Medical Report (3)

Re: Wayne Douglas – Benzodiazepine Dependence

Prepared by: Dr. Graeme Judson, Clinical Director, Mental Health & Addiction Services, Taranaki District Health Board

Prepared for: Tokyo High Court

Date: 7 April 2010

Signature: Graeme Judson

Introduction

I understand there have been some discrepancies regarding the following:

1. The application of the DSM-IV-TR in relation to the evidence
2. Shortfalls in prescription doses
3. Possibility of anxiety disorder
4. Consistency of previous reports in relation to evidence (patient files)

Subsequently, this report serves to address each of these.

After having had the opportunity to view the transcripts of Wayne’s patient files that were provided to me by Wayne, I can confirm that the content of these files does not alter anything as far as maintaining the dependence diagnosis is concerned.

Before outlining the reasons why, I would like to take this opportunity to make it clear to all relevant parties that my objective regarding Wayne’s case is simply to determine whether he was dependent.

My objective does not involve diagnosing the cause of his original complaint, whether it be Sylvian Aqueduct Syndrome (indicated by Dr. X), or an “Acute Vestibulopathy” (suspected by Neurologists, Dr. K and Dr. Hutchinson), neither of which has any bearing whatsoever on the dependence diagnosis. In addition, I would like to make it clear that the argument over whether Wayne had an anxiety disorder (Autonomous Nervous Disorder) does not for grounds for ruling out dependence.

This report consists of 3 sections as follows:

1. Background Information
2. DSM-IV-TR & Patient Files
3. General

Section One is based on background information to give a better insight into the nature of Benzodiazepines and how dependence is formed and diagnosed.

Section Two is based fundamentally on the evidence in relation to the DSM-IV-TR Criteria.

Section Three is also based on the evidence, but includes rationale with regards to the disputes over the shortfalls in prescription doses, differential diagnosis etc. and other general information.

The reference numbers to evidence items lodged in the court were provided to me by Wayne and his lawyer and I have not been able to verify them firsthand, however, I trust they are consistent with the court records.

(1) Background Information

1.1     Characteristics of Benzodiazepines

1.2     Diagnosing Benzodiazepine Dependence

1.3     Prescription Duration / Dosages & Patient Files

Read Section One

(2) DSM-IV-TR & Patient Files

2.1     Tolerance

2.2     Withdrawal

2.3     Loss of Control

2.4     Impact on Life

2.5     Continued Use Despite Knowledge of Harm

Read Section Two

(3) General

3.1     Recovery

3.2     Shortfalls in Prescription Doses

3.3     Differential Diagnosis

3.4     Consistency of Previous Reports & Evidence

3.5     Future Reports & Possible Testimony

Read Section Three

Summative Conclusion

1. Wayne showed signs of developing the early stages of tolerance following about 1.5 months of treatment.

2. This was further compounded by several more months of daily dosing, after which, Wayne developed several more new symptoms that were consistent with withdrawal and tolerance (following about 4~6 months of prescriptions).

3. It was around this time that Wayne’s friends began voicing their concerns regarding his wellbeing.

4. Feeling concerned that his condition was deteriorating; Wayne reports that he tried unsuccessfully to stop his drug intake in late November 2000.

5. Soon after this attempt, Wayne returned to see Dr. K at the STRC Hospital on 13th December 2000 to request a re-referral to another hospital, showing an awareness that the drugs were possibly causing him harm.

6. Wayne then began to make a list of new symptoms, dated 18th December 2000, so that he could better convey his concerns with regards to his deteriorating condition to Dr. X. Many of the symptoms contained in this list were consistent with withdrawal due to tolerance.

7. Subsequently, we can estimate that Wayne had likely developed Benzodiazepine dependence following about 4~6 months of treatment, which based on statistics, is a typical timeframe for dependence to form (See reference on page 13 of Report One).

8. Soon after changing hospitals, a reduction plan was negotiated with Dr. M. In accordance with this plan, Wayne made a second unsuccessful attempt at reduction.

9. Following this attempt, Wayne decided to return to New Zealand, where following another unsuccessful attempt at stopping, he sought professional help from our service.

10. During the formal reduction program, his symptoms intensified again along with the development of other withdrawal symptoms.

11. Wayne recovered from most of his symptoms within about 3 months of completing the initial withdrawal phase of the reduction program. Other symptoms took up to 1 year to recover from gradually improving over time, which is suggestive of a protracted withdrawal syndrome.

12. Following completion of the reduction program, Wayne was able to make a gradual return to recreational activities, where he made significant gains in weight, strength and stamina, which was made apparent by his ability to work as an adventure tour guide and yardman.

13. He has since been able to make a return to living and working in Japan, and despite being under considerable more stress on this occasion with his ongoing case for compensation, he continues to maintain a much better state of health.

14. I have been informed that there were some questions raised with regards to what “dependence” actually is. Dependence does not simply refer to a state in which people find it difficult to stop taking the drugs. It is a severe illness, which can result in considerable mental and physical suffering for the patient, potentially causing significant damages to their livelihoods including work, family social life, and general wellbeing, as highlighted by Professor Ashton below.

“Benzodiazepine withdrawal is a severe illness. The patients were usually frightened, often in intense pain, and genuinely prostrated. The severity and duration of the illness are easily underestimated by medical and nursing staff, who tend to dismiss the symptoms as "neurotic." In fact, through no fault of their own, the patients suffer considerable physical as well as mental distress.”

(See Benzodiazepine Withdrawal: An Unfinished Story. Prof. C. H. Ashton. 1984, Page 12/13 of online version).

15. Based on the content of my previous reports and after having had the opportunity to view the patient files (evidence) firsthand, I am able to reconfirm that Wayne meets 5 criteria of the DSM-IV-TR.