13 June 2018

Portuguese drug policy changes save lives wholesale. Sydney meeting.

Big turn-out on rainy Sydney evening for drug law reform meeting.  Tuesday 5th June 2018. St Stephen’s Church, Macquarie Street, Sydney.
 
“An evening with Manuel Cardoso the man who helped reform Portugal’s drug policy”. 
 
Take-home message to get through to our politicians: decriminalisation is now proven to save lives, money and much more. 
 
The most impressive part of this evening was actually the audience, all like me, frustrated supporters of drug law reform, some for up to 40 years.  And I estimate that there were over 1000 in attendance on a cold wet winter evening.  An email blitz had offered a free umbrella for the first 250 to attend. 
 
The evening consisted of a fireside chat type presentation – no power-point slides, etc.  Will Tregoning PhD was a whippy and knowledgeable compere with his three guests on a couch up front with microphones and cameras for live-stream on FaceBook.  
 
Dr Manuel Cardoso said that he was an optimist and did not recall anything bad, just the good.  So when people asked what were the triggers for the move to decriminalization in 2001 in his country he said he could not recall that far back.  His CV seems to indicate that he was not involved in the drug field in 2001 so the title of the evening’s talk seems a little odd.  He explained that he was the deputy and was modest about the dramatic changes in his country following decriminalisation. 
 
Other information indicates very serious drug-related events in his country with some of the worst stats in Europe for a number of major outcomes such as overdose deaths, HIV transmission, incarceration, etc.  Also the economy was in the doldrums.  I understand that there was a coming together of three great minds being a politician, a radio host and a law professor.  And an opposition in parliament which was also on-side or at least on the same page, partly due to so many overdose deaths, some children of prominent citizens.  The entire story is carefully described in an excellent report by the CATO Institute (G. Greenwald, 2009) as quoted by one speaker (see links below). 
 
Dr Cardoso was also giving talks in Hong Kong, Argentina, Luxembourg, Norway and elsewhere on this trip, seemingly in great demand.  We were told that only Norway is in any political place to introduce decriminalisation, in great distinction from Sweden which has long had a zero tolerance approach despite their poor outcomes of drug related morbidities in such an environment.  Only America has a worse system and even the current unprecedented overdose crisis seems unable to move the prohibition monster. 
 
During the talk I realised that decriminalization brings out those who really DO have problems with drugs as distinct from those who like using their drugs, finding they can get on with their lives, work, raise families, pay tax, etc without problems.  This became clear as Dr Cardoso was talking about alcohol which some people use quite seriously but without apparent harm while others get into trouble with excess use and serious social/medical consequences.  This latter group needs help in numerous ways, just like others with disabilities or illness.  Indeed, the evening has taught me to be more tolerant of illicit drug use in my methadone patients when it is clearly low-risk and in some cases may even be quasi-therapeutic. 
 
Three of the best comments of the night came from the floor after the main interviews were over.  Marion Mc’Connell who co-founded Family and Friends for Drug Law Reform spoke about her frustration at seeing so little progress since the death of her son over 20 years ago.  This was then reflected by Rev Bill Crewes who dated his first meeting on the subject to the 1970s.  He also mourned the lack of serious moves away from the failed policies of prohibition and harm maximization.  Then an articulate young lady introduced herself as the new Labor candidate for Balmain in State Parliament, saying much work needed to be done by and within political parties.  She promised to push the issue as best she could but added that politicians can only act when they know what their constituents want and/or what expert opinion is suggesting.  Why are we still locking up drug users? 
 
This latter was taken up by ex-Premier Geoff Gallop whose government in WA virtually decriminalised cannabis.  He pointed out that two factors were crucial to successful change: bipartisan support as well as public forums with expert evidence pointing to a need for change.  Even some of his own (Labor) government’s easing of cannabis restrictions in WA were rolled back by a subsequent (Liberal coalition) government. 
 
Dr Marianne Jauncey spoke briefly about her experience as director of the Medically Supervised Injecting Centre in Kings Cross.  This is the only place in Australia where it is legal to possess illicit drugs.  Despite its success clinically over 17 years (no deaths after up to a million injecting episodes) and public acceptance, it has not been duplicated by the NSW Health Department, which is regrettable.  After numerous false starts it appears that Melbourne may soon have an injecting centre. 
 
