ABC news item Mon 23/6/08
http://www.abc.net.au/news/stories/2008/06/23/2282439.htm
'Hillbilly heroin' makes its mark on Australian streets.
Doctor shopping: dealers rove from surgery to surgery conning doctors.
Audio: Black market booming for prescription painkillers (AM) There are any number of illegal drugs on Australian streets at any one time, but a relative newcomer, known as 'hillbilly heroin', is becoming more popular - subsidised by taxpayers. Audio: http://mpegmedia.abc.net.au/news/audio/am/200806/20080623-am06-oxycodone.mp3
News story:
There are increasing fears that the use of drugs such as oxycodone is growing and becoming a serious problem in Australia.
Oxycodone and similar drugs such as morphine are restricted and only available by prescription, but ABC Radio's AM program has discovered the legitimate market is being rorted by drug dealers.
Twenty-two-year-old Steven - not his real name - moved to Sydney from the United States several years ago.
He brought with him an addiction to the painkiller oxycodone, which is mostly sold under the brand name OxyContin.
In the United States drugs like OxyContin and morphine, usually sold as MS Contin, are widespread. They are called 'hillbilly heroin'.
However when Steven got to Australia, he initially found it hard to find them. But he says that situation changed very quickly.
"I knew that it was prescribed here, but it just wasn't very prevalent. Over the time since getting here, it became more and more, and I heard about it and finally found people selling it down in Melbourne.
"It has become much more prevalent and people do know what it is now and it is definitely growing."
In the United States, the abuse of oxycodone and morphine is rampant and they cause large numbers of overdose deaths.
In Australia, the drugs are restricted and obtainable only with a prescription from a doctor in cases of severe pain.
But there are strong indications the illegal use of these drugs is increasing in Australia. The Australian Crime Commission's recent Illicit Drug Data Report stated morphine use was rising in Queensland and the ACT.
The director of Sydney's Medically Supervised Injecting Centre, Dr Ingrid Van Beek, says she noticed a change about two years ago.
"Of course these medications have always been injected over the years by injecting drug users, but it was about two years ago that we started to see quite a significant increase."
On average around 220 people use the centre each day. Dr Van Beek says now up to 45 per cent of these people report using either oxycodone or morphine.
They get them from people like Sammy, a longtime drug dealer in Sydney's Kings Cross.
He says oxycodone and morphine are more popular than heroin.
"Heroin only holds you for four hours before it starts coming out of your system; where oxycodone or morphine sulphate holds you for 48 hours and one is cheaper than the other," he said.
Sammy gets his supply by what he calls 'doctor shopping' - that is roving from surgery to surgery conning doctors into believing he needs the drugs for medicinal purposes.
"They'd give me what I needed because I looked respectable. If I went in with tracksuit pants and a t-shirt and an Adidas jacket or something like that you know, typical bogan basically, then they would have had second thoughts about prescribing them to me," he said.
Sammy show he has dozens of used packets of OxyContin and MS Contin that he obtained doctor shopping.
These were often bought for less than $5 for a packet of 20 tablets - a price subsidised by the Pharmaceutical Benefits Scheme.
Dr Andrew Byrne is an addiction specialist operating out of Redfern in inner-city Sydney. He says almost all of his patients now report using either oxycodone or morphine, often to the exclusion of heroin.
He says it is far too easy to obtain legal drugs for illegal purposes.
"Given that the doctor doesn't believe that the patient is a drug addict, the doctor is allowed to write a prescription for strong opiate drugs at any quantity and with any number of repeats that they feel is appropriate," he said.
Dr Byrne says it is effectively an illegal drug trade subsidised by the taxpayer.
Based on a report by Michael Edwards for AM.
Tags: drugs-and-substance-abuse, law-crime-and-justice, crime, drug-offences, australia, nsw, sydney-2000, vic, melbourne-3000
Related stories:
http://www.abc.net.au/news/stories/2007/06/04/1942150.htm
Gulf War veteran admits holding up pharmacies
http://www.abc.net.au/news/stories/2008/02/15/2163636.htm
Health workers asked to help police in prescription drugs crackdown
9 June 2008
English study shows opiate users knew what they needed.
A pilot study for a randomized controlled and patient preference trial of buprenorphine versus methadone maintenance treatment in the management of opiate dependent patients. Pinto H, Rumball D, Maskrey V, Holland R. Journal of Substance Use 2008 13;2:73-82
Dear Colleagues,
This pilot study demonstrates the ethical and practical differences between the British and American approach to drug treatment and research. The first author told me that they were trying to prove that they could obtain as good or better results using buprenorphine when compared with methadone in order to force their local NHS formulary to include it. Hence they attempted to randomise subjects applying for opioid prescription to methadone or buprenorphine and then follow progress. However, the first and probably most important finding of this study was that not one single patient of almost 50 presenting to their service over a six month period agreed to this randomisation. Apparently, each patient already had a clear preference for buprenorphine or methadone. Note that combination buprenorphine did not rate a mention in this context despite most doses being non-supervised.
Of those who agreed to be followed for this study, 22 chose methadone and 20 buprenorphine. Of those opting for methadone, 80% had had a previous script for the drug. Only 30% of those choosing buprenorphine had had a previous prescription for that drug (and 40% had tried methadone previously). Thus methadone choice was largely based on previous experience while buprenorphine mostly on second hand information. Consistent with the literature they report: “At 6 months more methadone patients were retained (68 vs. 55% for buprenorphine) …”. There was one ‘cross-over’ patient from each group, each ending the trial on the alternative medication.
Despite no randomisation and no significant differences found between those followed “open-label” over 6 months, these authors make a spectacular reversal of both the above ‘trend’, numerous randomised controlled trials and a Cochrane summary, based on slightly different baselines for methadone against buprenorphine subjects. “As a pilot this study lacked power but the results suggest that, in practice, in the UK, buprenorphine may be more able to retain patients in treatment, suppress illicit opiate use and improve functioning [despite that not happening in RCT elsewhere]. Given the significantly higher cost of buprenorphine a larger study is needed to answer these questions.”
Even if one showed significant differences between methadone and buprenorphine outcomes, this would not “favour” one or other drug, both of which are highly effective in a substantial proportion of heroin addicts presenting for treatment. Further, because patients already know what they want, discussion about which drug has a better retention rate or ability to suppress illicit drug use is almost academic. This may be the first reported series of buprenorphine subjects who had all been offered methadone initially as a choice. The finding of comparable results is greatly reassuring for those of us who prescribe buprenorphine regularly.
These authors take another unreferenced ‘dig’ by stating that methadone “causes a degree of persisting intoxication (which can limit the users’ ability to function) … and has a prolonged abstinence syndrome in withdrawal, leading some to suggest that it prolongs dependence.” Thus they perpetuate the myth that methadone is a sedative drug and buprenorphine is not. They base this purely on anecdotal reports that certain patients feel more energy on buprenorphine after having been on methadone. The reverse may be true for certain patients. It is well known that when stabilised, patients on methadone can drive, operate machinery and look after children perfectly safely. If Dr Pinto has patients reporting sedation on methadone then he might consider lower or split doses as recommended by Payte and others.
