A disappointing 'guideline' on methadone treatment.

Methadone Safety Guidelines. Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society. Chou R, Cruciani RA, Fiellin DA, Compton P, Farrar JT, Haigney MC, Inturrisi C, Knight JR, Otis-Green S, Marcus SM, Mehta D, Meyer MC, Portenoy R, Savage S, Strain E, Walsh S, Zeltzer L. The Journal of Pain 2014 15;4:321-337

 

 

This promising document attempts to give guidelines for the safe use of methadone in pain management, dependency and paediatrics.  With two contributors in common, it appears to be based on an earlier ‘guideline’ initially published on-line in Annals of Internal Medicine and then withdrawn, only to be re-published three months later omitting CSAT in the title (ref 1).  In both these cumbersome and non-evidence based ‘guidelines’ on safe methadone use the reader is first advised to warn individual patients of possible cardiac complications before treatment.  Then, whether for pain or dependency, one is advised to perform ECG before and during treatment. 

 

After such worrying information some patients may request an alternative medicine which may be less effective and more costly than methadone.  No mention is made of other significant complications such as constipation and hormone disturbances. 

 

We are told that there is only low-quality evidence for ordering ECG yet a recent Cochrane summary finding ‘no evidence’ for ECG in prevention of cardiac complications is not cited.  So these authors just seem to think ECG is a ‘good idea at the time’ with no suggestion of a cost-benefit analysis or international perspective.  Their call for more research is rather bewildering in a decades old treatment.  Controlled trials are impractical for long-term and very rare events such as TdP [sic].  Mandating ECG in some countries may mean the difference between getting treatment or not getting treatment (for pain or dependency).  This issue is not addressed in this particularly American document. 

 

Opioid therapy for analgesia and dependency have quite different goals of therapy yet these authors consider the cardiac risk in a parallel fashion.  A reasonable risk for dependency patients may be an unacceptable one in pain management.  These authors do not make this distinction adequately in my view. 

 

While these authors quote the very low rate of torsade de pointes (TdP) found in a large national study in Norway (Anchesen et al.), they fail to quote a larger and equally reassuring French study by Perrin-Terrin (ref 2).  The latter found extremely low rates of TdP in the national “pharmaco-vigilence” program in France.  Krantz has written that methadone maintenance substantially improves cardiac safety in several respects (ref 3). 

 

Twelve years after the first description of TdP in methadone patients there is still no proof that methadone causes this syndrome using strict scientific criteria.  There were no case reports in 35 years of widespread international use of methadone.  Nevertheless, as patients aged and new adjuvant treatments came into use for HIV, hepatitis C and other conditions, substantial evidence has accrued including over 100 published case reports, official adverse event reports, literature summaries and forensic studies on sudden death cases.  These make it clear that when TdP occurs it nearly always has precipitating events in methadone patients, usually when used in high dose over long periods.  It is generally agreed that TdP is multifactorial (ref 4). 

 

These authors do not appear to be aware of this literature.  For instance, Wedam’s finding of substantial QTc abnormalities in up to 10% of newly enrolled methadone patients in at odds with an almost complete lack of reports of TdP in patients new to methadone.  Numerous other inconsistencies make these guidelines inappropriate and unduly alarmist.  The authors scarcely mention the consequences of treatment failure, balancing this with the occurrence of side effects.  They also fail to discuss common side effects such as alterations of calcium metabolism which can lead to osteoporosis in later life, not to mention severe constipation which is not always a trivial complication. 

 

The recommended starting dose of 2.5mg 8^th hourly in a patient who is transferring from morphine is highly questionable and almost a recipe for failure (and thus transfer to yet another formulation).  For dependency, 30-40mg starting doses have been the long standing recommendation for most patients.  Yet the US TIP guidelines allow up to 60mg on the very first day (under specific circumstances and in split doses).  They also allow somewhat faster increments than permitted here by these authors where it could take three weeks to reach the common dose of 100mg daily.  Inadequate dose escalation is yet another reason for methadone treatment ‘failure’ and drop out in the case of clinic patients, and a known high mortality (ref 5), unlike TdP which is “controllable 100% of the time” according to cardiologist Phibbs (ref 6).  Overdose in the first two weeks of treatment is also a risk, hence the need for professional daily supervision. 

