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Healthcare, MedHeads

A Call to Action and Reflection

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August 31 marks International Overdose Awareness Day, a significant global event dedicated to raising awareness about drug overdose, reducing the stigma associated with addiction, and honouring those who have lost their lives to overdose. This day serves as a vital reminder of the ongoing public health crisis and the urgent need for compassionate responses, effective prevention strategies, and robust support systems for individuals affected by substance use disorders.

Understanding the Crisis in Australia

Drug overdose continues to be a critical public health issue in Australia, with profound impacts on individuals, families, and communities. The crisis involves complex interactions between substance use, mental health challenges, and socio-economic factors. It is crucial to recognize addiction as a medical condition that requires comprehensive treatment and support.

Key Australian Statistics for 2023:

  • 2,350 drug-induced deaths were reported in Australia in 2023.

  • Opioids, including prescription painkillers, heroin, and synthetic opioids like fentanyl, are significant contributors to overdose deaths.

  • The increasing rate of overdose deaths underscores the need for enhanced prevention and treatment efforts.

Reducing Stigma and Promoting Understanding

International Overdose Awareness Day aims to dismantle the stigma surrounding addiction. Stigma can prevent individuals from seeking help and perpetuate feelings of shame and isolation. Promoting empathy and understanding is essential for creating a supportive environment for those affected by substance use disorders.

Strategies to Reduce Stigma:

  • Education: Raise awareness about addiction as a chronic disease, not a moral failing.

  • Language: Use non-judgmental, person-first language to humanize individuals with addiction.

  • Supportive Communities: Foster inclusive communities that embrace and support those with lived experiences of addiction.

Honoring Lives Lost

This day provides an opportunity to remember and honour those who have lost their lives to overdose. These individuals were more than statistics; they were cherished members of families and communities. Memorials and tributes play a crucial role in acknowledging their stories and reinforcing the need for continued action.

Ways to Honor Lives Lost:

  • Participate in Local Events: Join vigils, memorial walks, and awareness campaigns in your community.

  • Share Stories: Personal stories can highlight the human impact of overdose and inspire collective action.

  • Advocate for Change: Support policies and initiatives that improve access to treatment and address the root causes of substance use disorders.

Meducate’s Commitment to Education: Addiction Plus Course

In line with the goals of International Overdose Awareness Day, Meducate is committed to advancing education in addiction medicine through our comprehensive Addiction Plus course. This course is designed for healthcare professionals seeking to enhance their knowledge and skills in managing addiction and overdose.

Meducate Addiction Plus Course Highlights:

  • Comprehensive Curriculum: Covers essential topics such as addiction medicine fundamentals, opioid overdose prevention and management, and harm reduction strategies.

  • Expert Instruction: Learn from leading experts in the field, including practical insights and evidence-based approaches.

  • Flexible Learning: Available in both audio and video formats, allowing you to learn at your own pace and convenience.

  • CPD Accreditation: Earn Continuing Professional Development (CPD) points with each completed module, contributing to your professional growth and compliance with CPD requirements.

How to Enrol:

  1. Visit the Meducate Website: Access the Addiction Plus course through our online platform.

  2. Engage and Learn: Dive into the course content at your own pace and complete the modules.

  3. Earn CPD Points: Accumulate CPD points for each completed module, advancing your professional development.

Conclusion

International Overdose Awareness Day is a crucial occasion to reflect on the ongoing challenges of drug overdose, honour those affected, and advocate for effective solutions. By reducing stigma, supporting individuals in need, and advancing education through initiatives like Meducate’s Addiction Plus course, we can make a meaningful impact on the overdose crisis. Join us in using this day to inspire change, offer support, and contribute to a more compassionate and effective response to addiction.

5 doctors around a hi tech table
Healthcare, MedHeads

Harnessing Appreciative Inquiry for Breakthrough Changes

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A Fresh Lens on Problem-Solving

Introduction: Beyond Traditional Problem-Solving

In an enlightening episode of “Cracking Addiction,” Dr. Ferghal Armstrong engaged with Andy Smith, a pioneer in the application of Appreciative Inquiry (AI). Smith advocates for a paradigm shift from conventional problem-focused methods to a strategy that celebrates what works, offering a beacon of hope for transformative change in healthcare.

