tag:blogger.com,1999:blog-296818642024-02-19T17:29:08.471+11:00Dr. Andrew's OpinionsWelcome to our web site which is dedicated to dependency treatments, research and education. On this site you will find summaries of research articles, lectures and conferences from Dr Andrew Byrne and his colleagues. 75 Redfern St, Redfern, Australia. Phone 9319 5524Unknownnoreply@blogger.comBlogger335125tag:blogger.com,1999:blog-29681864.post-51769908690882508202022-12-03T21:23:00.008+11:002022-12-04T08:14:53.490+11:00Medical Postcard from New York City, November 2022. <h2><span style="font-size: 14pt;">Medical Postcard from New
York City, November 2022.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></h2><div>
<p class="MsoNormal"><span style="font-size: 14pt;">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.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt; mso-fareast-font-family: "Times New Roman"; text-indent: -18pt;"><span style="mso-list: Ignore;">1.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;">
</span></span></span><!--[endif]--><span style="font-size: 14pt; text-indent: -18pt;">America to catch
up with rest of world on community methadone.<span style="mso-spacerun: yes;"> </span></span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -18pt;"><!--[if !supportLists]--><span style="font-size: 14pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7pt "Times New Roman";"> </span></span></span><span style="font-size: 14pt;">Report on first
twelve months of New York’s first injecting centres. <o:p></o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -18pt;"><!--[if !supportLists]--><span style="font-size: 14pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7pt "Times New Roman";">
</span></span></span><span style="font-size: 14pt;">'Bernese’
transfer methadone/bupe being done do-it-yourself. <o:p></o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -18pt;"><!--[if !supportLists]--><span style="font-size: 14pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7pt "Times New Roman";">
</span></span></span><span style="font-size: 14pt;">New guidelines
for protection of children when cannabis legalised.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -18pt;"><!--[if !supportLists]--><span style="font-size: 14pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7pt "Times New Roman";">
</span></span></span><span style="font-size: 14pt;">100<sup>th</sup>
birthday of Dr Joyce Lowinson, addiction treatment pioneer.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoListParagraphCxSpLast" style="mso-list: l0 level1 lfo1; text-indent: -18pt;"><!--[if !supportLists]--><span style="font-size: 14pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7pt "Times New Roman";">
</span></span></span><span style="font-size: 14pt;">Death of Dr.
Mitchell Rosenthal, Phoenix House Founder. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">1. America to catch up with
rest of world on community methadone:</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">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.</span><span style="font-size: 14pt; mso-spacerun: yes;">
</span><span style="font-size: 14pt;">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.</span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">This move was first mooted in
New South Wales in 1986 as a preventive measure for the HIV epidemic.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">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).</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">I was involved
in the first group of primary care physicians and there have now been almost
1000 licensed doctors in my state alone.</span><span style="font-size: 14pt; mso-spacerun: yes;">
</span><span style="font-size: 14pt;">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.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">The US clinic lobby uses this
latter as an argument favouring their continued monopoly.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">Yet it is this very monopoly which has denied
doctors and pharmacists the experience to utilise this highly effective treatment
in a safe manner.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">Methadone is no more
dangerous than insulin, cortisone, warfarin, morphine and many other strong
drugs.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">Each requires comprehensive but
straightforward guidelines for safe and effective clinical use.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><i style="mso-bidi-font-style: normal;"><span style="font-size: 14pt;"><span style="mso-spacerun: yes;"> </span>“The U.S.
government’s top addiction researcher is calling for broad deregulation of
methadone, a key drug used to treat opioid use disorder.”</span></i></p>
<p class="MsoNormal"><i style="mso-bidi-font-style: normal;"><span style="font-size: 14pt;"><o:p> </o:p></span></i><i style="mso-bidi-font-style: normal;"><span style="font-size: 14pt;">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.</span></i></p>
<p class="MsoNormal"><i style="mso-bidi-font-style: normal;"><span style="font-size: 14pt;"><o:p> </o:p></span></i><i style="mso-bidi-font-style: normal;"><span style="font-size: 14pt;">“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.”</span></i><span style="font-size: 14pt;"> [snip: see link below]</span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><a href="https://www.statnews.com/2022/11/16/nora-volkow-nida-broad-deregulation-methadone/"><span style="font-size: 14pt;">Top U.S. addiction scientist calls for broad methadone
deregulation (statnews.com)</span></a></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">2. Report on first twelve
months of New York’s first injecting centres.</span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">The one year anniversary of
the New York injecting rooms (Overdose Prevention Centres or OPC’s).</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">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).</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">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.<span style="mso-spacerun: yes;"> </span>Let me know if you wish to see the session on
YouTube or try </span><a href="https://www.youtube.com/watch?v=_utvHv4K86E&ab_channel=DPAVoices"><span face=""Calibri","sans-serif"" lang="EN-US" style="font-size: 11pt; mso-ansi-language: EN-US; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">at this link</span></a><span style="font-size: 14pt;"> .</span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">Sam Rivera gave an excellent
overview with moderator Dr Ompad asking numerous questions about the
practicalities, facilities, catchment populations, etc.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">We were told about drug purity and
contaminants, most fentanyl being about 10% pure and very little in the way of
benzodiazepines.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">Most drugs were what
the client had thought they were with some notable exceptions.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">The most dangerous was cocaine which was
heavily contaminated with fentanyl which could easily be fatal.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">We learned of many of the
same issues as in Sydney but some unique to local area.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">One of the centres had mainly smokers while
the other a majority were injectors, all done under supervision of trained
health workers.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">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.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">Sam Rivera told us that a bathroom is
considered private and injecting may be done with staff nearby in case of
emergency.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">They even described timed movement
detectors inside the otherwise private bathrooms.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">Telephone supervision also available from
numerous providers (this started in Canada apparently some years ago).</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">The centres had from 200 to
300 drug use episodes daily with no deaths reported.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">One was open Mon to Fri 8am to 8pm where the
other was open daily but shorter hours.</span><span style="font-size: 14pt; mso-spacerun: yes;">
</span><span style="font-size: 14pt;">‘The saddest time is when we have to close the gates’.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">We were told it was a matter of finance.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">To celebrate its 21<sup>st</sup>
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.<span style="mso-spacerun: yes;"> </span></span><a href="https://www.youtube.com/watch?v=SUJ1br4qYrc">Reverend Harry Herbert
Oration Full Event - YouTube</a></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">3. ‘Bernese’ methadone of
transfer from high dose methadone to buprenorphine.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">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’.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">In America the smallest
buprenorphine product is 2mg so microdosing is no simple matter.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>This is not recommended by the
manufacturer, however, nor is it ‘standard practice’.<span style="mso-spacerun: yes;"> </span>There are groups in Vancouver, London
(Ontario), Sydney and elsewhere who are instituting this graduated transfer
process both in hospital and in the community.<span style="mso-spacerun: yes;">
</span>In Australia there are smaller strengths available such as
0.2mg, 0.4mg sublingual tablets used as a strong analgesic.<span style="mso-spacerun: yes;"> </span>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 </span><a href="https://pubmed.ncbi.nlm.nih.gov/32657496/">Use of a novel prescribing
approach for the treatment of opioid use disorder: Buprenorphine/naloxone
micro-dosing - a case series - PubMed (nih.gov)</a><span style="font-size: 14pt;">.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span></span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">Patient responses have been
largely very positive.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">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.</span><span style="font-size: 14pt; mso-spacerun: yes;">
</span><span style="font-size: 14pt;">“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”.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">Patients on buprenorphine are less likely to
report constipation, excess sweating and sexual disturbance when compared with
those taking methadone.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">It is hoped that
calcium metabolism will be improved and less premature osteoporosis might be
seen.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">Methadone depresses testosterone
levels in some men who may then need hormone replacement.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">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).</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">4. Ensuring the Protection of
Youth in State Marijuana Legalization Efforts</span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">Columbia University Drugs and
Society forum 7.30pm Tues 15/11/22</span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">Dr Linda Richter, PhD; Robyn
Oster, BA</span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">Recommended Youth Protection
Provisions in State Adult Use Marijuana Laws.</span><span style="font-size: 14pt; mso-spacerun: yes;">
</span><span style="font-size: 14pt;">An excellent talk looking at results for the following issues:</span></p>
<p class="MsoNormal"><span style="font-size: 14pt; mso-fareast-font-family: "Times New Roman"; text-indent: -18pt;"><span style="mso-list: Ignore;"><span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span></span><span style="font-size: 14pt; text-indent: -18pt;">1. Product
composition</span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -18pt;"><!--[if !supportLists]--><span style="font-size: 14pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-size: 14pt;">Packaging and
labeling<o:p></o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -18pt;"><!--[if !supportLists]--><span style="font-size: 14pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-size: 14pt;">Advertising and
marketing<o:p></o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -18pt;"><!--[if !supportLists]--><span style="font-size: 14pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-size: 14pt;">Manufacture and
sale<o:p></o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -18pt;"><!--[if !supportLists]--><span style="font-size: 14pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-size: 14pt;">Marijuana use<o:p></o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -18pt;"><!--[if !supportLists]--><span style="font-size: 14pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-size: 14pt;">Sale and
distribution to youth<o:p></o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l1 level1 lfo2; text-indent: -18pt;"><!--[if !supportLists]--><span style="font-size: 14pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">7.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-size: 14pt;">Use of tax and
penalty revenue for public education, prevention, treatment, monitoring, and
provision enforcement<o:p></o:p></span></p>
<p class="MsoListParagraphCxSpLast"><span style="font-size: 14pt;">The speakers detailed the available
data from various states which legalised cannabis first and detailed
recommendations for each of the above issues.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">[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.<span style="mso-spacerun: yes;"> </span>One weird provision which seems to
be non-controversial is that generally, licence holders must have had at least
one previous cannabis conviction.<span style="mso-spacerun: yes;"> </span>Go figure!?<span style="mso-spacerun: yes;"> </span>This is a country of contrasts to be
sure!<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">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.</span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">5. 100</span><sup>th</sup><span style="font-size: 14pt;"> birthday
of Dr Joyce Lowinson, addiction treatment pioneer.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">Psychiatrist Dr Joyce Lowinson,
long time editor-in-chief of Substance Abuse, a Comprehensive Textbook, had her
100</span><sup>th</sup><span style="font-size: 14pt;"> birthday in New York City.</span><span style="font-size: 14pt; mso-spacerun: yes;">
</span><span style="font-size: 14pt;">I have known this pioneer colleague for over 20 years.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">She was involved in the very first methadone
research paper (JAMA, Dole and Nyswander 1965).</span><span style="font-size: 14pt; mso-spacerun: yes;">
</span><span style="font-size: 14pt;">Dr Lowinson was also instrumental in opening up large methadone clinics
in the Bronx at a time when there was enormous need.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">6. Death of Dr. Mitchell
Rosenthal, Phoenix House Founder.</span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">19</span><sup>th</sup><span style="font-size: 14pt;"> Nov, New York
Times: Dr. Mitchell Rosenthal, Phoenix House Founder, Dies at 87</span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">A psychiatrist, he was an
early apostle for treating drug and alcohol addiction with group therapy in a
residential setting. [click below for link]<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><a href="https://www.nytimes.com/2022/11/19/nyregion/mitchell-rosenthal-dead.html"><span style="font-size: 14pt;">Dr. Mitchell Rosenthal, Phoenix House Founder, Dies at
87 - The New York Times (nytimes.com)</span></a></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">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.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">At one time there was some animosity between
drug-free ‘treatments’ and opiate maintenance advocates.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">Now most agree that there is enormous demand
for both detoxification services as well as maintenance programs.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">Many of our patients have benefitted from
each at different times so antagonism is pointless and understanding and
cooperation the way to go.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">I have always
had a congenial relation with James Pitts and his colleagues in Sydney, Australia.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"><o:p> </o:p></span><span style="font-size: 14pt;">Written by Andrew Byrne,
retired addictions physician, Sydney, Australia.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal" style="line-height: 115%; margin-bottom: 10pt;"><br /></p></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-21196119901320137972022-08-10T01:58:00.004+10:002022-08-10T02:00:39.102+10:00Did Covid related liberalisation of methadone dispensing affect overdose rates?<h2><span style="font-size: 13pt;">Dear Colleagues, </span></h2><div><p class="MsoNormal"><span style="font-size: 13pt;">Finally we are seeing some
useful publications regarding the major changes in provision of opiate
maintenance during the Covid pandemic (see links below).<span style="mso-spacerun: yes;"> </span>Yet the jury is still out regarding the value
of supervised consumption of methadone (and buprenorphine) in long-term opiate
maintenance.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">Jones, Volkow and colleagues
report American opiate overdose death rates with and without methadone
involvement before and after March 2020 when new guidelines were being
implemented.<span style="mso-spacerun: yes;"> </span>Clinics were permitted to
give 28 or 14 take-home doses for ‘stable’ and ‘less stable’ patients
respectively.<span style="mso-spacerun: yes;"> </span>They examined coroner
records for overdoses, noting that historically most methadone overdoses were
in pain patients (unsupervised) rather than in those in dependence programs (with
supervised dosing).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">Starting from January 2019
the group extracted monthly data on overdose deaths to August 2021 from
official and preliminary (2021) the CDCP.<span style="mso-spacerun: yes;">
</span>They found a brief spike in all overdoses at the commencement of the
Covid pandemic around April 2020 but no significant increases in the months
following despite supervision of methadone doses being reduced dramatically.<span style="mso-spacerun: yes;"> </span>They also found that overdoses not involving
methadone continued to increase progressively through August 2021 and correspondingly,
the proportion of overdose deaths involving methadone declined.<span style="mso-spacerun: yes;"> </span>Other authors report May 2020 as the peak in
the US with overdoses 50% higher than a year earlier.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">Overdose is the most serious
complication of unsupervised methadone but there are others such as treatment
drop-outs, relapse to the use of alternative drugs and alcohol, sometimes with
concomitant mental illness.<span style="mso-spacerun: yes;"> </span>Fentanyl is a
major risk factor in America but is seen less in Australia to date.<span style="mso-spacerun: yes;"> </span>A search on Google Scholar found a small
number of papers which looked at these matters, none finding significant or
lasting changes after the change in methadone guidelines (see below).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">Old research shows that most
diverted or ‘black market’ methadone is taken by people who would normally
qualify for methadone treatment. Worryingly however, such recipients are also at
highest risk of overdose from unknown quantities of diverted, street or
prescribed opioids.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">In our Sydney clinic from
March 2020 we increased our provision of dispensed (non-supervised) doses as
well as introducing a raft of preventive measures including social distancing, ‘telehealth’
consultations, mask mandate, perspex shield at dispensing counter, hand
sanitizer, gloves for staff, home visits for Covid infected patients, encouraging
vaccination, etc.<span style="mso-spacerun: yes;"> </span>We also suspended routine
urine toxicology tests.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">While there were no reports
of overdose in our patient group, in the early weeks of the new guidelines we
noted that a proportion (~5%) of patients were running out of methadone
early.<span style="mso-spacerun: yes;"> </span>We provided occasional
supplementary doses and if these were requested more than once more frequent
attendance was recommended.<span style="mso-spacerun: yes;"> </span>One patient
stated: “Look Doc, when it comes to opiates I am a pig.<span style="mso-spacerun: yes;"> </span>If I have four bottles for four days they are
always gone in three or less.<span style="mso-spacerun: yes;"> </span>That
leaves me in withdrawals”.<span style="mso-spacerun: yes;"> </span>He sought return
to Monday, Wednesday and Friday attendance and did well thereafter through the
pandemic.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">Regarding the lack of control
in some given extended ‘take-homes’, higher doses may be needed by some, others
more frequent attendance, others still may need more psychosocial supports.<span style="mso-spacerun: yes;"> </span>Anxiety, panic disorder, insomnia and
depression are common in this population group: American treatment guidelines state
that patients should not be denied appropriate treatment just because they are
on OTP.<span style="mso-spacerun: yes;"> </span>Long acting benzodiazepines
should only be prescribed in modest doses, limited quantities and with close
monitoring when appropriate. <span style="mso-spacerun: yes;"> </span>Antidepressants are effective in a significant
minority of cases in our experience.<span style="mso-spacerun: yes;"> </span>Since
the introduction of real-time prescription monitoring in Australian states patients
are no longer so easily able to attend multiple doctors and pharmacies without
detection.<span style="mso-spacerun: yes;"> </span>Prescribed medications will
always be safer than unknown quantities of short acting, high-potency black
market drugs.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">Back to the point of the
article by Jones, Volkow and colleagues: what is the purpose of dose
supervision?<span style="mso-spacerun: yes;"> </span>Regular attendance gives some
daily discipline for new, unstable and unhappy patients.<span style="mso-spacerun: yes;"> </span>But how long is it needed?<span style="mso-spacerun: yes;"> </span>This has never been studied systematically to
my knowledge so the current naturalistic experiment should be used to determine
how far one can go.<span style="mso-spacerun: yes;"> </span>But now some experienced
researchers need to collect appropriate longitudinal clinical data to give
further guidance on best practice.<span style="mso-spacerun: yes;"> </span>Most
would agree that after the initial period of daily attendance more flexible
arrangements should be available for those who can show that they have moved
away from illicit drugs and become more socially integrated with work, study,
family life, etc.<span style="mso-spacerun: yes;"> </span>But then?<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">See references below for
other aspects of the current loosening of take-home provisions for methadone
maintenance patients.<span style="mso-spacerun: yes;"> </span>I hope this is
useful for clinicians who practise in the field.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">Written by Andrew Byrne .. Now
semi-retired – Mobile: 0490408477<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">[with thanks to J James, C.
Jones and R Hallinan for editing assistance] <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; margin-left: 4.8pt; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184; width: 782px;">
<tbody><tr style="height: 14.4pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td nowrap="" style="height: 14.4pt; padding: 0cm 5.4pt; width: 469.2pt;" valign="bottom" width="782">
<p class="MsoNormal"><a href="https://www.tandfonline.com/doi/full/10.1080/08897077.2021.1986768?src=recsys"><span face=""Calibri","sans-serif"" style="font-size: 13pt; mso-fareast-font-family: "Times New Roman";">COVID-19-related policy changes for methadone take-home
dosing: A multistate survey of opioid treatment program leadership: Substance
Abuse: Vol 43, No 1 (tandfonline.com)</span></a><u><span face=""Calibri","sans-serif"" style="color: blue; font-size: 13pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></u></p>
</td>
</tr>
<tr style="height: 14.4pt; mso-yfti-irow: 1;">
<td nowrap="" style="height: 14.4pt; padding: 0cm 5.4pt; width: 469.2pt;" valign="bottom" width="782">
<p class="MsoNormal"><u><span face=""Calibri","sans-serif"" style="color: blue; font-size: 13pt; mso-fareast-font-family: "Times New Roman";"><o:p><span style="text-decoration: none;"> </span></o:p></span></u></p>
<p class="MsoNormal"><a href="https://www.tandfonline.com/doi/full/10.1080/00952990.2021.1979991"><span face=""Calibri","sans-serif"" style="font-size: 13pt; mso-fareast-font-family: "Times New Roman";">The impact of relaxation of methadone take-home protocols
on treatment outcomes in the COVID-19 era: The American Journal of Drug and
Alcohol Abuse: Vol 47, No 6 (tandfonline.com)</span></a><u><span face=""Calibri","sans-serif"" style="color: blue; font-size: 13pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></u></p>
</td>
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<tr style="height: 14.4pt; mso-yfti-irow: 2; mso-yfti-lastrow: yes;">
<td nowrap="" style="height: 14.4pt; padding: 0cm 5.4pt; width: 469.2pt;" valign="bottom" width="782">
<p class="MsoNormal"><u><span face=""Calibri","sans-serif"" style="color: blue; font-size: 13pt; mso-fareast-font-family: "Times New Roman";"><o:p><span style="text-decoration: none;"> </span></o:p></span></u></p>
<p class="MsoNormal">* <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2793744">Methadone-Involved
Overdose Deaths in the US Before and After Federal Policy Changes Expanding
Take-Home Methadone Doses From Opioid Treatment Programs | Psychiatry and
Behavioral Health | JAMA Psychiatry | JAMA Network</a></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><a href="https://www.sciencedirect.com/science/article/pii/S0955395922000111">Methadone
exposures reported to poison control centers in the United States following
the COVID-19-related loosening of federal methadone regulations -
ScienceDirect</a></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><a href="https://www.sciencedirect.com/science/article/pii/S0740547222000836">Treatment
retention, return to use, and recovery support following COVID-19 relaxation
of methadone take-home dosing in two rural opioid treatment programs: A mixed
methods analysis - ScienceDirect</a></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><a href="https://www.recoveryanswers.org/research-post/unprecedented-increase-overdose-deaths-covid-19-substantial-regional-variation/">»
Unprecedented increase in overdose deaths during the COVID-19 pandemic – with
substantial regional variation (recoveryanswers.org)</a><u><span face=""Calibri","sans-serif"" style="color: blue; font-size: 13pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></u></p>
</td>
</tr>
</tbody></table>
<p class="MsoNormal"><span style="font-size: 13pt;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">Please let me know if you do
not wish to receive these emails: reply ‘unsubscribe’.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;"><o:p> </o:p></span></p>
<p class="MsoNormal"><a href="https://methadone-research.blogspot.com/">Dr.