 

Despite a constant theme of cardiac prevention, the reader is not informed that while it is most unpleasant and to be avoided, TdP is exceptionally rare and apparently universally non-fatal in dependency patients.  Furthermore, it usually occurs in patients with more than one risk factor and thus can be predicted up to a point.  TdP should be seen in a balanced context, like all side effects. 

 

These authors overlook the repeated finding in controlled studies that methadone has better retention and lower intercurrent drug use when compared with buprenorphine at therapeutic doses (ref 7).  We read here instead that they have ‘similar efficacy’ which is less than candid with the reader (and another bonus point to - or from - buprenorphine manufacturers).  And nowhere is cost-effectiveness mentioned even though most medical schools now place this as an important item in therapeutics tuition - and for the third world it is often critical. 

 

By getting members of pain, dependency and paediatric specialties to agree with previous untested and unproven “guidelines” these authors have unwittingly allowed themselves to be aligned to the drug industry in its time honoured strategy to denigrate low-profit drugs in favour of expensive and high-profit medications (indeed, that is their duty to their shareholders).  As clinicians we should be able to balance such commercial fervour with common sense in our patients’ interests.  

 

A national conference “side show” some years ago entitled ‘Cardiac complications of methadone treatment’ funded by Reckitt Benckiser brought these tactics into focus.  Their drug, buprenorphine, is the only licensed alternative to methadone for opioid maintenance in Australia so why would they not support publicising alleged problems with methadone?  Despite being over 30 years old buprenorphine still attracts extremely high prices.  Its various formulations combined with naloxone have not been shown to be superior to pure buprenorphine (and remarkably this is not even required under normal TGA regulations for a new pharmaceutical product).  It is unfortunate that thousands of Australian patients are currently taking naloxone every day (1) with no proven benefit and (2) with little long term safety data. 

 

With new measures attempting to ward off rare complications, these guidelines would be more appropriate for a brand new drug.  However, with decades of safe use worldwide new prescribing restrictions or ‘safeguards’ should only be added with good reason.  The authors avoid the term ‘drug of choice’ yet with its track record and superiority in retaining patients, reducing high-risk behaviour, methadone may fairly claim this status in opioid maintenance. 

 

Another area which is studiously avoided by these authors is the supervised administration of methadone in clinics and that uniquely American conundrum that most methadone clinics have been unable or unwilling to prescribe buprenorphine while their private community practice colleagues are not permitted to prescribe methadone for addiction.  So these ‘guidelines’ are of little or no use to a large proportion of American doctors who prescribe for opiate dependence … and should be received with great scepticism by others, such is their narrow clinical message. 

 

Some might expect methadone treatment guidelines to be written by doctors who prescribing the drug, aided by pharmacologists, public health physicians and/or others with training in therapeutics.  The list of authors shows a quite contrary group, including some serial offenders as being critical of methadone and some have been paid advocates of buprenorphine, the only licensed alternative to methadone for dependency treatment.  The conflict statement would appear to be delinquent in these respects. 

 

I apologise for bringing such a GIGO* publication to the notice of readers. 

 

Written by Andrew Byrne ..

 

* Garbage in, garbage out.

 

References:

 

1. Krantz MJ, Martin J, Stimmel B, Mehta D, Haigney MCP. QTc Interval Screening in Methadone Treatment. Ann Intern Med 2009 150;6:387-395

 http://methadone-research.blogspot.com.au/2009/03/close-examination-finds-flaws-with_4855.php4

 

2. Perrin-Terrin A, Pathak A, Lapeyre-Mestre M. QT interval prolongation: prevalence, risk factors and pharmacovigilance data among methadone-treated patients in France. Fundam Clin Pharmacol. 2010 Sep 6
 

3. Krantz MJ. Clinical Concepts- Cardiovascular Health in MMT Patients. Addiction Treatment Forum 2001 No 4 (copy on request). 
 

