If you have any questions you need answered by the doctors about methadone, here is the place to send them. yourtype@tir.com    However, please read this first, or your question may not be answered.

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Rapid Opiate Detox - (March 1998, Vol. III, No. III Methadone Today)

Dr. Shinderman's Answer

Dr. Byrne's Answer

Doses Over 100 mg. (January 1998, Vol. III, No. I Methadone Today)

Cimetadine Along with Methadone (December 1997, Vol II, No. XII Methadone Today)

Withdrawal Symptoms from Menstrual Cycle? (November 1997, Vol. II, No. 11 Methadone Today)

Klonopin, Clonidine, and Benzodiazepines (October 1997, Vol. II, No. X Methadone Today)

Comments from Dr. Byrne (Australia) to August & September 1997 Dr. Columns

Dear Doctor:

My question is, does Klonopin, benzos in general, and clonidine get prescribed to people who are STILL on methadone? If so, are methadone's effects magnified? I've done a lot of drugs, but my impression was that Klonopin was not much more favorable than cloniDINE - perhaps a lot less.

I also remember someone describing terrible side effects such as hallucinations and the like. Was it Klonopin or Clonidine that caused these effects? And, is it TRUE that it increases the effects of the methadone? Does it make it "stay" in the body any longer? - Methadone Patient

Dear Methadone Patient:
Benzodiazepines--drugs like Valium, Xanax, and Klonopin, temporarily raise methadone levels. After having been on a steady dose of benzos for a few weeks, and stopping, you may feel that your methadone dose is too low as a result.

Similar effects occur with alcohol use, but they are usually more severe and develop more rapidly. Once patients are on adequate methadone doses, they usually do not abuse either alcohol or benzodiazepines.

Some patients actually benefit from medications like Xanax or Klonopin and have no problem managing them. These medications are useful in psychiatric disorders, including Bipolar Disorder, Panic Disorder, and Post Traumatic Stress Disorder, or for treatment of a seizure disorder.

Most clinics have a lot of mythology--benzodiazepines "running the methadone out or your system" or that "all patients will abuse" these drugs or that "withdrawal from them is fatal." It can be fatal if you are in the hands of people that prevent you from getting them (or anticonvulsants) and you are on a very high dose. Does anyone here know personally of a friend who died from benzo withdrawal? I do not know of one who did so among the ten thousand MMT patients that I have treated.

Overdose is another story. It is difficult to overdose on these drugs alone but very possible when taken in combination with methadone.

Clonidine is a completely different drug. It is usually prescribed for the treatment of high blood pressure and has many side effects. It should be administered by an MD who knows what he is doing. It can be used effectively to reduce distress related to opioid withdrawal. It can be dangerous. If you take it for a couple of weeks and stop abruptly, you might get high blood pressure and bleed into your brain. If you take too much, you can faint and lose consciousness abruptly from low blood pressure.

In regard to these drugs causing hallucinations, it is rare. Neither clonidine nor Klonopin (clonazepam) cause hallucinations in most people.

Dr. Marc Shinderman
Center for Addictive Problems (CAP)
Chicago, Illinois

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In ten years of methadone prescribing I have only seen about six cases of blood level alterations from other drugs. We order blood levels all the time in patients who are unsure of their requirements and so they know what their levels are. The list of possible culprits reprinted from Addiction Treatment Forum is not based on science, but it stands to breed uncertainty where patients should have complete confidence in their treatment.

There is no evidence to my knowledge, and certainly no consistent case reports of altered metabolism due to vitamins, Tylenol, alcohol or urinary acidifiers. Patients and doctors should be wary of some anti-TB drugs, anti-HIV agents and anti-epileptic agents. Otherwise, methadone levels and their effects are as constant as any other drug in the book. And there are far fewer interactions than with many other commonly used medications.

Of course addicts often get symptoms which could be caused by intoxication or withdrawal. However, once on regular doses of methadone, it is much more likely that such problems stem from ordinary causes such as viruses, vapors, fibrositis or the weather, just like everyone else.

Some other comments on your August issue: The patient (C.O.) who seeks Dr Hopper's advice on withdrawal is obviously not ready to detox. Of course he can't sleep and of course he wants to get high as he comes off methadone. He is a drug addict, isn't he? And one who is not yet ready to come off MMT. But I am pleased that he tried. And he might do the same as Thomas de Quincey, the writer of 'Confessions' who attempted a serious withdrawal once every year (usually failing: he used his 'laudanum' to a ripe old age).

