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• After considering extensive scientific and medical evidence, a New South Wales Legislative Council multiparty committee recommended that medicinal cannabis should lawfully be made available for selected-use pharmacotherapy. • The evidence indicates that cannabis has genuine medicinal utility in patients with certain neuropathic conditions, with acceptable levels of risk from mostly mild side effects. • The potential medical benefits of cannabis pharmacotherapy have largely been overlooked, with research and society's attention, in most parts of the world, being directed towards the hazards of its recreational use. • The NSW Government has since dismissed the unanimous and compassionate recommendations of their committee.

Two pharmacotherapies recently introduced in Australia, acamprosate and naltrexone, provide a major advance in the treatment of severe alcohol dependence, a common condition leading to a considerable burden of illness and major costs to the community. Acamprosate and naltrexone reduce alcohol intake, and increase the likelihood and prolong the duration of abstinence (Level I evidence). Compared with naltrexone, the benefits of acamprosate have been confirmed in a larger number of studies involving larger numbers of patients with longer durations of follow-up. Unlike naltrexone, acamprosate appears to achieve a sustained benefit. There is no known interaction effect between alcohol and acamprosate or naltrexone. Both drugs are well tolerated, although naltrexone blocks the action of opioid analgesics. Adjunctive psychosocial treatment with close follow-up is required for acamprosate and recommended for naltrexone. As yet, no studies have reported a reduction in mortality following the use of any pharmacotherapy for alcohol dependence.

Objective: To document adverse effects of anabolic-androgenic steroid (AAS) use in community-based users attending a medical clinic. Design and setting: Prospective recruitment, questionnaire-based interview, physical examination and investigations, with follow-up, of people who attended, anonymously, an inner-city hospital clinic established specifically to examine AAS use. Participants: 58 men, comprising 27 past AAS users, 14 present users and 17 potential users (who formed the control group). Main outcome measure: Clinical adverse effects and abnormal laboratory findings. Results: Cyclical use of oral and intramuscular, human and veterinary AASs were reported. The most commonly reported source of AASs was friends (59%), gymnasiums (25%) and doctors (14%). The most common reported adverse effects were alterations in libido (61%), changes in mood (48%), reduced testis volume (46%) and acne (43%). Although mean systolic and diastolic blood pressure was not significantly different between groups, five present (29%), 10 past (37%) and one potential user (8%) were hypertensive. Gynaecomastia was found in 10 past users (37%; P

OBJECTIVES To describe point prevalence of HCV antibody and relevant risk behaviour among people who inject drugs and who attended selected needle and syringe programs throughout Australia in 1995, 1996 and 1997. DESIGN AND SETTING Repeated cross-sectional surveys of one week's duration were carried out in 21, 20 and 23 needle and syringe program sites throughout Australia in 1995, 1996 and 1997, respectively. PARTICIPANTS All clients attending participating sites during the designated survey week were asked to complete a self-administered questionnaire and provide a finger-prick blood sample for HCV antibody testing. MAIN OUTCOME MEASURES Prevalence of HCV antibody. RESULTS Survey response was 41% (n = 979) in 1995, 51% (n = 1463) in 1996 and 48% (n = 1699) in 1997. HCV prevalence declined significantly from 63% in 1995 to 51% in 1996 and 50% in 1997 (P < 0.001). Among respondents who reported injecting for less than three years, prevalence declined from 22% in 1995 to 13% in 1996 and 1997 (P < 0.001). Reported use of needles and syringes after someone else in the previous month declined from 31% in 1995 and 28% in 1996 to 15% in 1997 (P < 0.001). CONCLUSIONS Despite an apparent decline in HCV prevalence, carriage rates of HCV antibody remain high.

Apply the science, use a team approach, help patients to promote their own health, ensure access to support and accept a public health role. These are the practical lessons of our experience in HIV medicine.

OBJECTIVE To alert physicians to the dangers of a readily available, non-prescription drug by describing the clinical and pathological features of myopathy due to chronic poisoning with ipecac syrup in a patient with an eating disorder. CLINICAL FEATURES A 27-year-old woman presented in 1991 with a right foot drop, followed a few months later by progressive severe neck and limb weakness associated with dysphagia, faecal incontinence and diffuse body ache. It emerged that she had been consuming increasing quantities of ipecac syrup (up to 200 mL per week) for three months to induce vomiting and weight loss. The serum creatine kinase activity was slightly elevated and electromyographic examination results were in keeping with a necrotising proximal myopathic process. Muscle biopsy showed vacuolar degeneration with myofibrilolysis and fine cytoplasmic body formation, consistent with a diagnosis of emetine myopathy. INTERVENTION AND OUTCOME The patient was advised to stop taking ipecac and observed for the next few months. The symptoms resolved gradually and strength returned to normal in four months. CONCLUSION Chronic emetine toxicity, with its potentially catastrophic consequences, should be remembered in the evaluation of neuromuscular symptoms in young women, in whom eating disorders are common and often unrecognised.

ustralia is rightly proud of its response to HIV. Thanks to superb formulation of public policy in the early days of the epidemic, it is not only a low-prevalence country but an international leader in many aspects of its clinical and public health responses. To maintain this fine record, Australia should change policy so that infant male circumcision rates are boosted in the face of rising heterosexual transmission of HIV. Regular surveillance indicates that HIV in Australia is slowly following the trend in Western Europe and North America toward an increased proportion of transmission occurring through heterosexual contact. 1 Although the epidemic in Australia is likely to remain concentrated for some time among men who have sex with men, the proportion of new diagnoses attributable to heterosexual contact has risen from the negligible levels of the epidemic’s early days. 1 The World Health Organization, the Joint United Nations Programme on HIV/AIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria have endorsed male circumcision to control HIV attributed to heterosexual contact in hyperendemic areas, stating: “The efficacy of male circumcision in reducing female to male transmission of HIV has been proven beyond reasonable doubt. This is an important landmark in the history of HIV prevention.” 2 This raises the question of whether low-prevalence countries such as Australia — with an increasing proportion of HIV cases attributed to heterosexual contact — should consider increasing the rate of infant male circumcision to reduce future HIV infections. The protection conferred to heterosexual males by circumcision is similar in hyperendemic and low-prevalence settings. 3-5 In 2008, the Centers for Disease Control and Prevention (CDC) concluded that male circumcision “may also have a role in the prevention of HIV transmission in the United States”. 3 The CDC is now formulating a new policy. 4 Being a low-prevalence country does not preclude a populationwide approach to HIV prevention. For example, we test pregnant women to prevent cases of vertical HIV transmission. Infant male circumcision would be a comparable, albeit more interventionist, population-wide strategy. A wealth of research has shown that the foreskin is the entry point that allows HIV to infect men during intercourse with an infected female partner. 5,6 Soon after the HIV pandemic was first recognised, much lower HIV prevalence was found in areas of subSaharan Africa where more than 80% of males had been circumcised than in areas where the circumcision rate was less than 20%. 5,6 These findings were then replicated in Asia. 7 In Australia, infant male circumcision was once routine, but plummeted in the 1970s.

New guidelines and a multidisciplinary approach have the potential to help patients in need while minimising inappropriate use of opioids.

Harm-reduction approaches are more easily embedded in policy when drugs are legally regulated.

Increasing HIV transmission among drug users has often been the prelude to a wider epidemic in the community, but not in Australia, where successful preventive strategies have been applied. The weak link in these efforts has been in the prisons, which may become epidemic hotspots.

Injecting drug use can not only lead to HIV infection via the sharing of injecting equipment, it can also complicate the course and management of infection.