Sydney Medically Supervised Injecting Centre: Some statistics after 5 years

Dear Colleagues,

I have attended the Sydney Medically Supervised Injecting Centre about once per week for the past 5 years. I have had a 'guided tour' of the centre as well as being a local resident delegate on their 'community consultative committee'. The service now has strong majority support (up to 80%) from residents and businesses in Kings Cross and has been supported by most police, medical, church and health authorities.

Quite apart from the documented practical benefits for local drug users and residents, this service has given us a unique insight into drug use in Sydney over the past five years. It has been a barometer of street drug trends, while also emphasising the shortage of treatment services, both abstinence orientated and otherwise.

We learned very early that drug users were taking enormous risks with unsafe injecting practices. In many cases, there was 'blood everywhere' while injecting took place. This observation was one of the first useful 'messages' passed out by staff at medical meetings, written reports and local briefings to other health care workers. Many thought that by providing clean needles, we could be sure that infections in drug users would be curtailed. While this was true of HIV, it certainly did not apply to hepatitis B or C and skin infections.

Over 5 years, almost 9000 individuals have been reminded by staff to wash their hands before and after injecting. They have been provided with clean injecting equipment, good lighting and a safe and closely supervised environment to inject themselves in almost a third of a million injecting episodes between 9.30am and 9.30pm most days over the 5 year period of service.

The latest information is that heroin availability has declined dramatically since January this year and just as common now are prescribed pain killers morphine/oxycodone (31%). These have shown to produce a far lower overdose rate (less than half that of street heroin). Also, for the first time in 20 years, brown heroin (38%) from Afghanistan has appeared on the Sydney market. 'Crystal meth' or 'ice' is still popular (6%) and cocaine is used by 21% of attendees.

On average about 200 visits occur each day and some days there are more than 300 injecting episodes in the centre. I have noted that most mornings, there are usually one or two people in the waiting room but on exceptional occasions have counted up to 13 people waiting to be assessed at the front reception. This is not unlike many other businesses.

There were 87 overdoses recorded on average per quarter ranging from 47 to 175, possibly reflecting the variable strength/cost of street drugs over the years. Thus every one of the 1747 overdoses observed was a potential death statistic yet nobody died. We will never know the proportion who would have died without treatment. However, out of 300,000 injections we would certainly expect some deaths and considering these include some of the most high risk drug users, dozens of deaths might be predicted. Yet none occurred. The independent report estimated a number of lives were saved during the initial trial period. Many more lives have probably been saved since then.

Well known and consistent longitudinal studies on the natural history of opioid use show that of the 9000 people who have used these facilities, a high proportion are opioid dependent. Of these, after 7 years, approximately one third are likely to be drug free. Up to 50% could be expected to be on some form of maintenance treatment, 5-10% are likely to be dead with a similar proportion incarcerated.

Major Watters has said that if the injecting centre is shown to save lives that he would support it. Further, I understand that he supports all measures which result in (alive) abstinent citizens. I can only hope he can follow up on these sentiments as we need all the support we can get for this underprivileged group in our society. I know a number of (completely) drug-free citizens who may be alive today due to their attendance at the injecting centre when their drug using was at its most chaotic.

Some may expect the injecting room to lead to abstinence yet on the other hand, we do not expect the hospice to 'cure' many if any patients. Both services have shown their different places in the health care system. I support closing this injecting centre when its use falls below sustainable levels. However, on current usage, and with a continued shortage of available treatment options in New South Wales, I cannot see that happening for many years. Call me a pessimist.

Comments by Andrew Byrne ..

Lung cancer and cannabis. No association found in literature review, but precancerous changes shown in some

Arch Intern Med. 2006;166:1359-1367

The Association Between Marijuana Smoking and Lung Cancer: A Systematic Review.
Mehra R, Moore BA, Crothers K, Tetrault J, Fiellin DA.

Dear Readers,

Our attention is drawn to this week's Archives of Internal Medicine with its catchy, capitalized headline "The Association Between Marijuana Smoking and Lung Cancer". Despite the appearance of an assumed association, in fact the researchers published findings, after examining 19 rigorous studies, were that there was NO association between cannabis smoking and cancer. So why would the journal's editors imply in big letters that such an association exists?

The authors state: 'Observational studies of subjects with marijuana exposure failed to demonstrate significant associations between marijuana smoking and lung cancer after adjusting for tobacco use'. <snip> 'Therefore, we must conclude that no convincing evidence exists for an association between marijuana smoking and lung cancer based on existing data.'

Many of us believe that there probably is an association between any smoked organic product and lung damage. However, when 19 rigorous studies fail to show an association with cancer, we are entitled to conclude that the effect must be relatively small, and substantially less than the long accepted causation with tobacco. The authors' conclusions is that 'physicians should advise patients regarding potential adverse health outcomes' of cannabis.

It would appear that politics even pervades peer reviewed journals. Reefer madness is still with us! I note that the study and one of its authors were partially supported by the National Institute on Drug Abuse (NIDA) in America. This is the second 'difficulty' for Director Nora Volkow in a week (see magic mushroom story elsewhere).

Further evidence of the disconnect between science and drug policy is that even the most serious scientists and clinicians in America still often use the slang term 'marijuana' rather than the correct scientific (Latin) 'cannabis' or common English 'Indian hemp'.

Comment by Andrew Byrne ..

Mehra R, Moore BA, Crothers K, Tetrault J, Fiellin DA. The Association Between Marijuana Smoking and Lung Cancer: A Systematic Review. Arch Intern Med. 2006;166:1359-1367

Large study details benefits from addiction treatment

Drug Alc Depend 2006 83;2:174-180

One year outcomes for heroin dependence: Findings from the Australian Treatment Outcome Study (ATOS). Teesson M et al.