We have known for 15 years that buprenorphine can obtain results almost as favourable as methadone. It seems that buprenorphine can lead to increased early drop-outs, possibly due to a lack of agonist reinforcement and/or inadequate doses (Kakko used an average of about 30mg daily). It is hardly surprising that some do better on buprenorphine, even though it is clear that rather more will always do better on methadone in general (see Kakko’s classic study in which most buprenorphine-started patients ended up on methadone ‘rescue’). The lack of toxicity in overdose for buprenorphine must be a major factor in a country like England where more than 90% of opiate maintenance doses are apparently still non-supervised (‘take-aways’).
Regarding price, generic buprenorphine is now available in Europe and at certain dose levels should be comparable in price with methadone. I understand that it is not an expensive drug to manufacture.
In America most research has been performed in a situation where treatment is in extremely short supply and any offer to join funded drug research, even where placebo is a possible offering, is generally taken up promptly by illicit drug users. Many of us have found ethical flaws in this environment, where “choice” is really taken out of the equation, like offering a ‘choice’ of food in a famine, or for prison settings. None can be considered a genuine volunteer when the alternative to being in a trial is to receive no treatment at all (even though this is apparently the norm for 6 out of 7 American addicts currently).
Comments by Andrew Byrne ..
Dear Colleagues,
This pilot study demonstrates the ethical and practical differences between the British and American approach to drug treatment and research. The first author told me that they were trying to prove that they could obtain as good or better results using buprenorphine when compared with methadone in order to force their local NHS formulary to include it. Hence they attempted to randomise subjects applying for opioid prescription to methadone or buprenorphine and then follow progress. However, the first and probably most important finding of this study was that not one single patient of almost 50 presenting to their service over a six month period agreed to this randomisation. Apparently, each patient already had a clear preference for buprenorphine or methadone. Note that combination buprenorphine did not rate a mention in this context despite most doses being non-supervised.
Of those who agreed to be followed for this study, 22 chose methadone and 20 buprenorphine. Of those opting for methadone, 80% had had a previous script for the drug. Only 30% of those choosing buprenorphine had had a previous prescription for that drug (and 40% had tried methadone previously). Thus methadone choice was largely based on previous experience while buprenorphine mostly on second hand information. Consistent with the literature they report: “At 6 months more methadone patients were retained (68 vs. 55% for buprenorphine) …”. There was one ‘cross-over’ patient from each group, each ending the trial on the alternative medication.
Despite no randomisation and no significant differences found between those followed “open-label” over 6 months, these authors make a spectacular reversal of both the above ‘trend’, numerous randomised controlled trials and a Cochrane summary, based on slightly different baselines for methadone against buprenorphine subjects. “As a pilot this study lacked power but the results suggest that, in practice, in the UK, buprenorphine may be more able to retain patients in treatment, suppress illicit opiate use and improve functioning [despite that not happening in RCT elsewhere]. Given the significantly higher cost of buprenorphine a larger study is needed to answer these questions.”
Even if one showed significant differences between methadone and buprenorphine outcomes, this would not “favour” one or other drug, both of which are highly effective in a substantial proportion of heroin addicts presenting for treatment. Further, because patients already know what they want, discussion about which drug has a better retention rate or ability to suppress illicit drug use is almost academic. This may be the first reported series of buprenorphine subjects who had all been offered methadone initially as a choice. The finding of comparable results is greatly reassuring for those of us who prescribe buprenorphine regularly.
These authors take another unreferenced ‘dig’ by stating that methadone “causes a degree of persisting intoxication (which can limit the users’ ability to function) … and has a prolonged abstinence syndrome in withdrawal, leading some to suggest that it prolongs dependence.” Thus they perpetuate the myth that methadone is a sedative drug and buprenorphine is not. They base this purely on anecdotal reports that certain patients feel more energy on buprenorphine after having been on methadone. The reverse may be true for certain patients. It is well known that when stabilised, patients on methadone can drive, operate machinery and look after children perfectly safely. If Dr Pinto has patients reporting sedation on methadone then he might consider lower or split doses as recommended by Payte and others.
We have known for 15 years that buprenorphine can obtain results almost as favourable as methadone. It seems that buprenorphine can lead to increased early drop-outs, possibly due to a lack of agonist reinforcement and/or inadequate doses (Kakko used an average of about 30mg daily). It is hardly surprising that some do better on buprenorphine, even though it is clear that rather more will always do better on methadone in general (see Kakko’s classic study in which most buprenorphine-started patients ended up on methadone ‘rescue’). The lack of toxicity in overdose for buprenorphine must be a major factor in a country like England where more than 90% of opiate maintenance doses are apparently still non-supervised (‘take-aways’).
Regarding price, generic buprenorphine is now available in Europe and at certain dose levels should be comparable in price with methadone. I understand that it is not an expensive drug to manufacture.
In America most research has been performed in a situation where treatment is in extremely short supply and any offer to join funded drug research, even where placebo is a possible offering, is generally taken up promptly by illicit drug users. Many of us have found ethical flaws in this environment, where “choice” is really taken out of the equation, like offering a ‘choice’ of food in a famine, or for prison settings. None can be considered a genuine volunteer when the alternative to being in a trial is to receive no treatment at all (even though this is apparently the norm for 6 out of 7 American addicts currently).
Comments by Andrew Byrne ..
3 June 2008
Dr Alex Wodak responds to Ms Miranda Devine.
An Open Letter to Ms Miranda Devine from Dr Alex Wodak:
A shorter version of this letter (without references) was offered to the Sydney Morning Herald but declined. This commentary is a response to arguments made in an article by Ms Devine published in the Sydney Morning Herald on 15 May 2008. This response was posted on the Update Listserver of the ADCA in Canberra on Monday 2nd June 2008.
REDUCING THE HARMS OF CANNABIS AND CANNABIS POLICIES
In her recent article on cannabis in the Sydney Morning Herald [1], Ms. Miranda Devine expressed three main concerns about taking this drug out of the domain of law enforcement and into the domain of public health. Firstly, that a public health approach will inevitably increase cannabis use in Australia at a time of declining consumption. Secondly, that cannabis increases psychosis. Thirdly, that the Swedish zero tolerance approach demonstrates best how to reduce illegal drug consumption. Some support for each of these views may be adduced from partial quotation of selected research and opinions, including a recent letter [2] to the Sydney Morning Herald by Dr. Don Weatherburn and Professor Wayne Hall. However, a thorough review of research to date does not support Ms. Devine�s case.
Assertions that cannabis use is certain to increase if the drug is taxed and regulated are just beliefs, no doubt strongly held, but unsubstantiated beliefs nonetheless. A European comparative study and an overview of research conducted in the USA and Australia found [3] no convincing relationship between drug policies and prevalence rates of cannabis use. In his evaluation of the effects of the 1987 partial decriminalisation on cannabis use in South Australia, Professor Hall concluded [4] that the increase in consumption in South Australia was not significantly greater than the average increase in the other three states included in the study.