Andrew's Opinions (methadone-research.blogspot.com)</a></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><span style="font-size: 13pt;"><o:p> </o:p></span></p><br /></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-70163330659165979322022-04-30T01:42:00.012+10:002022-05-20T07:41:31.548+10:00Difficult times ... and an escape hatch! <h2><span style="font-size: medium;"><span style="font-weight: 400;">Fish bone, bowel blockage by adhesions, retirement and closure of clinic after 38 years. </span></span></h2><h2><span style="font-size: medium; font-weight: normal;">Dear colleagues, </span></h2><div><span style="font-size: medium;"><span>In October 2021 at a siblings reunion dinner I swallowed one or possibly two fishbones with my first excited mouthful. After long Covid lock-down and with family I suddenly developed the dreaded sensation of a sharp foreign body in my throat. And when</span><span> it did not go away I booked myself in for a gastroscopy three days at Bowral Private Hospital. However, to my surprise, nothing was found. Subsequent examination at St Vincent's in Sydney was equally unremarkable. CT scan, MRI scan (a punishing experience) and subsequent oesophagoscopy under anaesthetic were also all normal yet I knew there was still a bone (or two) there in the lower gullet or upper chest region. Eventually, by the middle of January this year, the foreign body seemed to have either dissolved or moved on. But I had more to worry about. </span></span></div><div><span style="font-size: medium;"><span><br /></span></span></div><div><span style="font-size: medium;">The 'normal' rigours of running a solo medical practice were added to by the pandemic. Apart from the daily threat to staff and patients, I was obliged to enter every patient's details on Service NSW Covid-safe web site by the close of trading, even on my 'days off'. Getting 95% of our patients vaccinated was a challenge which we were also equal to. Yet the enjoyment of running the practice was considerably impacted by all of these contingencies as well as the requirements of registration, accreditation, fire compliance, pest report, safety drills, etc. So I decided to pull the plug and tell my staff it was a very sad day but we would be closing down. Telling the patients was also tough. Prior to that I had an assurance from the owner of a nearby large addiction clinic that they could manage to take most or all of our 165 opiate maintenance patients. </span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;">An old adage is that people often develop illness, injury or other misadventure straight after retiring. So it happened that just 8 weeks later I developed a bowel obstruction requiring urgent laparotomy with two weeks recuperation, somewhat cramping my style and confidence. I thank the staff of Bowral District Hospital for magnificent care from the Emergency Ward to the operating theatres, intensive care and general wards. Night staff especially were caring and prepared to go the extra distance in customised advice and support. It must be especially exacting looking after fellow health workers and I was not an 'easy' patient by any means. </span></div><div><span style="font-size: medium;"><br /></span></div><div><span style="font-size: medium;"><span>So at some point I need to look back on my early general practice
and expanding addiction cohort after I became one of the first NSW GPs to
prescribe methadone.</span><span> </span><span>One of my early
patients was a doctor from a medical family.</span><span>
</span><span>He had been debarred over some drug use matter and never practised
again, despite doing well on methadone for many years.</span><span> </span><span>He joined the church and became a vital
volunteer yet he lacked the confidence to return to medicine despite my
encouragement.</span><span> </span><span>He taught me a great deal
about addiction when there were few sources.</span><span> </span></span></div><div>
<p class="MsoNormal"><span style="font-size: medium;"><span>An elderly musician and composer retired to the Redfern
flats and became my patient for her last years.</span><span>
</span><span>One morning on a home visit she presented me with a three page piano
piece written in my honour.</span><span> </span><span>One look at
the manuscript showed it was far too difficult for my modest keyboard talents
and it was not for another 25 years that I heard it played by a professional.</span><span> </span><span>It is absolutely charming, original and
possibly even an 'Alter ego' of myself (which was its title).</span><span> </span><span>[contact me if you wish to hear it]</span><span> </span></span></p>
<p class="MsoNormal"><span style="font-size: medium;"><span>Other remarkable events happened with regularity in our
practice, many of which one could not predict in a century of guesswork.</span><span> </span><span>Unfortunately many such details may give away
identities and are too personal to be revealed.</span><span>
</span><span>One very early (1980s) GP patient was a truck driver who inadvertently
caused a massive traffic jam by blocking lanes on the Sydney Harbour
Bridge.</span><span> </span><span>He just walked in that afternoon
and revealed what had happened and that he needed a certificate for a few days
off.</span><span> </span><span>His truck was in a mess yet he was
remarkably untouched, at least physically.</span><span> </span></span></p>
<p class="MsoNormal"><span style="font-size: medium;"><span>Successes?</span><span> </span><span>What is a
success regarding addiction?</span><span> </span><span>Survival is
pretty important.</span><span> </span><span>Keeping out of
trouble, avoiding harms, looking after families, work, study and social
integration are also admirable.</span><span> </span></span></p>
<p class="MsoNormal"><span style="font-size: medium;"><span>The majority of our patients were on social security
benefits and did some family responsibilities, part time work, hobbies or
volunteer work.</span><span> </span><span>Yet I also had many
patients who worked, paid taxes and were part of the movers and shakers of our
society.</span><span> </span><span>One became a member of a Royal
College while another obtained a PhD.</span><span>
</span><span>Others included successful lawyers, a police officer, business people,
motor mechanic, retailers, teachers, nurses, graphic artist and other key
community workers.</span><span> </span><span>No politicians … but
several highly placed public servants.</span></span></p>
<p class="MsoNormal"><span style="font-size: medium;"><span>No clerics, rabbis, reverends to date but one most
interesting and troubled long-term seminarian studying divinity at a major
institution.</span><span> </span></span></p>
<p class="MsoNormal"><o:p><span style="font-size: medium;">More on Abrahamic religions later from this card-carrying atheist. </span></o:p></p><p class="MsoNormal"><span style="font-size: medium;">Andrew Byrne .. </span></p></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-43570991604826741012022-02-10T21:21:00.006+11:002022-02-10T21:21:37.762+11:00Closure of Byrne Surgery Clinic after 38 years. <h2><span style="font-size: 14pt;">6. Treating dependency patients … retirement of Dr Andrew Byrne.</span></h2><div>
<p class="MsoNormal"><span lang="EN-US" style="font-size: 14.0pt; mso-ansi-language: EN-US;"><o:p> </o:p></span><span style="font-size: 14pt;">It has been my privilege to treat thousands of dependency patients over 35
years in our medical practice in Redfern, an inner suburb of Sydney,
Australia. Just as smokers are sometimes the most interesting people at a
party, drug users have often led extraordinary lives punctuated by risk taking,
harrowing stories, personal interactions and more. Some of the most
talented people in our society also suffer from drug and alcohol dependence,
and many die young due to prevailing circumstances (brilliant artist Brett
Whiteley was one of many local examples).</span><span style="font-size: 14pt;"> </span></p>
<p class="MsoNormal"><span lang="EN-US" style="font-size: 14.0pt; mso-ansi-language: EN-US;"><o:p> </o:p></span><span style="font-size: 14pt;">A majority of my opioid maintenance patients did not finish school and
are lower socio-economic citizens.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">They now
mostly live on social services in public housing with family and friends away
from poverty and crime with access to medical, mental health and vocational
facilities in our relatively well served area.</span><span style="font-size: 14pt;">
</span><span style="font-size: 14pt;">Many were victims of abuse as children and many have been from the Aboriginal
stolen generations.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">A substantial minority,
however, are school teachers, nurses, tradies, drivers, business people, etc.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">A small number have been university educated
professionals.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">There were doctors,
lawyers, academics and even one police officer in this group over the years.</span><span style="font-size: 14pt;"> </span></p>
<p class="MsoNormal"><span lang="EN-US" style="font-size: 14.0pt; mso-ansi-language: EN-US;"><o:p> </o:p></span><span style="font-size: 14pt;">After a difficult 2 years dealing with the Covid pandemic and all the
other ‘normal’ stresses of running a business I have decided to close our
clinic and seek quieter pastures in semi-retirement.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">My thanks to the many local doctors, clinics,
pharmacies and hospitals who have offered to take on my current opioid
maintenance patients.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">And apologies to
these patients for the disruption caused.</span><span style="font-size: 14pt;"> </span></p>
<p class="MsoNormal"><span lang="EN-US" style="font-size: 14.0pt; mso-ansi-language: EN-US;"><o:p> </o:p></span><span lang="EN-US" style="font-size: 14pt;">I also propose to continue writing about comparative Abrahamic religions
having been a fellow-traveller in a major Sydney synagogue as well as a mosque for
over a decade. In both places I have
been accorded a substantial welcome despite being a secular outsider. </span><a href="https://cantorialcrossoverculture.blogspot.com/">Cantorial cross-over
culture (cantorialcrossoverculture.blogspot.com)</a></p>
<p class="MsoNormal"><o:p> </o:p><span style="font-size: 14pt;">Piano, opera, astronomy and cooking are also my regular pastimes as my
regular readers will know.</span><span style="font-size: 14pt;"> </span></p>
<p class="MsoNormal"><span lang="EN-US" style="font-size: 14.0pt; mso-ansi-language: EN-US;"><o:p> </o:p></span><span style="font-size: 14pt;">Best regards, Andrew Byrne ..</span></p>
<p class="MsoNormal"><span lang="EN-US" style="font-size: 14.0pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></p></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-80563840767176536372022-01-11T05:34:00.035+11:002022-01-21T19:30:02.252+11:004. Microdose transfers from methadone to buprenorphine – 5. Will this spell the end of the methadone clinic? <h2></h2><h2><span style="font-size: small;"><span style="color: black; font-family: ""serif"","serif"; font-weight: normal;">Part the third: Harm reduction and supervised
benzodiazepine prescribing in opiate programs. [See my old
summary </span><span style="color: black; font-family: ""serif"","serif"; font-weight: normal;"><a href="https://methadone-research.blogspot.com/2021/07/date-presenters-psychiatrist-and.html">Dr. Andrew's Opinions: Benzodiazepines in psychiatry and addiction medicine - do they still have a place in chronic care? (methadone-research.blogspot.com)</a> New summary to follow later when time permits.]</span><span style="color: black; font-weight: normal;"> </span></span></h2>
<h2><span style="font-size: small;"><span style="font-weight: normal;">Part the fourth: </span><span style="font-weight: normal;">‘</span><span style="font-weight: normal;">Microdose’ transfers from methadone to buprenorphine. Will this spell less need for methadone clinics with more patients benefitting from
buprenorphine in community practice? </span></span></h2>
<p class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="font-weight: normal;"><span style="color: black; font-size: 14pt;">4. Due to precipitated withdrawal,
transfer of high dose methadone patients to buprenorphine was generally
considered impossible. Gradual reductions to 40mg have enabled some to
transition successfully. However for many others such reductions
have proven untenable. </span><span style="color: black;"><o:p></o:p></span></span></p>
<p class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="font-weight: normal;"><span style="color: black; font-size: 14pt;">But things have changed. We now
know that many patients can be transitioned using an overlapping dosing regimen
starting with full dose methadone along with ‘micro-doses’ of buprenorphine
(eg. 0.4-0.8mg SL) then reducing doses of methadone and increasing doses of
buprenorphine after 3 days of the priming doses. </span><span style="color: black;"><o:p></o:p></span></span></p>
<p class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="font-weight: normal;"><span style="color: black; font-size: 14pt;">While this is novel in Australia it was
first described in 2010 by Dr Robert Haemmig in Bern, Switzerland and has been
recently taken up by a number of centres in Canada (see references below from
London, Ontario and Vancouver, BC). Despite minor differences in
protocols the essence is the same. Seven cases were described by Brar and
colleagues in July 2020 using a type of ‘Bernese’ protocol. </span><span style="color: black;"><o:p></o:p></span></span></p>
<p class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="font-weight: normal;"><span style="color: black; font-size: 14pt;">The NSW Health Department first approved a
"Bernese" protocol in November 2020 and a major hospital has
performed a substantial number of trial cases with ethics committee approval,
initially as in-patients, then as out-patients. In our practice we have
performed three initial transfer patients with singular satisfaction from the patients
involved and minimal input from staff. </span><span style="font-size: large;"><span style="color: black;">Now we have a wait-list for
further candidates to try this innovation. </span><span style="color: black;"><o:p></o:p></span></span></span><span style="font-family: "Times New Roman", "serif";"><span style="font-size: large;">It is time consuming and not always successful.</span></span></p>
<p class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="font-weight: normal;"><span style="color: black; font-size: 14pt;">Extended unsupervised doses of
buprenorphine can often be given as it is far safer than
methadone. There is also the prospect of long acting, depot
buprenorphine injections up to monthly intervals. It is known that
buprenorphine has less propensity to alter the endocrine system and it is hoped
that osteoporosis will be rarer in long-term use compared with
methadone. </span><span style="color: black;"><o:p></o:p></span></span></p>
<p class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="font-weight: normal;"><span style="color: black; font-size: 14pt;">The microdosing method staggers the
cessation of methadone and simultaneously introduces ‘micro-doses’ of
buprenorphine (eg. 0.4mg, 0.8mg, 2mg) to ‘prime’ the mu receptors and thus
prevent the withdrawal cascade which can be precipitated when they are
saturated with partial agonist. So, rather than a sudden switch
which can risk a precipitated withdrawal reaction the process is smoother and
associated with high patient tolerability. Dr Nolan's group in
Vancouver has performed over 200 such transfers on patients taking up to 200mg
methadone and she reports zero incidence of precipitated withdrawal and a 95%
satisfaction with buprenorphine with just 5% returning to methadone (pers
comm.). </span></span><span style="font-size: medium;">Furthermore, she emphasises that flexibility is the
key, allowing slightly longer cross-over periods when necessary, antiemetics,
sedatives and analgesics for those with symptoms in the transition period. </span></p><p class="MsoNormal"><span lang="EN-US"><o:p></o:p></span></p><p class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="font-weight: normal;"><span style="color: black; font-size: 14pt;"><span style="font-size: 14pt;"> </span></span></span><span style="font-size: 14pt;"> 5. So, is this the end of the
‘methadone clinic’ as we knew it with most patients moving on to
buprenorphine? Our five recent transfer patients (including 2 direct low
dose transfers) have reported a variety of benefits such as less sweating, less
constipation, ‘clearer head’, less stigma, better mood, better sleep, easier
storage and more. Do I sound like a commercial? The only regret from
some was that they did not do this transfer long ago! </span></p>
<p class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="font-weight: normal;"><span style="color: black; font-size: 14pt;">Over the years I have visited
methadone clinics across the world including Brighton, England, San Francisco,
Honolulu, Maui, Manhattan, Brooklyn, Bronx, Chicago, Beijing, Hong Kong and
beyond. None could be mistaken for a resort hotel and some were scruffy
and uninviting dens. In the past methadone clinics were necessary … a
time when heroin addiction was spreading widely, HIV threatened, overdoses were
increasing when neither traditional hospital, pharmacy, medical or psychiatry
clinics were able to deliver the necessary treatment in sufficient
numbers. And methadone was the only opiate maintenance drug
available.<span style="mso-spacerun: yes;"> </span>While buprenorphine has
changed the field in most countries, sadly in the USA the price of
buprenorphine is beyond the reach of many who need treatment.<span style="mso-spacerun: yes;"> </span></span><span style="color: black;"><o:p></o:p></span></span></p>
<p class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="font-weight: normal;"><span style="color: black; font-size: 14pt;">Now in many countries GPs and community
pharmacies can be involved in delivering quality opiate maintenance using
buprenorphine. They may need back-up support and assistance from
addiction specialists for new and complex cases. Time will tell but I
predict less need for OTP clinics and the expansion of addiction referral
centres. These should
support GPs and other community services and need to be comprehensive,
involving smoking cessation, vaping information, alcohol detox services, medical
cannabis, harm reduction information, hepatitis monitoring, stimulant programs
and associated mental health assistance. And good coffee!<span style="mso-spacerun: yes;"> </span></span><span style="color: black;"><o:p></o:p></span></span></p>
<p class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="font-weight: normal;"><span style="color: black; font-size: 14pt;">With best regards to my faithful readers. </span><span style="color: black;"><o:p></o:p></span></span></p>
<p class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span face="Arial, Helvetica, sans-serif" style="background-color: white; font-size: 14pt;">Disclaimer: the Bernese method is still not a standard treatment and should only be done under close supervision with experienced staff and Health Department approval. </span></p><p class="MsoNormal" style="background-color: white; color: #222222; font-family: Arial, Helvetica, sans-serif; font-size: small; margin: 0px;"> </p><div><span style="color: black; font-size: 14pt;"> </span><span style="color: black; font-size: 15pt;">References:</span></div>
<p class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"></p><u style="text-align: center;"><span face=""Calibri","sans-serif"" style="color: blue; font-size: 11pt; mso-fareast-font-family: "Times New Roman";"><a href="https://insight.qld.edu.au/training/wows-lite-dr-ken-lee-the-bernese-method-of-buprenorphine-micro-dosing/detail">Insight - WOWS Lite - Dr Ken Lee - The Bernese
Method of buprenorphine micro-dosing</a></span></u><div><div style="text-align: center;"><span face="Calibri, sans-serif" style="color: blue;"><span style="font-size: 14.6667px;"><u><br /></u></span></span></div><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4959756/" style="text-align: center;">Use of microdoses
for induction of buprenorphine treatment with overlapping full opioid agonist
use: the Bernese method (nih.gov)</a></div><div><br /><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970598/" style="text-align: center;">Buprenorphine–naloxone
“microdosing”: an alternative induction approach for the treatment of opioid use
disorder in the wake of North America’s increasingly potent illicit drug market
(nih.gov)</a><br /><div class="separator" style="clear: both; text-align: center;"><p class="MsoNormal"><a href="https://pubmed.ncbi.nlm.nih.gov/32657496/">Use of a novel prescribing
approach for the treatment of opioid use disorder: Buprenorphine/naloxone
micro-dosing - a case series - PubMed (nih.gov)</a></p><p class="MsoNormal"><br /></p></div><div class="separator" style="clear: both; text-align: center;">
<p class="MsoNormal"><o:p></o:p></p>
</div><p></p></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-65058624454520765852022-01-11T05:16:00.002+11:002022-01-11T05:32:11.308+11:002. Reconsidering the usefulness of adding naloxone to buprenorphine.<p align="center" class="MsoNormal" style="text-align: center;"><span style="font-size: 15pt; text-align: left;">Part the second, Dr Byrne’s blog notes (abbreviated due to two articles
I have found which have done most of the work I set out to do). </span></p>
<p class="MsoNormal"><span lang="EN-US" style="font-size: 15pt; mso-ansi-language: EN-US;"><o:p>2. </o:p></span><span style="font-size: 15pt;">As I prepared my references about the addition of naloxone I
happened upon a recent scholarly review paper by Blazes and Morrow from U Michigan at
Ann Arbor (see link below which I highly recommend). Their review of the
literature and clinical history of the combination product finds little
evidence for the addition of naloxone. They emphasise the current opioid
overdose crisis and the underutilization of buprenorphine in America. </span></p>
<p class="MsoNormal"><span style="font-size: 15pt;">These authors avoid mention of commercial, marketing and patent factors
but state: “…we cannot unambiguously conclude that naloxone is an effective
deterrent to parenteral misuse of buprenorphine. At best, naloxone may reduce
or delay the subjective “high” users experience, but in the absence of any
dramatic effect on abuse liability, this partial blockade of subjective
euphoric effects is of dubious clinical value.”</span></p>
<p class="MsoNormal"><span style="font-size: 15pt;">To cast further doubts on the combination product one should consider
the substantially higher post-treatment mortality found in combination-treated
patients in WA when compared with those prescribed the pure drug (n=3455) over
a nine year period. I could only find two comparative clinical trials,
one a pilot study reporting significantly higher doses needed when transferring
from the pure drug to combination (not blinded: see Bell below). The
other was a large RCT reporting more withdrawal syndrome in those given
combination buprenorphine versus the pure drug (25% vs 18% of subjects: see
Fudala below). </span></p>
<p class="MsoNormal"><span style="font-size: 15pt;">I leave the reader to consider the evidence and decide what is best for
their own patients. </span></p>
<p class="MsoNormal"><span style="font-size: 15pt;">Written by Andrew Byrne .. Regards for a safe New Year for 2022 for all
my readers.</span><span style="font-size: 15pt;"> </span></p>
<p class="MsoNormal"><span style="font-size: 15pt;"> </span></p>
<p class="MsoNormal"><a href="https://www.frontiersin.org/articles/10.3389/fpsyt.2020.549272/full#B31"><span style="font-size: 15pt;">Frontiers | Reconsidering the Usefulness of Adding
Naloxone to Buprenorphine | Psychiatry (frontiersin.org)</span></a><span style="font-size: 15pt;"> Blazes and Morrow 2020</span><span lang="EN-US" style="font-size: 15pt; mso-ansi-language: EN-US;"><o:p></o:p></span></p>
<p class="MsoNormal"><br /></p>
<p class="MsoNormal"><a href="https://pubmed.ncbi.nlm.nih.gov/29433352/"><span style="font-size: 15pt;">Buprenorphine alone or with naloxone: Which is safer?