Dear Colleagues,
Professor Teesson and co-workers have performed yet another observational report of large numbers of heroin addicts one year after starting various forms of treatment (or no treatment - ref 1). Like the British "NTORS", the Australian "ATOS" (Australian Treatment Outcome Study) documents the most fundamental expectations of dependency treatment. Unlike the British study, Teesson's group also looked at 80 drug users who were not in treatment (initially) as a comparison group.
Just like Dole and Nyswander's work of 40 years ago, Teesson and colleagues found that a majority of subjects (52-65%) were abstinent at 12 months. They also found substantially less crime, risk taking behaviours and psychopathology in the 80% who could be contacted 12 months after entering a variety of drug and non-drug treatments.
Teesson is also an author on another related paper in an upcoming issue of D&A Dependence (ref 2) which looks at possible drug substitution or 'swapping' in the face of reduced heroin use during treatment. They find none. In fact the frequency of use for other opioids, cocaine, amphetamine and benzodiazepines was also uniformly lower when heroin use was also reduced in treatment (as part of the same ATOS). A recent Canadian report found similar positive findings with improvements in general health for patients: 91% one-year treatment retention rates with mean dose 90mg daily (ref 3).
Repeated studies like this would be unnecessary in other fields, but drug treatments, including detoxification units and harm reduction services, are constantly under threat. Hence such reports can help to defend addiction treatment from critics. Such studies also remind us of the dramatic benefits of treatment and the disastrous consequences when it is limited, inflexible or almost non-existent such as in Russia, Korea and some American states.
So, partly due to the intransigence of the few remaining Australian members of the "temperance league" more public money is spent on (and researchers' time devoted to) finding the same outcomes from established treatments helping in drug addiction. It should be no surprise that dependent patients in fact behave just like those with other diagnoses (eg. depression, hypertension, diabetes, etc): good treatment leads to good outcomes.

Comments by Andrew Byrne ..

Citations:

1. Teesson M, Ross J, Darke S, Lynskey M, Ali R, Ritter A, Cooke R. One year outcomes for heroin dependence: Findings from the Australian Treatment Outcome Study (ATOS). Drug and Alcohol Dependence 2006 83;2:174-180


2. Darke S, Williamson A, Ross J, Teesson M. Reductions in heroin use are not associated with increases in other drug use: 2-year findings from the Australian Treatment Outcome Study. Drug and Alcohol Dependence 2006 Article in Press accessed 4/6/06


3. Villeneuve P, Challacombe L, Strike C, Myers T, Fischer B, Shore R, Hopkins S, Millson P. Change in health-related quality of life of opiate users in low-threshold methadone programs. Journal of Substance Use 2006 11;2:137-149

Welfare to Work, Implications for your Patients. Case Studies.

Tuesday May 30th May, 2006.

Case studies (provided by Dr Richard Hallinan, Dr Frank McLeod, Sue Jeffries) with a summary of discussion, and including comments from Brian Baker, Disability Support Officer, Area East Coast, Centrelink. Summary by Richard Hallinan.

Click here for summary of main presentation

The following are eight case studies where things went well, or not so well, for people with substance dependency problems in dealing with Centrelink. They show ways in which doctors can help get the best outcomes for their patients. Each case has comments from Centrelink, including advice on new arrangements after July 1 2006.

Some of the changes in how Centrelink deals with people with medical problems are:

1. The Centrelink Disability Officer will now be the Centrelink Senior Customer Service Adviser, and will have more of a roving supervisory role rather than just seeing clients by appointment.


2. Documents including medical certificate and care plans are presented, at the front desk, to the Customer Service Adviser. If it is clear from the documents what kind of benefit/activity is appropriate the Customer Service Adviser (with or without the supervision/advice of the Senior Customer Service Adviser) will make those arrangements.


3. If further assessment is required, the customer will be referred to a "Job Capacity Assessor", which will be a health professional or service (for example a psychologist, or Health Services Australia, or Commonwealth Rehabilitation Service) under contract to provide this service to Centrelink. There is no provision for a treating doctor to liaise directly with a Job Capacity Assessor but .


4. If there is a problem with a customer meeting their participation requirements, the case is passed onto the "Participation Solutions Team", a centralised office in each Centrelink area.

The doctor's avenues for liaising with Centrelink will therefore be:

1. through documentation given to the patient to provide to the Customer Service Adviser


2. by marking documents to the attention of the Senior Customer Service Adviser, or telephoning them - the old contact numbers for the Centrelink Disability Officers apply.


3. by contacting the Participation Solutions Team if problems arise (such as a patient's benefits being stopped due to problems arising out a medical condition)

Case 1: Whose responsibility is the Treating Doctors' Report? Centrelink's policy when doctors refuse to complete TDR; Cost shifting between Medicare and Centrelink.

The first case was a 49yo woman on MMT whose previous medical certificates for Centrelink were provided by a GP who had retired. Other doctors, including the methadone prescriber, refused to fill in a Treating Doctors' Report (TDR). She says she was cut off by Centrelink because she didn't produce the TDR.

Centrelink confirmed that no costs are met by Centrelink for Medical Certificates or Treating Doctors' Reports. The time taken to complete the medical report may be claimed under a Medicare item when included as part of a consultation.

A Treating Doctors' Report may be requested:

1. if the certificate showed that the symptoms are likely to persist more than two years


2. in ALL cases when applying for Disability Support Pension


3. or if a Capacity to Participate/Medical Assessment/Work Capacity Assessment was being organised.

Doctors are under no legal obligation to complete Centrelink paperwork, and although it was agreed a Centrelink client should not be penalised if a doctor refused to do so, it was unclear what mechanism if any was in place for this scenario. It was unlikely that the client had payments stopped for failure to submit this form but they may have failed to submit their own part of this paperwork.

A Medical Certificate (with exemption from the activity test) is normally accepted if a client

1. has recently started MMT - considered temporary incapacitated whilst stabilising. (OR if dose change and a short period needed to stabilise).


2. is in a rehab program - residential or home - provided well supervised and involving activities such as regular counselling, NA/AA etc


3. had a Care Plan recently implemented with a series of strategies- eg investigation or management of other conditions- eg Hep C, psychiatric conditions.

If there was active drug/alcohol use and no interventions were in place, the client was not necessarily considered temporary unfit for work but barriers would be recognised and the Personal Support Programme* would be appropriate. Medical Certificate or Treating Doctors' Report would not be required.

*provided by such groups as Centacare, Salvation, and Mission Australia under contract to help people overcome personal obstacles and prepare for entry into the workforce.

Case 2: The importance of access to Disability Support Officers; Centrelink's policy when doctors refuse to complete the Treating Doctors' Report.

