23 May 2017

Medical post-card from New York in April 2017

Butler Library, Columbia University
Dear Colleagues,
New York has had an early spring but all talk is about the new President and his almost daily tweets.  In medical circles, however the opioid overdose crisis across America is top news yet solutions are hard to find and some (like methadone in general practice) are unmentionable.  After three years of investigations I believe I now know why methamphetamine is less of a problem on the US East Coast and it seems to be due to cocaine being so cheap being less than five dollars per cap in some areas.  For the same financial reasons benzodiazepines are less of a problem due to their high price in America.  With national health schemes Valium and other stronger sedatives are relatively easy to obtain at low cost in France, Israel, Australia, etc.  Ergo a larger abuse problem. 
Safer injecting facilities are now being pushed for in public health forums but by few in authority in America.  Naloxone without prescription is now commonplace which is gratifying ... yet by definition it requires the presence of another person at the scene of the overdose to save a life.  Opioid maintenance TREATMENT can ensure a way to stabilize the opioid epidemic yet such treatment is very hard or impossible to access in much of the United States due to the restrictions on methadone programs and the high cost of buprenorphine.  It is a mystery to me why methadone is not available from private American physicians, nor why American pharmacists are banned from administering methadone in addiction programs.  In a meeting at Rockefeller University I was told the reason was the lack of a profit motive as the drug is old and out of patent in its pure form (about 50 cents per dose). I was pleased to be able to get a world authority on buprenorphine, Dr Doug Kramer into the Journal Club of a world authority on methadone, Professor Mary Jeanne Kreek for a lively discussion including the history of FDA approvals and initial dose recommendations. 
A new publication in the British Medical Journal (including an American editorial) attests to the dramatic reduction in mortality, both overdose and all-cause mortality, in those taking opioid maintenance treatment when compared with opioid dependent citizens who are out of treatment.  The metanalysis across several countries shows substantial reductions in deaths, something which has been shown in smaller studies for over 20 years.  See: http://www.bmj.com/content/357/bmj.j1947 (free access for both editorial and article on the subject).  The acute need for action is talked about daily in the US media yet nobody seems to talk about the elephant(s) in the room which are a lack of treatment availability and drug company culpability for pushing profitable opioid analgesics for so long.  As a maintenance treatment, buprenorphine is excellent for those who can afford it and those with lesser habits and the ability to tolerate the induction requirements (being in or near withdrawal before starting).  The lack of a community methadone program is costing America dearly.  One recent report quoted 50,000 deaths in one single year which out-numbers victims or war, cancer, accidents and suicides. 
An interesting side issue is that American states which legalised 'medicinal' cannabis in recent years have significantly lower overdose rates and the initial figures are now being confirmed in longer term statistics.  While one can speculate on the reasons, the 'normalisation' and decriminalisation of cannabis which has been spearheaded by the Drug Policy Alliance, funded by George Soros must now be given credit for saving hundreds or even thousands of lives.  This organisation has been directed by Ethan Nadelmann who stepped down in April after 20 years at the helm.  His send-off was a moving event with supporters, colleagues and friends including Ira Glasser, Stanton Peele, Joyce Lowinson, Ernie Drucker, Clovis Thorn, asha bandele, Chris Soda, Ellen Flenniken, Dr Robert Newman, Tony Newman, Tony Pappa, and many others including Chief Prosecutor from Albany, David Soares and his wife.  I was happy to be able to represent Australia at such an auspicious gathering in Chelsea overlooking the Hudson River. 
Hepatitis C remains a festering issue between outrageous drug prices and limited funding.  The New York based activist group V.O.C.A.L. has long been advocating strongly for State and Federal subsidies for such treatments to be more widely available.  We are very fortunate in Australia that our PBS struck a very favourable deal with the suppliers, allowing universal access to five new direct acting anti-viral (DAA) drugs (the maximum yearly outlay was capped regardless of the number of prescriptions written).  After just over twelve months, an estimated 38,000 patients have been treated ... which is 15% or more of all the cases in Australia.  This makes hepatitis C eradication possible within the next several years.  Only tiny Iceland has done a similar effort, with its reported 1200 HCV cases.
I had very fruitful discussions with senior colleagues at Columbia University and at Rockefeller University regarding the possible safe use of benzodiazepines in stable OTP patients as well as our own recent experience with treating hepatitis C.  It appears that cirrhosis based on viral hepatitis may be partly reversible, contrary to the popular wisdom and I was able to give some examples from Australia.  We have had ~30 viral clearances out of ~30 patients on Direct Acting Antivirals (DAA) over the past 14  months.  This compares with about 45 out of 55 successful treatments on interferon and ribavirin (plus protease inhibitors more recently) over about 9 years (and it was NOT all easy going). 
My last days in Manhattan included some touristy things such as Katz's Deli (a disappointment), Barney Greengrass Deli (a high point), Hello Dolly with Bette Midler ($59 seats in back row sold on day of performance only) and the 50th Anniversary concert at the Metropolitan Opera House.  Details and photos on request (or on my other blogs soon). 
With best regards,
Andrew Byrne ..