Tuesday, September 28, 2010

Four Corners - Oxy: The Hidden Epidemic

Here is a spiel on last night's Four Corners episode. Please correct me if I have made any stupid errors:

So Four Corners aired its expose of the hidden epidemic last night and as much as it pained me to miss out on the X Factor elimination decision, I dragged myself over to channel 2. For what it is worth, my opinion is that it ended up doing a number of things:

a) reinforcing existing perceptions of illicit opiate users as less-than-human
b) portraying opiate use as a surefire path to death
c) presented a misleading depiction of illicit drug use and illicit use of licit drugs
d) evoked compassion for 'innocent' chronic pain 'victims' and 'unsupported' GPs
e) shed light on irresponsible prescribing practices by GPs
f) highlighted the inadequacies of the pain management sector in this country
g) gave no coverage to the role of pharmaceutical corporations

The episode opened with the case of 'party boy' Neumann, a now-deceased "heavy recreational drug user". Such a description is then confirmed with vague details of a 5-day binge which ended with a fatal overdose caused by a combination of alcohol, diazepam and oxycodone. The diazepam was prescribed by a GP, who then prescribed the oxycodone a couple of days later.

From what I can gather from the show's content in relation to Neumann, here was an opiate-naive individual who was looking for a way to come down from a serious party session, presumably involving stimulants (that would explain the 5-day duration and fit the mold of what the mainstream media considers 'recreational'). The interview with his girlfriend did not reveal any drug awareness regarding the very serious risk that was being taken and the mother firmly believes Neumann would still be alive today if the doctor had refused to prescribe oxycodone, with his family believing that he didn't know the potency of oxycodone.

With all due respect to the people involved, I am more concerned about a situation where a supposedly experienced illicit drug-taker makes a concerted effort to use a serious drug which holds significant potential for overdose, especially in an opiate-naive person, and especially when other depressants are on board. Neumann didn't take an opiate that just happened to fall in his lap whilst stumbling around a hotel room in a complete daze surrounded by a raucous party of people. He turned up at a doctors surgery twice in several days for two different depressant drugs and then presumably had the scripts filled at a pharmacy. He must have been reasonably alert to achieve this.

Yes, the death is tragic, but Neumann made incredibly risky decisions - firstly, he partied for 5 days straight and secondly, sought out a full opiate agonist without a tolerance for such drugs. I have been around countless people who take stimulants who would never go for 5 days straight and would not, in their wildest dreams, think about opiate use to come down with, especially if they are opiate-naive. These are the decisions that people who have been exposed to drug awareness within a harm reduction framework are able to make. Or who simply take an informed approach to their drug use. There is nothing in the segment to indicate that Neumann and his friends were provided with or sought out such education (his family believe he didn't know the potency of oxycodone. Really? Then why did he consider it such a "jackpot" to find a GP who would prescribe it?). I also question Neumann's mother's belief because with such an unaware and risk-inclined mindset, he may well have done something equally risky if he was unable to obtain oxycodone. Four Corners mentions nothing about the extreme nature of this behaviour and the viewer is provided with yet another tragic story that has become representative of drug use in the mainstream media, a notion that is reinforced throughout the remainder of the show.

The episode then moves to King's Cross and it is here that viewers are provided with their first description of what prescription opioids actually are: "heroin in a tablet". That's right, a very scientific and in-depth description. Why educate viewers about drugs? The less they know, the better, right? It is also explained that these opioids provide "addicts a cheap and long-lasting high". Not 'people', but 'addicts'. Apart from the fact that non-dependent people also use these drugs, as shown in the introductory example of Neumann, the term 'addict' removes any notion of human involvement. We are dealing with an unfairly stigmatised section of the community and the media needs to be aware of this. Is it unreasonable or onerous to instead state "these drugs provide people with a cheap and long-lasting high"? What is also interesting, especially within the context of King's Cross is that no explanation is given for why these 'addicts' use such strong painkillers. I'm sure the staff at the Medically Supervised Injecting Centre (MSIC) could shine a lot of light on this matter. So instead, the viewer is left merely with a depiction of addicts hunting the streets for their next cheap hit, a depiction that is reinforced later, contrasted against the 'innocent victims' interviewed.