The second case was a 46 yo man who had recently restarted on MMT after a heavy relapse into heroin use. He had been on Newstart and a 3-month Medical Certificate was provided citing heroin dependency and chronic hepatitis C. A TDR form was given to the patient by Centrelink in response to a second 3-month Medical Certificate annotated "care plan in preparation."

This case described the doctor's frustrating attempts to speak to a responsible person at the Centrelink Office, where the only telephone access is via Helpline 132717, who refused to provide the phone number for the Centrelink Office but herself could not provide the information required The Helpline staff twice phoned the Centrelink office and relayed unsatisfactory answers back to the doctor. Eventually the Centrelink office called the doctor back, and confirmed that the TDR was not really needed. The doctor was given contact details for the Centrelink Disability Officer, who accepted the medical certificate with care plan appended. This contact number for Centrelink Disability Officer was subsequently used frequently and to good effect, with Care Plans regularly copied to Centrelink with patients' permission.

Centrelink's response: Centrelink has now provided a contact number for the "Participation Solutions Team", a centralised office in each Centrelink area. Contact details are: Tel 95822262. Email participation.solutions.eastcoast@centrelink.gov.au . (for health professional staff only, East Coasts Area only)

The existence of a Care Plan indicates that the conditions have not been fully treated and stabilised. Hence the conditions would be accepted as temporary and Medical Certificate would be sufficient. This case also highlights the need for all relevant information to be provided on Medical Certificate. However a TDR would NOT be required. A phone call to an experienced Centrelink Officer (Centrelink Senior Customer Service, or Participation Solutions Team) may solve a lot of trouble for doctors and their patients.

See introductory notes on how to do this after July 1st 2006.

Case 3: 'Sickness Allowance' for people who have a job to return to.

The next case was a 47 yo man, who had been on MMT 15 years, and working the last 13 years. He currently works 2 jobs as a driver up to 60 hours a week, says not paid overtime. He has Hepatitis C genotype 3 with Stage 3 fibrosis and needs 24 weeks interferon/ribavirin treatment but has only 4 weeks sick pay accumulated. He has a sympathetic employer, but doesn't know how he will pay his mortgage is he cannot work during interferon/ribavirin.

Centrelink's response: he would be entitled to Sickness Allowance after his sick leave expires, but should apply immediately, not when the sick pay expires. He is eligible for Sickness Allowance whilst remains temporarily unfit for his usual job and that job remains open for him - which is a 60 hour week job.

Maximum rate of Sickness Allowance is $416.40 per fortnight. If he had some work capacity he may consider supplementing his Sickness Allowance by doing a few hours at work.

The calculations are as follows:

Income test cut off currently is $671.43 per fortnight.

Under Welfare to Work, if he earns $400 per fortnight

Income free area= $62.

50% taper over 62- 250 per fortnight and 60% taper after $250.

(400-250) x .06 + 94 = $184 per fortnight.

Total Income = wage $400pf + Sickness Allowance $184 = $584 per fortnight

Case 4: The correct sequence of application for benefits and provision of a medical certificate.

The fourth case was a 29 yo woman, a chaotic patient on MMT, with chronic hepatitis C and high risk alcohol use, regular cannabis, periodic injecting of stimulants. She was on Newstart with intermittent work, but said she was "being hassled by Centrelink" for not completing work for dole. After a poor response to one month trial of mirtazepine and acamprosate she announced she was cut off social security benefits a week prior. A Medical Certificate was provided with 4 week retrospectivity and a care plan including:

psychiatrist and liver clinic assessment, possible interferon/ribavirin treatment and further attempt at home-based alcohol detoxification.

The patient returned 3 days later claiming Centrelink staff had rejected the medical certificate saying: "you are not currently a Centrelink client and have to reapply for benefits" and throwing the certificate back at her. The doctor phoned the Centrelink Disability Officer and owing to the patient's poor compliance with Centrelink requirements, DSO would insist she participate in Personal Support Programme.

Centrelink's response: if this was a new claim the medical certificate is currently "pended" until an interview with the Senior Customer Service Adviser to decide regarding exemption/appropriate referral. After 1 July, she would likely to be referred to a "Job Capacity Assessor" who will do likewise. The medical certificate was not rejected as such, though through poor communication the client may have been under the impression it was. Personal Support Programme may not be appropriate considering her recent work history. However she might be referred to the Job Network with a temporarily reduced capacity for work.

It was not inappropriate for the doctor to provide the certificate.

Case 5: Catch 22, Go to gaol

A 30 yo man was released after 11 yrs in gaol. After paying for rent/board, his first week of methadone, clothes, shoes, toiletries, smokes he was advised needs to get on Centrelink benefit. He was entitled to a Centrelink cheque, but first needed a bank account, and the bank did not accept gaol ID or a letter of ID, requiring instead a birth certificate, which costs money and takes six weeks to get. No money for board, food, smokes and done...it's all to hard... go back to gaol

As the submitter of this case said: "please don't say this doesn't happen - it happened to one of my clients yesterday.

Centrelink's response: Centrelink has field officers in the prison system to try to facilitate payments. However, this service has not yet reached rural areas (and it can break down when prisoners are released at night or on weekends).

Case 6: Convenience is not a medical issue

This was the case of a man who had no transport owing to the sickness of his mother (who drove him everywhere) and requested a Medical Certificate so he didn't have to make the long trip to town to fulfil Centrelink requirements. This was denied on the grounds that convenience is not a medical issue

Centrelink's response: when a medical condition doesn't prevent participation the patient/job seeker should be encouraged to discuss with a Senior Customer Service Adviser or Social Worker. There are other ways of addressing these issues than via medical certificates. Although exemptions are discouraged there is provision for short term exemptions due to a major personal crisis or caring requirements.

Question on Notice: 'buck passing' when Centrelink officers tell individuals to see their doctor and get a Medical Certificate (for no good reason).

Centrelink's response: if a job seeker failed to comply with requirements and is "breached", they often say they have a medical condition or were sick on the day.

If they are not currently sick and certificates cannot be back-dated, preferable would be a note from the Doctor confirming existence of an illness that can from time to time prevent attendance. Centrelink can ensure the job seeker is not penalised, but directed to the best pathway

Case 7 : The borderline personality coping with bureaucracy, and how to deal with intermittent fitness for work.

