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.

So what is the Australian Alcohol and Other Drug Treatment Sector?

I had the interesting experience this week of attempting to explain the Alcohol and Other Drug (AOD) treatment sector to a mental health nurse from Hong Kong who was visiting the clinic I work in on an observational placement... for the record I think I failed.

The general gist of the explanation (not verbatim; my memory isn't that good) was as follows:

Well, you see, there are 2 levels of government that control our treatment delivery in various ways. The federal government and the state/territory governments each have separate sets of legislation as well as bureaucratic and funding structures that regulate AOD treatment. And the regulations and service delivery structures in each of the states differs. The type of treatment and how it is funded and structured depends on which of either the state or federal programs is providing the service.


No, not all the treatment services are provided by government. Many of the treatment services are run by non government organisations (NGOs). Some of the NGOs are charities, other are not for profit organisations. Yes there is some private work, but it's not really a profitable area. So which services tend to be provided by NGOs and which ones are provided by government? Well that actually depends on what state or territory you happen to be in. For example here in Victoria the government has actually opted out of a lot of the service provision in AOD treatment - they still provide some funding but as a service purchaser not a service provider. A lot of the AOD treatment is tendered out to various NGOs. No there isn't really any over-arching governance over the service provision, so really there are a lot of different organisations all doing their own thing. Duplication? Well, I guess so. There would have to be wouldn't there?


Of course the set up is different across the border in New South Wales. They tend to have more treatment services embedded within their area health services and directly provided by state government run health organisations. It's kind of different again in Western Australia and different again in Tasmania, and so on.


The funding for different treatment programs can depend on the type of drug treatment too. Opiate replacement pharmacotherapy is delivered in quite a complex manner (yes, even more complex that what I was talking about before). You see, the medication is provided by the federal government. No-one actually pays for methadone and buprenorphine as such. However, people may have to pay to be on the opiate replacement program but that depends on the state government. The delivery on the opiate replacement is the responsibility of state government, and the approach varies state to state. Here in Victoria the state government funds the training and accreditation of doctors and pharmacists to provide treatment but they don't fund the delivery of treatment much at all. This means that GPs will bill either the federal government through Medicare or bill the patient, and the pharmacies charge a dispensing fee (yes they set their own fees so it can vary greatly). In New South Wales there is a mix of public clinics where opiate replacement is provided by doctors and nurses and pharmacists employed by government and private doctors and pharmacists who charge for their service... etc


I wish I could say that I was observant enough to notice that the poor fellow's eyes were well and truly glazed over at this point, but I have to admit that I kept going for a bit longer and actually started exploring the differences between the AOD sector and the mental health treatment sector. I'm worried that I may have actually committed a crime against humanity.

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).

Medicine in Addiction Coference - Melbourne 2011 - pictorial extra - the debate

Images from Saturday's debate

 Dr Michael Aufgang opening the debate

Magistrate Margaret Harding began on a serious note borrowing on examples from the Drug Diversion Court

A/Prof Adrian Dunlop encouraging the audience to "get drunk" with  glass of red in hand... I'm still trying to sort out the relevance

Dr Matt Frei responding by quoting Homer Simpson

Mr John Ryan calling on Matt Frei to stand and comparing him to Superman... Matt in return comparing  John to Wonder Woman... no costumes please!

Medicine in Addiction Conference - Melbourne 2011 - Day 3

Today was the third and final day of the inaugural Medicine in Addiction conference in Melbourne. The focus of today's presentations was the complex issues that create challenges in managing patients' substance use.

The first presentation of the day was Dr Glenys Dore speaking on comorbid PTSD substance use disorder. The occurrence of trauma is common in the substance using population, and this population is vulnerable to developing PTSD. There are challenges involved in managing the withdrawal period when the symptoms of PTSD are likely to re-emerge, as well as treating PTSD in the post withdrawal period in order to reduce its impact as a trigger for relapse. Resources such as the National Guidelines on the management of comorbidities can provide some useful strategies. There have been some encouraging results for COPE (Concurrent Prolonged Exposure) therapy involving integrated CBT addressing both substance use and PTSD.