Next up is an interview with Bruce. Bruce, like Neumann

Anyway, back to Bruce. It is revealed that "large parts of his vascular system have been damaged", but what this actually means is unclear. He pulls down his pants when explaining that he used to inject in his legs, but there was still no adequate explanation of the "damage". Bruce makes no mention of pill filters or any other harm reduction measures and instead seems intent only on purging himself in front of the cameras, taking us to scoring locations and showing the manner in which he forged scripts. There is no mention of the many users who don't end up injecting in their legs - instead, another extreme case is shown. The 'piece de resistance' is then delivered when Bruce takes reporters to a hospital ward where he explains that 'addicts' manipulate cancer patients and pensioners out of their medication, "doing them a favour" with "cash for treatment". Wham bam! If you didn't hate 'addicts' before tonight, you sure as hell do now. Of course, the show delves no further and certainly doesn't explain that this is not representative of all people who use opiates.

The Australian statistics, which are alarming, reveal that 80 percent of all overdoses or poisonings are now due to prescription opioids. And a death toll is given, with 61 fatal overdoses in Tasmania in 2007/08. This is indeed alarming and incredibly sad, but is Four Corners sure about this? I ask this question because the harm reduction sector continues to inform people that the vast majority of overdoses are caused by combining depressants, with overdoses rarely occurring due to opiates alone. Now I could be wrong, but admitting such a fact would detract from the demonisation of opiates that the show is indulging in, no? What also comes to my mind is the isolation, ostracisation and clandestine lives that people are forced to adopt when opiates are used, and the lack of adequate overdose education people receive. Further information may be required here.

The next section with Dr Currie is alarming. With seemingly good intention, Dr Currie is actually having to articulate to colleagues that, with regards to 'doctor shoppers', "One of the most important of all, that is that they don’t want you to look at them or do an exam for backs. ‘No, no. I just need the Oxycontin, It’ll be fine I’ve been examined. Had that a hundred times before. No I don’t need that. Just want the Oxycontin. I do not give you permission to communicate with the other six GPs that I have seen or the people interstate. And I do not give you ongoing permission.'" No wonder we are in the situation we are in! GPs who are paid quite well, hold considerable status in the community and who have studied for many, many years need to be reminded of such simple guidelines? Who in their right mind would prescribe a schedule 8 drug like Oxycontin without clear supporting documentation, direct communication with other involved GPs and a physical examination? The only explanation I can come up with is fear of violence. But really, these are rudimentary skills that a low level drug and alcohol worker would be aware of. Something just doesn't add up here.

Suburbia is then brought into focus and "everyday Australians" are juxtaposed against "street addicts". These are "not your typical addicts", Dr Nick Lintzeris explains, with stigma receiving a mention. We are introduced to Ruth who was started on 40mg/day and then found herself on 300mg/day after "she strained her lower back" (are you kidding me! Surely something more serious occurred for such prescribing to be warranted). Ruth explains how she deliberately overdosed to end her life due to the situation she found herself in (her husband found her "off her face" and "dozing off"). Now I'm no psychiatrist, but I am guessing there is more to the picture here. Regardless, the story is indeed a saddening one. However, Ruth then ends her interview with a horror story of wanting to jump off a balcony when withdrawing from opiates and denying herself the remaining opioids in her handbag. Who the hell allowed her to go 'cold turkey' from 300 mg/ day! There is no mention of the need to titrate dose etc., and instead the viewer is left with the 'opiates = death' equation. I can just see the uninformed producers salivating over the balcony story ("Put that in! That's a pearler!"). The poor woman underwent a misguided, torturous and traumatic process that should never have taken place. Who cares, though, right?

