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.