Ms. Devine cited criticism [2] by Weatherburn and Hall of a study by Reinarman, Cohen and Kaal comparing [5] cannabis consumption in San Francisco and Amsterdam as evidence against my views. Weatherburn and Hall argued that differences in demographics may have explained the higher consumption in San Francisco. But it is clutching at straws to believe that the small demographic differences that were found in this study can explain a more than three-fold greater prevalence of smoking cannabis in the city with the more punitive approach. The study also found that the prevalence of use of every other illicit drug was dramatically higher in San Francisco. National surveys in both countries consistently confirm these same differences. If the peer reviewers for the top public health journal in the world had considered demographic differences to be a serious limitation of the study, they would have demanded that the authors indicate this.
Weatherburn and Hall are correct that the samples were not exactly matched. But both were rigorously random, representative samples of experienced users in the household populations of the two cities and the survey instruments and measures used were identical.
The fact that the findings of this study were consistent with virtually all other studies in showing that the great majority of cannabis users clearly reduce use or cease altogether as they get older suggests that the slightly higher average age of the San Francisco respondents was more likely to have reduced use in San Francisco relative to Amsterdam rather than to have increased it. Dr. Weatherburn and Professor Hall have it backwards.
These researchers also appear to cite the comparative study selectively. They did not mention that the slightly higher likelihood of unemployment in the two years before the study was conducted in San Francisco was most likely due to temporary problems of the high technology industry at the time of the study. It is difficult to believe that Weatherburn and Hall could argue that this temporary slightly higher unemployment explains the threefold higher cannabis consumption found in San Francisco.
It is also misleading for these researchers to claim that �consumption increased substantially in the Netherlands after the creation of a de facto legal market�. While cannabis use did increase in the Netherlands at that time, it also increased in almost every other Western country where cannabis prohibition was continued. In some countries, cannabis consumption increased even more than in the Netherlands. Thus, the causal claim that these respected researchers make is too simplistic. Cause cannot be established without proper comparisons and when these comparisons are made, the increase in use cannot be solely attributed to the de facto decriminalization of cannabis in the Netherlands.
Although Dr. Weatherburn and Professor Hall say in their letter that �in research in NSW, most regular cannabis users say they would use it more often if it was legal�, Weatherburn�s own study suggests otherwise. Weatherburn and a colleague concluded [6] �that two-thirds of respondents definitely wouldn't use more cannabis if it were made legal. The remainder, however, would not rule out using cannabis more frequently if it were legal. Four per cent of the sample said they definitely would use more cannabis, about 10 per cent said that they would probably use more and about 19 per cent said that they probably wouldn't use more but, nonetheless, did not rule out the possibility�.
The Police Foundation of the United Kingdom noted [7] in their �Drugs and the Law� report in 2000 that �the consequences of drug use are more important than the numbers of users.� Quite so. The fundamental principle of harm reduction is that reducing harm is more important than a single minded focus on reducing consumption, whatever the cost. Drug law enforcement authorities in Australia have also questioned [8] the wisdom of harsh penalties for cannabis use noting �[cannabis offences] � absorbed a significant proportion of resources dedicated to drug law enforcement. In addition, in contrast to most other illicit drug use, there appears to be a comparatively low rate of associated crime and harm to other individuals and the community. The decriminalisation of personal cannabis use and production may greatly reduce both police and legal resource expenditure�.
Policy determination must include a balancing of benefits and costs. That is why the costs of cannabis prohibition should not be ignored. According to Professor Hall, the costs of cannabis prohibition include �the creation of a large black-market; disrespect for a widely broken law; harms to the reputation of the unlucky few cannabis users who are caught and prosecuted; lack of access to cannabis for medical uses; and an inefficient use of law enforcement resources� [9]. Ms. Devine makes much of my somewhat facetious comments about the realistic options for selling cannabis. But she does not acknowledge the current realities: cannabis is now sold on the black market with no health standards or regulation. Ms. Devine should explain why she prefers cannabis to be sold with no health standards or regulation.
Despite Ms. Devine�s conviction that a causal relationship between cannabis use and mental illness is only questioned by drug law reformers, debate continues among experts. Professor Louisa Degenhardt and colleagues found [10] a �steep rise in the prevalence of cannabis use in Australia over the past 30 years� but �no evidence of a significant increase in the incidence of schizophrenia�. They concluded that �cannabis use does not appear to be causally related to the incidence of schizophrenia, but its use may precipitate disorders in persons who are vulnerable to developing psychosis and worsen the course of the disorder among those who have already developed it.� If cannabis use is associated with a significant risk of causing or worsening serious mental illness, why does Ms. Devine prefer cannabis to be sold only by criminals or corrupt officials?
Ms. Devine�s conviction [1] that Sweden demonstrates �that prohibition is the most certain way to reduce drug use� is shared by few others. What matters more: drug use or drug-related harms? For example, the rate of drug overdose deaths in Sweden (16.9/million) is more than twice that in the Netherlands (7.5/million) [11]. Not so long ago, all Scandinavian countries had the same drug policy. Now Sweden is the last Scandinavian country and among the last countries in Western Europe to reject harm reduction. In 2006, the UN Special Rapporteur on the Right to Health visited Sweden and specifically recommended [12] to the UN General Assembly that: �[T]he Government has a responsibility to ensure the implementation, throughout Sweden and as a matter of priority, of a comprehensive harm reduction policy, including counselling, advice on sexual and reproductive health, and clean needles and syringes�.
But surely if country comparisons with Australia are to be made, we should compare ourselves with a country that shares many of our social, economic, cultural, linguistic and political characteristics: the United States of America. In contrast, Australia has little in common with Sweden. Why does Ms. Devine chose to compare drug outcomes in Australia only with Sweden rather than with the United States of America? After all, Sweden and the United States of America both reject harm reduction and prefer zero tolerance. The US Congress even passed legislation in 1988 mandating that the country would become drug free by 1995. The reason is obvious. Drug-related deaths, disease, HIV, crime and corruption are out of control in the USA. With 737 prisoners per 100,000, the USA has the highest incarceration rate in the world - five times higher than Australia - and more than a third of these inmates are serving sentences for drug related offences. Ms. Devine compares only drug use in countries. But surely drug-related harms count for more than just drug consumption? While the relationship between levels of consumption of legal drugs and drug-related harms is clear both for individuals and communities, the relationship between levels of consumption of illegal drugs and drug-related harms is anything but clear.
Although Ms. Devine quotes Professor Hall approvingly, she should be aware that in 2007, and with important caveats, he advocated [13] �a limited legal cannabis market� accompanied by �grudging tolerance�. Such a system would presumably need to include the same limiting measures I have advocated: taxation, strict regulation of cultivation and sale, health warnings, consumer quality controls, age restrictions on sale and assistance for users when trying to quit. No policy is ever going to be perfect but this approach is surely less costly to the community and less harmful to cannabis consumers than just leaving the market to the Al Capones of this world as Ms. Devine appears to favour.
The wisdom of the decision to include cannabis with the global prohibition of opium poppy and coca plant in the 1961 Single Convention is now being increasingly questioned. The UNODC, the major organization implementing drug policy on behalf of the UN system recently acknowledged [14] �either the gap between the letter and spirit of the Single Convention, so manifest with cannabis, needs to be bridged, or parties to the Convention need to discuss redefining the status of cannabis�.