This was followed by a presentation on medical consequences of long term opioid use presented by A/Prof Nick Lintzeris. With greater, long term survival of opiate dependent individuals as well as changing patterns of opioid use (the increase in use of prescribed opiates), there is a growing  population of older people dependent on opiates. This has resulted in increasing rates of the various clinical consequences of long term opiate use. The conditions that were discussed in some detail included hypogonadism from opiate induced androgen deficiency (OPIAD) with all of its sequelae which can adversely affect quality of life and morbidity(poor libido, fatigue, depressed mood...), and increasing rates of central sleep apnoea which leads to increased overdose risk in the older opiate dependent patient.

A/Prof Kate Conigrave spoke on the challenges in providing treatment to indigenous Australians. There are socioeconomic and cultural factors that can make the delivery of any health care, and particularly AOD treatment with all its baggage of guilt and shame, difficult. The levels of grief and loss in indigenous communities is high. Community and family hold a vital importance both as  protective factors and as a triggers for relapse. The Aboriginal Medical Services can be a valuable resource, but as the community can be small there are times when a patient will not feel comfortable in accessing them. Understanding differences in communication styles is an important element in interacting with indigenous patients - visual resources are more helpful than text based resources, and clarifying "sharing" is important in taking substance use history.

Dr Beth Whitehouse from Austin Health (Talbot Hospital) discussed challenges involved in managing substance misuse in patient who have an acquired brain injury. Management often involves a multidisciplinary and multi-service team, and it is important for clear and specific goals to be decided upon. Patients often have poor insight and high impulsivity, and it is important to put practical strategies in place that are tailored to the patient's level of function and circumstances. It is important to provide psychoeducation to patients delivered at a level that they are able to make sense of.

The final session of the conference was a windup of the issues. Professor Michael Farrell, the new director of NDARC, spoke on future directions for the sector. After a sum total of 5 whole days in the job (and in the country), he was asked to sum up where we were at as a sector and predict what our future challenges were likely to be. He did a phenomenal job of summing up the discussions and concerns raised throughout the conference and, more importantly, presented some pertinent questions - As doctors working in this sector what are our goals? What outcomes do we want to see? What is our voice and our message? The delegates were then also left pondering what footy team he was likely to adopt now he is here in Australia (of course the issues came up - the conference was in Melbourne after all).

The conference was closed by Prof Dan Lubman as we all broke for lunch full of anticipation for the next conference...

Medicine in Addiction Conference - Melbourne 2011 - Day 2

Day 2 of the Medicine in Addiction Conference started off with a session on prescribed medication dependence. Dr Malcolm Dobbin called on data from USA and Canada to paint a picture of increasing use and harms from dependence and misuse of prescribed medications - particularly strong narcotics and benzodiazepines. In some of the data from these jurisditions, prescribed narcotics are 3rd only to alcohol and cannabis of drugs that people are reporting to use recreationally, and this heavy use is reflected in the hospital activity and drug related mortality data. Trends in Australian data show that we are headed rapidly in the same direction. A/Prof Nick Lintzeris discussed some of the evidence around the potentially dependence causing medications that are commonly prescribed and the universal precautions for safe prescribing. In a health system that is focussed on acute care and has little support for psychosocial supports or for realistic drug monitoring systems, it can be challenging to balance access to appropriate treatment with reduction in risk of drug misuse and diversion. Dr Adrian Reynolds, the director of drug treatment services in Tasmania, reported on the Apple Isle's coordinated response to prescribed medication misuse which includes a real time drug reporting system. He gave a strident call to arms for medical folk involved in drug treatment to be involved in lobbying for better directions and choices nationally to improve outcomes.

The second session of the day looked at various medical complications of drug and alcohol use. Prof Paul Haber discussed the aetiology and treatment of alcoholic liver cirrhosis. The key take home message was that it is never to late to stop drinking - even in people with established fibrosis, some reversal of disease can occur following a substantial perion of abstinence. There are some medications used in specialist units that can help manage the problem. Dr Ian Kronborg discussed the difficult issues of sleep in the drug using population. It was unsurprising to hear that benzodiazepines simply don't work in the long term. In spite of claiming not to be an expert, Dr Richard Hallinan gave a broad and detailed overview of sexual dysfunction in the substance using population. The most disturbing question I'm left with is - who is Mrs Palmer and her 5 daughters?