Unpacking Appreciative Inquiry

Appreciative Inquiry stands out as a methodology initially crafted for organizational growth but has found its place in various settings, including healthcare. Instead of fixating on defects, AI champions the discovery of what functions well, promoting these elements to foster improvement and resolve issues with a positive twist.

Core Tenets of Appreciative Inquiry

  1. Strength-Based Focus: AI thrives on leveraging what’s already successful within the system.

  2. Inclusive Exploration: It encourages participation from all levels of an organization to contribute insights.

  3. Positive Questioning: AI promotes questions that lead to uplifting and collaborative discussions.

Andy Smith’s Transformative Journey
Smith’s path to AI was unconventional. With a background in politics and a subsequent career in the high-stress world of IT, he transitioned into hypnotherapy. His exploration for more effective interaction techniques led him to Neuro-Linguistic Programming (NLP) and eventually to the philosophy of Appreciative Inquiry, where he found a synergy between his NLP skills and AI’s collective approach.

Synergy of NLP with Appreciative Inquiry

While NLP delves into personal cognitive frameworks, AI uses this understanding to foster group dynamics that shift focus from problems to possibilities.

Case Study:
Revolutionising Drug Distribution in a UK Women’s Prison

Smith illustrated AI’s impact with a project in a UK women’s prison where drug distribution was a contentious issue. Through AI, prison and healthcare staff collaborated, focusing on their peak experiences to devise innovative, harmonious solutions that respected both security and care requirements.

Significant Results

  1. Improved Teamwork: The exercise dissolved longstanding barriers, enhancing unity among staff.

  2. Creative Problem-Solving: Participants crafted novel approaches to drug distribution, balancing safety with efficiency.

Tackling Burnout in Healthcare with AI

Post-COVID, burnout has surged, and here, Smith highlights AI’s role in revitalizing healthcare professionals. By concentrating on positive experiences, AI fosters an environment where creativity and empathy can flourish, crucial for combating burnout.

The Neuroscience Supporting AI

Smith cites Dr. Richard Boyatzis’s research on brain networks, explaining how AI activates the brain’s default mode network, encouraging creativity and empathetic interactions, essential for resilience in healthcare.

Implementing Appreciative Inquiry: Practical Tips

Smith provides actionable advice for adopting AI:

  1. Broad Participation: Engage every stakeholder in the AI process.

  2. Reframe Challenges: Concentrate on what you want to achieve, not just what’s wrong.

  3. Encourage Open Dialogue: Cultivate environments where generative conversations can naturally occur.

Connecting with Andy Smith

For those keen on exploring AI further, Andy Smith can be reached through his website at coachingleaders.co.uk, or he can recommend local practitioners for those outside Europe.

Conclusion: Appreciative Inquiry as the Future of Healthcare Innovation

Appreciative Inquiry represents not just a method but a movement towards a more positive, collaborative, and innovative healthcare system. The discussion between Dr. Armstrong and Andy Smith on “Cracking Addiction” not only highlights AI’s potential but also invites healthcare professionals to envision a future where strengths lead the way to better health outcomes.

Alcohol Anti-Craving Medications
Cracking Addiction, Global Awareness, Healthcare

Alcohol Anti-Craving Medications

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Alcohol Anti-Craving Medications

On Cracking Addiction 

The aim of anti-craving medications in alcohol use disorder is to prevent relapse or decrease cravings for alcohol. They are typically prescribed for relapse prevention once acute alcohol withdrawal is over and the best evidence favours the co-prescribing of anti-craving medications with behavioural modification therapies.

Naltrexone

Naltrexone is a mu opioid receptor antagonist which blocks the endorphin mediated pleasurable effects of alcohol which reduces the rate of heavy drinking and the craving for alcohol. Naltrexone is absorbed from the gastrointestinal tract and metabolised in the liver. The side effects include nausea, diarrhoea, fatigue and headaches. Naltrexone is contraindicated in pregnancy, when using opioid analgesia for pain, in opioid dependence and severe hepatic or renal impairment.