Fortunately, Ruth received assistance from Dr Melissa Sui at St Vincent's Hospital in Melbourne who explains that her opioid patients report that the medication has "little to no effect" on pain. Extraordinary stuff, but as a former pain clinic attendee I can tell you that the opioids certainly did have an effect. I still felt pain, but I managed so much better. I know others who would agree. What I found most infuriating were the attitudes of the medical professionals I would encounter (except for one - hello Dr Gisbus!). Of course, there are people who will continue to feel pain but the different stories don't emerge. Now I'm not advocating for opiate-drenched living, I just think the picture is more colourful than what was presented. Ruth's section ends positively as she provides much-needed hope for others who want to get off opioids. I am also glad to report that the inadequacy of the pain management system is then highlighted and Professor Currie makes a good point when he says, "The answer is to talk to the person, see what the person would do best with and often it's not a tablet and particularly it's not Oxycontin."

We are then introduced to Mark who was turned "into a raging addict". Mark politely informs us of how he felt: "I'd rather be dead than live like this, yeah. That, and that sums it all up. That was no, no way to live. No one should live like that. And, and if you if you choose to take the path to take those drugs, um, or ,or if you're in the position where, where you take those drugs, it's where you will end up. It's, it's, it's as plain as that, you know." Gee Mark, I work with a tonne of people who would be dead if they didn't have opiates. So yeah, it's not as "plain as that". It is then revealed that Mark was not properly monitored and his addiction wasn't picked up. Great. It would have probably been worthwhile for the show's producers to discuss daily pick-up options at this stage and the fact that opiates do not agree with everyone. But no, they then go on to describe Suboxone as "an opiate blocker" that Mark explains has "no adverse effects". Well, to be exact, Suboxone is the brand name for buprenorphine that is half antagonist and half agonist. People do experience 'positive' opiate effects and there are adverse effects (it is dependence-forming, causes constipation and dryness of the mouth etc.). Details, details...

The episode then ends with Kos Sclavos from the Pharmacy Guild who suggests that 'Real Time Monitoring', as occurs with pseudoephedrine, could be of benefit with prescription opioids. At least he uses "misuse" instead of "abuse".

And to end this overly-long rant, I can't help but think that we need more advanced types of medication for pain issues and I hope that this show doesn't make things more difficult for people in genuine need. These drugs aren't ideal, but for many people it is ideal for whatever time of their life they are in or for the entirety of their life. Cannabis preparations have also shown to be effective and ketamine infusions are starting to be used as well. At the end of the day, there is a section of the community who will always engage in such drug use and if opioids go away, what will take their place? We have already seen what heroin shortages can create and also the accessing of ingredients/ drugs via other means (the Internet, other countries etc.). The black market has been endowed with so much power by Prohibition that most of us are at its mercy in one way or another.

Here is a link to the episode.

Monday, September 27, 2010

Media Release: News media turns young people off illicit drugs

This was released today:


Now I wonder what effect these oh so wonderful media reports have on the way young people perceive people who use or who have problems with drug use? And I wonder what level of drug awareness these young people have, based on such media reports? AND, I wonder how these young people will manage situations where they or their friend has taken a drug and something goes wrong? Or, how will these young people manage extended periods of drug use?

I also wonder what results like this mean when no young person in their right mind would openly respond to a researcher with "Nah. After I watched *insert media report* I thought, fuck yeah, let's go out and try that!", or "They make it look shit, but my mate who lives around the corner smokes joints every weekend and I love hanging with him". Plus, the media that is being discussed here never explores the positive effects that people attain from drugs or convey harm reduction messages - it is a no-brainer that participants are going to respond in this way.

Just some thoughts...

Launch of blog today

Thank you to anyone who has popped in after the launch today.

What can I say? Some people have punching bags; I have this blog :-)

Montana Meth Project ineffective - Journal of Health Economics

The following contribution has been kindly provided by Paul Dessauer:

The Montana Meth Project claims to have had a significant effect on methamphetamine use since it's inception in 2005;


Now the project is expanding to other states and seeking increased Federal funding;

<<<>>> (both quotes from www.montanameth.org/ ).

Recently the University of Washington's D M Anderson has reviewed the Montana Meth Project.

He claims there is no evidence it had any influence on rates of methamphetamine use in Montana at all.