- PubMed (nih.gov)</span></a><span lang="EN-US" style="font-size: 15pt; mso-ansi-language: EN-US;"><o:p></o:p></span></p>
<p class="MsoNormal"><br /></p>
<p class="MsoNormal"><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US;">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<o:p></o:p></span></p>
<p class="MsoNormal"><br /></p>
<p class="MsoNormal"><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US;">Fudala PJ, Bridge TP, Herbert S, et al. Office-Based Treatment of Opiate
Addiction with a Sublingual-Tablet Formulation of Buprenorphine and Naloxone.
NEJM (2003) 349:949-958<o:p></o:p></span></p><br /><br />Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-18580665204444883252021-12-12T19:59:00.013+11:002021-12-14T06:46:06.313+11:001. Changes to opiate treatment programs during Covid – benefits for some, harms for others. <h2><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman"; text-indent: -18pt;"><span style="mso-list: Ignore;"><span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US; text-indent: -18pt;">1 Changes to opiate
treatment programs during Covid – benefits for some, harms for others.<span style="mso-spacerun: yes;"> </span></span></h2><div>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -18pt;"><!--[if !supportLists]--><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2</span></span><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US;"> Pure versus
combination buprenorphine – drug company tactics, ‘smoke and mirrors’.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -18pt;"><!--[if !supportLists]--><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3</span></span><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US;"> Harm reduction and
diazepam prescribing in opiate programs.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -18pt;"><!--[if !supportLists]--><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4</span></span><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US;"> Microdose transfers
from methadone to buprenorphine – the ‘Bernese’ method measures up.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoListParagraphCxSpLast" style="mso-list: l0 level1 lfo1; text-indent: -18pt;"><!--[if !supportLists]--><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;"><span style="font: 7pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US;">5 Are we seeing the
end of the ‘methadone clinic’?<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p><p class="MsoListParagraphCxSpLast" style="mso-list: l0 level1 lfo1; text-indent: -18pt;"><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US;"><span style="mso-spacerun: yes;"></span></span></p><p class="MsoListParagraph" style="mso-list: l0 level1 lfo1; text-indent: -18pt;"><span lang="EN-US" style="font-size: 14pt; text-indent: -18pt;">6.<span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span><span lang="EN-US" style="font-size: 14pt; text-indent: -18pt;">The role of OTP
clinics in Covid vaccination, diagnosis, </span><span style="font-family: "Times New Roman", "serif"; font-size: 14pt;">prevention, </span><span style="font-size: 14pt; text-indent: -18pt;">quarantine, home dosing, etc. </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">Part the First: Covid changes.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US;">Covid has taught us many things about many things, including opiate
maintenance treatments.<span style="mso-spacerun: yes;"> </span>From early in the
Covid pandemic most patients were given extra take-home or dispensed
doses.<span style="mso-spacerun: yes;"> </span>For about a month due to the delta
crisis in New South Wales our practice gave no supervised doses but just doses
for home consumption from the practice window.<span style="mso-spacerun: yes;">
</span>Although substantial numbers of our patients benefited greatly from
increased liberties with take-away or dispensed doses of methadone and
buprenorphine, a minority have got into trouble, some in a small way, others
seriously.<span style="mso-spacerun: yes;"> </span></span></p><p class="MsoNormal"><span lang="EN-US" style="font-size: 14pt; mso-ansi-language: EN-US;">In our practice we detected
about ten percent of our patients, mostly ‘doubling up’ on doses and thus
running out before normal return dates.<span style="mso-spacerun: yes;">
</span>Others were injecting the medication, selling it or just saving amounts
‘for a rainy day’ (in case the clinic were closed down).<span style="mso-spacerun: yes;"> </span>One patient developed serious septic thrombosis
from regular inguinal injecting, requiring in-patient treatment for an extended
period.<span style="mso-spacerun: yes;"> </span>Yet another was reported to be
selling doses to others in the practice.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">Daily supervised dosing has been the usual practice in nearly all opiate
maintenance research and practice, at least initially.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">However, the place of continued supervised
dosing has never been systematically investigated to my knowledge.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">We found no distinguishing factors in those
who ‘stumbled’ when given extra dispensed doses during Covid lock-down periods.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">Some were stable, employed, long term
patients while others were known to use other drugs including alcohol and had
less stable lives generally.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">Detection of irregularities with adherence was made by self-report,
venipunctures, requests for supplements or hospitalisations.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">Such patients often dictated their own safety
measures such as more regular attendance, increased dose supervision and for
some, dose adjustments.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">Transfer from
methadone to buprenorphine was also considered in some cases.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">During the period of zero supervision, several of our patients started
taking split doses, finding the benefit of less sedation and longer duration of
action.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">They were disappointed when dose
supervision resumed once the clinic re-opened for regular operation.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">The most obvious solution for this is
transfer to buprenorphine which is longer acting and usually non-sedating.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">This can now be accomplished, even in those
on high doses of methadone, using the ‘Bernese’ microdosing technique without
the need to reduce methadone doses at all (more about that in a future posting).</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">Several groups have tried to measure changes from the Covid provisions
in opiate maintenance yet there is still no systematic examination of the
outcomes of dose supervision and regular attendance for medication.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">A Yale University group headed by addiction
psychiatrist Ayana Jordan was working on the subject during the early months of
Covid in mid-2020.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">A press release waxes
about the benefits of increased dispensed doses in American methadone programs
(see first reference below).</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-size: 14pt;">However, I
have read little about the ‘down side’ which we have noted
above.</span><span style="font-size: 14pt; mso-spacerun: yes;"> </span><span style="font-family: "Times New Roman", "serif"; font-size: 14pt;">Evidence based treatment will always be safest even though it may be inconvenient.</span><span style="font-family: "Times New Roman", "serif"; font-size: 14pt;"> </span></p>
<p class="MsoNormal"><a href="https://abcnews.go.com/Health/wireStory/covid-pandemic-changed-methadone-treatment-addiction-79422346" style="font-size: 14pt;">How
COVID pandemic changed methadone treatment for addiction - ABC News (go.com)</a></p>
<p class="MsoNormal"><u><span style="color: blue; font-size: 14pt; mso-fareast-font-family: "Times New Roman";"><a href="https://www.sciencedirect.com/science/article/pii/S0740547221003160?dgcid=author">Did
drug use increase following COVID-19 relaxation of methadone take-out regulations?
2020 was a complicated year - ScienceDirect</a></span></u></p>
<p class="MsoNormal"><a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.13382" style="font-size: 14pt;">Opioid
agonist treatment and patient outcomes during the COVID‐19 pandemic in south
east Sydney, Australia - Lintzeris - - Drug and Alcohol Review - Wiley Online
Library</a></p>
<p class="MsoNormal"><span style="font-size: 15.0pt;"><a href="https://pubmed.ncbi.nlm.nih.gov/34600258/">The impact of COVID-19 on
opioid treatment programs in the United States - PubMed (nih.gov)</a></span></p><p class="MsoNormal"><u><span style="color: blue; font-family: "Calibri","sans-serif"; font-size: 15.0pt; mso-fareast-font-family: "Times New Roman";"><a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1465-3362.2011.00394.x">A pilot
randomised controlled trial of brief versus twice weekly versus standard
supervised consumption in patients on opiate maintenance treatment - HOLLAND -
2012 - Drug and Alcohol Review - Wiley Online Library</a><o:p></o:p></span></u></p><p class="MsoNormal"><span lang="EN-US" style="font-size: 14.0pt; mso-ansi-language: EN-US;"> </span></p><p class="MsoNormal"><span style="font-size: 14pt;">
</span></p><p class="MsoNormal"><span lang="EN-US" style="font-size: 14.0pt; mso-ansi-language: EN-US;"> </span></p><p class="MsoNormal"><span style="font-size: 14pt;"><br /></span></p><p class="MsoNormal"><span style="font-size: 14pt;">Written by Andrew Byrne ..</span></p>
<p class="MsoNormal"><br /></p></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-80027855339749481242021-07-04T00:44:00.003+10:002021-07-04T00:47:01.283+10:00Benzodiazepines in psychiatry and addiction medicine - do they still have a place in chronic care?<h2>Sydney Addiction Seminar</h2>
<p class="MsoNormal"><span style="font-size: 14.0pt;">Wednesday 28th November, 2018<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">“Benzodiazepines in
psychiatry and addiction medicine - do they still have a place in chronic
care?”</span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">Vladan Starcevic, Paul Haber,
Andrew Byrne. Moderator Dr Richard Hallinan.</span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14.0pt;">Psychiatrist and Associate Professor
Vladan Starcevic spoke about the safety and effectiveness of diazepam and
related drugs for anxiety. He stressed
the poor results from almost every treatment tried since the time of
Hippocrates for this common and disabling condition. This changed dramatically with the
introduction of benzodiazepines starting with chordiazepoxide (Librium) in 1959. We were shown numerous trials which included
comparisons with tricyclic antidepressants, SSRI’s, SNRI’s and non-drug
alternatives (talking therapies, yoga, acupuncture, etc). The benzodiazepines came out as more
effective nearly every time. The speaker
emphasised the low rates of side effects (‘almost none’) as well as the low
rates of dependence on the drugs (around 2% in most studies). It seems that sedation is not considered a
side effect of sedatives but a dose related effect, sometimes wanted, as for
insomnia, or unwanted for daytime anxiety patients. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">Some myths were busted such
as the canard that antidepressants are not habit forming, do not develop
tolerance and do not have any withdrawals (further supportive studies were cited).</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">The saga of the use and alleged abuse of fluoxetine
(Prozac) was quoted.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">Professor Starcevic
almost sounded like an advertisement for benzodiazepines yet he is clearly
expert in the field and quoted rigorous studies to support his views.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">He also serves on a number of international
committees on the treatment of anxiety and related disorders.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">We have all seen the pendulum swing from Valium
and related drugs being the panacea to the pariah.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">Despite this prescribers all know the great
benefits which can be had by using careful assessments, judicious prescribing with
psychosocial supports for stress cases who can be very vulnerable and for whom
there are few effective alternatives.</span><span style="font-size: 14pt;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14.0pt;">This led into a talk by Prof
Haber of some aspects of pharmacology of GABA receptors and the respective
places in the neurone where barbiturates, alcohol, benzodiazepines, etc, were
thought to act … and how flumazanil can block the process of hyper-polarisation
when chloride ions are allowed into the cell making it less likely to
depolarise. Then Prof Haber reminded us of
the origin of the suffix ‘PAM’ attached to so many of the benzodiazepines - and
said it might be the only thing some audience members might remember from the whole
evening. <i>Positive Allosteric Modulators</i> (PAM) of the neurone. We were shown slides from PBS to demonstrate
the enormous popularity of sedatives in Australia since the benzodiazepines replaced
the barbiturates from about 1960 onwards.
<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14.0pt;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14.0pt;">I spoke next about our negative
experience using the zero-tolerance approach.
This had resulted in many patients relapsing after periods of
benzodiazepine reductions or abstinence, often associated with high potency
products such as alprazolam, clonazepam or flunitrazepam (Xanax, Rivotril,
Hypnodorm). These were sometimes
prescribed but most commonly were obtained from the street market. We selected some long-term patients who were
clearly benzodiazepine dependent and allowed a limited daily dose, initially
under supervision. This was most usually
diazepam in doses from 2mg to 15mg daily.
<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">American treatment guidelines
point out that just because a patient in on OTP they should not be denied
benefits of benzodiazepines for anxiety, panic disorder, insomnia or
epilepsy.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">And those with dependency need
to have this addressed.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">Yet this should
not simply mean “Valium on demand”.</span><span style="font-size: 14pt;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">I was asked whether I was
treating dependence or psychiatric symptoms of stress and anxiety: which is almost
like the question of which came first, the chicken or the egg?</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">Just as methadone maintenance patients may
comprise pain management cases as well as some recreational drug users, the
matter becomes academic once the patient gets to a certain point in their
opiate consumption.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">It is now widely
agreed that whether one started drug use in a medical setting or the illicit
market, opiate dependency treatment should be the same.</span><span style="font-size: 14pt;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">Withdrawal symptoms from both
opiates and benzodiazepines usually involve dysaesthesia, anxiety and/or
insomnia.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">Hence it is not surprising
that for some OTP patients, the consumption of opiates and benzodiazepines is
closely aligned and equally important to them.</span><span style="font-size: 14pt;"> </span></p>
<p class="MsoNormal"><span style="font-size: 14pt;">We have long used the
principles of ‘universal precautions’ which assumes that all patients are
potentially dependent and should be treated as such, with some dose
supervision, some counselling and occasional urine toxicology testing.</span><span style="font-size: 14pt;"> </span><span style="font-size: 14pt;">Equally, all patients may be genuine anxiety
disorder sufferers and thus deserve consideration of pharmacotherapy for that
just like any other medical or psychiatric patient.</span><span style="font-size: 14pt;"> </span></p>
<p class="MsoNormal"><br /></p>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-29400919475911954402021-06-10T19:21:00.001+10:002021-07-04T19:23:35.435+10:00This is my Covid warning email sent to family members on 26th Jan 2020 ... <h2><b><span lang="EN-US" style="font-family: "Tahoma","sans-serif"; font-size: 10.0pt; mso-ansi-language: EN-US;">Subject:</span></b><span lang="EN-US" style="font-family: Tahoma, sans-serif; font-size: 10pt;"> Corona virus alert is serious and we should all be
taking note.</span></h2><div>
<p class="MsoNormal">I have followed this and it is a REAL worry, not only for
China but for us as well. </p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">At this early stage we don’t know that much … but that this
disease is a very serious form of respiratory infection which can spread from
droplets just like colds and influenza. </p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">We would be crazy to eat in a busy restaurant in Hurstville
just at the moment. Or to travel to China at all, probably. </p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">We should all have <u>and wear</u> face masks whenever in
public transport or enclosed public spaces. I have a small supply at the
surgery but any chemist should supply (but Gold Cross Pharmacy in Redfern have
run out already!!). </p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">So please take this threat seriously and get take-away food,
avoid public transport if possible and WEAR a mask when out of the house. </p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">In a few more days our entire lives could be changed by both
the disease and our authorities’ response to it. Already China has restricted
travel to and from large parts of the country. Wuhan is at a crossroads
in central China and twice in the past has been the capital of China.