4. Justo D, Gal-Oz A, Paran Y, Goldin Y, Zeltser D. Methadone-associated Torsades de Pointes (polymorphic ventricular tachycardia) in opioid-dependent patients. Addiction. 2006 101:1333-1338

 

5. Grönbladh L, Öhlund LS, Gunne LM. Mortality in heroin addiction: impact of methadone treatment. Acta Psychiatr Scand (1990) 82:223-227

 

6. Phibbs B. Advanced ECG: boards and beyond. 2006 Elsevier p142

 

7. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014 Feb 6

 http://www.ncbi.nlm.nih.gov/pubmed/24500948?dopt=Abstract

Opioid overdose epidemic in America - NYT story

American overdose crisis worsens. New hydrocodone product approved against advice.  Also overdose editorial by Prof Shane Darke (see below*). 

 

Reference: ‘New Painkiller Rekindles Addiction Concerns’ pD1 Science Times, New York Times, Tues April 22. 

 

This is a featured article by reporter RC Rabin about the marketing of a new long-acting hydrocodone preparation in the context of ever-increasing overdose deaths in the US.  Such is the crisis in Massachusetts that the Governor has taken the unprecedented step of declaring a state of emergency over the overdoses.  Gov. Deval Fitzpatrick banned this drug outright, despite its approval by the FDA.  A court over-ruled the Governor and so Zohydro joins dozens of other over-priced and dangerous opioid analgesics on American pharmacy shelves. 

 

“Nearly half of the nation’s 38,329 overdose deaths in 2010 involved painkillers according to the CDC.  These narcotics now kill more adults than heroin and cocaine combined, sending 420,000 Americans to emergency rooms each year.” 

 

“The FDA approved Zohydro ER, a long-acting version of the opioid hydrocodone, against the advice of it advisory committee”. 

 

It was also Governor Deval Fitzpatrick who used his emergency powers for the approval of naloxone for distribution to emergency workers, police and ambulance who are now all supplied with these in Massachusetts.  Since 2006 the drug has been made available in that state as a nasal spray from existing approved syringe product, as an off-label use for friends or relatives of known or suspected drug users in an attempt to reverse overdoses.  The traditional ampoule of naloxone is cheap (around $30 per dose) and there are claims that thousands of overdoses have been successfully resuscitated using the drug nasally.  A newly FDA approved auto-load syringe has recently been publicised but will cost over $200 and two may be required for a single overdose (it also has ‘talking instructions’ which I hope will be in two languages, like America itself).  It will not be available for several months at least. 

 

My view is that this intervention should be examined carefully by public health experts to determine pros and cons.  On my recent trip to New York the overdose crisis was mentioned many times and is the subject of great concern amongst the public and policy makers alike. 

 

And the elephant in the room?  Despite the life saving potential, nobody seems to be talking about methadone and similar treatments which are simply not available to most Americans who need them.  Such treatments were not even mentioned in this long NYT article.  Methadone maintenance is limited to clinics in the United States and buprenorphine is beyond the budget of many opioid dependent citizens (and is usually given as a simple prescription without supervision, psychosocial supports or urine toxicology - making it a non-evidence based, expensive, experimental intervention - although probably better than no treatment at all).  On any rational economic grounds such treatments should be subsidised by the government which currently wastes millions of tax-payer dollars on law enforcement. 

 

There is a mistaken belief, even amongst educated Americans, that methadone clinics are available for addiction treatments yet the workers on the ground have reported that only about 1 in 7 opioid dependent Americans get access to the opiate maintenance treatment they need and which is life saving (and these figures were from long before the current crisis).  For those who want or need abstinence based treatments the line for treatment positions is even longer. 