His review was published in the Journal of Health Economics last week;

<<< The strides in prevention touted by the Meth Project's supporters, he said, do not stand up from a statistical standpoint. "If I had found the meth project had an effect, that's what would have been reported," he said. "I just wanted to know if this anti-drug campaign worked and I found that it didn't." Similar concerns have been raised about a drug prevention program that began in the 1980s, Drug Abuse Resistance and Education. Also known as DARE, it is now employed by schools across the country despite multiple studies over the past two decades that said it yielded little or no benefit. The findings on the Montana Meth Project also are in line with work done by an Australian researcher. David Erceg-Hurn, a doctoral candidate in clinical psychology at the University of Western Australia, said in 2008 that the Meth Project had distorted its successes by emphasizing positive numbers. Erceg-Hurn found that after six months of exposure to the ads, there was an increase in the percentage of teens who said using methamphetamine was not a risky behavior or who strongly approved of regular meth use. >>>

Full article;


Bill Slaughter, (director of Montana Meth Project) responds to the University of Washington review;


However the key plank to his argument is addressed by Anderson in the Chicago Tribune article I linked to (above);

<<< Supporters also argued that the decline in meth abuse has accelerated since the campaign was launched. Between 1999 and 2005, the number of youths reporting they had used meth fell 39 percent. Between 2005 and 2009, the drop was 63 percent. However, a closer examination reveals that the change in percentages was in part a function of the number of youths taking meth: As that number got lower, the same pace of decline yielded a more dramatic percentage drop. But the actual change was identical in both time periods. >From 1999 to 2005, the percentage of Montana youths reporting meth use
fell from 13.5 percent to 8.3 percent -- a 5.2 percent change. From 2005 to 2009, it fell to 3.1 percent -- another 5.2 percent change. >>>

Review of fellow West Aussie Erceg-Hurn's research from back in 2006;


<<< Erceg-Hurn wrote that teens exposed to six months of MMP advertisements showed a threefold increase in self-reporting the opinion that meth use is not a risky behavior, and teens also were more likely to report that using heroin or cocaine is not risky, either. Erceg-Hurn also found that teenagers who saw the ads were four times more likely to strongly approve of regular meth use. The study also found that 50 percent of teenagers said they felt that the MMP advertisements exaggerated the risks associated with meth use. "The idea behind the ad campaign is that teenagers take meth because they believe it is socially acceptable, and not risky -- and the ads are meant to alter these perceptions," said Erceg-Hurn. "However, this theory is flawed because the MMP's own data shows that 98 percent of teenagers strongly disapproved of meth use and 97 percent thought using meth was risky before the campaign started." >>>

More commentary here;


<<< But a new study from the University of Washington published in this month's issue of the Journal of Health Economics casts doubt on the project's claim to have influenced meth use rates. The rate of meth use in Montana was already declining by the time the Montana Meth Project got underway, the study found. "Methamphetamine use was trending downward already, and the research shows that the project has had no discernable impact on meth use," said study author D. Mark Anderson, a UW doctoral student in economics. Anderson said the project had not been empirically and rigorously scrutinized until his study. Using data from Youth Risk Behavior Surveys conducted by the Centers for Disease Control and Prevention, Anderson compared meth use rates to rates nationwide and in nearby states. Using demographically similar Wyoming and North Dakota, which undertook no anti-meth project programs, as control cases, Anderson showed that in all three states, meth use declined gradually between 1999 and 2009. Anderson also scrutinized drug treatment admission reports from the Substance Abuse and Mental Health Services Administration (SAMHSA) and found that the Montana Meth Project had no measurable effect on meth use among young Montanans. His findings suggested that other factors, such as law enforcement crackdowns prior to 2005 or increasing knowledge of the ill-effects of meth use, were more likely to have led to declining levels of meth use. "Perhaps word got around on the street, long before the campaign was adopted, that meth is devastating," Anderson said. "Future research, perhaps of meth projects in the other states, should determine whether factors that preceded the campaigns contributed to decreases in usage.">>>

See also;




Yours truly,


Paul Dessauer,

Outreach Coordinator, WASUA.

