3 December 2022

Medical Postcard from New York City, November 2022.

Medical Postcard from New York City, November 2022. 

It was a great pleasure to be able to travel to America again and meet up with colleagues and share information about Covid, overdose, etc. 

1.    America to catch up with rest of world on community methadone. 

2.    Report on first twelve months of New York’s first injecting centres.

3.    'Bernese’ transfer methadone/bupe being done do-it-yourself.

4.    New guidelines for protection of children when cannabis legalised. 

5.    100th birthday of Dr Joyce Lowinson, addiction treatment pioneer. 

6.    Death of Dr. Mitchell Rosenthal, Phoenix House Founder.

1. America to catch up with rest of world on community methadone: 

 NIDA (National Institute on Drug Abuse) head Nora Volkow finally announces support for methadone in community pharmacies and the lifting of the blanket ban on private American doctors prescribing methadone for addiction.  While she is quoted as saying that there are (some) other countries which do this, I don’t know any western country that has NOT implemented some system of community methadone maintenance treatment, at least after initiation and stabilisation.

 This move was first mooted in New South Wales in 1986 as a preventive measure for the HIV epidemic.  It was implemented over several years to widen access to opiate maintenance treatments by ‘normalising’ them to existing community services (GPs and pharmacists mostly – but also psychiatrists, hospitals, clinics and jails).  I was involved in the first group of primary care physicians and there have now been almost 1000 licensed doctors in my state alone.  We know that it is not simple or straight forward as the Victorian experience showed since methadone itself when not carefully titrated and supervised can also be lethal. 

 The US clinic lobby uses this latter as an argument favouring their continued monopoly.  Yet it is this very monopoly which has denied doctors and pharmacists the experience to utilise this highly effective treatment in a safe manner.  Methadone is no more dangerous than insulin, cortisone, warfarin, morphine and many other strong drugs.  Each requires comprehensive but straightforward guidelines for safe and effective clinical use. 

  “The U.S. government’s top addiction researcher is calling for broad deregulation of methadone, a key drug used to treat opioid use disorder.”

 American doctors should “absolutely” be allowed to prescribe methadone directly to patients, Nora Volkow, the director of the National Institute on Drug Abuse, said Wednesday.

 “There’s absolutely no reason why not,” Volkow said. “There are countries where physicians are providing methadone, and the outcomes are actually as good as those they get [at] methadone clinics.” [snip: see link below]

 Top U.S. addiction scientist calls for broad methadone deregulation (statnews.com)

 2. Report on first twelve months of New York’s first injecting centres.

 The one year anniversary of the New York injecting rooms (Overdose Prevention Centres or OPC’s).  A Zoom meeting was co-hosted by Drug Policy Alliance, NY Health Department and others with a huge participation judging from the dozens of health workers and advocates logging in from all over the world (including Sydney and Melbourne). 

 Entitled “Reflections from OnPoint NYC: Lessons Learned from the U.S.’s First Sanctioned Overdose Prevention Centers”. The main speaker was Sam Rivera aided by toxicology consultant Yarelix Estrada with moderator Dr Danielle Ompad who even became slightly emotional over the unprecedented activities described. Dr Ompad has been involved in harm reduction research at NDRI and now NYU.  Let me know if you wish to see the session on YouTube or try at this link .

 Sam Rivera gave an excellent overview with moderator Dr Ompad asking numerous questions about the practicalities, facilities, catchment populations, etc.  We were told about drug purity and contaminants, most fentanyl being about 10% pure and very little in the way of benzodiazepines.  Most drugs were what the client had thought they were with some notable exceptions.  The most dangerous was cocaine which was heavily contaminated with fentanyl which could easily be fatal. 

 We learned of many of the same issues as in Sydney but some unique to local area.  One of the centres had mainly smokers while the other a majority were injectors, all done under supervision of trained health workers.  We were told about the concept of ‘bathroom’ or unsanctioned injecting centres but they had been doing this informally for 5 years before open officially.  Sam Rivera told us that a bathroom is considered private and injecting may be done with staff nearby in case of emergency.  They even described timed movement detectors inside the otherwise private bathrooms.  Telephone supervision also available from numerous providers (this started in Canada apparently some years ago). 

 The centres had from 200 to 300 drug use episodes daily with no deaths reported.  One was open Mon to Fri 8am to 8pm where the other was open daily but shorter hours.  ‘The saddest time is when we have to close the gates’.  We were told it was a matter of finance. 

 To celebrate its 21st anniversary the Unitingcare team who run Sydney’s facility have instigated an annual oration in Macquarie Street which began last month with a talk by Michael Kirby.  Reverend Harry Herbert Oration Full Event - YouTube

 3. ‘Bernese’ methadone of transfer from high dose methadone to buprenorphine.  The same process in principle can be used as induction from heroin, fentanyl, oxycodone or other strong opiate agonists and yet avoid the very unpleasant and much feared ‘precipitated withdrawal syndrome’. 

