It was a great pleasure to be
able to travel to America again and meet up with colleagues and share
information about Covid, overdose, etc.
1.
America to catch
up with rest of world on community methadone.
2. Report on first
twelve months of New York’s first injecting centres.
3.
'Bernese’
transfer methadone/bupe being done do-it-yourself.
4.
New guidelines
for protection of children when cannabis legalised.
5.
100th
birthday of Dr Joyce Lowinson, addiction treatment pioneer.
6.
Death of Dr.
Mitchell Rosenthal, Phoenix House Founder.
1. America to catch up with
rest of world on community methadone:
NIDA (National Institute on
Drug Abuse) head Nora Volkow finally announces support for methadone in
community pharmacies and the lifting of the blanket ban on private American
doctors prescribing methadone for addiction.
While she is quoted as saying that there are (some) other countries
which do this, I don’t know any western country that has NOT implemented some
system of community methadone maintenance treatment, at least after initiation
and stabilisation.
This move was first mooted in
New South Wales in 1986 as a preventive measure for the HIV epidemic. It was implemented over several years to
widen access to opiate maintenance treatments by ‘normalising’ them to existing
community services (GPs and pharmacists mostly – but also psychiatrists,
hospitals, clinics and jails). I was involved
in the first group of primary care physicians and there have now been almost
1000 licensed doctors in my state alone.
We know that it is not simple or straight forward as the Victorian
experience showed since methadone itself when not carefully titrated and
supervised can also be lethal.
The US clinic lobby uses this
latter as an argument favouring their continued monopoly. Yet it is this very monopoly which has denied
doctors and pharmacists the experience to utilise this highly effective treatment
in a safe manner. Methadone is no more
dangerous than insulin, cortisone, warfarin, morphine and many other strong
drugs. Each requires comprehensive but
straightforward guidelines for safe and effective clinical use.
“The U.S.
government’s top addiction researcher is calling for broad deregulation of
methadone, a key drug used to treat opioid use disorder.”
American doctors should “absolutely” be allowed to
prescribe methadone directly to patients, Nora Volkow, the director of the
National Institute on Drug Abuse, said Wednesday.
“There’s absolutely no reason why not,” Volkow said.
“There are countries where physicians are providing methadone, and the outcomes
are actually as good as those they get [at] methadone clinics.” [snip: see link below]
Top U.S. addiction scientist calls for broad methadone
deregulation (statnews.com)
2. Report on first twelve
months of New York’s first injecting centres.
The one year anniversary of
the New York injecting rooms (Overdose Prevention Centres or OPC’s). A Zoom meeting was co-hosted by Drug Policy
Alliance, NY Health Department and others with a huge participation judging
from the dozens of health workers and advocates logging in from all over the
world (including Sydney and Melbourne).
Entitled “Reflections from
OnPoint NYC: Lessons Learned from the U.S.’s First Sanctioned Overdose
Prevention Centers”. The main speaker was Sam Rivera aided by toxicology
consultant Yarelix Estrada with moderator Dr Danielle Ompad who even became
slightly emotional over the unprecedented activities described. Dr Ompad has
been involved in harm reduction research at NDRI and now NYU. Let me know if you wish to see the session on
YouTube or try at this link .
Sam Rivera gave an excellent
overview with moderator Dr Ompad asking numerous questions about the
practicalities, facilities, catchment populations, etc. We were told about drug purity and
contaminants, most fentanyl being about 10% pure and very little in the way of
benzodiazepines. Most drugs were what
the client had thought they were with some notable exceptions. The most dangerous was cocaine which was
heavily contaminated with fentanyl which could easily be fatal.
We learned of many of the
same issues as in Sydney but some unique to local area. One of the centres had mainly smokers while
the other a majority were injectors, all done under supervision of trained
health workers. We were told about the
concept of ‘bathroom’ or unsanctioned injecting centres but they had been doing
this informally for 5 years before open officially. Sam Rivera told us that a bathroom is
considered private and injecting may be done with staff nearby in case of
emergency. They even described timed movement
detectors inside the otherwise private bathrooms. Telephone supervision also available from
numerous providers (this started in Canada apparently some years ago).
The centres had from 200 to
300 drug use episodes daily with no deaths reported. One was open Mon to Fri 8am to 8pm where the
other was open daily but shorter hours.
‘The saddest time is when we have to close the gates’. We were told it was a matter of finance.
To celebrate its 21st
anniversary the Unitingcare team who run Sydney’s facility have instigated an
annual oration in Macquarie Street which began last month with a talk by
Michael Kirby. Reverend Harry Herbert
Oration Full Event - YouTube
3. ‘Bernese’ methadone of
transfer from high dose methadone to buprenorphine. The same process in principle can be used as
induction from heroin, fentanyl, oxycodone or other strong opiate agonists and yet
avoid the very unpleasant and much feared ‘precipitated withdrawal syndrome’.