Others had particular questions for Dr Cardoso about the situation in Portugal and how that might be relevant to other jurisdictions.  His answers while direct were generic.  I asked him if there were any moves in Portugal to return to old policies such as from the Catholic Church, older citizens or conservative forces.  He replied that he knew of no such moves and would be surprised if there were any.  The Church, he said, was wholly supportive.  It seems that the benefits have been so widespread and so obvious that the entire population, not just drug users, can see the benefits.  There may be similarities to the lifting of alcohol prohibitions in America 90 years ago. 
 
There was a great deal of camaraderie in the foyers afterward with nice mingling over savouries and drinks with many old colleagues, some I had not seen for ages.  It was also nice to see a younger generation of health professionals, advocates, researchers, etc in attendance at such a gathering. 
 
My summation of the event was that there is a groundswell of keen support for total decriminalisation of personal drug use and that the Portuguese experience was one of the largest social experiments of our time … and every indication is that it has proven beyond any doubt that prohibition has failed and removing it along with increasing access to treatment and harm reduction is successful.  This ‘experiment’ (my colleagues say I should not call it an experiment) was so large and so successful in a country with many similarities to our own that it places our system of prohibitions of drugs as being out-dated, counter-productive, wasteful and inhumane. 
 
If everyone at this meeting made an appointment to see their local member of parliament with their views we may see the start of something big.  It took the ‘Mothers of America’ to start the moves against prohibition in that country … maybe we need a similar movement here.  The rationale is compelling … and in America with the overdose crisis the case is overwhelming. 
 
Written by Andrew Byrne, Redfern Addiction Physician. 
 
 
References: Greenwald G. Drug Decriminalization in Portugal: Lessons for Creating Fair and Successful Drug Policies. Cato Institute. 2009  https://www.cato.org/publications/white-paper/drug-decriminalization-portugal-lessons-creating-fair-successful-drug-policies
 
 
 
 
 

8 May 2018

Medical Postcard from New York: overdose crisis summary from NYU.

Dear Colleagues,
 
During a recent New York visit I had numerous encounters in the medical, public health and dependency fields.  The opioid overdose crisis dominates conversation, media and even the White House has been involved.  Below is a summary of one key lecture I attended followed by some other events which may be of interest. 
 
Regards from Andrew Byrne .. now back in Sydney, Australia. 
 
April 19 2018         Stephen Ross, MD
The Opioid Epidemic: How We Got Here and How Do We Fix the Problem?” Associate Professor, Departments of Psychiatry and Child and Adolescent Psychiatry Senior Director, Division of Substance Abuse, Bellevue Hospital. Director, Addiction Psychiatry, Tisch Hospital, NYU.
 
This was an action-packed talk filled with a vast quantity of detail but with the overall ‘messages’ carefully enunciated by Dr Ross who was introduced by department Chair with a string of accolades from early life in Johannesburg, South Africa to medical school in the US, psychiatry training, teaching awards, research publications and more.  Dr Ross has also authored some interested papers on the therapeutic possibilities of hallucinogens in patients with serious medical disease. 
 
We were told about the epidemics of opioid use starting early in the 19th century when opium, laudanum and paragoric became very popular.  A series of advertisements for these products while cute and dated also had their same ring of snake oil tactics still used by today’s drug companies who he repeatedly blamed, at least in part, for much of the current problems in America.  Dr Ross reminded us that the lessons of history should be heeded right now since overdose problems have happened in several surges of opiate popularity over the 20th century and the circumstances can almost be predicted, or should have been. 
 
The present epidemic seems to have started after an air of confidence in medically prescribed opioids with a low risk of addiction.  These were started by two brief communications published as letter to the editor, one from Russell Portenoy and colleagues in NYC Sloane Kettering.  Both brief letters which Dr Ross showed on the screen pointed out the low rate of dependency they found following medical prescription of opioids for pain.  Neither was a RCT nor even a prospective study and yet they were given a significance well beyond their actual scientific value by some well meaning doctors and avaricious drug companies.  Dr Ross also pointed out that prescribing by experienced pain management teams with multi-disciplinary measures is very different from a dentist or ‘orthopedist’ writing up a month of opioid pain killers for post operative cases as some do routinely to this day (we were given examples). 
 
