12 November 1998

Doctor shopping: dependency and a consistent approach to drug policy issues

The Health Insurance Commission's (HIC) approach to 'doctor shopping' may not be the most effective strategy. The HIC is driven by finances, public opinion and, to some extent, by government policy.

Claims that 'doctor shopping' has decreased in the time of the HIC's efforts in this area do not prove that these are necessarily causal. We know that historically all drug and alcohol use fluctuates in response to influences from many quarters. I understand that 'doctor shoppers' are currently defined as those who can be identified as attending more than 15 doctors in a year.

The medical profession should only support measures which are medically and scientifically sound. For example, we now have strong support for the provision of clean needles for drug users, correct labelling of alcoholic beverages, tobacco warnings, nicotine patches, methadone and the like.

The consumption of benzodiazepines is a major problem for a small minority of the Australian population. Dr Andrew Parkes of the HIC invited participants to have an input into this matter, but before any consultations, the momentum was already strongly in favour of the current 'voluntary' reporting arrangements. The scientific approach was rejected over a politically saleable scheme with no clear rationale. There is little reason to think that the current measures address any fundamental problem although they could be part of an overall strategy to counter the harms occurring from the use of tranquillizers in our society. The current measures are an invitation to use false Medicare cards, to use black market sources and generally avoid addressing the underlying problem. I am not aware of the involvement of dependency specialists, urine testing, psychiatric intervention or other more logical and medical approaches.

We know that around 700 young Australians died from heroin overdose last year alone and about a third may have been on benzodiazepines which may have contributed to the deaths. These drugs have been shown to be associated with risk-taking behaviour and it is clear that they can affect judgement, memory, balance and sleep patters, even in modest doses. In older patients, it is now proven from numerous studies that therapeutic doses are associated with more than doubling of the rates of falls and hip fractures.

While banning benzodiazepines outright is no solution, the continued NHS subsidy is equally inappropriate. But for political sensitivity, these drugs would be dropped from the 'free-list' immediately. Government funding of sedative use by young people who have no clinical indications for the drugs seems bizarre. Indeed, the easy availability of the drugs due to the NHS scheme has undoubtedly contributed to the current overuse of benzodiazepines. It also gives some ill-founded legitimacy to a treatment for which there is little clinical justification under the current prescribing instructions.

We need to look at why people take these drugs. Surveys on the reasons for episodes of drug use have commonly come up with the reply "because it was there". Some users are undoubtedly recreational drug takers. Some become truly dependent on the drugs, others are binge users and a small number are arguably on therapeutic doses for clinical indications.

When I spoke to the HIC officials about this matter, the department had done virtually no research on the subject, although they have access to an enormous amount of relevant statistical information. I suggested that the department look at the number of 'doctor shoppers' who had ever had a urine drug screen ordered. This simple step defined a group of patients who had mostly volunteered for methadone treatment in the past who were currently attending large numbers of doctors for sedatives. Hence, they could be identified as patients who were already in contact with D&A treatment services, albeit with sub-optimal results.

Although there is no proven treatment for benzodiazepine addiction, doctors should still be involved in the treatment of a dependence for which the profession is at least partly responsible. The principles of 'primum non nocere' apply here as elsewhere in practice. 'Harm reduction' is a closely related concept which has been used to let the general public know what doctors have always done where short-term 'cure' is not feasible.

Public health policies have ensured that in the case of tobacco, alcohol and even opiates that there is a clean source of a safe form of the drug. Tobacco is easily the most dangerous of these although it is probably subject to the least controls. These controlled drugs are only available to adults in safe quantities from certain licences premises at restricted hours. Benzodiazepines should be no different than other drugs on doctor's prescription. A safe supply should be accompanied by an appropriate degree of medical supervision, advice and psychosocial supports.

While there are still many unknowns in addiction studies, it is quite clear from the research that when there is increased availability, longer hours of operation or reduction in price, there is generally an increase in overall consumption. This 'availability theory' is supported by many research studies as well as being based on sound fundamental principles. Serious arguments against it still come from such parties as the tobacco and alcohol industry. Some tobacco industry officials still claim that nicotine is not addictive and that tobacco does not cause lung cancer.

We should press for a more logical approach to drug policy as it impinges on our practices, the health budget and the lives of our patients.

Comments by Andrew Byrne ..

11 September 1998

Dose-Related Efficacy of Levomethadyl Acetate

Eissenberg T, Biglow GE, Strain EC, Walsh SL, Brooner RK, Stizer ML, Johnson RE. Dose-Related Efficacy of Levomethadyl Acetate for Treatement of Opioid Dependence. JAMA 1997 277;24:1945-51

This study confirms the place of LAAM (levomethadyl acetate) in the treatment of opioid dependence. For over 20 years in the US it has proven safe and effective in a variety of situations. As well as being a useful alternative to methadone, this drug has a sufficiently long half life to allow three times weekly dosing, thus doing away with daily attendance.

