7 May 2014

Opioid overdose epidemic in America - NYT story

American overdose crisis worsens. New hydrocodone product approved against advice.  Also overdose editorial by Prof Shane Darke (see below*). 
Reference: New Painkiller Rekindles Addiction Concerns pD1 Science Times, New York Times, Tues April 22. 
This is a featured article by reporter RC Rabin about the marketing of a new long-acting hydrocodone preparation in the context of ever-increasing overdose deaths in the US.  Such is the crisis in Massachusetts that the Governor has taken the unprecedented step of declaring a state of emergency over the overdoses.  Gov. Deval Fitzpatrick banned this drug outright, despite its approval by the FDA.  A court over-ruled the Governor and so Zohydro joins dozens of other over-priced and dangerous opioid analgesics on American pharmacy shelves. 
Nearly half of the nations 38,329 overdose deaths in 2010 involved painkillers according to the CDC.  These narcotics now kill more adults than heroin and cocaine combined, sending 420,000 Americans to emergency rooms each year. 
The FDA approved Zohydro ER, a long-acting version of the opioid hydrocodone, against the advice of it advisory committee. 
It was also Governor Deval Fitzpatrick who used his emergency powers for the approval of naloxone for distribution to emergency workers, police and ambulance who are now all supplied with these in Massachusetts.  Since 2006 the drug has been made available in that state as a nasal spray from existing approved syringe product, as an off-label use for friends or relatives of known or suspected drug users in an attempt to reverse overdoses.  The traditional ampoule of naloxone is cheap (around $30 per dose) and there are claims that thousands of overdoses have been successfully resuscitated using the drug nasally.  A newly FDA approved auto-load syringe has recently been publicised but will cost over $200 and two may be required for a single overdose (it also has talking instructions which I hope will be in two languages, like America itself).  It will not be available for several months at least. 
My view is that this intervention should be examined carefully by public health experts to determine pros and cons.  On my recent trip to New York the overdose crisis was mentioned many times and is the subject of great concern amongst the public and policy makers alike. 
And the elephant in the room?  Despite the life saving potential, nobody seems to be talking about methadone and similar treatments which are simply not available to most Americans who need them.  Such treatments were not even mentioned in this long NYT article.  Methadone maintenance is limited to clinics in the United States and buprenorphine is beyond the budget of many opioid dependent citizens (and is usually given as a simple prescription without supervision, psychosocial supports or urine toxicology - making it a non-evidence based, expensive, experimental intervention - although probably better than no treatment at all).  On any rational economic grounds such treatments should be subsidised by the government which currently wastes millions of tax-payer dollars on law enforcement. 
There is a mistaken belief, even amongst educated Americans, that methadone clinics are available for addiction treatments yet the workers on the ground have reported that only about 1 in 7 opioid dependent Americans get access to the opiate maintenance treatment they need and which is life saving (and these figures were from long before the current crisis).  For those who want or need abstinence based treatments the line for treatment positions is even longer. 
I have a personal theory to explain the present excessive death rates from opioids in America.  Popular drug use, combined with the Puritan sentiment for abstemiousness may have led many dependent citizens to go through cycles of short term sobriety, just as happens with many smokers.  The important difference however is that a recently withdrawn opioid dependent person is at enormous risk of death from overdose, having no tolerance.  This is combined with other disadvantages in America.  For instance, whenever an ambulance is called to an overdose the police are usually called as well; clean needles are often hard to access; penalties are high for drug possession so people may inject in haste; etc. 
*The above should be seen in context with an enlightened article by Prof Shane Darke, a world expert in overdose from Sydney.  He has enumerated four oft-repeated myths about overdose, knowing the facts prove quite the contrary: (1) most overdoses are in young, inexperienced users; (2) it is a variation in the purity of the drug which frequently leads to overdose; (3) the opioid is usually the culprit rather than other drugs; (4) impurities lead to overdose symptoms. 
After a lifetime of working the dependency field, Darke has a number of lessons for public health policy in his lead editorial in D&A Review.  He belabours that the greatest protection against overdose is being in a treatment program, giving many references for the fact that most overdose deaths occur in those not currently in treatment.  He also gives reasons why this frequently observed fact might be so, including the lessened use of opioids and non-opioid depressants in this population. 
According to Darke, response to overdose is another area needing urgent attention, especially the delays which occur in calling the ambulance.  Also Darke supports the provision of naloxone based on experience in numerous countries over a long period showing few problems and anecdotal reports of many resuscitation cases.  Darke also calls for emphasis on high risk periods such as the 2 weeks after release from prison (or detox ward) when tolerance is low and other factors raise the risk greatly (by a factor of 10 to 20 in some reports).  Polydrug use (including alcohol) is the last factor dealt with and he calls for public education campaigns.  It would be hard to find more widespread publicity than the numerous recent overdose deaths of high profile figures in the entertainment industry.  Yet the problem continues with little or no change in public policy in either American or Australia. 
It is clear to me that opiate programs should be available to all who need them in community based facilities at no cost to the consumer.  Yet they remain few in number and poor in quality with some demanding up to $100 per week for a drug which should cost about 50 cents per day.  The universities and GP’s colleges are still remiss in not treating this area as a priority in my view.  Some states do not even have an active sub-group dealing with this important field. 
Written by Andrew Byrne .. Redfern addiction doctor.
Andrew's blog http://ajbtravels.blogspot.com/