Is the idea of cannabis taxation really so outlandish? After all, US Congress enacted the Marihuana Tax Act in 1937. This remained legislation until 1970. As recently as 2005, 500 US economists (including Professor Milton Friedman and two other Nobel Prize winners) published [15] an Open Letter to leading politicians including the President and members of Congress calling for the taxation of cannabis.
Ms. Devine is right [1] that Britain recently reclassified cannabis from Class C to Class B (where Class A drugs are considered the most dangerous, Class B intermediate and Class C least dangerous). This was the first time that the British Government had ignored the views of its expert advisory body (the Advisory Council on the Misuse of Drugs). The UK police then announced that they would not change policing practices on cannabis because of this reclassification. Also, cannabis use had declined in the UK after cannabis was classified from Class B to Class C. Does Ms Devine believe that symbolism trumps outcomes or the reverse?
Ms. Devine expressed concern [1] that Australia �ranks in the top 10 drug users of 193 nations in the UN's 2007 World Drug Report�. But the Howard government introduced a �Tough on Drugs� policy in 1997 and continued this policy until it lost office in 2007. Is the high ranking for drug consumption in Australia explained by the Howard government not being tough enough on drugs or does a supposedly tough drug policy have little impact on drug consumption even after ten years?
One of the hallmarks of a poor argument and weak evidence is the use of personal attacks. Ms. Devine shows the weakness of her case by her reliance on gratuitously personal attacks on myself and my 26 years of practice, research and advocacy in this field.
Yours sincerely,
Dr Alex Wodak,
President,
Australian Drug Law Reform Foundation, Darlinghurst, NSW 2010
References:
[1] Ms. Miranda Devine, Puff goes the drug liberalizer, Sydney Morning Herald, 15 May 2008 [2] Dr. Don Weatherburn, Professor Wayne Hall. Mismatch on dope figures (Letters) Sydney Morning Herald, 13 May 2008 [3] V. Maag. Decriminalisation of cannabis use in Switzerland from an international perspective-European, American and Australian experiences. International Journal of Drug Policy. 2003; 14 (3); 279 - 281.
[4] Neil Donnelly; Wayne Hall; Paul Christie. The effects of the Cannabis Expiation Notice system on the prevalence of cannabis use in South Australia: evidence from the National Drug Strategy Household Surveys 1985-95. Drug and Alcohol Review. 2000; 19 (3); 265-269.
[5] Reinarman C, Cohen PD, Kaal HL. The limited relevance of drug policy: cannabis in Amsterdam and in San Francisco. Am J Public Health. 2004; 94(5): 836-42.
[6] Don Weatherburn, Craig Jones. Does prohibition deter cannabis use? Number 58, August 2001. Contemporary Issues in Crime and Justice. Crime and Justice Bulletin. http://www.lawlink.nsw.gov.au/lawlink/bocsar/ll_bocsar.nsf/vwFiles/cjb58.pdf/$file/cjb58.pdf
[7] Drugs and the Law: Report of the Independent Inquiry into the Misuse of Drugs Act 1971. The Police Foundation, London, 2000.
[8] The Australian Bureau of Criminal Intelligence. Australian Illicit Drug Report 1996-97.
[9] Wayne Hall. Reducing the harms caused by cannabis use: the policy debate in Australia. Drug and Alcohol Dependence. 62 (3); 163 - 174.
[10] Louisa Degenhardt, Wayne Hall, Michael Lynskey. Testing hypotheses about the relationship between cannabis use and psychosis. Drug and Alcohol Dependence. 2003. 71 (1); 37- 48.
[11] European Monitoring Centre for Drugs and Drug Addiction, 2007 Annual report, Table DR5 Part (i) http://www.emcdda.europa.eu/stats07/drdtab05a
[12] Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Paul Hunt. Addendum: Mission to Sweden.
http://daccessdds.un.org/doc/UNDOC/GEN/G07/111/82/PDF/G0711182.pdf?OpenElement
[13] Wayne Hall. A cautious case for cannabis depenalisation. pp 91-112. Pot Politics. Marihuana and the costs of prohibition. (ed) Mitch Earleywine. Oxford University Press 2007.
[14] United Nations Office on Drugs and Crime, 2006 World Drug Report [15] Open Letter to the President, Congress, Governors, and State Legislatures.
http://economics.about.com/gi/dynamic/offsite.htm?zi=1/XJ&sdn=economics&cdn=money&tm=38&gps=174_306_1008_577&f=00&su=p649.0.147.ip_&tt=2&bt=0&bts=0&zu=http%3A//www.prohibitioncosts.org/endorsers.html
[addition: Hall's response to this on link http://www.crikey.com.au/Blogs/Croakey/Tackling-the-double-standards-on-drugs.html]
A shorter version of this letter (without references) was offered to the Sydney Morning Herald but declined. This commentary is a response to arguments made in an article by Ms Devine published in the Sydney Morning Herald on 15 May 2008. This response was posted on the Update Listserver of the ADCA in Canberra on Monday 2nd June 2008.
REDUCING THE HARMS OF CANNABIS AND CANNABIS POLICIES
In her recent article on cannabis in the Sydney Morning Herald [1], Ms. Miranda Devine expressed three main concerns about taking this drug out of the domain of law enforcement and into the domain of public health. Firstly, that a public health approach will inevitably increase cannabis use in Australia at a time of declining consumption. Secondly, that cannabis increases psychosis. Thirdly, that the Swedish zero tolerance approach demonstrates best how to reduce illegal drug consumption. Some support for each of these views may be adduced from partial quotation of selected research and opinions, including a recent letter [2] to the Sydney Morning Herald by Dr. Don Weatherburn and Professor Wayne Hall. However, a thorough review of research to date does not support Ms. Devine�s case.
Assertions that cannabis use is certain to increase if the drug is taxed and regulated are just beliefs, no doubt strongly held, but unsubstantiated beliefs nonetheless. A European comparative study and an overview of research conducted in the USA and Australia found [3] no convincing relationship between drug policies and prevalence rates of cannabis use. In his evaluation of the effects of the 1987 partial decriminalisation on cannabis use in South Australia, Professor Hall concluded [4] that the increase in consumption in South Australia was not significantly greater than the average increase in the other three states included in the study.
Ms. Devine cited criticism [2] by Weatherburn and Hall of a study by Reinarman, Cohen and Kaal comparing [5] cannabis consumption in San Francisco and Amsterdam as evidence against my views. Weatherburn and Hall argued that differences in demographics may have explained the higher consumption in San Francisco. But it is clutching at straws to believe that the small demographic differences that were found in this study can explain a more than three-fold greater prevalence of smoking cannabis in the city with the more punitive approach. The study also found that the prevalence of use of every other illicit drug was dramatically higher in San Francisco. National surveys in both countries consistently confirm these same differences. If the peer reviewers for the top public health journal in the world had considered demographic differences to be a serious limitation of the study, they would have demanded that the authors indicate this.
Weatherburn and Hall are correct that the samples were not exactly matched. But both were rigorously random, representative samples of experienced users in the household populations of the two cities and the survey instruments and measures used were identical.
The fact that the findings of this study were consistent with virtually all other studies in showing that the great majority of cannabis users clearly reduce use or cease altogether as they get older suggests that the slightly higher average age of the San Francisco respondents was more likely to have reduced use in San Francisco relative to Amsterdam rather than to have increased it. Dr. Weatherburn and Professor Hall have it backwards.
