Hepatitis C virus incidence among injecting drug users on opioid replacement therapy. Hallinan R, Byrne A, Amin J, Dore GJ. ANZ J Public Health 2004 28;6:576-578
Dear Colleagues,
At last there is some good news about hepatitis C. In an article published this week in the ANZ Journal of Public Health we have shown that the incidence of HCV can be kept very low in drug users who are in treatment (with methadone or buprenorphine). While much of the recent information about this virus shows continued sero-conversions as being the rule, this study shows that by using treatment consistent with established guidelines, such cases can become exceptional. In fact, it was our experience that nearly all of the few cases of sero-conversion were in patients who had had their treatment interrupted and/or had been placed in custody for a time.
Between January 1996 and July 2003 54 treatment entrants were initially HCV negative. In the study period 5 sero-conversions occurred, yielding in 131.1 person years (py), an incidence of 3.8/100 py (95% CI 1.2 – 8.9/100 py). Four sero-conversions occurred in the sub-group with interrupted opioid replacement therapy (n=20) during a total of 54.2 py, an incidence of 7.4/100 py (95% CI 2.0 – 18.9/100 py). One sero-conversion occurred in the sub-group with continuous opioid replacement therapy (n=34), during a total of 76.8 py, an incidence of 1.3/100 py (95% CI 0.03 – 7.3/100 py).
The conclusion states: “HCV incidence among IDUs receiving opioid replacement therapy in our clinic was relatively low. Those IDUs without interruptions to their treatment appeared to be at particularly low risk of HCV infection. These findings support the role of opioid replacement therapy in HCV prevention for IDUs.”
Comments by Andrew Byrne.
5 May 2004
Dissolving the Mind-Brain Barrier. New York psych conferenceproceedings May 04.
Dissolving the Mind-Brain Barrier. New York psych conferenceproceedings May 04.
American Psychiatric Association, 2004 Annual Meeting. Psychotherapy andPsychopharmacotherapy. Dissolving the Mind-Brain Barrier. New York. 157thannual Meeting, 1-6 May 2004.
Dear Colleagues,
Despite not having attended this meeting, I have had an opportunity toreview the enormous 'proceedings summary' for this conference which wasgiven to me by one of the large group of Australian psychiatrists whoattended in springtime New York. It consisted of 370 pages of very smallprint! Like all big scientific conferences these days, nobody could attendall the parallel sessions and it is hard to imagine that they could not havebeen pared down for relevance, quality and length. Regarding addictionrelated presentations there was a mixture and these also varied in quality.In our field we are used to being left to the end of days, following theother more 'mainstream' topics.
Even some of the general lectures/workshop titles were very esoteric.'Music and the mind: Beethoven'; 9/11 Research: Reviews; 'Surviving JockCulture'; 'Why does the human brain become addicted'; 'The brain in love';'Better Sex: Naturally'; 'Postwar mental health services'; 'Leash on life:Human attachment to animals'; 'Detection of Malingering'; 'Juvenile Justice. Jazz and Blues'; 'Sexual satisfaction . in Orthodox Jewish Women'; 'Thesissy duckling . gender variance'; 'Psychotherapy in Asian women'; 'Gaynessand God'; 'Modafinil treatment of chronic shift work sleep disorder'; 'Foodand drug cravings: metaphor or common mechanism?' . I could go on . Yogatechniques, show biz, teaching, forensic psychiatry, twin studies,topiramate for alcoholism, terrorism, PTSD, AA, ADD, etc, etc, etc.
From the program, there was still plenty for the 'bread-and-butter'psychiatry issues of anxiety, depression and psychoses, as behoves such alarge conference. We forget just how 'big' psychiatry is in the UnitedStates. While it is exceptional for Australians to have a psychiatrist, itis almost compulsory for middle class Americans.
Regarding addiction, there were a number of papers, many authored by wellknown researchers and clinicians but on a surprisingly limited range ofsubjects. These mostly revolved around the newfound availability ofbuprenorphine for maintenance of opioid addiction in office based practice.When properly used, such work can be enormously professionally rewarding .and prescribing opioids to addicts is something American doctors have beenlargely banned from doing since the 1920s. Also, uniquely in the US,pharmacists are barred from administering methadone in the treatment ofaddiction. Buprenorphine (mostly in combination with naloxone) has beenmade available on a 'waiver' prescription system under the Drug AddictionTreatment Act of 2000 from certified doctors as outpatient management. Thisis without the normal addiction clinic requirements for supervisedadministration, counselling, urine testing, etc. Medication can beprescribed for up to six months on one prescription, including repeats or'refills'.