Kassandre Katastroff a 45yo of fluctuating gender, on MMT, with chronic hepatitis C seeks a medical certificate for pension, saying she was on Disability Support Pension before and was 'tricked' out of it. File notes read: "he was able to hold down 40 hour job only recently and now feels totally and permanently incapacitated. Is she for real?"

Kassandre is seldom long enough between jobs to get Newstart and he is keen to work but lurches from one unstable period of employment to another, with always some new drama (flatmate does a runner with the rent money, flat broken into, wallet stolen and all ID lost, skin breaking down and chronic itch, teeth falling out and recurrent dental infections). KK can't sleep and seeks valium, every time she has problems "I take drugs or drink".

Frustrated by being still hassled from all sides, especially Centrelink, she was given Newstart Jobsearch exemption on the basis of Medical Certificate and a care plan involving liver and dental clinics, psychiatrist and dermatology review. KK arrives hung over after drinking a bottle of bourbon to cope after receiving letter from Job Ventures telling him he was breached for non-compliance. She was drunk for psychiatrist appointment, but admits she didn't tell psychiatrist that she was drunk: "if he couldn't tell I was pissed, how could he tell if I was koo-koo". Interferon treatment was in doubt because of this episode.

The doctor discussed the matter with the Centrelink Disability Officer. There had been an error of notification at Centrelink with paperwork lost: all was easily solved.

Centrelink's response: Newstart with exemption from participation requirements may be more appropriate than Disability Support Pension as the listed conditions have not yet been fully treated and stabilised.

Disability Support Pension eligibility: the condition(s) must be fully diagnosed, treated and stabilised.

1. a physical , intellectual or psychiatric impairment of at least 20 points under the impairment tables; and


2. at least 16 years of age; and


3. continuing inability to work for at least two years; and


4. an Australian resident at the time of the inability to work occurred; or


5. qualifying Australian residence.

Impairment Tables: Alcohol or Other Drug (AOD) use does not in itself indicate permanent impairment.

5 pts AOD use sufficient to cause intermittent or temporary absence from work.

20 pts AOD dependence well established over time, sufficient to cause prolonged absences from work. ? reversible end organ damage

30 pts AOD Dependence well entrenched over many years, minimal residual work capacity. ? irreversible end organ damage

40 pts AOD use with severe functional disability and irreversible end organ damage.

Case 8: Helpful and less helpful partners in care planning.

The last case was a 29 yo woman on MMT, cannabis and alcohol dependent with hepatitis C. There had been repeated attempts at ambulatory alcohol detoxification.

During one such, a medical certificate was provided for Centrelink for 6 weeks. Care planning was discussed with the Job Network Member* who asked for a copy to her but shied at idea of participating in a care plan, saying she would send her back to Centrelink if she is unwell.

* Providers such as Job Futures/Work Ventures, Jobfind, Employment Plus under contract to provide people with assistance in getting employment.

Centrelink's suggestion: refer to the Participation Solutions Team:

"I have seen Care Plans that incorporate an interview with a Centrelink Senior Customer Service Adviser (CDO) - which is a good way of flagging the barrier to Centrelink. Need to do so via Participation Solutions team. The Job Network Member JNM would follow Centrelink's direction - ie accept she is totally unfit and leave her alone or comply with the reduced work capacity direction and assistance recommendations."

Summary by Richard Hallinan.

Welfare to Work, Implications for your Patients.

Concord Seminar: Tuesday May 30th May, 2006.

Presenters:
Yvonne Samuel, Business Support Manager, Area East Coast, Centrelink.
Brian Baker, Disability Support Officer, Area East Coast, Centrelink.

The 2005 Federal Budget saw some radical changes to our Australian welfare system. Yvonne Samuel took us through some of these changes in the first half of the seminar, and the second half of this seminar involved some feisty discussion centred around the case studies presented, with Brian Baker's comments included after each case study. The case studies will be posted separately in the second half of this write-up.

The Federal Coalition Government and Centrelink have published an information pack called "Helping people move into work," (a title chosen by the Coalition government) a copy of which was given to seminar participants and is available from Centrelink for those who wish to obtain one. This information package details many of the changes that are about to take effect on the 1st of July 2006. The package also has sample letters that have already been sent out to many people on Centrelink benefits, including both those who will and will not be affected. There is no doubt that patients will start to express their anxieties and concerns to their treating doctors and other health professional staff.

Yvonne Samuel began by explaining the Federal government/Centrelink rationale for the changes. They state that the aim of the changes is twofold: 1) to increase workforce participation and 2) decrease welfare dependency. They want to decrease the number of working age Australians on welfare (working age being defined as 18-64 inclusive). They state that they are driven by the changing age demographics in Australia; currently 13% of our population are over 65, but in 30 years the projection is that 33% will be over 65. We were told that those aged 15-20 who are not at school or in some other study will be "encouraged into a revitalised Australian welfare system to make it more sustainable" and moved into education wherever possible.

There are several elements to the reform:

(1) Increased obligations for people who are deemed fit to work at least 15 hours per week. (2) Payments and incentives will be changed, including a shifting of some people from DSP (Disability Support Pension) onto, in most cases, Newstart, and in some cases the ability to earn more money working before the Centrelink benefit cuts off. (3) The government states that there will be an injection of money to expand Centrelink services (4) There will be a new "compliance" framework, including the suspension of payments from Centrelink and restoration when the person starts fulfilling their "obligations" again. If a job-seeker does not comply with requirements without good reason, their future payment will depend on "re-engagement" with their service provider. (5) Increased funds to employers to encourage them to employ those with the most difficult job prospects eg those aged over 50.

There will be four main groups of people affected: (1) parents (2) people with disabilities (3) long-term job seekers (4) "mature age customers" defined by Centrelink as being those between 50 and 64 inclusive and deemed to be fit for work.

(1) Parents:

There is a one year transition period so that people currently on a parenting payment will continue to receive that payment until 30th June 2007, as long as at least one of their children is under 16 years of age.

