23 April 2004

Going Too Far: When the Ordinary Becomes Addictive

Fri 23 April 2004

New York State Psychological Association, Division on Addictions. Annual Conference.

The conference was co-sponsored by the 'Masters Program in Mental Health and Substance Abuse of the New School University' and was held at the New School University on 5th Avenue at 15th Street, near Union Square.

This conference was well attended with a series of august speakers and interesting addiction related topic including eating and sex.

Andrew Tatarsky discussed recreational drug use and just what this means. He pointed out that old fashioned immutable labels need to be changed as we now know much more about drug users moving from dependent, harmful and occasional use with OR without treatment. And people use a variety of drugs at different times making labelling even more difficult.

Sippio Michael Small spoke of his work with drug affected youth in central and east Harlem. He had many interesting anecdotes and observations on addictions. He responded to various questions with practical suggestions reflecting his wisdom and long work in the field.

Stanton Peele spoke eloquently about 'Recreational drug use and the path from pleasure to addiction'. He illustrated the talk with some crucial figures on the public record but rarely reproduced about the incidence of heroin addiction in Vietnam veterans. He said that about 60% of heroin dependent servicemen (nearly all were male) used heroin at least once back in America but only 10% of them were ever diagnosed as needing treatment for dependency, although this was widely available to veterans at the time.

Wendy Miller then spoke on eating disorders from her experience in a Women's Behavioural Treatment service. Her points about guilt, body image, depression and food as a cure to many of life's difficulties were well made. She made some other very valid points about 'perfectionism' in eating disorders, bulimia and obesity. We were told that having spent so long preparing her talk, in guilt over ignoring her pit-bull terrier she fed it a bone filled with cream cheese!! I was not sure if she was serious.

Afternoon sessions

Julie Barnes started the afternoon sessions with 'Psychiatric medications: when use IS abuse'. She quoted alarming figures about the proportion of Americans who have taken non-sanctioned, non-prescribed drugs. The variety was broad from antibiotics to tranquillizers to antidepressants to analgesics.

Bob Foreman was good enough to share his research on web sites offering 'prescription-free' drugs for home delivery. He pointed out that a single web search for a particular drug yielded over 100 sites, most of which turned out to be genuine. A few were non-existent when he tried to contact them. However, others would consign various drugs including strong, controlled drugs such as hydrocodone, morphine, methadone, buprenorphine, etc in various manners and with various marketing strategies. In one case a company offered to send the first 20 tablets free and after these had been paid for 40, 60 and then 80 would be consigned 'on approval' which is precisely the way street drugs are often sold! (the first dose is often free) We were told that such illicit operators can do their commerce from a foreign address using a foreign bank, local post and all can be changed overnight. Several web sites mention the very low probability of postal packages being intercepted and that just by giving another mailing address, they will send a second consignment free of charge. Since at least half of my own spam mail has been for Viagara and other drugs, I was interested to know just how it all works. It appears that the high cost of accessing medical services and pharmaceuticals in America is responsible for much of the spam mail on the 'net. It also appears that many Americans have become addicted to 'prescription' drugs which were never legally prescribed to them.

Dr Mark Green who is an addiction psychiatrist spoke on "Prescription Opioids: New Formulation - Same Old Addiction". Dr Green has recently opened the first methadone treatment service in Vermont, previously a 'dry' state regarding methadone. He is also prescribing buprenorphine in a 'shared-care' type of model utilising certain existing services.

He took over some points made by Stanton Peele in the morning sessions which Dr Green termed 'set and setting' (after Norman Zinberg) in drug use, abuse and dependency. Dr Green pointed out that a large proportion of entrants to methadone treatment in some parts of the country were not heroin users but were addicted to prescription opioids such as Oxycontin, Viocodin, etc. Such patients may be true chronic pain sufferers but most had tried opioids outside of the medical setting and enjoyed the effect. As was emphasised several times during the day's talkfest, medical use of opioids only very rarely was associated with continued opioid use and dependency (around 1 to 5%). We had a detailed description of the drugs, their actions and specific case of Oxycontin was aired. Treatment options and the principles of opioid maintenance were broached, including the "therapeutic dance" (which might also be termed 'give and take').

