Thursday, May 24, 2007


A Canadian mental health professional was barred entry to the US because a search of the internet came up with a 2001 publication in which he acknowledged using LSD - four decades earlier (NY Times, May 14)! A US Government spokesperson defended the action by saying that drug users are not welcome in America, and all possible means will be used to identify them. The thwarted visitor, Andrew Feldmar, noted: "I should warn people that the electronic footprint you leave on the Net will be used against you. It cannot be erased."

Tuesday, May 22, 2007


Question: I have patients who ask me to crush their buprenorphine to shorten the supervision time. Our shared care monitoring group has discussed this and is generally in favour as we believe it will reduce diversion of buprenorphine onto the streets. However, we're a little unclear about the practicalities - what is the procedure for crushing and administering supervised buprenorphine doses? Can you show us how it's done?

Answer: Crushing is popular in Australia, for both of the reasons that you have given, indeed in some states it is mandatory for the pharmacist to crush unless the doctor writes 'do not crush' on the prescription.

However, buprenorphine (Subutex) becomes unlicensed when it has been crushed, and the patient must be warned of this. They can be reassured that they are unlikely to feel any different; data from Australia (Muhleisen P, Spence J & Nielsen S: "Crushing buprenorphine tablets" (letter) Drug and Alcohol Review Dec 2003 p471-2) suggests that there is no difference in bioavailability of the drug when doses were crushed, as evidenced by the fact that patients were encouraged to request an increased dose if they required it, and did not do so.
(The Royal College of General Practitioners (UK), Substance Misuse Management in General Practice, SMMGP) (dgs-info, 7, Mai-Juni 2006)

To crush or not to crush - buprenorphine tablet administration; Drug and Alcohol Review (2003) 22;4:471-2; Muhleisen P, Spence J, Nielsen S. Crushing buprenorphine tablets.
Crushing buprenorphine and supervised consumption. (Bob Dunkley, 2005 National Drug Treatment Conference, London, UK). Power-Point Präsentation.

2003 haben die Gesundheitsbehörden in Victoria/Australien verfügt, Subutex ausschließlich in gemörserter Form abzugeben. Ärzte werden gebeten, die Formulierung ‚Do not crush’ nicht auf die Verordnung zu schreiben (Drugs and poisons unit Newsletter May 2003

Die britische Royal Pharmaceutical Society hat 2005 Empfehlungen publiziert (The Pharmaceutical Journal, Vol 274 No 7343 p401; 2 April 2005):
The Royal Pharmaceutical Society has issued guidance for pharmacists regarding the crushing of buprenorphine sublingual tablets (Subutex) before their administration.

Im März 2007 erschien in Drug and Alcohol Review der Artikel: Buprenorphine supply by community pharmacists in Victoria, Australia: perceptions, experiences and key issues identified (Volume 26, Number 2/March 2007; DOI 10.1080/09595230601146645, Pages 143-151), der die aktuelle Lage beleuchtet. (Abstract)

Tuesday, May 08, 2007


A Washington Post article headline "Pain doctor is guilty of drug trafficking" appeared April 28, 2007. It reports on the outcome of the second trial of Dr. William Hurwitz. One would hardly guess from the headline that Dr. Hurwtiz was never accused of profiting from the prescriptions he wrote. Traffickers may "come in all shapes and sizes" as US Attroney Rosenberg is quoted as saying. But a drug trafficker whom prosecuters acknowledge never made a penny from the trade defies imagination!

Monday, May 07, 2007


The following was a letter-to-the-editor I sent to the Washington Post. While never published, I thought it important to publish it here and get your opinions.

A Washington Post article (April 25, 2007) reported on the record increase in worldwide opium production (April 25): Antonio Maria Costa, Executive Director of the UN Office on Drugs and Crime, as stressing that “consuming countries need to get serious about curbing drug addiction.” Absolutely correct! In this market demand drives supply, yet millions of individuals throughout the world have no access to any form of treatment for their dependence on opiates.

Sadly, America is not a model for other countries in this regard. It is conservatively estimated that of the roughly 900,000 heroin-dependent Americans and untold more dependent on prescription opiates, no more than 20% are receiving treatment. Worse, no branch of government at the federal, state or local level seems to care, as evidenced by the total lack of initiatives to lessen, let alone eliminate, the unconscionable gap between need for and availability of services.

Robert G. Newman, MD
International Center for Advancement
of Addiction Treatment,Baron Edmond
de Rothschild Chemical Dependency Institute
of Beth Israel Medical Center

Thursday, May 03, 2007


Americans can only marvel at the fact that safe injection sites are a reality in other countries – and yet the world keeps spinning. Wow!)

The Daily Telegraph (Sydney, Australia)
Piers Akerman
May 02, 2007 (excerpts from a wider-ranging letter focused mainly on marijuana policies)

The most obscene evidence of the state’s softly-softly approach to drugs remains the NSW Government’s embrace of its Kings Cross shooting gallery despite the absence of any hard evidence that it serves any purpose other than to ensure that addicts will always have a place to legally shoot-up if they so choose when they happen to be in the area and in possession of illicit drugs.

Put simply, the reports produced by the heroically named Medically Supervised Injecting Centre fall apart when examined by competent and genuinely independent experts.