 

I have a personal theory to explain the present excessive death rates from opioids in America.  Popular drug use, combined with the Puritan sentiment for abstemiousness may have led many dependent citizens to go through cycles of short term sobriety, just as happens with many smokers.  The important difference however is that a recently withdrawn opioid dependent person is at enormous risk of death from overdose, having no tolerance.  This is combined with other disadvantages in America.  For instance, whenever an ambulance is called to an overdose the police are usually called as well; clean needles are often hard to access; penalties are high for drug possession so people may inject in haste; etc. 

 

*The above should be seen in context with an enlightened article by Prof Shane Darke, a world expert in overdose from Sydney.  He has enumerated four oft-repeated myths about overdose, knowing the facts prove quite the contrary: (1) most overdoses are in young, inexperienced users; (2) it is a variation in the purity of the drug which frequently leads to overdose; (3) the opioid is usually the culprit rather than other drugs; (4) impurities lead to overdose symptoms. 

 

After a lifetime of working the dependency field, Darke has a number of lessons for public health policy in his lead editorial in D&A Review.  He belabours that the greatest protection against overdose is being in a treatment program, giving many references for the fact that most overdose deaths occur in those not currently in treatment.  He also gives reasons why this frequently observed fact might be so, including the lessened use of opioids and non-opioid depressants in this population. 

 

According to Darke, response to overdose is another area needing urgent attention, especially the delays which occur in calling the ambulance.  Also Darke supports the provision of naloxone based on experience in numerous countries over a long period showing few problems and anecdotal reports of many resuscitation cases.  Darke also calls for emphasis on high risk periods such as the 2 weeks after release from prison (or detox ward) when tolerance is low and other factors raise the risk greatly (by a factor of 10 to 20 in some reports).  Polydrug use (including alcohol) is the last factor dealt with and he calls for public education campaigns.  It would be hard to find more widespread publicity than the numerous recent overdose deaths of high profile figures in the entertainment industry.  Yet the problem continues with little or no change in public policy in either American or Australia. 

 

It is clear to me that opiate programs should be available to all who need them in community based facilities at no cost to the consumer.  Yet they remain few in number and poor in quality with some demanding up to $100 per week for a drug which should cost about 50 cents per day.  The universities and GP’s colleges are still remiss in not treating this area as a priority in my view.  Some states do not even have an active sub-group dealing with this important field. 

 

Written by Andrew Byrne .. Redfern addiction doctor.

 

Clinic web page: http://methadone-research.blogspot.com/

 

Opera blog: http://andrewsopera.blogspot.com/

 

Andrew's blog http://ajbtravels.blogspot.com/

Magnificent Manhattan never ceases to amaze: April engagements.

I was privileged to attend a number of functions on a recent trip to New York.  Each had some relevance to our field and two were talks I gave myself. 

1. Ernie Drucker gave an oration at NYU in the law school to an audience on the subject of “Challenging Punishment: The Road to Restorative Justice.” He coined the word ‘decarceration’ and there was a lively discussion about the dismantling of the Rockefeller laws.  31/3/14

2. “Is the War on Drugs Over?” A Panel Discussion on the Drug War's Effects on Human Rights and US Policies.   Vanderbilt Hall, Law School, NYU 4/4/14   

http://methadone-research.blogspot.com.au/2014/04/is-war-on-drugs-over-new-york-panel.html 

3. ‘VOCAL’ is an American ‘users’ group which had its 15^th anniversary dinner and award ceremony (Americans are very serious about awarding deserving citizens - unlike Australia which still has a ‘tall poppy’ syndrome in some ways).   10/4/14 http://methadone-research.blogspot.com.au/2014/04/15-years-of-client-representation-in.html

4.  NYU also had a fascinating and challenging talk by Professor Susan Lindee, University of Pennsylvania. “Are genetic diseases genetic? Thinking about the history of Cystic Fibrosis”  Larmark had many attractions, even in Darwin’s lifetime.  16/4/14   http://postgenomic.files.wordpress.com/2013/08/lindee-are-genetic-diseases-genetic.pdf 

