholic beverages, tobacco warnings, nicotine patches, methadone and the like.
The consumption of benzodiazepines is a major problem for a small minority of the Australian population. Dr Andrew Parkes of the HIC invited participants to have an input into this matter, but before any consultations, the momentum was already strongly in favour of the current 'voluntary' reporting arrangements. The scientific approach was rejected over a politically saleable scheme with no clear rationale. There is little reason to think that the current measures address any fundamental problem although they could be part of an overall strategy to counter the harms occurring from the use of tranquillizers in our society. The current measures are an invitation to use false Medicare cards, to use black market sources and generally avoid addressing the underlying problem. I am not aware of the involvement of dependency specialists, urine testing, psychiatric intervention or other more logical and medical approaches.
We know that around 700 young Australians died from heroin overdose last year alone and about a third may have been on benzodiazepines which may have contributed to the deaths. These drugs have been shown to be associated with risk-taking behaviour and it is clear that they can affect judgement, memory, balance and sleep patters, even in modest doses. In older patients, it is now proven from numerous studies that therapeutic doses are associated with more than doubling of the rates of falls and hip fractures.
While banning benzodiazepines outright is no solution, the continued NHS subsidy is equally inappropriate. But for political sensitivity, these drugs would be dropped from the 'free-list' immediately. Government funding of sedative use by young people who have no clinical indications for the drugs seems bizarre. Indeed, the easy availability of the drugs due to the NHS scheme has undoubtedly contributed to the current overuse of benzodiazepines. It also gives some ill-founded legitimacy to a treatment for which there is little clinical justification under the current prescribing instructions.
We need to look at why people take these drugs. Surveys on the reasons for episodes of drug use have commonly come up with the reply "because it was there". Some users are undoubtedly recreational drug takers. Some become truly dependent on the drugs, others are binge users and a small number are arguably on therapeutic doses for clinical indications.
When I spoke to the HIC officials about this matter, the department had done virtually no research on the subject, although they have access to an enormous amount of relevant statistical information. I suggested that the department look at the number of 'doctor shoppers' who had ever had a urine drug screen ordered. This simple step defined a group of patients who had mostly volunteered for methadone treatment in the past who were currently attending large numbers of doctors for sedatives. Hence, they could be identified as patients who were already in contact with D&A treatment services, albeit with sub-optimal results.
Although there is no proven treatment for benzodiazepine addiction, doctors should still be involved in the treatment of a dependence for which the profession is at least partly responsible. The principles of 'primum non nocere' apply here as elsewhere in practice. 'Harm reduction' is a closely related concept which has been used to let the general public know what doctors have always done where short-term 'cure' is not feasible.
Public health policies have ensured that in the case of tobacco, alcohol and even opiates that there is a clean source of a safe form of the drug. Tobacco is easily the most dangerous of these although it is probably subject to the least controls. These controlled drugs are only available to adults in safe quantities from certain licences premises at restricted hours. Benzodiazepines should be no different than other drugs on doctor's prescription. A safe supply should be accompanied by an appropriate degree of medical supervision, advice and psychosocial supports.
While there are still many unknowns in addiction studies, it is quite clear from the research that when there is increased availability, longer hours of operation or reduction in price, there is generally an increase in overall consumption. This 'availability theory' is supported by many research studies as well as being based on sound fundamental principles. Serious arguments against it still come from such parties as the tobacco and alcohol industry. Some tobacco industry officials still claim that nicotine is not addictive and that tobacco does not cause lung cancer.
We should press for a more logical approach to drug policy as it impinges on our practices, the health budget and the lives of our patients.