From the 1st July 2007, or when their youngest child turns seven, whichever happens later, parents will have to register with an employment services provider and look for paid work of at least 15 hours per week. They will be transferred onto (in most cases) Newstart or the Youth Allowance, the payment from which is less than the current parenting payment. If there is childcare available from a formal and approved child care provider, then by the government's definition this is "suitable child-care" and the parent will have to accept the job. Principal carers who are on the Partnered Parenting allowance will be transferred onto Newstart when their youngest child is six, and principal parents who are on the Single Parent Allowance may be eligible for Parenting Payment until their youngest child turns eight. Indigenous parents can stay on or join the CDEP (Community Development Employment Project) and may be eligible for a CDEP participant supplement from Centrelink. There are a list of various exemptions and special circumstances that may be considered.

(2) People with disabilities:

People who were receiving the DSP on 10th May 2005 and before will not be affected by the Welfare to Work changes. However, if this group of people do return to the workforce and their job lasts greater than 2 years, and they then lose that job, they will be reassessed for DSP under the new rules and may therefore lose their DSP. People who were granted DSP after 10 May 2005 up until 30th June 2006 may be reassessed against the new rules within two years. They may be given a Job Capacity Assessment. In most cases they will keep their Pensioner Concession Card and still receive Pharmaceutical Allowance and Telephone Allowance. The new rules, from the 1st July 2006, state that a person is not eligible for a DSP if they are able to work for at least 15 hours per week without assistance, or with assistance and training, are able to work at least 15 hours per week independent of support within 2 years. If deemed fit to work for at least 15 hours, people will be transferred onto, in most cases, Newstart or Youth Allowance, which is less money than the DSP.

(3) Long-term Job seekers:

If a person is on Newstart or Youth Allowance and has completed two rounds of "Intensive Support Customised Assistance" they will be reviewed for either a "wage assist" package that will be paid to an employer who employs them, or they will be required to participate in full-time Work for the Dole for 50 hours per fortnight and they must still keep looking for work and continue their usual regular contact with their employment service provider or Centrelink.

(4) Mature age people (defined by Centrelink as aged 50 and over):

People on Newstart and over 50 will have increased participation requirements. Those who are aged 50-54 will now have exactly the same job search requirements as younger job seekers- eg making 10 job search "efforts" per fortnight. They will no longer be able to meet their activity test requirements by doing voluntary and/or part-time work. Job seekers on Newstart aged 55 and over will have an obligation to look for work, and this can include part-time or voluntary work for 30 hours or more per fortnight. All mature age people will be subject to the rules set out below in the new "compliance" system.

New "Compliance" System:

From 1st July 2006, a new system of penalties will come into place for people who do not meet their obligations as defined by the Treasurer in his 2005 budget. The penalty for a third or subsequent failure within 12 months will be eight weeks without income support. An eight week non-payment penalty will also apply for more serious failures to participate. Anyone who now fails to declare their earnings correctly will now have to pay their debt back to Centrelink, plus a 10 per cent "recovery" fee.

This seminar was highly interactive with a lot of concerns about these new changes being expressed by the audience. The onus is definitely now on our patients (Centrelink's "customers") to let Centrelink know as soon as possible if they are unable to meet their job-seeking obligations. Yvonne Samuel told us that people who are medically "fit" but under a lot of stress, can be offered a range of support services such as access to Centrelink's Personal Support Programme (PSP), without their payments being suspended. Whether patients will be willing to divulge their histories of personal distress to a government bureaucracy is yet to be seen. A look through the case studies provided help to illustrate the difficulties to come, such as whether those with very chaotic lives will lose financial benefits as a result of their inability to communicate in the new ways expected. One of the cases presented the already destitute circumstances of some patients. Should patients in these circumstances be unable to comply with the new "compliance" system, then there are obvious risks of homelessness.

Other considerations include the dubious morality of making Centrelink, an organisation that has traditionally been there to provide financial support to those in need, a debt collector, as outlined under the above heading of new "Compliance" System. With dependency patients in mind, this is unlikely to encourage them to let Centrelink know about their situations of personal distress and thereby avoid a two month period without payments. There were a range of emergent issues that were not covered at the seminar such as the difficulties that single parents will face in obtaining child care if they are forced back into the workplace. It was also unclear how the job seeking requirements will pan out for the parents of children with disabilities.

Of further concern are the rights of people who have periodic fitness for work, given the tighter eligibility rules for the DSP. Will our patients with cyclical periods of good mental health associated with an ability to work part-time, but substantial periods of psychiatric disability, be excluded from the security of the DSP? Will the new Centrelink changes themselves become another stress that contribute to emotional distress and subsequent disability, as was mentioned in one of the cases. There are still many unknowns about the implementation of these changes.

This seminar ended with various other issues being outlined in the case studies presented by Dr Richard Hallinan. It is only with the passage of time that we will understand the full effect of these new changes many of which will begin on 1st of July this year.

Written by Dr Jenny James, Daruk Aboriginal Medical Service.

Opioid receptors, addiction and beyond

Inter-Institutional Narcotic and Ethanol Group Lecture
1:00pm Tuesday, May 2, 2006 - Caspary Hall 1B, Rockefeller University, York Avenue, NYC.

Professor Brigitte Kieffer, Ph.D.,
Institut de Génétique et de Biologie Moléculaire et Cellulaire, CNRS/INSERM/ULP, Université de Strasbourg, France

Dear Colleagues,

In little over an hour, this informative presentation brought us up to date on the state of the art regarding cloned opioid receptors, rat experiments, fluorescent antibodies and cellular changes associated with opioids. Clinically in opioid addiction, these involve: initiation, maintenance, dependency, habituation, withdrawal, abstinence and relapse to drug use.

Dr Kieffer started with the simplest description of drug use and the inevitable brain changes which occur with tolerance at the receptor level. As she pointed out, all of the consequences of drug use are mediated by such receptors and can be understood in terms of old pharmacology research with corroboration from more recent work on the defined receptors themselves. Dr Kieffer's group in Strasbourg was the first to clone the opioid receptor, which was also done independently at the same time by Evans' group in California.

We were told about behavioural experiments in mice cloned to have one, two or three gene 'knock-outs' being mu, kappa or delta opioid receptors. The first and most important finding was that such animals (even triple 'knock-outs') are still viable, proving that (some) mammals do not require the opioid system for survival and procreation.