5. I gave Mental Health Grand Rounds at the Fort Hamilton VA Hospital at Bay Ridge, Brooklyn on “Methadone and buprenorphine: Clinical & Research Perspectives”. The talk also touched on hepatitis C assessment and treatment.  4/4/14 

6. Also the monthly Columbia University meeting at Faculty House, Drugs In Society Group where my talk was entitled: “Australian Perspectives on Harm Reduction” 8/4/14

7. I also attended Bellevue Hospital Divisional Rounds where three presentations were given, chaired by Dr Marc Galanter.  There were interesting talks on (1) modern designer drugs, (2) opiate addiction in chronic pain and (3) prescription opioid abuse.  I was shocked to learn that it is estimated that Americans spend 70 BILLION dollars annually on prescription opioids, reportedly with very little benefit overall … and pain is STILL undertreated in many cases.  2/4/14

8. Also meeting at Rockefeller University with Prof Mary Jeanne Kreek and her lab staff.  21/4/14

My travel/food blog: http://ajbtravels.blogspot.com.au/

Also heard the “New Pavarotti” in Cinderella at the Met: clip:

http://www.metoperafamily.org/video/watch/la-cenerentola-si-ritrovarla-io-giuro-javier-camarena/3483491158001#play

15 years of client representation in New York.

15^th Anniversary celebration of the New York “VOCAL” group (Voices of Community Advocates & Leaders in New York).

 

There was a true celebratory mood amongst those who attended and EVERYONE had interesting stories to tell and were most welcoming to this outsider from down-under.  Many photos of the evening have been posted on the VOCAL web site ... there were politicians, drug law reform advocates, treatment / research sectors joining the user group members (the latter funded by the former in a clever 'deal').  Ethan Nadelmann, Tony Newman, Marsha Rosenbaum, Ira Glasser and Gabriele Sayegh were present from the DPA while there were many other familiar faces, all delightful but don't ask me for names!  

 

On arriving at the venue there was incredible energy, enthusiasm and electricity in the magnificent 33^rd floor ‘penthouse’ in West 42^nd Street next to the Port Authority bus terminal.  The brief walk from Times Square at rush hour was an education in itself as most days in New York tend to be. 

 

The presentations were to honor:

 

Melissa Mark-Viverito, SPEAKER OF THE NEW YORK CITY COUNCIL

 

asha bandele, AUTHOR & POET, DIRECTOR OF ADVOCACY GRANTS PROGRAM, DRUG POLICY ALLIANCE

 

gabriel sayegh, NEW YORK STATE DIRECTOR, DRUG POLICY ALLIANCE

 

Charles King, PRESIDENT & CEO, HOUSING WORKS

 

Robert “Bobby” Tolbert, LEADER & BOARD MEMBER, VOCAL-NY

 

Each spoke well and it was an uplifting event for all.  In very different fields these honorees had each devoted time and energies on aspects of relieving suffering for those with addictions, viral infections and other consequences of under-privilege. 

 

I met up with dozens of people at the function and would estimate that about half were professionals and half user/client representatives.  Some of course were both.  Each seemed to have very interesting stories, deep insights and individual perspectives on the subjects.  By 9pm I was longing to meet somebody who was boring! 

 

Photos have been posted by an efficient organisation: https://www.flickr.com/photos/vocal-ny/sets/72157643893705294/

 

http://www.vocal-ny.org/blog/vocal-nys-15th-anniversary-gala/   

 

 

Written by Andrew Byrne ..

 

It might seem churlish to say the our Australian equivalents, NUAA and Family Drug Support (and VIVAIDS) were started 25 and 17 years ago respectively.  But considering all the barriers and difficulties that exist in a country of Puritan origin, it is a wonder that there is such a group at all.  I note the group’s name is not really descriptive of their charter which started originally with housing for HIV sufferers. 

 

 

"Is the War on Drugs Over?" New York panel discussion.

April 4, Vanderbilt Hall, Law School, NYU. "Is the War on Drugs Over?" A Panel Discussion on the Drug War's Effects on Human Rights and US Policies.