After lunch we broke into groups for the workshop sessions. Dr Sathya Rao challenged us with a discussion of borderline personality disorder and being aware of counter-transference in the management of these patients. Tobie Sacks presented a practical "non drug" approach to dealing with chronic pain. I was unable to attend Ms Catherine Dwyer's workshop on Motivational Interviewing, but feedback received from atendees was very positive. Several people expressed their intention on following up with the website.

The highlight of day 2 would have to be the debate on involuntary treatment. It was refreshing to hear the views from a member of the legal fraternity, especially when those views came from Margaret Harding who is the magistrate presiding over the drug diversion court. A/Prof Adrian Dunlop and Dr Matthew Frei traded some lively banter on the topic, although I wonder about the academic rigor of the debate  with Adrian quaffing wine and advising folk to "get drunk" and Matthew quoting Homer Simpson. There was also the somewhat disturbing image of Matthew as Superman and Mr John Ryan as Wonder Woman. The take home message was that the evidence is poor.

An engaging and entertaining second day. It all winds up tomorrow.

Medicine in Addiction Coference - Melbourne 2011 - Day 1

The inaugural Medicine in Addiction Conference started in Melbourne today. The conference is a collaborative effort between the Royal Australia and New Zealand College of Psychiatrists (section of Addiction Psychiatry), the Royal Australian College of General Practice (special interest faculty of Addiction Medicine) and the Royal Australasian College of Physicians (Chapter of Addiction Medicine), and was driven in a large part by the effort and force of personality of Professor Dan Lubman who chairs the section of Addiction Psychiatry. The conference brings together health professionals (mainly medical) working in the area of the medical treatment of addiction and has practical, clinical focus.

The program for Day 1 predominantly dealt with addiction treatment in a hospital setting. The first session of the day had a focus on the Emergency Department. We started with an overview of the epidemiology of alcohol and drug issues presenting to the ambulance services and then through to ED based on Victorian data presented by  Turning Point's senior research fellow in population health, Dr Belinda Lloyd. Unsurprisingly, alcohol was the substance most associated with hospital presentations, although the typical (and visible) injury related presentations were overshadowed by admissions related to the medical complications of chronic alcohol use. What was particularly interesting was the increase in alcohol related presentations in the older age groups. The public health perspective was followed up by 2 presentations from Emergency Medicine Physicians on clinical presentation to the ED and clinical management. The bulk of substance related presentations occur in the time period from the afternoon through to the early hours of the morning and therefore EDs (being 24 hour services) end up managing the bulk of these issues as the other services like the non-acute mental health and AOD support services are only open office hours. This provides a particular challenge as EDs also tend to have a high proportion of junior and temp staff who may not have particularly well developed skills in dealing with these issues. Comorbid substance use and mental health presentations are particularly challenging - not overly surprising to anyone working in the field. Brisbane addiction psychiatrist, Dr Mark Daglish, then presented the outcomes of an program to provide brief interventions to people using substances in a harmful manner as identified by screening in the ED. When services work together you get better integration of care and improve access to services - again unsurprising, but it is good to see evaluations of projects that work (more information to present to funding bodies and administrators to try and improve service provision).

After morning tea, we launched into session two dealing with managing pain and addiction in the hospital setting. The presentations amusingly borrowed (in part) titles from the Stieg Larsson "girl" novels to reflect the different aspects of treatment - at least those of us who were familiar with the books (unlike the session chair A/Prof Nick Lintzeris) found the titles amusing. Dr Bronwen Evans, anaesthetist and coordinator of acute pain services at Western Health, presented a comprehensive synopsis of her approach to managing perioperative pain in opiate dependent patients, and how she addresses the challenges posed by tolerance and hyperalgesia. Dr Bridin Murnion discussed the issue of general acute pain management in hospital inpatients dependent on opiates, and especially the need for good discharge planning and communication with community based services. Dr Mike McDonough provided some cautionary tales on inappropriate prescribing, particularly involving pethidine.

