Australian Professional Society on Alcohol and other Drugs (APSAD)
Dear Colleagues,
This action-packed second conference day had a couple of light points which punctuated an otherwise serious scientific program on dependency management, policy, etc.
Three keynote plenary speakers were led by George Koob talking on how basic sciences can inform treatment decisions. He had written an amusingly-titled paper �Cocaine Reward and Dopamine Receptors: Love at First Site� which was parallel to much of his talk. But there seems to be a complete �disconnect� between such coherent scientific efforts to understand addiction and the almost complete absence of logic in American drug treatment policy over the years. The next speaker, Professor Rudolf Moos, also from California, seemed to be equally hampered in his talk on �how treatment should inform and influence research�. As regards opiates, only a small proportion of the total US dependent population receive appropriate treatment, thus skewing findings, outcomes and policies when compared with other western countries where most people have access to treatment. It was still a privilege indeed to hear the seven invited, diverse and eminent American speakers during the conference (Ling, Vocci, Davis, Maxwell, Grabowski were the others).
The last plenary speaker was Margaret Hamilton giving her ideas on getting research into practice. She gave a �mea culpa� (or her customized plural �we-are culpa�) concerning deficiencies of her own institution. She conceded that sometimes important findings were still not promulgated before researchers �went on to write the next paper�. This is not unique to her institution, of course, nor to our field. However, it is a reminder that we all need to look at our current practices and see if they are consistent with established guidelines as well as new innovations as defined by the evidence. This applies to drug prescribing as well as other components or �black box� factors which are always harder to define than drug, dose and manner of administration.
One of the light points was an afternoon debate on the premise �Are we drowning in the gene pool?� Wittily introduced by Ross Young, two opposing teams of 3 took turns to make light of the subject, starting with Alison Ritter. She had done some homework on drosophila fruit flies put through a silo-like �enebriometer�, courtesy of some ancient vivisecting biologist. George Koob gave a brief but pointed speech including sex, drug and rock/roll, thus taking the genetic low moral ground, but gaining at the same time total audience sympathies. Professor Moos also gave an amusing and increasingly contradictory description of the subject for the affirmative. After the use of an early Picasso absinthe drinker the day before, Dr Barbara Mason ended the presentations (following John Whitfield from RPAH and Nick Martin) with a Degas reproduction, including male emigr� looking the worse for the popular fin-de-siecle drink.
Modern technology now allows a unique level of audience participation using remote multi-choice equipment. On the Monday, a panel discussion on clinical alcohol presentations used the device to gain audience responses to numerous questions (there were 10 seconds of agonising �musak� after which beautiful color-coded histograms appeared for each of the several options). Gerry Springer uses a similar technique on some of his seedier shows, I believe. Even some unlikely options were chosen by participants, eg: response to intoxicated patient: �telephone 000 and hit him with a ruler�!. It was somewhere between a jury room and a flesh market as case histories were gradually revealed and the various possible treatment interventions canvassed by first the audience and then the panels in turn. The alcohol cases on Monday were followed on the Tuesday with an opiate using pregnant woman and a violent stimulant abuse case. The panels included Ingrid van Beek, Alan Gijsbers, Richard Mattick, Roger Brough and many more. For some reason these interesting sessions were not well attended yet other sessions on opioid therapies, pain management, club drugs, rapid detox, neurobiology, genetics etc were nearly all full to overflowing during the conference. It was a shame that there were not more middle sized rooms in the hotel complex, but it is always difficult to predict such matters ahead of time.
A second session on neurobiology included Professor Mac Christie speaking on neuroadaptation followed by papers on club and party drugs and the users� personality traits, genetic polymorphism etc from a Hong Kong study by Alfreda Stadlin. Frank Vocci took the prize for complexications with his final paper on GABA-B receptors and their possible effects in cocaine withdrawals (something others say does not exist). His statements about the occasional incomprehensibility of his papers was appreciated by the audience. The issue of using dexamphetamine or other stimulants for cocaine users was raised by several speakers during the conference.
There was an illuminating session on the 1999 NSW Drug Summit and its longer term consequences given by Dr Tony Gill, John Leary and Larry Pierce, chaired by James Bell. We were reminded that short term political expedience can sometimes give rise to longer term benefits. Substantially more funding was put into public methadone services; case management was made mandatory and clinic accreditation and a take-away dose review commenced. After a comment about the public clinics� withdrawal of all take-home doses due to alleged problems with diversion, John Grabowski made some pertinent comments from the audience. He said that research in the US showed that most diverted methadone was in fact used by other addicts who were not currently registered, thus making �another layer of unofficial treatment�. Professor Grabowski also quoted research showing that take-away dosing improves retention rates and overall outcomes of methadone treatment in his own country, the USA. Despite being generally considered more conservative than Australia, US authorities now allow a week or even more consecutive �home� dosing in certain long term, stable cases. A user representative at the meeting stated that she found the attention paid to consumer views at the NSW Drug Summit were generally not followed up with actions, including the �Treatment Agreement� and other matters. She said it was �lip service only� for some of the �too difficult� issues. It was also said that despite leading many changes in drug treatments, that the NSW Health Department had done very little in evaluating these policy changes for their benefits and costs.
The chair reminded us that the most novel outcome of the Summit was the Kings Cross injecting room which has indeed been extensively evaluated - with almost universally positive outcomes officially reported. It was recently granted a 4 year extension and now attracts up to 350 injectors daily.
There were also parallel sessions on prevention, dual diagnosis, workforce development, NGO�s, tobacco, diversion/policing, etc. All were well received and choice was very difficult on some occasions.
The �Rankin Oration� was given in the presence of Jim Rankin by Margaret Hamilton who donned yet another hat to give an impression of what the future might bring. No clairvoyant, she nevertheless made many far-sighted predictions about �virtual conferences�, tropical island existence, brain �chips� and intimate interactive telecommunications. She confessed to not understanding all the neurobiology but said she was starting to make some inroads after all the lectures on the limbic system, transmitter chemicals and the like.
Incredibly, not content with launching two publications the previous day, she also announced yet another book, this time from Turning Point in collaboration with Trevor King who was also present and took a bow. I look forward to seeing how the Victorians approach this field and how it needs to be improved.
There was a private meeting of the newly formed Chapter of Addiction Medicine (RACP) of which there are almost 150 members across all states and territories. The APSAD annual general meeting was held on the Monday evening with a psychiatry college sub-group meeting also held at the conference.
The conference dinner was held in the Sheraton ballroom which was almost unrecognisable from an hour earlier as the stage was set for pseudo-Phantom of the Opera and para-Pavarotti and Bialla Boheme, each bringing joy and sonorous shrills to the air. We even had the world cup theme sung as a trio! [Nessun dorma for those who know Turandot, the opera]
Dr James Bell gave a witty address showing how the need for a Chapter of Addiction Medicine was itself a kind of dependency, complete with craving, salience and divers other attributes. He raised a few laughs with his comparison of the Foundation Fellowship Committee with Phillip Ruddock (any babies overboard here?), and a reference to certain doctors keeping their patients on high doses of drugs in order to minimise the time they spend with them, maintain their dependency and �to ensure the viability of their practices�. Serious allegations, even in the bacchanalian context.
The wine flowed, the dance floor filled and several dour professors became agile dancers and ardent romantics. Some others ended up under the table, in one case literally. A credit to the organising committee in Brisbane.
Comments by Andrew Byrne ..