 

Three panel members (the fourth cancelled in unfortunate but almost humorous circumstances) were very actively chaired by Mattathias Schwartz. 

 

Kathleen Frydl is an award-winning historian of US policies.  Her most recent book, Drug Wars in America 1940-1973, was hailed by SUNY Professor Paul Gootenberg as "the most compelling scholarly book to date written on … America's post-war transition to punitive domestic drug policy". 

 

Hamilton Morris is a research chemist and an expert on synthetic and psychedelic drug and contributes to Harper's and is science editor at Vice, where he hosts "Hamilton's Pharmacopeia", a video series. 

 

Cesar Gaviraia served as President of Colombia from 1990 to 1994 and Secretary General of the Organisation of American States from 1994 to 2004.  He is a member of the Global Commission on Drug Policy, which has advocated a shift towards de-criminalization, harm reduction, and demandside anti-drug programs. 

 

Michael Botticelli is Acting Director of the White House Office of National Drug Control Policy, also know as the office of the drug czar.  He previously served as Director of the Bureau of Substance Abuse Services for the State of Massachusetts. [cancelled and no substitute available]

 

Vice drug ‘czar’ Mr Michael Botticelli was missing in action having apparently had an underling call the moderator earlier to cancel.  We were told an amusing description of the chain of events.  Moderator Mr Swartz asked if another drug office person might fill in and when that was declined, even the staffer, who seemed to be very knowledgeable about the subject himself, was asked if he would like to attend and represent the Government.  No go.  

 

This chain of events is hardly surprising in the current climate where popular opinion and science are diametrically opposed to long-time official Washington policy.  One of the pertinent comments of the evening was a question as to how one might get members of a prohibitionist orientated administration “into the same room” as the activists, doctors and public health experts.  My answer from Australian experience would be to wait until a member of one of the high profile families is affected by drugs or, even more likely, affected adversely by current drugs policy in America. 

 

The moderator was highly effective young journalist Mattathias Schwartz who writes on national security and state power for The New Yorker, the London Review of Books, and other publications.  "A Mission Gone Wrong," his most recent New Yorker story, gives a history of the drug war as waged abroad.  [A rather long-winded but fascinating article available on http://www.newyorker.com/reporting/2014/01/06/140106fa_fact_schwartz?currentPage=all  ]

 

This meeting was one of the most enlightening I have been to in some time.  It was held in the beautiful and high-tech Vanderbilt lecture hall at NYU Law School near Washington Square.  Three eminent speakers and an ‘on-side’ (the side of reason) moderator were unanimous in agreeing that the drug war was not yet over, although signs were present that an end might be in sight, at least for some aspects of that long, expensive and unproductive conflict/noble experiment. 

 

Mr Schwartz asked ex-President Gavaria if he would still condone his government’s pursuit and assassination of Pablo Escobar in 1993.  Schwartz repeated his proposition that Escobar might have just been replaced by another king-pin anyway and asked if it was therefore right to go ahead with his killing.  Gavaria had no hesitation is saying that as a fugitive and acting against the country’s rule of law that ‘of course action had to be taken against him’.  However, the ex-President followed up by saying that the breaking of the Escobar cartel made little if any difference to the flow of drugs northwards which continues to this day unabated.  Mr Gavaria emphasised that only measures which affect demand in the consumer countries can have any meaningful effect on this. 

 

El ex-Presidente then spoke at length about numerous issues, belabouring and berating journalists and politicians especially for their lack of attention to drug related matters.  He described modern journalism as the ‘art of the unusual’, (making quite a lot of sense to my mind).  He said that nobody wanted to hear about public health statistics but anecdotes, even those contrary to trends, are more likely to be published prominently than small changes elsewhere which might save hundreds of lives.  He gave an example of legalisation of cannabis in which a teenager has a car accident and kills a family while intoxicated even though the ‘main game’ of crime, corruption and medical consequences are far more significant to the country. 