These researchers also appear to cite the comparative study selectively. They did not mention that the slightly higher likelihood of unemployment in the two years before the study was conducted in San Francisco was most likely due to temporary problems of the high technology industry at the time of the study. It is difficult to believe that Weatherburn and Hall could argue that this temporary slightly higher unemployment explains the threefold higher cannabis consumption found in San Francisco.
It is also misleading for these researchers to claim that �consumption increased substantially in the Netherlands after the creation of a de facto legal market�. While cannabis use did increase in the Netherlands at that time, it also increased in almost every other Western country where cannabis prohibition was continued. In some countries, cannabis consumption increased even more than in the Netherlands. Thus, the causal claim that these respected researchers make is too simplistic. Cause cannot be established without proper comparisons and when these comparisons are made, the increase in use cannot be solely attributed to the de facto decriminalization of cannabis in the Netherlands.
Although Dr. Weatherburn and Professor Hall say in their letter that �in research in NSW, most regular cannabis users say they would use it more often if it was legal�, Weatherburn�s own study suggests otherwise. Weatherburn and a colleague concluded [6] �that two-thirds of respondents definitely wouldn't use more cannabis if it were made legal. The remainder, however, would not rule out using cannabis more frequently if it were legal. Four per cent of the sample said they definitely would use more cannabis, about 10 per cent said that they would probably use more and about 19 per cent said that they probably wouldn't use more but, nonetheless, did not rule out the possibility�.
The Police Foundation of the United Kingdom noted [7] in their �Drugs and the Law� report in 2000 that �the consequences of drug use are more important than the numbers of users.� Quite so. The fundamental principle of harm reduction is that reducing harm is more important than a single minded focus on reducing consumption, whatever the cost. Drug law enforcement authorities in Australia have also questioned [8] the wisdom of harsh penalties for cannabis use noting �[cannabis offences] � absorbed a significant proportion of resources dedicated to drug law enforcement. In addition, in contrast to most other illicit drug use, there appears to be a comparatively low rate of associated crime and harm to other individuals and the community. The decriminalisation of personal cannabis use and production may greatly reduce both police and legal resource expenditure�.
Policy determination must include a balancing of benefits and costs. That is why the costs of cannabis prohibition should not be ignored. According to Professor Hall, the costs of cannabis prohibition include �the creation of a large black-market; disrespect for a widely broken law; harms to the reputation of the unlucky few cannabis users who are caught and prosecuted; lack of access to cannabis for medical uses; and an inefficient use of law enforcement resources� [9]. Ms. Devine makes much of my somewhat facetious comments about the realistic options for selling cannabis. But she does not acknowledge the current realities: cannabis is now sold on the black market with no health standards or regulation. Ms. Devine should explain why she prefers cannabis to be sold with no health standards or regulation.
Despite Ms. Devine�s conviction that a causal relationship between cannabis use and mental illness is only questioned by drug law reformers, debate continues among experts. Professor Louisa Degenhardt and colleagues found [10] a �steep rise in the prevalence of cannabis use in Australia over the past 30 years� but �no evidence of a significant increase in the incidence of schizophrenia�. They concluded that �cannabis use does not appear to be causally related to the incidence of schizophrenia, but its use may precipitate disorders in persons who are vulnerable to developing psychosis and worsen the course of the disorder among those who have already developed it.� If cannabis use is associated with a significant risk of causing or worsening serious mental illness, why does Ms. Devine prefer cannabis to be sold only by criminals or corrupt officials?
Ms. Devine�s conviction [1] that Sweden demonstrates �that prohibition is the most certain way to reduce drug use� is shared by few others. What matters more: drug use or drug-related harms? For example, the rate of drug overdose deaths in Sweden (16.9/million) is more than twice that in the Netherlands (7.5/million) [11]. Not so long ago, all Scandinavian countries had the same drug policy. Now Sweden is the last Scandinavian country and among the last countries in Western Europe to reject harm reduction. In 2006, the UN Special Rapporteur on the Right to Health visited Sweden and specifically recommended [12] to the UN General Assembly that: �[T]he Government has a responsibility to ensure the implementation, throughout Sweden and as a matter of priority, of a comprehensive harm reduction policy, including counselling, advice on sexual and reproductive health, and clean needles and syringes�.
But surely if country comparisons with Australia are to be made, we should compare ourselves with a country that shares many of our social, economic, cultural, linguistic and political characteristics: the United States of America. In contrast, Australia has little in common with Sweden. Why does Ms. Devine chose to compare drug outcomes in Australia only with Sweden rather than with the United States of America? After all, Sweden and the United States of America both reject harm reduction and prefer zero tolerance. The US Congress even passed legislation in 1988 mandating that the country would become drug free by 1995. The reason is obvious. Drug-related deaths, disease, HIV, crime and corruption are out of control in the USA. With 737 prisoners per 100,000, the USA has the highest incarceration rate in the world - five times higher than Australia - and more than a third of these inmates are serving sentences for drug related offences. Ms. Devine compares only drug use in countries. But surely drug-related harms count for more than just drug consumption? While the relationship between levels of consumption of legal drugs and drug-related harms is clear both for individuals and communities, the relationship between levels of consumption of illegal drugs and drug-related harms is anything but clear.
Although Ms. Devine quotes Professor Hall approvingly, she should be aware that in 2007, and with important caveats, he advocated [13] �a limited legal cannabis market� accompanied by �grudging tolerance�. Such a system would presumably need to include the same limiting measures I have advocated: taxation, strict regulation of cultivation and sale, health warnings, consumer quality controls, age restrictions on sale and assistance for users when trying to quit. No policy is ever going to be perfect but this approach is surely less costly to the community and less harmful to cannabis consumers than just leaving the market to the Al Capones of this world as Ms. Devine appears to favour.
The wisdom of the decision to include cannabis with the global prohibition of opium poppy and coca plant in the 1961 Single Convention is now being increasingly questioned. The UNODC, the major organization implementing drug policy on behalf of the UN system recently acknowledged [14] �either the gap between the letter and spirit of the Single Convention, so manifest with cannabis, needs to be bridged, or parties to the Convention need to discuss redefining the status of cannabis�.
Is the idea of cannabis taxation really so outlandish? After all, US Congress enacted the Marihuana Tax Act in 1937. This remained legislation until 1970. As recently as 2005, 500 US economists (including Professor Milton Friedman and two other Nobel Prize winners) published [15] an Open Letter to leading politicians including the President and members of Congress calling for the taxation of cannabis.
Ms. Devine is right [1] that Britain recently reclassified cannabis from Class C to Class B (where Class A drugs are considered the most dangerous, Class B intermediate and Class C least dangerous). This was the first time that the British Government had ignored the views of its expert advisory body (the Advisory Council on the Misuse of Drugs). The UK police then announced that they would not change policing practices on cannabis because of this reclassification. Also, cannabis use had declined in the UK after cannabis was classified from Class B to Class C. Does Ms Devine believe that symbolism trumps outcomes or the reverse?
