Dear Colleagues,
I have been in New York City for three weeks and will try to summarize some of my activities relating to dependency issues (opera blog below for those interested). I will give more detailed accounts of some of these meetings in the future but wanted readers to know what issues were being looked at currently in the dependency field at the four or more centers of learning here in New York.
It has been a terrible time for public funding of research in our field and some of the most well endowed and well known organisations have been threatened with closure over a lack of continuing funding from NIDA under current austerity measures as well as increasingly strict guidelines and requirements for such funding. I noted a lack of enthusiasm across the board in the development and research areas but continued optimism in those involved in the clinical side of dependency medicine and what Americans often refer to as ‘recovery’, a word seldom used by Australian patients and clinicians in my experience. It may be partly due to the lack of public funds that drug company sponsorship is also eagerly sought, despite it ensuring that research is almost always slanted towards the use of big-profit drugs and avoidance of ‘bread and butter’ medications (see many references for this and work of Marcia Angell, previous NEJM editor).
My trip began with a 3 hour seminar/dinner at Columbia University in which Dr Deborah Hasin told us that the essential change to DSM-V is that the new classification will lose the distinction between abuse and dependency so that there will only be one diagnosis based on 11 criteria. Substance Use Disorder (SUD) will be ‘moderate’ if 2 or 3 are present and severe SUD if there are 4 or more. Patients with just one of the criteria will have no DSM diagnosis and will not be considered to have SUD. The old criterion of involvement in frequent legal issues has been removed while 'cravings' has been added this time. The time frame for such reports needs to be within 12 months apart in general. The concept of 'dependence' now only refers to the physiological states of tolerance and withdrawal. I cannot help thinking that the new definition will have no benefits and may cause confusion in the 'dependency' field for years to come. It is slated for introduction in May 2013.
Grand rounds at Bellevue Hospital were chaired by Dr Marc Galanter: three addiction medicine registrars discussed literature reviews on three topics: ADHD in SUD (and vice versa); Acupuncture in dependency treatments; Ketamine in the treatment of severe depression. These were each comprehensive and equally fascinating - more anon.
Fort Hamilton, Brooklyn, is where the Guantanamo Bay trials were televised for New York journalists, family members and others. I was asked to give Grand Rounds on methadone maintenance treatments in Australia there and was paired with one of their experienced doctors, Lucas Dreamer who spoke about buprenorphine. It was intriguing that most American doctors who routinely prescribe buprenorphine in their practices (on in this case the Veterans Administration) have never prescribed methadone for addiction cases (and vice versa for many doctors in methadone clinics). There was a lively discussion about maintenance, detox, psychosocial service, induction and transfer from one agonist to the other.
I also gave a talk at Beth Israel Medical Center only a stone’s throw from the institution where methadone was first used in addiction treatment. The department ‘Leaders’ seemed pleased to hear about treatment down-under. There were discussions about hepatitis C, diazepam ‘maintenance’, needle provision and injecting centres.
I had a brief discussion with a colleague from NDRI who is investigating drug courts in America. These vary in the way they operate in different states with methadone and buprenorphine available as a treatment option in only a minority of cases (30-40%). Reasons for a lack of maintenance treatments included court bans, financial factors, lack of prescriber and sometimes that the person was already detoxified by the time of reaching the court.
The Drug Policy Alliance gave me their usual 'open arms' welcome at their new offices in 33rd Street. Boss Ethan Nadelmann and his capable staff are working on a series of initiatives from ‘medical marijuana’ (cannabis to Australians), chronic pain medications, buprenorphine and much, much more.
Today would have been the 99th birthday of Dr Vincent P. Dole who died in 2006. Dr Dole, who was a great friend, colleague and mentor to me and lots of others, changed the lives of many people during his long career. In fact he pioneered blood ion measurement (sodium/potassium, etc) and cholesterol aggregation research years before they became commonplace, prior to his ground-breaking work on drug addiction treatments at Rockefeller University in 1964.
I was interviewed by a senior anthropologist who is doing an in-depth study on the history and implementation of buprenorphine treatment. Her group is only too aware of the commercial factors involved in each aspect, some very positive and in the interests of dependency patients while other moves by the manufacturer or distributor may have in fact denied substantial numbers of dependent patients receiving any opioid maintenance treatment at all, both in America and elsewhere. It is by no means unique for drug companies to endeavour to 'evergreen' their profitable products using numerous well known means. However, in this case it may be unique that a drug developed over 30 years ago remains in the high-profit bracket.
Dr Tom Haines brought me up to date with the situation in Portugal as well as the history of how their government brought in decriminalisation of all personal drug use 12 years ago … stemming amazingly from the persistent use of derogatory humour by a popular radio personality and whose views were then supported by the Law Faculty at Lisbon University and both political parties numerous early public forums on the subject. While it has not eliminated drug use, the Portuguese ‘experiment’ has been a success in every other way according to reports which have been published in reputable places. In a way, the implementation of interdiction of drugs from the 1950s was in fact a world-wide, uncontrolled experiment, only to compare with the American experiment with alcohol in the 1920s. We never learn from history!
My last evening in the city is back to where I started with a panel discussion including Dr Jerome Carroll, Herman Joseph, Charles Winick and George De Leon on the past, present and future of dependency interventions starting from the 1950s. This is the final meeting for Dr Carroll who has run these meetings for over ten years.
I hope these brief notes are of interest to readers.
Andrew Byrne .. (back to Australia next weekend).
Clinic web page: http://methadone-research.blogspot.com/
Opera blog: http://andrewsopera.blogspot.com/