Such receptors were predicted long before they were specifically isolated and such rats were bred in the late 1980s. The experiments with mu receptors were all completely predictable based on previous pharmacology but this was not the case with delta or kappa receptors. To examine analgesic and euphoric effects, they used tests of self administration ('press the lever'), tail immersion, dark room, bright lights, place preference, preferred routes, maternal smell recognition and a number of other interesting tests on the cloned and 'wild type' rodents. Consistent with some of the pharmacology, similar results were found in relation to alcohol and cannabis, demonstrating that some of their properties are mediated by the mu system as well. Dr Kieffer's particular interest seemed to be the delta receptors which she feels are related to learning, stress and even mood alterations such as anxiety and depression.

Much of the second part of the talk went over my head, dealing with sub-cellular and membrane changes, much amazingly documented visually.

A fascinating power point clip showed a 20 minute neuron clip speeded up to just 8 seconds showing fluorescence for delta-receptors. In this time, smooth layers of visible glowing membrane-bound receptor rapidly became clumps of granulated intracellular material, altering the cell dramatically. I was told that this was not depolarisation, but a much slower response to other stimuli, some of which may have regulated sensitivities. Most impressive of all, perhaps, were several 3-D representations of the actual receptor molecule with neat little indentations where opioid molecules could trigger pre-determined responses for depolarisation or blocking of the neurone involved or in some cases, movement of dopamine and other neuro-transmitters. So the old 'key in lock' analogy is also valid on a physical molecular level!

Finally there were some questions about the fine points of her field of cloning, obtaining antibodies, etc. It is always a delight to return to Rockefeller University in York Avenue on the East River. Its gardens are quite spectacular and the modern paintings hanging in the dining area are a pleasure and an education. All are on loan from the Rockefeller family collections (see sample below). Dr Kreek's office has a fine view of Brooklyn and Queens across the elegant Queensborough Bridge. Just three blocks away on York Avenue, Sotherby's Auctions were previewing some important French impressionist to be sold in London later in the year (see below). Several had reserves over a million dollars. The only sadness this year is that Dr Vincent P. Dole, aged 94, is quite unwell and no longer able to contribute actively to the field although he did sign the award certificates and send a greeting to the AATOD conference in Atlanta in April.

Comments by Andrew Byrne ..

Please don't mention the real HIV issues - CNN viewers may not like it!

In the US, CNN aired a prime-time program on HIV on Saturday 29th April 2006. Its topic was world eradication of this epidemic yet the content was surprisingly thin and limited. Hosts were the long-serving CNN (and New York Times) doctor-at-large Sanjay Gupta and Bill Clinton, who has taken a high-profile and personal interest in the subject.

Any hopes of this program being a useful contribution were quickly dashed. Even with the involvement of a committed and informed person of President Clinton's status, the facts were glossed over and the entire program had an air of unreality. It was held in a church with gospel singers, an odd decision in my view for a supposedly serious presentation on public health and epidemiology. Even more distressing is that at least one mainstream church has contributed to the extent of the epidemic by banning condom use, even in marriage. And a church spokesman had the effrontery to address this audience on the 'benefits of abstinence'.

The use of a particular church for the program's venue may also have offended some sensitive Christians, Jews, Moslems and even atheists, many of whom must feel strongly about the subject but not be too keen to be associated with formalities of other faiths.

The program looked as if random people stood from the audience to speak yet it would appear that each was carefully chosen. One of the first was a spokesman for the pharmaceutical industry which is telling. Mr Clinton had already said some 'softly' things including the gratifying reduction of the price of some antiviral drug courses from $400 to $300 in response to humanitarian calls. Mention was made of the enormous commitment of the industry to research. No mention was made of running treatment trials using placebos for some subjects in the third world, nor of why treatment in Canada and Mexico is so much cheaper. A young female victim stood to tell us about the futility of telling young people in impoverished regions about the benefits of sexual abstinence. She explained that it was 'fun' and 'for free', and hence the need for education and protection for all young people.

Some alarming statistics were given by President Clinton and it was pointed out that there are still much HIV transmission in the United States every year. Yet the words 'needles', 'syringe', 'gay', 'methadone' were strenuously avoided in over an hour of palaver. While it is an on-going tragedy, no mention was made of the ability of simple public health measures to prevent transmission of HIV. The US uniquely spends large sums on banning needles and syringes, a policy which neither reduces drug use while at the same time facilitating continued spread of contagious diseases benefiting nobody except drug companies and funeral homes.

This television 'special', far from informing the American public or overseas CNN listeners, clearly resulted in keeping its audience in the dark about the basic facts of this modern epidemic. It would seem that 'freedom of the press' gives unique immunity in the US. It ensures neither balance nor truth.

Numbers of Swiss opiate users decline while harm reduction measures introduced. Lancet article.

Nordt C, Stohler R. Incidence of heroin use in Zurich, Switzerland: a treatment case register analysis. The Lancet 2006 367:1830-1834

Dear Colleagues,

This definitive study succinctly refutes the last remaining criticism of harm reduction: whether it encourages drug use. It appears to do precisely the opposite, as these authors report.

Switzerland’s ‘cantons’ have registers of drug treatment approvals going back to the 1970s. It is therefore possible to derive statistically valid measures of the rate of addiction of its citizens over the period when needle services, injecting rooms, methadone treatment, heroin prescription and most recently, buprenorphine treatment were being introduced. Such data reflect the natural history of opiate use through interactions with treatment services such as methadone maintenance treatment (MMT), withdrawal from such treatments, mortality and other demographics.

The canton of Zurich has 1.2 million people (a fifth of the Swiss population) over half being rural. Between 1991 and 2005 about 10,000 patients underwent 24,000 episodes of opiate prescribed treatment (2.4 per person). By 2005 there were 3000 still in treatment and 7000 who had been discharged.

Of those who left treatment in Zurich in 1991-1993, 33% never re-entered treatment, 66% rejoined treatment within 10 years, only 1% returning after a decade. The authors derived a long-term annual abstinence rate of 4%, comparing this with an Australian report of 5% along with others. Each year, the mean age of those in current treatment increased by 9 months, reflecting fewer new entrants and high retention rates.