Similar things happened with the Great Plague in 1349 … but much slower … see: <a href="https://en.wikipedia.org/wiki/Black_Death">https://en.wikipedia.org/wiki/Black_Death</a>
. </p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">I wish I could say, like global warming, that this was all a
hoax … but I strongly fear it is for ‘very real’. AB ..</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal"><br /></p></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-31966234258025035942020-10-18T19:00:00.004+11:002020-10-18T19:02:40.287+11:00Face-masks not only prevent Covid infections but reduce severity in those who contract virus. New UCSF analysis.<h2><br /></h2><div><span style="font-size: 13pt;">An impressive paper from Dr Monica
Gandhi and colleagues* has brought together several strands of evidence showing
that as well as reducing Covid-19 infections, the wearing of masks substantially
reduces the severity of infections. </span></div><div>
<p class="MsoNormal"><span style="font-size: 13pt;">Along with a persuasive
hamster experiment from Hong Kong, they quote the Diamond Princess in Japan and
the Greg Mortimer cruise ship in South America where symptomatic infections
were 80% and 20% respectively. This
radical difference is alleged to be largely due to universal wearing of masks
on the latter ship, including N95 masks for all crew members. Several examples are quoted of large Covid clusters
in factories which supplied masks with up to 95% of infections being asymptomatic. The authors use other historical,
geographical and basic science evidence to support the conclusion that the
quantity of virus exposure (‘inoculum’) is related to infection severity. </span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">One can understand how
climate change denial has a political slant but the politicisation of mask
wearing seems beyond explanation. Older
readers may remember a minority who refused to use seat belts when they were
introduced. They were soon silenced by
statistics showing reduced injuries and saved lives. Masks were widely used in the 1918 influenza
epidemic – and made compulsory in many jurisdictions. Yet there were ‘conscientious objectors’ then
as now. </span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">We should all wear masks when
in buses, trains, elevators, taxis, shops, etc, as currently advised by many health
authorities. </span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">Written by Andrew Byrne,
Redfern Addictions Physician. Usual
email </span><a href="mailto:ajbyrne@ozemail.com.au"><span style="font-size: 13pt;">ajbyrne@ozemail.com.au</span></a></p>
<p class="MsoNormal"><br /></p>
<p class="MsoNormal"><span style="font-size: 13pt;">References:<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">*</span> <span style="font-size: 13pt;">Gandhi M, Beyrer C, Goosby E. Masks Do More Than
Protect Others During COVID-19: Reducing the Inoculum of SARS-CoV-2 to Protect
the Wearer. 2020 Journal of General Internal Medicine. </span></p>
<p class="MsoNormal"><a href="https://link.springer.com/article/10.1007/s11606-020-06067-8"><span style="font-size: 13pt;">https://link.springer.com/article/10.1007/s11606-020-06067-8</span></a><span style="font-size: 13pt;"> <o:p></o:p></span></p>
<p class="MsoNormal"><br /></p>
<p class="MsoNormal"><span style="font-size: 13pt;">One More Reason to Wear a
Mask: You’ll Get Less Sick From COVID-19. News Summary from UCSF. <o:p></o:p></span></p>
<p class="MsoNormal"><a href="https://www.ucsf.edu/news/2020/07/418181/one-more-reason-wear-mask-youll-get-less-sick-covid-19"><span style="font-size: 13pt;">https://www.ucsf.edu/news/2020/07/418181/one-more-reason-wear-mask-youll-get-less-sick-covid-19</span></a><span style="font-size: 13pt;"> <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;"> <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 13pt;">Chronology of COVID-19 Cases
on the Diamond Princess Cruise Ship and Ethical Considerations: A Report From
Japan.<o:p></o:p></span></p>
<p class="MsoNormal"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7156812/"><span style="font-size: 13pt;">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7156812/</span></a><span style="font-size: 13pt;"> <o:p></o:p></span></p>
<p class="MsoNormal"><br /></p>
<p class="MsoNormal"><span style="font-size: 13pt;">COVID-19: in the footsteps of
Ernest Shackleton.<o:p></o:p></span></p>
<p class="MsoNormal"><a href="https://thorax.bmj.com/content/75/8/693"><span style="font-size: 13pt;">https://thorax.bmj.com/content/75/8/693</span></a><span style="font-size: 13pt;"> <o:p></o:p></span></p>
<p class="MsoNormal"><br /></p>
<p class="MsoNormal"><a name="OLE_LINK2"><span style="font-size: 13pt;">Surgical
Mask Partition Reduces the Risk of Noncontact Transmission in a Golden Syrian
Hamster Model for Coronavirus Disease 2019 (COVID-19)</span></a><span style="font-size: 13pt;"><o:p></o:p></span></p>
<a name="OLE_LINK4"></a><a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa644/5848814"><span face=""Calibri","sans-serif"" style="font-size: 13pt; mso-ansi-language: EN-AU; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa644/5848814</span></a><span face=""Calibri","sans-serif"" style="font-size: 13pt; mso-ansi-language: EN-AU; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"> </span></div>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-23914987025137282332020-06-29T16:13:00.002+10:002020-06-30T15:54:55.060+10:00Historical paper on the development of opiate maintenance and links with AA. 'ALCOHOLISM' Clinical and Experimental Research Vol 15/No 5 Sept/Oct 1991 <br />
<br />
EDITORIAL Addiction as a Public Health Problem: Vincent P. Dole <br />
<br />
<br />
WHEN I FIRST became involved in studies of addiction 30 years ago, a society dedicated to this topic would have had no place in organized medicine. The subject was not even considered in the curricula of medical schools. Back then we assumed that addiction simply was a sign of psychopathology. Drug abuse and alcoholism were regarded as shameful dependencies on chemical substances, used for illicit gratification and escape from reality. If the subject came up in discussion, a typical physician would say that addicts were morally weak: they needed discipline, not medical treatment and certainly not a medically prescribed drug. This negative attitude still has considerable force today in medical and political circles. <br />
<br />
Times are changing, however. The existence of this society bears witness to the official recognition of addicts as sick persons, deserving serious study and medical treatment, when appropriate. I have seen some of the changes that have led us to this point and have had the privilege of learning from persons who are now legends. Let me describe these experiences. <br />
<br />
In 1960 I was a laboratory-based investigator at Rockefeller University-busy in specialized work and insulated from the real world. I commuted to New York from a comfortable house with a big lawn and view of the water in Rye, New York. I worked during the day in a laboratory on the University campus, and returned home in the evening, usually reading and editing journal papers in transit. Sometimes I looked out of the window. Occasionally, to save time in the morning, I left the train at the 125th Street Harlem Station and continued the trip to my laboratory on the elevated Third Avenue trolley (now gone). Walking the short distance between stations on 125th Street and then travelling 60 blocks on the elevated trolley-in effect a moving aerial platform-I saw drugs being sold on the sidewalks, drunks sleeping in doorways, young men idling on corners, young women apparently available at a price, shabby buildings, and busy bars. <br />
<br />
Of course I had been aware of social problems in the inner city. Then, as now, the media were filled with reports of gang wars, murders, rape, arson, drug abuse, police raids, etc. But being in the neighborhood made the problems real. Society was disintegrating in my own city, not in another world. Something very bad had happened to people in what not long ago had been decent neighborhoods. The community was sick. What should be done? <br />
<br />
In the basic sense of the term, this was a public health problem. Young people had grown up in disorder, without adequate education or employment, and many were now addicted to alcohol and drugs. Streets were littered. Buildings had deteriorated. Successful persons had left the area. Drug abuse had made the victims of the process the vectors of further spread. Treatment would have to go beyond hiring more police. By analogy with epidemics of infectious disease, critical interventions were needed to halt transmission of drug abuse without adding to the damage, and do this with limited resources. In public health terms, where were the feasible points of attack on the epidemic of drug abuse? <br />
<br />
Obviously, this would be more complicated than dealing with an epidemic of infectious disease, but it seemed reasonable to hope that a comprehensive public health approach could succeed, if backed by consistent political support. Large scale effective treatment programs were needed for persons already addicted, coupled with rational measures for prevention of new cases. However, it soon became apparent that this was too much to expect. A profound disruption of society, then as now, fragments a community into special-interest groups opposing each other. Elected officials become powerless to resist vocal minorities, or to institute needed reforms. And the medical profession, which should have provided leadership, was uninvolved. <br />
<br />
Conversations with experts over the next several months showed confusion at all levels, from the technical details of treatment to the feasibility of social rehabilitation. However, by then I had become too deeply concerned with the problem to quit. At least I could examine one detail of the problem, namely the pharmacology of heroin addiction, to see if an effective large-scale treatment could be developed. Having no experience in the field, I needed help. <br />
<br />
The event that changed my life was finding Marie Nyswander. I had read her book entitled “The Drug Addict as a Patient”, and it made sense. Moreover, I heard that she was the only doctor in New York who was willing to treat drug addicts outside of an institution. Other doctors were uninterested, or feared harassment by the Federal Bureau of Narcotics. I invited her to lunch at Rockefeller, expecting to meet a formidable lady. <br />
<br />
To my surprise the lady who arrived was a gentle person, vibrantly alert but small in stature, soft spoken, shy in manner. What I remember most vividly about our first meeting is how tired she looked. Later I learned why. She was supporting herself as a practicing psychiatrist on Park Avenue while also counseling addicts in Spanish Harlem and fending off the bullies of the Federal Bureau of Narcotics. At that time even psychiatric treatment of addicts without prescription of any medication (she had surrendered her narcotic license to avoid entrapment) was considered suspicious by the Bureau. Nevertheless she persisted. Although she had had little long-term success in treating heroin users with psychotherapy, psychoanalysis (she was also a certified analyst), group therapy, and social services, she was determined to continue her work and find a better treatment. On the positive side, she had found the addicts to be cooperative patients who were desperately in need of help. What had sustained her during a decade of lonely struggle was a sense of injustice-sick people asking for help and being rejected-and the gratitude of the patients even when her efforts failed. She expressed the conviction that narcotic addiction is basically a medical problem, an organic disease needing an effective medicine to abolish the pathological craving for narcotic drugs before social and psychological help could be effective on a large scale. Coming from an experienced psychiatrist who had been trained at the Federal Treatment Center in Lexington, Ky, and subsequently had devoted 10 years of her life to the problem, this was persuasive. I invited her to join me in setting up a physiological study of heroin addicts in Rockefeller Hospital. She accepted. Three years later we were married and remained inseparable companions until her death from cancer 5 years ago. <br />
<br />
During the first year of this work we had the good fortune to recruit a talented young clinician, Dr. Mary Jeanne Kreek, to participate in the testing program. We started where previous studies had stopped. Research on narcotic pharmacology in the Public Health Hospital (Lexington, Ky), although carefully conducted, had been incomplete. Short-term, toxic, and analgesic effects of various narcotic drugs had been well documented, but long-term behavioral pharmacology (which for narcotic drugs is quite different from the acute effects because of the development of tolerance and physical dependence) had not been adequately studied outside of a prison environment. In particular, the possibility of using a narcotic drug for maintenance of intractable addicts had been dismissed because earlier attempts to maintain addicts with morphine had failed. Knowing that the term “narcotic” comprises a wide range of drugs with significantly different properties, we decided to look further, testing other pharmacological agents in the narcotic category on addicted volunteers. <br />
<br />
To our surprise we found that one of the tested drugs, methadone (but not any of several other narcotics that we tested), had a normalizing, rather than narcotic, effect on long-term administration at a constant dose. This paradoxical finding of a narcotic drug having a normalizing effect was not understood until some years later when the pharmacokinetic studies of Dr. Kreek showed that the blood level of methadone is stabilized by first pass removal of about 98% of an oral dose, thus in effect creating a slow-release depot. As the circulating drug is removed from blood by metabolism, it is replaced by dissociation of molecules absorbed in the depot. The nervous system adapts to the steady level of methadone in the blood, thus abolishing its depressant effects. The medication thereafter acts as a normal neuromodulator, apparently substituting for dysfunctional components. Repeated testing by many independent observers during the past 25 years has verified this functional normalization. A patient who is stabilized on an adequate, constant daily dose of methadone is alert, healthy, and responds normally to painful stimuli. <br />
<br />
That is enough to say about the pharmacology of methadone in the present discussion, but before leaving the topic I must acknowledge the essential contributions made by many hundreds of dedicated physicians, counsellors, nurses, social workers, administrators, lawyers, volunteers, and ex-addicts who in their collective efforts translated a research finding into a treatment program. The original team deserves special recognition: Physicians: Drs. Joyce Lowinson, Robert Newman, Robert Millman, Elizabeth Khuri, Harold Trigg; Administrators: Ray Trussell and Detlev Bronk; Lawyer: Dona1 O’Brien; numerous ex-addicts who will remain anonymous; and the indispensable Herman Joseph, who is too versatile to characterize and too important to omit from this list. <br />
<br />
Now to the second topic, alcoholism. In the early 1960’s I was honored (and puzzled) by an invitation to join the Board of Alcoholics Anonymous as a Class A (nonalcoholic) trustee. Under the Constitution of AA only seven nonalcoholic persons could occupy this position, while several hundred thousand regular members of AA had entered the Fellowship the hard way, by being alcoholics. I was afraid that they might have made a mistake, and so before accepting the position, I discussed my research with executives of the Fellowship and raised the question as to whether this appointment might involve a conflict of interest, or at least the appearance of one. Would it embarrass the Fellowship to have an investigator of chemotherapy for narcotic addiction included in the Board of AA? They insisted that they saw no problem since the objectives were parallel-namely providing the best treatment available to sick persons. They also pointed to AA’s Fifth Tradition, which states that the mission of AA is solely to help alcoholics, and firmly rules against taking a position on other issues. They were right. There never has been a problem in my association with AA, and my admiration for Bill Wilson and the dedicated AA members that I came to know has increased over the years. <br />
<br />
Needless to say, I have gained far more from AA than the Fellowship did from me. It was my privilege to witness the healing force of personal service, group support and humility, while my only serious responsibility was to serve on a few committees and be an alert observer. As an organization, AA is the purest form of democracy. Major questions are submitted to the membership at the annual meetings of delegates representing all groups. Ultimately, questions of policy are resolved in a statement of the Group Conscience. The headquarters of AA, the General Services Office, is just what the name states. The secret of AA’s strength is service. It is a secret that certainly should be shared with the medical profession. <br />
<br />
Throughout most of my time on the Board I continued to be puzzled by the original question: Why had I, specifically, been invited to serve? If a physician experienced in treatment of alcoholics had been needed for professional opinion, there were many persons with better qualifications than I. If an administrative advisor was sought, I would be near the bottom of any search list. My only qualification was caring. One answer gradually became clear: In the early years of AA Bill and the original trustees were acutely sensitive to the danger of the Fellowship being distorted by aggressive persons with dogmatic opinions. During my time on the Board, I never detected any sign of this happening, but perhaps that simply reflected the success of the Traditions in the mature organization, keeping the Fellowship on track. Anyway, I assumed that I had been brought in as sort of a smoke alarm, a canary in the mine. <br />
<br />
A more specific answer, however, emerged in the late 1960s, not long before Bill’s death. At the last trustee meeting that we both attended, he spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. Always the good shepherd, he was thinking about the many sheep who are lost in the dark world of alcoholism. He suggested that in my future research 1 should look for an analogue of methadone, a medicine that would relieve the alcoholic’s sometimes irresistible craving and enable him to continue his progress in AA toward social and emotional recovery, following the Twelve Steps. I was moved by his concern, and in fact subsequently undertook such a study. <br />
<br />
Until its closure this year, my laboratory sought an analogue of alcoholism in mice so as to be able to test potential medicines that could benefit human alcoholics. We failed in this, but the work is only begun. Talented investigators in other laboratories are working on various aspects of the analogue problem. With the rapid advance in neurosciences, I believe that Bill’s vision of adjunctive chemotherapy for alcoholics will be realized in the coming decade. <br />
<br />
Now let me describe a coincidence that linked my work with Bill’s in an unexpected way, and perhaps explains my reaction to the scenes on the 125th Street 30 years ago. In Bill’s biography, he recalls a time in the winter of 1940 when the future of AA looked bleak. There was no activity in the newly opened club on 24th Street, and he was resting upstairs. Someone called up that a bum had come in, asking for Bill. Stumping up the steps was a stooped man with a cane who identified himself as a Jesuit priest. He said that he had come to meet Bill because of his admiration for the Twelve Steps. They were, he said, remarkably similar to the precepts of St. Ignatius Loyola, the founder of his religious order. As Bill’s biographer put it, “thus began a conversation that lasted 20 years.” <br />
<br />
My association with AA came much later, but my contact with Edward Dowling, the priest in this story, antedated Bill’s meeting with him by 15 years. He was my classroom teacher in first year high school at Loyola Academy in Chicago in the mid 1920’s. At that time he was a slim and vigorous young novitiate with jet black Irish hair and an intense manner. Among other subjects he discussed ethical conduct, not as an abstract thesis, but as a practical obligation toward others, and as a service that brings its own reward. <br />
<br />
In his subsequent busy career as a priest Father Dowling lived what he had taught, friend and advisor to people in trouble, to young families, to students, to alcoholics. I saw him only infrequently in later years, but remember most clearly the contrast between his continued intellectual force and his deteriorating health. Medically, he had severe rheumatoid spondylitis. He became progressively more stooped, white haired, limited in travel. Yet he did not even seem to be aware of his disability. He was too occupied with the problems of others. <br />
<br />
Marie Nyswander, Bill Wilson, and Edward Dowling are no longer with us, but their inspiration remains. For each, life was a continuing Twelve Step. They cared for people who suffered and especially those with the double jeopardy of being sick and being rejected. They left a positive record of success in dealing with these problems. <br />
<br />
It is my privilege, as their student, to greet the Society for Addiction Medicine, and transmit the expectations that they surely would have had for its future. They would have welcomed the strength and scientific discipline that you bring to the field. They would expect you to study and debate the technical details of treatment while being united in compassion for addicts. They would look to you for leadership that rises above special interests and prejudice. They would hope that you could lead the way to rational measures of prevention, and a variety of effective, nonpunitive treatments for various addictions. Certainly they would expect you to be concerned with the enormous public health problem of addiction: tens of thousands of drug addicts and hundreds of thousands of alcoholics who still remain untreated. It would be their fervent hope that you succeed.<br />
<br />
From The Rockefeller University, New York, New York. Receivedfor publication May 8, 1991; accepted May 24. 1991 The Distinguished Science Lecture presented at the Annual Meeting of the American Society of Addiction Medicine, Boston, MA, April 19, 1991. Reprint requests: Vincent P. Dole, The Rockefeller University. I230 York Avenue, New York, NY 10021-6399. Copyright 0 I991 by The Research Society on Alcoholism. Alcohol Clin E.xp Re.\. Vol 15, No 5. 199 I; pp 749-752 <br />
<br />Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-44896483965237715452020-02-02T01:34:00.000+11:002020-02-02T01:36:48.186+11:00Fentanyl manufacturer and top executives jailed for unlawful marketing.