The third session, directly following lunch, looked at specific addiction psychiatry issues. Dr Grant Christie from New Zealand gave an overview of ADHD and substance use disorder. The evidence indicates that there are some clear benefits in treating children with ADHD, including a lower rate of development of substance use disorder in patients with ADHD who had treatment as a child compared with those who id not have treatment as a child. The evidence for treating adults for ADHD is less convincing. Animal models looking at cocaine seeking in mice exposed to methyl phenidate at various stages in the life cycle showed that juvenile mice exposed to methyl phenidate showed less cocaine seeking as adults, whereas mice exposed as adolescents showed more cocaine seeking as adults and exposure of adult mice did not alter cocaine seeking at all. Prof Shane Thomas discussed problematic gambling and introduced the draft guidelines that are available for consultation. Prof Dan Lubman discussed affect and anhedonia in patients with dependence issues and the impact this has on treatment.

The fourth and final session of the day had a focus on developing new therapies. Prof Andrew Lawrence discussed the neuroscience of target sites for new therapies - to either decrease the drivers for relapse or boost the promoters of abstinence. The animal models were fascinating, although he did acknowledge that you can do things with with rats that you simply cannot do in patients. I, for one, am delighted that the slides will be available after the conference as the speed with which he covered the neuroscience defeated me somewhat, but the future looks bright. Prof Jason White gave an overview of new directions in pharmacotherapies for alcohol and opiates, including baclofen, topiramate, buprenorphine implants and naltrexone depot injections. Dr John Boyle gave a brief run down of aspects of psychological therapies. He also managed to order the chair, Prof Paul Haber, back into his seat, a feat I haven't seen done previously.

All in all a fabulous first day. Hope day two lives up to it.

Coroner calls for restriction of methadone takeaway doses

The coroner in Victoria has commented on the intrinsic risk of methadone takeaway (unsupervised) doses in her finding in the inquest into the death of a girl who took a methadone dose which was dispensed to her cousin. The statement from the coroner indicates a concern about who should take responsibility for methadone doses and a view that "[leaving] the decision-making and storage arrangements solely in the hands of the addicted person seems to be an approach which is fraught with risk, given the unreliability often associated with persons suffering with substance addiction".

Whilst the coroner has made a valid point in relation to the risks involved in the provision of methadone doses, the resources involved in inspecting medication storage arrangements of each and every patient receiving methadone takeaway doses would be prohibitive and impossible to enforce.

The requirement for checks on stability of patients prior to providing takeaway doses is designed to try an minimise the risk such that only patients who are stable enough in treatment so that their "unreliability" is lessened are eligible for takeaway doses - i.e. only patients who are able to take responsibility for storing takeaway doses appropriately have access to them. If a patient who is stable and has had the importance of appropriate storage of their takeaways explained to them then choses not to store their takeaway doses correctly, they need to be held responsible for that lack of care.

Perhaps instead of a call for greater direct supervision (which would be resource intensive in a sector that already suffers from a shortage of resources) there should be a greater onus on ensuring that the checks for stability are more closely adhered to. This would prevent "unreliable" patients form having takeaway doses.

Patients need to be seen regularly, need to have their dosing at the pharmacy checked up on, need to have random urine screening, need to be checked for injecting sites... It is part of the clinical risk assessment that is vital to the safe provision of service (and in Victoria the stability criteria are clearly documented in the state prescribing policy). Arguably if a prescriber is unable to check on adequate stability for takeaway doses, then that prescriber should not be prescribing takeaway doses.

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...

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.

...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...

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...

Legalising Heroin?

<http://www.theage.com.au/national/legalise-addicts-heroin-experts-20090922-fyse.html>

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...

Alprazolam misuse

http://www.themercury.com.au/article/2009/09/04/95181_most-popular-stories.html

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...

http://www.youtube.com/watch?v=sTPsFIsxM3w&feature=player_embedded

Workforce... what workforce?

How do you overcome the challenges of staff turnover?

Over the last month or so, the clinic I work with has lost 2 case workers and 1 outreach worker, and is about to lose a doctor and a social worker within the next 2 weeks. We have advertised, and there has been some promising interest, but even when we recruit we are still faced with that lag time as the new staff members learn their jobs. All this whilst trying to maintain care to a population that is often difficult to engage with.

Drug and alcohol work is not glamorous and is often frustrating, and yet when you get a win (as rare as they are) and you see someone that you are working with get better you really value it.

When you look at the work environment, the people who work in the AOD sector are often faced with aggressive behaviour, emotional distress and people in crisis situations. Is it surprising that people don't stick around?

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 ...