There were also numerous papers on cocaine and cannabis, with uniquelyAmerican flavours, and thus often of limited relevance to normal medicalpractice in other countries.
Nowhere was there mention of the current uncomfortable conundrum of doctorssometimes prescribing the second best drug for arbitrary regulatory reasons.Methadone is the recommended maintenance drug for pregnant addicts, yet itis not available in some states and is very limited in the others.Methadone is also more effective than buprenorphine for those with hightolerance. Trials often show better outcomes for methadone so it should bethe first line drug in some or even most patients. One could understandthis being omitted by the authors in the section sponsored by drugcompanies. Yet it is not mentioned in the many other free papers, as far asI could determine.
Many of the most prominent personalities of drug research in the US wererepresented here, including names like Ling, Kosten, Kleber, Galanter,McNicholas, Volkow, Rounseville, Portnoy, Tsuang, O'Brien, Millman, McLellanand Bankole Johnson.
Some of their views were controversial, others questionable, such as theclaim that methadone should be avoided in HIV cases because of its supposednegative effect on the immune system. The myths of buprenorphine beingeasier to withdraw from and having less dependence features were alsoresurrected by some contributors. Buprenorphine withdrawals have no bettersuccess than methadone withdrawals. Nobody ever mentions the ratherimportant fact that there are simply no long-term safety data onbuprenorphine, especially in combination with naloxone. Indeed, themanufacturer seems not to be sponsoring any such research currently.
It was gratifying to find so many papers on nicotine dependence. In my viewpsychiatrists have a much wider community responsibility than immediatepatient care. It is tragic that is has taken so long for them to realisewhat psychiatrist Marie Nyswander wrote about 50 years ago . that treatingaddicts with psychotherapy was fraught with frustration without usingmaintenance pharmacotherapy for appropriate cases. And with such therapy itcan be enormously rewarding for doctor and patient as addicts put theiroften considerable talents towards normal life issues rather than constantlyprocuring drugs.
There were only small contributions from overseas including adolescentpsychiatry (one from ANU and another from the UK). There was also areference in Walter Ling's insightful paper on treating chronic pain inmaintenance patients. He quoted some important work from Adelaideresearchers on the subject of induced hyperalgesia in such patients and theneed for different approaches for the future as there will be so many moresuch patients. Australia has contributed much to the field of psychiatry(eg. a Melbourne doctor first devised lithium treatment).
It is a shame that more prominence was not given to a RCT by Bankole Johnsonin which he measured quality of life in alcoholics given topiramate, a newdrug used for cravings and/or relapse prevention. There was a significantpositive effect. So now we have at least four drugs in this class:naltrexone, acamprosate, ondansetron and topiramate. The latter two couldonly be used off-label in Australia and thus should probably only beprescribed in specialist or research settings. The first two should befamiliar to all Australia doctors who come into contact with alcoholics -and who doesn't?
Comments by Andrew Byrne ..
American Psychiatric Association, 2004 Annual Meeting. Psychotherapy andPsychopharmacotherapy. Dissolving the Mind-Brain Barrier. New York. 157thannual Meeting, 1-6 May 2004.
Dear Colleagues,
Despite not having attended this meeting, I have had an opportunity toreview the enormous 'proceedings summary' for this conference which wasgiven to me by one of the large group of Australian psychiatrists whoattended in springtime New York. It consisted of 370 pages of very smallprint! Like all big scientific conferences these days, nobody could attendall the parallel sessions and it is hard to imagine that they could not havebeen pared down for relevance, quality and length. Regarding addictionrelated presentations there was a mixture and these also varied in quality.In our field we are used to being left to the end of days, following theother more 'mainstream' topics.
Even some of the general lectures/workshop titles were very esoteric.'Music and the mind: Beethoven'; 9/11 Research: Reviews; 'Surviving JockCulture'; 'Why does the human brain become addicted'; 'The brain in love';'Better Sex: Naturally'; 'Postwar mental health services'; 'Leash on life:Human attachment to animals'; 'Detection of Malingering'; 'Juvenile Justice. Jazz and Blues'; 'Sexual satisfaction . in Orthodox Jewish Women'; 'Thesissy duckling . gender variance'; 'Psychotherapy in Asian women'; 'Gaynessand God'; 'Modafinil treatment of chronic shift work sleep disorder'; 'Foodand drug cravings: metaphor or common mechanism?' . I could go on . Yogatechniques, show biz, teaching, forensic psychiatry, twin studies,topiramate for alcoholism, terrorism, PTSD, AA, ADD, etc, etc, etc.