Email me at [outreach@wasua.com.au]

Article in SMH from Don Weatherburn and Professor Wayne Hall

This article appeared in the Sydney Morning Herald this week and I believe it warrants a speedy response. For what they are worth, here are my thoughts:
I just had a few points I wanted to raise in relation to the Weatherburn/Hall piece. Now I know my credentials are far outweighed by the gentleman responsible, but if you got a spare minute or thirty, I thought we might have the opportunity to share:

Firstly, to represent the existing paradigm as being comprised merely of two diametrically opposed 'sides' is greatly misleading. I am puzzled why anyone of stature would place 'harm reduction' and 'black and white' in close proximity as the authors do here. Harm reduction is a philosophy that embraces the 'grey area' and has been a saviour in the 'black and white' world of Prohibition. Furthermore, the regulatory perspectives that have been presented over time do not preclude the role of law enforcement and do not advocate for a world of 'free drugs', as has been presented elsewhere. The authors here unfortunately support the continued, tedious misrepresentation of pro-regulationists like Release in the UK.

Gee, if you get arrested in a fair, regulatory, post-Prohibition environment, you probably deserve it!

Next I would like to yet again speak out against dodgy analogies. That is, comparing oranges to apples; chalk and cheese; that kind of thing, yeah? So, when the esteemed authors compare the failure of the 'War on Drugs' with drink driving I was kinda disappointed. As far as I am aware, the 'War' has the clear intention of eradicating the selected drugs; no two ways about it. 'Booze buses' on the other hand are a harm reduction measure, right? As far as I am aware, the designers of breath testing have always acknowledged that people will not stop drinking and driving (they even established a legal limit), and if they really wanted to do that they would need to ban alcohol (or driving). But hang on, they won't do that because it wouldn't work. But hang on, so why do they maintain the ban on other drugs... Oh, sorry, I'm getting all tangled up here.

Anyhow, I then go on to read that the 'War on Drugs' is not designed to eradicate the selected drugs and the massive rise in prices is the key. Ohhh, I must have misinterpreted the meeting about a "drug-free world by so and so year". Well okay, so now I'm meant to change the way I perceive a war that 'protects' the masses at the expense of the most vulnerable. That's right, because who most often ends up trying to meet those ridiculously high prices, regardless of the consequential risks and poverty? That's right ladies and germs: the most vulnerable. Those of us who end up risking our safety with street-based sex-work; those of us who have suffered abuse; those of us who are poor in developing countries; those of us most damaged. And who ends up paying when such desperate people resort to crime? That's right, the 'protected' masses. Also, the higher prices don't prevent wealthy people from affording these drugs and this reinforces double standards in society, whereby it's okay for the rich because they can get away with it.

And then, the heroin shortage is cast in a positive light due to a reduction in crime, morbidity and mortality! That may well be the case folks, but here in Melbourne we saw people swapping to other (often more risky) drugs and an increase in self-harming amongst marginalised youth. Again, the most vulnerable lose out.

The authors then confuse me further when they seem to unintentionally expose a gross inconsistency. If decriminalisation has little impact on prevalence, why the hell don't they raise this point in relation to the price-hiking 'success' of the 'War', thereby exposing a serious flaw? They state that Prohibition reduces consumption and harm to levels lower than what they would be without law enforcement. But hang on, you have then written that decriminalisation has little impact on prevalence. So if enforcing the law reduces harm and consumption, why doesn't removing the criminality of a law increase use and therefore the harms? They also state that treatment is far more effective than punishment for already-dependent users and they are the ones who will use more if legalisation occurs. In which case, just make it legal and reduce the harms for those who do use because the rest of the community will be okay and an increase in use does not always lead to disaster! Am I the only one perplexed here?