The entire US system of MMT will soon be shown up to be a fabrication of the DEA by developments in Canada and elsewhere. Your DEA claim that they have no interest in interfering between doctor and patient. But this is precisely what they have done for thirty years since they first pestered Dr. Dole in New York. He was doing something like what the Swiss have done with their heroin trial. It was new, bold and lateral. But it 'worked' for most of those enrolled and in ways which few would have predicted at the time.

P.S. If anyone is visiting Sydney, there are two dispensaries ten minutes from the airport who could get suitable patients onto MMT within the hour. Our state has over 200 prescribers and hundreds of dispensaries, most charging about US$5 per day.

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Dear Doctors,

I have been on methadone for 6 years and this is the 3rd or 4th time I have been on maintenance. I have recently discovered a new side effect, and am wondering if there is anything I can do to alleviate it. It is somewhat delicate but here it goes...Every month, a few day before and during the first few days of my period, I get some withdrawal symptoms. I have a pretty heavy period, and it lasts for at least 7 days; this has always been the case, and it is regular. Now I don't think this is in my head because it took me a couple of months to discover the pattern and the cause of my "uncomfortable" times during the month.

Has anyone ever complained of this to you? And is there anything I can do? I am on 60 mg. now, and don't want to increase my dose because I need the "steps" to cut down on gas and mileage to and from the clinic (the clinic is in another town, and I work in yet a third town). Thank you for your time. - S.K.

Dear SK,

Although Dr. Schuster and I have not heard of withdrawal symptoms at the time of menstruation, we will try to provide some thoughts that may be of help. My review of the medical literature didn't turn up any similar reports, but this may simply mean that researchers and clinicians haven't thought of or asked about this type of problem. An association between smoking and menstrual symptomatology has recently been reported (I'll come back to this).

You might start to get a handle on this problem by thinking about your typical menstrual symptoms before you started methadone. Are there similarities between your menstrual symptoms and your withdrawal symptoms?

Researchers are just beginning to look at the relationship between menstrual symptoms, smoking/alcohol/drug use, and tobacco withdrawal. These interactions are quite complex and poorly understood (Marks, et al. 1994; DeBon, et al. 1995, Pomerleau, et al. 1994). Although controversial, some clinicians are advocating that smoking cessation be timed as not to occur during menstruation.

What does this mean for you? Consider keeping a diary for three or four months that lists your symptoms, time of the menstrual cycle, and other factors that may be important (smoking, alcohol use, stress level). For some people, simply "seeing" a pattern to their symptoms can be reassuring. If your discomfort is still troublesome, I think it would be very reasonable to try a small increase in methadone dose. I'm not exactly sure what you mean by the "steps" to cut down on gas use. It is very unfortunate if your program is requiring extra visits based only on a methadone dose above 60 mg.

Dr. John Hopper, M.D.
Assistant Professor, Internal Medicine,
Pediatrics, Psychiatry
Medical Director, Clinical Research Division on Substance Abuse, Wayne State University

The steps to which this patient refers means how many times per week she has to go to the clinic. Unfortunately, that is exactly what it means -- if she goes above 60 mg., she will have to give up some of her take homes. Crazy -- do we want patients to work or not? Do we punish them for needing a higher dose? Apparently so in some clinics -- Editor

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Dear Doctors,

I have read and heard that using cimetadine along with methadone can enhance the effects of the opioid. I am on a program and use methadone as both a means to manage my addiction and as an analgesic ( I have a non-terminal chronic pain problem that is essentially untreatable but manageable with opioids). I gave up on pain management clinics after several years of incredibly shabby treatment and sub-analgesic doses of medications even from the more compassionate care providers, and after spending some time writing my own prescriptions, found myself on methadone.

