Medical postcard
from New York, April 2016
Dear Colleagues,
I can report that
spring has sprung in New York. After a
cold start, April has seen a wonderful transition from winter bareness to a
colour-wheel of splendid blossoms, bulbs and canopy greenery. Easter was early this year and so were the
cherry blossoms which are at their peak over a week before the advertised dates
of the Brooklyn festival (‘Sakura Matsuri’桜祭).
I have been afforded
the usual generous welcome for Australians by numerous New York institutions
where, by contrast with the general public in America, I am usually speaking to
“the converted”. Public health experts,
criminologists and addiction medicine workers now mostly know the facts. Most are also aware of the 15-year-long
highly successful Portuguese experiment in decriminalisation. Likewise the failure of the ‘Rockefeller’
drug laws where severe penalties had no impact on drug usage, but caused vast
disruption to the lives of a generation of non-violent ‘criminals’ (and fuelled
a profitable gaol-building industry).
At my talk at
Columbia University I was pleased to note that most were already aware of the
interesting finding that allowing alcohol in homeless refuges appears to decrease the overall average amount of
alcohol consumed. The first work on this
dates from the 1990s. Marlatt in Seattle
also found that this was time-related and that after a year in such lodgings
the average amount consumed decreased by around 50%, not to mention reduced use
of medical and legal services (references on request). The findings have been replicated in Canada
and Holland where alcohol in limited quantities was actually provided by staff
in several hostels with ‘managed alcohol programs’ in place and with similar
positive findings and few problems. We
were also told that New York City also has a ‘Housing First’ initiative,
whereby residents may bring alcohol into their lodgings. It is a mystery to me why Australia has not yet
trialled this logical and humanitarian measure for severe alcoholics who are
homeless.
Constant coverage
this month of the Presidential election has presently pushed the alarming rates
of opioid overdose deaths off the front pages.
Despite this crisis affecting a broad spectrum of American society,
little sensible appears in the media or from politicians about this well-researched
area. Any student of public health could
describe the measures needed to prevent most of these deaths yet nothing seems
to happen. Even the death of
high-profile personalities brings only sympathy, even from the President, but
no moves to address the crisis logically.
The death of Prince might also have some association with opioid
use.
I learned that over
30 million Americans live in southern states centred on Mississippi where there
is a worsening crisis of opiate use and HIV with a lack of access to opiate
maintenance treatments. Most of the
predicted HIV cases are from lower socio-economic groups and many have not even
been tested as yet. Needle services are
rare or absent. The few methadone
clinics in the affected areas are mostly at or near capacity. Buprenorphine is only available at
substantial expense from a small number of licensed physicians. There is a recurring theme in America (and to
some extent in Australia) that many people with dependency and mental health
issues are missing out on treatment.
Naloxone has been
touted as an answer yet it can only help when there is a second party present at
the overdose scene - lone users, without other measures, will always be at risk
of death without other measures. At a
Columbia University meeting I was shown a nasal insufflation product which can
now be purchased in some states without prescription for around $40. It would be instructive to know the effect of
just spraying pure water up the nose of an overdose victim, quite apart from the
reversal effect from naloxone. This has
not been systematically tested; and since there is no injecting centre in
America it would be difficult to do so. Many
public health experts believe, however, that sufficient evidence is available
in the present urgent circumstances for widespread naloxone availability to be
implemented. My information is that
injecting centres only rarely use naloxone in the great majority of overdose
cases (which are all ‘early’ overdoses and quite unlike most which are treated
by paramedics or hospitals).
One might think that
after 50 years of opiate research in America that there would be some voice
calling for normalization of opiate maintenance into medical and pharmacy
practice, as happens in most other western countries. Yet I have not read one letter to the editor,
one op-ed opinion piece, one quoted lawmaker or journalist calling for expansion
of opiate maintenance treatment in America.
I asked a professor of addiction medicine in a faculty meeting why she
does not write such a piece. She said
that as the ‘mother of methadone that is the one thing I cannot do’. I just do not follow this logic. Equally, despite frequent stories in the
media about the epidemic of drug use, there is little discussion of injecting
centres or other harm-reduction measures.
Apologies if this reads
like a stuck record … yet the wealth and knowledge in America which put a human
on the moon could surely see the less fortunate looked after in a more humane
manner. There are many in America doing
good works. President Obama has extended
health care enormously. Let’s hope that
the next President can better that.
Best wishes from the
Big Apple.
