Tuesday, September 22, 2009

Legalising Heroin?


I had a sense of deja vu reading this article in The Age this week. There have been murmurings about legalisation of heroin in Australia for years now.

The arguments for legalisation are sound. Take away the illegality and the black maket prices should be less astronomical, and the people who do use the drug are less exposed to legal harm and more likely to seek help when they need it.

However, there also has to be a balance with retaining enough control so that the legal supply doesn't end up being diverted in large amounts into the black market.

The experience overseas has looked at models where people on heroin treatment had to use the drug onsite at a drug treatment clinic. This has the advantage of being supervised therefore reducing the risk of diversion into the black market. It does require adequate resourcing to provide appropriate staff and facilities, especially considering the fact that heroin is relatively short acting and the frequency of injecting is sometimes several times per day.

Certainly worth at least considering as an option...

Thursday, September 3, 2009

Alprazolam misuse


Yet another report on prescription drug misuse...

Alprazolam is one of my particular bug bears. What is it about alprazolam that makes it such a problem in misuse? In brief terms, it is very potent, quick to act, and short acting... an absolutely disastrous combination.

The effects of alprazolam, apart from reducing anxiety, are sedation, reduced inhibitions, impaired judgement and loss of memory. When it is misused, you find people who have their inhibitions removed (a bit like alcohol actually, but the effect comes on quicker) and will therefore do really stupid, impulsive, reckless and sometimes violent and antisocial things. They are sedated, and therefore have poorer control over functions like walking and running, and are therefore more likely to get injured. The memory loss then kicks in and they can't remember the stupid things that they have done or how they got injured...

Does alprazolam have a legitimate place in the treatment of anxiety? Yes, but a small one. It may be useful in responsible and reliable individuals in the acute treatment of a panic attack as a "rescue" medication. There is absolutely no rationale for its use as an ongoing, regular-dose medication. If a benzodiazepine is being used as a regualr dose (and the usefulness of that for anxiety is debateable) then a slower acting and longer acting agent is much more likely to provide a stable effect.

Being a potent sedative, the additive effect with other sedatives is also more of a risk with alprazolam. This represents a bigger overdose risk.

So how do we ensure that the patients who need alprazolam have access and still reduce the risks involved in misuse? I believe that, similar to Rohypnol, alprazolam should only be available on authority (no private prescriptions) with the recommendation of a psychiatrist after the patient has had a comprehensive psychiatric review, and that one of the contraindications that would prohibit prescribing is a history of misuse of any substance (alcohol and other drugs).

This is good

I really like this short clip produced by a couple of guys in Amsterdam in response to some harsh and judgemental commentary coming out of America...