Ms. Devine expressed concern [1] that Australia �ranks in the top 10 drug users of 193 nations in the UN's 2007 World Drug Report�. But the Howard government introduced a �Tough on Drugs� policy in 1997 and continued this policy until it lost office in 2007. Is the high ranking for drug consumption in Australia explained by the Howard government not being tough enough on drugs or does a supposedly tough drug policy have little impact on drug consumption even after ten years?
One of the hallmarks of a poor argument and weak evidence is the use of personal attacks. Ms. Devine shows the weakness of her case by her reliance on gratuitously personal attacks on myself and my 26 years of practice, research and advocacy in this field.
Yours sincerely,
Dr Alex Wodak,
President,
Australian Drug Law Reform Foundation, Darlinghurst, NSW 2010
References:
[1] Ms. Miranda Devine, Puff goes the drug liberalizer, Sydney Morning Herald, 15 May 2008 [2] Dr. Don Weatherburn, Professor Wayne Hall. Mismatch on dope figures (Letters) Sydney Morning Herald, 13 May 2008 [3] V. Maag. Decriminalisation of cannabis use in Switzerland from an international perspective-European, American and Australian experiences. International Journal of Drug Policy. 2003; 14 (3); 279 - 281.
[4] Neil Donnelly; Wayne Hall; Paul Christie. The effects of the Cannabis Expiation Notice system on the prevalence of cannabis use in South Australia: evidence from the National Drug Strategy Household Surveys 1985-95. Drug and Alcohol Review. 2000; 19 (3); 265-269.
[5] Reinarman C, Cohen PD, Kaal HL. The limited relevance of drug policy: cannabis in Amsterdam and in San Francisco. Am J Public Health. 2004; 94(5): 836-42.
[6] Don Weatherburn, Craig Jones. Does prohibition deter cannabis use? Number 58, August 2001. Contemporary Issues in Crime and Justice. Crime and Justice Bulletin. http://www.lawlink.nsw.gov.au/lawlink/bocsar/ll_bocsar.nsf/vwFiles/cjb58.pdf/$file/cjb58.pdf
[7] Drugs and the Law: Report of the Independent Inquiry into the Misuse of Drugs Act 1971. The Police Foundation, London, 2000.
[8] The Australian Bureau of Criminal Intelligence. Australian Illicit Drug Report 1996-97.
[9] Wayne Hall. Reducing the harms caused by cannabis use: the policy debate in Australia. Drug and Alcohol Dependence. 62 (3); 163 - 174.
[10] Louisa Degenhardt, Wayne Hall, Michael Lynskey. Testing hypotheses about the relationship between cannabis use and psychosis. Drug and Alcohol Dependence. 2003. 71 (1); 37- 48.
[11] European Monitoring Centre for Drugs and Drug Addiction, 2007 Annual report, Table DR5 Part (i) http://www.emcdda.europa.eu/stats07/drdtab05a
[12] Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Paul Hunt. Addendum: Mission to Sweden.
http://daccessdds.un.org/doc/UNDOC/GEN/G07/111/82/PDF/G0711182.pdf?OpenElement
[13] Wayne Hall. A cautious case for cannabis depenalisation. pp 91-112. Pot Politics. Marihuana and the costs of prohibition. (ed) Mitch Earleywine. Oxford University Press 2007.
[14] United Nations Office on Drugs and Crime, 2006 World Drug Report [15] Open Letter to the President, Congress, Governors, and State Legislatures.
http://economics.about.com/gi/dynamic/offsite.htm?zi=1/XJ&sdn=economics&cdn=money&tm=38&gps=174_306_1008_577&f=00&su=p649.0.147.ip_&tt=2&bt=0&bts=0&zu=http%3A//www.prohibitioncosts.org/endorsers.html
[addition: Hall's response to this on link http://www.crikey.com.au/Blogs/Croakey/Tackling-the-double-standards-on-drugs.html]
2 June 2008
Hall and Degenhardt on opioid prescribing regulations: researchers suggest more research!
Lead Editorial - November Addiction journal “Regulating opioid prescribing to provide access to effective treatment while minimizing diversion: an overdue topic for research.”
These Australian authors fail in their apparent twin tasks of commenting the London General Medical Council case against several English addiction doctors and their attempt to tie it to the issue of drug diversion.
I do not understand why British journal editors would solicit opinions about opioid diversion without including a prescriber working in the field. Hall and Degenhardt’s editorial does not add clarity to this important area, but goes off into tangent and anecdote, especially on medico-legal aspects. They also fail to emphasise the major impact of treatment quality and availability on the market for diverted opioids.
Following the laws of supply and demand, improving both access to and the quality of addiction treatments would seem to be the most logical ways to reduce drug diversion. These authors call for more research in their title (they ARE researchers themselves), yet they fail to give the current state of knowledge on the subject. We need to define “best practice” and determine how closely it is followed in the various jurisdictions being described. It is pointless to alter regulations or clinical recommendations if current ones are ignored as they are in the UK, for example. Despite well publicised 1999 treatment guidelines recommending a minimum dose of 60mg daily for methadone patients, Strang found that 90% of prescriptions were for less than this with a mean of 37mg published in 2004 (there have been some reported improvements since then).
Hall and Degenhardt seem to discount the major ‘naturalistic’ experiments between jurisdictions with different regulations. For example, the state of Victoria had by far the most restrictive policy on take-away doses of methadone and buprenorphine, yet they had the highest reports of diversion. This must have some relevance scientifically, even though not ‘hard evidence’ or a RCT. While excessive supervision (eg 7 day attendance) is known to be counter-productive, we also know that easy availability and a lack of dose supervision may also lead to problems (Denmark; UK; France; USA; Ireland; NZ). Increased restrictions may not always be the best way to reduce diversion (Ritter).
A policy which frequently jails doctors who prescribe too many narcotics (as in the US) does not ensure a drug free society. Quite the contrary, and now, as if to codify bad medical practice, buprenorphine is freely available to be prescribed without supervision, urine testing or counselling on doctors prescription for up to 6 months at 32mg daily! And this is only for patients who can manage to afford the very high costs of American doctors and then pharmacy dispensing.
Rhoades and Grabowski reported substantial and significant improvements to several important outcomes, including less HIV risk behaviour, when methadone was supervised twice weekly when compared with five times (weekdays), even in early treatment. Other American open-label studies have shown successful results using once weekly or even less frequent attendance (Yancowitz; Senay; Schwartz). Hence the ideal proportion of supervised doses is still not certain, but it is at least twice weekly in new and unstable patients and possibly less often in those who have shown consistent progress in treatment. The British GP’s guidelines are still very weak on this matter, assuming that many patients can do without supervision but without details on how to choose such subjects, nor how to diagnose relapse with any degree of certainty.