Although this has proven largely effective for me, I do have breakthrough pain that methadone is very poor at managing. I refrain from using heroin regularly to avoid compromising my status on my methadone program. I stumbled across a note and remarks recently suggesting that cimetadine would potentiate the effects of methadone, and gave it a try for several days. Indeed, at doses of 600mg. cimetadine daily about 45 minutes before I dose (my current methadone dose is 80mg a day, soon to be raised to 90mg and a week later to 100mg. in. d.), I did notice a perceptible augmentation of both the sedative and analgesic effects of the opioid. Since I generally have to detox myself about every 8-9 months in order to preserve the analgesic effects of methadone (I reach a maximum dose of about 120mg. in. d., after which no physicians I have met are willing to increase my dose further). I am planning to attempt using cimetadine to stretch the period out a little further between forced detoxes. This is in addition to trying cimetadine as a treatment for breakthrough pain.

My question is, has anybody elucidated the mechanism by which cimetadine enhances the effects of methadone? I have speculated that the effect might come from the action of cimetadine in reducing gastric acid production, thereby allowing more methadone to escape destruction in the gut prior to absorption, but if this is the case, it seems to me that any of the Histamine2 antagonists would work as well as Tagamet. Yet, the few technical references I have found regarding concurrent use of cimetadine and methadone make no mention of other drugs in the Tagamet class. Can you comment on the mechanism of cimetadine potentiation of methadone, and also point to any special issues of contraindication or adverse reaction linked to the concomitant use of both of these drugs? Thanks in advance. R.L.R.
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Dear R.L.R.,

The use of Tagamet (cimetidine) to augment the effects of methadone reminds me of a story my father used to tell about the use of penicillin when it was first introduced in the 1940s. The drug (it was only allowed for the military) was so hard to get that the soldiers' urine was collected each day. The penicillin was then recycled by fractional crystallization and returned to the pharmacy!

Now, methadone is cheap (about 50¢ per dose) and easily available, so the above should not apply. However, the unwillingness of some physicians to prescribe according to medical principles has caused an epidemic of underdosing amongst methadone recipients. I would say that there are more risks with underdosing than with overdosing. Apart from the first few days of treatment, reports of overdose from prescribed methadone are exceedingly rare.

All the research (and there is lots) teaches us that attempts to limit the term of methadone treatment or the dose level both lead to high failure rates. Longer term treatment at appropriate dose levels leads to high chance of success with extremely low levels of side effects. There is no other area of medical prescribing (e.g. cholesterol lowering agents, diabetes, arthritis, migraine, depression) where anyone questions the dose levels or continued treatment for patients who are doing well. So why is methadone any different?

You may need more than 100mg of methadone daily on a regular basis (our present maximum is 300mg, average around 80mg). With your reductions, you are following Thomas de Quincey who wrote Confessions of an English Opium Eater in 1821. Once each year he reduced, and stopped ('almost'), his daily laudanum consumption. He then had a dreadful week or two in which he could hardly write a line of prose or make a pot of tea, and then he invariably recommenced his opium.

The use of cimetidine to increase the blood levels has been described by Dr Thomas Payte from Texas. My feeling is that it is a strange way to do what could be done by simply increasing the daily dose of a safe and cheap medication. When this can be monitored with blood levels it is abundantly safe and appropriate. Split dosing also increases the *average* blood levels, but only slightly.

However, if it works, and it is not feasible to have a dose increase, then it may be justified. While cimetadine is probably not approved for this purpose, it is likely to be safer than using illicit heroin or other analgesics. How this works is speculative, although I think people have assumed that liver metabolism of the drug is slowed down. We already know that some epileptic tablets, HIV medications and anti-TB drugs can *increase* this metabolism. I have not read any papers describing the reverse, but it certainly happens in patients who *stop* taking the above medications ... while on constant doses of methadone they can become quite intoxicated, a state you have probably never been in ... at least not from methadone.

You should have your methadone levels measured 24 hours after dosing. The result will probably be around 0.2mg/l or lower in which case you are at the lower end of the 'therapeutic range' which may go as high as 0.5mg/l. Note that the 'peak' levels (measured about 3 hours after a dose) are usually about double these figures but they are less reliable in my experience.
Best of luck with your inquiries - and your efforts to educate both yourself and your careers.

