Paul Smith

“ But they started a domino effect in other

areas of healthcare, like mine, where you are facing stigma and discrimination.

“ It is still a very recent thing for us, the past 10 or 15 years perhaps. But it has echoed what hap-

career in the bin.

pened in HIV.

It was the early 1990s. Addiction medicine

“ We have got paid consumers working within

was not a recognised specialty, there was no clear

services, people with lived experience of the

training pathway, and drug and alcohol services

issues those services were dealing with.

back then sat well outside medicine’ s prestige

“ They have had a much greater say as to the

economy.

purpose of treatment, the aim of treatment and

Junior colleagues were openly horrified,

how we engage and connect with patients.”

Professor Lintzeris tells Australian Doctor.

They have also eroded( although cer-

“‘ You only work with drug users?’

tainly yet to eradicate) the moral judge-

“ But I was interested in that intersection

ments cast by society when it comes to

between criminology and medicine, and clearly,

the treatment of alcohol and drug

that touched on drug addictions.

addictions.

“ A position came up at a government drug

The other change has been the

and alcohol service in Victoria. I was curious, so

medications, a change Professor

I applied. It turned out I was the first and only

Lintzeris has played a leading

applicant, even though it was the third time they

role in bringing about and one of

had put out the advert.”

the biggest reasons why he was

Clean? As opposed to dirty?

He started work in 1991. Were these enlightened

one of the medical names in the Australia Day Honours list back in January— the wide-

times? No, not really, he says.

spread use of new treatments,

By 1986, Australia was officially wedded to

such as the long-acting injecta-

the concept of harm minimisation. In theory,

ble buprenorphine.

needle exchange programs were legal. In real-

This is not so much about rad-

ity, the treatment philosophy within the services remained deeply punitive.

“ There was a moral logic where, if you ended

ically new modalities in the medications themselves as seen in, say, oncology.

NEWSPIX

up in trouble with your drinking or drug-taking,

“ It is the development

well, that was your fault.

of medication that allows patients with addic-

“ There are more people in methadone and

“ You can’ t prescribe your way out of addic-

“ If you could not get clean, that was your

tion issues to be treated in the community just

buprenorphine treatment on any given day than

tion. And to me, that complexity— far from being

fault, too. Even the language we would often use reflected this mentality.

like any other person.“ These medications are safe, and they work

all other forms of treatment for drug and alcohol combined. That is a paradigm shift to me.”

a drawback— is the field’ s greatest strength.” Given the role of health’ s social determinants

“ Clean? What, as opposed to being dirty?

— treatments such as methadone and buprenor-

But enticing junior doctors to the so-called

on the lives of his patients, Professor Lintzeris

“ And if people did not get better, then under

phine, both medications used for either heroin

cinderella specialty? What is the pitch?

does not shy away from the politics. You suspect

the care model, you could be kicked out of the

addiction or chronic pain treatment.

“ You know, a lot of people say,‘ How can you

it would be impossible for it to be otherwise.

program. If you continued to use drugs or drink,

“ They allow patients to function, hold down

work with drug addicts? That must be exhaust-

He is blunt. The prohibition approach to drugs,

then you would be discharged.”

a job or stay home looking after the kids. You can

ing. You know they don’ t get better.’

still the dominant ideology, has failed.

This was strange medicine:“ Unlike epilepsy

be a bus driver, a teacher or a reporter for a medi-

“ Actually, our outcomes for patients are as

“ The whole premise of prohibition, the whole

or diabetes, addiction was treated as a problem of

cal magazine. That is something new.”

good as, if not better than, most chronic disease

fundamental philosophy underlying the axiom of

character rather than health.” What surprised him most, however, the thing that seduced him when it came to his chosen

The mad and bad

“ The dominant model of drug and alcohol,

outcomes. When was the last time a rheumatologist cured someone?”

He laughs as he says this, but the point is

prohibition is one of stigma and discrimination.“ You need to make the drug user‘ the other’. There are normal people, and then there are drug

vocation, was not the system but the patients.

historically, has been similar to mental health

serious.

users.”

“ They were rational; they were not psychotic; they were not mad, sad or bad. They were usually people just with a drug problem, and clinically, they were easy to work with because you have those conversations about goals, work, families and futures.”

He talks of two revolutions in addiction medi-

‘ You can’ t prescribe your way out of addiction. And to me, that complexity is the field’ s greatest strength.’

Chasing rather than healing

“ Decriminalisation does not change the narrative

, either. Yes, it is legal to use the drug, but it is illegal to buy it, and it is illegal for you to access it. So you still have to engage with illegal communities.

cine since he made it the heart of his professional

“ We have taken the approach that the best

life. One was witnessing what happened in the

models described by the philosopher Michel Fou-

“ Often, when chronic conditions do get better,

way to regulate drug use is to leave all manufac-

context of HIV medicine during the darkness of

cault: a means of protecting society from the

it is because they have resolved spontaneously or

turing of the drugs to criminal gangs. We will

the 1980s.

so-called mad and bad.

a surgeon came along and cut something out— to

then leave the marketing up to criminal gangs,

It, too, was marginalised, subjected to the

“ So as a drug addict, you need to be detoxed,

get rid of that inflamed gallbladder.”

and we will leave the distribution to criminal

deep prejudice of wider society against homosex-

cleaned and then you need to go to rehab.

So when it comes to the young generation of

gangs.”

uality and its entrenched moral prudery when it

“ I will send you far, far away because you

doctors, he says he tells them that addiction med-

Until the overriding ideology changes, he

came to sex.

need to be re-educated and reprogrammed

icine sits at the crossroads of everything medi-

says society is stuck in a punitive loop:“ Criminal

“ The’ 80s were pioneering for us,” Professor

before you can come back as a normal person into

cine claims to value.

gangs are profiting, and we are having to spend

Lintzeris says.

society.”

It is deeply clinical: you see patients, build

all this money in society chasing people because

“ The changes in HIV medicine were led by a

He says, when he started work in the sector,

relationships and make tangible differences. It is

they use drugs rather than healing them.”

politically savvy, well-connected group of activists who knew how to press the buttons; they knew how to make things work.

“ They were middle class and educated.

about 5000 people were in methadone treatment. Now, between 65,000 and 70,000 people are being treated in the community with methadone and buprenorphine.

also public health medicine, grounded in equity, social determinants and justice. It allows doctors to move between clinical care, research, teaching and policy.

Professor Lintzeris was awarded an AM in the Australia Day Honours list for his significant service as a clinical researcher in addiction medicine.