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