From the program, there was still plenty for the 'bread-and-butter'psychiatry issues of anxiety, depression and psychoses, as behoves such alarge conference. We forget just how 'big' psychiatry is in the UnitedStates. While it is exceptional for Australians to have a psychiatrist, itis almost compulsory for middle class Americans.
Regarding addiction, there were a number of papers, many authored by wellknown researchers and clinicians but on a surprisingly limited range ofsubjects. These mostly revolved around the newfound availability ofbuprenorphine for maintenance of opioid addiction in office based practice.When properly used, such work can be enormously professionally rewarding .and prescribing opioids to addicts is something American doctors have beenlargely banned from doing since the 1920s. Also, uniquely in the US,pharmacists are barred from administering methadone in the treatment ofaddiction. Buprenorphine (mostly in combination with naloxone) has beenmade available on a 'waiver' prescription system under the Drug AddictionTreatment Act of 2000 from certified doctors as outpatient management. Thisis without the normal addiction clinic requirements for supervisedadministration, counselling, urine testing, etc. Medication can beprescribed for up to six months on one prescription, including repeats or'refills'.
There were also numerous papers on cocaine and cannabis, with uniquelyAmerican flavours, and thus often of limited relevance to normal medicalpractice in other countries.
Nowhere was there mention of the current uncomfortable conundrum of doctorssometimes prescribing the second best drug for arbitrary regulatory reasons.Methadone is the recommended maintenance drug for pregnant addicts, yet itis not available in some states and is very limited in the others.Methadone is also more effective than buprenorphine for those with hightolerance. Trials often show better outcomes for methadone so it should bethe first line drug in some or even most patients. One could understandthis being omitted by the authors in the section sponsored by drugcompanies. Yet it is not mentioned in the many other free papers, as far asI could determine.
Many of the most prominent personalities of drug research in the US wererepresented here, including names like Ling, Kosten, Kleber, Galanter,McNicholas, Volkow, Rounseville, Portnoy, Tsuang, O'Brien, Millman, McLellanand Bankole Johnson.
Some of their views were controversial, others questionable, such as theclaim that methadone should be avoided in HIV cases because of its supposednegative effect on the immune system. The myths of buprenorphine beingeasier to withdraw from and having less dependence features were alsoresurrected by some contributors. Buprenorphine withdrawals have no bettersuccess than methadone withdrawals. Nobody ever mentions the ratherimportant fact that there are simply no long-term safety data onbuprenorphine, especially in combination with naloxone. Indeed, themanufacturer seems not to be sponsoring any such research currently.
It was gratifying to find so many papers on nicotine dependence. In my viewpsychiatrists have a much wider community responsibility than immediatepatient care. It is tragic that is has taken so long for them to realisewhat psychiatrist Marie Nyswander wrote about 50 years ago . that treatingaddicts with psychotherapy was fraught with frustration without usingmaintenance pharmacotherapy for appropriate cases. And with such therapy itcan be enormously rewarding for doctor and patient as addicts put theiroften considerable talents towards normal life issues rather than constantlyprocuring drugs.
There were only small contributions from overseas including adolescentpsychiatry (one from ANU and another from the UK). There was also areference in Walter Ling's insightful paper on treating chronic pain inmaintenance patients. He quoted some important work from Adelaideresearchers on the subject of induced hyperalgesia in such patients and theneed for different approaches for the future as there will be so many moresuch patients. Australia has contributed much to the field of psychiatry(eg. a Melbourne doctor first devised lithium treatment).
It is a shame that more prominence was not given to a RCT by Bankole Johnsonin which he measured quality of life in alcoholics given topiramate, a newdrug used for cravings and/or relapse prevention. There was a significantpositive effect. So now we have at least four drugs in this class:naltrexone, acamprosate, ondansetron and topiramate. The latter two couldonly be used off-label in Australia and thus should probably only beprescribed in specialist or research settings. The first two should befamiliar to all Australia doctors who come into contact with alcoholics -and who doesn't?