When opioid pain relief is required naltrexone must be discontinued 72 hours prior to opioid dosing. The Sinclair method involves taking Naltrexone one hour prior to drinking to decouple pleasurable stimuli with drinking ‘pharmacological extinction’.

The dose is usually 50mg daily (though it can be commenced on 25mg daily for first few days to reduce side effects) and the duration of treatment variable but can extend from 12 weeks to 12 months.

Acamprosate
Acamprosate modulates NMDA receptor transmission and GABA-A transmission and helps decrease the highly glutamatergic states associated with alcohol withdrawal. It isabsorbed from the gastrointestinal tract over four hours and has peak concentration 5-7 hours post ingestion and achieves a steady state after 7 days of usage.

Common side effects include diarrhoea, nausea, vomiting, skin rash and reduced libido. It is contraindicated in renal failure and Child Pugh C liver cirrhosis.
The common dose is 2 tablets tds if over 60kg or 2 tablets mane, 1 midi and 1 nocte if less than 60kg.

Disulfiram
Disulfiram irreversibly inhibits aldehydye dehydrogenase which is the enzyme that converts acetaldehyde to acetate and leads to an accumulation of acetaldehyde after drinking alcohol. Acetaldeyde causes an unpleasant reaction and acts as a psychological deterrent to drinking as an ‘aversive therapy’. The inhibition of enzyme activity occurs in 12 hours and lasts more than 5 days.

The symptoms that it invokes includes flushing, headache, palpitations, dyspnoea, hypotension, prostration and ECG changes. Symptom onset can start within 10 minutes, peaks at 20-30 minutes and lasts for 1-2 hours. Patients need to abstain from alcohol one days before taking medication and for one week after cessation of treatment.

Common side effects include drowsiness, tiredness, confusion, headache, neuropathies, gastric upset, garlic taste and optic neuritis. Disulfiram is contraindicated in psychosis, IHD, severe renal or hepatic disease, pregnancy, allergies to compounds in medication and cognitive issues.

Disulfiram also interacts with a lot of medications including metronidazole, isoniazid, phenytoin, benzodiazepines and anticoagulants.
The dose is 100mg daily for 1-2 weeks then 200mg daily for 6 weeks to 6 months though duration of treatment is variable and maximum dosage can be 300mg daily.

Baclofen
Baclofen is a GABA-B receptor antagonist that suppresses alcohol mediated dopamine release. It has limited hepatic metabolism and well tolerated in those with chronic liver disease. It can cause sedation, drowsiness, headache, rash and urinary difficulties. Baclofen needs to be weaned gradually to avoid withdrawal syndrome such as confusion, anxiety, seizures, delusions, hallucinations and delirium.

The dose of baclofen for alcohol use disorder is given three times per day initially at 15-30mg daily (5-10mg tds) and increased to a maximum daily dose of 150mg if required.

Topiramate
Topiramate reduces glutamatergic function and enhance GABA-A receptor activity or modulate impulsivity. Common side effects include sedation, unsteadiness, paraesthesia, headache, dizziness, depression, anxiety, cognitive impairment and glaucoma. It is contraindicated in pregnancy.
The dose starts at 25mg bd and can be up to 150mg bd.

We Don’t Want Druggies in our Surgery
Cracking Addiction, Global Awareness, Healthcare, MedHeads

We Don’t Want Druggies in our Surgery

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We Don’t Want Druggies in our Surgery

Yesterday I attended GPCE at Melbourne.
I had the opportunity of discussing buprenorphine based pharmacotherapy with a bunch of my GP colleagues. One GP came up and took a handful of sweets from the table at which I was sitting and then said to me, “I don’t want druggies at my surgery.” Before I could reply, he walked off. This is what I wanted to say to him.

Most patients with substance use disorder are grateful for the help that I give them. I would challenge anyone to spot the “druggy” sitting in my waiting room. My surgery has a zero tolerance policy towards violence and aggression. In the last twelve months I have “expelled” three people from my surgery for this kind of behaviour.

First was a woman who threatened me with legal action because I refused to agree to stop prescribing her mother diazepam to treat a new diagnosis of serotonin syndrome. Second was a woman who referred to my Vietnamese physiotherapy colleague as a “Monkey” Third was an elderly lady whom I had reported to Vic Roads.

