Monday, November 29, 2010

APSAD 2010 Day 1

I'm here in Canberra at the APSAD conference 2010. What a fantastic effort by local organising committee.

Prof Lloyd Sansom's keynote talk on the Australian Pharmaceutical Benefits Scheme (PBS), whilst not directly on an AOD topic, was a fascinating explanation on the process of evaluating medications for subsidy on the PBS. This is a process which was quite arcane for many of us working in the health sector and I was delighted to have some light shed on the matter. Equally interesting was the fact that nobody asked a question about what I thought would be the elephant in the room - namely the possibility of PBS listing for opiate replacement pharmacotherapies. I'm sure the topic will arise in other forums.

The 2nd keynote was from Prof Michael Farrell on the risk issues for prisoners following release from prison. The key take home messages were (1) to question whether it is appropriate to lock up drug users at the rates that we do and (2) the key period for risk of death is the 2 to 3 weeks after release from prisons.

The concurrent session were chock full of interesting topics. Well done to the Addiction Medicine Registrars for presenting their work -  particularly fascinating was the presentation of the difficult diagnostic case of Non Convulsive Status Epilepticus secondary to alprazolam withdrawal - thanks Adam Pastor for the presentation.

Day 2 tomorrow...

Monday, September 13, 2010

Treatment works!

Yesterday I had a win!

A patient I have been seeing for several years had reduced off opiate substitution pharmacotherapy. I'm not normally so happy to hear of someone stopping treatment, as addiction is of course a chronic, relapsing condition. In this case, however, I'm chalking it up as a success.

I first started seeing this patient (lets call her Ms X for sheer originality, and to keep all identities well hidden) at a time of crisis for her. She had been on/off pharmacotherapy for some time but had been struggling trying to stay in treatment and dosing. This was in large due to her partner who was a drug dealer, and supplied her with various drugs in order to keep her dependent on him. He had just been arrested for dealing and was looking at a substantial period of incarceration, and she was left sick, in withdrawal, and homeless.

Ms X was from a country town, where her parents still live. She had a young son from a previous relationship whose care she had given over to her parents. At the time I met her, she had not seen her son for close to a year, although she had maintained enough of a connection with her parents to keep in phone contact.

Ms X restarted opiate substitution pharmacotherapy, and we linked her in with a case manager as well as some psychological therapies. After a short period of time in crisis accommodation, she found some more stable (although still transitional) housing through one of the housing services. With support, she gets free of illicit drugs.

After a few months, she moved back to the country town to live close to her parents and her son. This period of time close to the support of her family and away from her old drug using haunts was pivotal in getting her well. She started a new relationship with a non drug using person, and now has her son back in her care.

A few months ago, her new partner was transferred by his work place to Melbourne. She is living with him in the suburbs. She has not used illicit drugs for 2 years. Her son goes to the local school. Opiate pharmacotherapy becomes an inconvenience and an embarrassment for her in her local community. We therefore work out a gradual dose reduction schedule to get her off treatment - she completed this reduction 4 weeks ago.

I saw her yesterday 1 month off treatment and still drug free. The withdrawals from stopping treatment have now resolved, and she reports no cravings or thoughts of drug use. She sees a counsellor for ongoing relapse prevention regularly. She has plans to return to study part time next year.

I have a real sense of optimism for her future success.

It's a win, and I'll take those where I can.

Friday, August 27, 2010

My thoughts on Ben Cousins and his retirement from football

I admit it, I was one of the many glued to the television watching the Ben Cousins documentary.

As I listened to his narrative, I couldn't help but reflect on the interactions I have on a day to day basis with people who struggle with addiction but are not in fame's spotlight. His words rang true in many ways, but I feel that there are still aspects of his condition that he has yet to face.

Ben Cousins certainly speaks like someone who has been in therapy and dealing with treatment services for a long time. The repetition of the statement "addiction is a chronic, relapsing condition" is certainly a concept that treatment services work hard to impart to people - it is a health condition that can be managed with ongoing treatment, but we don't have a cure for. He clearly has an intellectual appreciation for what addiction is; time will tell how well he translates the information he has been given into real life changes.

Growing up in Western Australia, and being a West Coast Eagles supporter for many years, I remember clearly the draft when Ben was picked up under the Father/Son provisions inot the Eagles squad. From the beginning he was a high profile draft pick, with the media waxing lyrical about his football talent and the sheer good fortune of the Eagles recruiter that his father Brian played for the WAFL. What is the real impact of throwing that much adulation (not to mention the money) toa 17 year old?

In part 2 of the documentary, the story of recovery is closely linked to the story of returning to footy. Being an AFL player is what has given Ben Cousin's meaning in his life. The striving and the adrenalin of the competition is something that obviously lifts him and gives hims a rush.The structure and discipline of training clearly helps to impose structure on his life in general. What does a person do when the thing that gives life meaning is no longer there? There is bound to be a period of grieving and a sense of loss - how will he respond to this?

One of the concepts I discuss with the patients I see who see me for addiction related issues is readiness to stop using. When the drug is taken out of someone's life (removing all the rituals that go with obtaining and using the drug, all the social contacts that are held together by drug use, the pleasant sensations of euphoria or relaxation or absence of pain related to drug use) it leaves a whole, a gap. Filling that gap with positive things is a key element in the prevention of relapse into drug use. To my eyes, Ben filled the gap by working harder on his footy - take away the footy and what else will take its place? What will he do with the time that he used to train in? If he doesn't have the rush of getting out on the paddock on game day, what else in his life will give the rush and buzz? When the AFL isn't looking over his shoulders monitoring him for drug use, will he let his guard drop?

This is a critical time in his recovery. I wish him well in his recovery and with building good things in his life.

Monday, August 16, 2010

...the system (by which I mean Medicare)...

Since I last comented on this blog, Medicare in its wisdom has indeed allocated item numbers to the specialty of Addiction Medicine.

For any chance reader unfamiliar with the Australian system, a Medicare item number is a description linked payment that the goverment insurer (Medicare) will pay for a type of interaction a health provider has with a patient.

With a significant lack of consultation, or maybe a consultation with the wrong parties (still trying to work that out), the government decided to allocate 2 items for the specialty - an item for new patients and an item for reviews. There are no collaborative care or team care items, no items linked to referrals to allied health professionals, no group therapy items, no care plan items... Basically the items in no way match the style of practice which most Addiction Medicine SPecialists actually practice. I don't know any one of my colleagues who doesn't work with psychologists, social workers, AOD nurses and counsellors as part of their standard practice.

Needless to say, we are attempting to negotiate further on this matter. First of all, we need to get this pesky little thing called a Federal Election out of the way so we know which team we will be negotiating with...

I'll keep you posted...

Thursday, February 11, 2010

Addiction Medicine a medical specialty

Well it has finally happened... in December 2009, the health minister has recognised Addiction Medicine as a medical specialty. What will this mean to those of us practising in the field? Time alone will tell, but I certainly hope that it will help to attract and retain doctors in work within drug & alcohol treatment services.

The next step in the process will be discussions on Medicare rebates. The challenge will be for the disparate collection of doctors that make up Addiction Medicine to come to some sort of agreement about what the models of billing "should" be...

Watch this space...