A review of the statistics by Dr Joe Santamaria (former head of community medicine, St Vincent’s Hospital, Melbourne); Dr Stuart Reece (addiction medicine specialist, Brisbane); Dr Lucy Sullivan (social researcher); Dr Greg Pike (director of Southern Cross Bio-Ethics Institute, Adelaide) and Gary Christian (senior manager, welfare industry) demonstrate that despite the claims of the shooting gallery’s advocates, it is unlikely to have saved even one life.

Dr van Beeks letter to Daily Telegraph May 03 (Dr Ingrid van Beek, Medical Director, MSIC)

Mr Akerman cites Drug Free Australia’s “review of the statistics” of the first 18 months’ operation until October 2002, of the Medically Supervised Injecting Centre (MSIC) in Kings Cross, as evidence that it has “failed” (DT 3/5/07) despite a range of health professionals respectfully pointing out the various flaws in its extrapolations over the past several years.

The irrefutable statistics are that in the 6 years the MSIC has now been operating, around 400,000 injecting episodes have occurred in this clinical facility instead of public parks, back alleys and public toilets etc, improving public amenity; more than 2,000 drug overdose cases have been successfully treated undoubtedly saving lives and drug users have been referred to treatment and other relevant services on more than 6,000 occasions. Meanwhile the number of drugs users in the Kings Cross area has decreased 40%, the number of ambulance callouts to overdoses has decreased 86% and drug-related crime has decreased 30 – 40%. These facts perhaps explain why 80% of local residents living in the area over these past 6 years support the MSIC.

Please also note that the MSIC is funded by the confiscated proceeds of crime and not tax payer revenue and that I am employed by the Area Health Service and not the Medical Faculty of the University of NSW, which employs the MSIC’s evaluation team.

Comment May 03 by Ralf Gerlach (Deputy Director, INDRO e.V., Muenster, Germany)

I really wonder why, apparently, there is so much opposition towards medically supervised injecting rooms in Australia. For instance, there are 24 such facilities operating in Germany, all of which have been evaluated comprehensively by the relevant state authorities. Research and practical experience clearly indicate that drug users and local communities benefit substantially from such harm reduction provisions. Not only are they well accepted by the German Government but also by local citizens and residents, political parties, police and shopkeepers. Usually there occurs no congregation of drug users and dealers in front of injecting facilities, no disturbances of the public order in the immediate neighborhood, no honey pot effect as well as hardly ever exceptional police actions. Drug use in public places is considerably reduced. Such positive results and reactions have also been reported from other countries running supervised injecting rooms (SIR), and I have not heard of one single SIR that had to be closed because of ineffectiveness or public protest. SIRs provide shelter to drug using people and facilitate drug use under hygienic and medically controlled conditions, thus increasing dramatically the likelihood of successful life-saving measures. They reach a large group of drug users which never had any contact to the drug-help system before and acute medical care can be provided for the first time (e.g. wound dressings, treatment of abscesses, basic first aid). Also, psychosocial counseling is offered often resulting in referrals to specialized detoxification facilities, GPs prescribing substitute substances (methadone, buprenorphine), primary health careers, agencies advising on in-patient, abstinence-oriented therapies (therapeutic communities) and social welfare services. The statistics published on the effectiveness of the Sydney medically supervised injecting room are very similar to those published in other countries. Therefore, I see no reason to doubt the objectivity of those who evaluated the Sydney injecting facility.

Referring to “shooting galleries” is not only absolutely wrong (since they are operated in private and mostly unhygienic environments without medical supervision and counseling) but simply reveals negative attitudes and beliefs towards harm reduction and life-saving assistance by an abstinence apostle ignoring the fact that only those drug users have a chance to decide for striving at a life abstinent from drugs who survive periods of compulsive and life-threatening using patterns. I strongly believe that professionally operated SIRs offer such a chance, not only in Germany and other countries, but also in Australia.

Tuesday, May 01, 2007


An AP report May 1 states that 27 tons of cocaine were found "buried along the Pacific coast." Question: does finding such a phenomenal buried treasure represent good news or bad news, and for whom? To those who view this report positively, one might ask: Is there any reason to believe it will have an impact on US cocaine demand and consumption - or even price? And/or could it be that this "record seizure" merely is testimony to the utter failure of America's decades-long war on production and export of Colombian cocaine - a war that has cost hundreds of billions of US taxpayer dollars?


A Crain's NY Business article reporting on buprenorphine appeared on 16 April, headlined "Addiction's magic pill." Those of us who are old enough may recall another headline that appeared in a weekly magazine called The Mirror which also referred to a magic potion - in that case methadone, which it described as a "Cinderella medication."

Any and all medications or other treatment interventions that offer the promise of helping those with drug dependence are welcome, and that definitely applies to buprenorphine. But raising expectations that are clearly not realistic - i.e., the prospect of "curing" addiction - will in the long run be strongly counter-productive. In addition, there are references to buprenorphine leaving patients more "level-headed" and less "befuddled" than methadone - a claim that is often heard but as far as we know absolutely without scientific support.

Finally, there is out-and-out misinformation, such as the statement that methadone must be "dispensed in controlled settings in daily doses." For many years now it has been perfectly legal to provide stable, long-term patients with up to a full month supply of methadone for unsupervised consumption.