Importantly, about 50% of Swiss subjects entered methadone treatment within 2 years of starting to use heroin with only small differences depending on sex, age and injector status. This contrasted with an average of 4 years to enter treatment in Italy and probably longer in some other countries. The authors further estimate that at any one time, about 50% of those with problem opioid use are on MMT. With fewer new initiates in Switzerland, they project this figure will rise to 64% by 2010. These figures are comparable with reports from Amsterdam in the 1990s.

Perhaps most crucial are the findings regarding the numbers of Zurich canton citizens taking up heroin for the first time. From around 80 people in 1975, this increased progressively to ~850 new users annually by 1990, only to drop again to ~150 by 2002 at the height of the harm reduction interventions. These included prescription heroin to a small but consistent proportion of maintenance cases.

So we can now quote reliable knowledge that in a modern western country which advocates and practises harm reduction in its most progressive form (apart from decriminalized cannabis) there are not more, but fewer young people availing themselves of the opiate class of drugs. Indeed, we can now say with confidence that harm reduction measures do not “send a message” encouraging drug use. The authors believe that by ‘medicalizing’ addiction, an impression is created that it is unpleasant and undesirable, to be avoided, which is just what has happened.


Comments by Andrew Byrne ..

Atlanta AATOD 2006 conference report

"Treating people with dignity"

April 22-26 2006, Hyatt Regency Hotel, Atlanta, Georgia

This year's AATOD meeting seemed more bland than usual with fewer scientific papers but more emphasis on areas of special need such as social equality, dignity, criminal justice, housing, recovery, etc. Few of the scientific sessions had patient representatives involved.
There were education sessions for health care professionals as well as patient representatives on the Saturday and Sunday prior to the conference proper. There was also a European session, as usual, on the Sunday afternoon, including Swiss, French, Italian, Slovakian, Bulgarian, Ukrainian and other representatives.

Monday 24th:

With fog in Washington (is that an omen?) and airline delays I missed the early sessions on Monday. Afternoon workshops included "Medical Aspects of Methadone: What Counselors Need to Know about the Medication". Judith Martin spoke clearly about the intrinsic benefits of methadone and the need to emphasise to patients why they 'should prefer it' to heroin (or other opioid).
In a parallel session we had James Carleton speaking about his experience with the Rhode Island penal system where there is one large jail for men and two smaller ones for women. When inmates had been on methadone prior to incarceration, this could be continued whilst in holding cells, but only for a limited period. We were told that primary medical care of inmates was quite separate and only those who were already on treatment were able to receive the methadone, albeit on reducing doses, on the authority or their original legal prescription. When pressed, Dr Carleton said that 30 to 60 and sometimes to 90 days treatment could be arranged in that state's lock-ups.
A perceptive participant asked whether a person who developed or redeveloped an opioid habit in jail could be treated by his team in this way. He told us that the prison administration would probably not physically allow such a person to attend for methadone treatment, but that indeed drugs were available in Rhode Island jails. Very recently there had been an overdose leading to hosptialization of the inmate, with a stay in intensive care, presumably at the jail's expense. It would appear that all around the world a drug-free jail is just about as realistic as a drug-free society. Yet US jails allowing methadone are still exceptional (see Tuesday plenary on the subject below).
Andrew Rosenblum from New York spoke about opioid prescription abuse in OTP patients in 70 centers across the country. Data were presented from the past 12 months on over 8000 subjects enrolled in OTP's across the country. The findings show a dramatic difference between whose whose primary drug of choice was heroin or prescribed analgesics. Big-city and metropolitan residents were far more likely to be heroin users while small town people were more often pill takers in their study. The former were 75% injecting while only one third of the pill takers reported injecting. Most of the latter (~80%) reported accessing their drugs primarily from 'dealers', while other sources were from friends, doctors prescription, emergency room, theft and internet or forged prescription (~3%). The prescription drug users were twice as likely to be in work and half as likely to be on public benefits. They were also younger (32 vs. 37) than heroin users and 97% were Caucasian (cf. 54% for heroin users in treatment). Pill takers were also more likely to report chronic pain (>6 months >5/10 severity pain). Prescription drug users were predictably more likely than heroin users to have used more than one drug.
Paul Bowman, NAMA advocate from Massachusetts was billed to speak to "Patient and Provider Groups: Methods and Models". This was one of only a few sessions with consumer input.
There was also a presentation by Randy Seewald on methadone and overdose prevention. Research shows that just being in treatment (of any kind) reduces overdose likelihood. The antagonist naloxone is being distributed in some areas with instructions on emergency resuscitation. Apparently it is available without prescription in Italy. In what seems to be an American habit, in some states naloxone supply has been 'waivered' from medical malpractice action, despite no evidence of its benefits over potential harms in drug overdose treatment by non-medically trained drug users and their associates. Consistent experience from legal injecting rooms shows that only a small minority of 'early diagnosed' observed and confirmed overdoses require naloxone, and that just supportive treatment is sufficient for most.
This New York research group was brave enough to use the "harm reduction" term in their slides, in opposition to the American federal policy against this wording, despite the issue being 'routine' or even 'motherhood' in many countries. They further reminded their audience of the intrusive and unnecessary regulation on methadone prescription.

Tuesday 25th:

The morning plenary was on treatment in the penal system, chaired by Paul Samuels, a long time advocate for rational approaches to the field of addictions and crime.
We heard at length from the Atlanta District Attorney, Paul Howard, about the incarceration statistics, progress with the need for treatment and prevention programs.
Our host lawyer said that for those outside the deep south should take something back home and offered us a local expression: 'lazy as a rigid mule'.
On any one day, 4-7% of prisoners in New York City are getting high on drugs. When he was commissioner in Pennsylvania, the rate was allegedly 10% which dropped to 1% after a concerted effort at interdiction.
Various parts of the country are now moving to allow limited methadone treatment in jails. These include San Francisco; Orange County, Seattle; Orlando, Florida; New York City (not up-state where most prisoners are housed); Rhode Island.
Timothy Ryan spoke eloquently about their implementation of a system of methadone in Florida which gave methadone to existing patients under certain strict rules. He pointed out that one needs to tread lightly as there are 'no absolutes in this area'. I countered afterward to him privately that surely giving correct treatment to all inmates is an appropriate absolute goal. And since drug use is such a high priority issue and methadone treatment is so cheap and effective, there is no excuse for denying such treatment to prisoners on any basis except to punish them twice (like solitary cells and interstate transfers). As Commissioner Martin Horn from New York pointed out to the audience, they work for the Department of Corrections, not the department of punishment.


