27 April 2016

Postcard from New York April 2016

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’). 
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. 

30 January 2016

When alcohol abstinence fails supervised serving may reduce harms. "MAP" or wet rooms.

Managed Alcohol Programs - (MAP). Slow progress of effective hostel protocol to save money, suffering and dignity of our most marginalised citizens. 
Dear Colleagues,
I have been writing these summaries for many years but there is little more dramatic I can think of than the findings of three published studies and numerous other reports of allowing alcohol to alcoholics in refuges under strict supervision with psychosocial supports.  I wrote enthusiastically about a Canadian study by Tiina Podymow in 2006 ( http://www.redfernclinic.com/c/2006/01/supplying-alcohol-to-alcoholics-may_9924.php4 ).  The other two are from 2009 and 2012, both from Seattle (see refs below). 
Essentially these interventions allow limited quantities of alcohol such as one standard drink per hour in previously ‘dry’ hostels. Thus there is a supervised supply from trained staff inside the establishments from opening at 5 or 6pm up to 10pm or later. 
The published findings of events before and after implementation of the ‘managed alcohol program’ show substantial and significant improvements.  Both medical and police interactions dropped while overall alcohol consumption also dropped.  The authors of some of the studies quantify the benefits using estimates of the costs of police and medical services, each showing very dramatic savings per individual. 
These subjects were all hostel residents who had had multiple attempts at abstinence, detoxification, meetings and medical interventions without success.  Hence for some of these high-end alcohol users “managed alcohol” may be a better goal than enforced abstinence in return for the bed for the night.  The may also be some parallels with the use of nicotine replacement therapies, opiate maintenance treatments and other harm reduction strategies.  Outright overnight bans on alcohol in these hostels may be a well meaning policy which has paradoxically increased harms to those it was intended to help. 
The very fact that the trials were able to be performed is impressive.  It is my belief that these publications are so persuasive that a randomised trial is warranted on a large scale, such are the potential benefits to the alcoholic drinkers, their families and society at large. 
The take-home message from the three reports is that when abstinence based interventions for chronic alcoholics are unsuccessful, further pursuit of abstinence, even temporarily may lead to unwanted consequences which are expensive, painful and time consuming.  And they are avoidable. 
One possibly reason for the findings might be that residents facing overnight lock-up may drink very heavily in the period immediately before entering the hostel.  Such binge drinking is known to be associated with complications from falls and injuries, chest infections, nerve/skin damage from pressure necrosis, liver disease, ulcers, etcetera. 
In 2011 Time Magazine was so impressed that they ran an enthusiastic article (The ‘Wet House’ Where Alcoholics Can Keep Drinking - link below).  This was based on an original story in the New York Times (link below). 
Next time you hear of someone’s operation being postponed due to lack of hospital bed, recovery services or operating theatre time, it is possible that the services are being used by a person in the position above suffering some urgent but preventable medical or surgical complication requiring your local hospital services.  This may also apply to casualty waiting times, blood transfusion services, ambulance, rehabilitation and more.  Likewise, when the police are tied up with local issues of this nature they could be attending to other important policing matters. 
Notes by Andrew Byrne .. http://methadone-research.blogspot.com/
Since writing this I have become aware that Prof Kate Dolan has done a lot of work in this area and has provided much needed summaries of the English and Canadian experience with detailed suggestions for Managed Alcohol Programs in Sydney (refs below). 
Podymow T, Turnbull J, Coyle D, Yetisir E, Wells G. Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol. CMAJ 2006 174;1:45-49        http://www.cmaj.ca/content/174/1/45.full
Larimer ME, Malone DK … (et al.) Marlatt GA. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009 Apr 1;301(13):1349-57      http://www.ncbi.nlm.nih.gov/pubmed/19336710
Collins SE, Malone DK, et al. WG, Marlatt GA, Larimer ME. Project-based Housing First for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories. Am J Public Health. 2012 Mar;102(3):511-9        http://www.ncbi.nlm.nih.gov/pubmed/22390516
Happy Hour? ‘Wet Houses’ Allow Alcoholics to Drink, With Surprising Results. Time Magazine            http://healthland.time.com/2011/04/27/happy-hour-wet-houses-allow-alcoholics-to-drink-with-surprising-results/
The Wet House Where Alcoholics Can Keep Drinking            http://www.nytimes.com/2011/05/01/magazine/mag-01YouAreHere-t.html?_r=1
Feasibility of a Managed Alcohol Program for Sydney.
Introduction to Professor Kate Dolan’s work in this area:
British Columbia’s North-West remote areas.
Ottawas MAP

I acknowledge the traditional owners and custodians of this land on which I walk and work, the Gadigal people of the Eora nation, and pay my respects to elders both past and present.