Mandatory Drug Testing for Welfare Recipients - The Sequel (an unwanted policy that keeps coming back)

So I haven't blogged for a while - a circumstance that I'll attribute to the fact that life happens and other priorities like having a family and moving house have preoccupied my time. However, looking at what is in the medical and general news media recently, I feel compelled to take to the keyboard once again...

The Coalition Government here in Australia are yet again proposing to drug test welfare recipients (Newstart and Youth Allowance), and putting any who test positive for drugs on an income management program which quarantines payments on to a cashless debit card. This is despite similar proposals being ditched after facing criticism from experts in the health and welfare sectors, and the lack of evidence that similar programs overseas have achieved any meaningful outcomes.

Government rhetoric is full of emotive statements about ensuring welfare recipients using money to "put food on the table, send the kids to schools and pay the bills rather than on drugs", and how "[b]eing on drugs stops you getting a job". This is clearly a simplistic view of the factors that contribute to inequality in our community.

With the current levels of Newstart payments, affording the basics like housing, food, clothing and health care is already a struggle. Not only will mandatory drug testing cause further stigma for people on welfare, income management with a cashless debit card would prevent people from engaging with the more flexible cash economy that helps them to make ends meet. Buying second hand goods like clothing is more difficult without cash; buying cheaper fruits and vegetables at the end of the day from a market couldn't be done without cash.

And what of the testing itself. Only a minority of welfare recipients use drugs. Mandatory testing would have to test many people to get a single positive result. Screening tests (usually immunoassay based) have significant false positive and false negative rates; confirmation tests (usually GCMS) are expensive. Testing is intrusive - formal urine drug screening involves passing urine whilst being observed by a worker in the collection centre. A testing program would be a costly way to achieve very little.

As an Addiction Medicine Physician, I am appalled by how hard the government is pushing this policy in the absence of any evidence to support their position and in defiance of the many voices (many of whom come from a background of significant expertise) raised against it. As a taxpayer, I am appalled by the utter waste of money that this proposal represents.

The dilemma of Pain and Addiction

I read this article in the Wall Street Journal online recently which discussed some of the issues about pain medication in America. The difficulties experiences by doctors in the USA are definitely shared by those of us here in Australia.

The challenges of dealing with people presenting with chronic pain and requesting narcotic analgesics are numerous.

Firstly, pain is subjective. There may be only a partial relationship between the actual severity of the problem (illness or injury) causing the pain and the intensity of the pain itself. A person's experience of pain is also influenced by their beliefs about what the pain stimulus means, their intrinsic ability to cope with stress/distress, learnt responses to pain from past experiences, current emotional state and other psychosocial influences. This can be particularly so in the context of chronic pain.

Secondly, even in the absence of addiction, narcotics may well be a poor treatment choice for treatment of pain. The scientific evidence for the use of narcotics in acute pain is pretty good whereas the evidence for the use of narcotics in treating chronic pain is scant and inconclusive. In many cases narcotics will have a detrimental effect on health as many people who dull their pain with narcotics then opt not to participate in the physical rehabilitation needed to improve injuries or the psychological therapies which could improve quality of life.

Thirdly, the risk of developing an addiction to a narcotic following a significant exposure is estimated at around the 10% "ball park". This means that in a significant number of people that are prescribed narcotics, the doctor will be causing an addiction... and remember "do no harm"

Fourthly, doctors are trained to help people and it can be difficult for a doctor to refuse a narcotic prescription to a patient who wants something to stop pain. We (doctors) are not well trained enough in how to say "no" when we need to.

Fifthly (I did say "numerous"), people with opiate addictions do lie about experiencing pain in order to get narcotics to feed their addictions. Often these same folk exhibit a range of inappropriate drug seeking behaviour and can be aggressive and violent towards hospital or clinic staff, "doctor shop" to multiple prescribers, engage in illegal activities such as theft or forgery.

Sixthly, there is a substantial black market for diverted opiate medications. In Australia this is particularly problematic as the national subsidy for medications (the PBS) means that folk on social security only pay just over $5 AUD for a prescription for a month's worth of medication but can sell individual tablets for up to $1/mg morphine (receiving $80 for a single 80mg tablet, where 60 tablets cost $5). This presents a real temptation to on sell their medication, resulting in more narcotics on the streets contributing to overdose risk, injecting drug use related risks. etc.

Seventhly, opiates are not completely benign medications. They represent a significant overdose risk as well as increase the risk of other health issues including sleep apnoea, falls, osteopaenia, cardiac problems (eg ST segment prolongation and heart block)...

The challenge for the health sector, not just individual doctors, is to ensure that people who legitimately need treatment are able to receive it; that people with no legitimate need do not get access to it either via prescriptions or the black market; that medications are prescribed safely and responsibly taking into account the potential risks. This involves the development of better prescription monitoring systems that provide real time reporting, and the development and widespread adoption of universal precautions in opiate prescribing in order to reduce the substantial risks that narcotics can represent (the Prescription Opioid Policy put together by the combined efforts of the colleges of physicians, anaesthetists, GPs and psychiatrists discusses this at length).

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.

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.

Deja Vu

I sat in a 2 hour meeting today discussing, amongst other things, the lack of resources in the Alcohol and other drug (AOD) treatment sector. I had a distinct sense of deja vu - I'm sure I've had the same discussion before, several times.

Working in AOD treatment in Australia is interesting. Each of the state and territories does things differently. Even the laws regulating the provision of treatment are significantly varied. Unlike any other part of the health industries, where the structures for providing treatment are fairly consistent, AOD services are diverse at best and inconsistent at worst. The only thing that the various treatment services share is that they are all horribly under resourced.

... and yet ... alcohol and tobacco use are amongst the most significant causes of disease and death in our community ...