26 December 2018

Christmas 'post-card' from Andrew Byrne in Redfern ...

Accreditation albatross; Honour role; ‘Ice’ age; Successful OTP patients; Hep C; rat research using cannabinoids and amphetamine. 

Dear friends, neighbours and colleagues,

It has been a mixed year, but we seem to have survived more-or-less intact at the surgery in Redfern.  Accreditation has been the great bug-bear and I believe it is high time for health professions to reject what masquerades as a motherhood safety net but which I firmly believe is strangling health care in Australia.   More of that later. 

It has been my privilege on annual trips to New York City to meet top people in our field, some of whom have become close friends.  These soldiers, saints and scholars include Vincent P. Dole (RIP), Don Des Jarlais, Charles O’Brien, Joyce Lowinson, Ethan Nadelmann, Herman Joseph, Ernie Drucker, Mary-Jeanne Kreek, Jerome Jaffe and Herb Kleber (RIP).  But none was as close to sainthood as Dr Robert G. Newman who died this year after a car accident in The Bronx.  His loss will be felt in many countries where he advocated for opiate maintenance treatment, harm reduction and ethical medical treatment for drug addiction in parallel with other medical conditions.  Sympathies to his wife Seiko and their children on their huge loss.  And ours. 

It has been a challenging year but with many rewards as we watch our patients achieve their goals, major and minor.  As I approach retiring age I can provide more customised treatment for those with opiate, benzodiazepine and alcohol problems.  Specifically we use split doses, high doses, low doses, frequent swaps between methadone and buprenorphine along with adjuvant therapy using anti-depressants, mood stabilisers, disulfiram, fluvoxamine, propranalol and propantheline.  Yet we are frustrated on a daily basis by the use of ‘crystal’ methamphetamine ('ice').  Previously stable, pleasant methadone maintenance patients have become unpredictable and unreasonable.  There have been frequent admissions to psychiatric wards where nothing much can be done after assessment and possibly antipsychotic medication.  We have tried prescribing dexamphetamine for some consenting trial cases but without success at eliminating the use of ‘ice’ (methamphetamine), even for short periods.  We await a positive strategy, perhaps from one of the younger members of the addiction Chapter (RACP). 

We continue to address the widespread use of benzodiazepine tranquillizers in our patient population (18-50% dependency among OTP patients according to AATOD).  We have started performing differential urine toxicology which can determine the diazepam-temazepam-oxazepam group from the more potent and dangerous alprazolam, clonazepam and flunitrazepam preparations.  We supervise detoxifying doses in new or unstable patients with some receiving ‘staged supply’ dispensing of diazepam for limited periods for anxiety and/or dependency using either 2mg or 5mg tablets.  The supply of diazepam is contingent on the usual stability criteria for take-home doses of methadone or buprenorphine (sober presentation, housing, vocation, family, finances, attendance, psychiatric, toxicology, etc).  ‘Doctor shopper’ information is now available on line.  More will be said on these matters following a seminar at Sydney University (RPAH) in November by Prof Starcevic, Prof Haber and a brief appearance by myself, chaired by Dr Richard Hallinan of our practice. 

We have also had numerous patients leave opiate maintenance successfully in the past 12 months with many others achieving vocational, family and other goals, far from uncontrolled illicit drug or alcohol use.  A fork-lift licence, university degree, new baby, paid off debts, smoking cessation and new housing can all be life changing benefits for those involved.   For others such goals are still at some distance. 

The new oral treatments for hepatitis C have allowed us to almost eradicate the disease from our patient group after sometimes frustrating times with interferon-based treatments in the past.  This has been enormously gratifying for patients, their families and our staff as a very positive outcome.  Congratulations are due to Dr Hallinan for most of this important public health work which is subject of continuing publications. 

My niece Gracie Hay has spent a couple of sessions in the practice after completing her psychology honours year at Macquarie University.  She has published a fascinating paper on her work with Professor Cornish using cannabinoids to diminish behavioural symptoms of withdrawal and relapse in amphetamine-primed rats (see citation below).  Gracie is now a medical student at Notre Dame University and has some busy years ahead of her.  [Hay GL, Baracz SJ, Everett NA, Roberts J, Costa PA, Arnold JC, McGregor IS, Cornish JL. Cannabidiol treatment reduces the motivation to self-administer methamphetamine and methamphetamine-primed relapse in rats. Journal of Psychopharmacology 2018 1 –10. Link below to free publication on-line] 

Merry Christmas and Happy New Year to all from the Byrne Surgery staff, hoping 2019 is a good one for all.

Andrew Byrne ..