<span style="font-size: 13.0pt; line-height: 115%;">
<span style="font-size: 13.0pt; line-height: 115%;">Fentanyl
manufacturer and top executives jailed for unlawful marketing. </span></span><span style="font-size: 13.0pt; line-height: 115%;"><span style="font-size: 13.0pt; line-height: 115%;">Financial
Times 24 January 2020</span></span><br />
<span style="font-size: 13.0pt; line-height: 115%;"></span><br />
<div>
<span style="font-size: 13.0pt; line-height: 115%;"><span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><br /></span></span></div>
<div>
<span style="font-size: 13.0pt; line-height: 115%;"><span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">John Kapoor, who founded Insys Therapeutics, was sentenced
to 5½ years in prison for Big Pharma crimes including the marketing of
fentanyl, a product only approved in the USA for cancer break-through
pain.<span style="mso-spacerun: yes;"> </span>See news item on </span><a href="https://www.ft.com/content/a27bbc80-3d35-11ea-a01a-bae547046735"><span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">https://www.ft.com/content/a27bbc80-3d35-11ea-a01a-bae547046735</span></a></span></div>
<div>
<span style="font-size: 13.0pt; line-height: 115%;"><span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"></span><br /></span></div>
<span style="font-size: 13.0pt; line-height: 115%;">
<span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-spacerun: yes;"> </span>“Opioid executive
admits to ‘no morals’ ahead of prison term”</span><br /><div>
<span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<div>
<span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">‘US pharmaceutical executives have been put on notice that
they could be held criminally liable for fuelling America’s epidemic of opioid
addiction, after the founder of the drugmaker Insys was sentenced on Thursday
to five-and-a-half years in prison for masterminding a scheme to bribe doctors
to prescribe a dangerous painkiller.’</span></div>
<br />
<span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Despite causing great satisfaction in some quarters, such
prosecutions are unlikely to make much difference to opioid deaths
currently.<span style="mso-spacerun: yes;"> </span>In America, where addiction
to prohibition is endemic, opioid use has now moved from prescription drugs
back to the black market where we know regulation has no effect on price and
little effect on availability.<span style="mso-spacerun: yes;"> </span></span><br />
<br />
<span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Comment by Andrew Byrne .. any replies best to </span><a href="https://www.blogger.com/null"><span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">ajbyrne@ozemail.com.au</span></a><span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">
</span><br />
<br />
<span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Along the same line, relating to Mundipharma in Australia: Wall
St Journal article. </span><br /><div>
<span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">“OxyContin Made The Sacklers Rich. Now It’s Tearing Them
Apart.” </span><a href="https://www.wsj.com/articles/oxycontin-made-the-sacklers-rich-now-its-tearing-them-apart-11562990475"><span style="font-size: 13.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">https://www.wsj.com/articles/oxycontin-made-the-sacklers-rich-now-its-tearing-them-apart-11562990475</span></a><span style="font-size: 14.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-spacerun: yes;"> </span></span></div>
<div>
<br /></div>
<span style="font-size: 14.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">And further: alleged actions denying life-saving
buprenorphine treatment by hiking costs to patients and insurers.<span style="mso-spacerun: yes;"> </span></span><br />
<span style="font-size: 14.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">“Federal prosecutors said that starting in 2010, Indivior
falsely marketed its film as being safer and less prone to abuse than cheaper
tablet forms, illegally earning billions of dollars in a "nationwide
scheme" to bill healthcare providers and insurers including Medicaid.”</span><br />
<span style="font-family: "calibri" , "sans-serif"; font-size: 11.0pt; line-height: 115%;"><a href="https://www.npr.org/2019/07/11/740856948/reckitt-benckiser-agrees-to-pay-1-4-billion-in-opioid-settlement"><span style="font-size: 14.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">https://www.npr.org/2019/07/11/740856948/reckitt-benckiser-agrees-to-pay-1-4-billion-in-opioid-settlement</span></a></span><span style="font-family: "calibri" , "sans-serif"; font-size: 14.0pt; line-height: 115%;"> </span>
<br />
</span><br />
<i></i><u></u><sub></sub><sup></sup><strike></strike>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-50816486202211598202018-12-26T16:05:00.002+11:002018-12-26T18:08:44.527+11:00Christmas 'post-card' from Andrew Byrne in Redfern ... <span style="font-size: 17.33px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"></span><br />
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<span style="font-size: 17.33px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span style="font-size: 13pt; margin: 0px;">Accreditation albatross;
Honour role; ‘Ice’ age; Successful OTP patients; Hep C; rat research using
cannabinoids and amphetamine.<span style="margin: 0px;"> </span></span></span></div>
<span style="font-size: 17.33px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">
</span>
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</div>
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</div>
<div style="margin: 0px;">
<span style="font-size: 13pt; margin: 0px;">Dear friends, neighbours and
colleagues, </span></div>
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</div>
<div style="margin: 0px;">
<span style="font-size: 13pt; margin: 0px;">It has been a mixed year, but
we seem to have survived more-or-less intact at the surgery in Redfern.<span style="margin: 0px;"> </span>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.<span style="margin: 0px;"> </span>More of that later.<span style="margin: 0px;"> </span></span></div>
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</div>
<div style="margin: 0px;">
<span style="font-size: 13pt; margin: 0px;">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.<span style="margin: 0px;"> </span>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).<span style="margin: 0px;"> </span>But none was as close to sainthood as Dr
Robert G. Newman who died this year after a car accident in The Bronx.<span style="margin: 0px;"> </span>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.<span style="margin: 0px;"> </span>Sympathies to his wife Seiko
and their children on their huge loss.<span style="margin: 0px;">
</span>And ours.<span style="margin: 0px;"> </span></span></div>
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<div style="margin: 0px;">
<span style="font-size: 13pt; margin: 0px;">It has been a challenging
year but with many rewards as we watch our patients achieve their goals, major
and minor.<span style="margin: 0px;"> </span>As I approach retiring age I
can provide more customised treatment for those with opiate, benzodiazepine and
alcohol problems.<span style="margin: 0px;"> </span>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.<span style="margin: 0px;"> </span>Yet we are frustrated on a daily basis by the
use of ‘crystal’ methamphetamine ('ice').<span style="margin: 0px;">
</span>Previously stable, pleasant methadone maintenance patients have become
unpredictable and unreasonable.<span style="margin: 0px;"> </span>There
have been frequent admissions to psychiatric wards where nothing much can be
done after assessment and possibly antipsychotic medication.<span style="margin: 0px;"> </span>We have tried prescribing dexamphetamine for
some consenting trial cases but without success at eliminating the use of ‘ice’
(methamphetamine), even for short periods.<span style="margin: 0px;">
</span>We await a positive strategy, perhaps from one of the younger members of
the addiction Chapter (RACP).<span style="margin: 0px;"> </span></span></div>
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</div>
<div style="margin: 0px;">
<span style="font-size: 13pt; margin: 0px;">We continue to address the
widespread use of benzodiazepine tranquillizers in our patient population
(18-50% dependency among OTP patients according to AATOD).<span style="margin: 0px;"> </span>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.<span style="margin: 0px;"> </span>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.<span style="margin: 0px;"> </span>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).<span style="margin: 0px;"> </span>‘Doctor shopper’ information is now available
on line.<span style="margin: 0px;"> </span>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.<span style="margin: 0px;"> </span></span></div>
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<div style="margin: 0px;">
<span style="font-size: 13pt; margin: 0px;">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.<span style="margin: 0px;"> </span>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.<span style="margin: 0px;"> </span>For others such goals are still at some
distance.<span style="margin: 0px;"> </span></span></div>
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<div style="margin: 0px;">
<span style="font-size: 13pt; margin: 0px;">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.<span style="margin: 0px;"> </span>This has been enormously
gratifying for patients, their families and our staff as a very positive
outcome.<span style="margin: 0px;"> </span>Congratulations are due to Dr
Hallinan for most of this important public health work which is subject of
continuing publications.<span style="margin: 0px;"> </span></span></div>
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<div style="margin: 0px;">
<span style="font-size: 13pt; margin: 0px;">My niece Gracie Hay has spent
a couple of sessions in the practice after completing her psychology honours
year at Macquarie University.<span style="margin: 0px;"> </span>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).<span style="margin: 0px;">
</span>Gracie is now a medical student at Notre Dame University and has some
busy years ahead of her.<span style="margin: 0px;"> </span>[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]<span style="margin: 0px;">
</span></span></div>
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<div style="margin: 0px;">
<span style="font-size: 13pt; margin: 0px;">Merry Christmas and Happy New
Year to all from the Byrne Surgery staff, hoping 2019 is a good one for all. </span></div>
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<div style="margin: 0px;">
<span style="font-size: 13pt; margin: 0px;">Andrew Byrne .. </span></div>
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<div style="margin: 0px;">
<span style="font-size: 13pt; margin: 0px;"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 10.5pt; margin: 0px;"><a href="https://www.researchgate.net/publication/327938519_Cannabidiol_treatment_reduces_the_motivation_to_self-administer_methamphetamine_and_methamphetamine-primed_relapse_in_rats"><span style="color: blue;">https://www.researchgate.net/publication/327938519_Cannabidiol_treatment_reduces_the_motivation_to_self-administer_methamphetamine_and_methamphetamine-primed_relapse_in_rats</span></a>
</span> </span></div>
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Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-31167617365423259642018-06-13T10:45:00.000+10:002018-06-13T10:45:25.710+10:00Portuguese drug policy changes save lives wholesale. Sydney meeting. <div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">Big turn-out on rainy Sydney evening for drug law reform meeting.<span style="mso-spacerun: yes;"> </span>Tuesday 5<sup>th</sup> June 2018. St
Stephen’s Church, Macquarie Street, Sydney. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">“An evening with Manuel
Cardoso the man who helped reform Portugal’s drug policy”.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Take-home message to get
through to our politicians: decriminalisation is now proven to save lives,
money and much more.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">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.<span style="mso-spacerun: yes;">
</span>And I estimate that there were over 1000 in attendance on a cold wet
winter evening.<span style="mso-spacerun: yes;"> </span>An email blitz had
offered a free umbrella for the first 250 to attend.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">The evening consisted of a
fireside chat type presentation – no power-point slides, etc.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Dr Manuel Cardoso said that
he was an optimist and did not recall anything bad, just the good.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>He
explained that he was the deputy and was modest about the dramatic changes in
his country following decriminalisation.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">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.<span style="mso-spacerun: yes;"> </span>Also
the economy was in the doldrums.<span style="mso-spacerun: yes;"> </span>I
understand that there was a coming together of three great minds being a
politician, a radio host and a law professor.<span style="mso-spacerun: yes;">
</span>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.<span style="mso-spacerun: yes;"> </span>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).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Dr Cardoso was also giving
talks in Hong Kong, Argentina, Luxembourg, Norway and elsewhere on this trip,
seemingly in great demand.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Only America has a worse
system and even the current unprecedented overdose crisis seems unable to move
the prohibition monster.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>This latter group needs
help in numerous ways, just like others with disabilities or illness.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Three of the best comments of
the night came from the floor after the main interviews were over.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>This was then reflected by Rev Bill Crewes
who dated his first meeting on the subject to the 1970s.<span style="mso-spacerun: yes;"> </span>He also mourned the lack of serious moves
away from the failed policies of prohibition and harm maximization.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Why are we still locking up drug users?<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">This latter was taken up by
ex-Premier Geoff Gallop whose government in WA virtually decriminalised
cannabis.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Even some of his own (Labor) government’s
easing of cannabis restrictions in WA were rolled back by a subsequent (Liberal
coalition) government.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Dr Marianne Jauncey spoke
briefly about her experience as director of the Medically Supervised Injecting
Centre in Kings Cross.<span style="mso-spacerun: yes;"> </span>This is the only
place in Australia where it is legal to possess illicit drugs.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>After numerous false starts
it appears that Melbourne may soon have an injecting centre.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Others had particular
questions for Dr Cardoso about the situation in Portugal and how that might be
relevant to other jurisdictions.<span style="mso-spacerun: yes;"> </span>His
answers while direct were generic.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>He replied that he knew of no such moves and
would be surprised if there were any.<span style="mso-spacerun: yes;">
</span>The Church, he said, was wholly supportive.<span style="mso-spacerun: yes;"> </span>It seems that the benefits have been so
widespread and so obvious that the entire population, not just drug users, can
see the benefits.<span style="mso-spacerun: yes;"> </span>There may be similarities
to the lifting of alcohol prohibitions in America 90 years ago.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">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.<span style="mso-spacerun: yes;"> </span>It was also nice to see a younger generation
of health professionals, advocates, researchers, etc in attendance at such a
gathering.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="color: black; font-family: "Helvetica","sans-serif"; font-size: 13pt; mso-fareast-language: EN-AU;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">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.<span style="mso-spacerun: yes;"> </span>It
took the ‘Mothers of America’ to start the moves against prohibition in that
country … maybe we need a similar movement here.<span style="mso-spacerun: yes;"> </span>The rationale is compelling … and in America
with the overdose crisis the case is overwhelming.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Written by Andrew Byrne,
Redfern Addiction Physician.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">References: </span><span style="color: black; font-family: "Arial","sans-serif"; font-size: 13pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;">Greenwald G. Drug
Decriminalization in Portugal: Lessons for Creating Fair and Successful Drug
Policies. Cato Institute. 2009<span style="mso-spacerun: yes;"> </span></span><a href="https://www.cato.org/publications/white-paper/drug-decriminalization-portugal-lessons-creating-fair-successful-drug-policies"><span style="font-family: "Arial","sans-serif"; font-size: 13pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><span style="color: blue;">https://www.cato.org/publications/white-paper/drug-decriminalization-portugal-lessons-creating-fair-successful-drug-policies</span></span></a><span style="color: black; font-family: "Arial","sans-serif"; font-size: 13pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="color: black; font-family: "Arial","sans-serif"; font-size: 13pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="color: black; font-family: "Arial","sans-serif"; font-size: 13pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;">Melbourne injecting room: </span><a href="https://www.theage.com.au/national/victoria/ice-will-be-allowed-in-melbourne-safe-injecting-room-20180410-p4z8th.html"><span style="font-family: "Arial","sans-serif"; font-size: 13pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"><span style="color: blue;">https://www.theage.com.au/national/victoria/ice-will-be-allowed-in-melbourne-safe-injecting-room-20180410-p4z8th.html</span></span></a><span style="color: black; font-family: "Arial","sans-serif"; font-size: 13pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-AU;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Calibri","sans-serif"; font-size: 11pt; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Calibri","sans-serif"; font-size: 11pt; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"><o:p> </o:p></span></div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-22768800835650443152018-05-13T09:30:00.001+10:002018-12-26T16:12:45.600+11:00Dr Kandel on memory loss in the elderly. <div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYWE5su_bo1XoweBZP6bvaF-Al6gz-DAzbb0zoGqxJkzZwqfJCVM5-LNSWFmKqcLbTAkNQtmUy74xOJ26qEiVUG1vw15hH8BlGvj2HIt1ICIkgDLauzwVllMBupM3O51EPQgrqCg/s1600/kane0418.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1229" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYWE5su_bo1XoweBZP6bvaF-Al6gz-DAzbb0zoGqxJkzZwqfJCVM5-LNSWFmKqcLbTAkNQtmUy74xOJ26qEiVUG1vw15hH8BlGvj2HIt1ICIkgDLauzwVllMBupM3O51EPQgrqCg/s400/kane0418.JPG" width="306" /></a></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">April 12 2018<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">The Eric Simon Lecture in
Basic & Translational Neuroscience<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Eric R. Kandel, MD<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">University Professor and Fred
Kavli Professor<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Department of Neuroscience<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Columbia University<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Senior Investigator<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Howard Hughes Medical
Institute<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Smilow Seminar Room<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">I had been invited by
Addiction Textbook editor Dr Joyce Lowinson to a talk by Nobel Laureate Eric
Kandel on memory loss in the elderly.<span style="mso-spacerun: yes;"> </span>His
Nobel Prize in 2002 was for work on snails and the laying down of short and long
term memory in brain cells.<span style="mso-spacerun: yes;"> </span>I sat in the
front row next to a doctor from Bellevue Hospital where some of the rat experiments
quoted by Prof Kandel had been done.<span style="mso-spacerun: yes;"> </span>The
speaker was introduced by Dr Eric Simon who was honoured by this annual address
and who was the first to name endogenous endorphins in the human brain. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">The initial point of the talk
was to emphasise the important differences between Alzheimer’s disease and
‘benign senescent memory loss’.<span style="mso-spacerun: yes;"> </span>The
latter had first been described (allegedly) by a member of the audience and is a
well known syndrome.<span style="mso-spacerun: yes;"> </span>A side point was
made that despite modern publications needing 20 or more pages plus appendices,
Crick and Watson’s paper reporting the double helix was only 3 pages long.<span style="mso-spacerun: yes;"> </span>And Sigmund Freud wrote some critical papers
of a similar length.<span style="mso-spacerun: yes;"> </span>Dr Kandel reported
being at James Watson’s 90th birthday the week before.<span style="mso-spacerun: yes;"> </span>We were indeed in the presence of
greatness!<span style="mso-spacerun: yes;"> </span>I might add that Dr McBride’s
report of thalidomide consequences was less than half a page in Lancet.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">The most important message of
the talk was that rodent experiments had confirmed the difference between
modest memory loss due to age and Alzheimer’s Disease with amyloid build-ups,
tangles and other typical pathological findings which can be induced in rats.<span style="mso-spacerun: yes;"> </span>Dr Kandel’s main finding was that high levels
of ‘osteocalcin’ were associated with benefits in retaining memory functions,
even into old age (which for rats is 18 to 24 months).<span style="mso-spacerun: yes;"> </span>It seems that this hormone is produced in
osteoclasts mostly in bone but also in the circulating blood stream.<span style="mso-spacerun: yes;"> </span>He also described on a specific haplotype
which was apparently associated with low level of osteocalcin and a propensity
to significant memory less.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Over the past five years of
research Dr Kandel found that the best way to elevate osteocalcin levels is to
exercise to the level of walking about 3 kilometres every day (for a human –
most of his experiments so far have been with rats).<span style="mso-spacerun: yes;"> </span>There are numerous other benefits of walking
for the heart, blood pressure, stress levels, etc, etc.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">There was a wide ranging and
lively Q&A session after the presentation. An audience member asked if swimming
was as good as walking but we were told that since one is weightless it is
probably less effective on the bones producing osteocalcin … also, “one could
drown” (a comic interjection from an Israeli colleague in the audience – to
which the speaker quipped “you Israelis are always worried about existential
threats”).<span style="mso-spacerun: yes;"> </span>I asked Dr Kandel if taking
exogenous osteocalcin would do the same as exercise.<span style="mso-spacerun: yes;"> </span>Some enterprising audience members had
already searched for supplies and found some company allegedly selling the
chemical already!<span style="mso-spacerun: yes;"> </span>This remains to be
trialled, it appears.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">My neighbour from Bellevue had
done some rat trials and told me quietly that their rats were very keen on
exercise, running on their treadmills for hours on end, thus improving their
experimental memory scores into ‘old age’ (>18 months for rats).<span style="mso-spacerun: yes;"> </span>I wanted to ask whether they were in small
cages or ‘rat-park’ enclosures as per Bruce Alexander’s work in Canada but time
ran out and I may never know.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "calibri" , "sans-serif"; font-size: 11pt;">Notes by Andrew Byrne .. visiting addictions
physician from Sydney, Australia.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "calibri" , "sans-serif"; font-size: 11pt;"><span style="mso-spacerun: yes;"></span></span> </div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<br /></div>
<span style="font-family: "calibri" , "sans-serif"; font-size: 11pt;"></span><div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<br /></div>
<span style="font-family: "calibri" , "sans-serif"; font-size: 11pt;">
<span style="mso-spacerun: yes;"><div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "times new roman"; font-size: small;">
<span style="font-size: 13pt;"><span style="font-family: "times new roman";">Summary in brief in talk by
Dr Kandel: </span><a href="https://www.youtube.com/watch?v=X15zFT7jyh4"><span style="color: blue; font-family: "times new roman";">https://www.youtube.com/watch?v=X15zFT7jyh4</span></a><span style="font-family: "times new roman";">
<o:p></o:p></span></span></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "times new roman"; font-size: small;">
</span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p><span style="font-family: "times new roman";"> </span></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "times new roman"; font-size: small;">
<span style="font-size: 13pt;"><span style="font-family: "times new roman";">Also brilliant TED talk on
neuroscience approach to portraiture: </span><a href="https://www.youtube.com/watch?v=Jyc7FIglkHI"><span style="color: blue; font-family: "times new roman";">https://www.youtube.com/watch?v=Jyc7FIglkHI</span></a><o:p></o:p></span></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "times new roman"; font-size: small;">
</span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p><span style="font-family: "times new roman";"> </span></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "times new roman"; font-size: small;">
</span></div>
</span><div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p></o:p><br /></div>
</span><br />
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
</div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-76794309645218231532018-05-08T10:33:00.003+10:002018-05-26T00:12:40.714+10:00Medical Postcard from New York: overdose crisis summary from NYU. <div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Dear Colleagues, <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">During a recent New York
visit I had numerous encounters in the medical, public health and dependency
fields.<span style="mso-spacerun: yes;"> </span>The opioid overdose crisis
dominates conversation, media and even the White House has been involved.<span style="mso-spacerun: yes;"> </span>Below is a summary of one key lecture I
attended followed by some other events which may be of interest.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;">Regards from Andrew Byrne ..
now back in Sydney, Australia.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">April 19 2018<span style="mso-tab-count: 1;"> </span>Stephen Ross, MD<o:p></o:p></span></div>
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<span style="font-size: 13pt;">“<i style="mso-bidi-font-style: normal;">The Opioid Epidemic: How We Got Here and How Do We Fix the Problem?</i>”
Associate Professor, Departments of Psychiatry and Child and Adolescent
Psychiatry Senior Director, Division of Substance Abuse, Bellevue Hospital.
