Kuala Lumpur - miscellaneous photos

It's my last night in Kuala Lumpur. I've arranged for a taxi to pick me up in time to get to the Kuala Lumpur International Airport. 2 hours before an international flight. An hour to get the 45 minute drive from here to the airport.  Tomorrow I fly the 2 hours and some to Siem Reap.  Angkor Wat , the Buddhist temple complex, is there. I'm not sure where I'm going to stay. Some hotel with a safe and wifi.  That's upscale. I didn't mind where I stayed when I only had a wallet passport and camera.  That was years ago. Now I worry about laptops, iPads, iPhones and cameras.  I've also been encouraged to hire a driver for the day.  It's a big complex.
I thought to go out tonight but ,after the conference ended, I came back to the hotel, ordered room service dinner and haven't moved since.  I'm actually watching television.  I tried getting to a meeting last night but only ended up in a dangerous part of town with junkies lying  on the street.
There's an exotic bird park and a butterfly place here. I'd have liked to have got to either those. I felt the same about the night safari in Singapore zoo.  There's things I'd like to do but I'm touristed out tonight and looking forward to early bed. I've packed and have a couple of hand washed shirts and shorts drying.
I'm actually missing home.  I'm looking forward to the next couple of days, more sights, being a tourist, "free man in Paris", the hope for more spiritual experience in a place of spirituality.  But already I miss my own bed, Gilbert, my boat, the routine, friends, the known.  I feel alien a lot in my life without being an actual alien. There's a desire to be more with people who are more like me, whatever that is.
I remember an old man who joined my father in the assisted living home. He'd been a farmer and enjoyed that he could talk about farming with Dad who understood him.  They talked about the weather.  Yet our similarities are our core. I know that.  I liked meeting the Malaysia catholic doctor and talking about spirituality.
I've a book launch too.  It's an accomplishment. I look at the pages, I've a copy with me, and enjoy what I've written. Already looking forward to the next book.  I'm looking forward to visiting family too.  It's a good life.  Full and rich and blessed.
Thank you Jesus.  Thank you God of Gods.  Saints of all religions I bow to you too.
ISAM is meeting in Japan next year, then Scotland.  I hope to be in Scotland before that.  There's an English doctors meeting next fall I've been planning on attending for a couple of years.  The boat engine needs fixing though.  Africa is waiting too.  I like all the Australians and New Zealanders I know.  Just when I'm growing weary with living out of a suitcase I'm remembering places I'd like to go to.
I think my mind is a little overloaded by all the learning these last three days.  There's a stretch that occurs with all the intellectual learning coupled with the gestalt experience of being in a foreign place.
On the other hand, I don't feel guilty I'm not exploring any further. I usually get these lovely hotel rooms and then spend so little time in them when I'm at a conference. Right now I'm watching Captain America, the Avengers,  Thor and a whole bunch of superheros protect the earth from annihilation on tv. I've cream sauce spaghetti with garlic toast on the way. I love room service.  All that is missing is Gilbert.  He's a great companion when there's room service.
I have a group of pictures I've taken while here that I haven't included.  They'll fit in right here.  I liked the Convent with the Motorcycle.  I liked the motorcycle paths that are here and there. I liked the MacDonald's too.  Parents taking pictures of their little daughter.  The two rivers meeting here.  Now I'm going to watch Alex Cross on tv. I've read the books.  Thank you God for the wonders and sights of this trip, the education, the organizers and contributors, the Armada Hotel and staff, keeping me safe.  Kuala Lumpur is an amazing city with so much diversity.  The people have all been so friendly and helpful.

An update on Naltrexone and Flumazenil in Polydrug and Alcohol Abuse - George O'Neil - ISAM 2013 Kuala Lumpur

Endorphin tolerance develops quickly and needed more
Eg. 42 yo man who was unable to sleep through night having to get up and smoke several times.  Gave naltrexone - patient described increased anxiety - using very small doses of naltrexone - all of these people stopped smoking completing - using naltrexone and benzo - little doses in the pre use phase and on chronic user putting big does of both drugs under skin.  Very different ways of using drugs.
Mellanby showed that tolerance developed with first drug
PHREE program - pharmacology and overall care
Accelerated detox 48 hour, versus 7 days detox. accelerated had 89% versus 30%
Moving patients to long acting implant naltrexone
Medications are to get people in quickest possible time into community and back to family
Norway study RCT- Implant trial,  Russian RCT with implants too
Implant Naltrexone is 25 times more efficient than oral natrexone at preventing opiate overdose dates in the  first 120 days post detox
Perth Overview
 4000 opioid patients
- average 8-10 month
 500 amphetamine patietns
500 alcohol patients
Flumazenil implant  used for benzodiazpeine addiction, with alcohol and other detoxifications, anxiety and sleeping disorders, parkinson's disease
Nasal delivery systems and sublingual for naltrexone and flumazenil.
Treating cravings of nicotine with naltrexone and flumazinel.  250 ug naltrexone


