Tues 25 March 2003
"What causes addiction - and does it matter?" Dr Richard Matthews.
"Practical issues in prison entries and exits - a new scheme is trialed" Dr Gilbert Whitton.
"Proposed new on-line, web based interface for S8 approvals". Ms Kanan Gandecha, Pharmaceutical Services Branch, NSW Health.
Chair Dr Andrew Byrne.
Dear Colleagues, Dr Richard Matthews has a wealth of knowledge about the history of drug use as well as the philosophy and attendant mayhem in attempts to control it. He reminded us that despite the popularity of drugs over the centuries, only the last 100 years have seen a variety of psychoactive drugs available to most citizens in western countries. For the first time in history the poor could be well fed and have excess income for mind altering drugs which are now major world trade commodities.
We were reminded of the history of the 'big three' legal drugs: caffeine, alcohol and tobacco, followed by the 'big three' illicits stimulants, opiates and cannabis. It is only when three factors coincide that drug use 'takes off': availability, low price and peer pressure. This appears to apply to illicits as much as legal drugs. Dr Matthews pointed out the interesting history of futile attempts to ban the various drugs including tobacco and coffee. Even draconian efforts such as decapitation did not prevent their use! Only today, with taxation, education, warnings and restricted places where smoking is allowed, we have seen substantial reductions in consumption. John Mills essay "On Liberty" was quoted in which sane adults were said to have the sovereign rights over their bodies (and thus what they consumed).
We were told the Coca Cola story in context of the temperance movement from the mid-1800s which saw alcohol as the major evil, ignoring patent medicines and tonics such as cola. Various combinations of caffeine, cocaine, alcohol and other drugs were purveyed to the delectation of Victorian era consumers. The caffeine was originally obtained from the coca nut but subsequently using more economical 'sweepings' from tea processing plants.
Following the Madame Butterfly story, US troops were encouraged to take Coca Cola wherever they went including world wars and other regional conflicts, often selling the drink at a loss (a 'nickel' or 5 cents per bottle).
We also had a lesson in the meaning of the term 'addiction' from the Latin 'ad' meaning 'to' or 'towards' and 'dicere' the verb 'to declare'. From the word's origin we glean the element of a lack of control as the individual is "declared towards" consuming the drug, despite other dissuading factors. This term could be applied equally to behaviours such as gambling, sex or shopping. We know that the ancients were familiar with the addictive properties of opium from the writings of Galen and others.
Keats, Byron, King George IV, William Wilberforce, Thomas de Qunicey were just a few of the 19th century notables who used opiates, largely laudanum. It was only with the invention of the hypodermic syringe that the major acute dangers of opiates (morphine) became evident. Yet, still at high prices, intravenous opioids did not become generally popular for another 100 years.
Regards drug use generally, Dr Matthews used a graph of two parallel alcohol studies to show that three groups emerge of (1) dabblers, (2) 'accelerators' and (3) heavy users. It is this last group consumes 80% of the total drug supply and also has most of the morbidity. Why this occurs is speculative, but its significance is obvious regarding harm reduction interventions such as needle services, methadone treatment, injecting rooms etcetera. The final conclusion was that we do not know the full story of the cause of addiction, but that its quest probably DOES matter.
Rather than just looking at drug use in prison entrants, Dr Matthews started with psychiatric symptomatology. He showed elegantly from a large study that anxiety, psychosis, depression and mental defection were each greatly over represented when compared with community findings. Predictably we also saw drug and alcohol use/dependency far more common and especially polydrug use in prison inmates. Several of the figures were more than 100-fold the community prevalence! Dr Matthews questioned whether prison was always the right place for such folk who in a previous age may have not used drugs at all, and if they did, may not have been subject to the risks attended by the illicit market.
Next, and on the same topic, Dr Gilbert Whitton let us know about a new scheme to facilitate prison inmates moving to community methadone, buprenorphine [and ?naltrexone] prescription on discharge. The new scheme will operate in regional areas rather than the current centralised system. Area coordinators will liaise with GPs, clinics and hospital to attempt to facilitate transfers without interrupting treatment which is so often a cause of relapse, reoffending and reincarceration. We were told by the PSB representative that any GP in NSW can prescribe temporarily for such a patient if appropriate authority is obtained (Tel 02 9879 5246). This would require that the patient is already on stable treatment and this is to be continued in a supervised manner with a 'mentor' arrangement either with another community specialist or the original prison prescriber. Presumably take-home doses would be very limited if available at all in such cases initially.
Ms Kanan Gandecha next told us to expect major changes in PSB approvals in the next few months as web-based application trials come to the field. Security will be similar to that used for internet banking with a 'user name' and ID number for prescribers (the current prescriber number will be used to avoid duplication). Access will be strictly limited to the doctor's own patients, or to clinic patients for clinic managers. Prison medical authorities will be considered as one special group, allowing information to be shared more easily in this special case.
Numerous questions were raised concerning privacy, out of hours access, changing addresses, doses, pick up points, etc. All applications will still need individual pharmacist approval for patient, doctor AND pick up point. This will simplify transfers from methadone to buprenorphine (or vice versa for those unhappy with buprenorphine). PSB processes up to 100 applications per day and attempts to keep to a 24 hours turn around time. These include methadone, buprenorphine, stimulants (for ADD) and opioids for chronic pain which are all handled by only 6 pharmacists. Urgent applications, such as priority cases of pregnancy, HIV are always processed first, sometimes within 2 hours or even less.