Regards,
Andrew Byrne
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Dr Andrew Byrne, General Practitioner, Drug and Alcohol,
75 Redfern Street, Redfern,
New South Wales, 2016, Australia
Tel: (612) 931-95524 Fax: (612) 931-80631
E-mail ajbyrne@ozemail.com.au
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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Dear Doctor,

My dosing nurse told me quite coldly (as usual) that the Feds do not like to approve take homes over 100mgs, she says because they feel we are masking our true feelings by increasing our dosage, instead of dealing with our problems. She said quote "kinda like putting a band aid over our actual problems" that have led us to use drugs to begin with.

Dear Methadone Patient,

She should be reprimanded; that is not true. They have rules which must be followed. The rules seem to be designed to make sure that a physician takes responsibility and takes some care in awarding take home privileges in higher-dosed patients.

I can hold my breath for a really long time. My favorite thing is to make one of these moral philosophers hold their breath as long as I can; they can't. Not even close. Then I tell them that my need for air is NORMAL, and theirs arises from a deep-seated anxiety and irrational fear which needs years of "oxygen deprivation therapy" and group treatment. I offer to make them breathe a mixture of oxygen and nitrogen through a mask, while they are in treatment, IN MY EMPLOY, but I will control the oxygen levels. Without telling them, and for their own good, I will change the amount of oxygen that they get based on my estimate of their air-hogging behavior when they are not under my observation. We can do this with random tests. The less oxygen they take, the better human beings they are. We believe this fervently, but most, due to moral weakness, relapse to their usual levels of oxygen consumption, in and out of treatment.

More to the point: The Feds will permit takehomes as soon as you demonstrate stability on the new dose and the MD writes a letter attesting to this. At CAP and CAP Downers Grove, the turnaround time averages 10 days before returning takehomes to the patient's previous level, 2 or 3 time/wk. One time pickups may take longer, going to twice a week for a while. If they deal with this in any other way, it is local or clinic rules which they are using against you. They may just be uninformed, but what the nurse said is B.S. A 500 mg. patient has the same blood levels as a 50 mg. patient, if they are each doing well in treatment.

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Dear Doctor,

I've been on methadone for 4 years this November. I first stabilized at 70mg and then 85mg for 1 1/2 years. When I switched clinics, I stabilized at 96mg. and stayed there for about 2 years. Somewhere near the beginning of '97, I started detoxing slowly--first 1mg a week, then 2mg a week. I was doing great and didn't really feel it very much. All this while, I had 3xweekly take-homes. Then, in September, I was at 62mg and was told I had a negative methadone UA. Of course, my counselor asked me what was going on. I told her I was tapering my dose and that's probably why it was negative. She told me that my current dose (62mg) should still be showing in my urine and then asked me if I was selling my take-homes. I was so enraged I ordered a retest, and it retested -methadone. I hadn't used any illegal drugs, so I thought it was a fluke error--until it happened several times more within Oct. and Nov. They gave me monitored UAs every time I went to the clinic for 2 weeks. I've now lost all my take homes because of this. I work full-time, and going there every day by bus almost always makes me late for work.

There have been some changes in my exercise routine in the last 4 months. I bought a bike and was biking to the clinic, but was it was too far (5 miles one way). However, I WAS biking to and from work (2 miles one way). I also get more exercise during work, and as a result drink a lot more fluids. I sweat a lot--more so than other methadone patients. I break out in a sweat at the most simple task, and it streams down my face. Even my counselor said it was excessive.

After several very serious talks with my counselor, telling her over and over, "I have not been skipping my doses, and if I was, I would tell you." She does seem to believe me and told me I should see a doctor if I get another negative UA for methadone. I went to the doctor and they have no idea what's going on. The only test they ran was one UA taken at 5 p.m. (I dose in the morning) and told me if that one comes up positive, then everything's ok. That's it. They did admit they were concerned and didn't have any reason why.

I'm still suffering for a crime that was never committed. I told the clinic I'd take a lie detector test or anything else, but they all just assume I'm lying! It makes me furious! Is there any test other than a UA that can detect methadone? ANYTHING?! I assure you, dear sir, I take my methadone and all of it. I would not go to the doctor if I knew why this happened nor, would I load this big messy experience on a true professional.

Simple logic seems to tell me that from being at nearly 100mg for 4 years, then when I was detoxed 34mg below my stabilized dose and started showing negative methadone, I would assume my body was using up the methadone with in 24 hours. At my clinic, they say it takes at least 24 (usually 48) hours for it to get out of one's system. And they also refuse to budge on the stance that a patient does not show negative methadone until 20 or less mg. Is that true?