It was most instructive to me that among this broad audience of psychologists and other addiction professionals, many or even most were sympathetic to the harm reduction approach of dealing with clients/consumers in a nonjudgmental way. Not one person voiced any sympathy for punishment models, zero tolerance, etc although numerous speakers and audience members mentioned historical moves away from such out dated philosophies. [This is the state which tried more than anywhere with the Rockefeller laws which have proven so counter-productive in all respects.]

The later sessions were devoted to understanding and dealing with 'sex addiction' and involved Marlene Reil, J.P. Cheuvront and Joseph Cohen.

Participants were encouraged to put in their own views at the break-out session, discussing 'labels' or diagnostic categories. All in all a satisfactory conference on a 'hot topic' with lots of lessons from experienced clinicians.

comments by Andrew Byrne ..

6 April 2004

Cocaine-related deaths / Forum on takeaway doses

Session 1 "At their peril: Cocaine-related deaths in NSW." Prof Shane Darke, National Drug and Alcohol Research Centre

Session 2 "Forum on takeaway doses." Prof James Bell, The Langton Centre.

Chair Dr Gary Swift

Shane Darke spoke on his findings from coroner's records in NSW from 1993 to 2002 of nearly 150 deaths in which cocaine was a cause of death (86%) or a contributing factor. He contrasted the use of cocaine in Australia and America. Ours is very Sydney-based and mostly injected. In the US, cocaine is ubiquitous and it is usually smoked as �crack� or �freebase�. He told us that of all sudden deaths in New York, 25% had cocaine in the body. This may make it a contributing factor in some cases, but it may equally be that it reflects the widespread use of cocaine in those dying from other causes.

We were told of the different �cliques� of users: snorting, non-dependent �middle class� users to injecting addicts who may swap from one drug to another (speed, coke, heroin, pills, etc).

The mixing of drugs and alcohol was the major risk factor in 146 deaths reported from NSW, 96% being poly-drug overdoses. Heroin was the most common accompanying drug (79% as morphine), with alcohol coming second (36%). The medium alcohol level was 0.07%. Others had a variety of other drugs such as cannabis, etc. The actual cause of death appears more complex than with opioids where respiratory depression and hypoxia kill victims, usually within an hour or two. Stimulants are more varied in their effects on the nervous and cardiovascular systems with cardiac and cerebrovascular accidents (stroke) most common reported causes of death.

The time of death found weekends over-represented but there was no strong �payday peak� as with heroin deaths. The place of death was a home in 53% of cases with a higher proportion of inner city deaths occurring in hotels. Over a third of all cocaine related deaths in NSW occurred in Kings Cross or Surry Hills postal areas (2010, 2011). Only three deaths occurred outside of Sydney. This does not accord at all with heroin deaths which were much more widespread in suburban Sydney as well as in nearly all rural areas. [It does, however, fit well with a common manner of drug spread early in an epidemic as described by Frischer and others.]

Half of the overdose victims in Darke�s study were in paid employment with half of them in professional positions. This is in contrast to heroin deaths which mostly occur in the unskilled and unemployed. Nearly all cocaine deaths occurred in males. The mean age was almost 35 which we were told may reflect an on-going pathogenic process such as arteriosclerosis in some cases or in a lack of resistance as drug users approach middle age.

Despite giving some very helpful pointers, Professor Darke said that as a researcher, regarding clinical matters he would defer to his audience. Questions from the large audience centred around just what we as clinicians can do. Education of our patients was the most obvious answer amongst the many other less obvious manoeuvres. Should we advise our own patients to use the Kings Cross injecting room? Should we recommend non-injecting routes of administration? It would seem that basic therapeutic tenets should be strengthened - �engagement� with the drug user, specific drug �education�, sympathetic enquiry into coexisting psychosocial disorders, etc, etc. For those on methadone or other dependency treatment, these need to be optimised in the usual ways and if necessary, a second opinion sought.

In the second half of the Concord Seminar, Associate Professor James Bell gave a talk on the issues surrounding take-away provision for methadone and buprenorphine in New South Wales. He discussed the 'anguish' in delicate decisions regarding how we all entrust take-away doses to patients.

We were reminded about the clinical methadone audit performed in 2001. Dr Bell said that such information was not likely to be released by the current authorities but that he personally understood that those who provided the data (pharmacists, doctors, nurses, patients, etc) were entitled to expect some feedback on the audit. Some doctors have apparently received critical feed-back, but no averages, ranges or recommended figures have been released. Dr Bell said that one figure from his own research showed 12 month retention rates which were 37% and were the same in private and public sectors.