Volunteer heroin addicts were randomised to low, medium and higher dose regimens. Predictably, there was significantly less illicit heroin used at higher doses (2.5 days per month reported heroin use vs. 6.3 in the low dose group). Retention in treatment at 17 weeks was not particularly high at 55% - 65% but there was no significant difference between the three groups.

This is the first time that a positive dose response has been demonstrated with LAAM, and in a representative group including women (39%). Patients had used heroin for an average of 8 years and most reported a previous treatment episode.

This study adds crucial pieces to the drug treatment jigsaw. Recent research also allows us to discern the position of other developments like buprenorphine, naltrexone, heroin prescription and ultra-rapid detoxification.

With numerous patients who are unsuccessful with methadone, LAAM should be made available in Australia without further delay.

Written by Andrew Byrne

19 July 1998

Australian naltrexone trial performed in Newcastle, Mater Hospital 1994-6

Foy A, Sadler C, Taylor A. An open trial of naltrexone for opiate dependence. Drug Alcohol Rev 1998 17:167-174

This pilot study was performed on heroin addict volunteers in order to determine the safety and acceptability of naltrexone treatment in preparation for a larger controlled trial. The drug is still unregistered in Australia but is likely to come on the market later this year.

There were 43 patients (29 male, 14 female) prescribed naltrexone 50mg daily for six months following detoxification lasting from 5 to 10 days using clonidine. Of 32 who could be contacted at one year, 8 had ceased heroin use for virtually the whole period. A further 2 patients had patterns of remission and relapse which were confirmed by clear urine tests specific for morphine (heroin metabolite) for at least one full month.

Only two patients (5%) took naltrexone for the full six months yet retention was reported at 34%. By ten weeks, more than half the patients had stopped taking naltrexone and had dropped out of treatment.

Three patients ceased the drug due to side effects in the first two weeks. One had a seizure and two had symptoms associated with depression. There were 20 patients (47%) who developed headache in the first 3 days, but only one, with associated depression, had to stop the treatment.

There were weekly visits to the clinic with dosing apparently unsupervised.

Comment: This study results are consistent with the literature on the subject which shows little if any benefit in unselected addicts prescribed oral naltrexone. Rather than justifying a larger trial in such patients, more might be gained by examining groups which have already shown promising results such as professionals, prisoners and 'probationers' (not to mention alcoholics).

Compliance in methadone, buprenorphine and prescribed heroin trials is much higher than in this report. Twelve month retention is of the order of 50 to 80% and continued illicit drug use is consistently low. All of these treatments need better matching to appropriately diagnosed patients especially so as to determine who may be suitable for general practice management. Buprenorphine, a long acting opioid, has been prescribed widely in France recently by GPs with no regulatory framework in place and results have been gratifying thus far.

Comments by Andrew Byrne ..

6 June 1998

BMJ letter on New South Wales prison methadone treatment.

BMJ 1998;316:1744 (6 June)


Methadone treatment is widely accepted in prisons in New South Wales

EDITOR: The study by Seaman et al provides the first confirmation of what many have observed for years that there is strong evidence that appropriate treatment for drug misuse should be made available to all prisoners, especially before release.1 It is normal practice (and a requirement under international treaties) to provide medical treatment for prisoners that is similar to that which they would receive in the community. Methadone and other treatments for drug dependence should be no different. We know that there are illicit drugs in most prisons. Additionally, the prevalence of infection with HIV and hepatitis B and C is higher in prisoners than in the general population, and risk taking behaviour is widespread.

Methadone treatment was introduced into prisons in New South Wales in 1987 as a pre-release measure. Treatment has since been expanded to become more widely available for voluntary maintenance. Despite some initial misgivings, there has been almost universal acceptance of this treatment by prisoners, staff, and medical authorities. It has been associated with reduced injecting in prisons,2 and is currently being studied in relation to the transmission of blood borne viral infections.

Andrew Byrne, General practitioner.
75 Redfern St, Redfern, 2016 NSW, Australia

Kate Dolan, Senior research fellow.
National Drug and Alcohol Research Centre, University of New South Wales, Sydney, 2033 NSW, Australia
Seaman SR, Brettle RP, Gore SM. Mortality from overdose among injecting drug users recently released from prison: database linkage study. BMJ 1998; 316: 426-428[Abstract/Full Text]. (7 February.)
Dolan K, Hall W, Wodak A. Methadone maintenance reduces injecting in prison. BMJ 1996; 312: 1162.