Is there something terribly wrong with my body? Or is the clinic playing with me by saying they don't know why I'm coming up negative? I'm very concerned, and I don't know whether it's my health or bad clinic policies and bad treatment of patients I should be more worried about.

I'm sorry to go on and on for so long but I want you to know what exactly is happening. I've been doing really good in the past year and half, and now I get punished. If I dont find out why this is happening to me and get evidence to prove it, I'll never get my take-homes back. - Cher
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Dear Cher,

Your reported treatment has been unfortunate, arbitrary and absolutely contrary to normal medical ethics. The doctor responsible should be reprimanded.

Doctors often receive unexpected test results from the pathologist, radiologist or other diagnostic specialists. We are taught in medical school to take such results seriously. But the first thing to do is to repeat the test when surprising or conflicting answers arrive. Yours was repeated and was positive for the drug, which is what one may expect.

There are many factors which can cause a negative methadone urine test in a methadone patient. We turn up the odd one in our practice as your clinic obviously does too. The answer you were given says it all-- below 20mg you expect this to occur, but they know that you are taking at least 35mg daily on average, even if you did not consume any of your take-home doses. In women even more than men, the body stores methadone for well over 48 hours. So they have disproved their own thesis!

In addition, anyone in the field would know that patients who have dropped their dose substantially (as you have done) are much more likely to be tempted to buy extra doses rather than to sell them. Doctors are taught only to alter someone's treatment on the basis of significant documented, factual information. This might be altering doses of insulin, seeing blood pressure patients less often, applying a plaster cast, instituting treatment for glaucoma or stopping it.

Your treatment (and your whole daily routine) has been radically changed on the basis of very doubtful information (from the lab) which is inconsistent with your clinical story as you give it. Quite frankly, I do not know why they are testing you for methadone every time--in your case, it is obviously a waste of time and money as you are swallowing it in front of the staff most of the time anyway. In some countries (such as England and France), you may receive the whole week's supply at one attendance with very little supervision at all. Here in Australia, you would receive twice weekly attendance with 5 take-home doses in most states (especially if you are working).

I hope you will tell your clinic that they are simply not following correct medical principles. Ask them for the medical evidence that withdrawing take-homes in people with negative tests for methadone is appropriate [there is none]. There is very persuasive evidence that withdrawing such 'privileges' encourages people to leave treatment prematurely. They go back to heroin, they get involved in crime and they die at a very high rate. Is the clinic there for the patients?

I hope this information helps to drive a little common sense into what is really a simple medical treatment for a complex medical and behavioural problem.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Dr Andrew Byrne, General Practitioner, Drug and Alcohol
75 Redfern Street, Redfern, New South Wales, 2016, Australia
Tel (61- 2) 9319 5524 Fax 9318 0631; ajbyrne@ozemail.com.au

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Dear Doctor:
I am curious about Ultra Rapid Opiate Detox (UROD), which I read about on the Internet. UROD is offered by the Center for the Investigation and Treatment of Addictions (CITA). They claim they can detox an opiate patient from heroin, morphine, codeine, opium, and methadone by putting them under anesthesia for 6 hours, under deep sedation, and the patient "experiences no withdrawal symptoms." Then they put the patient on a "nine-month Naltrexone regimen" which they claim creates no dependency. They claim a success rate of 73% of patients not returning to opiate use.

I find this all quite hard to believe. I called my internist, who is also an addictions specialist, for her opinion, and she said to me, "I sure hope you're not thinking of doing this; going under anesthesia for that length of time is dangerous, and there is no quick fix!"

I met a woman who had been on methadone for 7 years and heroin for 15 years who went through this "UROD" treatment. She said she felt so horrible for three weeks afterward, she finally relapsed with heroin (I wonder if they would count her as one of their "successes!"). She said they put her under for 12 hours (not 6), and after she woke up, the doctor admitted they had had two deaths from the procedure! I'd like your opinion. - Curious Methadone Patient

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Dear Curious:
The National Institute of Health (NIH) rejects the claims of CITA, and Columbia U has rejected them as a partner in research of rapid detox because they would not submit a protocol. CITA in particular was spoken about among the professionals at the recent NIDA meeting as not being straightforward with regard to their results, their affiliations and endorsements. My experience with rapid opioid detox is that patients relapse and feel terrible following the procedure in the few cases that I know of. Usually they do not want to return to methadone treatment and eventually are re-addicted to illicit opiates.