Director, Addiction Psychiatry, Tisch Hospital, NYU.<o:p></o:p></span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">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.<span style="mso-spacerun: yes;"> </span>Dr Ross has also authored some
interested papers on the therapeutic possibilities of hallucinogens in patients
with serious medical disease.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">We were told about the
epidemics of opioid use starting early in the 19<sup>th</sup> century when
opium, laudanum and paragoric became very popular.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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
20<sup>th</sup> century and the circumstances can almost be predicted, or
should have been.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">The present epidemic seems to
have started after an air of confidence in medically prescribed opioids with a
low risk of addiction.<span style="mso-spacerun: yes;"> </span>These were
started by two brief communications published as letter to the editor, one from
Russell Portenoy and colleagues in NYC Sloane Kettering.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>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.<span style="mso-spacerun: yes;">
</span>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).<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">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).<span style="mso-spacerun: yes;"> </span>Of course pain is a symptom and not a sign at
all yet for marketing purposes this was highly effective.<span style="mso-spacerun: yes;"> </span>And furthermore there was very limited
evidence that opioids were effective for chronic non-cancer pain.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">Dr Ross divided the recent
overdose epidemic into three parts starting in about 2001: (1) prescribed opioids,
(2) heroin then (3) fentanyl additives.<span style="mso-spacerun: yes;">
</span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Opponents at the time were accused of
‘opiophobia’ (Dr Ross quipped that this would become a new DSM diagnostic
category!).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">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.<span style="mso-spacerun: yes;"> </span>These
knee-jerk restrictions caused many who were unwittingly addicted to move to
illicit heroin which flooded the market from Mexico.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">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.<span style="mso-spacerun: yes;"> </span>Because
these drugs are hundreds to thousands of times more potent than heroin they can
be imported in small packets undetected.<span style="mso-spacerun: yes;">
</span>Also we were told that innovations of the dark web, bitcoin and ‘pill
presses’ have added further to the difficulties.<span style="mso-spacerun: yes;"> </span>Two pills which look identical may have
vastly different potencies.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">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.<span style="mso-spacerun: yes;">
</span>The number of deaths has now exceeded all casualties of war including
both world wars for the US.<span style="mso-spacerun: yes;"> </span>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).<span style="mso-spacerun: yes;"> </span>We were shown age at death tables to show
that this is affecting all age groups but that younger people are now involved.<span style="mso-spacerun: yes;"> </span>The number of drug overdose deaths in the USA
was estimated to have been over 60,000 per year by 2017. <o:p></o:p></span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">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.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">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’.<span style="mso-spacerun: yes;"> </span>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).<span style="mso-spacerun: yes;"> </span>I saw a TV interview with a mother who had
found both of her late-teenage sons dead after a family celebration.<span style="mso-spacerun: yes;"> </span>It was chokingly tragic but is being repeated
all over the country every single day.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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</div>
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<span style="font-size: 13pt;"><span style="font-size: small;">
<span style="font-size: 13pt;">Naloxone programs were
mentioned and commended briefly but the obvious fact that they are of no
assistance when the overdose victim is alone.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></span><br />
<span style="font-size: small;">
</span><br />
</span><br />
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<span style="font-size: 13pt;"><span style="font-size: 13pt;"><span style="font-size: small;">Dr R</span>oss 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.<span style="mso-spacerun: yes;"> </span>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).<span style="mso-spacerun: yes;"> </span>Funds saved in the
criminal justice sector were put into treatment which had been substantially
expanded and improved.<span style="mso-spacerun: yes;"> </span>From having the
worst statistics in Europe for consequences of drug use most improved year by
year to be some of the most envious.<span style="mso-spacerun: yes;">
</span>These included reduced overdose rates, HIV and Hep C transmission,
crime, etc.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></div>
<span style="font-size: 13pt;">
</span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">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.<span style="mso-spacerun: yes;">
</span>While treatment availability in American cities is quite limited, in rural
areas such services were often completely absent.<span style="mso-spacerun: yes;"> </span>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).<span style="mso-spacerun: yes;">
</span>The ratios of drug users to treatment facilities were as unfortunate as
they could be.<span style="mso-spacerun: yes;"> </span>[see NY Times interactive
map with opioid overdose rates for every county: </span><a href="https://www.nytimes.com/interactive/2017/12/22/upshot/opioid-deaths-are-spreading-rapidly-into-black-america.html"><span style="font-size: 13pt;"><span style="color: blue;">https://www.nytimes.com/interactive/2017/12/22/upshot/opioid-deaths-are-spreading-rapidly-into-black-america.html</span></span></a><span style="font-size: 13pt;"> ] 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. <o:p></o:p></span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">Unlike many Americans, our
speaker was happy to mention prevention, treatment and harm reduction in the
one breath.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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 19<sup>th</sup> century.<span style="mso-spacerun: yes;"> </span>Some facetious comments even refer to
inappropriate interventions such a blanket prohibition as being ‘harm
maximization’.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-size: 13pt;">There were a few Q&A’s at
the end after a major applause showing the audience appreciation.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;">Notes by
Andrew Byrne .. visiting addictions physician from Sydney, Australia.<span style="mso-spacerun: yes;"> </span></span><span style="font-size: 13pt;"><a href="http://methadone-research.blogspot.com/"><span style="mso-font-kerning: 14.0pt;"><span style="color: blue;">http://methadone-research.blogspot.com/</span></span></a><u><span style="color: blue; mso-font-kerning: 14.0pt;"> <o:p></o:p></span></u></span></div>
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<u><span style="color: blue; font-size: 13pt;"><o:p><span style="text-decoration: none;"> </span></o:p></span></u></div>
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<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;">Dr Ross’s talk video: <a href="https://med.nyu.edu/psych/education/continuing-medical-education-cme/grand-rounds-archives/grand-rounds-archives-2017-2018"><span style="color: blue;">https://med.nyu.edu/psych/education/continuing-medical-education-cme/grand-rounds-archives/grand-rounds-archives-2017-2018</span></a>
<o:p></o:p></span></div>
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<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;"><o:p> </o:p></span></div>
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<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;">IN BRIEF: <o:p></o:p></span></div>
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<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;">** Lecture by Dr Steve Ross on the opioid
crisis and what to do about it (summary/link above).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;">** Lecture by Nobel Laureate Dr Eric Kandel on
memory loss in the elderly (exercise more!)<o:p></o:p></span></div>
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<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;">** 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.<span style="mso-spacerun: yes;">
</span>Second speaker was Michael Charness, Boston VA, on alcohol interventions
in 50 years time.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> It was also in honour of Dr Stuart Gitlow who had been instrumental in Ms Collins' success. </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;">** Subsequent web-stream ASAM talks of
interest: <a href="https://www.youtube.com/watch?v=a8IcJXdwKbE&feature=youtu.be"><span style="color: blue;">https://www.youtube.com/watch?v=a8IcJXdwKbE&feature=youtu.be</span></a>
<o:p></o:p></span></div>
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<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;">** Harm reduction still a long way to go in
America.<span style="mso-spacerun: yes;"> </span>American Society of Addiction
Medicine (ASAM).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<br />
<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;">** 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.<span style="mso-spacerun: yes;"> </span>Yet they
are rarely if ever given in the same institution by the same staff thus
transfers are complex and sometimes impossible. <br />
<span style="font-family: Times New Roman;">
</span><span style="font-family: Times New Roman;">
</span><span style="font-family: Times New Roman;">
</span><span style="font-family: Times New Roman;">
</span><span style="font-family: Times New Roman;">
</span><table border="0" cellpadding="0" cellspacing="0" style="border-collapse: collapse; width: 65px;"><colgroup><col style="mso-width-alt: 2073; mso-width-source: userset; width: 49pt;" width="65"></col><tbody>
<tr height="18" style="height: 13.8pt;"><td height="18" style="background-color: transparent; border: 0px black; height: 13.8pt; width: 49pt;" width="65"><span style="font-family: Arial;"><a href="https://store.samhsa.gov/shin/content//SMA18-5063PT3/SMA18-5063PT3.pdf">https://store.samhsa.gov/shin/content//SMA18-5063PT3/SMA18-5063PT3.pdf</a> </span></td></tr>
</tbody></colgroup></table>
<o:p></o:p></span></div>
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<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;">** Meeting with Dr Mary Jeanne Kreek at
Rockefeller University wide ranging discussions including high dose methadone
and methadone for pain.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;">** I gave a talk on optimising outcomes in
opiate maintenance treatment at Columbia University (more info on
request).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;">** Meetings also with Dr Joyce Lowinson, Dr
Robert G. Newman, Prof Ernie Drucker, Dr Herman Joseph, Dr Doug Kramer, Ethan
Nadelmann and many others.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "calibri" , "sans-serif"; font-size: 13pt;">** Recommended TED talk J. Hari: <a href="https://www.youtube.com/watch?v=PY9DcIMGxMs"><span style="color: blue;">https://www.youtube.com/watch?v=PY9DcIMGxMs</span></a>
“Everything you think you know about addiction is wrong”.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-family: "calibri" , "sans-serif"; font-size: 11pt;"><o:p> </o:p></span></div>
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<span style="font-family: "calibri" , "sans-serif"; font-size: 11pt;"><o:p> </o:p></span></div>
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<span style="font-family: "calibri" , "sans-serif"; font-size: 11pt;"><o:p> </o:p></span></div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-41138912802134579322018-03-25T01:40:00.001+11:002018-03-25T02:00:06.535+11:00Buprenorphine alone or with naloxone: Which is safer? Subutex versus Suboxone<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;">Buprenorphine alone or with
naloxone:<span style="mso-spacerun: yes;"> </span>Which is safer?<span style="mso-spacerun: yes;"> </span>Kelty E, Cumming C, Troeung L, Hulse G.
Journal of Psychopharmacology (2018) in press. 1-9<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;">Dear Colleagues, <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;">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.<span style="mso-spacerun: yes;"> </span>However there was a significant increase in
mortality post-treatment in those who were prescribed the combination product
(odds ratio 1.59).<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>These extended to the post treatment period
and the authors conclude that: “<i style="mso-bidi-font-style: normal;">The
addition of naloxone does not appear to improve the safety profile of
buprenorphine</i>”.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;">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.<span style="mso-spacerun: yes;">
</span>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.<span style="mso-spacerun: yes;"> </span>The 90% transition rate was partly because in
WA take-away doses of the pure drug were banned coercively.<span style="mso-spacerun: yes;"> </span>There may have been an exemption for pregnant
women for whom the pure drug remains the recommended product.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;">So here finally we have a
study comparing pure buprenorphine with the combination product, although not a
randomised controlled trial.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>As with
other approved medicines, there is no obligation to do comparative research
before TGA/FDA approval.<span style="mso-spacerun: yes;"> </span>Indeed, all of
the early research was on the pure product including the MOTHER study in 2009.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Yet it would seem self evident that a pure
drug would be more desirable to drug seekers than a combination, regardless of the
constituents.<span style="mso-spacerun: yes;"> </span>Two studies indicated the
need for higher doses when the combination drug was used (Fudala and
Bell).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;">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.<span style="mso-spacerun: yes;">
</span>However, they also found that subjects appeared to require substantially
higher doses (>50% on average) when naloxone was added.<span style="mso-spacerun: yes;"> </span>Fudala et al. found substantially more
cravings in a large multi-centre RCT in the combination group using fixed doses.<span style="mso-spacerun: yes;"> </span>There have been no confirmatory studies to my
best knowledge.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;">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.<span style="mso-spacerun: yes;"> </span>And with earnest, experienced
and one-time well funded researchers.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;">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.<span style="mso-spacerun: yes;"> </span>It is also
possible that this was the cause of the Sydney patients seemingly requiring
higher doses in Bell’s old study.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;">A good investigative journalist
might make a good story over the profit motive, drug ‘evergreening’ and such,
but I leave all this to others.<span style="mso-spacerun: yes;"> </span>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!).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;">Notes by Andrew Byrne .. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;">References: <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;">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<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;">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<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-23793703560753357792017-10-02T16:16:00.006+11:002017-10-02T16:16:58.688+11:00Large study shows torsade risk remote and ECG non-predictive in methadone maintenance.<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;">
</span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;">Methadone and the QTc Interval: Paucity of Clinically Significant Factors in a Retrospective Cohort. Bart
G, Wyman Z, Wang Q, Hodges JS, Karim R, Bart BA. J Addiction Medicine pre-publication 2017.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;">Dear
Colleagues, <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;">Dr
Bart and co-authors have examined the medical records of around 1000 admissions
to methadone maintenance nearly all of whom had at least one ECG on or off
methadone (or both).<span style="mso-spacerun: yes;"> </span>They then compared
clinical cardiac events and mortality over 7000 patient years from the major
health facility in Minneapolis.<span style="mso-spacerun: yes;"> </span>There
was an average increase in QTc of 13 milliseconds in those on methadone at the
time of the ECG, consistent with other studies.<span style="mso-spacerun: yes;">
</span>This was associated with a very low rate of cardiac events of 2.5 per
1000 and QTc intervals were not predictive.<span style="mso-spacerun: yes;">
</span>Sudden cardiac death (SCD) rate was lower than age-adjusted community
rates (0.4 versus 1.75 per 1000 based on CDC state statistics).<span style="mso-spacerun: yes;"> </span>This parallels numerous other reports
attesting to the general protective value of being on methadone treatment (see
Krantz ref below on cardiac protection).<span style="mso-spacerun: yes;">
</span>No case of torsade des pointes was identified by the present authors
over 15 years. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;">This
study gives great reassurance in the cardiac safety of methadone maintenance
treatment.<span style="mso-spacerun: yes;"> </span>The authors also suggest that
the requirement for ECG in methadone patients should be reviewed since it does
not appear to serve any practical purpose.<span style="mso-spacerun: yes;">
</span>A Cochrane review also found no evidence to support QTc screening.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;">Concerns
over the supposed dangers of QTc prolongation have been over-played, partly by
commercial factors favouring the only licensed alternative to methadone
maintenance.<span style="mso-spacerun: yes;"> </span>Of about 150 torsades cases
reported in the literature since 2002 only one was fatal to my best
knowledge.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;">A
paper by Mori Krantz from Denver in 2002 claimed to have found an extraordinary
number of tachycardia cases from Colorado methadone clinics and a pain
management service in Canada.<span style="mso-spacerun: yes;"> </span>Torsade
des pointes was reported </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 14pt; mso-ansi-language: EN-US;">as a side effect
of methadone yet Krantz’s findings have never been replicated elsewhere, even
in large samples of closely studied patients over 30 years of research
literature.<span style="mso-spacerun: yes;"> </span>In the present series by
Bart and colleagues not one case was identified in 7000 patient-years.<span style="mso-spacerun: yes;"> </span>About 150 anecdotal reports in the literature
since 2002 shows this rare event occurs mostly in high-dose, complex methadone
patients who were taking other medications, were over 40 years of age and with
a higher rate in female patients.<span style="mso-spacerun: yes;"> </span>My own
practice with approximately 3000 patient-years has identified one single
torsade case (non-fatal).<span style="mso-spacerun: yes;"> </span>Alcohol and
pre-existing heart disease were also associations in this aging
population.<span style="mso-spacerun: yes;"> </span>Krantz’s claim that methadone
was associated with large numbers of otherwise unexplained deaths has also
never been supported by the literature (Byrne, Stimmel. Lancet 2009*).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;">Notes
FYI by Andrew Byrne, Sydney, Australia.<span style="mso-spacerun: yes;"> </span><a href="http://methadone-research.blogspot.com/"><span style="color: blue;">http://methadone-research.blogspot.com/</span></a>
<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;">Reasons
for cardiac protection by Mori Krantz (2001): <a href="http://www.redfernclinic.com/c/2008/11/dr-mori-krantz-on-cardiac-protections_8506.php4"><span style="color: blue;">http://www.redfernclinic.com/c/2008/11/dr-mori-krantz-on-cardiac-protections_8506.php4</span></a><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;">Krantz
on cardiac concerns from the following year (no mention of the balancing
protections above): Krantz MJ, Lewkowiez L, Hays H, Woodroffe MA, D. Robertson
AD, Mehler PS. Torsade de Pointes Associated with Very-High-Dose Methadone. Ann
Intern Med. 2002 137:501-504 <a href="http://www.annals.org/cgi/reprint/137/6/501"><span style="color: blue;">http://www.annals.org/cgi/reprint/137/6/501</span></a>
<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;">*Byrne
A, Stimmel B. Methadone and QTc prolongation. Lancet 2007 369:366<span style="mso-spacerun: yes;"> </span><a href="http://www.thelancet.com/journals/lancet/article/PIIS0140673607601810/fulltext"><span style="color: blue;">http://www.thelancet.com/journals/lancet/article/PIIS0140673607601810/fulltext</span></a>
<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt;"><o:p> </o:p></span></div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-76510913982191626742017-05-23T21:28:00.001+10:002017-06-05T08:50:50.885+10:00Medical post-card from New York in April 2017<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<div class="separator" style="clear: both; text-align: center;">
</div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsAj5SmT9SJHbHxSGweQrt-D_oWJeMcVI_eJ2JJtxCsAvbDAqKfuLrH8vMTTSDD4g0y0YyCVicxbY4cXbw9jRcKW9zICJ3JeYQXgfaxTFGHOpZdxcBm2p4hBGrXA2q2Z6WcpKP_A/s1600/017.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsAj5SmT9SJHbHxSGweQrt-D_oWJeMcVI_eJ2JJtxCsAvbDAqKfuLrH8vMTTSDD4g0y0YyCVicxbY4cXbw9jRcKW9zICJ3JeYQXgfaxTFGHOpZdxcBm2p4hBGrXA2q2Z6WcpKP_A/s320/017.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Butler Library, Columbia University</td></tr>
</tbody></table>
Dear Colleagues, </div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
New York has had an early spring but all talk is about the
new President and his almost daily tweets.<span style="mso-spacerun: yes;">
</span>In medical circles, however the opioid overdose crisis across America is
top news yet solutions are hard to find and some (like methadone in general
practice) are unmentionable.<span style="mso-spacerun: yes;"> </span>After three
years of investigations I believe I now know why methamphetamine is less of a
problem on the US East Coast and it seems to be due to cocaine being so cheap
being less than five dollars per cap in some areas.<span style="mso-spacerun: yes;"> </span>For the same financial reasons
benzodiazepines are less of a problem due to their high price in America.<span style="mso-spacerun: yes;"> </span>With national health schemes Valium and other
stronger sedatives are relatively easy to obtain at low cost in France, Israel,
Australia, etc.<span style="mso-spacerun: yes;"> </span>Ergo a larger abuse
problem.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Safer injecting facilities are now being pushed for in
public health forums but by few in authority in America.<span style="mso-spacerun: yes;"> </span>Naloxone without prescription is now
commonplace which is gratifying ... yet by definition it requires the presence
of another person at the scene of the overdose to save a life.<span style="mso-spacerun: yes;"> </span>Opioid maintenance TREATMENT can ensure a way
to stabilize the opioid epidemic yet such treatment is very hard or impossible
to access in much of the United States due to the restrictions on methadone
programs and the high cost of buprenorphine.<span style="mso-spacerun: yes;">
</span>It is a mystery to me why methadone is not available from private
American physicians, nor why American pharmacists are banned from administering
methadone in addiction programs.<span style="mso-spacerun: yes;"> </span>In a
meeting at Rockefeller University I was told the reason was the lack of a
profit motive as the drug is old and out of patent in its pure form (about 50
cents per dose). I was pleased to be able to get a world authority on
buprenorphine, Dr Doug Kramer into the Journal Club of a world authority on
methadone, Professor Mary Jeanne Kreek for a lively discussion including the
history of FDA approvals and initial dose recommendations.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
A new publication in the British Medical Journal (including
an American editorial) attests to the dramatic reduction in mortality, both
overdose and all-cause mortality, in those taking opioid maintenance treatment
when compared with opioid dependent citizens who are out of treatment.<span style="mso-spacerun: yes;"> </span>The metanalysis across several countries
shows substantial reductions in deaths, something which has been shown in
smaller studies for over 20 years.<span style="mso-spacerun: yes;"> </span>See: <a href="http://www.bmj.com/content/357/bmj.j1947"><span style="color: blue;">http://www.bmj.com/content/357/bmj.j1947</span></a>
(free access for both editorial and article on the subject).<span style="mso-spacerun: yes;"> </span>The acute need for action is talked about
daily in the US media yet nobody seems to talk about the elephant(s) in the
room which are a lack of treatment availability and drug company culpability
for pushing profitable opioid analgesics for so long.<span style="mso-spacerun: yes;"> </span>As a maintenance treatment, buprenorphine is
excellent for those who can afford it and those with lesser habits and the ability
to tolerate the induction requirements (being in or near withdrawal before
starting).<span style="mso-spacerun: yes;"> </span>The lack of a community
methadone program is costing America dearly.<span style="mso-spacerun: yes;">
One recent report quoted 50,000 deaths in one single year which out-numbers victims or war, cancer, accidents and suicides. </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
An interesting side issue is that American states which
legalised 'medicinal' cannabis in recent years have significantly lower overdose
rates and the initial figures are now being confirmed in longer term
statistics.<span style="mso-spacerun: yes;"> </span>While one can speculate on
the reasons, the 'normalisation' and decriminalisation of cannabis which has
been spearheaded by the Drug Policy Alliance, funded by George Soros must now