I read elsewhere that about 15 years ago the Joint Commission for Medicare and Medicaid Services (CMS) had required reporting of pain in therapeutic outcomes after numerous parties had pushed a well meaning but fundamentally flawed and dishonest campaign of : “Pain as the Fifth Vital Sign” (after pulse, temp, BP and respirations).  Of course pain is a symptom and not a sign at all yet for marketing purposes this was highly effective.  And furthermore there was very limited evidence that opioids were effective for chronic non-cancer pain. 
 
Dr Ross divided the recent overdose epidemic into three parts starting in about 2001: (1) prescribed opioids, (2) heroin then (3) fentanyl additives.  The last has been the most deadly as his graph showing yearly deaths had three lines of increasing slope, ending at the terrible annual toll of 60,000 for ~2016/7.  It seems that there is general agreement that aggressive marketing and lax regulations from 2002 to about 2009 led to the initial dramatic increase in opiate problems in America based on the assertions (1) that addiction rarely follows medical prescription and (2) the claim that chronic pain was widely undertreated.  Opponents at the time were accused of ‘opiophobia’ (Dr Ross quipped that this would become a new DSM diagnostic category!). 
 
The predictable and protracted reaction against this over-prescribing by the states was to restrict opiate prescription in numerous ways: triplicate prescription requirements, limited quantities, and refills, reduced insurance rebates, and (supposedly) less abusable formulations.  These knee-jerk restrictions caused many who were unwittingly addicted to move to illicit heroin which flooded the market from Mexico.  Only a very small proportion could take advantage of addiction treatments due to high cost as well as limited availability in many areas, thus there was a second wave of drug use and consequent deaths. 
 
Then we were told about a third and most worrying phase of the overdose crisis being the unprecedented increase in deaths in the past 3 years which has been associated with replacement with and contamination by some of the opiates using fentanyl and carfentanil, mostly manufactured in China.  Because these drugs are hundreds to thousands of times more potent than heroin they can be imported in small packets undetected.  Also we were told that innovations of the dark web, bitcoin and ‘pill presses’ have added further to the difficulties.  Two pills which look identical may have vastly different potencies. 
 
Dr Ross was extremely critical of drug regulation authorities, criminal justice, customs, drug companies, medical insurers, medical schools and health practitioners all of whom he said had played a role in the current disaster which leads to an overdose death every 12 minutes in America.  The number of deaths has now exceeded all casualties of war including both world wars for the US.  The annual death rate has topped cancer, suicide, road deaths and is now the leading cause of death in 20-50 year age group (I think I got that right).  We were shown age at death tables to show that this is affecting all age groups but that younger people are now involved.  The number of drug overdose deaths in the USA was estimated to have been over 60,000 per year by 2017.
 
Dr Ross put up a table of the types of practitioners most involved in the current prescribing and I was surprised to see the orthopaedic surgeons and dentists were high on the list along with family physicians, psychiatrists, gastroenterologists, etc. 
 
It appears that many minor procedures such as arthroscopy are routinely prescriber 30 or even 90 days of opiate pain killers and that there is a significant financial incentive to do so under some payment ‘plans’.  In my discussions during my time in New York I heard of a 15 year old boy who returned to school after a knee arthroscopy as a day procedure with a bottle of 90 Vicodin tablets (containing paracetamol plus hydrocodone).  I saw a TV interview with a mother who had found both of her late-teenage sons dead after a family celebration.  It was chokingly tragic but is being repeated all over the country every single day. 
 
Naloxone programs were mentioned and commended briefly but the obvious fact that they are of no assistance when the overdose victim is alone. 


