17 November 2004

APSAD Conference, Fremantle, Western Australia - Day 3

Wednesday 17th November 2004

Day Three

Dear Colleagues,

The third full day of this conference found some delegates somewhat jaded after the conference dinner the night before. A relief then at 9am to find that every chair in the plenary hall attended by a box labelled "Hangover recovery kit"! With my aversion to advertising of almost all kinds I had to pass it up.

Straight to business, however, with a brilliant talk by Thomas Stopka from California describing numerous studies on "secondary needle exchange". For Australians this is a rather odd concept, although it does happen to some extent, even in Australia. In places where there is major difficulty obtaining clean needles and syringes, there are retail intermediaries, entrepreneurs or unofficial purveyors of clean "works". Some may be diabetics with legal access to injecting equipment. Others are non-drug users (incorrectly termed 'alcoholics' by injectors interviewed in the US). But the majority as described by Dr Stopka are unemployed drug users who make a small income out of a restricted market [another overlooked benefit of prohibition!].

An example was a group of people living close by, converting a two-hours-per-day needle program into a 24 hour program, albeit with limited stock each day - and at a premium price. An inducement used in some areas is the provision of additional clean needles for each old one returned. Thus, as in the case of aluminium cans, people can be found 'cleaning' back lanes and stairways, ridding them of discarded 'works', in order to profit (even though the equipment provided has a commercial value of only a few cents).

It is a sign of the drastic toll which continues to be exacted by the American public due to its own laws that serious discussions regarding extraordinary research such as this exists. Only in recent months were Californian pharmacies permitted (under certain restricted circumstances) to sell syringes to drug users. I understand that up to 8000 people annually contract HIV from contaminated syringes in California. It is to be hoped that this figure can be reduced towards zero as new policies are gradually incorporated into the scene.

Next we heard from Paul Gruenwald on the important subject of alcohol policy - from global to local approaches. It was a wide ranging and very logical description of what can be done, what has been done (and undone) and what SHOULD be done for the future. There seems little controversy on the basics. While prohibition does not work (introduced as 'another Californian', Dr Gruenwald should know), age limits, differential taxation, venue licence conditions, law enforcement, labelling, drink driving strategies and education all have a place in reducing consumption and therefore, resulting harms. We were told that a 10% increase in price causes a 7.5% decrease in consumption and this in known to include the most heavy drinkers. Age limit changes also have potential benefits but these can hardly continue into middle age! Venue regulation enforcement, server responsibility and other details can also reduce consumption and harms.

After morning tea we heard from Kate Conigrave on alcohol screening in pre-operative cases in a large teaching hospital. She pointed out that previous work from Scandinavia published in the BMJ shows that it is possible to reduce post-operative complications dramatically by simply diagnosing and acting upon alcohol excess in the weeks before surgery (they used disulfiram 'Antabuse' as well as other measures). She pointed out how difficult it was from their own attempts at Sydney's Prince Alfred Hospital to co-opt anaesthetists, surgeons, secretaries, etc, due to all the other presumably necessary 'fuss' entailed in getting to surgery. In their own pilot study, only dedicated research assistants working in pre-admission clinics could reach sufficient numbers of patients, yet their efforts even then were often fruitless because operations were scheduled for the next day or two, long before any useful alcohol intervention such as disulfiram (Antabuse), counselling et cetera could be instituted.

There were parallel sessions on stimulant use, party drugs, policy, harm reduction and aboriginal issues. For the remaining stoics, the afternoon sessions comprised some innovative areas for APSAD. These included a study of rat mortality using buprenorphine and benzodiazepines which had been mentioned by Nick Lintzeris at last year's meeting but here was presented in person by Suzanne Nielsen. She had measured the breathing rates of variously drugged rodents, no mean feat in my book, and pointed out that buprenorphine is no benign drug when used in combination with other drugs, especially alcohol or benzodiazepines.

Robert Ali gave an enlightened presentation on why official doctors' groups should be involved in policy activism. He pointed out that many common causes of death were related to obesity, drugs, behaviours, life-style choices, diet, etc. Many of these were amenable to changes with simple measures. Likewise, regarding alcohol, tobacco and illicit drugs we should be able to give expert advice on what is best for our patients and for society generally [and this might balance in some small way what is best for breweries, tobacco industry, their shareholders and the 'sleaze' factor in lobbying]. All attending were given a copy of the booklet "Illicit Drugs Policy" published by the RACP, RANZCP and GROW (Self Help).

This conference has been a high point of the year for those of us up to our necks in dependency work. The convenors Simon Lenton, Steve Allsop and other Perth colleagues are to be congratulated for getting together a group of interested and interesting folk from all around the country (and the world) in a congenial venue. We were fortunate to have some of the most important players in research and clinical matters in our field present at the conference. Walter Ling (bup, ntx and other fields), John Grabowski (who first 'proved' that take-away doses improve outcomes), S. S. Lee who is running harm minimisation in Hong Kong and workshops for China; Robert Ali (multitude of inputs from clinical science to policy and administration); Nick Crofts (Asian Harm Reduction Network and many other contributions); Alex Wodak who almost single-handed 'invented' needle programs almost 20 years ago (to name just a few of the 'notables').

We look forward to the next APSAD conference in Melbourne, 2005.

comments by Andrew Byrne ..