From what I have seen over the last fifteen or so years, I think I would rather see more people using a cheaper form of heroin in a non-discriminatory society than less people using prohibitively expensive dope in a 'junkie-hating' world. I don't think I need to explain why. Plus, this is where the misrepresentation of regulation comes in again. The drugs in question would pose a serious risk to illicit producers because they would not just be offered to seriously dependent users, but would also be available to others in a pure form, dispensed with appropriate equipment by qualified professionals. Or that is how one model goes, because, contrary to this article, there is a variety of models up for consideration.

Next, the authors write of "toxic drugs" with "quite toxic mental effects". Wooaaahh, dude, the state could never support those kinds of drugs. One minute, I just need to attend to yet another client who is suffering from the toxic effects of alcohol and alprazolamdexamphetamine AND ritalin - he seemed positively jubilant and healthy. Also, such drugs would not be regulated merely to remove the black market (even though that is a mighty fine reason), as the authors write. The primary benefit would be for the people who use or may use these substances and the wider community - the authors seem to forget about the person in the equation. Their safety; their dignity; the financial cost to society; the prevalence of viruses. The list goes on. And we may be able to have greater control over who uses the drug, and at what age - the strength of the black market means these decisions often lie in the hands of people who aren't qualified to make such calls, with availability rampant due to the profitability.

So then the authors mention the problems we face with pharmaceutical opioids. Now I'm not telling anyone how to suck eggs, but it is essential to comprehend a problem before using it as an example to support an opinion. So what then is the problem with this form of prescribed drug? From my point-of-view it goes a little like this:

a) people experiment with drugs like Oxycontin because they might be more accessible due to their legality and the growing popularity of opioid-based pain management

b) people who are already opiate users seek out such preparations due to reduced quality of heroin, unavailability of heroin, lower prices or assurance of purity.

c) some people perceive it to be less dangerous due to the licit status of the drug/s

d) people who receive legitimate prescriptions change the mode of administration to increase bioavailability and speed up onset of action (these people are often frustrated by the treatment they receive from medical professionals, whereby they experience judgement and a seeming absence of genuine compassion)

e) people inject the tablet, patch or capsule preparations and experience related harms as a consequence (systemic infection, localised infection, vein damage etc.)

The nature of this problem, far more involved than the passing reference by the authors, strikes me as one borne of a society that refuses to acknowledge that injecting is an enduring practice that is far better managed in a compassionate and health framework, where injectable preparations are required (like they are required, and exist, in other countries). To merely frame this point as "medicalisation doesn't necessarily mean a reduction in crime and corruption - look at prescription opioid misuse as evidence of this", is misleading and comfortably fits into the dangerously simplistic presentations we too often see in the mainstream media. As is always the case, the prescription opioid issue is part of a much bigger picture and exists within a continuing Prohibitionist system. Of course crime and corruption persist, because the issue is not yet medicalised (it is still criminalised of course), with these medications solely prescribed for chronic pain (not drug dependence) and available in a limited range of preparations (no injectable forms and very restricted access to medications with rapid onset of action).

Last, but not least, I must have missed the memo that stated that coerced treatment is effective. I thought we had already established that voluntary treatment with the widest variety of options was the best way to go for the vast majority of people and adheres to human rights principles. The authors present a "sad" situation where people enter treatment only when financial or legal troubles arise. And yes, it is sad when people seek treatment too late for whatever reason. However, in specific relation to this article's information, we should be arriving at an understanding that people might actually fare better if provided with education and support that allows people to manage their own drug use, without the threat of arrest/imprisonment or ongoing poverty/financial ruin. Especially when the drug being used is not causing significant harm and is actually contributing to the person's happiness. Imagine that? A person having a positive experience with drugs, whereby paternalistic sterility is replaced with something meaningful and enjoyable? I'm just a stupid dreamer, aren't I?

There are positives in this article, like the exploration of police seizures, but does the topic always need to be framed in terms of 'treatment'? Real education supported by a humanist and drug-aware framework is the best way to manage, and even prevent, drug use. Education that isn't patronising, is honest and recognises the complexity of the subject matter will do wonders. A society that also prioritises support, rights and equality cannot be underestimated either.

Maybe Gandhi (I think it was him) said it best when he explained that the worth of a society can be judged by how it treats its most vulnerable.