During some discussion with the audience it was agreed that official Guidelines had numerous benefits in dependency practice. (1) They assist doctor say �no� when patients may be unfairly demanding. (2) They save time in preventing undue and lengthy arguments over numbers and timing of such doses, so that, as Dr Bell pointed out, we can spend more time on �caring�. (3) They demarcate unambiguous boundaries or limits. (4) They assist busy GPs who may be inexperienced in dependency matters by providing a simple �recipe� for governing take away provisions based on times in treatment, defined stability and in some cases, dose levels (exceptions may be tolerated at 40mg daily or less according to the current methadone take-away guidelines which were promulgated in November 2004).

It was agreed by the speaker and the audience that buprenorphine was a safer drug for take-home doses and that the new guidelines should reflect that fact. This was also a finding of the buprenorphine forum held in October 2002.

Dr Bell pointed out that to free up places for new patients, there needs to be regular movement of patients from the public to the private sector. Currently, one of the few incentives would seem to be the provision of more take-away doses. It is still not clear if this �works� as many public patients are long term. However, NSW is unique in looking after such folk who are often indigent or homeless, sometimes indefinitely, in the public sector without cost to the individual. One wonders what happens to such folk in other states when money for pharmacies and/or the exigencies of private practice, appointments etc may preclude continued maintenance pharmacotherapy.

Andrew Byrne pointed out that most long-term stable patients in the NSW private sector are currently treated perfectly adequately with four take-away doses weekly (eg. Mon, Wed, Fri attendance). Such patients need to clearly document their stability on a regular basis and it is always the prescriber�s responsibility to elicit and record such details. This includes attendance history, work record, family responsibilities, vein condition, urine testing, etc. For experienced doctors, this should involve no anguish, just good clinical acumen and routine practices which most doctors are used to.

Finally, it was pointed out that regular buprenorphine take-away doses are currently permitted for certain stable patients in NSW under certain conditions� as well as for emergencies and pregnancy. Despite this, most doctors in the room had not authorised such doses, possibly due to a lack of communication, hence the utility of seminars such as this � and thanks go to Professor Bell for his participation.

summaries by Richard Hallinan and Andrew Byrne.

4 April 2004

Can you 'drug-proof' children? Of course not, but you can empower them.

Harm minimization in school drug education: final results of the School Health and Alcohol Harm Reduction Project (SHAHRP). McBride N, Farringdon F, Midford R, Meuleners L, Phillips M. Addiction (2004) 99:278-291

Dear Colleagues,

This may be the most significant study of its kind and its findings are a shining beacon in the sometimes murky field of prevention. It shows significantly less alcohol use and reduced high risk behaviours over a three year period in adolescents who were exposed to a comprehensive school-based education program, in comparison with others who received the existing school approaches in Perth, Western Australia.

The title, ‘harm minimization’ may confuse some readers. Its meaning appears to be comprehensive, evidence-based and informative education with a pragmatic approach to issues. We should not be surprised at the results. If children were given structured information on any other aspect of life from cooking to hygiene, it would be expected that they would cope better with those matters than children who did not receive such education.

This important lead research paper in the Addiction journal also has four commentaries, two from New Zealand, one from South Australia and a rather wry one from Holland. These wrest the gist of the paper, only Peter Anderson from Holland being critical. He states that alcohol problems are so pervasive in our community that schools projects like this are ‘barking up the wrong tree’. This view is so clearly amiss that one wonders if he is being purposely perverse.

The findings are dramatic and significant, yet they are in no way surprising if we follow what most educationalists have been saying for many years. Drug education (like personal hygiene, sex, politics, religion, etc) should usually be taught by existing teachers in the normal course of school classes. The courses should be evidence based, factual and appropriate to the level of understanding of the age being taught. Hence, learning more about alcohol, its many dangers, possible benefits, history and place in society can hardly disadvantage a young person coming into contact with the substance. Some will wisely choose not to drink, following the legion logical reasons for abstinence. Some may choose to drink small amounts in the company of family or others. Others still may choose to binge drink, thus taking the (informed) risks and suffer the predictable negative outcomes.