She subsequently failed an occupational driving test and lost her licence. She came back to my clinic and berated me and accused me of deliberately lying on my original referral to Vic roads. She then threatened me with regulatory referrals.

None of these people were druggies.

The patients with substance use disorder that that I look after continue to to sit quietly in my waiting room and continue to express gratitude for the help that I am able to give them.

Opioid weaning
Cracking Addiction, Global Awareness, Healthcare

Opioid weaning

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Just as “No man is an island entire of itself” (John Donne), so too is no prescriber an island.

You’ve decided to start prescribing MATOD. You’ve decided to start prescribing either Suboxone or methadone. Great. Very soon you will develop a following of patients who will become dependent on your prescription, your signature and perhaps most importantly, you. If you get sick or go on holiday, and don’t manage your absence properly, the lives of your patients could be put into turmoil. Furthermore if you work in a group practice your practice colleagues will need to pick up the pieces in your absence.

What if they are not MATOD trained? What if they are “anti-druggies?” Not everyone is as enlightened as you are, not everyone wants to help the most vulnerable people in our society.

Because you cannot operate in isolation, because you cannot prescribe in isolation it behoves you to establish good working relationships with your colleagues so that in the event of any absence, planned for unplanned, then at least some form of agreement can be made in principle regarding the management of your patients.

At the very least any doctor who has access to your patient record can act as your Locum and can theoretically continue a pharmacotherapy prescription – even without training. Of course Ideally, any Locum you engage or any other doctor in your practice who is prepared to manage your patients when you are away, should be trained in pharmacotherapy.

So just as you have a duty to engage with your colleagues in order to arrange Locum cover, so too should your colleagues acknowledge your expertise skills and attitudes to your patients. I have heard too often stories of GPs who have undergone special training to prescribe pharmacotherapy, who have gone back to their surgeries and told everyone the good news that they want to engage in this line of work, only to be told by the “Senior Partner” or the practice manager, that the surgery doesn’t do drug addicts.

Please, I urge all surgeries and colleagues to facilitate and encourage any doctor who wants to prescribe pharmacotherapy. By nurturing this skill, your surgery will be better able to meet the combined challenges of prescription opioid dependence and real time prescription monitoring.

Whether you like it or not the tide is coming in, these issues will affect us all, and it is better to have a pharmacotherapy prescriber on your team: imagine having to cope with these challenges without such talent batting on your team.

Heart and Pills
Global Awareness, Healthcare, MedHeads

High dose opioids kill people

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High dose opioids kill people

Ome > 100 = 7*rod

The above mathematical formula can be translated as follows.

Patients suffering from chronic non-cancer pain who are on doses of opioid analgesics that exceed the equivalent of morphine 100 mg daily are potentially seven times more likely to die than those not taking opioids to manage their pain.

What is OME?

OME is the oral morphine equivalent: it is an estimate of the potency of the opioid as compared to morphine. For example, oxycodone at a dose of about 60 mg daily is equivalent to morphine 100 mg daily.

What is 7*ROD?

This means seven times higher risk of death.

This is a wake-up call to us all. As doctors we can no longer simply escalate the dose of opioids for our patients who suffer from chronic pain: we cannot chase the pain with opioids as we may have done in the past. We have to focus on patient safety and, in the first instance we need to act to minimise this risk of death. Secondly, we must be cognisant of the other risks associated with long term opioid therapy including the endocrine side effects of adrenal suppression and sexual dysfunction. Not many of our male patients are aware that opioids can cause erectile dysfunction, loss of libido and infertility.

Opioid weaning is now recommended for patients who are on doses of opioids that exceed the 100 mg morphine equivalent per day. The recommended rates vary but are around the 10 percent per week mark. Opioid weans are fraught with angst, especially in those patients that suffer from depression, present with high pain scores, or are already on very high doses of opioids. Nonetheless we cannot ignore the brutal reality of the situation. These are the very patients we should be weaning off opioids for one very important reason: their elevated risk of death

Question
Cracking Addiction, Global Awareness, Healthcare

Prescription Opioid Crisis

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Prescription Opioid Crisis

I have just started using SafeScript. This is the Victorian Department of Health’s response to the current prescription opioid crisis.

I think it is fabulous. Even though it is not yet mandatory in my area, I am nonetheless able to access the service online. It has thrown up some interesting challenges.

For instance I have a female patient with a relatively new diagnosis of seronegative arthritis. She is embarking upon her journey into biological therapies. She also loves her endone. I have been a bit uneasy in dishing it out, but I have rationalised that she has a proven arthritis syndrome, she is already under the care of pain specialists who have recommended clonidine which she takes. So what the harm?

That is until now. I have just seen her SafeScript record. We have all been doing it, my other colleagues and I. We have all been feeling sorry for her and we have all been giving her endone scripts. It has mounted up.

Thanks to SafeScript I can now see that she is getting the equivalent of 50 mg daily of endone. The information was there all along had I chosen to look carefully at it, however now with SafeScript it has been presented to me in an easily digestible format with red alarms all over it. I now have to do something about it.

I have a difficult conversation ahead of me, but at least I now know the facts.

I Just Need a Script
Cracking Addiction, Global Awareness, Healthcare, MedHeads

I Just Need a Script

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I just need a script

She breezed in saying those words I dread, “I just need a script”.

I had never seen her before.

I looked at her prescription record. She was on mirtazapine 15 mg nocte and sertraline 100 mg mane. That’s ok, I thought. Then I saw the Panadeine Forte.

So I printed off the antidepressants and smiled sweetly at her.

“Is everything going well?”

“yes, she said, apart from my dental pain. I have just been told I need dental surgery, and the waiting list is nine months. So I need my Panadeine Forte as well.”

My heart sank.

“It’s the only thing that works for me, I have tried everything else, and Dr… always gives me some.”

“Have you tried anti-inflammatories in combination with regular Panadol?”

“Yes, of course, I have. Nothing else works for my pain except Panadeine Forte, I have tried Nurofen, and that upsets my tummy.”

What started as a “quick script” consult turned into a twenty-minute discussion during which I told her the following.

The efficacy of codeine is dependent on its conversion to morphine.

The RACGP does not recommend the use of codeine for non-traumatic dental pain.

Opioids, including codeine, have no evidence of benefit beyond three months.

Opioids, including codeine, have plenty of evidence of harms in the long term, including dependency.

Her history of depression and her personal circumstances were risk factors for aberrant behaviour and ware relative contra-indications to long-term opioid use.

If an upset stomach was the only thing preventing her from using anti-inflammatories, then concomitant use of Nexium would protect her stomach and facilitate the use of an NSAID.

I ended the consultation by suggesting that she might benefit from a powerful NSAID. I suggested meloxicam; I told her that the vet had given my dog meloxicam for her post-operative hysterectomy pain. It had worked for Millicent; perhaps it might work for chronic dental pain in humans.

She left clutching her scripts for antidepressants and a new script for meloxicam 15 mg daily and Nexium 20 mg daily.

I wonder if she will see Dr… soon for a refill of her Panadeine Forte. It will be interesting to see what will happen when Safescript becomes mandatory in my area.

Lower Your Diabetes Risk
Global Awareness, Healthcare, MedHeads

Lower Your Diabetes Risk by 36%

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A new study finds people who consume two servings of fruit per day have 36 percent lower odds of developing type 2 diabetes than those who consume less than half a serving. The research was published in the Endocrine Society’s Journal of Clinical Endocrinology & Metabolism.

Diabetes is a disease where people have too much sugar in their bloodstream, and it is a huge public health burden. Approximately 463 million adults worldwide were living with diabetes in 2019, and by 2045 this number is expected to rise to 700 million. An estimated 374 million people are at increased risk of developing type 2 diabetes, the most common form of the disease. A healthy diet and lifestyle can play a major role in lowering a person’s diabetes risk.

“We found people who consumed around 2 servings of fruit per day had a 36 percent lower risk of developing type 2 diabetes over the next five years than those who consumed less than half a serving of fruit per day,” said study author Nicola Bondonno, Ph.D., of Edith Cowan University’s Institute for Nutrition Research in Perth, Australia. “We did not see the same patterns for fruit juice. These findings indicate that a healthy diet and lifestyle which includes the consumption of whole fruits is a great strategy to lower your diabetes risk.”

The researchers studied data from 7,675 participants from the Baker Heart and Diabetes Institute’s Australian Diabetes, Obesity and Lifestyle Study who provided information on their fruit and fruit juice intake through a food frequency questionnaire. They found participants who ate more whole fruits had 36 percent lower odds of having diabetes at five years. The researchers found an association between fruit intake and markers of insulin sensitivity, meaning that people who consumed more fruit had to produce less insulin to lower their blood glucose levels.

“This is important because high levels of circulating insulin (hyperinsulinemia) can damage blood vessels and are related not only to diabetes, but also to high blood pressure, obesity and heart disease,” Bondonno said.

Reference: Bondonno NP, Davey RJ, Murray K, et al. Associations between fruit intake and risk of diabetes in the AusDiab cohort. J. Clin. Endocrinol. Metab. 2021;(dgab335). doi: 10.1210/clinem/dgab335

This article has been republished from the following materials. Note: material may have been edited for length and content. For further information, please contact the cited source.

Food Addiction
Global Awareness, Healthcare, MedHeads

Food Addiction

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Binge eating disorder was a diagnosis formulated in the Diagnostic Statistical Manual, 5th edition (DSM5) and represents a step forward towards the formal recognition of food addiction. This term itself is now rendered problematic by DSM5’s change from the term addiction to the term substance use disorder.

The advent of DSM5 has heralded a re-evaluation of the diagnosis of food addiction. The following criteria for food addiction have been proposed as modifications of the current DSM5 criteria for substance use disorder

1. Food often consumed in larger amounts or over a longer period than was intended

2. Persistent desire of unsuccessful efforts to cut down or control food intake

3. Great deal of time is spent in activities necessary to obtain or overeat on foods or recover from its effects

4. Craving, or a strong desire or urge to eat specific foods

5. Recurrent overeating resulting in a failure to fulfill major role obligations at work, school, or home

6. Continued overeating despite having persistent or recurrent social or interpersonal problems causes or exacerbated by the effects of specific foods

7. Important social, occupational, or recreational activities are given up or reduced because of overeating on foods

8. Recurrent overeating in situations in which it is physically hazardous

9. Overeating is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by overeating on foods

10. Tolerance defined as a need for markedly increased amounts of food to achieve desired effect or a markedly diminished effect with continued use of the same amount of food

11. Withdrawal defined as a withdrawal syndrome when refraining from eating specific foods or when specific foods are eaten to relieve or avoid withdrawal symptoms

The diagnosis of food addiction according to the above would require the presence of at least two symptoms, however, one of the criticisms of this rubric is the potential for overdiagnosis of food addiction, especially when one considers that non-obese patients who struggle with the cycle of overeating and dieting may endorse at least two criteria.

The Yale Food Addiction Scale version 2 (YFAS2) has been developed as a tool for the diagnosis of food addiction. It has thirty-five questions which are based on the current eleven substance use disorder criteria described by DSM5.

Obesity, food addiction and binge eating disorders can be seen to be closely related, but nonetheless distinct clinical entities each with their own diagnostic criteria.

Obesity is diagnosed when the body mass index is more than 30 kg/m2. Binge eating disorder is diagnosed when binges (consumption of large amounts of food in a limited time frame such as two hours) occur at least weekly for the last three months and where these binges are associated with a loss of control of eating and significant distress to the patient.

Using the YFAS2 the prevalence of food addiction in those with obesity ranges from 20-50%, in those with anorexia nervosa, 70% in those with anorexia nervosa, 80% in those with binge eating disorder and 95% in those with bulimia nervosa.

Therefore, the management of both obesity and binge eating disorder can be approached from the perspective of addiction treatment. Such paradigms already exist, e.g., “Food Addicts In Recovery Anonymous”. Whilst medication can play a role in the management of these conditions it is important to understand, identify and manage the underlying psychological issues that predispose to and perpetuate these food related behaviours. Failure to do so results in an ongoing cycle of emotionally driven overeating and self-loathing.

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