In America the smallest
buprenorphine product is 2mg so microdosing is no simple matter. Hence some doctors have been advising
patients to cut 2mg strips into four equal lengths to take 0.5mg sublingually
each day for a few days to start the process of achieving adequate doses to
prevent withdrawal and attain stability, remove cravings and allow once daily
dosing. This is not recommended by the
manufacturer, however, nor is it ‘standard practice’. There are groups in Vancouver, London
(Ontario), Sydney and elsewhere who are instituting this graduated transfer
process both in hospital and in the community.
In Australia there are smaller strengths available such as
0.2mg, 0.4mg sublingual tablets used as a strong analgesic. Research protocols have been approved and
more results should be published in due course after Dr Nolan’s first 7 cases
in D&A Review (with Brar Use of a novel prescribing
approach for the treatment of opioid use disorder: Buprenorphine/naloxone
micro-dosing - a case series - PubMed (nih.gov). There are numerous transition guidelines for 5-14
day transfers but all start with 0.2-0.5mg once or twice daily and end with
16-24mg buprenorphine while methadone is either continued as normal or reduced
to half then quarter doses on days 4 to 7 depending on the patient’s
response.
Patient responses have been
largely very positive. Some have needed night
sedation (eg with diazepam), others anti-emetics (eg ondansetron) for a couple
of days but most have tolerated some slight discomfort knowing the benefits
which have described by some in glowing terms.
“I thought I was going to be an old lady on daily methadone but now I go
to the hospital once a month for my injection and all my old side effects have gone”. Patients on buprenorphine are less likely to
report constipation, excess sweating and sexual disturbance when compared with
those taking methadone. It is hoped that
calcium metabolism will be improved and less premature osteoporosis might be
seen. Methadone depresses testosterone
levels in some men who may then need hormone replacement. Hence the commonly held view that high dose
methadone patients need to cut to 30mg to transfer to buprenorphine is now no
longer the case thanks to this intervention which was devised originally in
Bern, Switzerland by Dr Robert Haemigg (he also ran the first heroin
prescription programs almost 30 years ago).
4. Ensuring the Protection of
Youth in State Marijuana Legalization Efforts
Columbia University Drugs and
Society forum 7.30pm Tues 15/11/22
Dr Linda Richter, PhD; Robyn
Oster, BA
Recommended Youth Protection
Provisions in State Adult Use Marijuana Laws.
An excellent talk looking at results for the following issues:
1. Product
composition
2.
Packaging and
labeling
3.
Advertising and
marketing
4.
Manufacture and
sale
5.
Marijuana use
6.
Sale and
distribution to youth
7.
Use of tax and
penalty revenue for public education, prevention, treatment, monitoring, and
provision enforcement
The speakers detailed the available
data from various states which legalised cannabis first and detailed
recommendations for each of the above issues.
[from CNN on related matter:]
Just this month the NY State legislature is considering applications for
cannabis licences which fall into numerous categories for growing, wholesale,
retail, etc with rules about labelling, sites being away from schools,
etc. One weird provision which seems to
be non-controversial is that generally, licence holders must have had at least
one previous cannabis conviction. Go figure!? This is a country of contrasts to be
sure! The pp slides are available on
request as the speakers had detailed data from interviews with hundreds of
citizens in numerous states in the process of legalising cannabis for
recreational use.
It surprised me that despite
no licences being issued as yet there are already cannabis dispensaries all
over New York City. Again, a country of contrasts.
5. 100th birthday
of Dr Joyce Lowinson, addiction treatment pioneer.
Psychiatrist Dr Joyce Lowinson,
long time editor-in-chief of Substance Abuse, a Comprehensive Textbook, had her
100th birthday in New York City.
I have known this pioneer colleague for over 20 years. She was involved in the very first methadone
research paper (JAMA, Dole and Nyswander 1965).
Dr Lowinson was also instrumental in opening up large methadone clinics
in the Bronx at a time when there was enormous need.
6. Death of Dr. Mitchell
Rosenthal, Phoenix House Founder.
19th Nov, New York
Times: Dr. Mitchell Rosenthal, Phoenix House Founder, Dies at 87
A psychiatrist, he was an
early apostle for treating drug and alcohol addiction with group therapy in a
residential setting. [click below for link]
Dr. Mitchell Rosenthal, Phoenix House Founder, Dies at
87 - The New York Times (nytimes.com)
I believe that Phoenix House
has parallels or models for Sydney’s Odyssey House which has been providing
detox and rehab in a therapeutic community setting for many years. At one time there was some animosity between
drug-free ‘treatments’ and opiate maintenance advocates. Now most agree that there is enormous demand
for both detoxification services as well as maintenance programs. Many of our patients have benefitted from
each at different times so antagonism is pointless and understanding and
cooperation the way to go. I have always
had a congenial relation with James Pitts and his colleagues in Sydney, Australia.
Written by Andrew Byrne,
retired addictions physician, Sydney, Australia.