be given credit for saving hundreds or even thousands of lives.<span style="mso-spacerun: yes;"> </span>This organisation has been directed by Ethan
Nadelmann who stepped down in April after 20 years at the helm.<span style="mso-spacerun: yes;"> </span>His send-off was a moving event with
supporters, colleagues and friends including Ira Glasser, Stanton Peele, Joyce
Lowinson, Ernie Drucker, Clovis Thorn, asha bandele, Chris Soda, Ellen
Flenniken, Dr Robert Newman, Tony Newman, Tony Pappa, and many others including
Chief Prosecutor from Albany, David Soares and his wife.<span style="mso-spacerun: yes;"> </span>I was happy to be able to represent Australia
at such an auspicious gathering in Chelsea overlooking the Hudson River.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Hepatitis C remains a festering issue between outrageous
drug prices and limited funding.<span style="mso-spacerun: yes;"> </span>The New
York based activist group V.O.C.A.L. has long been advocating strongly for
State and Federal subsidies for such treatments to be more widely
available.<span style="mso-spacerun: yes;"> </span>We are very fortunate in
Australia that our PBS struck a very favourable deal with the suppliers,
allowing universal access to five new direct acting anti-viral (DAA) drugs (the
maximum yearly outlay was capped regardless of the number of prescriptions
written).<span style="mso-spacerun: yes;"> </span>After just over twelve months,
an estimated 38,000 patients have been treated ... which is 15% or more of all
the cases in Australia.<span style="mso-spacerun: yes;"> </span>This makes
hepatitis C eradication possible within the next several years.<span style="mso-spacerun: yes;"> </span>Only tiny Iceland has done a similar effort,
with its reported 1200 HCV cases. </div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
I had very fruitful discussions with senior colleagues at
Columbia University and at Rockefeller University regarding the possible safe
use of benzodiazepines in stable OTP patients as well as our own recent
experience with treating hepatitis C.<span style="mso-spacerun: yes;"> </span>It
appears that cirrhosis based on viral hepatitis may be partly reversible,
contrary to the popular wisdom and I was able to give some examples from
Australia.<span style="mso-spacerun: yes;"> </span>We have had ~30 viral
clearances out of ~30 patients on Direct Acting Antivirals (DAA) over the past
14<span style="mso-spacerun: yes;"> </span>months.<span style="mso-spacerun: yes;"> </span>This compares with about 45 out of 55
successful treatments on interferon and ribavirin (plus protease inhibitors
more recently) over about 9 years (and it was NOT all easy going).<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
My last days in Manhattan included some touristy things such
as Katz's Deli (a disappointment), Barney Greengrass Deli (a high point), Hello
Dolly with Bette Midler ($59 seats in back row sold on day of performance only)
and the 50th Anniversary concert at the Metropolitan Opera House.<span style="mso-spacerun: yes;"> </span>Details and photos on request (or on my other
blogs soon).<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
With best regards, </div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Andrew Byrne ..<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p><br />
<o:p></o:p> </div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-92207474423668188932017-02-12T02:20:00.004+11:002017-02-13T20:47:55.278+11:00Lower mortality and better retention in OTP patients prescribed benzos.<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Bakker A, Streel E. Benzodiazepine maintenance in opiate
substitution treatment: Good or bad? A retrospective primary care case-note
review. Journal of Psychopharmacology 2016 1-5</div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Dear Colleagues, </div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Finally we have some strong evidence that prescribing
benzodiazepines for patients on opiate maintenance treatment is not only safe
and effective but in some cases may be obligatory, under careful supervision
with adequate psychosocial supports.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Dr Bakker in London has done us the great service of
publishing the data he has extracted from his own general practice from over 20
years of caring for drug dependent patients.<span style="mso-spacerun: yes;">
</span>His practice is based on sound harm reduction principles, prescribing
long acting, low potency benzodiazepines such as diazepam or clonazepam using
graduated supervision for dependent patients.<span style="mso-spacerun: yes;">
</span>In this he bucked the trend based on what he considered good medical
practice, albeit non-evidence based (like much prescribing practice).<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Bakker reports on 278 OTP patients since 1998 (1289
patient/treatment years) comprising a high proportion of socio-economically
deprived citizens, two thirds being male.<span style="mso-spacerun: yes;">
</span>Regarding prescription for benzodiazepines (bzd) from the practice, patients
were classified ‘never prescribed bzd’, ‘occasional prescription bzd’ and
‘maintenance bzd.<span style="mso-spacerun: yes;"> </span>Further, he examined
those still in treatment against those who had departed (96% still in UK, 4%
gone overseas, lost to follow-up).<span style="mso-spacerun: yes;"> </span>From
comprehensive statistics kept by the British NHS Bakker was able to derive
accurate mortality figures for these six groups with surprising results for
retention and mortality.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt 36pt; text-indent: 36pt;">
Never<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>Occasional<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>Maintenance</div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Current pats:<span style="mso-tab-count: 1;"> </span>223t/y<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>301t/y<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>765t/y<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Mortality:<span style="mso-tab-count: 1;"> </span>1.79p100ty<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>0.33p100ty<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>1.31p100ty</div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Retention<span style="mso-tab-count: 1;"> </span>34
months<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>51
months<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>72
months <span style="mso-tab-count: 1;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Ex-patients: <span style="mso-tab-count: 1;"> </span>267t/y<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>320t/y<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>305t/y</div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Mortality:<span style="mso-tab-count: 1;"> </span>2.24
p100t/y<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>0.63
p100t/y<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>5.90 p100t/y</div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Excess mort:<span style="mso-tab-count: 1;"> </span>125%<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>191%<span style="mso-spacerun: yes;"> </span><span style="mso-tab-count: 1;"> </span>450%</div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
T/y = treatment years</div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Contrary to some expectations, retention was highest in the
group prescribed maintenance benzodiazepines.<span style="mso-spacerun: yes;">
</span>Furthermore, mortality was lower than in the group never prescribed
sedatives and the lowest mortality was intriguingly in those occasionally
prescribed sedatives.<span style="mso-spacerun: yes;"> </span>However, the most
meaningful, and very worrying statistic is the high mortality in maintenance
patients who transferred elsewhere for their treatment (more than 4 fold those
remaining in treatment at Dr Bakker’s practice in London).<span style="mso-spacerun: yes;"> </span>The authors report that following health
authority directives very few maintenance prescribers in the UK allow
benzodiazepine prescription in parallel as Dr Bakker’s practice does.<span style="mso-spacerun: yes;"> </span>Hence the likely inference that these patients
had legal supplies of benzodiazepines curtailed on transferring elsewhere for
their OTP treatment.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Another important finding was that the death rates were lowest,
and very significantly lower, in those prescribed benzos occasionally, both in-house
patients and in those transferred elsewhere.<span style="mso-spacerun: yes;">
</span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
This report is not a randomised controlled trial, nor was it
prospective, yet it involves large numbers of patients in a normal medical
population over a long period with very few lost to follow-up (4%).<span style="mso-spacerun: yes;"> </span>Hence the findings are very meaningful for
those involved in comparable practice providing opiate maintenance with
methadone and/or buprenorphine in a community setting.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
From this paper is it apparent that withdrawing
benzodiazepines may increase mortality substantially.<span style="mso-spacerun: yes;"> </span>Hence, official guidelines and clinical
recommendations which warn against benzodiazepine prescription may be
contributing to excess deaths rather than preventing them.<span style="mso-spacerun: yes;"> </span>In my experience most OTP prescribers have a
small number of patients who are prescribed benzodiazepines, some long-term.<span style="mso-spacerun: yes;"> </span>Yet up to 70% of our patients have had
problems with sedatives and so to ignore this and advise: ‘just say no’ may not
be the proper approach.<span style="mso-spacerun: yes;"> </span>However,
prescribing is well beyond the comfort zone for many in our field without
formal protocols.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
It is my view that all dependent patients should be able to
access benzodiazepines under some clinical framework although this should not
be open-ended, just like methadone.<span style="mso-spacerun: yes;">
</span>There should be dose supervision initially ranging to normal
unsupervised prescription for those who are socially integrated but unable or
unwilling to cease sedative use.<span style="mso-spacerun: yes;"> </span>Those abusing
alcohol should be excluded until they can demonstrate abstinence.<span style="mso-spacerun: yes;"> </span>Trial dose reductions should be negotiated
periodically, as with methadone.<span style="mso-spacerun: yes;"> </span>In our
own practice we use diazepam and we aim to a dose of 4-15mg daily which is
satisfactory for the great majority after initial reductions.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Notes by Andrew Byrne .. </div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Bakker article PDF:</div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<a href="http://journals.sagepub.com/doi/pdf/10.1177/0269881116675508"><span style="color: blue;">http://journals.sagepub.com/doi/pdf/10.1177/0269881116675508</span></a></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
References: Franklyn AM, Eibl JK, Gauthier G, Pellegrini D,
Lightfoot NK, Marsh DC. The impact of benzodiazepine use in patients enrolled
in opioid agonist therapy in Northern and rural Ontario. Harm Reduction Journal
2017 14:6</div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Weizman T, Gelkopf M, Melamed Y, Adelson M, Bleich A. 2003
Treatment of benzodiazepine dependence in methadone maintenance treatment
patients: A comparison of two therapeutic modalities and the role of
psychiatric comorbidity. Aust N Z J Psychiatry 37: 458–463</div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Lader M. Benzodiazepines revisited—will we ever learn?
Addiction 2011 106:2086-2109</div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
Liebrenz M, Boesch L, Stohler R, Caflisch C. Agonist
substitution-a treatment alternative for high-dose benzodiazepine-dependent
patients? Addiction 2010 105;11:1870–1874</div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<o:p> </o:p></div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-13070272188354456642016-04-27T15:39:00.001+10:002016-04-27T15:40:58.116+10:00Postcard from New York April 2016<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Medical postcard
from New York, April 2016<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Dear Colleagues, <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">I can report that
spring has sprung in New York.<span style="mso-spacerun: yes;"> </span>After a
cold start, April has seen a wonderful transition from winter bareness to a
colour-wheel of splendid blossoms, bulbs and canopy greenery.<span style="mso-spacerun: yes;"> </span>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’</span><span class="tnihongokanji"><span lang="JA" style="font-family: "simsun"; mso-ansi-language: EN; mso-ascii-font-family: "Times New Roman"; mso-fareast-language: JA; mso-hansi-font-family: "Times New Roman";">桜</span></span><span lang="ZH-CN" style="font-family: "simsun"; mso-ascii-font-family: DDG_ProximaNova; mso-bidi-font-size: 10.0pt; mso-hansi-font-family: DDG_ProximaNova;">祭</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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”.<span style="mso-spacerun: yes;"> </span>Public health experts,
criminologists and addiction medicine workers now mostly know the facts.<span style="mso-spacerun: yes;"> </span>Most are also aware of the 15-year-long
highly successful Portuguese experiment in decriminalisation.<span style="mso-spacerun: yes;"> </span>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).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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 <i style="mso-bidi-font-style: normal;">decrease</i> the overall average amount of
alcohol consumed.<span style="mso-spacerun: yes;"> </span>The first work on this
dates from the 1990s.<span style="mso-spacerun: yes;"> </span>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).<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>We
were also told that New York City also has a ‘Housing First’ initiative,
whereby residents may bring alcohol into their lodgings.<span style="mso-spacerun: yes;"> </span>It is a mystery to me why Australia has not yet
trialled this logical and humanitarian measure for severe alcoholics who are
homeless.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Constant coverage
this month of the Presidential election has presently pushed the alarming rates
of opioid overdose deaths off the front pages.<span style="mso-spacerun: yes;">
</span>Despite this crisis affecting a broad spectrum of American society,
little sensible appears in the media or from politicians about this well-researched
area.<span style="mso-spacerun: yes;"> </span>Any student of public health could
describe the measures needed to prevent most of these deaths yet nothing seems
to happen.<span style="mso-spacerun: yes;"> </span>Even the death of
high-profile personalities brings only sympathy, even from the President, but
no moves to address the crisis logically.<span style="mso-spacerun: yes;">
</span>The death of Prince might also have some association with opioid
use.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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.<span style="mso-spacerun: yes;"> </span>Most of the
predicted HIV cases are from lower socio-economic groups and many have not even
been tested as yet.<span style="mso-spacerun: yes;"> </span>Needle services are
rare or absent.<span style="mso-spacerun: yes;"> </span>The few methadone
clinics in the affected areas are mostly at or near capacity.<span style="mso-spacerun: yes;"> </span>Buprenorphine is only available at
substantial expense from a small number of licensed physicians.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>This has
not been systematically tested; and since there is no injecting centre in
America it would be difficult to do so.<span style="mso-spacerun: yes;"> </span>Many
public health experts believe, however, that sufficient evidence is available
in the present urgent circumstances for widespread naloxone availability to be
implemented.<span style="mso-spacerun: yes;"> </span>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).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>I asked a professor of addiction medicine in a faculty meeting why she
does not write such a piece.<span style="mso-spacerun: yes;"> </span>She said
that as the ‘mother of methadone that is the one thing I cannot do’.<span style="mso-spacerun: yes;"> </span>I just do not follow this logic.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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.<span style="mso-spacerun: yes;"> </span>There are many in America doing
good works.<span style="mso-spacerun: yes;"> </span>President Obama has extended
health care enormously.<span style="mso-spacerun: yes;"> </span>Let’s hope that
the next President can better that.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Best wishes from the
Big Apple.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Andrew Byrne .. </span><a href="http://methadone-research.blogspot.com/"><span style="font-size: 11pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><span style="color: blue;">http://methadone-research.blogspot.com/</span></span></a><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p></o:p></span></div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-68907539546198560552016-01-30T14:41:00.002+11:002016-02-07T01:11:04.417+11:00When alcohol abstinence fails supervised serving may reduce harms. "MAP" or wet rooms. <div class="MsoNormal" style="margin: 0cm 0cm 0pt; mso-layout-grid-align: none; mso-pagination: none; punctuation-wrap: simple;">
<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Managed Alcohol Programs - (MAP). Slow
progress of effective hostel protocol to save money, suffering and dignity of
our most marginalised citizens.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Dear Colleagues, <o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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.<span style="mso-spacerun: yes;"> </span>I wrote enthusiastically about a Canadian
study by Tiina Podymow in 2006 ( <u><span style="color: blue;"><a href="http://www.redfernclinic.com/c/2006/01/supplying-alcohol-to-alcoholics-may_9924.php4">http://www.redfernclinic.com/c/2006/01/supplying-alcohol-to-alcoholics-may_9924.php4</a></span></u>
).<span style="mso-spacerun: yes;"> </span>The other two are from 2009 and 2012,
both from Seattle (see refs below).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">The published findings of events before and
after implementation of the ‘managed alcohol program’ show substantial and
significant improvements.<span style="mso-spacerun: yes;"> </span>Both medical
and police interactions dropped while overall alcohol consumption also
dropped.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">These subjects were all hostel residents who
had had multiple attempts at abstinence, detoxification, meetings and medical
interventions without success.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>The may also be some parallels with the use
of nicotine replacement therapies, opiate maintenance treatments and other harm
reduction strategies.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">The very fact that the trials were able to
be performed is impressive.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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.<span style="mso-spacerun: yes;"> </span>And they are avoidable.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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.<span style="mso-spacerun: yes;">
</span>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.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">In 2011 Time Magazine was so impressed that
they ran an enthusiastic article (<i>The ‘Wet House’ Where Alcoholics Can Keep
Drinking</i> - link below).<span style="mso-spacerun: yes;"> </span>This was
based on an original story in the New York Times (link below).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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.<span style="mso-spacerun: yes;"> </span>This may also apply to casualty waiting
times, blood transfusion services, ambulance, rehabilitation and more.<span style="mso-spacerun: yes;"> </span>Likewise, when the police are tied up with
local issues of this nature they could be attending to other important policing
matters.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Notes by Andrew Byrne .. </span><u><span style="color: blue; font-size: 11pt;"><a href="http://methadone-research.blogspot.com/">http://methadone-research.blogspot.com/</a>
</span></u><span style="font-size: 11pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Refs: <o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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<span style="mso-tab-count: 1;"> </span><u><span style="color: blue;"><a href="http://www.cmaj.ca/content/174/1/45.full">http://www.cmaj.ca/content/174/1/45.full</a></span></u>
<o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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<span style="mso-tab-count: 1;"> </span><u><span style="color: blue;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/19336710">http://www.ncbi.nlm.nih.gov/pubmed/19336710</a></span></u>
<o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">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<span style="mso-tab-count: 1;"> </span><u><span style="color: blue;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/22390516">http://www.ncbi.nlm.nih.gov/pubmed/22390516</a></span></u>
<o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Happy Hour? ‘Wet Houses’ Allow Alcoholics to
Drink, With Surprising Results. Time Magazine<span style="mso-tab-count: 1;"> </span><u><span style="color: blue;"><a href="http://healthland.time.com/2011/04/27/happy-hour-wet-houses-allow-alcoholics-to-drink-with-surprising-results/">http://healthland.time.com/2011/04/27/happy-hour-wet-houses-allow-alcoholics-to-drink-with-surprising-results/</a></span></u>
<o:p></o:p></span></div>
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<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">The </span><span style="font-size: 13pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">‘</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Wet
House</span><span style="font-size: 13pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">’</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"> Where Alcoholics Can Keep
Drinking<span style="mso-tab-count: 1;"> </span></span><u><span style="color: blue; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><a href="http://www.nytimes.com/2011/05/01/magazine/mag-01YouAreHere-t.html?_r=1">http://www.nytimes.com/2011/05/01/magazine/mag-01YouAreHere-t.html?_r=1</a></span></u><span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"> </span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Feasibility of a Managed Alcohol Program for
Sydney.<o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<u><span style="color: blue; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><a href="http://www.fare.org.au/wp-content/uploads/research/Feasibility-of-a-Managed-Alcohol-Program-for-Sydney%E2%80%99s-homeless.pdf">http://www.fare.org.au/wp-content/uploads/research/Feasibility-of-a-Managed-Alcohol-Program-for-Sydney%E2%80%99s-homeless.pdf</a></span></u><span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Introduction to Professor Kate Dolan’s work
in this area:<o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<u><span style="color: blue; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><a href="https://www.churchilltrust.com.au/fellows/detail/3905/Kate+Dolan">https://www.churchilltrust.com.au/fellows/detail/3905/Kate+Dolan</a></span></u><span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Full report (18 pages): <u><span style="color: blue;"><a href="https://www.churchilltrust.com.au/media/fellows/Dolan_Kate_2014_To_investigate_managed_alcohol_programs_for_the_homeless.pdf">https://www.churchilltrust.com.au/media/fellows/Dolan_Kate_2014_To_investigate_managed_alcohol_programs_for_the_homeless.pdf</a></span></u><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<u><span style="color: blue; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><a href="http://www.connections.edu.au/researchfocus/managed-alcohol-programs">http://www.connections.edu.au/researchfocus/managed-alcohol-programs</a></span></u><span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">British Columbia’s North-West remote areas. <o:p></o:p></span></div>
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<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
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<u><span style="color: blue; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><a href="https://www.sunshinecoasthealthcentre.ca/2014/03/what-are-managed-alcohol-programs/1032014/">https://www.sunshinecoasthealthcentre.ca/2014/03/what-are-managed-alcohol-programs/1032014/</a></span></u><span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; mso-layout-grid-align: none; mso-pagination: none; punctuation-wrap: simple;">
<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; mso-layout-grid-align: none; mso-pagination: none; punctuation-wrap: simple;">
<span style="mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; mso-layout-grid-align: none; mso-pagination: none; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Ottawa</span><span style="font-size: 13pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">’</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">s
MAP<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; mso-layout-grid-align: none; mso-pagination: none; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; mso-layout-grid-align: none; mso-pagination: none; punctuation-wrap: simple;">
<u><span lang="EN-US" style="color: blue; font-size: 13pt;"><a href="http://shepherdsofgoodhope.com/about-us/programs/managed-alcohol-program-map/">http://shepherdsofgoodhope.com/about-us/programs/managed-alcohol-program-map/</a></span></u><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; mso-layout-grid-align: none; mso-pagination: none; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p> </o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<i>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.<u1:p></u1:p></i><o:p></o:p></div>
<span style="background-color: rgba(255, 255, 255, 0);"></span></div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-58510666321163760452015-09-12T01:10:00.000+10:002016-02-07T01:12:15.332+11:00BMJ article: increasing overdoses but they ignore known solutions (+ Hari TED talk).<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;">Dear
Colleagues, <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;">There
is no more ‘final’ statistic regarding drug use than overdose deaths. And
in England the official figures go back to Victorian times, then often
involving opium, laudanum and other strong drugs including alcohol. The
British Coroner’s Act of 1844 was ahead of its time and even pre-dated the
famous Broad Street Pump reports of the London cholera epidemic of 1854.