In the context of minimizing diversion, it is not clear why Hall and Degenhardt would bring up two British malpractice cases, one from the 1960s and one more recent. Like many or even most British maintenance prescribers, Dr Colin Brewer was found to have been ‘too trusting’ and overly generous with take-away or dispensed doses, a matter which he conceded in his GMC hearing which took over 2 years. The authors of this editorial misconstrue Brewer’s testimony and therefore his motives regarding patient assessments. They say that Brewer stated that restrictions were ‘bureaucratic’ yet in context he clearly used the term to mean medical record documentation. Hall and Degenhardt also overlook some aspects of his practice which were found to be commendable in the case. Despite being found to have erred in some serious matters (he was deregistered), over 50 of the malpractice charges against him were found to be “not proved”. Of the other charges “proved” in the case, 6 referred to an inadequate assessment of the patient’s financial ability to pay for private treatment, a matter which would be irrelevant or even laughable in other jurisdictions, most notably America. From the evidence in the transcripts, Brewer was clearly committed to GP shared care (where this was feasible in a climate of over-worked NHS GPs). Uniquely, he used hair shaft testing for drug use history corroborations. He was also one of the first to describe post-dose physical examinations for titration of methadone and other dosages. Finally, flexible treatment regimens were instigated for stable patients (and some were found to be too flexible). Some of these particular facets of treatment might well be incorporated into dependency practice to advantage elsewhere, while other lessons learned regarding documentation and supervision. The Jarndycian case against Brewer and colleagues (both in fact exonerated) also raised some important deficiencies in the NHS system of addiction treatment whereby nearly all of their British patients were indeed ‘refugees’ from the official Government treatment agency, the NHS (the clinic also treated patients from overseas including itinerant Australians).
As recently as 2007, Strang reported that a majority of UK prescriptions for methadone still involve no doses being witnessed. While supervision at pharmacies is now slowly being introduced, following Strang’s committee’s 1999 recommendations, there are still major problems in maintenance treatments in the UK (the average dose is still well below optimal levels and a high proportion of prescriptions are for ‘new’ patients). Hall and Degenhardt dismiss these gross and long-standing failings by quoting this very review despite its positive findings being very modest compared to its negative ones.
In my view, the situation is one of the most scandalous episodes in British medical history with the sorry consequences of increased HIV, hepatitis C, crime and overdose all reflecting these deficiencies. And most of this toll could have been prevented with an evidence based approach as was used in British Hong Kong, a sorry lesson for those at home in the UK.
Could it be that the Addiction editorial board wanted to highlight this case to take the spotlight off the real issue of poor treatment standards across the country (with some notable and commendable exceptions, including Sheffield, Manchester, Portsmouth and some parts of London and Scotland)? This is an area the editors have neglected for decades which is regrettable. To my best knowledge, Addiction has never covered this quite fundamental matter, despite its overwhelming importance to public health in the UK. In the past I have suggested it to editor Griffith Edwards who accepted its importance but then completely ignored the matter for years in the journals over which he has ruled for a generation.
Drug diversion is also covered is several other recent prominent articles. Readers interested in this field will learn much by reading some of the items below while passing over the pusillanimous November Addiction editorial by Hall and Degenhardt.
Comments by Andrew Byrne .. http://www.redfernclinic.com/
Hall W, Degenhardt L. Regulating opioid prescribing to provide access to effective treatment while minimizing diversion: an overdue topic for research. Addiction 2007 (November)
Drug Misuse and Dependence – Guidelines on Clinical Management. Working Group Chair: Strang J. Department of Health, London, United Kingdom. 1999 ISBN 0113222777
Strang J, Sheridan J, Hunt C, Kerr B, Gerada C, Pringle M. The prescribing of methadone and other opioids to addicts: national survey of GPs in England and Wales. Brit J General Practice 2005 55; 515: 444-451
Robinson GM, Dukes PD, Robinson BJ, Cooke RR, Mahoney GN. The misuse of buprenorphine and a buprenorphine-naloxone combination in Wellington, New Zealand. Drug Alcohol Dependence (1993) 33;1:81-6
O'Connor JJ, Moloney E, Travers R, Campbell A. Buprenorphine Abuse Among Opiate Addicts. British Journal of Addiction 1988 83:1085-1087
Rawson RA, Maxwell J, Rutkowski B. OxyContin Abuse: Who Are the Users? American Am J Psychiatry 164:11, 1634-6
Carise D, Dugosh KL, McLellan AT, Camilleri A, Woody GE, Lynch KG. Prescription OxyContin Abuse Among Patients Entering Addiction Treatment. Am J Psychiatry 164:11:1750–1756
Smith MY, Bailey JE, Woody GE, Kleber HD. Abuse of Buprenorphine in the United States: 2003-2005. Journal of Addictive Diseases 2007 26;3:107-111
Stimmel B. Buprenorphine Misuse, Abuse, and Diversion: When Will We Ever Learn. Journal of Addictive Diseases 2007 26;3:
Frazer J, valentine k. Comparison of take-away policies in NSW and Victoria. Conference presentation(s); monograph, UNSW 2007.
Rhoades HM, Creson D, Elk R, Schmitz J, Grabowski J. Retention, HIV Risk, and Illicit Drug Use during Treatment: Methadone Dose and Visit Frequency. 1998 Am J Public Health 88:34-39
Ritter A, Di Natale R. The relationship between take-away methadone policies and methadone diversion. Drug Alcohol Rev (2005) 24;4:347-352
Yancovitz SR, Des Jarlais DC, Peyser NP, Drew E, Friedmann P, Trigg HL, Robinson JW. A randomised trial of an interim methadone maintenance clinic. (1991) American Journal of Public Health 81:1185-91
Senay EC, Barthwell AG, Marks R, Bokos P, Gillman D, White R. Medical Maintenance: A pilot Study. J Addictive Diseases; 1993: 12(4): 59-76.
Strang J, Manning V, Mayet S, Ridge G, Best D, Sheridan J. Does prescribing for opiate addiction change after national guidelines? Methadone and buprenorphine prescribing to opiate addicts by general practitioners and hospital doctors in England, 1995–2005. Addiction 2007 102:761-770
These Australian authors fail in their apparent twin tasks of commenting the London General Medical Council case against several English addiction doctors and their attempt to tie it to the issue of drug diversion.
I do not understand why British journal editors would solicit opinions about opioid diversion without including a prescriber working in the field. Hall and Degenhardt’s editorial does not add clarity to this important area, but goes off into tangent and anecdote, especially on medico-legal aspects. They also fail to emphasise the major impact of treatment quality and availability on the market for diverted opioids.
Following the laws of supply and demand, improving both access to and the quality of addiction treatments would seem to be the most logical ways to reduce drug diversion. These authors call for more research in their title (they ARE researchers themselves), yet they fail to give the current state of knowledge on the subject. We need to define “best practice” and determine how closely it is followed in the various jurisdictions being described. It is pointless to alter regulations or clinical recommendations if current ones are ignored as they are in the UK, for example. Despite well publicised 1999 treatment guidelines recommending a minimum dose of 60mg daily for methadone patients, Strang found that 90% of prescriptions were for less than this with a mean of 37mg published in 2004 (there have been some reported improvements since then).
Hall and Degenhardt seem to discount the major ‘naturalistic’ experiments between jurisdictions with different regulations. For example, the state of Victoria had by far the most restrictive policy on take-away doses of methadone and buprenorphine, yet they had the highest reports of diversion. This must have some relevance scientifically, even though not ‘hard evidence’ or a RCT. While excessive supervision (eg 7 day attendance) is known to be counter-productive, we also know that easy availability and a lack of dose supervision may also lead to problems (Denmark; UK; France; USA; Ireland; NZ). Increased restrictions may not always be the best way to reduce diversion (Ritter).