Dr Ross alluded briefly to the Portuguese drug law reform implemented in 2001 which involved removal of all sanctions for persons found in possession of quantities of drugs (defined) consistent with only personal use.  He emphasised that drug dealers were still arrested but that there were no legal sanctions against drug users apart from being introduced to treatment services (de-addiction committees … which the subject could take-or-leave referrals to treatment services).  Funds saved in the criminal justice sector were put into treatment which had been substantially expanded and improved.  From having the worst statistics in Europe for consequences of drug use most improved year by year to be some of the most envious.  These included reduced overdose rates, HIV and Hep C transmission, crime, etc. 
 
Dr Ross pointed out that the most effective form of treatment for opiate dependence included Medication Assisted Treatment (MAT) with buprenorphine and methadone. In the USA extended release injectable naltrexone is also included in MAT despite the small and largely unimpressive evidence for effectiveness, safety and cost effectiveness compared to methadone and buprenorphine.   While treatment availability in American cities is quite limited, in rural areas such services were often completely absent.  We were shown various colour-coded maps of the country showing the paucity of approved physicians for buprenorphine and even worse availability of methadone clinics (methadone is not available in American pharmacies unlike other western countries).  The ratios of drug users to treatment facilities were as unfortunate as they could be.  [see NY Times interactive map with opioid overdose rates for every county: https://www.nytimes.com/interactive/2017/12/22/upshot/opioid-deaths-are-spreading-rapidly-into-black-america.html ] The expansion and improvement of maintenance treatments is the most important part of the package of measures needed in the USA to reduce the number of opioid overdose deaths.
 
Unlike many Americans, our speaker was happy to mention prevention, treatment and harm reduction in the one breath.  The common reticence was partly due to a White House edict some years ago that any grant application which mentioned ‘harm reduction’ was to be refused.  This is despite its complete compatibility with good public health polices as first exemplified in the Broad Street Pump reports of cholera in London in the 19th century.  Some facetious comments even refer to inappropriate interventions such a blanket prohibition as being ‘harm maximization’.  
 
There were a few Q&A’s at the end after a major applause showing the audience appreciation.  Prof Ernie Drucker brought up the issue of cannabis and mentioned that he had discussed with Lester Grinspoon about heroin users modulating their opioid use with cannabis products which may explain the lower overdose rates being reported in states which have legalised cannabis. 
 
Notes by Andrew Byrne .. visiting addictions physician from Sydney, Australia.  http://methadone-research.blogspot.com/
 
 
IN BRIEF:
** Lecture by Dr Steve Ross on the opioid crisis and what to do about it (summary/link above). 
** Lecture by Nobel Laureate Dr Eric Kandel on memory loss in the elderly (exercise more!)
** Opening address at ASAM meeting at San Diego (seen on web-stream) by Dr Ellinore McCance-Katz, after a statistical run-down and promise of research funding, then started to sound more political than like the caring physician I know her to be.  Second speaker was Michael Charness, Boston VA, on alcohol interventions in 50 years time.  Surprisingly, popular singer Judy Collins had equal time in the third plenary (and sang her songs rather too often), giving her profound story of long-term sobriety and lessons for others. It was also in honour of Dr Stuart Gitlow who had been instrumental in Ms Collins' success.   
** Subsequent web-stream ASAM talks of interest: https://www.youtube.com/watch?v=a8IcJXdwKbE&feature=youtu.be
** Harm reduction still a long way to go in America.  American Society of Addiction Medicine (ASAM). 

** New guidelines in US on prescribing for opiate maintenance TIP63 but there is still no “connect” between buprenorphine and methadone even though they should obviously be complimentary, both being licensed for opiate dependence.  Yet they are rarely if ever given in the same institution by the same staff thus transfers are complex and sometimes impossible.
https://store.samhsa.gov/shin/content//SMA18-5063PT3/SMA18-5063PT3.pdf
** Meeting with Dr Mary Jeanne Kreek at Rockefeller University wide ranging discussions including high dose methadone and methadone for pain. 
** I gave a talk on optimising outcomes in opiate maintenance treatment at Columbia University (more info on request). 
** Meetings also with Dr Joyce Lowinson, Dr Robert G. Newman, Prof Ernie Drucker, Dr Herman Joseph, Dr Doug Kramer, Ethan Nadelmann and many others. 
** Recommended TED talk J. Hari: https://www.youtube.com/watch?v=PY9DcIMGxMs “Everything you think you know about addiction is wrong”. 
 
