Medical Report (4)

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: 27 July 2010

Signature: Graeme Judson

Introduction

I have been invited to write this additional report with regards to Wayne’s patient file held by us, which was released to him, upon his request, from our Quality Risk Control Department on 28th June 2010.

Further to Report 3, which focused mainly on Wayne’s Benzodiazepine dependence in relation to the patient files from Japan, in this report I would like to focus mainly on the patient files from New Zealand and how Wayne’s dependence diagnosis was initially determined.

In addition, I would like to take this opportunity to advance my opinion with regards to prescribing issues, informed consent and monitoring in Wayne’s case. This is because I will be busy with various hospital commitments over the next several months and I understand the court proceedings present various time constraints as well.   

This report consists of 4 main sections as follows:

1. Confirmation of Prescriptions (Diazepam equivalents)
2. Diagnosis & DSM-IV-TR (initial assessment)
3. Differential Diagnosis (additional information based on NZ files)
4. Prescribing, Informed Consent, Monitoring

Section One looks at confirming the exact doses that Wayne was prescribed and the Diazepam equivalents.

Section Two looks at the grounds upon which I made my initial dependency diagnosis, including the application of the DSM-IV-TR, and the symptoms that Wayne presented with.

Section Three provides additional information regarding the differential diagnosis based on Wayne’s previous history contained in his New Zealand medical records.

Section Four looks at prescribing, informed consent and monitoring based on Wayne’s case in relation to recommendations outlined by the World Health Organization and other general prescribing guidelines.

Once again, 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) Confirmation of Prescriptions

1.1     Diazepam Conversions

1.2     Reasons for Differing Diazepam Conversions

1.3     Tofisopam

1.4     Addictiveness of Benzodiazepines

1.5     Breakdown of Reduction Attempts

1.6     Formal Reduction History Breakdown

1.7     Clarification of File Content

1.8     Previous History of Drug Use

1.9     Findings

Read Section One

(2) Diagnosis & DSM-IV-TR

2.1     Diagnostic Procedure

2.2     Original Grounds for Diagnosis (Etiology)

2.3     DSM-IV-TR Based on Initial Assessment

2.4     Symptoms on Presentation

2.5     Recovery (additional information)

2.6     Records

Read Section Two

(3) Differential Diagnosis

3.1     Dr. ter Haar’s File (History of Complaints)

3.2     Dr. Whitwell’s File (History of Complaints)

3.3     Mental Health & Addiction Services (History of Complaints)

Read Section Three

(4) Prescribing, Informed Consent, Monitoring

4.1     Prescribing Issues

4.2     Informed Consent

4.3     Monitoring

4.4     Clinical Considerations

4.5     Findings

Read Section Four

Cumulative Summary / Conclusion

Below is a cumulative summary based on the evidence outlined in both Report 3 and this Report 4.

1. In 1999, Wayne traveled to Japan in good health with no previous history relating to psychological conditions (including any anxiety problems) or neurological complaints.

2. In late 1999, he developed some stress symptoms whilst working at a stressful job in Shizuoka, which are recorded on pages 12~13 of the STRC Hospital ENT patient file and include fatigue / lethargy, pressure in temple areas, swelling of temporal veins, shortness of breath, sleep disturbances.

3. Wayne subsequently changed jobs in late March 2000 and reported that he really liked his new job, which was also noted on page 13 of the STRC Hospital ENT patient file.

4. On 11th May 2000, he suddenly awoke at 2am with an attack of vertigo, which left him with an ongoing balance problem – unsteadiness in gait.   

5. Wayne was initially seen at the STRC Hospital and underwent a series of tests including an MRI scan, all of which showed up negative. Neurologist, Dr. K, who saw Wayne initially, and Neurologist, Dr. Hutchinson, who saw Wayne later, both suspected a “vestibular problem”.

6. Wayne began to develop feelings of anxiousness over not being able to receive a clear diagnosis for his vertigo attack and the balance problem that followed.

7. In June 2000, he decided to get a referral to see Dr. X, who specializes in balance problems.

8. Dr. X diagnosed Wayne as having “Sylvian Aqueduct Syndrome”. Anxiety was not included in his diagnosis.

9. Dr. X began prescribing multiple drugs including 3 different kinds of Benzodiazepines (anxiolytic drugs)  and 1 tricyclic antidepressant for over a 6 month period without any change in dosage.

10. This prolonged prescribing of multiple Benzodiazepines would have increased the likelihood of Wayne becoming dependent to about 50~100%.

11. According to information supplied by Neurologist, Dr. Hutchinson, Benzodiazepines would not have been suitable for treating either “Sylvian Aqueduct Syndrome”, or a “vestibular problem”, and neither are they suitable for the long term treatment of stress symptoms due to the fact that dependence can be rapidly formed.

12. Dr. X did not inform Wayne as to the reason why the drugs (3 different kinds of Benzodiazepines and 1 tricyclic antidepressant) were being prescribed. As far as Wayne knew, these drugs were being prescribed as a means of treatment for “Sylvian Aqueduct Syndrome” and he had no idea that they were Benzodiazepines or what Benzodiazepines are designed for.

13. Wayne showed signs of developing the early stages of tolerance following about 1.5 months of treatment, which was evident in that some of his symptoms settled initially and then returned along with the development of others including palpitations.

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

15. In response, to these complaints, including the palpitations, Wayne reports that he was told not to drink cold water directly after taking a bath, not to fill the bath water over his chest, he needed to eat more, he was probably feeling worse because of recent bad weather, and that he had to toughen up.

16. Following about 4~6 months of treatment, when Wayne’s condition was deteriorating, his friends began voicing their concerns regarding his wellbeing.

17. Feeling concerned for his wellbeing, Wayne reports that he tried unsuccessfully to stop his drug intake in late November 2000.

18. 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.

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

20. 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).

21. After having lost faith in Dr. X and his treatment, Wayne decided to change hospitals. At his final consultation he asked for information about the drugs that he was being prescribed to serve as future reference, which was refused.

22. 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.

23. Following this attempt, Wayne decided to return to New Zealand one week short of completing his employment contract, where he made another unsuccessful attempt at stopping.

24. Dr. Whitwell declared him unfit to work and referred him to our service for professional help, as he was having problems with withdrawal.

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

26. Wayne made a steady recovery from most of his symptoms following about 3 months of completing the initial withdrawal phase of the reduction program (6 months following cessation). Other symptoms took up to 1 year to recover from gradually improving over time, which is suggestive of a protracted withdrawal syndrome.

27. 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 later return to work as an adventure tour guide and yardman.

28. 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.

29. After reviewing the notes, I can confirm that 5 of the 7 DSM-IV-TR criteria can be applied to Wayne’s initial dependency diagnosis based on the information we had in our files before proceedings for compensation began.

30. Further, the additional information that surfaced later, as a result of Wayne’s legal case for compensation, including the patient files from Japan, does not detract from the fact that Wayne met these 5 criteria.