 In America the smallest buprenorphine product is 2mg so microdosing is no simple matter.  Hence some doctors have been advising patients to cut 2mg strips into four equal lengths to take 0.5mg sublingually each day for a few days to start the process of achieving adequate doses to prevent withdrawal and attain stability, remove cravings and allow once daily dosing.  This is not recommended by the manufacturer, however, nor is it ‘standard practice’.  There are groups in Vancouver, London (Ontario), Sydney and elsewhere who are instituting this graduated transfer process both in hospital and in the community.  In Australia there are smaller strengths available such as 0.2mg, 0.4mg sublingual tablets used as a strong analgesic.  Research protocols have been approved and more results should be published in due course after Dr Nolan’s first 7 cases in D&A Review (with Brar Use of a novel prescribing approach for the treatment of opioid use disorder: Buprenorphine/naloxone micro-dosing - a case series - PubMed (nih.gov).  There are numerous transition guidelines for 5-14 day transfers but all start with 0.2-0.5mg once or twice daily and end with 16-24mg buprenorphine while methadone is either continued as normal or reduced to half then quarter doses on days 4 to 7 depending on the patient’s response. 

 Patient responses have been largely very positive.  Some have needed night sedation (eg with diazepam), others anti-emetics (eg ondansetron) for a couple of days but most have tolerated some slight discomfort knowing the benefits which have described by some in glowing terms.  “I thought I was going to be an old lady on daily methadone but now I go to the hospital once a month for my injection and all my old side effects have gone”.   Patients on buprenorphine are less likely to report constipation, excess sweating and sexual disturbance when compared with those taking methadone.  It is hoped that calcium metabolism will be improved and less premature osteoporosis might be seen.  Methadone depresses testosterone levels in some men who may then need hormone replacement.  Hence the commonly held view that high dose methadone patients need to cut to 30mg to transfer to buprenorphine is now no longer the case thanks to this intervention which was devised originally in Bern, Switzerland by Dr Robert Haemigg (he also ran the first heroin prescription programs almost 30 years ago). 

 4. Ensuring the Protection of Youth in State Marijuana Legalization Efforts

 Columbia University Drugs and Society forum 7.30pm Tues 15/11/22

 Dr Linda Richter, PhD; Robyn Oster, BA

 Recommended Youth Protection Provisions in State Adult Use Marijuana Laws.  An excellent talk looking at results for the following issues:

 1. Product composition

2.    Packaging and labeling

3.    Advertising and marketing

4.    Manufacture and sale

5.    Marijuana use

6.    Sale and distribution to youth

7.    Use of tax and penalty revenue for public education, prevention, treatment, monitoring, and provision enforcement

The speakers detailed the available data from various states which legalised cannabis first and detailed recommendations for each of the above issues. 


[from CNN on related matter:] Just this month the NY State legislature is considering applications for cannabis licences which fall into numerous categories for growing, wholesale, retail, etc with rules about labelling, sites being away from schools, etc.  One weird provision which seems to be non-controversial is that generally, licence holders must have had at least one previous cannabis conviction.  Go figure!?  This is a country of contrasts to be sure!  The pp slides are available on request as the speakers had detailed data from interviews with hundreds of citizens in numerous states in the process of legalising cannabis for recreational use. 

 It surprised me that despite no licences being issued as yet there are already cannabis dispensaries all over New York City. Again, a country of contrasts.

 5. 100th birthday of Dr Joyce Lowinson, addiction treatment pioneer. 

 Psychiatrist Dr Joyce Lowinson, long time editor-in-chief of Substance Abuse, a Comprehensive Textbook, had her 100th birthday in New York City.  I have known this pioneer colleague for over 20 years.  She was involved in the very first methadone research paper (JAMA, Dole and Nyswander 1965).  Dr Lowinson was also instrumental in opening up large methadone clinics in the Bronx at a time when there was enormous need. 

 6. Death of Dr. Mitchell Rosenthal, Phoenix House Founder.

 19th Nov, New York Times: Dr. Mitchell Rosenthal, Phoenix House Founder, Dies at 87

A psychiatrist, he was an early apostle for treating drug and alcohol addiction with group therapy in a residential setting. [click below for link]

 Dr. Mitchell Rosenthal, Phoenix House Founder, Dies at 87 - The New York Times (nytimes.com)

 I believe that Phoenix House has parallels or models for Sydney’s Odyssey House which has been providing detox and rehab in a therapeutic community setting for many years.  At one time there was some animosity between drug-free ‘treatments’ and opiate maintenance advocates.  Now most agree that there is enormous demand for both detoxification services as well as maintenance programs.  Many of our patients have benefitted from each at different times so antagonism is pointless and understanding and cooperation the way to go.  I have always had a congenial relation with James Pitts and his colleagues in Sydney, Australia.   

 Written by Andrew Byrne, retired addictions physician, Sydney, Australia.