The latter is sometimes quoted as the first exercise in modern, scientific
public health. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;">The
BMJ has reported increasing overdose deaths in the UK which are little short of
disastrous, reflecting experience in America - doubling in a few short years
and overtaking other causes of death like a tragic game of leap-frog. The
UK now has about 50 overdose deaths per million of population or 3346 in 2014
of which 952 were from heroin or morphine. In Portugal it is about a
tenth of this rate according to EMCDDA. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;">The
familiar story of increasing overdoses happened in Portugal before 2001 when a
forward thinking and science based experiment was undertaken moving away from
prohibition. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;">Portugal
decriminalised personal drug use 14 years ago, heralding a new era in public
health in that small country. Since the liberalisation experiment the
country has gone from a pariah to a paragon of public health outcomes.
HIV, overdose and addiction rates have dropped significantly while resources
have been strongly diverted to treatment and social services. The UK and
USA have comparable drug control laws strongly relying on punishment, in stark
contrast to Portugal. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;">Like
seeing refugees on a television screen, overdose deaths only come home to us
when they are personalised by a friend, family member or particularly moving
portrayal such as the recent footage of a dead young boy on a beach in
Turkey. Why is nobody taking notice of one of the biggest and longest and
most successful real-life experiments in drug law reform? Why are those
supporting prohibition so successful in beating a drum which has no scientific
or empirical basis? And their actions are leading to preventable deaths
every single day. I recommend a 14 minute talk by Johann Hari about his
‘journey’ investigating addiction*. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<u><span style="color: blue; font-size: 14pt;"><a href="http://www.bmj.com/content/351/bmj.h4754"><span style="color: blue;">http://www.bmj.com/content/351/bmj.h4754</span></a></span></u><span style="font-size: 14pt;"> BMJ article. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<u><span style="color: blue; font-size: 14pt;"><a href="http://www.washingtonpost.com/news/wonkblog/wp/2015/06/05/why-hardly-anyone-dies-from-a-drug-overdose-in-portugal/"><span style="color: blue;">http://www.washingtonpost.com/news/wonkblog/wp/2015/06/05/why-hardly-anyone-dies-from-a-drug-overdose-in-portugal/</span></a></span></u><span style="font-size: 14pt;"> <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span style="font-size: 14pt;">*
<u><span style="color: blue;"><a href="https://www.youtube.com/watch?v=PY9DcIMGxMs"><span style="color: blue;">https://www.youtube.com/watch?v=PY9DcIMGxMs</span></a></span></u>
Everything You Think You Know About Addiction Is Wrong. Johann Hari. TED
Talks </span><br />
<span style="font-size: 14pt;"></span><br />
<br />
<span style="font-size: 14pt;"><span style="font-size: small;">
</span><br />
<div class="MsoNormal" style="margin: 0cm 0cm 0pt;">
<span style="font-size: small;"><i>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.<u1:p></u1:p></i><o:p></o:p></span></div>
<span style="font-size: small;">
</span><span style="background-color: rgba(255, 255, 255, 0);"></span><span style="color: navy;"><o:p></o:p></span></span> </div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-28673780312922383952015-05-15T08:08:00.005+10:002015-05-15T08:08:47.408+10:00Medical Postcard from New York, April 2015<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">It was my privilege
to again spend a month in Manhattan learning about American developments in
alcohol and drugs issues as well as passing on some of the Australian
experience. <o:p></o:p></span><br />
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">My main mission in
New York this year concerned our current plague of stimulant use in Australia
and whether there were any answers from colleagues in the Big Apple. One
only has to open an Australian newspaper to find another notable crime or
accident traced, at least in part, to amphetamine type stimulants, ‘ice’ or
‘crystal meth’. I have done my best to ascertain how much of the reported
mayhem from ‘ice’ is actuality and how much hype. The authorities certain
seem to be taking it seriously with various enquiries under way. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">America had a spate
of methamphetamine use about ten years ago but without the reported behavioural
consequences we are seeing at home. A senior Justice Health clinician
told me that ‘crystal meth’ problems were starting to become prominent about 6
years ago, perhaps heralding the current reports of adverse consequences in the
wider community. Others have confirmed that acute drug-related psychosis
cases presenting to mental health facilities are now commonplace, even more so
than the conditions they are trained, funded and able to treat like
schizophrenia, bi-polar disorder, depression, phobias, etc. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">In the past month
alone three of our practice patients (n=180) were hospitalised due to
complications ascribed to stimulant use, two for psychosis and one having had a
stroke. And this was while they were IN TREATMENT. On the other
hand we have numerous patients who seem to do well taking prescribed stimulants
for ADHD at the same time as their opiate maintenance. Sydney’s St
Vincent’s Hospital Stimulant Clinic has prescribed dexamphetamine under medical
supervision for the past 8 years with a positive experience in selected
cases. We are now doing the same in the private sector on a small
scale. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">Several stories
have shocked Australians including a report of a Cairns mother killing eight
children before stabbing herself (non-fatally) in the chest and neck. In
another case a previously normal man became so paranoid that he chiseled the
initials of the person he believed was targeting him into his leg so that “the
coroner will know who did the deed after I’ve been killed”. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">In New York I was
told by several experts that stimulants just don’t usually cause major
behavioural disturbances. Yet we have reports of previously normal people
starting to wield weapons, leap off buildings or become acutely paranoid.
Some senior clinicians in America told me that such reports are likely to be
associated with mixed drugs, PCP, alcohol, benzos, etc. It is hard to
reconcile statements from prominent public figures about amphetamine being a
“horrendous new drug which is causing such mayhem” when we prescribe it widely
amongst school children where there is a lack of such reports. As
Paracelsus noted 500 years ago, a useful medicine at one dose may become a
poison at a higher dose. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">Heroin overdose has
now become a national emergency in America and several state Governors have
enacted crisis provisions. I read that there are now more heroin overdose
deaths than motor accidents, suicide and cancer put together (this may be in
certain age groups). Such is the epidemic that naloxone peer-distribution
has been implemented in various situations despite not fulfilling the usual
requirements of safety and effectiveness required for other drug
interventions. There are uncertainties about how to give it (IV, IM or
nasal insufflation) and how much to give. The overseas experience of
early heroin overdose (such as in injecting centres) shows that naloxone is
rarely required. Physical manoeuvres and oxygen are sufficient in most
cases. Most ambulance and casualty services treat overdose cases much
later which is quite a different clinical situation. It may be that
resuscitation education is also worth emphasising in the drug using population
and associates. Despite these limitations, a parallel benefit to the
approval of naloxone has been concurrent Good Samaritan rule in some states
such as New Jersey and Hawai’i. If one calls an ambulance to an overdose
case one will not be automatically subject to police action as a result. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">The prospect of
tens of thousands of doses of naloxone being sold for just a few ampoules
actually used must be joy to some drug company shareholders. One only
hopes that any associated side effects or adverse consequences are minimal as
the saving of even one life is important. Future research should determine
these matters as well as a cost benefit analysis since there are various other
life-saving interventions which could be implemented. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">The Americans are
known for their ‘noble experiments’ some of which have paid off, others, such
as alcohol prohibition, proved to be unmitigated disasters. It seems
bizarre that with a heroin addiction problem and overdose crisis US authorities
still ban methadone treatment in normal medical practice despite it being used
successfully in most western countries. Methadone clinics are also now
commonplace in China. Methadone treatment is known to dramatically reduce
opioid overdoses when used under established clinical guidelines. It is
cheap [sic], meaning no profit for Big Pharma … and it requires only a modest
amount of medical education and no new infrastructure. Methadone and
buprenorphine treatments also prevent HIV and very probably hepatitis C as
well. So why is it still restricted to registered clinics in America,
especially when few new clinics have opened in the last 20 years? I am an
onlooker, respectful of the great works the US has done for medical research,
yet I am unable to answer this question. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">There has been a
highly publicised report of 140 new cases of HIV transmission in a small rural
county on the Indiana/Kentucky border in just a few weeks. This has
prompted the Governor Mike Pence to countenance needle programs for the first
time, although only temporarily. He still says he does not ‘believe’ in
needle availability and one wonders if he knows better than health experts who
support such services which are commonplace across the rest of the western
world. A two month period of limited needle and syringe ‘exchange’
programs is unlikely to make much difference as the epidemic is already advanced.
Perhaps the Governor should ban the provision of ash trays … which may
discourage smokers! This is the level of his logic (or lack of it).
<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">In New York I was
given a tour of the John Jay College of Criminal Justice in 59<sup>th</sup>
Street. A more than life-sized bronze statue in flowing robes celebrates
John Jay who was America’s first Chief Justice in 1789. The magnificent
new wing with its long atrium, ramps and roof top lawn is joined
tastefully to the old building adjacent with its magnificent classical façade
(ref below). <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">My medical contacts
have taken me back to the origin of methadone treatment at Rockefeller
University, Columbia University, Bellevue Hospital, West Midtown Medical Group
(methadone, buprenorphine and general practice uniquely under the one roof),
Drug Policy Alliance, New School University with NY State Psychological
Society, Addictions group. To name just a few, I was also in touch with
Prof Ernest Drucker, Herbert Kleber, Mary Jeanne Kreek, Robert Heimer, Tom
Haines, Lynne Paltrow, Robert G. Newman, Terry Furst, Doug Kramer, Andrew
Tatarsky, Scott Kellogg, Richard Juman, Joyce Lowinson, Herman Joseph, Ethan
Nadelmann, Tony Newman, Tony Papa, gabriel sayegh and asha bandele, who are all
key players in our small field of drug and alcohol treatment, research and
policy. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">Annual conference
of New York State Psychological Society addiction chapter at New School
University in 13th Street near 6th Avenue. Richard Juman gave the oration
and introductions while Andrew Tatarsky and Scott Kellogg, both previous
presidents of the organisation, spoke on their approach to addictions in a
non-abstinence based therapeutic setting. This setting gave me a balance
to the usual chemical approach used by doctors in dependency (aka ‘methadone’)
clinics. I was surprised to learn that the majority of patients for these
clinicians were mandated from court decisions. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">Other issues
broached on this trip included ‘lethal’ synthetic cannabis (and it IS, unlike
the real thing!); new hepatitis C treatments which avoid interferon injections;
police victimization of minorities has been a topic with some balance pointing
out the difficulties of policing some localities; Puerto Rico has allegedly
adopted the policies once used in the Northern Territory, putting addicts onto
flights to Chicago for example, with a vague promise of treatment on
arrival. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">Another important
observation is that most of the colleagues I meet up with in New York are over
60 and some are over 80. Some younger folk are getting involved but not
nearly enough to replace those of us who are bowing out. Australia still
only has a fledgling community of addiction specialists and there is no secure
career path for such doctors. I hope these reflections may be of interest
to the reader. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">Written by Andrew
Byrne .. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">New York travel-log
<a href="http://ajbtravels.blogspot.com.au/"><span style="color: blue;">http://ajbtravels.blogspot.com.au/</span></a>
<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">Clinic web page: <a href="http://methadone-research.blogspot.com/"><span style="color: blue;">http://methadone-research.blogspot.com/</span></a>
<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0pt; punctuation-wrap: simple;">
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<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">References: <u><span style="color: blue;"><a href="http://edition.cnn.com/2015/03/27/health/indiana-hiv-outbreak/index.html"><span style="color: blue;">http://edition.cnn.com/2015/03/27/health/indiana-hiv-outbreak/index.html</span></a></span></u>
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<u><span lang="EN-US" style="color: blue; font-size: 13pt; mso-ansi-language: EN-US;"><a href="http://www.wbez.org/news/puerto-rico-exports-its-drug-addicts-chicago-111852"><span style="color: blue;">http://www.wbez.org/news/puerto-rico-exports-its-drug-addicts-chicago-111852</span></a></span></u><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;">
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<u><span lang="EN-US" style="color: blue; font-size: 13pt; mso-ansi-language: EN-US;"><a href="http://colleges.usnews.rankingsandreviews.com/best-colleges/cuny-john-jay-2693/photos"><span style="color: blue;">http://colleges.usnews.rankingsandreviews.com/best-colleges/cuny-john-jay-2693/photos</span></a></span></u><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"> <o:p></o:p></span></div>
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<u><span lang="EN-US" style="color: blue; font-size: 13pt; mso-ansi-language: EN-US;"><a href="http://www.nyspa.org/"><span style="color: blue;">http://www.nyspa.org/</span></a></span></u><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US;"> <o:p></o:p></span></div>
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Unknownnoreply@blogger.comtag:blogger.com,1999:blog-29681864.post-91375122972971344042014-12-23T23:56:00.002+11:002014-12-24T00:32:57.869+11:00Obituary on Henry Harris. <div class="MsoNormal" style="margin: 0cm 0cm 0pt; mso-layout-grid-align: none; mso-pagination: none; punctuation-wrap: simple;">
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<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">One of Australia</span><span style="font-size: 13pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">’</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">s great medical researchers Professor Sir Henry Harris died at his home
in Oxford on 31 October 2014 aged 89.<span style="mso-spacerun: yes;">
</span>Harris was hand picked by Howard Florey (of penicillin fame) for a
career in medical research - and when Lord Florey retired in 1964 Harris was
appointed to head his William Dunn School of Pathology in Oxford.<span style="mso-spacerun: yes;"> </span>This he ran for over 30 years and continued
an association until his death.<span style="mso-spacerun: yes;"> </span>The
institute was featured on our old fifty dollar bank note, adjacent to Florey</span><span style="font-size: 13pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">’</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">s image.<span style="mso-spacerun: yes;">
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<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">As exemplified by the single historical English Pope </span><span style="font-size: 13pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">“</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">No prophet becomes famous in his home town</span><span style="font-size: 13pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">”</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">.<span style="mso-spacerun: yes;"> </span>So
was Henry Harris who, after Sydney Boys High, University of Sydney and
Melbourne University, lived and worked in Oxford for the rest of his life.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">While unfamiliar to most Australians, Harris</span><span style="font-size: 13pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">’</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">s prodigious talents and energies were well
known to his year members including my late father, John Justinian Byrne, Prof
Jim Lance, Malcolm Coppleson, JG Richards and other doctors of their
generation.<span style="mso-spacerun: yes;"> </span>Henry started at Prince
Alfred Hospital measuring sodium, potassium and chloride in severely ill
hospital patients.<span style="mso-spacerun: yes;"> </span>Melbourne had the
only flame photometer in the country so my father, who lived near Mascot
airport, would courier the specimens and with luck, the results were wired that
evening to the Clinical Research Ward, sometimes too late to be of help such
were the life-and-death conditions being treated.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Harris</span><span style="font-size: 13pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">’</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">s
contributions to medical science were legion but his main interest appears to
have been regarding malignant transformations, tumour suppressor genes and the
re-emergence of cancer cells.<span style="mso-spacerun: yes;"> </span>He
pioneered induced cell fusion which allowed a multiple myeloma cell to produce
any number of specific mono-clonal antibodies.<span style="mso-spacerun: yes;">
</span>This work was adopted by others who introduced new and effective
treatments for cancers as well as certain autoimmune diseases, some recognised
by Nobel prizes.<span style="mso-spacerun: yes;"> </span>For his services to
medical science Harris was elected to the Royal Society in 1968 and received a
knighthood from the Queen in 1993.<span style="mso-spacerun: yes;"> </span>He
served after Richard Doll as Oxford Regius Professor of Medicine for 13 years
from 1979.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">My own tenuous connection with Henry Harris began with a hectic day
spent with the great man on a brief visit to Oxford in 1971.<span style="mso-spacerun: yes;"> </span>It was a revealing and rewarding glimpse into
the researcher</span><span style="font-size: 13pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">’</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">s
life for an antipodean medical student.<span style="mso-spacerun: yes;">
</span>During a busy but unscripted day, Henry dealt with postgraduate
students, journalists, laboratory, library and the like as well as fielding
calls from a minister of the Crown, newspaper editor, overseas parties, etc,
making me realise that a life in academe was neither boring nor was it
easy!<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Years later in (partial) retirement Henry resumed a regular
correspondence with my late father.<span style="mso-spacerun: yes;"> </span>One
of his last letters, all written in long-hand, spoke to his longing for
Australia, saying that no matter how long they have lived there, Australians
are never fully accepted by the English </span><span style="font-size: 13pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">…</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"> and yet, he wrote further, should he return to
Australia after so long he might find little familiar from his youth, even
among his own countryfolk.<span style="mso-spacerun: yes;"> </span>Like others,
Henry was bemused by my association with Judaism, writing with good humour that
I may be sitting in his very seat at Central Synagogue!<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">In another piece of serendipity, the treatment I was offered when
suffering from lymphoma some years ago was based on Henry Harris</span><span style="font-size: 13pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">’</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">s ground-breaking research, a monoclonal
antibody drug called rituximab [Mabthera].<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></div>
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<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Henry was born in Russia whence his family migrated when he was
four.<span style="mso-spacerun: yes;"> </span>He is survived by his wife and
three children.<span style="mso-spacerun: yes;"> </span>By another chance, Henry</span><span style="font-size: 13pt; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">’</span><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">s first cousin once removed, Dr Newman
Harris, works in Sydney in my related field of pain management and drug
dependency.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;">Written by Dr Andrew Byrne. Published by Australian Jewish News. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<u><span lang="EN-US" style="color: blue; font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><a href="http://www.theguardian.com/science/2014/nov/17/sir-henry-harris">http://www.theguardian.com/science/2014/nov/17/sir-henry-harris</a></span></u><span lang="EN-US" style="font-size: 13pt; mso-ansi-language: EN-US; mso-fareast-language: ZH-TW; mso-font-kerning: 14.0pt;"><o:p></o:p></span></div>
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Unknownnoreply@blogger.com