The authors caution that this is a single study and its findings need to be corroborated in further work. Whether the benefits are sustained beyond the teenage years is also unknown. The field is of such importance that it should take a high priority for official funding, like interventions for smoking, illicit drugs and other dangerous behaviours. The results contrast starkly with the American DARE (Drug Abuse Resistance Education) experience in which armed, uniformed police administer drug education to children. Evaluations have shown either no effect on drug use or, in one case of rural children, worse outcomes!

Even at this stage, it would seem appropriate that a comprehensive education curriculum should be introduced into schools with the aims of reducing alcohol related harms.

comments by Andrew Byrne ..

Education package: http://www.curtin.edu.au/curtin/centre/ndri/shahrp/

Full citation: McBride N, Farringdon F, Midford R, Meuleners L, Phillips M. Harm minimization in school drug education: final results of the School Health and Alcohol Harm Reduction Project (SHAHRP). Addiction (2004) 99:278-291

New York Times on futility of harsh sentences for drug use, dealing.

Dear Colleagues,

This item shows just how hard it can be to reverse bad laws once enacted, despite widespread agreement amonst the various parties.

Time Eases Tough Drug Laws, but Fight Goes On.

By AL BAKER Published: April 16, 2004

ALBANY, April 15 - For years, one of the most divisive topics in New York State has been how to soften the Rockefeller-era drug laws, which sought to counter the drug scourge of the 1970's by setting long sentences even for relatively minor drug crimes.

Opponents of the laws, which were enacted at the request of Gov. Nelson A. Rockefeller, often portray the laws' legacy as one in which many low-level offenders, tripped up by tough mandatory minimum prison sentences, have languished in prisons as victims of the antiheroin efforts of the day.

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Of the 16,564 drug offenders imprisoned as of April 3, fewer than 3 percent of them, or 481 people, were serving time for the state's most serious drug offenses, A-1 felonies; that number is down from the 724 imprisoned similarly in 1995. Furthermore, Gov. George E. Pataki has been using his clemency powers in the most compelling cases, releasing 26 of those prisoners during his administration. The governor has also pursued a strategy of releasing nonviolent felons, including drug offenders, early.

When the laws were instituted in 1973, Governor Rockefeller called them "the toughest antidrug program in the nation." They required a minimum sentence of 15 years to life for sale of one ounce of narcotics, or the possession of two ounces. They also increased the penalties for those caught with smaller amounts of drugs.

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"We have enacted some reforms over the course of the years and we have lessened the harshness of the pre-existing Rockefeller drug laws," Mr. Pataki, a Republican, said as the issue bubbled up on Wednesday. "But having said that, I still believe there is room for significant additional reform."

As Joseph L. Bruno, the Senate's Republican Majority leader, put it, the number of inmates who deserve some type of relief may have "dwindled down to a few." But, he said, "That is no justification for keeping those few there if it is unjust."


BMJ letter on alcohol driving limits ...

Dear Colleagues,

It is amazing that in most countries, despite the evidence, the legal limit for alcohol is still 0.08%, making some think that below such a level is ‘safe’! This BMJ letter from a Canadian doctor is a reminder how far advanced Australian states are in comparison to elsewhere (0.05% is the limit I last read). The talk of saliva tests in Victoria for ‘drug driving’ is much more complex and should not be supported generally until the benefits are shown to outweigh the disadvantages and costs. There also needs to be community support when we are better informed of the issues.


BMJ 2004;328:895 (10 April) Letter

“Alcohol limit for drink driving should be much lower”

EDITOR—For more than a century alcohol has been recognised as one of the principal risk factors for motor vehicle crashes. Nearly half of the roughly 35 000 fatal motor vehicle crashes in the United States each year are alcohol related, meaning that someone in the crash, usually a driver, is intoxicated.

Currently, a blood alcohol concentration ranging from 0.08 to 0.10 mg per 100 ml constitutes prima facie evidence in most countries for driving under the influence of alcohol. In the United Kingdom, United States, Canada, South Africa, and Sri Lanka the legal limit is 0.08 mg per 100 ml, which is too high as driving skills deteriorate and the risk of becoming involved in a crash risk increases from a concentration of 0.02 mg per 100 ml.

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Because the legal blood alcohol concentration in most countries is so high, people often mistakenly believe that they may drive up to a blood alcohol concentration of 0.8 mg per 100 ml, overlooking the fact that driving is impaired at lower concentrations.

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Drinking and driving policies and decisions about enforcement need to be hinged on the scientific evidence.

Ediriweera B R Desapriya, Vancouver, BC, Canada