(These are my rough notes. I apologize for any errors. George was one of the most interesting speakers and one of the most experienced. His questions  and discussion after presentations was always most interesting. He had a number of Perth colleagues present as well. I had the pleasure of talking to several of the individuals and was impressed with their medical knowledge and their compassion for their patients.  There is really a place for this type of work and these solutions to specific problems. There's a terrific sense that this is tailored to individuals and their wants and needs rather than the one shoe fits all approach.  I was most impressed and would encourage anyone who can give serious consideration to these options for treatment. I will be discussing these studies with colleagues. )

Prevalence of alcohol, nicotine and hypnotic abuse in earthquake and tsunami stricken areas in Japan - Mitsuru Kimura - ISAM 2013 - Kuala Lumpur

It has been noted that alcohol and drug abuse increase after disaster. This study compared coast group and inland group.  Coastal groups had homes destroyed, most of damage done by tsunami rather than the initial earthquake.
Did interviews and standard questionnaire. 4.2% were seen as alcohol abuse.
Frequency of heavy alcohol use (more than 60 gram/da
Compared AUDIT scares , coastal and inland - difference not statistically signifiant.
Frequency of tobacco use higher in coastal group
Coast group, in female benzodiazepine use higher in coastal group
Benzodiazepine were mostly prescribed, with rare exception, for sleep or anxiety

Effects of Modafinil in a novel model of relapse to cocaine use - Richard Foltin - ISAM 2013 - Kuala Lumpur

Taking individuals who report heavy cocaine use and urine tests supports and we give them cocaine and study them . There is not a treatment component.
Binge pattern of use - we model effect - done periods of hours to days,
On average our guys 3-4 x a week, and spend $300 to $400 a week
We let people use a lot of drugs. Like they did on street in short period of time.  In other studies had used just one dose.
We did a study on Modafanil and showed it significantly reduced cocaine craving
Modafinil also shown to reduce the amount of money people were willing to pay.
Cost $5 to smoke cocaine,  We have them buy dose  of cocaine like on street from money earned in study.
Modelling relapse behaviour in the laboratory.
Playing game of bingo got money.  Had pressing computer bar 4000 to get does of cocaine.  In crease of the cost of cocaine and work didn't reduce the number of dose.
To look at relapse - gave free dose and there was a little increase
Modafinil given for 5 days.  This decreased cocaine use by about 1 dose - they were dosing 4to 6 time.
Modafinil didn't decrease cocaine use when it was cheap but it did when the cocaine was more expensive.  The effects are modest.
Modafinil can be used patients on Methadone
Pretty safe medication
If you drink alcohol modafinil doesn't work as all

 (These are my rough notes. I apologize for any errors. It was a deep discussion of a remarkable and elegant research design.  I was very impressed by the ingenuity of the researchers in setting up laboratory equivalents of the contextual reality of street cocaine use.  There is definitely a place for modafinil in the armamentium of addiction medicine. Another useful tool in the toolbox.)

Salome - Study to assess longer term opioid medication effectiveness - a progress report -Suzanne Brissette -ISAM 2013

European studies and the NAOMI trial demonstrated that prescribed heroin helped.
NAOMI - double blind validation of self -report illicit heroin use - hydromorphone
Patients appeared not to know that they were getting hydromorphone versus heroin
Treatment retention good, treatment response good.
- this lead to Salome

Hydromorphone has advantage of being a licensed drug in Canada versus
Selection criteria, 19 or over, 5 years injectable medication use, had two previous treatment, one an opiate agonist treatment
The Salome group mean 19 years use, 17 years injecting, 45 or older mean, 100% on welfare, $1500 a month - average welfare $800, indicates what they did to supplement drug use.
Right now patients are attracted to the program with possibility of getting heroin.  We know diacetylmorphine outcomes but we want to see if hydromorphone works as well.
Polydrug abuse was apparent at base line but we don't have ongoing studies as yet.

Imprisonment among opiate dependent patients on community based Medication Assisted Treatment - Norsiah Ali

This study looked at the reduction in re offence after being on methadone. It also showed that Malays were 1.5 x less likely to be re imprisoned.  165 patients out of 18,000.
In this country if you are found to have positive urine you would be put in 2 year observation, not being put in prison, but need to report monthly at police office.  If you had a positive urine and were caught with another positive urine you'd be put into jail..  Those under observation are first time offenders. We were only doing random monthly urine in our population.
There was a significant improvement in quality of life and reduction of stealing and physical assault.
None in program sero converted.
 
In the Question and Answer period people who had attended the off site prison treatment program yesterday