 
 

25 March 2018

Buprenorphine alone or with naloxone: Which is safer? Subutex versus Suboxone

Buprenorphine alone or with naloxone:  Which is safer?  Kelty E, Cumming C, Troeung L, Hulse G. Journal of Psychopharmacology (2018) in press. 1-9
 
Dear Colleagues,
 
After a ten year chronological comparison of 3500 patients prescribed either pure buprenorphine or the combination product with naloxone these authors found few differences in hospital admissions or death rates while in treatment.  However there was a significant increase in mortality post-treatment in those who were prescribed the combination product (odds ratio 1.59).  There were also higher all-cause hospital admission rates in those prescribed the combination product but slightly lower rates for those with skin infection diagnosis.  These extended to the post treatment period and the authors conclude that: “The addition of naloxone does not appear to improve the safety profile of buprenorphine”. 
 
These Western Australian researchers had access to Health Department prescribing records which were then compared with hospital admission rates and mortality over a ten year period, month by month, in 3500 patients starting in 2001.  The combination product was introduced in the middle of the study period and it quickly became about 90% of the market, allowing a useful comparison.  The 90% transition rate was partly because in WA take-away doses of the pure drug were banned coercively.  There may have been an exemption for pregnant women for whom the pure drug remains the recommended product. 
 
So here finally we have a study comparing pure buprenorphine with the combination product, although not a randomised controlled trial.  To my knowledge, despite the claims for benefit, there has been little rigorous comparative research before widespread replacement of the pure product with the combination.  The opioid antagonist naloxone was added to an existing sub-lingual product with the intention that it would be safer by being less attractive to inject.  As with other approved medicines, there is no obligation to do comparative research before TGA/FDA approval.  Indeed, all of the early research was on the pure product including the MOTHER study in 2009.  The only real support for the combination product meantime has been some indication that it was marginally less desirable on the black market, attracting a slightly lower reported price.  Yet it would seem self evident that a pure drug would be more desirable to drug seekers than a combination, regardless of the constituents.  Two studies indicated the need for higher doses when the combination drug was used (Fudala and Bell). 
 
In a small pilot study Bell and colleagues found that after transitioning to the combination product most seemed to do quite well on a number of indices.  However, they also found that subjects appeared to require substantially higher doses (>50% on average) when naloxone was added.  Fudala et al. found substantially more cravings in a large multi-centre RCT in the combination group using fixed doses.  There have been no confirmatory studies to my best knowledge. 
 
Western Australia has always been a good location for serious D&A research, Perth being a wealthy metropolis with good public health facilities in a relatively isolated position.  And with earnest, experienced and one-time well funded researchers. 
 
Kelty et al. point out that significant amounts of naloxone are in fact absorbed and that this is known to up-regulate the opioid receptors, possibly making some patients more vulnerable to overdose even after ceasing treatment.  It is also possible that this was the cause of the Sydney patients seemingly requiring higher doses in Bell’s old study. 
 
A good investigative journalist might make a good story over the profit motive, drug ‘evergreening’ and such, but I leave all this to others.  Suffice it to say that currently our government through the PBS is paying high prices whereas in France the pure product has been used since 1994 and is sold to the government suppliers as a cheap generic (and by an Australian company I believe!). 
 
Notes by Andrew Byrne ..
 
References:
 
Bell J, Byron G, Gibson A, Morris A. A pilot study of buprenorphine-naloxone combination tablet (Suboxone®) in treatment of opioid dependence. Drug Alcohol Rev 2004 23;3:311-318
 
Fudala PJ, Bridge TP, Herbert S, Williford WO, Chiang CN, Jones K, Collins J, Raisch D, Casadonte P, Goldsmith RJ, Ling W, Malkerneker U, McNicholas L, Renner J, Stine S, Tusel D. Office-Based Treatment of Opiate Addiction with a Sublingual-Tablet Formulation of Buprenorphine and Naloxone. NEJM (2003) 349:949-958