11 February 1998

It's all in the gram stain: endocarditis in drug user

"Skin rash and joint pains occurring in a heroin addict who has recently commenced treatment should be taken seriously."

by Andrew Byrne

The patient presented with a 24 hour history of acutely tender, swollen left ankle and right elbow. Subsequent lack of response to treatment and florid rash led to a life-threatening diagnosis.


A month earlier, my 25 year old patient had started methadone for a six month heroin habit. 'Toong' had first used opium at the age of 12 back in his home village in Thailand. He became dependent in his early teenage with regular daily use of poppy tea and then smoked opium. His father who was a religious man and tried to stop his son from using drugs. An amputee, he died when Toong was 18 years old. His mother brought the rest of the family to Australia when Toong was aged 20. He worked in a restaurant for a living and used no illicit drugs for his first four years in his new country. After running into a friend from Bangkok, he began dabbling again, working his habit up to $50 per day. He also began injecting.

Toong had tried cocaine, amphetamine and ecstasy but had never used these drugs on a regular basis. When he could not obtain supplies of heroin he took tranquillizers so he could sleep. He bought these on the street for a dollar a tablet. He smoked cannabis about three times daily, using a bong, but did not use tobacco which gave him asthma. He never drank alcohol. He had no other previous past ill-health.

He was injecting four times daily and was supporting his habit by dealing in drugs. Toong had spectacular evidence of venipuncture sites up and down both arms. The pupils were very large as he was in withdrawal, having not used narcotics for 2 days. There were six previous episodes of detoxification, including one in a Buddhist compound where he was given foul green liquid to make him vomit. Each time he had returned to heroin use.

His blood count was normal. Liver function tests showed low grade hepatitis with enzymes about double the normal upper limit. Bilirubin and creatinine were normal. Antibodies for HCV and HBV were positive and he was HIV negative.

Commenced on 30mg of methadone daily, his dose was gradually increased to 55mg. He ceased all heroin use and went back to his English studies and worked part time in a Thai restaurant. After three weeks, his estranged girlfriend came for a discussion about his treatment. She commented on how well he looked and suggested that he cut out the methadone as soon as possible.

With good initial progress as documented by voluntary urine testing, he requested dose reductions to 25mg over a number of weeks. He ran into some old friends and relapsed to heroin use. His previous dose was restored and he stopped illicit drug use.


After a month in treatment he presented with a day's history of pain in the left ankle and right elbow. There was no previous history of arthritis. Both joints were acutely inflamed with tenderness and limitation of movement. He was hot and sweaty with normal mental state. He had constipation which was thought to be due to the methadone. His temperature was 38.4, pulse 110 and regular. He had lost 4kg after having gained about the same amount since his original presentation.

A presumptive diagnosis of gout was made, blood tests ordered and naproxen prescribed at a dosage of 500mg three times daily. The pains were worse two days later and he was booked in to see a rheumatologist the following day. By this time, he had a florid erythematous rash over the entire body. Blood tests were unremarkable apart from an ESR of 60. Uric acid was 0.39, white count 5,900 with normal electrolytes and creatinine. Rheumaton test for rheumatoid arthritis was negative. He was HLA B52 negative.

Post viral arthritis was diagnosed but as the patient was so unwell, he was admitted to hospital. There was noted to be a soft systolic murmur. Fluid aspirated from the ankle was turbid but had no significant growth on overnight media. Blood cultures, however, were positive for staphylococcus aureus.

Infective endocarditis was confirmed by echocardiogram which showed vegetations on the tricuspid valve. Chest X ray showed multiple areas of subsegmental collapse indicating a probable embolic process.


The patient was immediately commenced on high dose intravenous antibiotics and serial examinations were ordered. These showed an ongoing process in the heart with poor ventricular function and pericardial effusion.

The oral daily methadone dose was kept constant throughout and he stated that he had no desire to use heroin or other illicit drugs. He asked to come off the methadone after three weeks in hospital and gradual reductions were ordered.

His stormy hospital course included complications both from the disease as well as the treatment. Nine weeks later his condition had settled to the point where he was discharged on oral antibiotics, inotropic agents and diuretics. Surgery had been contemplated, but was not needed. Though they were extensive, the vegetations had not damaged the valve irretrievably.

While in hospital Toong had met up with a Buddhist monk who spoke his language. He had become quite religious following his serious illness. His decision was to withdraw from all drugs and lead a 'pure' life. He took advice of the D&A specialist at the hospital and over 5 months reduced his methadone dose to zero. He moved to the country to attend a Buddhist temple retreat with like minded souls to rebuild his shattered life.

Dr Andrew Byrne is a Sydney GP who specialises in drug and alcohol medicine.