CITA, here, paid a patient who had a terrible experience and required 6 weeks of inpatient treatment and was still suicidal months after the detox, to say that the procedure was wonderful. He has not, to my knowledge, relapsed but is having a rough time in general. The cost of that detox was fifty thousand dollars and took months before the patient began to feel well at all if you include the hospital treatment and his poor condition when they ejected him from treatment there. If you include the month hospitalization prior to the detox, add another thirty thousand.

When CITA says that 60 percent of patients are drug free or a "success" a year after treatment, you have to understand their method of determining this. First they telephone all the patients. Only those who answer are counted. They are asked by the telephone interviewer, "Have you used heroin every day of the last fourteen days?" If the answer is "No, 13 days," CITA counts it as a SUCCESS. This is an unreliable reporting system which features very low criteria to be counted as "success," leaving questions with limited response possibilities and no means of validation.

CITA employees go out of their way to stigmatize methadone treatment, even though it is acknowledged as the safest and most effective treatment of heroin addiction. The deaths due to rapid detox and those following any form of detox are a matter of record, and every person involved in the treatment of opioid addiction should be aware of the risks. Patients should know them also. Twenty-five percent of deaths from heroin overdose occur following detox and are related to the vulnerability to respiratory depression in addicts who detoxify.

Naltrexone implants or tablets, which are supposed to transform the detox procedure into "treatment," are associated in at least one study with a higher rate of intentional and fatal overdose than is methadone maintenance treatment. Vulnerability to death from overdose in patients treated with naltrexone for days and weeks and who then discontinue it is great. Patients with depression seem especially poor candidates for naltrexone-based treatment. Naltrexone blocks reinforcement for many other activities. Eating, sex, laughing, drinking and nurturing are among them. One day detox under general anesthetic may be a good treatment for the few patients who enjoy perfect health, excellent social and financial circumstances and higher levels of education. It seems to work with doctors and nurses who are employed, for instance.

Dr. Marc Shinderman, Center for Addictive Problems, Chicago
==========================

Dear Curious Methadone Patient,
Your reservations about rapid detox are well placed. The research literature is still very sparse on outcomes, but there are reports of several types of accelerated opiate detoxification being used around the world.

The Israeli *organisation which claims to have invented the general anesthetic detox did no such thing. It was invented by Dr. Loimer in Vienna around 1987. There were adaptations made by doctors in England in the late 1980s which are similar to what the Israeli doctors began doing around 1992. This is all well documented in a number of scientific publications.

Claims that the process is always painless are incorrect. A significant proportion of patients develop fatigue, insomnia and major body aches. These symptoms may persist for a couple of weeks but they are usually controlled with simple remedies and reassurance.

The most exciting development recently is the use of naltrexone detox under sedation rather than full anaesthetic. It can even be done at home and has been used for the past few years in Spain on hundreds of patients.

There is no doubt that all of these procedures can 'unhook' any patient who is addicted to heroin, methadone or other opiates, regardless of the doses used. Many such patients have been advised to take naltrexone regularly under supervision after the detoxification. Hence there are two quite separate processes at work here: (1) opiate detoxification and (2) maintenance of abstinence.

These *utilise naltrexone in most cases. Trials of naltrexone have been promising, and there is no doubt that when it is taken regularly, there is effective opiate 'blockade' for up to 3 days. This treatment could equally well be used after traditional detox and it is only comparisons of these two modalities which will prove whether 'rapid detox' is more or less likely to result in long-term abstinence.

My advice is that stable patients on MMT should open a bank account ear-marked for rapid detox in the future. It is still not well enough tested for me to be confident to recommend it to my patients. Future evidence will guide us regarding who is most likely to succeed and at what stage of their addiction career it is appropriate to implement.

*This is the correct spelling in Australia
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Dr Andrew Byrne, General Practitioner, Drug and Alcohol
75 Redfern Street, Redfern, New South Wales, 2016, Australia
Tel (61 - 2) 9319 5524 Fax 9318 0631; E-mail: ajbyrne@ozemail.com.au

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