12 September 2015

BMJ article: increasing overdoses but they ignore known solutions (+ Hari TED talk).

Dear Colleagues,
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. 
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.  
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. 
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.  
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*. 
* https://www.youtube.com/watch?v=PY9DcIMGxMs Everything You Think You Know About Addiction Is Wrong. Johann Hari. TED Talks 

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.

15 May 2015

Medical Postcard from New York, April 2015

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. 
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. 
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. 
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. 
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”. 
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. 
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. 
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. 
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. 
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). 
In New York I was given a tour of the John Jay College of Criminal Justice in 59th 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 fa├žade (ref below). 
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. 
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. 
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. 
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. 
Written by Andrew Byrne ..