 

He then told us that one of the worst consequences of being placed on ‘schedule one’ meant effectively that scientific research on that drug was effectively prevented as the drugs could only be obtained in exceptional circumstances with enormous paperwork and safeguards.  Hamilton mentioned that this was a ‘disaster’, especially for LSD and numerous other drugs which had shown promise in certain diverse medical and clinical fields, migraine being just one he mentioned.

 

Morris Hamilton then mentioned that just one day before the seminar, naloxone had been approved by the FDA for public dispensing.  An off-label nasal formulation of the opioid reversal agent has been widely circulated already in some states.  ‘Evzio’ will be marketed by Kaleo but it is not clear who will pay  the estimated $200 for each unit - which will include audible instructions once the unit is opened, rather like a defibrillator.  http://www.bostonglobe.com/lifestyle/health-wellness/2014/04/03/fda-approves-user-friendly-device-reverse-opioid-drug-overdoses/aPUzTAmmY0uMGQn3PwMR7H/story.html

 

In addition, we were given some intriguing information about the leglisation of all synthetic cannabinoids in New Zealand, contrary to trends elsewhere to continue banning anything which appeared to be popular (see http://www.huffingtonpost.com/2013/08/02/new-zealand-drug-law_n_3696809.html  )

 

Other panellists pointed out the fallacy of banning a relatively safe drug like cannabis when legal alternatives may turn out to be far more dangerous and are only or largely used because of prohibition of the progenitor.  ‘Spice’, ‘bath salts’ and other designer drugs were mentioned. 

 

More than once the Presidente made a statement which was highly controversial with the other panellists and some audience members: “All drugs are bad”.  He defended this, but after much goading, finally admitted that it was just necessary politically to make such statements.  Yet others pointed out that all drugs could be bad and all drugs could be good and it was the ‘set and setting’ which made the difference.  It was Paracelsus who wrote (in Latin) that the difference between a poison and a drug was just the dose.  That might apply to homeopathy as well. 

 

Ms Frydl made the point that she was ‘agnostic’ about good and bad with drugs.  When it comes to what should be more strongly regulated she said that such decisions should be based on evidence of actual harms, and the consequences of regulation.  So often it was said that the bans were more harmful than the drug itself.  She mentioned work of the DPA and the legalization issues and an audience member pointed out that DPA supremo Ethan Nadelmann was present in the room.  He had in fact just been in New Zealand giving a keynote address to a conference partly devoted to the new synthetic drug laws. 

 

It was pointed out that prohibition did sometimes work as with methaqualone and some analgesics.  Yet the flat balloon analogy was used by El Presidente that if you restrict one popular drug then another will take its place very quickly, sometimes with disastrous consequences.  One panel member said that recent changes in availability of prescribed opioids in places like Vermont had cause them to be largely replaced with street heroin which in turn had been associated with very high numbers of overdoses … every one preventable.  Vermont has one single methadone program which is totally inadequate for a state which has a rural population and long distances for most residents to reach such a facility.  Fortunately buprenorphine is available for some who can afford it. 

 

In question time I made a comment about the lamentable reluctance of Americans to allow their doctors to prescribe methadone and of their pharmacists to supervise its administration.  Ms Frydl interjected that methadone is always available in clinics in this country (a rather pusillanimous sentiment considering waiting lists and high costs to consumers).  I was surprised but touched that the Colombian ex-President said that some of the most sensible comments and arguments he had heard had come from Australian physicians (probably including Dr Alex Wodak who often speaks common sense at international forums on the subject). 

 

We were told that one major factor in the repeal of alcohol prohibition in America was the fear of the general population that they would be subjected to income tax, something which only affected the very rich in that era.  Legalising alcohol again would ensure a flow of excise funds to government to use for schools, hospitals, etc.  I had never heard of this before, always assuming that it was the ‘mothers of America’ who were campaigning against the occurrence of truancy and drunken school children who were the main force against the prohibition of the 1920s.  Maybe it was both. 

 

Very brief and incomplete summary of this informative talkfest - written by Andrew Byrne ..