The morning workshops included the interactions between pharmacotherapy providers and homeless mental patients who are incarcerated; culturally sensitive treatments; older patients in drug treatments; child protection issues and linkages between recovery community and pharmacotherapy providers. Beth Israel New York is the oldest and largest methadone treatment service in the country having over 7,000 patients of whom 20% are over the age of 55 (max 84 years) while in clinics generally the proportion is about 6% and growing each year. There were already 2% over 75 years. The issues addressed included multiple medications for other illnesses more common in older age - this includes possible drug interactions. Arthritis can make 'child-resistant' bottle lids into 'adult-resistant' which may be the bane of life for some, needing attention. Also eye sight issues and mental state may require simpler labelling in some cases. Nursing homes, hospice care, third party drug collections by registered family members or associates, social services and legal issues were addressed. Just as there may be a place for adolescent dependency services, a clinic for older adults may have advantages so a trial is being run in New York presently.

On the Tuesday afternoon we were presented with the so-called Matrix model of evidence based stimulant abuser treatment (despite there being no scientific evidence of its effects over other treatments or placebo/no treatment as far as I am aware). There was another session on details of implementing drug treatments in the prison system. There were also talks on recovery, technology transfer (is this modern term for education?) and the role of the family, work mates and others beyond the drug dependent subject. A web site for family members is being developed by the daughter of a patient.

Poster displays:

As seems to be the trend, rather than just having poster displays passively available in the 'intermissions', there was a designated 'author session' on Tuesday afternoon which was very well attended. There was the full range of dependency issues, including domestic violence, abstinence based treatments, buprenorphine, viral diseases, PTSD, jails, policy, mothers and drugs, alcohol co-morbidity, childhood methadone overdoses, internet data gathering, methadone mortality, client surveys, office based treatments, oxycodone use and abuse.
I will mention two outstanding posters, the first from a Canadian group from Alberta who describe their completely logical system of treatment involving shared care between community physician, specialist clinic, pharmacist and their liaison. Importantly, the Canadian pharmacists are involved in administering methadone to those who need it while also 'dispensing' take-home doses when ordered for suitable stable cases.
Next was an excellent if depressing description of how clinics across the US are addressing hepatitis C virus infection (HCV) by Sheila Strauss and NDRI colleague Janetta Astone. They have on-going studies of staff awareness and other aspects of HCV in dependency clinics. After piloting their survey in a number of clinics around the country including Florida, there is still much room for improvement. Little or no education is given in 16% of clinics and no testing in 30% in their sample. Yet we are told that there are 4 million HCV patients in the country (and one million with HIV) and the largest single group are potentially attending government registered and accredited clinics and thus are ideally placed for education, testing and referral.

Wednesday 26th:

Morning sessions included motivational interviewing, women in jails, drug interactions with dependency medications, measuring cost effectiveness and lastly, suicide, depression and overdose in pharmacotherapy patients.
The final plenary session was given by General Barry McCaffrey, popular drug advisor for the Clinton White House. He gave a most captivating and realistic presentation, starting with some facts on drug use in America. About one million Americans were regular heroin users and about 3.4 million had used the drug ('lifetime exposure'). Another 2.8 million had abused a prescribed ('synthetic') opiate which he labelled "the new heroin". He pointed out that it was a growing and changing problem. McCaffrey punctuated his comments with dramatic and clearly well-sourced statistics. An untreated heroin addict costs society about US$48,000. In jail, they might 'cost' $27,000 annually, but that the average prison stay is only measured in weeks, even in America. The USA, we were told, incarcerates more of it population than almost any other country (Russia and South Africa are the exceptions).
The much decorated general then reminded his audience that this was the ideal opportunity to introduce mandated treatment as in the drug court program which has been so successful in many jurisdictions. He said that there were 241,000 patients on methadone treatment in the US currently. He quoted MMT as being associated with 70% less heroin use, 57% less crime committed and 24% increase in employment rates (these figures are probably quite conservative in my view). He has no hesitation in saying that 'coercion works' (as with drug courts and contingency measures). That same week, Mexico announced that it was introducing decriminalization of all drugs for personal use, like Portugal did some years ago. Along with freeing access to treatment, this would seem a more logical approach than the traditional prohibition tactics instigated by the US after the second world war.
McCaffrey, who did not frame the current laws and has done much to counter their negative effects, quoted the famous line from 'Trainspotting': "If you have got heroin, who needs friends?!" He also gave a hilarious scenario of a person lost in a hot air balloon who found himself lost in a fog 30 feet above a man tending a garden ... "Can you tell me where I am?" ... "You are in a hot air balloon, 30 feet in the air!" ... "Thanks very much, I see you are a scientist!". (Gulp!) "However did you know?" ... "Well, what you have told me is technically correct ... but is of no use whatever, to anyone!" ... "Well, it seems you must be a government policy officer" ... "However could you tell?" ... "You do not have your feet on the ground, your head is in the clouds and despite your best efforts, you have no idea where you have been, where you are, nor where you are going". [my memory may be imperfect]

Comments by Andrew Byrne ..

Combination Therapy for Alcohol Dependence

From: JAMA Vol. 295 No. 17, May 3, 2006

Dr Byrne has suggested the following is an important research study. He will consider doing a more formal summary of it in future to ascertain its relevance to regular medical practice and alcohol dependent citizens seeking treatment. We still need to accept that the more effective options we have, the more subjects we can help.

"The efficacies of medication and behavioral therapies, alone or in combination, for treating alcohol dependence were assessed in the multicenter randomized Combined Pharmacotherapies and Behavioral Interventions (COMBINE) study, in which study participants were randomly assigned to 1 of 9 treatment groups. Anton and colleagues report that patients in all groups had an increased number of days of abstinence. However, patients receiving naltrexone, CBI, or both along with medical management had more days of abstinence and fewer heavy drinking days than patients in other treatment groups."

Link to abstract (full text is available for JAMA subscribers only).