Editor's Note:Dr Byrne (and his associates) advocate for better policies which are proven to reduce risks for drug users and the general community under a framework in parallel with Australia's official policy of harm minimization.
The findings of the New South Wales Drug Summit recommend better access to methadone, detoxification and other dependency treatments.
It also advised investigating alternative services such as supervised injecting centres, leading to the opening of the Sydney Medically Supervised Injecting Centre in 2001.
Dr Andrew Byrne has been involved in opioid treatments from a primary care background for 20 years at the same site in Redfern, an inner suburb of Sydney.
He is recognised worldwide as a specialist in the addiction field and was involved in the seminal stages of the Chapter of Addiction Medicine, Royal Australasian College of Physicians.
He received the Dole-Nyswander award from the American Association for the Treatment of Opioid Dependence in April 2006.
In this edition of i2P, Dr Byrne comments on a Concord Seminar, held at Concord Hospital (Western Sydney, Australia), Conference Room No 1.
Subject: Concord Seminar summary:
Subject: “Practising in Addiction Medicine: how not to be sued!”
Speaker: Professor Robert Batey.
Professor Batey began by asking his audience to consider why this subject was being covered and also why he had been asked to speak on it. He pointed out that despite doctors being of a certain age and seniority, mistakes and miscalculations could still occur. A prevention strategy was essential using established safeguards. However, when these failed, such errors need to be dealt with appropriately and openly. This applies to doctors, nurses and all allied health professionals.
No amount of renown could avoid this issue. No connection with great physicians, great institutions or fine academic reputation could help when things go wrong. We were told that despite a love of the profession and hitherto keeping out of the way of lawyers, none of us should become complacent or over-confident that it would remain that way.
Connections with great physicians could help in one respect: by following their examples in what they taught about good medical practice.
* The art and practice of medicine.
The value of spending time with patients.
The need to be ‘vulnerable’ rather than ‘all-knowing’.
* The absolute necessity to know what you are doing while admitting any areas of uncertainty.
* The reality that you might appear to be rude while still acting consistently and fairly.
* Patients may accept mistakes if you demonstrate that your are sincere and competent.
We can all name some great physicians we have worked with but it would be hard to match Dr Batey’s list of mentors:
Allan McGuiness, Charles Ruthven Blackburn, Sheila Sherlock, Mr Michael Stephens, Dr Dick Richards.
Those who worked at Sydney’s Prince Alfred Hospital or Sydney University may know three of these.
Some behaviours which patients and colleagues may sometimes overlook include:
* Use of long phrases no one can understand.
* Gruffness to the point of rudeness.
* Late for rounds but never missing them.
However, this is contingent on the clinician displaying consistent excellence and reliability in the longer term, leading to the earning of respect.
In the field of Addiction Medicine there is another credential needed: A capacity to set boundaries. At this we were shown a slide of the Great Wall of China!
In order to demonstrate some ways NOT to practise we were shown some cases from 2007:
Presents with female partner, both on methadone: 65mg and 50 mg respectively for >10 yrs and receiving 4 take away doses.
Neither are employed at present but both had been working in local area 12 months ago.
No children at home
SO far so good but -
They want to switch to oral Physeptone (methadone tablets) so they can just pick up scripts for 2 weeks supply. They also admit to not sleeping well and to using benzodiazepines regularly. No other major issues. The main issue is a desire for increased “freedom”.
Totally anti-buprenorphine as partner had tried to change and failed miserably. They talk constantly and when one stops to draw breath the other starts up. They have no insight into the issues.
It is late in the day
You weaken and write their first script of physeptone tablets, enough for 5 days “to see how they go”.
No no no!
This is dangerous, unwarranted and indefensible.
At this point……Is there a way forward??
40 yr old, unemployed hairdresser, past heavy alcohol intake (120 gm/d as beer), but now nil intake. He lives alone, and no contact with children and had one hospital admission for pancreatitis 8 yrs ago. Apparently this settled but n ow complains of abdominal pain on a daily basis
* Oxycontin 10 mg qid
* Oxycontin 20 mg tds
* Oxycontin 40 mg prn
And asks for proladone suppository twice a day to add to his pain relief program.
You give him proladone. You have no idea what his pain is due to or indeed if he has pain at all.He is dependent, he has a “dog’s breakfast” of a management plan.
BUT HE LOVES YOU for being so ‘caring’ !!!
The state pharmaceutical authorities may not be sympathetic - although after removal of the 2 month rule on opioid prescription in New South Wales in 2006 this may be ‘legal‘ even though it may be ‘poor medicine’.
Ms GG, aged 38.
Admitted to local hospital semi-conscious with signs of pneumonia. Uncertain what is happening but assessment reveals:
* Pneumonia of right lower lobe.
* Obtunded with pin point pupils.
* Injection marks L ante cubital fossa.
* Poor nutrition.
* Lives with husband and 3 children 10, 9 and 4.
* She does not work, he is a motor mechanic.
* No major past medical problems.
* Both she and he are on methadone program.
* She is on 80 mg/d and he 90 mg/d.
* Both get 6 takeaway doses per week.
* No safe storage sites at home
* No urine drug screens performed in past year.
* Pharmacist concerned regarding stability.
Why does she get 6 T/A’s….. “Well, my husband gets them”.
She responds to Narcan injection subcutaneously and admits to injecting her doses.
Assessed for HCV and HBV and has both. One child has evidence of exposure to HBV and vaccination program not completed.
Is this all OK??
Should there be a full review of their dependency treatment?
* Has had Crohn’s disease for 15 yrs, with several recurrences when Inflammatory Bowel Disease (IBD) treatment reduced, plus s urgery x 3, fistula complicating this.
Intermittent analgesia when in hospital.
* Tried heroin from friend “for pain relief”.
* Now on methadone program 50mg/d.
* Presents wanting pain relief from IBD.
He convinces you of his pain.
* He asks for morphine injections prn.
* You are convinced of his need for pain relief.
* You write script for morphine ampoules and arrange for him to come in for doses when needed.
* He is found dead with signs of O/D. Not a good situation.
Is a 78 year old widow d ependent on benzodiazepines you commenced years ago for insomnia. You become convinced benzos are bad for people and discuss trying to withdraw them which she refuses, and is then a dmitted to hospital for an acute surgical problem.
She experiences a significant withdrawal as no-one took a medication history.
She decides that she was not adequately informed about the risks and sets a litigation process in motion.
Who should have done more?
The next topic was “WHAT AM I DRIVING AT” which reminded us that it is OUR RESPONSIBILITY to ensure that patients are safe to drive, operate machinery and look after children while taking medication.
All patients should be warned that new medication and changes in doses of existing drugs, including alcohol, may affect ability to perform adequately.
Professor Batey’s final advice to us was:
* Spend time taking a good history and performing a full physical examination.
* Communicate appropriately with your patients.
* Document findings and management plans in the notes.
* Evaluate progress rationally and regularly.
* Do not become enmeshed with patient stories rather than reality.
* Set boundaries clearly and compassionately.
* Seek peer support.
* Adhere to good clinical practice guidelines.
* Seek second opinions in unusual circumstances where guidelines may not apply.
Further case histories presented will be posted to the web site shortly. http://www.redfernclinic.com/ just search ‘Batey’ to find summary.