A policy which frequently jails doctors who prescribe too many narcotics (as in the US) does not ensure a drug free society. Quite the contrary, and now, as if to codify bad medical practice, buprenorphine is freely available to be prescribed without supervision, urine testing or counselling on doctors prescription for up to 6 months at 32mg daily! And this is only for patients who can manage to afford the very high costs of American doctors and then pharmacy dispensing.
Rhoades and Grabowski reported substantial and significant improvements to several important outcomes, including less HIV risk behaviour, when methadone was supervised twice weekly when compared with five times (weekdays), even in early treatment. Other American open-label studies have shown successful results using once weekly or even less frequent attendance (Yancowitz; Senay; Schwartz). Hence the ideal proportion of supervised doses is still not certain, but it is at least twice weekly in new and unstable patients and possibly less often in those who have shown consistent progress in treatment. The British GP’s guidelines are still very weak on this matter, assuming that many patients can do without supervision but without details on how to choose such subjects, nor how to diagnose relapse with any degree of certainty.
In the context of minimizing diversion, it is not clear why Hall and Degenhardt would bring up two British malpractice cases, one from the 1960s and one more recent. Like many or even most British maintenance prescribers, Dr Colin Brewer was found to have been ‘too trusting’ and overly generous with take-away or dispensed doses, a matter which he conceded in his GMC hearing which took over 2 years. The authors of this editorial misconstrue Brewer’s testimony and therefore his motives regarding patient assessments. They say that Brewer stated that restrictions were ‘bureaucratic’ yet in context he clearly used the term to mean medical record documentation. Hall and Degenhardt also overlook some aspects of his practice which were found to be commendable in the case. Despite being found to have erred in some serious matters (he was deregistered), over 50 of the malpractice charges against him were found to be “not proved”. Of the other charges “proved” in the case, 6 referred to an inadequate assessment of the patient’s financial ability to pay for private treatment, a matter which would be irrelevant or even laughable in other jurisdictions, most notably America. From the evidence in the transcripts, Brewer was clearly committed to GP shared care (where this was feasible in a climate of over-worked NHS GPs). Uniquely, he used hair shaft testing for drug use history corroborations. He was also one of the first to describe post-dose physical examinations for titration of methadone and other dosages. Finally, flexible treatment regimens were instigated for stable patients (and some were found to be too flexible). Some of these particular facets of treatment might well be incorporated into dependency practice to advantage elsewhere, while other lessons learned regarding documentation and supervision. The Jarndycian case against Brewer and colleagues (both in fact exonerated) also raised some important deficiencies in the NHS system of addiction treatment whereby nearly all of their British patients were indeed ‘refugees’ from the official Government treatment agency, the NHS (the clinic also treated patients from overseas including itinerant Australians).
As recently as 2007, Strang reported that a majority of UK prescriptions for methadone still involve no doses being witnessed. While supervision at pharmacies is now slowly being introduced, following Strang’s committee’s 1999 recommendations, there are still major problems in maintenance treatments in the UK (the average dose is still well below optimal levels and a high proportion of prescriptions are for ‘new’ patients). Hall and Degenhardt dismiss these gross and long-standing failings by quoting this very review despite its positive findings being very modest compared to its negative ones.
In my view, the situation is one of the most scandalous episodes in British medical history with the sorry consequences of increased HIV, hepatitis C, crime and overdose all reflecting these deficiencies. And most of this toll could have been prevented with an evidence based approach as was used in British Hong Kong, a sorry lesson for those at home in the UK.
Could it be that the Addiction editorial board wanted to highlight this case to take the spotlight off the real issue of poor treatment standards across the country (with some notable and commendable exceptions, including Sheffield, Manchester, Portsmouth and some parts of London and Scotland)? This is an area the editors have neglected for decades which is regrettable. To my best knowledge, Addiction has never covered this quite fundamental matter, despite its overwhelming importance to public health in the UK. In the past I have suggested it to editor Griffith Edwards who accepted its importance but then completely ignored the matter for years in the journals over which he has ruled for a generation.
Drug diversion is also covered is several other recent prominent articles. Readers interested in this field will learn much by reading some of the items below while passing over the pusillanimous November Addiction editorial by Hall and Degenhardt.
Comments by Andrew Byrne .. http://www.redfernclinic.com/
Hall W, Degenhardt L. Regulating opioid prescribing to provide access to effective treatment while minimizing diversion: an overdue topic for research. Addiction 2007 (November)
Drug Misuse and Dependence – Guidelines on Clinical Management. Working Group Chair: Strang J. Department of Health, London, United Kingdom. 1999 ISBN 0113222777
Strang J, Sheridan J, Hunt C, Kerr B, Gerada C, Pringle M. The prescribing of methadone and other opioids to addicts: national survey of GPs in England and Wales. Brit J General Practice 2005 55; 515: 444-451
Robinson GM, Dukes PD, Robinson BJ, Cooke RR, Mahoney GN. The misuse of buprenorphine and a buprenorphine-naloxone combination in Wellington, New Zealand. Drug Alcohol Dependence (1993) 33;1:81-6
O'Connor JJ, Moloney E, Travers R, Campbell A. Buprenorphine Abuse Among Opiate Addicts. British Journal of Addiction 1988 83:1085-1087
Rawson RA, Maxwell J, Rutkowski B. OxyContin Abuse: Who Are the Users? American Am J Psychiatry 164:11, 1634-6
Carise D, Dugosh KL, McLellan AT, Camilleri A, Woody GE, Lynch KG. Prescription OxyContin Abuse Among Patients Entering Addiction Treatment. Am J Psychiatry 164:11:1750–1756
Smith MY, Bailey JE, Woody GE, Kleber HD. Abuse of Buprenorphine in the United States: 2003-2005. Journal of Addictive Diseases 2007 26;3:107-111
Stimmel B. Buprenorphine Misuse, Abuse, and Diversion: When Will We Ever Learn. Journal of Addictive Diseases 2007 26;3:
Frazer J, valentine k. Comparison of take-away policies in NSW and Victoria. Conference presentation(s); monograph, UNSW 2007.
Rhoades HM, Creson D, Elk R, Schmitz J, Grabowski J. Retention, HIV Risk, and Illicit Drug Use during Treatment: Methadone Dose and Visit Frequency. 1998 Am J Public Health 88:34-39
Ritter A, Di Natale R. The relationship between take-away methadone policies and methadone diversion. Drug Alcohol Rev (2005) 24;4:347-352
Yancovitz SR, Des Jarlais DC, Peyser NP, Drew E, Friedmann P, Trigg HL, Robinson JW. A randomised trial of an interim methadone maintenance clinic. (1991) American Journal of Public Health 81:1185-91
Senay EC, Barthwell AG, Marks R, Bokos P, Gillman D, White R. Medical Maintenance: A pilot Study. J Addictive Diseases; 1993: 12(4): 59-76.
Strang J, Manning V, Mayet S, Ridge G, Best D, Sheridan J. Does prescribing for opiate addiction change after national guidelines? Methadone and buprenorphine prescribing to opiate addicts by general practitioners and hospital doctors in England, 1995–2005. Addiction 2007 102:761-770
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