3 May 2014

Magnificent Manhattan never ceases to amaze: April engagements.

I was privileged to attend a number of functions on a recent trip to New York.  Each had some relevance to our field and two were talks I gave myself. 

1. Ernie Drucker gave an oration at NYU in the law school to an audience on the subject of “Challenging Punishment: The Road to Restorative Justice.” He coined the word ‘decarceration’ and there was a lively discussion about the dismantling of the Rockefeller laws.  31/3/14

2. “Is the War on Drugs Over?” A Panel Discussion on the Drug War's Effects on Human Rights and US Policies.   Vanderbilt Hall, Law School, NYU 4/4/14   

3. ‘VOCAL’ is an American ‘users’ group which had its 15th anniversary dinner and award ceremony (Americans are very serious about awarding deserving citizens - unlike Australia which still has a ‘tall poppy’ syndrome in some ways).   10/4/14 http://methadone-research.blogspot.com.au/2014/04/15-years-of-client-representation-in.html

4.  NYU also had a fascinating and challenging talk by Professor Susan Lindee, University of Pennsylvania. “Are genetic diseases genetic? Thinking about the history of Cystic Fibrosis”  Larmark had many attractions, even in Darwin’s lifetime.  16/4/14   http://postgenomic.files.wordpress.com/2013/08/lindee-are-genetic-diseases-genetic.pdf 

5. I gave Mental Health Grand Rounds at the Fort Hamilton VA Hospital at Bay Ridge, Brooklyn on “Methadone and buprenorphine: Clinical & Research Perspectives”. The talk also touched on hepatitis C assessment and treatment.  4/4/14 

6. Also the monthly Columbia University meeting at Faculty House, Drugs In Society Group where my talk was entitled: “Australian Perspectives on Harm Reduction” 8/4/14

7. I also attended Bellevue Hospital Divisional Rounds where three presentations were given, chaired by Dr Marc Galanter.  There were interesting talks on (1) modern designer drugs, (2) opiate addiction in chronic pain and (3) prescription opioid abuse.  I was shocked to learn that it is estimated that Americans spend 70 BILLION dollars annually on prescription opioids, reportedly with very little benefit overall … and pain is STILL undertreated in many cases.  2/4/14

8. Also meeting at Rockefeller University with Prof Mary Jeanne Kreek and her lab staff.  21/4/14

Also heard the “New Pavarotti” in Cinderella at the Met: clip: