Medical Forum WA 0319 Public Edn by Medical Forum WA

Talking Heads The Bone Bank Opioid Prescribing Clinicals, Lifestyle, Guest Columns and Much More â&#x20AC;¦

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March 2019

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EDITORIAL Dr Rob McEvoy, Medical Editor

A Drug Happy World It’s good to get back to basics. One problem now is over prescription of everything. Doctors are addicted to writing on their script books! And maybe prescribing is a nice way to signal the end of a consultation. However, we are told prescribing costs the country millions both directly and indirectly. Hospital admissions due to medication mishaps are costing the country millions. Or perhaps we can look at prescriptions for a similar but unrelated problem, adults with autism - we are told adults with autism spectrum disorder are prescribed mental health drugs without diagnosis. Poor medicine you might say. Poor prescribing others say. And the link between direct (PBS subsidising) and indirect (admission for medication mishaps) costs go beyond this.

illness quicker than expected and stop the medication they have been given. Maybe they know something we don’t. Maybe they know about misdiagnoses and that doctors now have feet of clay. Consumer attitudes to us have changed. We are no longer God-like, as researchers like Dr Gary Geelhoed have realised. He aims to keep research relevant to the community (see p 17) by engaging more health consumers. Into this evolving milieu doctors have descended and the prescribing of opioids has been a real eye-opener for many – which includes opioid addiction and deaths (76% of 1045 deaths of Australians aged 15-64 in 2016). In this edition we have tried to explain the problem of opioids and what to do about it. Find your own truth or solutions. There is plenty of food for thought. Researchers tell us that doctors are poor at identifying opioid dependence but on the other hand tend to underdiagnose genuine pain. That puts us in a no-win situation that many handle poorly. To top things off, we don’t handle dose reduction too well, mainly through lack of patient engagement. These thoughts, amongst others, are echoed by specialists in pain.

Of course, we have the training that equips GPs to deal with circumstances like this. As we pointed out in an earlier article, we are not trained to decrease or stop medications. So, should the emphasis be on something sexy such as artificial intelligence to assist decision making? Is the medical profession part of the solution or part of the problem? To health consumers, doctors may these days appear as a medical ‘Bunnings’ – look for a quick fix but the price has to be right. Shoppers like this, armed with their referral of convenience (i.e. not from their ‘usual’ GP), are part reason why chronic medications from specialists are stopped after a time, especially if it is preventive medicine, without anything to see or measure. The GP similarly, is left with people who get over their acute

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Marketing Manager Lois Paffett (0403 282 510) mm@mforum.com.au

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EDITORIAL TEAM Managing Editor Ms Jan Hallam + Mark Balnaves (0430 322 066) editor@mforum.com.au Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au

One pain specialist says we should look beyond pain and drugs to what makes us human and build resilience. This is a different approach to an overburdened system. As many GPs point out, the six-month wait to see a pain specialist is a long time and changes the dynamics of everything. The medical profession has a lot to learn from its prescribing patterns. Clear guidance for doctors is being provided in a new publication Responding To Pharmaceutical Opioid-Related Problems: A Resource for Prescribers, by the National Centre for Education and Training on Addiction at Flinders University.

Administration Jasmine Heyden (0425 124 576) jasmine@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au

Journalist Mr Peter McClelland journalist@mforum.com.au Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au

MARCH 2019 | 1

CONTENTS MARCH 2019

INSIDE 14 16 29 34

The Bare Bones of Tissue Donation “Muka” Blue Tree Suicide Voice Abdominal Pain in Children Understanding PET

NEWS & VIEWS 1 Editorial: A Drug Happy World - Dr Rob McEvoy 4 Letters to the Editor

10 14 16

17 21

Hep C Nurse Available Now - Ms Annette Fraser SSNHL an ear emergency - Ms Tennille Crooks Tale a Kidney Test - Ms Shilpa Jesudason WAPHA and Urgent Care - Ms Chris Kane Level B Item Lament - Dr Rohan Gay Have You Heard? The Bare Bones of Tissue Donation “Muka” Blue Tree Suicide Voice WA Rural GPs Remain Frontline WA Research Comes Home to Roost Improving Radiotherapy Access

LIFESTYLE 40 Wine Winner

41 42

The Funny Side Wine Review: Evans & Tate Wines - Dr Louis Papaelias Competitions

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CONTENTS MARCH 2019

CLINICALS

5 Workplace Culture

Haematological Abnormalities with Psychotropics Dr Paul Kruger

The Good, The Bad & The Ugly? Keynote Speakers: Clinical A/Prof Tim Bates Dr Angela Alessandri

29 Abdominal Pain in Children Dr Colin Kikiros

26 Trends in Pain Medicine Dr Roger Goucke

31 Safer Opioid Prescribing Dr Richard O’Regan

27 Back to the Grass Roots Approach Dr Max Majedi

33 Beyond Opiods – Treating Chronic Pain Dr Michael Veltman

28 Chronic Daily Headaches: A Transformation Prof Eric Visser

34 Understanding PET Dr Nat Lenzo

Panellists: Dr Frank Jones, Dr Ros Forward & Dr David Oldham

To attend or register for video streaming go to: www.doctorsdrum.com.au

35 Is There a Good Diet for Mental Health Ms Jo-Anne Dembo

37 Nutrient Deficiencies in Mental Health Dr Sanjeev Sharma

39 Feet for a Lifetime Mr Matthew Keating

40 Opiate Contracts – Useful or Not Dr Rupert Backhouse

Thursday April 4 7:15 - 8:50am The University Club, UWA

GUEST COLUMNS

SPONSORS

8 Between a Rock and a Hard Place Mr Paul Dessauer

18 We All Die Dr Tony Reid

23 E.M.D.R. Ms Claire Kullack

25 Silence of the Violence Ms Kedy Kristel

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Astrid Arellano (Infectious Disease Physician), Peter Bray (Vascular Surgeon), Pip Brennan (Consumer Advocate), Joe Cardaci (Nuclear & General Medicine), Fred Chen (Ophthalmologist), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Mark Hands (Cardiologist), Stephan Millett (Ethicist), Kenji So (Gastroenterologist), Alistair Vickery (General Practitioner: Academic), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon),

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MARCH 2019 | 3

LETTERS TO THE EDITOR

Dear Editor, In addition to the article Communicable diseases – keeping ahead of the game (February 2019 edition), HepatitisWA would like GPs practising in the metropolitan area to know that a GP Liaison nurse has been engaged to assist them in dealing with patients who have a positive Hep C screen. Annette Fraser (pictured) works directly with GPs and their practices to support them in the assessment, treatment and management of patients living with chronic HCV. An essential part of that support is to guide practices in recalling patients that have had a past positive screen, or have reported symptoms that may be indicative of hepatitis C infection. This project is a collaboration between the WA Department of Health and HepatitisWA as part of the wider commitment to the goal of eliminating hepatitis C as a public health threat by 2030. GPs may have received a letter from the Department of Health alerting them to a hepatitis C patient or patients in their practice.

“A blocked ear” is a common non-specific symptom for which patients and doctors may not have much concern, leading to a delay with evaluation/treatment, which can mean permanent hearing loss. All patients presenting with sudden sensorineural hearing loss (SSNHL) require urgent assessment and early treatment regardless of the cause and degree of hearing loss. Sudden sensorineural hearing loss is defined as a hearing loss (HL) of 30dB or more in three consecutive frequencies over a period of 72 hours or less measured by pure tone audiometry (PTA). The diagnosis and management of idiopathic SSHL has been always controversial because the cause is unknown and the outcome unpredictable. Dr Goubran Eskander proposes a standardised plan of management, using evidence-based medicine and available clinical guidelines (summarised here): Initial assessment: • History • Examination: otoscopy, tuning fork tests (TFTs), PTA, neurological examination. • Exclude conductive HL: PTA/ TFTs • Patient should be assessed by ENT specialist within 24 hours Management:

The next step is to contact me for more information on how this project can help.

• Request MRI - unless history strongly suggestive of alternative cause/ contraindication/ declined

I can visit your practice and provide links to resources, and can be contacted at HepatitisWA 9227 9800, email GPProject@hepatitiswa.com.au.

• Arrange follow-up

Ms Annette Fraser, GP Liaison Nurse HepC ......................................................................

SSNHL an ear emergency Dear Editor I recently assessed a patient with a sudden deterioration in hearing. The symptoms were a blocked sensation, reduced hearing, and a constant buzzing in the left ear. Otoscopic examination by the GP was normal and the history was otherwise unremarkable.

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for health professionals in Western Australia.

4 | MARCH 2019

• Commence oral steroids after discussion of possible risks/benefits use oral prednisolone • Repeat PTA • Consider blood investigations if autoimmune HL suspected. If no improvement (or oral steroids declined/ contraindicated), consider intra-tympanic steroids injections and repeat PTA. Counsel patients about possibility of incomplete recovery of HL/ possible benefits of hearing aids and other supportive measures (if required). Prompt assessment (including PTA), diagnosis, and treatment, will ensure the best chances of recovery. Ms Tennille Crooks, Audiologist, Perth

Take a kidney test

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Hep C nurse available now

Dear Editor This Kidney Health Week (8-14 April 2019), Kidney Health Australia is urging all Australians to take a simple online Kidney Risk Test. More Australians die with kidney-related disease each year than breast cancer, prostate cancer and road accidents combined, yet awareness remains low. If caught early, the disease can be slowed. The Kidney Risk Test, which helps people understand their risk factors, could help prevent this devastating and costly toll. Risk factors include diabetes, hypertension, heart problems, a history of stroke, a family history of kidney failure, obesity, smoking, a history of acute kidney injury, being 60+ years or, and being of Aboriginal and Torres Strait Islander origin. There are still 1.7 million (1 in 10) adult Australians affected by kidney disease, yet 1.5 million are not aware of it until it’s too late (you can lose 90% of kidney function without any symptoms). It’s devastating to see newly diagnosed patients who need to immediately start dialysis, or go on the wait list for a lifesaving transplant - which could have been prevented through taking a simple online test (visit: www.kidney.org.au/kidneyrisktest) For those Australians who need to travel to Perth for a live kidney transplant, deceased donation or dialysis education, Kidney Health Australia’s FAITH kidney transplant house offers comfortable, furnished accommodation where families can stay together, while easing their financial and emotional burden. Located in Morley, many families have stayed in these houses for lengthy periods, enjoying quality accommodation they could not otherwise afford - for more information visit: www.kidney.org.au Ms Shilpa Jesudason, Clinical Director Kidney Health Australia. ......................................................................

References on request

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Major Partner: Clinipath Pathology

By Paul Kruger, Haematologist

Haematological abnormalities seen with psychotropics The benefits of psychotropic agents outweigh the risks. Psychotropic agents are associated with haematological abnormalities, which may affect a single lineage or multiple lineages (see Table). Psychotropic drugs are thought to cause abnormal blood cell counts through bone marrow suppression or immunemediated destruction of mature blood cells. Abnormal blood cell counts can cause morbidity directly (e.g. symptomatic anaemia) or from complications (e.g. neutropenia complicated by sepsis). Prompt investigation and management of haematological abnormalities is necessary. Symptoms and signs that require further blood tests Blood testing is indicated if an abnormality in haemoglobin, white blood cells, or platelets is suspected, and increases in cell counts are less common than decreases. Anaemia (defined as haemoglobin <130 g/L for adult males and <115 g/L for adult females) may manifest as dyspnoea, malaise, pallor, chest pain or syncope. Leucopenia, specifically neutropenia (neutrophils <2.0 x109/L), may manifest as mouth ulcers, and if infection develops, fever, rigors, and localising signs of infection may be present. Thrombocytopenia (platelets <150 x109/L) may manifest as easy bruising, petechiae, purpura, mucosal bleeding, menorrhagia, and when severe can contribute to bleeding at any site. Diagnosis Laboratory tests are aimed at assessing the severity of haematological abnormalities, guiding whether antibiotics or transfusion of red blood cells or platelets is necessary, and monitoring response to change in psychotropic treatment. The full blood picture and blood film are the first step in diagnoses – providing the psychotropic agent’s name on the pathology request form is helpful for the laboratory to interpret abnormal results. Further tests depend on the blood cell lineage affected. Anaemia can be further investigated with serum iron studies, vitamin B12 and folate. For suspected haemolytic anaemia, the reticulocyte

AGENT

ABNORMALITY Hb

Antipsychotic agents Chlorpromazine Haloperidol Clozapine Olanzapine Risperidone Antidepressants Amitriptyline Nortriptyline Venlafaxine Citalopram Sertraline Mirtazapine Antianxiety agents Clonazepam Diazepam Lorazepam Oxazepam Mood stabilisers Carbamazepine Lithium Valproic acid

WCC

•

Neut

• • •

Plt

•

• • •

• • • • •

• •

•

• • •

• •

•

• •

•

• •

WCC

• • •

• •

Plt

• • • •

•

• •

•

Eo denotes eosinophils, Neut neutrophils, Plt platelets, WCC white cell count. count, bilirubin, lactate dehydrogenase, haptoglobins, and the direct antiglobulin test is necessary. Pancytopenia often indicates a bone marrow biopsy. Suspect alternative causes for haematological abnormalities when the abnormality is severe, persists after dose reduction or cessation of the psychotropic agent, the patient takes other medications which can affect haematologic results, or the patient has features of a primary haematological disorder (e.g. hepatosplenomegaly, lymphadenopathy, or abnormal blood cell morphology). Referral to a haematologist is suggested in these situations. Management The decision to change psychotropic therapy depends on the severity of the haematological abnormality and the degree of benefit the patient is deriving from the agent. Mild, non-progressive haematological abnormalities may be monitored while the psychotropic agent is continued. Moderate-severe abnormalities, progressive abnormalities, or abnormalities that cause symptomatic disease, usually indicate a dose reduction or cessation of the psychotropic agent. Changes should be made in consultation with the managing

psychiatrist or general practitioner. Most cases of haematologic abnormalities due to psychotropic agents resolve after stopping the offending agent. Serious haematologic syndromes Neutropenic sepsis, a temperature above 38°C in the presence of neutropenia, requires urgent admission to hospital for investigation and treatment with broadspectrum intravenous antibiotics. Severe neutropenia (neutrophils <0.5 x109/L) in a well patient may require granulocytecolony stimulating factor to reduce the risk of infection. Aplastic anaemia often manifests as pancytopenia with a low reticulocyte count (less than 1%) and is treated by discontinuation of the causative agent, potentially blood transfusion, corticosteroids, granulocyte colony stimulating factor, antibiotics if there is concurrent infection, and potentially a bone marrow transplant. Psychotropic agent induced haemolytic anaemia or thrombocytopenia may be serious if the rate of destruction of red blood cells or platelets is high. References available on request.

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200

Patient Results: 9371 4340

For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

www.clinipathpathology.com.au

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WAPHA and urgent care Dear Editor, WA Primary Health Alliance (WAPHA) with the Department of Health will commence a pilot project this year. We are now seeking metropolitan WA general practices to participate in the GP Urgent Care Clinics Pilot. Please register your interest if you have unfilled appointments which can be promoted to the WA public as being available for their urgent care needs, and you would like your practice to have access to a web-based scheduling function, clinical skill development and better communication with your local ED. The project is part of an election commitment from the State Government’s Putting Patients First. The 18-month pilot project commences mid-2019. The main aim of the project is to raise awareness and educate the public so they can then change their behaviour. A public awareness campaign and website is being developed to support behaviour change. GP urgent care is required on the day and would include: o Musculoskeletal and orthopaedic injuries; o Gastrointestinal illness such as diarrhoea and constipation; o Illnesses of the eye, ear, nose or throat; o Stings & bites, rashes and wound infections; o Abrasions and minor lacerations o All emergency and life-threatening conditions will continue to be referred to an emergency department. Expected benefits to practices participating in the pilot include: 1) Use of unused appointments; 2) Support continuity of care of primary care patients; 3) Access to upskilling in urgent care; 4) Opportunities to build relationships with hospital EDs. The main requirement for a participating practice is to be accredited by an agency recognised by RACGP. There will be no legal obligation from practices to commit to participating for the life of the pilot. It is not expected that practices change their business model, including hours of operation or billing practices.

6 | MARCH 2019

It is not a requirement that all GPs within the practice must participate in the pilot project and there has been no minimum number of available appointments you must use. How will it work? Practices will be required to identify available GP urgent care appointments to their current GP Scheduling service (eg: HealthEngine, HotDoc etc). Work is being progressed with the National Health Directory Service to provide a seamless electronic platform for patients to access available GP urgent care appointments. Governance & Evaluation: The pilot project is overseen by a Governance Committee that comprises WAPHA, DOH, RACGP (WA), AMA (WA), CHASM (for project evaluation) and the Health Service Providers. This presents a major opportunity for GPs to shape the direction of GP Urgent Care Clinics in WA. Email Chris.kane@wapha.org.au to receive an information pack. Ms Chris Kane, Strategy and Health Planning, WAPHA ......................................................................

Level B item lament Dear Editor, The other day, I was commenting on a report from the General Practice and Primary Care Clinical Committee. The report covers such recommendations as patient-centredness, a GP enrolment fee, and changes to chronic disease items and is available at www.health.gov.au/internet/main/ publishing.nsf/Content/mbs-review-2018taskforce-reports-cp/$File/General-Practiceand-Primary-Care-Clinical-CommitteePhase-2-Report.pdf. Key recommendations include a 6 minute floor to the level B, and a new item for consultations over 60 minutes, and a 40 minute minimum for care plan visits, and (back to the future) includes coordination of team care arrangements in the care plan with abolishment of item 723. The survey to respond is at https://racgp.au1. qualtrics.com/jfe/form/SV_9v5Iuw0ggyVv25v Whilst pondering it occurred to me that the meters were ticking on my internet, mobile phone, electricity, water, and all my financial transactions are time stamped to the second. It then hit me that the Level B Item was the single most destructive item in the entire MBS! Item 23, the Level B is the default consultation item claimed by most GPs. It is

defined as a professional attendance lasting less than 20 minutes, including ANY of the following: taking a patient history; performing a clinical examination; arranging any necessary investigation; implementing a management plan; providing appropriate preventive health care. What economist would propose a fixed payment rewarding the least time given, least activity performed and expect quality and value for money in return? Little wonder that few GP’s schedule 20 minute appointment slots (I am one of the few) let alone go beyond a patient’s presenting complaint to other matters that may matter more! Corporates can argue that any prolongation of a consultation is against shareholder interest. At Medicare’s launch in a paper-based 1984, 20 minutes was already generous. In the computerised age, so much can be done in a minute. How much time and money has been wasted on item numbers for care planning, medication reviews, and health assessments because of this one core malignancy? Extra minutes dismissed by Item 23 could be spent on these tasks, extra minutes that often impact more on the health of our patients than their presenting complaint. Planning and delivering health care shouldn’t be artificially separated into an either-or task. The implicit MBS message is that when we do both, one or other task is not worth remuneration. What better time to focus on COPD status and management planning than when a patient presents with a respiratory infection; what better time to focus on cardiovascular risk assessment than when a patient presents for a statin script? Instead we are told to put these tasks off until a dedicated one-size-fits-all, all-or-nothing Health Assessment or Care Plan Visit. A “plan” for most diagnoses is implicit in the diagnosis. A GP care plan collates the individual plans into one. But as the military adage goes, “No plan survives first contact” disease management is an ongoing process not a document. It is integral to every consultation and the medical record, and should grow with every visit, new diagnosis and measurement. Single one-size fits-all health assessment or care planning items magnify the folly and waste of Item 23. A 6 minute floor to a consultation is a start but this should be the base increment for a rate (a convenient one tenth of an hour): I still don’t want my 18 or 19 minutes equated to someone else’s 7-10. If we are going to remunerate care planning tasks, medication review tasks and health assessment tasks remunerate it with a rate not a single payment that overpays some and underpays others, or perhaps a loading for better constructed consult items for GPs truly taking on their patient’s overall care. Better still let us do our jobs in a consultation structure that let’s us concentrate on, and supports us doing our jobs. Dr Rohan Gay, A GP supervisor, RACGP examiner, WAGPET educator, Bayswater ......................................................................

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Between a Rock and a Hard Place Opioid dependence, addiction, withdrawal, and pain. By Paul Dessauer, Outreach Coordinator, Peer Based Harm Reduction WA Pain is famously subjective. Opium products have been used for millennia to treat pain. While pharmaceutical opioids remain essential in treating acute pain, concerns have arisen around the safety and efficacy of opioids in treating chronic, noncancer pain. Drug therapy for pain aims to control symptoms enough to reduce distress and restore function, while minimising the potential for adverse outcomes. Judicious prescribing involves balancing risks and benefits. Coupled with non-drug therapies, appropriate medication greatly improves quality of life for the patient.2 An estimated 20% of Australians suffer chronic pain. Chronic pain is multidimensional, affecting all aspects of someone’s life and conversely, many aspects of someone’s life can affect the perception of pain and ability to function. Pain is perhaps best understood, and treated, as a complex socio-psychobiomedical issue. These complexities multiply when someone is dependent upon opioids, or appears to have developed addictive patterns of behaviour. Prescribing concerns centre around accidental overdose, diversion or misuse, and initiating an iatrogenic Opioid Use Disorder (OUD). Given these challenges, what can the physician do? Here are three simple tips from a consumer perspective… 1) Don’t make assumptions. An opioid dependent person needs higher doses to treat episodes of acute pain3, (due to cross-tolerance and opioidinduced hyperalgesia), yet people engaged in opioid substitution therapy typically receive suboptimal treatment following injury or surgery, due to misconceptions of health providers.4 Screening for risk of opioid misuse is widely recommended; however screening for high-risk patients, treatment agreements and urine testing have not been shown to reduce overall rates of opioid misuse or overdose.5 Many physicians are confident they can identify patients who misuse opioid medications, yet research shows that doctors only identify 10% of ‘sham’ patients, while misidentifying a proportion of genuine patients as ‘shams’.1 Chronic opioid treatment will often lead to physical dependency6, but most patients

8 | MARCH 2019

Both deception and fear of deception have consequences. Patients can get too much medical care when the doctor is deceived… or insufficient medical care when the doctor fears deception... These consequences affect both the individual patient and society. – Beth Jung 1

are reduced with little or no consultation. Anxiety and depression are common, as are feelings of being judged. Clear communication and reassurance from a supportive physician can alleviate this. State your concerns and involve the patient in a manageable reduction. Acknowledge their symptoms, and be prepared to modify the plan to manage them. If your patient trusts (and feels trusted by) you, and if they feel their concerns are being taken seriously, you can mitigate risks while working in partnership to help them achieve the best quality of life possible. References

will not develop an OUD. Research finds that only 5% 7 to 6% 8 of patients treated with opioid analgesic therapy progress to meet diagnostic criteria for opioid misuse or abuse. While further research is needed, the risk appears to follow a U-shaped curve; inadequate7 or excessive8 treatment can both increase risk. While there are overuse risks associated with inappropriately liberal prescription of opioids, there are also risks associated when pain is not adequately addressed in patients who have a previous history of chronic opioid therapy or of illicit opioid use. Failure to engage effectively with these people increases the risk of them misusing prescribed medication, or of resorting to self-medication with diverted or illicit opioids. Apparent “drug-seeking” may actually be “pain-relief seeking” behaviour9. People with a previous history of misuse may relapse if genuine pain needs are dismissed or neglected by their doctor. 2) Manage withdrawal from opioids, and transition to non-opioid medications, sensitively. Ideally, withdrawal from chronic, high dose opioid regimes should be managed carefully, with a gradual reduction regime, the option of stable periods between reductions to allow acclimatisation to the lower dose, and a gentle taper before final cessation. When referring a patient to a Pain or Addiction Medicine specialist be aware that most have wait lists and you will need to ensure the patient is managed appropriately until they are properly assessed for specialist treatment. In the meantime, try to use counselling and psychosocial supports.

1 Jung & Reidenberg 2007 Physicians Being Deceived. Pain Medicine, Volume 8, Issue 5, 1 July 2007, Pages 433–437, https://doi.org/10.1111/j.1526-4637.2007.00315.x 2 Recommendations regarding the use of Opioid Analgesics in patients with chronic Non-Cancer Pain, 2015. http://fpm.anzca.edu.au/documents/ pm1-2010 3 ANZCA Working Group Faculty of Pain Medicine. Acute Pain Management 2015: http://fpm.anzca. edu.au/documents/apmse4_2015_final See 10.6 The opioid-tolerant patient and 10.7 The patient with an addiction 4 Alford et al 2006. Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy Published: Ann Intern Med. 2006;144(2):127-134. DOI: 10.7326/0003-4819-144-2-200601170-00010 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1892816/ 5 Devo et al 2015. Opioids for low back pain. BMJ. 2015 Jan 5;350:g6380. doi: 10.1136/bmj.g6380 https://www.ncbi.nlm.nih.gov/pubmed/25561513 6 Hartman H 2015. Risk factors for iatrogenic opioid dependence: An Australian perspective. AMSJ Dec 2015. http://www.amsj.org/archives/4445 7 Higgins et al 2018. Incidence of iatrogenic opioid dependence or abuse in patients with pain who were exposed to opioid analgesic therapy: a systematic review and meta-analysis. British Journal of Anaesthesia, 120 (6): 1335-1344 (2018) https://doi.org/10.1016/j.bja.2018.03.009 8 Edlund et al 2015. The Role of Opioid Prescription in Incident Opioid Abuse and Dependence Among Individuals with Chronic Non-Cancer Pain: The Role of Opioid Prescription. Clin J Pain. 2014 Jul; 30(7): 557–564. DOI: 10.1097/ AJP.0000000000000021 9 Weissman & Haddox 1989. Opioid pseudoaddiction--an iatrogenic syndrome. Pain. 36(3):363-6, MAR 1989 PMID: 2710565 https://www.ncbi.nlm.nih.gov/pubmed/2710565

3) Express genuine empathy, clearly explain the rationale behind treatment changes, and engage the patient in planning. Pain patients frequently report high levels of distress and dysfunction when doses

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INCISIONS

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Who benefits from cannabinoid therapies? Cannabinoid therapies (medicinal cannabis) were legalised in Australia in 2016.1 Since then, enthusiastic widespread community interest in its use has been coupled with broad scepticism and unwillingness to prescribe amongst clinicians. Almost two thirds of GPs have been asked by patients about using medicinal cannabis.2 Most clinicians admit that their knowledge of cannabinoid therapies is inadequate, and that they have insufficient information to prescribe. This likely stems from there being no formal medical curricular or vocational training for doctors in the use of cannabinoid therapies. In addition, the prescribing bureaucracy, both Federal and State, has been complex and unwieldy. Using the available published evidence, the Commonwealth Health department and relevant state governments have approved specific clinical indications for cannabinoid therapy. The approved and accepted indications for prescribing of cannabinoid therapies in Australia3 include: Chronic non-cancer pain (neuropathic) Cancer indications

Chemotherapy induced nausea and vomiting (CINV)

Cancer pain

Sarcopenia and anorexia Refractory epilepsy (particularly paediatric) Neurological spasticity

Multiple sclerosis

Parkinson’s disease Anorexia and wasting due to chronic illness

For nearly all indications, cannabinoid therapy is seen as acceptable having exhausted all other therapeutic modalities and in Western Australia, prescribers require support from a relevant specialist. Other indications currently under investigation include PTSD, primary insomnia and nocturnal agitation in the elderly. In neuropathic pain, systematic reviews and meta-analysis have demonstrated an opioid-sparing effect with concomitant cannabinoid therapies.4 Co-administration of cannabinoids may enable reduced opioids while maintaining analgesic efficacy,

Referral forms can be downloaded from www.emeraldclinics.com.au

without the same hazardous side effects. Why is this important? In the last 20 years, there has been a precipitous increase in prescribed opioids and subsequent related prescription deaths, Australia more than most.5 To help address this, OTC codeine was up-scheduled to prescription only in early 2018.6 Emerald Clinics comprehensively assess referred patients’ suitability for cannabinoid therapies, with a view to reducing reliance on opioid use for pain relief. This shared-care model involves the patient’s GP and relevant specialty colleagues to continue to coordinate comorbidities and downregulation of opioid medications.

By Dr Alistair Vickery References 1. Medicinal cannabis facts sheet. www.health.gov.au/internet/ministers/ publishing.nsf/Content/546FB9EF48A2D570CA257EE1000B98F2/$File/ Medicinal-cannabis-factsheet.pdf 2. Karanges EA, Suraev A, Elias N, Manocha R, McGregor IS. Knowledge and attitudes of Australian general practitioners towards medicinal cannabis: a crosssectional survey. BMJ open. 2018 Jun 1;8(7):e022101. 3. Medicinal cannabis - guidance documents www.tga.gov.au/medicinalcannabis-guidance-documents 4. Nielsen S, Sabioni P, Trigo JM, Ware MA, Betz-Stablein BD, Murnion B, Lintzeris N, Khor KE, Farrell M, Smith A, Le Foll B. Opioidsparing effect of cannabinoids: a systematic review and meta-analysis. Neuropsychopharmacology. 2017 Aug;42(9):1752. 5. Islam MM, McRae IS, Mazumdar S, Taplin S, McKetin R. Prescription opioid analgesics for pain management in Australia: 20 years of dispensing. Internal medicine journal. 2016 Aug;46(8):955-63. 6. Larance B, Degenhardt L, Peacock A, Gisev N, Mattick R, Colledge S, Campbell G. Pharmaceutical opioid use and harm in Australia: The need for proactive and preventative responses. Drug and alcohol review. 2018 Apr;37:S203-5.

For DIGITAL Referrals see www.emeraldclinics.com.au/uploads/ resources/181213_Emerald_Clinics_Referral_Form.pdf > or order referral pads through info@emeraldclinics.com.au

1300 436 363 For patients referrals or to join our network of specialists, visit our website at:

www.emeraldclinics.com.au

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MARCH 2019 | 9

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RACGP advises politicians General practice is the first port of call for all Australians, 2 million every single week, the RACGP advises in a pre-budget submission and ahead of the Federal Election, saying that general practice is also the most efficient and cost-effective part of the health system. A recent submission by the RACGP to the Australian Government focuses on four main areas: • Reducing patient out-of-pocket costs and support GP services – by ensuring patient rebates reflect increasing costs of providing care, • Modernising medicine – by including phone and video call consultations, • Providing more support for mental health – by supporting GPs to spend more time with patients suffering from mental health conditions, and • Supporting high-quality care for those who need it most – by improving the Medicare rebates to patients who require more time with their GP. The RACGP submission can be viewed at www.racgp.org.au/advocacy/ reports-and-submissions/2019-reportsand-submissions/2019-20-pre-budgetsubmission

Medlab, API and cannabis? Australian medical life sciences company Medlab has joined with Australian Pharmaceutical Industries (API) to expand Medlab’s nutraceutical range in Priceline Pharmacies (350 stores). Medlab also has interests in the cannabis race to market around pain management together with its nano-particle medicine delivery system, Nanocelle™ which is being applied to its medicines (off and

Saliva-based glucose test The Saliva Glucose Biosensor comprises the Glucose Biosensor Unit (a small, disposable strip, which when exposed to someone’s saliva provide a g]ucose measurement) and a digital healthcare app (a digital app on a patient’s smart device). An Australian invention, the Saliva Glucose Biosensor was by Prof Paul Dastoor and his team at the Centre of Organic Electronics at the University of Newcastle. The iQ Group Global acquired the biosensor technology in 2016 and has accelerated its development. The move away from finger prick testing will please some and may increase glucose monitoring and improve healthcare outcomes.

on patent). More than 2100 independent pharmacies will be able to access Medlab’s nutraceutical range. As part of the agreement with API, it will hold Medlab products in its warehouses, significantly expanding potential distribution into these independent pharmacies. “Medlab is very excited with this opportunity to work with Priceline Pharmacy and other independent groups as it allows us to support people in the community suffering chronic illnesses by providing them easier access to scientifically backed products via professional pharmacy”, CEO of Medlab Dr Sean Hall said but when we asked “Will the

agreement with Priceline pharmacies for nutraceuticals impact at all on your plans for cannabis?” we received no response.

The price of getting norovirus Most viral gastroenteritis comes from Norovirus, a resilient virus. About 700 million people contract the short but severe illness each year including 1.8 million Australians. No vaccine or cure is available. Targeted research on norovirus – which is responsible for most viral gastroenteritis outbreaks – has only recently been possible and a new study will enable us to understand the longevity and infectivity

ACDs: instructions for doctors A recent study found that 70% of older Australians are without an Advance Care Directive (ACD). ACDs are instructions for carers in the event patients are unable to make their own medical decisions, which happens in about 50% of cases. The research by Advance Care Planning Australia (ACPA: funded by the Commonwealth), is published in BMJ Open and looked at the health records of 51 Australian hospitals, aged care facilities and GP clinics, across six states and territories. About 30% of people gave their preferences for care with some appointing a legal substitute decision-maker. Dr Karen Detering, Medical Director of Advance Care Planning Australia, said ACDs prevented older people becoming vulnerable and without a voice, preventing decisions under the worst circumstances. Our reflection around an ageing population, thought ACDs may relieve pressure on hospital beds and act as a cost-saving initiative, at a time costs are important.

10 | MARCH 2019

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Health Minister Roger Cook has announced a new three-year $855,000 partnership between Healthway and the West Australian Country Football League (WACFL) to build club capacity and support for mental health. The Think Mental Health club program will be rolled out across all 25 country football leagues from the Kimberley to Esperance, engaging about 130,000 Western Australians. Harry Karelis, founder of Zelda Therapeutics, has moved to a nonexecutive chair role. Zelda Therapeutics Ltd is an Australian-based biopharmaceutical company specialising in the development of cannabinoidbased medicines for the treatment of some of the most important human diseases and disorders.

Prevention is heart attack cure A new report, No Second Chances, shows that prevention of secondary heart attacks and strokes is critical to combatting Australia’s number one killer - cardiovascular disease. Cardiovascular disease is the most expensive disease group costing Australia $12 billion a year; a figure estimated to rise to over $22 billion by 2032. The report, released by the Baker Heart and Diabetes Institute and sponsored by Bayer, says about 4.2 million Australians are living with a cardiovascular condition, and of those, 1.2 million have heart disease and are 5 to 7 times more likely to suffer future heart events. There are 1.1 million hospitalisations every year due to cardiovascular events – up to half are readmissions. Only 50% of Australian heart patients receive guideline-based care after a heart attack or stroke. The report shows (i) If you’ve had a heart attack, you are twice as likely to die prematurely, (ii) If you two more heart attacks, you are three times more likely; (iii) Within 12 months, one in ten heart attack survivors will have another heart attack, and (iv) In just 7 days, about 10% of people who have a stroke will have another.

of the highly contagious stomach bug. The elderly and those with compromised immune systems are particularly vulnerable - at risk of serious outcomes and longer recovery times. Patients shed the virus for up to several months after their illness but infectivity during this time is unknown.

• Prevented deaths from bowel and breast cancer

Do you agree - PHAA’s top 10?

Sales of migraine drug dented

The Top 10 report was released at the Australian Parliament House by the Public Health Association Australia (PHAA). The top 10 successes include: • Folate: reduced neural tube defects • Immunisation and eliminating infectious disease • Containing the spread of HPV and its related cancers • Oral health: reduced dental decay • Reduced incidence of skin cancer • Tobacco control: reduced deaths caused by smoking • Reduced the road death and injury toll • Gun control: reduced gun deaths in Australia • Contained the spread of HIV

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Despite public health successes public health investment in Australia currently amounts to less than 2% of the national health budget and has been generally declining since at least 2001. American prescription benefits manager CVS Health Corp has excluded Aimovig from the covered drugs, despite US FDA approval in May 2018. Teva’s Ajovy (fremanezumab) and Eli Lilly’s Emgality (galcanezumab) rapidly followed Aimovig approval with all three rival drugs launched at the same price point (US$6,900 per year). According to GlobalData, global migraine drug sales could reach $8.7bn by 2026 and the US will continue to dominate the market with a 77% share of total sales. There is strong similarity between the three drugs in terms of efficacy and safety. Given CVS’ decision, the battle for the leading CGRP antagonist drug is wide open.

continued on Page 12

Matthew Budge and Warren Harding are new board directors of Alzheimer’s WA. Mr. Budge has been heavily involved in fundraising for Alzheimer’s WA. Mr. Harding has 30 years management consulting experience, including work on not-forprofit boards. Child and Adolescent Health Service – Community Health (CAHS-CH) is seeking Expressions of Interest (EOI) from organisations that may have rent free space for use by CAHSCH. No rental fees will be paid to the successful provider(s) for use of the facility or room, but outgoings for day-to-day costs directly related to the use of the facility or room will be considered. Furniture and equipment will be provided by CAHS-CH. The nominal closing date is Tuesday 31st December 2019. For information on instructions for submission, call Sally Lee (08) 6456 5318, sally.lee@health.wa.gov.au. Murdoch University’s collaborative Australian National Phenome Centre has received $10 million from the Federal Government. to examine the complex interaction and influence of genes, the environment, diet and lifestyle on human health. The research will help them to better predict, prevent and treat complex diseases and conditions including obesity, diabetes, dementias and cancers. Murdoch University VC Eeva Leinonen, Minister for Health Greg Hunt, Prof Jeremy Nicholson (head of the Australian National Phenome Centre and Pro Vice Chancellor for Health Sciences at Murdoch) and Prof Elaine Holmes (Premier’s Science Fellow and Director of Systems Medicine, ANPC).

MARCH 2019 | 11

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continued from Page 11

Suicide can't be predicted Remember “suicidal ideation”. It used to be taught that anyone contemplating suicide would have suicidal thoughts that they would relay in conversation. This major Australian study (a review of data from 70 major studies of suicidal thoughts, published in BJPsych Open) shows that, as a stand-alone test, only 1.7% of people with suicidal ideas died by suicide. About 60% of people who died by suicide had denied having suicidal thoughts when asked by a psychiatrist or GP. Prof Matthew Large from UNSW's School of Psychiatry said “This study proves we can no longer ration psychiatric care based on the presence of suicidal thoughts alone. Hospital and community care teams in Australia are extremely under-resourced, and this needs to change.”

Please stay! Private health Participation in private health is now at 44.6%, the lowest it has been in 11 years, according to the Private Health Insurance Association. Private health insurance hospital coverage dropped by 12,370 people over the quarter and 64,657 over the year to date. At the same time, according to the latest Australian Prudential Regulation Authority data, episodes of care in the private sector rose 1.6 percent in the December quarter, with 940,922 privately insured hospital treatment episodes. Australian Private Hospitals Association CEO Mr Michael Roff says these numbers show the high value Australians place on access to private hospitals as well as showing a reduction of burden on the public health sector. Mr Roff also warned health insurance consumers to be careful on choice of exclusions and continually update their insurance policies to ensure they are covered for essential health needs. Policies that exclude services are now at 56 percent, up 0.3 percentage points over the quarter, according to Mr Roff.

Aboriginal recuperation service seeks $550,000 a year The Elizabeth Hansen Autumn Centre needs government funds to stay open. The centre offers 32 beds for Aboriginal patients and their carers, with the majority travelling from the Kimberley, Pilbara and Goldfields regions. The service provides residential recuperation and renal dialysis to Aboriginal patients. Derbarl Yerrigan Health Service Chairperson Jackie Oakley said management had battled to keep the Centre operating after WACHS withdrew recurrent operational funding for the centre three years ago. Since then, Derbarl Yerrigan Health Service has attempted to self-fund 70% of the centre’s operations and recently introduced a nightly gap charge for each client and carer. In the past three years over 200 people have used the centre. Ms Oakley said that a need for the service is widely acknowledged especially

12 | MARCH 2019

Remote physio technology PhysioROM is a start-up telehealth solution that conducts range-of-motion analysis via video. Using artificial intelligence and machine learning, and monitoring patients’ progress, the technology allows for remote physiotherapy sessions – post op patients of hip and knee surgery may benefit most, an alternative to continued hospital care, particularly patients from rural and remote communities. Healthtech startup Coviu secured $1.18 million in government grant funding to commercialise the technology. This Cooperative Research Centre Project has CSIRO’s Data 61, health clinic HFRC and the School of Sports Science, Exercise and Health at UWA. “If we could do it in a way that gives clinicians confidence they are doing it right, then we can send people home, we can open up a whole bunch of beds … and we can reduce the delays on waiting times,” according to Coviu founder and chief Silvia Pfeiffer.

with the recent closure of Genesis House in Salter Point which, effectively removed 60 beds from the system. “We have been unable to get a commitment from Government for recurrent funding to the tune of around $550,000 a year to keep this vital service afloat. If we cannot sustain the service will be forced to shut the doors,” she said.

Overall wellbeing of brain, mind and body focus of new centre Flinders new university centre of neuroscience, psychiatry, psychology, allied health, engineering, social science, education and public health, Orama, promises to make mental health wellbeing real, according to Prof Patrick McGorry AO, at the centre’s launch. He said awareness about mental health had become a substitute for actually doing something about it. He said that in Victoria 3 of 4 young people coming to receive clinical mental health problems have to be turned away due to insufficient resources. “It’s a broken system and this is a disgrace in a country like Australia.” Órama takes a whole-of-person approach, incorporating research at the brain and cellular level right through to research around people’s experiences, health systems, service delivery models and educational or preventative science. ABS Research suggests that at least one in five people aged 16-85 experience common forms of mental illness in any year, and estimated annual cost of mental ill-health in Australia is more than $60bn - around 4% of GDP, or about $4000 for every taxpayer.

Online psych for rural and remote communities Rural Help is now online, providing online psychological therapy services for regional and remote communities. Rural Help creator, psychologist Kerry Howard, says that remote communities are under-serviced for therapy by about 46%. The new service, not available to metropolitan clients, will provide a safe, secure and easy-to-use platform, with sessions being conducted from the comfort of a client’s home via video conference for one hour. The service is particularly helpful at a time when rural areas are experiencing stress from the impact of drought. Suicide rates are 40% higher than metropolitan areas. Under a Mental Health Care Plan, individuals living in rural or remote areas are able to access Medicate rebates for online therapy.

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FEATURE

The Bare Bones of Tissue Donation While organ donation may take the headlines, there is a steady recognition and investment in WA’s bone and tissue bank, PlusLife.

he State Government last year built a $10 million facility in Midland which threw a lifeline to WA’s bone and tissue bank, PlusLife, to upgrade and rehouse from its ageing facilities at Hollywood Hospital. Then last August, a $250,000 grant from Lotterywest has enabled it to kit out a dedicated research laboratory.

patients having hip replacement surgery can donate the ball of their hip, which is used commonly in a ground-up form for children with spinal deformities, complex joint surgery and dental and facial bone loss treatments for patients with dental and facial bone loss.

Prof Andrew Smith, who is on the board of PlusLife and is the chair of the research and development committee, believes that it will be the only clean room research lab for bone and associated heart tissue research in Australia.

Andrew, who is an oral and maxillofacial surgeon, said while PlusLife had engaged in research for a number of years, the new facility would allow a more focused approach in the areas of orthopaedic, spinal, dental and facial procedures.

“A clean room means that the air is microbiologically filtered so that no pathogens, bacteria or viruses can enter, which allows us to produce products for transplant that is absolutely safe,” he said.

It will also be a hub for post-graduate training with recent collaborations with the UWA, Curtin and Notre Dame medical schools.

The not-for profit PlusLife, which is the only bone bank in WA, has provided more than 18,000 grafts in its 25 years of operation though its beginnings were humble –a simple laboratory bench at QEII Medical Centre with just two staff and two freezers donated by the SCGH Women’s Auxiliary. The current managing director Anne Cowie said the Midland facility would include two tissue processing cleanrooms, freezer storage, a tissue testing laboratory and a dedicated research laboratory. Ways to donate PlusLife manages bone and tissue donations in WA and also provides graft material nationally and internationally. It operates two donor programs. Living

14 | MARCH 2019

And, as with organ donation, bone, tendons and ligaments can be donated after death with consent from next-of-kin.

“Principally, research will focus on orthopaedic surgery, which is specifically the targeted use of bone material for limb-saving procedures for people with cancer, mostly young children and adolescents,” he said. “There will also be an emphasis on dental products as a significant amount of bone is needed for jaw reconstructions. One of the most common uses for bone nowadays is in ordinary, fairly routine dental treatments such as implants.” “We pride ourselves on producing materials of the highest quality and ultimately the highest safety in the country.” Expanded vision “Our move to Midland has ensured that WA will be nearly self-sufficient in bone for the sort of purposes that we need, and it will also allow us to expand into new areas that we

have really only just started to develop, mainly the maxillofacial and dental aspects, where a lot of bone grafting is done now days.” “More bone is transplanted for dental purposes worldwide than for any other. Dental implants are often augmented by a bone graft, and frequently after dental extractions bone grafts are put in to maintain the bone stock in the jaw.” “Obviously there are very emotive areas, such as the limb-saving procedures performed by surgeons such as Richard Carey-Smith using our products so that children, and others, don’t have to have amputations.” “And then we do a lot of work in the spinal areas.” Andrew told Medical Forum that the new facility also gave PlusLife a profile nationally and international. “We’re interested in a national market, but the important thing to stress is that all of our product, the bone is only from Australian sources, and the testing and the way the material is processed is done to the highest possible standards. We are not convinced that these standards are mirrored by some other material that appears in Australia and WA.” “We are confident that as long as that product is Australian in origin there is not a problem, but some very big companies have moved into the business of bone, which is supplied to Australia and there is very little information available on the source or the biosecurity of that bone.” “I’m certainly not saying it’s illegal – it is completely above board – but central surveillance, we believe, is required to

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FEATURE The number of PlusLife donors and recipients Donors Recipients Grafts (total) Grafts (interstate) Interstate %

AVERAGE 630 521 827

2013 706 560 844

2014 629 498 758

2015 595 540 859

2016 596 554 908

2017 624 457 767

180 0.21

225 0.27

209 0.28

199 0.23

160 0.18

107 0.14

ensure quality. This is not us trying to be anti-competitive. We’ve done some research that we will be shortly publishing which will compare what we believe are the safety levels of the Australian bone product compared to the safety levels from bone sourced elsewhere in the world.”

tissue and bone donation, which is not the case in every other state.

There has been a lot of focus over the past couple of years on organ donation, with inquiries and soul-searching about donor rates.

“We hope to increase our number of cadaver bone harvesting procedures. In terms of donation from living donors, we find people are very positive about it. We make it quite clear to them that we are not for profit and nobody makes money out of the bone they donate.”

Plus of hip work Andrew said the majority of the bone donation to PlusLife is from people having hips replaced. “Our criteria for accepting bone is exceptionally strict and that means sometimes we can’t accept the donation. In the future, some of that bone that might not be able to be used for transplant could certainly be used for research purposes.” In WA, organ donors and their families are also counselled at the same time about

“We’ve got a building relationship with Donate Life here in WA. Tissue and organ donation often get confused, so sometimes opportunities do get missed,” Andrew said.

This is not the case in other places in the world and Andrew said PlusLife sought to reassure donors that their harvested tissue is for clinical rather than corporate gain. Future proofing? In a world where just about anything, it seems, can be grown in a petri dish, we asked Andrew if there would be time when PlusLife grew its own bone product.

“There is lots of research about growing bone from tissue culture and other material but I think our lab is more likely to be doing research on new technologies with the bone that we have, looking at different structures and properties of materials. Exploring what various growth factors added can to the rate of bone healing,” he said. “That’s how I see our laboratory developing. We probably won’t be kitted out for molecular biology style research, more for translational research into clinical activity.” Anne Cowie said the $10 million provided by the WA Government in 2016 to build the new PlusLife headquarters in Midland was a one-off contribution, which safeguarded our organisation's future but there is no ongoing government contract or funding. The building is owned by the State Government. Funds come from servicing the community. "When a graft is provided by PlusLife, a fee for service is charged and paid by the hospital, which is recoverable via health funds. This fee is intended to cover the costs associated with retrieving and preparing the graft for transplantation," Anne said. Lotterywest’s $250,000 was a one-off grant to equip the laboratory, but the establishment of a new charity foundation will help finance ongoing research through philanthropic means and to source other grants.

By Jan Hallam

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MARCH 2019 | 15

“Muka” Blue Tree Suicide Voice Jayden’s funeral that the family wanted to paint another tree blue. Grant, Jayden’s, father thought that the property could do with one more blue tree in memory of Jayden. A close friend and a cousin, Simon Comerford and, Jared Beagley, decided to paint a 15 metre dead tree on the Mukinbudin property. It took them four hours. It is not, of course, only young white males that kill themselves in rural and remote Australia. Western Australia’s Coroner Ros Fogliani’s recent report on the death of 13 indigenous children, five of them between 10 and 13, concluded that intergenerational trauma was having a major impact on the life chances of children in Aboriginal communities.

The blue tree before and after. In 2017, 409 people took their own lives in WA, the majority of them male.

That blue tree has now exploded online as a potent symbol of rural youth suicide.

In 2018, police found Jayden Whyte (aka Jaydo) dead in his Sydney apartment. His mother had been trying to contact him, with no success.

The online Blue Tree Project, supported by Jayden’s family and the local community, promotes open discussion on suicide and has been copied elsewhere, including overseas, in support of the initiative https://www.facebook.com/ bluetreeproject.com.au/

Mukinbudin is Jayden’s Wheatbelt home and his family is still farming there. Four years earlier Jayden with a friend painted a dead tree on the property blue, as a joke, to see how long it would take his father to notice.

The project is not simply virtual, of course. Tjarda Tiedeken, who painted the first blue tree with Jayden, told mourners at

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WA rural GPs remain frontline Compassion from WA’s rural doctors for suicidal patients has always been the silver lining in all reports, government and non-government, on what has become a mental health crisis in the state. Despite stressors that rural GPs expect in their own professional lives and have always coped with, nothing stops them pushing the system, publicly and organisationally, to ensure patients get the best possible outcome. According to the Australian Institute for Suicide Research and Prevention Study, Suicide in Remote Areas of Australia, “GPs become important gatekeepers in terms of recognising those people at risk of suicide and providing prevention frameworks to protect them.” GPs have also been proactive in encouraging open discussion on suicide. Medical teaching programs, like the Wheatbelt Medical Student Immersion Program (WBMSIP), have successfully encouraged future GPs to experience rural challenges, positive and negative. A recent student, Tess, reported that she travelled to Westonia with one other Curtin student and four Notre Dame postgraduate medical students. “My experience in Westonia was overwhelmingly positive; I was able to meet wonderful people and see aspects of rural life that were unlike anything else I have experienced. After my few days in the town, I felt like I became very involved.”

By Mark Balnaves

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NEWS & VIEWS

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FEATURE

WA Research Comes Home to Roost Big research projects marked out for WA is the first sign research funding may be, at last, starting to head West.

his year marks an exciting year for medical research in WA. It’s as if 2019 marks a culmination of the years of groundwork by researchers, funders and those charged with trying to bring everyone to the same table

The opening of the Australian National Phenome Centre at Perkins South has shown the country that big research projects can be successfully launched in WA. The WA Health Translation Network, led by Prof Gary Geelhoed, is now part of the Australian Health Research Alliance (AHRA) and when there’s strength in numbers governments tend to listen. One of the issues AHRA has been working on is identifying and overcoming barriers between research evidence and implementation. Gary spoke to Medical Forum about WATHN’s role in AHRA and the growing dialogue with government. “AHRA has taken on four responsibilities – Aboriginal health, data management, hospital systems research and the other, which WATHN is heading up with our Sydney partners, is consumer and community involvement in research.” “We have conducted a national survey on community involvement in research and it really reflects what’s happening in medicine generally. A generation ago, medicine was regarded as paternalistic where the doctor knew everything; they diagnosed the problem and told you how they were going to solve it.” “Now, medicine reflects a wider philosophy, that it’s a partnership. Patients are more literate and want to discuss their problems and possible treatments. Research is one of the pillars of the health system so consumers should be involved there as well to determine what research is important to patients and consumers.” Gary said nationally recognised WA consumer advocates Anne McKenzie

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and Pip Brennan were heavily involved in WATHN’s work in this area.

just the doing but also its intrinsic place in the WA health system.

Consumers have sway

“It is absolutely core business. There is weight of evidence that shows that a health service does best when it champions academic and research and innovation as equal pillars. It means you get a better service and better outcomes for patients.”

“WA has always been very strong in consumer advocacy and it’s the reason we put our hand up to lead this study – because of the leadership we’ve had from Anne and Pip and Michelle Kosky, beforehand. We’ve had some fantastic people working and influencing the national agenda.” “There are other areas of interest that are coalescing, some that are being suggested by us, some that are being suggested by the Minister Greg Hunt. For instance, he asked AHRA to explore national approaches to wound care. It may not be sexy research but wounds come at a terrible personal and community cost and some fantastic work was done.” “We are heading that up with the wound study along with the Brisbane group because of the strength and evidence of Silver Chain’s work in this state.” There is also a women’s health network that has sprung up and again we’re sending two representatives there so there is a lot going on.” Gary said that 2019, on a national level, looked encouraging in funding terms. The funding pot keeps growing with Medical Research Future Fund powering on as well as the NHMRC coffers swelling. “There is a doubling of the national pot, or the two biggest pots nationally, and that’s an incentive for everyone,” he said. The challenge is to see that more of that money heads West. “We only get 6% of NHMRC money yet we have 11% of the Australian population so could say we are roughly getting about half of what you might expect. To put it simply, if the pot is doubling, we should expect a doubling of the money coming into the state.” Attracting fair share “Our challenge, of course, is to increase that 6% of national money. What can we do to make our chances better? Well, there is a growing sense of collaboration in the state, and support for WAHTN from all of our partners.”

“There is often talk about trying to speed up the time between when things are discovered and when they become practice and some of the worst scenarios suggests 17 years is the time lag, which is just incredible.” “What we need to do is ensure that people in charge of research are actually sitting at the top table of our hospitals, they are actually a part of the executive so they have input on big decisions being made by the health services. How they affect research and how research will affect them.” Translational research is a concept that’s been around a long time now, but funders are getting serious about it. Gary said the NHMRC will be focusing more on what has been achieved by researchers rather than how many papers they have had published. “This is being very simplistic but once upon a time, success in academia was how many papers you have published, then you put it on the shelf and left someone else to translate those findings into action, which is probably explains the 17 years!” he said. “NHMRC are now looking into research and researchers whose work has led to improved health outcomes. When you apply for funding now, you have state what do you expect will be the impact of your research and how are you going to measure that impact.” “WA is waking up to the fact medical research and innovation is all about better outcomes for patients and that there are all sorts of positive spin offs. I mean it is very big business and this is something we have not been particularly good at, but there are now lots of groups here in WA focused and encouraged by people such as the Chief Scientist Prof Peter Klinken and the Health Minister himself who is promoting the Future Health and Innovation Fund.”

By Jan Hallam

Gary also said currently there was strong political support for medical research, not

MARCH 2019 | 17

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GUEST COLUMN

We All Die As WA faces heated legislative debate over end of life choices, Canadian family doctor Dr Tony Reid reflects on the impact his country’s legalised Medical Assistance In Dying (MAID) has had on his practice and life.

s family doctors, we care for patients as they die, sometimes peacefully and pain free, but often suffering from symptoms that are difficult to control. We have all seen “bad deaths,” with patients struggling and families in distress. Palliative care can address many end-oflife symptoms, but it cannot manage all of them—for example, it cannot manage complete loss of mobility; shortness of breath even on rolling over in bed; the fear of sudden, rapid gastrointestinal bleeding from a terminal cancer; or the ongoing psychological stress of losing one’s autonomy and dignity. In June 2016, after many years of lobbying by patients and groups like Dying with Dignity, the newly elected Liberal government (with a family physician as health minister) moved quickly to legalize medical assistance in dying (MAID). This has profoundly altered the approach to death and dying in Canada. My experience My personal journey started before the legislation was introduced on learning the stories of people who had challenged the courts for permission to end their lives, hearing of those who had gone to Switzerland to access MAID, and talking to colleagues in Belgium, where it had been legal for many years. Although the idea of assisting death seemed to be contrary to my role as a physician, I had seen many of my own patients suffering when they died despite receiving dedicated palliative care; I felt this was cruel and unacceptable. Thus, I was interested in how other societies dealt with this issue. Some European countries seemed to have developed a humane and careful approach. A powerful moment for me was seeing a YouTube video of Dr Don

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Low,1 who was a microbiologist at Mount Sinai Hospital in Toronto, Ont, during the SARS (severe acute respiratory syndrome) outbreak. In the video, he made a plea to the government to allow MAID, as he was dying of a brain stem cancer. He said, “I’m frustrated with not being able to have control of my own life; not being able to make the decision myself when enough is enough.”1 At home, the Quebec analysis of MAID and subsequent legislation were well thought out and sensitive to patients’ wishes and the concerns of conscientious objectors. Astonished at how quickly the federal legislation had passed, I saw an opportunity to become involved in a very personal way. I joined a committee to develop my local hospital’s policy for MAID and then decided to provide the care myself. For me, this was a natural evolution of my belief that patients have the right to choose how they might die, much as they choose treatments for their medical conditions. And if the situation ever arose I, too, wanted to have that choice. I collaborated with another physician in my community, and we assessed our first case in December 2016. The patient was suffering from end-stage laryngeal cancer, unable to eat and afraid of bleeding or choking to death. He met all the eligibility criteria, so on a cold winter night in January we went to his home. He was there with his sister, his only family; a pastor; and a friend. We talked about his life and then he said he was ready. We injected the medications and he slipped peacefully away. It was a profoundly moving experience, one that has been repeated with each subsequent case. Sharing this care with another physician has provided mutual support in performing a medical intervention that runs counter to our normal practice. Since then, we have cared for additional patients and

have developed more experience with the procedure. Some thoughts The most powerful factor in this care is the stories that patients tell us. They really solidify my conviction that this care is appropriate and compassionate. Each story is unique and often describes a long-standing struggle with a dreadful disease or the rapid progression of an aggressive condition. Several patients have had motor neuron diseases, such as amyotrophic lateral sclerosis, and faced an inevitable decline to helplessness, eventually succumbing to respiratory failure or other complications. Others have had end-stage cancer symptoms that were partially managed but faced, to them, an unbearable demise. Others were so debilitated that their quality of life was no longer meaningful—they were just waiting to die. In every case, when I hear the story, I understand the request for MAID and would likely choose it myself if I were in the same situation. I have been struck by the determination and courage of those requesting MAID, right up to the moment of their death. These patients have made up their minds and faced their choices unwaveringly. Many describe the relief they feel knowing that they have control over the end of their lives and that they will not fear the unknown or a possible struggle when dying. Much of the anxiety of a terminal diagnosis has been relieved for them and their family members. We have performed most of our medically assisted deaths at home where we believe it is most appropriate. We have found the cooperation with community nursing to be remarkably good. Palliative care nurses have been there to start intravenous drips and provide support to families;

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GUEST COLUMN pharmacies have been responsive and helpful. The final process has been very smooth and peaceful, and is over in a few minutes. After all the build-up, it seems almost anticlimactic. Families are extremely grateful for this care. They are relieved to see how peacefully their loved one dies and feel a sense of release from their own suffering as they witness that person’s decline. Of course they are sad, and hugs go all around. But they tell us that their loved one died on his or her own terms and they view this outcome as positive. Follow-up telephone calls to families several days after each medically assisted death have all been very positive, with no regrets expressed by the family. My colleague and I have not second-guessed the care in our cases. We have received a few referrals for MAID that we ultimately declined, as we believed that the cases did not meet the established criteria. The federal legislation on eligibility was deliberately conservative, and this is understandable while Canada gains experience with MAID. The criteria do require death to be “reasonably foreseeable,” although no timeline is given; thus, we find it challenging to consider people with intolerable conditions that are not foreseeably fatal. There are also populations excluded from the current criteria: children, those with mental illness, and patients developing dementia who

would like to “prequalify” for MAID when they are no longer living meaningfully. Addressing these situations is, apparently, on the agenda of a working group and I hope the criteria will be revised to be clearer and more inclusive. Our involvement with patients and their families is short-term but involves a very profound experience. We quickly form relationships that continue with families after the death; we have received cards and had donations made as thanks for MAID care. We consider it to be an extension of palliative care. And personally, as a family physician, I have found providing MAID to be astonishingly rewarding, as it combines so many of the skills and art that make family medicine so fulfilling. Almost universally, nurses are supportive of MAID, usually enthusiastically. In contrast, some physicians have expressed reservations and even disapproval. Perhaps the nurses’ hands-on perspective is more persuasive than the perspective of physicians, who spend less time with patients. At the same time, I suspect almost all family physicians have helped dying patients along the road to death with increasing doses of narcotics to relieve suffering. Is this really much different from providing a controlled death with less suffering, on the person’s own terms?

We are conducting 10-minute online surveys with GPs across Western Australia to explore any kind of care they provide to their patients in the last 12 months of life.

All participants receive $90 reimbursement for taking part in this project.

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Challenges Naturally, there have been problems. Determining capacity is sometimes a challenge when a patient’s level of consciousness fluctuates owing to his or her condition or medications. The paperwork is complex and requires careful documentation. The logistics of arranging nursing, medications, and schedules is very time- consuming. Travel to patients’ homes adds more time to the process. In many provinces there is no specific fee schedule for this care and there are still many areas in Canada that do not have access. These issues need to be addressed. Conclusion Despite the problems, MAID has been an important step forward in end-of-life care for Canadians. I challenge physicians who have reservations about MAID to hear the stories of patients. I suspect most would choose MAID for themselves in the same circumstances. We all die; in Canada we can now face death with a humane choice. ED: This is an edited extract from an article which first appeared in the Canadian Family Physician, a peer-reviewed medical journal which is the official publication of the College of Family Physicians of Canada.

Do you or your practice provide any kind of care for patients in their last 12 months of life? If you are interested in finding out more about this study or being sent the online survey link, please contact me at:

angus.cook@uwa.edu.au or phone (08) 6488 7805 Professor Angus Cook The University of Western Australia

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Improving Radiotherapy Access As WA expands, so too do the services gaps. Two private cancer service providers are attempting to address that. There has been a bustle of activity over the past three years among private cancer radiological services as the Perth metropolitan area expands rapidly north, south and east, and WA Health is looking to get the best value for money. Media releases have bounced in at regular intervals announcing yet another new service opening up, particularly in the rapidly expanding Rockingham/Peel and the Joondalup/Midland corridors. While they trumpet hi-tech services for patients close to home, there is an underlying serious business commitment by the players in question, GenesisCare and Icon. A key piece of equipment, the linear accelerator, is a cool $3 million, so not surprisingly these entities are looking towards growth markets. Medical Forum spoke to GenesisCare’s head of oncology services Michael Davis and Icon’s Mark Middleton for their perspectives. The Sydney headquartered GenesisCare’s involvement in the WA oncology space began in 2011 when it bought locally-owned Perth Radiation Oncology. It has forged a large national and international profile, but here in WA it has services in in Wembley and Joondalup and has contracts with the WA Department of Health for services at Fiona Stanley Hospital and the South West Radiation Oncology Service in Bunbury. Clinics are available in Albany, Busselton, Geraldton and Mandurah. “When GenesisCare won those public tenders, we thought the best way to provide those services was to expand on the good work that was already happening,” Michael said. “Perth Radiation Oncology was a private radiation oncology service with a number of local radiation oncologists, doctors and other staff that ran public services at Royal Perth Hospital, so we used that as a base with which to grow. That service transferred into Fiona Stanley Hospital and then we established a new service in Bunbury.” “Given that we had such a good grounding and strong local support, we developed

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and built the Joondalup service, which allowed us to close the service gap that was fairly expansive and substantial at the time in WA.” “So not only were we expanding and partnering with the State to provide services but we have also been able to expand the footprint of private services at Wembley and Joondalup. Michael said that GenesisCare was exploring expansion to the Peel region. “There’s huge growth there with expanding public and private infrastructure and with a lot of health care providers drawn to the area. There is a need for better access to oncology care, so we want to invest in that area to support the local community for years to come.” Michael said the $10 million Peel facility would open in the first half of the 2019 year with the first linear accelerator ready for action and possibly a second in operation later in the year. “Up until now, people from the Peel region had two options for radiation oncology. They turned left at the highway and came to Perth or they turned right and head to Bunbury. Radiation oncology treatment can be lengthy for many patients, sometimes seven to eight weeks. And its daily. So travelling 100 kilometres is tiresome and for some that distance can affect whether palliative patients choose to have radiotherapy treatment. Having access local access makes a difference.” Mark Middleton is CEO of the Brisbanebased Icon Group, which incorporates Icon Cancer Care, Radiation Oncology Centres, Epic Pharmacy and Slade Health.

access to these types of services. “It is often difficult for patients to make their way to the CBD for radiotherapy and to have all of their cancer needs met.” “In WA, Midland and Rockingham are areas of real need and having local services means patients don’t have the pressure to travel long distances at a difficult time.” Whereas chemotherapy and haematology services are covered by private health insurance in these centres, radiotherapy has MBS item numbers and the service is available to all patients. Being located close to public hospitals in these locations, it is not surprising that Mark said they were having “conversations” around establishing public-private partnerships. “We’ve been very active in the PPP radiation oncology space in Australia for many years in Queensland and so we continue to have that conversation with the relevant health areas.” “We think that’s a great arrangement. It ensures that public patients can access care close to home and it also in the long run saves the people of Western Australia a significant amount of money,” he said. While there are no formal contracts, Mark said clinicians working at the WA Icon centres also attended multi-disciplinary meetings at both Midland and Rockingham hospitals. “So, there is a lot of collaboration and there is a lot of cooperation. We’re working with all key stakeholders to ensure that patients can access care close to home and judging by how busy those sites are, I think we’re achieving that.

By Jan Hallam .

Over the past two years, Icon has opened radiation oncology centres in Midland and most recently in Rockingham. Icon, as GenesisCare, has a strong national and international profile. Where GenesisCare has expanded to the UK and Spain, Icon has looked to New Zealand and Asia, with centres in Singapore and China. In WA, Icon has moved to the expanding health hubs of Midland and Rockingham, which Mark said was to improve patient

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Eye Movement Desensitisation and Reprocessing Claire Kullack is a practitioner and trainer of EMDR. She tells us about its use in PTSD. This evidenced-based psychotherapy is internationally recognized as ﬁrstline treatment for Post-Traumatic Stress Disorder (PTSD) and has been heavily researched with over 20 controlled studies since 1989 showing that with EMDR the symptoms of PTSD are decreased or eliminated for most patients. PTSD may develop as a consequence of exposure to life-threatening traumatic events such as armed hold ups; physical, sexual and emotional abuse; medical traumas; natural disasters; accidents; or conflict. It is characterised by reexperiencing, hyperarousal, and avoidance symptoms. How EMDR works, in a nutshell EMDR allows a traumatic memory to be released, desensitized, processed, and resolved. It involves an eight-phase treatment protocol, guided by Shapiro’s Adaptive Information Processing (AIP) model, which carefully prepares the patient to safely connect with all elements of their memory—sensory, cognitive, somatic, and emotional components. Bilateral stimulation and dual attention is maintained throughout, hence the patient has one foot in the trauma (past) and one foot in the present, with the understanding they are processing an old memory, and not reliving the trauma.

The bilateral stimulation is thought to reactivate the trauma survivor’s natural information processing, thought imbalanced at the time of the trauma and thus impeding integration of the traumatic experience into memory. The bilateral stimulation (e.g. eye movements) is used until the memory becomes less disturbing and is associated with a positive thought and belief the patient has about themselves.

“recalibration” of the brain and body removes the persistent sense of danger the trauma survivor experiences. For the future EMDR is being evaluated for Acute Stress, Substance Use, OCD, Phobias, Psychosis, Depression, Anxiety, Personality disorders, Complicated Grief, Chronic Pain, Eating Disorders and Disturbing Memories. For effective use in children, modified EMDR protocols are necessary. Finding the right EMDR practitioner

The number of EMDR sessions required depends solely on the individual’s ability to process.

Reduction is possible if the patient has been prepared with psychoeducation plus grounding, self-soothing, and emotional regulation exercises, often part of the early phases of EMDR treatment. The end result The trauma survivor has reduced PTSD symptoms, and the unpleasant emotional charge and accompanying negative somatic sensations are removed.

EMDR is an advanced psychotherapy requiring a high level of skill. A mental health background helps so that psychiatrists, psychologists, social workers, occupational therapists, counsellors and mental health nurses who have done EMDR training are your first port of call. Certified EMDR therapists are located at https://emdraa.org/find-anemdr-therapist/. EMDR is endorsed by over five reputable international organisations that include the National Health and Medical Research Council (2007) and the US Department of Veterans Affairs and Department of Defense (2004).

The trauma image, once vivid, now appears foggy or distant with the trauma memory being perceived and felt as a historical rather than current event. This

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Silence of the Violence Women continue being murdered at the hands of current or former partners. Kedy Kristel looks at the role of non-fatal strangulation as a marker to future violence. A West Australian research paper on Non–Fatal Strangulation (NFS) has inspired a campaign by the WA Women’s Council for Domestic and Family Violence Services (WCDFVS). Non-fatal strangulation in sexual assault: A study of clinical and assault characteristics highlighting the role of intimate partner violence* highlights that there may be no visible signs when it comes to non-fatal strangulation. A US review paper in 2014 found the use of strangulation was often not to kill a partner but to let the victim know the perpetrator could kill them easily. • The use of strangulation is often not to kill a partner but to let the victim know the perpetrator could kill them very easily. • Of women who experience Intimate Partner Violence, 10% experience nearfatal strangulation. • Any deliberate action which has restricted the victim’s breathing just for a few seconds is non-fatal strangulation. • Strangulation in 50% of victims does not leave visible injuries but still may cause brain damage or internal injuries that may reveal themselves later.

• Strangulation is one of the strongest indicators for a significant increased risk of being killed by a violent partner. The Women’s Council has carried out a voluntary data collection between January to June 2018 from Women’s Refuges and DFV Specialist Services in WA to increase our understanding of the prevalence of NFS. All new DFV clients were asked: 1. Has your partner in the last 12 months put his/her hand/s (or other item) around/across your neck and applied pressure to restrain you? 2. Has your partner ever put his/her hand/s (or other item) around/across your neck and applied pressure to restrain you? The data indicated that 284 women and six children had experienced NFS. Only 156 people had visible injuries, seven of the women were pregnant at the time and they were mothers to 585 children; 247 of these victims had experienced NFS in the last 12 months.

BNFS is a gendered crime, almost always the victims are female and perpetrators are men.

Despite the high risk NFS indications can often be minimised or missed by police and medical staff particularly if there are no visible signs of injury. Victims may describe the NFS in language that often conceals and/or minimises the violence of the perpetrator’s actions. Currently the Criminal Code Act 1913 (WA) makes no specific mention of strangulation, but refers to violence of any kind in the commission of other offences. This charge covers offences where a perpetrator has used strangulation to restrain a victim for the purpose of sexually assaulting her. The new Family Violence Restraining Order legislation does not mention NFS. The Women’s Council is advocating for stand-alone legislation on this issue. There is specific NFS legislation in the UK, 30 states of the US (May 2012), New Zealand and Queensland. NSW and South Australia are currently considering specific legislation. The benefits of standalone legislation include: • An accurate recording of an offender’s prior criminal history; • Better information for risk assessment for victims and their children; • A requirement for additional education and training of justice and health professionals and a focus on raising community awareness; • NFS is a greater risk to victims than stalking behaviour, for which there is specific legislation. The WA Attorney-General has sought a report on the need for such legislation and appropriate penalties. Prosecutor Gael Strack and Forensic and ED Physician Dr Bill Smock from the Institute on Strangulation Prevention in San Diego, in conjunction with the Red Rose Foundation (QLD) will hold a two-day NFS workshop in Perth on Monday and Tuesday, April 1 and 2, 2019. Contact: kedykristal@ womenscouncil.com.au to register your interest. ED: *Zilkens R, Phillips M, Kelly M, Mukhtar S, Semmens J, Smith D. (2016)

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Trends in pain medicine By Dr Roger Goucke, Pain Medicine Physician, SCGH Australia led the world when pain medicine first developed back in the 1990s, so one might expect us to be further ahead with managing persistent pain than we are. Pain medicine is an add on specialty with, anaesthetists, rehabilitation physicians, neurosurgeons, psychiatrists and general practitioners having been trained in Western Australia. We are lucky to have this wide skill set available to help manage patients with chronic or persistent pain. Chronic or persistent pain should be seen as a chronic disease, managed but seldom cured, with most patients manageable in the general practitioner setting. Pain is a strange condition because it cannot easily be measured and is so variable – both between patients and within any one patient. It is a complex sensory and emotional experience. Because all pain is in the brain it is essential we don’t forget to manage this. The commonest complaint of patients seen in public (and private) pain clinics is chronic back pain. While the source of the presumed nociceptor is often sought, it is often hard to identify and even if one is found it is hard to treat. Many patients have had “successful” surgery but still have bothersome pain, and many patients have had multiple spinal injections yet continue with pain and poor function.

What to do? Engaging patients experiencing poor tolerance of pain and poor function is difficult. However, if appropriate expectations can be set (less pain, not no pain), then education about the causes of pain and sensitisation of the nervous system, together with involvement in a paced (a little bit, often) exercise program, and minimising medications (reduce or cease pregabalin and opioids) to improve cognitive function, progress can be made. More complex patients often need more support and education with additional non-drug coping strategies (best presented in a group-based setting). These more intense programs are usually only available in groups in the public sector because of the limited funding in the private/Medicare funded arena. Waitlists at the three pain clinics in Perth RPH, FSH and SCGH, are much improved over recent years and access should be possible within 6 to 9 months (still very long though for someone with significant pain and distress!). What about opioids. In the 1980s and 90s opioids were to be our saviour, and although caution was sounded in WA (1,2), with the widespread false marketing of the slow release opioid products they took hold of the community.

Pain is a hard one to define and even harder to fix. The misuse of drugs is just one part of the story involving doctor, patient, and various other people. We are now battling with the consequences of; pain equals opioids and a lot of pain equals a lot of opioids. Medically prescribed opioids have caused many deaths in Western Australia especially when coprescribed with benzodiazepines. Opioid induced cognitive impairment (brain fog) - often not apparent to the individual, tolerance (increasing doses to get the same effect), hyperalgesia (pain sensation beyond what would normally be expected) and opioid induced endocrinopathy are also widely seen with moderate to high dose opioids. The anti-epileptic/anti-neuropathic agent pregabalin is now widely prescribed for persistent pain, with little evidence of efficacy. It has become a drug of misuse. Initially indicated for neuropathic pain (pain due to a lesion or disease of the somatosensory nervous system) it is being used for all difficult-to-treat pain (outside the PBS Authority indication). Patients often quite like pregabalin, maybe because of its sedative/anxiolytic effects, which may explain its popularity in the prison population. What about cannabis? Will these be our next saviour? With regard efficacy at reducing pain and improving function the jury is definitely in - there is no reasonable evidence! The Australian Government Senate have an alternate view and have semi-legalised “medicinal” cannabis in Australia so it is likely the jury will continue to be challenged! Further Reading 1. Goucke CR, Graziotti PJ. Painful lessons: opioids, iatrogenic dependence and professional standards. Med J Aust. 1995 Nov 6;163(9):503. PMID: 7476646 2. Graziotti PJ, Goucke CR. The use of oral opioids in patients with chronic non-cancer pain. Management strategies. Med J Aust. 1997 Jul 7;167(1):30-4. PMID: 9236757

Author competing interests: nil relevant.

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CLINICAL OPINION

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Back to the grass roots approach By Dr Max Majedi, Pain Medicine Specialist and Anaesthetist at SCGH When navigating the complexity of the human condition, it is inevitable we will come across concepts such as suffering. In pain medicine, suffering is the ultimate end result. By the virtue of its multidimensionality and increasing sociological, psychological confounders and amplifiers, on top of relatively simple afferent nerve signals, we face significant challenges for modern societies. Inevitably, this comes with a price of deterioration in mental health as well as poor adaption to the brave new world where our physical needs are in close grasp, whereas our needs for purpose and identity are left behind. When this is combined with cluster B and C personality constructs, in approximately 40% of patients with persistent pain, we are confronted with an emerging form of destructive chaos. In the recent years, advancements in social sciences, neuroscience and psychology, facilitated by advanced tools such as functional MRI and collaborative efforts from multiple diverse disciplines, we are closer to understanding what it is to be human. Pain and suffering is inevitable in one’s life’s journey, and simply numbing one’s senses with drugs or invasive interventions are not going to address the underlying

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generators of pain and distress. We have a better appreciation of the role of genetics, environmental and epigenetics forces on the nervous system. We also are increasingly aware that we may not be the true authors of our thoughts and emotions and that we are simply observers of our mind’s narratives. As a medical practitioner we are often called upon to address suffering and pain with blunt tools such as drugs and invasive interventions driven by aggressive commercial interest motivated by financial profits, that may simply numb the symptoms and do very little for the underlying causes and generators of pain. Indeed, the whole mechanism places rewards and reimbursement for interventions that can increasingly result in further suffering and complications downstream. Perhaps it’s time that we, as health care providers, go back to the grass roots approach of being healers. In that sense, we need to try to look at our patient’s suffering from the perspective of the human condition and promote the tools of resilience and prevention rather than simply numb the symptoms.

Dr Majedi, is perplexed about how we deal with pain and suffering and says simply numbing symptoms will not work. and unconscious biases. Reassuringly, perhaps for the wrong reasons, both the health care providers and the industry surrounding them are subject to more intense scrutiny. So we have an opportunity to regain grass roots principles of objective science, healing and prevention. Maybe a significant change of direction from status quo, but a necessary one, to ensure health care is globally sustainable, equitable and not just yet another mechanism for a few to profit from.

Author competing interests: nil relevant.

To achieve this, we also need to acknowledge our own short comings as humans; we too are subject to conscious

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Chronic daily headaches: a transformation By Prof Eric Visser, Churack Chair in Pain Medicine UNDA & Pain Science Joondalup Risk factors for CDH are summarised by the 5Fs: Frequent analgesic use (two to five fold risk), Fearful (anxiety, stress), Female (four fold), Forties (middle-age), Fat (overweight, fivefold risk). Other risk factors include sleep disturbance, OSA, smoking, Caucasian race, family history and low socioeconomic status. CDH is essentially a ‘transformed’ (‘sensitised’) form of precursor headache, usually migraine, or a tension-type headache (TTH) or cervicogenic headache (e.g. post-whiplash) and more rarely, cluster-vascular headaches. There is a rare form of CDH known as ‘new daily persistent headache’ which usually affects young adults without an obvious cause (viral illness or stressful life events are implicated). NDPH is typified by patients remembering the exact time and circumstances of onset, even years later. The phenotype of CDH is similar to chronic TTH (diffuse ‘whole-of-head’, dull, aching,

pressure, occasional nausea and sensory sensitivity) with some of the features of the precursor headache. CDH nearly always leads to medication overuse headache (MOH) (analgesia use on at least 10 days per month) which worsens CDH in a vicious cycle. Medications include triptans, opioids (e.g. codeine), sedatives, ergots, NSAIDs and caffeine. Patients may try to prevent their headaches by taking analgesics pre-emptively (aka withdrawal headache). Management principles A multidisciplinary approach is required to manage CDH, particularly clinical psychology to deal with anxiety, stress and habitual medication-use behaviours. Management is difficult with a relapse rate of 30-50%, particularly with outpatient treatments. It helps to inform about CDH and MOH. Exclude headache ‘red flags’ (‘TINT’: Tumour, Temporal arteritis, Intracranial pressure [high or low], Inflammation

Affecting 5% of people, chronic daily headaches occur at least 15 days per month and are debilitating, affecting work and frequently leads to medication overuse. [meningitis], Neurological deficits, Trauma). MRI or CT cranium, lumbar puncture and manometry or ESR/CRP may be required if ‘red flags’ indicate a need. Consider other causes of CDH including cervicogenic (post-whiplash), sinus, facial pain/TMJ, trigeminal neuralgia and ophthalmic. Identify and manage ‘yellow flags’: psychosocial stressors, anxiety, sleep, substance and medication-overuse behaviours. Treat the original precursor headache (nearly always migraine) using amitriptyline, topiramate (migraine) or botulinum toxin injections (chronic migraine). All patients

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CLINICAL UPDATE

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CLINICAL UPDATE

Abdominal pain in children â&#x20AC;&#x201C; the difference By Dr Colin Kikiros, Paediatric Surgeon, Joondalup Pain origin is usually intra-abdominal. However, consider extra-abdominal causes such as pneumonia, tonsillitis with mesenteric adenitis, migraine, or torsion of a testis (male patient - always examine the testicles as a torted testicle can be saved if corrected within six hours of pain onset.) Groin examination is required in both sexes to look for an incarcerated hernia. Appendicitis is a very common cause of abdominal pain, typically commencing in the umbilical region and moving to the right iliac fossa. Vomiting and anorexia may occur. There is usually involuntary guarding in the right iliac fossa. A mild temperature is usually present, as is a raised white cell count and CRP. When in doubt, an abdominal ultrasound can help in diagnosis and if the appendix cannot be visualised, CT scan with oral contrast can assist in the diagnosis. A differential diagnosis is urinary tract infection.

Colicky abdominal pain may occur with constipation. The usual examination finding is tenderness but no guarding. Faecal masses are usually palpated and plain abdominal X-ray shows faecal overloading of the colon. Colicky pain also occurs with renal colic. Haematuria, either gross or microscopic, is usually present and the diagnosis is confirmed on ultrasound. If ultrasound fails to

KEY MESSAGES Most abdominal pain in children subsides within 12 to 24 hours with no cause found. Appendicitis is a common reason why children require surgery. Always examine the testicles in males presenting with abdominal pain.

Children have abdominal pain for mostly non-serious reasons. Duration >12 hours gets alarm bells ringing. Some younger children are reliant on a caregiverâ&#x20AC;&#x2122;s history. Some common childhood conditions are uncommon in adults. show the stone, it will normally be visualised on abdominal CT scan without contrast. Another common cause of colicky abdominal pain is gastroenteritis. Some viruses can cause abdominal pain and vomiting without diarrhoea. The abdomen is usually generally tender but not distended and there are no masses. Send stool for M.C and S and ova, viruses and parasites. Malrotation and volvulus, a surgical emergency, is associated with bile stained vomiting and confirmed with upper gastrointestinal contrast study or ultrasound. Intussusception typically occurs in the two to 24 month age range and often presents with colicky abdominal pain, pallor and vomiting and later red currant jelly stools. Females may have ovarian pain from volvulus or ovulation and they can also experience period pain. Chronic abdominal pain may be caused by lactose or fructose intolerance. On questioning, it may become clear that the pain is associated with the ingestion of dairy products or fruit. Breath hydrogen testing is non-invasive and usually very helpful. Gluten intolerance is also common and the diagnosis can be made with a blood test. If either of these conditions is suspected, referral to a Paediatric Gastroenterologist, for consideration of endoscopy, is recommended. Author competing interests: nil relevant disclosures. Questions? Contact the editor.

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Chronic daily headaches: a transformation with CDH should have at least one trial of GON (Greater Occipital Nerve) blocks. It is essential to manage MOH by dose tapering and cessation. Start a medication and headache diary. Try outpatient tapering in a motivated patient (amitriptyline and 10% dose reduction per week). Inpatient

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management for patients who canâ&#x20AC;&#x2122;t taper at home or at risk of headache flare-up or withdrawal: Five-day admission for GON blocks, amitriptyline, metoclopramide, prednisolone, IV ketamine and rescue analgesia (cranial TENS, indomethacin suppositories, clonidine, ondansetron, lorazepam or clonazepam). Opioid

withdrawal may need to be managed concurrently. Relapse prevention where possible and frequent follow up is vital. Author competing interests: nil relevant disclosures. Questions? Contact the editor.

MARCH 2019 | 29

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CLINICAL UPDATE

Difficult Conversations: Reducing or Stopping Opioids By Dr Richard O’Regan, Next Step Drug & Alcohol Service In recent years, much as been written about opioid medication in the treatment of chronic pain and its potential harm. Questions have been asked about the evidence base for long term opioid use. Demonstrated efficacy is modest, and long-term effectiveness is far less clear. Observational studies have shown that patients with chronic pain who take longterm opioids have worse pain and lower quality of life scores than those who do not. Opioid related deaths are increasing worldwide and in Australia With these issues in mind, when prescribing opioids in the treatment of chronic pain doctors may feel a sense of conflict between wanting to humanely treat pain and yet do no harm to the patient. Opioid availability should be limited in the interest of patient safety and for public health if aberrant behaviours emerge, e.g. self-escalation of dose, multiple early script renewal presentations, or if medications are reported “lost” or “stolen”. Can we be patient-centred and avoid the pitfalls of prescription abuse and dependence?

while those at ‘high risk’ should be discussed with an addiction medicine or pain specialist. 4. Consider a written treatment agreement – documenting issues such as dosing limits, remaining with a single prescriber, scripting boundaries and appointment attendance. 5. Monitor for opioid overuse e.g. early requests for repeat prescription, selfescalation of dose, or attending other doctors for additional medication. If overuse is occurring, restrict access by increasing the frequency of medication collection (i.e. to weekly, twice weekly, or daily pickup). While unpopular with patients, staged dispensing may address the issue of loss of selfcontrol, and will reduce the impact from medication loss, theft or bartering for other drugs. 6. Consider urine drug screening to monitor for illicit drug use that might harm patients. If detected, liaise with an addiction medicine specialist.

To prevent opioid prescribing ‘killing people with kindness’ and where the doctor has problems separating physical addiction from emotional anguish - these notes will help. Enhancing the patient's confidence to cease opioid use is important and may be achieved by discussing and normalising the process. Describe opiate withdrawal, and make sure the patient is aware that small dose reductions, say weekly, will minimize the effects (otherwise, abrupt opioid cessation causes discomfort so the patient may avoid further de-prescribing efforts). References available on request

Competing Interests Statement: Nil relevant. Questions? Contact the editor.

The things we can do It is useful to remember that all chronic pain commences as acute pain, and all long-term opioid prescribing begins as short-term use. Employing a “universal precautions” approach to the use of opioid medication provides a framework for the prescriber by which overuse, addiction and overdose death may be lessened. Here are some ideas: 1. Explain that opioid medication will not remove all pain, and discuss non-medication components of the management plan (e.g. activity pacing, weight control, physical therapy). 2. Managing pain includes teaching and supporting the patient to live with the pain while achieving best function possible. This means dealing with the mental health aspects of chronic pain (i.e. depression, anxiety, anger, frustration and loss). 3. Adopt safer prescribing practices when prescribing opioids in all circumstances, because the early features of opioid misuse can be difficult to recognise; The Opioid Risk Tool (Webster) may assist - patients at ‘moderate risk’ warrant background checks with the Medicines and Poisons Regulations Branch (9222 6883) or the Prescription Shopping Information Service (1800 631 181),

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“Can we be patient centred and avoid the pitfalls of prescription abuse and dependence?”

MARCH 2019 | 31

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Beyond opioids – a guide to treating chronic pain By Dr Michael Veltman, Pain Specialist, Joondalup The WHO’s 1986 pain ladder depicted a three-step process to treat pain starting with non-opioid analgesics (NSAID’s, paracetamol), then weak opioids (codeine, tramadol), then strong opioids (hydromorphone, oxycodone, fentanyl). This was intended to improve control of cancer pain, which was and is limited in many areas of the world. Understanding the context Although designed for cancer pain, it has been interpreted as a three-step protocol for general mild, moderate and severe pain. This became the basis of treatment for many acute pain services in the 1990s, with great success for post-surgical pain. Encouraged by this success, opioids have been increasingly used for severe chronic pain. This has led to a first world opioid epidemic and increasing toll of human lives from unintended prescription drug (mainly oxycodone and fentanyl) deaths. In Australia, opioids were responsible for over 1100 deaths per year, having tripled in a little over fifteen years. This leaves practitioners in a very difficult situation. Chronic pain is very common, and often starts from an acute episode which responds well to opioids. What starts as an effective treatment leads to tolerance, dose escalation and increasing harm to the patient, including a paradoxical worsening of pain (opioid induced hyperalgesia) and, death.

KEY MESSAGES Opioids have a role in cancer and acute pain but are associated with increasing mortality in higher doses. Chronic pain requires multidisciplinary assessment. Targeted medications and procedural interventions all have a role. Firstly, review medically, including all analgesics and integrate with a team based approach. Paracetamol is often ineffective but if there is a benefit, keep below 4g/day. NSAID’s – Celecoxib (if effective for that patient) has a good safety profile for longer term use. Discontinue if not helping pain. If opioids are used, avoid where possible opioids associated with increasing numbers of deaths (oxycodone, fentanyl in particular). Atypical opioids such as tapentadol and tramadol have antineuropathic effects, mostly due to noradrenergic reuptake inhibition, and have been less associated with opioid related deaths.

When a pain is persistent, the focus needs to change from just increasing opioids.

Keep opioid doses below 90 mg/day of morphine equivalent as per WA health guidelines. If the pain has neuropathic qualities (burning/electric shock/painful cold) then antineuropathic agents (gabapentinoids, serotonin/nor-adrenaline reuptake inhibitors or low dose tricyclic antidepressants) can also be trialled. They all carry significant side effects but can provide substantial pain improvement with neuropathic pain.

A graded approach based on SAFE principles is an alternative approach that balances risk and benefit.

Review allied health input; physiotherapy/ exercise physiology to restore and/or maintain function. Teach pacing strategies to

Managing persistent pain

Patients becoming dependent on opioids is a situation everyone tries to avoid. What are the alternatives? avoid boom/bust type behaviours. Clinical psychology review to learn coping strategies for persistent pain anxiety management. Physical interventions If the above is not helping, minimally invasive options are targeted lower risk procedures that include: joint and nerve blocks and steroid injections, neurotomy/ rhizotomy, Botox/ketamine infusion/ lignocaine infusions. Procedural interventions are generally low risk and especially suited to the elderly not tolerating medical therapies. They can provide low risk alternatives in a number of areas. Geniculate nerve rhizotomy for knee osteoarthritis provides an alternative for the elderly patient who might not tolerate arthroplasty. Consider major interventions when other measures have failed. For example, joint arthroplasty, or carefully selected back surgery for radicular pain. For axial back pain, and several other pain conditions, neuromodulation has high level evidence of its efficacy. The non-responders A group remains who do not respond within standard risk-benefit guidelines. Attempts to “fix” their pain, while well intentioned, have led to a rising number of deaths from high dose opioids. Use caution and fully inform patients of risks before using a treatment that lacks strong evidence base. Non-responders will understandably be searching for new treatments, and often find them. These include various off-label medications, cannabinoids, and procedures not well established. Pain is important and it is unlikely there will ever be a single “cure” that works for everyone. For non-responders, our role is to explain the risks, to expand the evidence for new treatments, and avoid doing more harm than good with well-meaning intentions.

Author competing interests: nil relevant disclosures. References and questions? Contact the editor.

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MARCH 2019 | 33

Understanding PET By Dr Nat Lenzo, Nuclear Physician, Palmyra Positron emission tomography (PET) was commercialised in the 1980s with the acquisition of CTI Molecular Imaging by Siemens, and the activities of Philips, General Electric and suchlike. PET is now a standard imaging test in mainly oncological conditions for which fluorodeoxyglucose (FDG) is the principal tracer. FDG tracer It works on the principle of increased use of glucose by many tumours and FDG is a short-lived tracer with a 2 hour halflife that requires a cyclotron to produce

the Fluorine-18 component of this radiopharmaceutical. FDG PET is now ‘standard’ in preoperative staging for lung and head and neck cancers and is used extensively in staging lymphoma and melanoma as well as in a number of other conditions (Table 1). There has been a worldwide explosion in this technology. In 2002, a group of dedicated Perth physicians and physicists established the first PET scanner in WA Health at Sir Charles Gairdner Hospital. In 2010, then followed the first private PET CT camera at Hollywood Private Hospital. In 2018, there were PET-CT scanners in central Perth (3

Table 1: Medicare-approved indications for FDG-PET* ONCOLOGY Diagnosis Staging Restaging for suspected recurrence Biopsy guidance Evaluation of residual structural lesions Assessment before definitive oncology surgery OTHER CONDITIONS Epilepsy Myocardial viability

PET imaging is being revolutionised and technological advances are at the forefront of what is happening. public, 3 private), 2 in outer metropolitan Perth (Joondalup and Rockingham) and 1 in regional WA (Bunbury) - part of the 80+ network throughout Australia. There is a growing evidence that FDG PET can be used in many more indications than what is currently covered by Medicare. In many developed countries it is reimbursed for such conditions as staging and restaging of breast cancer and pancreatic cancer, as well as non-oncological indications such as investigation of PUO, vasculitis assessment and dementia assessment. Major recent advances in PET imaging

Solitary pulmonary nodule that cannot be pathologically characterised or biopsied, and metastatic squamous cell carcinoma in cervical nodes with unknown primary Non-small cell lung cancer, cervical, oesophageal, gastric, head and neck carcinomas and lymphoma Epithelial ovarian carcinoma, lymphoma and head and neck carcinoma Primary brain tumours and bone/soft tissue sarcomas Primary brain tumours, colorectal carcinoma, sarcoma and lymphoma Apparently isolated liver or lung metastasis in colorectal carcinoma, apparently limited metastatic disease in melanoma

Evaluation of refractory epilepsy being evaluated for surgery where location of epileptogenic focus is not clear Prior to revascularisation in the presence of impaired left ventricular function when standard viability testing is negative or inconclusive

* only some facilities are eligible under Medicare

These relate to two technological advances: First, is faster and more accurate PET systems. Large gantry total body PET scanners (not in Australia yet) and fast digital PET-CT systems can acquire whole body images in under 5 minutes with much less radiation dose. As well, PET-MRI systems combine the metabolic information of PET with anatomic and metabolic information of functional MRI and MRspectroscopy (Figure 1 and 2). Digital PET CT systems are being installed over east with 3 PET-MRI systems operational there. All these systems show improved sensitivity down to 2-3 mm and the use of artificial intelligence (AI) algorithms are improving speed, reconstruction and image quality as well as improving reporting speed and minimising errors. Second, is new PET imaging tracers. Gallium-68 agents, produced by a generator and not by a cyclotron, are now manufactured and used in many public and

continued on Page 35

Figure 2. Gallium-68 PSMA PET – Recurrent disease in prostate bed and inguinal nodal metastases. Figure 1. FDG-PET MRI whole body image.

34 | OCTOBER 2018

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CLINICAL UPDATE

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CLINICAL UPDATE

Is there a good diet for mental health? By Ms Jo-Anne Dembo, Principal Dietitian, North Perth The variety and availability of food in Australia continues to improve, however a lack of nutrients has been linked to mental, emotional and brain health. Research supports the benefits of applying nutrition to aid the management of mental health disorders. Integrating dietary intervention together with appropriate treatment can have positive outcomes for patients. Dietary advice is directed towards incorporating quality nutrient-dense wholefoods. Studies support the benefits of nutrition in reducing the severity of depression and anxiety. For example, Professor Felice Jacka (Deakin University) has identified that improving diet quality can improve mental health. Participants assigned to a dietary intervention group with increased wholefoods and reduced processed foods, fast foods and high sugar drinks had a greater reduction in depressive symptoms over the 12-week study period, compared with participants receiving social support [1]. Several dietary components have been linked to improved mental health, including omega-3 fatty acids, dietary fibre and

probiotics, amino acids, zinc, magnesium, vitamin D, and B vitamins, including folic acid (see Table 1). The key message from current research is that a nutritious diet with lean meats, fish, eggs, nuts, seeds, legumes, vegetables and fruits is best. This approach, together with avoiding regular intake of processed foods, fast-foods, high fat foods (especially trans fats), and refined sugars, improves clinical outcomes for mental health disorders. Omega-3 fatty acids, highlighted for their anti-inflammatory properties, have been indicated as a key factor in improving mental health. Conversely, a lack of omega-3 fatty acids negatively impacts both mood and cognitive ability.

Table 1. Key Nutrients and foods associated with improved mental health NUTRIENT Omega-3 fatty acids Dietary fibre Probiotics Amino acids Zinc Magnesium Vitamin D Folate B vitamins

EXAMPLE FOODS Nuts, seeds, oily fish such as salmon, sardines, anchovies and mackerel Vegetables, fruit, wholegrains, legumes, nuts and seeds Yoghurt, kefir, kimchi, sauerkraut, kombucha Lean meats, fish, eggs, nuts and legumes Lean meats, oysters, wholegrains, pumpkin seeds and nuts Nuts, legumes, wholegrains, leafy green vegetables and soy Fish, eggs, fortified margarine, fortified milk (vitamin D is mostly obtained from exposure to sunlight) Leafy green vegetables, legumes, wholegrains, brewer’s yeast and nuts Lean meats, eggs, dairy, wholegrains and nuts

Dietary fibre and probiotics are also associated with mental health improvement, mostly for the action of promoting healthy gut bacteria and production of short chain fatty acids. Sources of dietary fibre include vegetables, fruits, wholegrains, legumes, nuts and seeds, with 25–30 grams recommended daily to achieve the overall health benefits of fibre. Additionally, fermented foods such as sauerkraut, kefir and kimchi are associated with promoting healthy gut bacteria. The concept of the gutbrain axis comes into play, whereby a healthy gut improves mood and behaviours. Further Reading: Food and Mood Centre www.foodandmoodcentre.com.au International Society for Nutritional Psychiatry Research www.isnpr.org ARCADIA https://medicine.unimelb.edu.au/ research-groups/psychiatry-research/melbourneclinic-research/arcadia-nutraceutical-and-lifestylemedicine-mental-health-research-group Reference 1. Jacka FN et al, A randomised controlled trial of dietary improvement for adults with major depression (the “SMILES” trial). BMC Med. 2017; 15:23.

Author competing interests: Nil relevant. Questions? Ask the editor.

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Understanding PET private PET imaging facilities in the form of Gallium-68 dotatate (targets somatostatin receptors) and Gallium-68 PSMA (targets prostate specific membrane antigen). Over 40 sites around Australia now offer Ga-68 PSMA for imaging of prostate cancer patients - non-reimbursed imaging fast becoming the gold standard in re-staging prostate cancer patients or the initial staging

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of high-risk prostate cancer patients (Figure 2). Ga-68 dotatate, as of May 2018, is Medicare reimbursed for staging/ re-staging of neuroendocrine tumours, the gold standard imaging for this type of tumour.

F-18 ethyltyrosine for brain tumours, F-18 DOPA for Parkinson’s disease and F-18 amyloid agents for diagnosing early Alzheimer’s. Other cyclotron-produced Copper-64 imaging agents will soon become available.

There is also increasing availability of other cyclotron-produced fluorinated agents such as F-18 PSMA for prostate cancer,

References available on request.

MARCH 2019 | 35

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Nutrient deficiencies in mental health By Dr Sanjeev Sharma, Consultant Integrative Psychiatrist Research clearly points out benefits of nutrients in general wellbeing. Eating balanced nutrient- dense food and supplementation of all key deficits could provide the missing link to support mental health and wellbeing.

improving the GABAergic pathway resulting in improvement of mood disorders. Zinc supplementation can also improve the efficacy of antidepressant drugs by working synergistically to improve patient outcome. For optimal efficacy of zinc monitoring of blood levels is very important.

ZINC DEFICIENCY

More than three billion people worldwide are estimated to be deficient in key nutrients, while depression alone affects more than 350 million people. Certain nutrients provide positive benefits in mental health through neurochemical properties, even in the absence of clear deficiencies. Australian and New Zealand soil is known to be depleted of certain nutrients. Magnesium and zinc particularly so. Deficiency of fundamental minerals is on the rise with an estimated 50% of the global population at risk, including in developing countries. Nutritional deficiencies and an excessive intake of nutritionally deprived foods are now recognised factors for poor mental health; the converse is true. The role of nutrients in psychiatric disorders is further explained by a recent meta-analysis to quantify the nutrient deficit in first episode psychosis, and to identify which vitamins and minerals were related to outcomes. Dietary pattern and food choices show a strong correlation between nutrient deficiencies and mental health disorders. It’s not only Zinc, magnesium and selenium deficiency associated with mood disorders, but Vit B12, C, D and folate are also low in people with mental disorders. Several mechanisms are involved in the link between mental illness and nutritional deficiencies. Beside nutrient epigenetics, genotype differences can interfere with absorption of nutrients (such as folate) in our system, which can in turn affect phenotype expression. For example, clinical trials have proved that the bioactive form of folate,

Magnesium’s role Magnesium is vital in brain biochemistry and influences several neurotransmission pathways. Deficiency of magnesium can lead to personality changes, including apathy, agitation, anxiety, confusion, delirium and depression.

methyl folate, is readily absorbed by most people i.e. absorption is not dependent on the genotype, which can lead to significant decreases in schizophrenic and depression symptoms in some. Zinc helps in modulating the immune system and multiple aspects of immune health are linked to Zinc. Complex biological processes in the body need Zinc at multiple steps. Immune function and mood support have strong correlations with the levels of Zinc, which is actively used when there is increased wound healing and infection. Zinc and Mood Zinc is required by the nervous system – researchers have shown that active supplementation of zinc during major depression and anxiety, assisted improvement. Zinc boosts brain function by increasing the brain derived neurotropic factors (BDNF) in the hippocampus (highest storage point of zinc). On the other hand, low zinc levels increase N-methyl-Daspartate (NMDA) receptor activity leading to increased glutamate3 and the excitation and stimulation results in a decrease of GABA and mood decline. Therefore, zinc supplementation is very effective in

Magnesium is important in the body, especially nervous system where it acts as a cofactor and activator for number of enzymes. It is essential for maintaining normal body and brain function and the is the second most abundant intracellular cation, needed by every cell in the body. Ion channels are regulated through magnesium. Personality changes are strongly related to magnesium levels. Biochemical processes in the brain need magnesium and it is linked to intellectual and neuronal function. Mood and quality of life is affected in migraine sufferers and can be easily addressed by using magnesium supplementation where other treatments can be expanded and the severity and frequency of migraine attacks can be reduced. Nutrients often act in combination. In a recent review on Vit D and magnesium, according to the author, the health benefits of exogenous and endogenous vitamin D may not happen without adequate magnesium. Vitamin D homeostasis is maintained through magnesium. References available on request.

Author competing interests: Nil relevant. Questions? Ask the editor.

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38 | MARCH 2019

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Feet for a lifetime By Matthew Keating, Senior Podiatrist, Wembley Downs

By Mr Peter Ammon Foot Ankle & Knee Surgery

The mobility of our ageing Imagine waking up tomorrow and find population is important. What it difficult to walk, happens when something goes or you suffered wrong with the feet? immense pain in your feet with any extended walking. Daily life becomes a challenge with even the simplest of tasks. You park closer to the shop entrance to limit walking; your beloved pet looks at you in angst for not being walked as often; or your grandchildren leave you looking for the closest seat! By 80 years of age, most people take over 215 million steps, equivalent to over 250,000 kilometres! Our feet are the “work horses” of our body. Like the rest of the body however, the foot with all its bones and moving joints eventually wear out and stiffen. The ageing foot This is often attributed to “osteoarthritis”. As the arthritis worsens the joints may exhibit stiffness, pain or even noticeable deformities. The foot joints are engineered to take our body weight during standing and movement. This intricate design allows weight (as a load) to start at the heel when it hits the ground and smoothly flow through the foot until it leaves the ground (or toe off).

Plantar fascia origin

With time, foot joints are more likely to develop osteoarthritis simply due to the excessive amount of work they perform throughout our lives. Functional orthotic insoles are a very useful, especially when managing osteoarthritic changes in the feet. The primary Welldesigned orthotics in these circumstances, can literally change how much loading certain joints take when weightbearing. Redistributing forces in joints, generally relieves pain and stiffness from osteoarthritis. CASE REPORT: Joan aged 74 years still enjoyed 3-4 rounds of golf per week. Over the last couple of years, she had progressively lost the ability to walk the golf course due to painful feet and she spent more time in a motorised golf cart, whereas walking the course was part of her love for the sport. Her quality of life was declining. She trialled various medications without much success. X-rays and various assessments by the podiatrist showed problems. The x-rays showed degenerative changes in some of the mobile foot joints, explaining why these joints were painful with use. Joan’s walking on video showed these joints moved excessively because her walking style was due to flat feet (ankles roll inwards, arch collapses below a normal threshold). Functional orthoses controlled some of the excess movements as well as supporting the arthritic joint zones. She was told to wear them during golf and as desired any other time. Within weeks she was walking the golf course with minimal pain. Author competing interests: No relevant disclosures. Questions? Contact the Editor.

MR PETER AMMON St John of God Medical Centre Suite 10, 100 Murdoch Drive Murdoch WA 6150 Telephone: (08) 6332 6300 Facsimile: (08) 6332 6301 www.murdochorthopaedic.com.au Murdoch Orthopaedic Clinic Pty Ltd ACN 064 146 774 ABN 23 070 745 210

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Opiate contracts – useful or a piece of paper? By Dr Rupert Backhouse, General Practitioner, Mandurah Opiate contracts would typically include documentation of which pharmacy the patient agrees to use, the intervals between picking up the medication and an understanding that lost or stolen medication will not be replaced. The use of such a contact can ensure the doctor is compliant with the health department, sets clear boundaries for the patient, protects the doctor from demands by the patient and facilitates continuity of care between doctors in the same practice if the main prescriber is not available. Despite such benefits opiate contracts are not commonly used outside an opiate substitution program. Reasons for this will include the time needed to complete the contract, patient resistance, a sense that the doctor does not trust the patient and thus impair the doctor/patient relationship, the resistance by the doctor for more paperwork and a belief that an opiate contract is ‘just a piece of paper’.

The health department rarely demand an opiate contract for people unless there has been evidence of medication misuse or is on a high dose of opiates. In these circumstances having an opiate contract not only satisfies the demands of the authorisation to prescribe but makes it much easier to implement tighter control if addictive behaviours emerge. A simple therapeutic relationship can be maintained (despite such contracts) if the doctor tries to provide whole person care and not focus on the opiate alone. We are increasingly inundated by forms from multiple agencies (e.g. hospitals, Centrelink, housing agencies, employers etc). To then take time to complete a contract for someone well known to the GP and who has never exhibited any drug seeking or addictive behaviours can seem a waste of time and the contract becomes ‘just a piece of (unwanted) paper’. Fortunately, this such patients are common in General Practice.

Opiate contracts may be demanded by the health department when issuing an authorisation to prescribe an opiate. What are they? Are they worth it?

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However, if a patient does begin to show such behaviours, a contract helps the patient and protects the doctor. Giving a patient a drug of addiction, without boundary setting as part of the overall care, is colluding with the patient’s illness. If the patient is unwilling to accept the conditions, the doctor can be confident of having tried their best to help the patient. Opiate contracts are usually of no use but occasionally can be very useful, like so many pieces of paper.

Author competing interests: nil relevant disclosures. Questions? Contact the editor.

Wine winner

US STUDENT REPLIES TO AN EXAM QUESTION ON HELL

Now, we look at the rate of change of the volume in Hell because Boyle's Law states that in order for the temperature and pressure in Hell to stay the same, the volume of Hell has to expand as souls are added. This gives two possibilities: If Hell is expanding at a slower rate than the rate at which souls enter Hell, then the temperature and pressure in Hell will increase until all Hell breaks loose. Of course, if Hell is expanding at a rate faster than the increase of souls in Hell, then the temperature and pressure will drop until Hell freezes over. So which is it? If we accept the postulate given to me by Teresa Banyan during my Freshman year, "...that it will be a cold day in Hell before I sleep with you." and take into account the fact that I still have not succeeded in having sexual relations with her, then, #2 cannot be true, and thus I am sure that Hell is exothermic and will not freeze.

40 | MARCH 2019

Farah lists a hearty Riesling as her favourite wine while according to Wine Master Dr Craig Drummond the Chardonnay was his pick of the Windows Estate wines. For her best wine experience she remembers a lazy summer's luncheon in a vineyard, followed by a wine tasting and laying with her husband in the cool shade while her children played in the adjoining gardens! It sounds like the Swan Valley somewhere. For these winning wines she has visions of enjoying them on a picnic rug by the river, a blue horizon with black swans gracefully gliding by, and “enjoying the rustling of the leaves as the breeze engulfs us”.

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First, we need to know how the mass of Hell is changing in time. So we need to know the rate that souls are moving into Hell and the rate they are leaving. I think that we can safely assume that once a soul gets to Hell, it will not leave. Therefore, no souls are leaving. As for how many souls are entering Hell, let's look at the different religions that exist in the world today. Some of these religions state that if you are not a member of their religion, you will go to Hell. Since there are more than one of these religions and since people do not belong to more than one religion, we can project that all souls go to Hell. With birth and death rates as they are, we can expect the number of souls in Hell to increase exponentially.

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WINE REVIEW

Evans & Tate Wines Businessman Peter Fogarty and his family began their venture into wine in 1996 by establishing Millbrook winery and vineyard on the old Chestnut Farm in Jarrahdale. Four years later a leap to the Hunter Valley saw the purchase of the highly prestigious Lakes Folly in Pokolbin, Australia’s first boutique winery created by Dr Max Lake in 1963. Expansion into the Yallingup sub district of Margaret River area came with the acquisition of Deep Woods Estate in 2005. Further expansion occurred in 2010 with the purchase of Smithbrook estate in Pemberton.

The purchase of Evans and Tate from McWilliams in 2017 cemented the Fogarty Group’s presence in the heart of Margaret River. The Redbrook vineyard in Wilyabrup began to be planted in 1975 by John Evans and John Tate, making it one of the oldest pioneering estates in the region. It therefore comes as no surprise that the group has a very large wine portfolio with many diverse offerings. Quality overall is high and at the top end of the range there are some stunning wines that compete with the best in the world.

By Dr Louis Papaelias

Evans & Tate Redbrook Estate Chardonnay 2017 ($40)

Evans & Tate Redbrook Estate Shiraz 2016 ($40)

A very modern chardonnay with a hint of “struck match” character lending to an attractive merger of stone fruit, florals and a touch of toast. Attractive right now.

As expected, a step up in quality from the Gnangara. Here the depth of Margaret River shines through giving the wine some character and personality. Black fruits and spice are evident in the suppleness on the palate. Lovely now but will keep.

Evans & Tate Gnangara Shiraz 2017 ($13) Once the flagship of the original Swan Valley property of Evans and Tate this is now a multi-regional blend. Made for current consumption it is an ideal barbeque red. Full of juicy spicy plummy flavours it is a well-made easy drink especially if cooled to around 18 degrees, a must in our summer climate.

Evans & Tate Redbrook Estate Cabernet Merlot 2016 ($40) Attractive aromas of black fruits with a touch of earth, olive and green leaf. Again, the word “supple” comes to the fore, a feature of Wilyabrup Cabernet. Tannins are firm but fine and ensure the wine will keep and improve.

Evans & Tate Redbrook Reserve Chardonnay 2014 ($65)

WINE TASTER'S

PICK

Hats off here! At five years of age it has a very youthful feel, the acidity invigorating all the disparate elements of wild yeasts, barrel fermentation and malolactic inhibition have come together, softened and allowed the crisp stone fruit to come forth. The fruit, above all, shows itself and continues into the long aftertaste The label is festooned with medals and it’s easy to see why.

MEDICAL FORUM

MARCH 2019 | 41

Enter Medical Forum's competitions! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link. Movie: French Film Festival This year marks the 30th anniversary of the Alliance Française French Film Festival in Australia and the feast of films across genres will be a celebration of French culture and cinema. Films fall into self-explanatory categories from Paris Snapshots to Critically Acclaimed.

Play: You Know We Belong Together After the sold-out success of the 2018 world premiere of You Know We Belong Together, the play is heading back to Perth for an encore season. You Know We Belong Together is a story of love; a theatrical celebration of this incredible force of nature that can strike us like a bolt out of the blue. Co-creator and host Julia Hales offers a deeply personal story of her own experiences of love as a daughter (her father is retired orthopaedic surgeon Peter Hales), actor, dreamer and person with Down syndrome.

In cinemas, April 4

Movie: Wonder Park Wonder Park is a wonderland created in young June’s imagination, but is in serious need of renovation as June grows up. Here’s an animated feature that shows the power of creativity for every child to love. Featuring the voice talents of Jennifer Garner, Matthew Broderick and Mila Kunis.

Heath Ledger Theatre, March 20-31

Movie: Storm Boy – Dr David Graham, Dr Glenn Liew, Dr Michelle Hunt, Dr Jessica Maloney, Dr Maxwell Robert Weedon, Dr Megan Foster

M E D I C A L F O R U M $ 12 . 5 0

Winners from November

In cinemas, April 4

Movie: Destroyer

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GP Insights; Consumer Choice; Bottlenecks Thrombectomy for Stroke Exercise; Nocturia; Retinopathy

Movie: On the Basis of Sex – Dr Stanley Khoo, Dr Craig Schwab, Dr Christina Wang, Dr Maria O'Shea, Dr Yohana Kurniawan, Dr Michael Armstrong, Dr Fiona Sluchniak, Dr Barry Vieira, Dr Nicole Leeks, Dr Robert McWilliam Products and services are provided by BOQ Specialist - a division of Bank of Queensland Limited ABN 32 009 656 740 AFSL and Australian credit licence No. 244616. All finance is subject to our credit assessment criteria. Terms and conditions, fees and charges and eligibility criteria apply. BOQS001163

Movie: Pet Sematary Stephen King’s beloved horror novel Pet Sematary is returning after two children discover a mysterious burial ground in the woods near the family’s new home and the usual unleashing of “unfathomable evil” ensues.

Bringing to the stage the voices and aspirations of a community rarely heard, You Know We Belong Together is an uplifting tale of love, relationships, acceptance and belonging – and Julia’s life-long dream of appearing on Home and Away.

Is your equipment finance getting you all tangled up?

Palace & Luna Palace cinemas from March 13-April 10

MAJOR PARTNER

Movie: The Front Runner – Dr Mathew Carter, Dr Jane Weeks, Dr David Jameson, Dr Kylie Seow, Dr Claire Waters, Dr Kellie Thurloe, Dr Andrew Christophers

November 2018 www.mforum.com.au

When LAPD detective Erin Bell (Nicole Kidman) goes undercover with a gang in the California desert, things go terribly wrong and the consequences take decades to unravel. Lots of chatter about Kidman’s performance in this film. In cinemas, March 21

Theatre: Senior Moments

Musical Theatre: Madiba – Dr Sol Ceber, Dr Carol McGrath

John Wood, Max Gillies, Benita Collings and Geoff Harvey return to Perth after a successful tour last with their comedy review about old people and the young people who have to deal with them.

Music: Christmas With Marina Prior – Dr Katherine Creeper

Heath Ledger Theatre, April 10-17, MF performance, April 11, 1pm

42 | MARCH 2019

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