Accreditation albatross;
Honour role; ‘Ice’ age; Successful OTP patients; Hep C; rat research using
cannabinoids and amphetamine.
Dear friends, neighbours and
colleagues,
It has been a mixed year, but
we seem to have survived more-or-less intact at the surgery in Redfern. Accreditation has been the great bug-bear and
I believe it is high time for health professions to reject what masquerades as
a motherhood safety net but which I firmly believe is strangling health care in
Australia. More of that later.
It has been my privilege on
annual trips to New York City to meet top people in our field, some of whom
have become close friends. These
soldiers, saints and scholars include Vincent P. Dole (RIP), Don Des Jarlais,
Charles O’Brien, Joyce Lowinson, Ethan Nadelmann, Herman Joseph, Ernie Drucker,
Mary-Jeanne Kreek, Jerome Jaffe and Herb Kleber (RIP). But none was as close to sainthood as Dr
Robert G. Newman who died this year after a car accident in The Bronx. His loss will be felt in many countries where
he advocated for opiate maintenance treatment, harm reduction and ethical
medical treatment for drug addiction in parallel with other medical
conditions. Sympathies to his wife Seiko
and their children on their huge loss.
And ours.
It has been a challenging
year but with many rewards as we watch our patients achieve their goals, major
and minor. As I approach retiring age I
can provide more customised treatment for those with opiate, benzodiazepine and
alcohol problems. Specifically we use
split doses, high doses, low doses, frequent swaps between methadone and
buprenorphine along with adjuvant therapy using anti-depressants, mood
stabilisers, disulfiram, fluvoxamine, propranalol and propantheline. Yet we are frustrated on a daily basis by the
use of ‘crystal’ methamphetamine ('ice').
Previously stable, pleasant methadone maintenance patients have become
unpredictable and unreasonable. There
have been frequent admissions to psychiatric wards where nothing much can be
done after assessment and possibly antipsychotic medication. We have tried prescribing dexamphetamine for
some consenting trial cases but without success at eliminating the use of ‘ice’
(methamphetamine), even for short periods.
We await a positive strategy, perhaps from one of the younger members of
the addiction Chapter (RACP).
We continue to address the
widespread use of benzodiazepine tranquillizers in our patient population
(18-50% dependency among OTP patients according to AATOD). We have started performing differential urine
toxicology which can determine the diazepam-temazepam-oxazepam group from the
more potent and dangerous alprazolam, clonazepam and flunitrazepam
preparations. We supervise detoxifying
doses in new or unstable patients with some receiving ‘staged supply’
dispensing of diazepam for limited periods for anxiety and/or dependency using
either 2mg or 5mg tablets. The supply of
diazepam is contingent on the usual stability criteria for take-home doses of
methadone or buprenorphine (sober presentation, housing, vocation, family,
finances, attendance, psychiatric, toxicology, etc). ‘Doctor shopper’ information is now available
on line. More will be said on these
matters following a seminar at Sydney University (RPAH) in November by Prof
Starcevic, Prof Haber and a brief appearance by myself, chaired by Dr Richard
Hallinan of our practice.
We have also had numerous
patients leave opiate maintenance successfully in the past 12 months with many
others achieving vocational, family and other goals, far from uncontrolled
illicit drug or alcohol use. A fork-lift
licence, university degree, new baby, paid off debts, smoking cessation and new
housing can all be life changing benefits for those involved. For others such goals are still at some
distance.
The new oral treatments for
hepatitis C have allowed us to almost eradicate the disease from our patient
group after sometimes frustrating times with interferon-based treatments in the
past. This has been enormously
gratifying for patients, their families and our staff as a very positive
outcome. Congratulations are due to Dr
Hallinan for most of this important public health work which is subject of
continuing publications.
My niece Gracie Hay has spent
a couple of sessions in the practice after completing her psychology honours
year at Macquarie University. She has
published a fascinating paper on her work with Professor Cornish using
cannabinoids to diminish behavioural symptoms of withdrawal and relapse in
amphetamine-primed rats (see citation below).
Gracie is now a medical student at Notre Dame University and has some
busy years ahead of her. [Hay GL, Baracz
SJ, Everett NA, Roberts J, Costa PA, Arnold JC, McGregor IS, Cornish JL. Cannabidiol
treatment reduces the motivation to self-administer methamphetamine and
methamphetamine-primed relapse in rats. Journal of Psychopharmacology 2018 1
–10. Link below to free publication on-line]
Merry Christmas and Happy New
Year to all from the Byrne Surgery staff, hoping 2019 is a good one for all.
Andrew Byrne ..