Comments by Andrew Byrne ..
The Surprising Truth About Addiction - Stanton Peele
http://www.psychologytoday.com/htdocs/prod/ptoarticle/pto-20040514-000007.asp
Psychology Today, May-June 2004, pp. 43-46
The Surprising Truth About Addiction
Stanton Peele, North Arlington, NJ
Summary: More people quit addictions than maintain them, and they do so on their own. That's not to say it happens overnight. People succeed when they recognize that the addiction interferes with something they value—and when they develop the confidence that they can change.
Change is natural. You no doubt act very differently in many areas of your life now compared with how you did when you were a teenager. Likewise, over time you will probably overcome or ameliorate certain behaviors: a short temper, crippling insecurity.
For some reason, we exempt addiction from our beliefs about change. In both popular and scientific models, addiction is seen as locking you into an inescapable pattern of behavior. Both folk wisdom, as represented by Alcoholics Anonymous, and modern neuroscience regard addiction as a virtually permanent brain disease. No matter how many years ago your uncle Joe had his last drink, he is still considered an alcoholic. The very word addict confers an identity that admits no other possibilities. It incorporates the assumption that you can’t, or won’t, change.
But this fatalistic thinking about addiction doesn’t jibe with the facts. More people overcome addictions than do not. And the vast majority do so without therapy. Quitting may take several tries, and people may not stop smoking, drinking or using drugs altogether. But eventually they succeed in shaking dependence.
Kicking these habits constitutes a dramatic change, but the change need not occur in a dramatic way. So when it comes to addiction treatment, the most effective approaches rely on the counterintuitive principle that less is often more. Successful treatment places the responsibility for change squarely on the individual and acknowledges that positive events in other realms may jump-start change.
Consider the experience of American soldiers returning from the war in Vietnam, where heroin use and addiction was widespread. In 90 percent of cases, when GIs left the pressure cooker of the battle zone, they also shed their addictions—in vivo proof that drug addiction can be just a matter of where in life you are.
Of course, it took more than a plane trip back from Asia for these men to overcome drug addiction. Most soldiers experienced dramatically altered lives when they returned. They left the anxiety, fear and boredom of the war arena and settled back into their home environments. They returned to their families, formed new relationships, developed work skills.
Smoking is at the top of the charts in terms of difficulty of quitting. But the majority of ex-smokers quit without any aid––neither nicotine patches nor gum, Smokenders groups nor hypnotism. (Don’t take my word for it; at your next social gathering, ask how many people have quit smoking on their own.) In fact, as many cigarette smokers quit on their own, an even higher percentage of heroin and cocaine addicts and alcoholics quit without treatment. It is simply more difficult to keep these habits going through adulthood. It’s hard to go to Disney World with your family while you are shooting heroin. Addicts who quit on their own typically report that they did so in order to achieve normalcy.
Every year, the National Survey on Drug Use and Health interviews Americans about their drug and alcohol habits. Ages 18 to 25 constitute the peak period of drug and alcohol use. In 2002, the latest year for which data are available, 22 percent of Americans between ages 18 and 25 were abusing or were dependent on a substance, versus only 3 percent of those aged 55 to 59. These data show that most people overcome their substance abuse, even though most of them do not enter treatment.
How do we know that the majority aren’t seeking treatment? In 1992, the National Institute on Alcohol Abuse and Alcoholism conducted one of the largest surveys of substance use ever, sending Census Bureau workers to interview more than 42,000 Americans about their lifetime drug and alcohol use. Of the 4,500-plus respondents who had ever been dependent on alcohol, only 27 percent had gone to treatment of any kind, including Alcoholics Anonymous. In this group, one-third were still abusing alcohol.
Of those who never had any treatment, only about one-quarter were currently diagnosable as alcohol abusers. This study, known as the National Longitudinal Alcohol Epidemiologic Survey, indicates first that treatment is not a cure-all, and second that it is not necessary. The vast majority of Americans who were alcohol dependent, about three-quarters, never underwent treatment. And fewer of them were abusing alcohol than were those who were treated.
This is not to say that treatment can’t be useful. But the most successful treatments are nonconfrontational approaches that allow self-propelled change. Psychologists at the University of New Mexico led by William Miller tabulated every controlled study of alcoholism treatment they could find. They concluded that the leading therapy was barely a therapy at all but a quick encounter between patient and health-care worker in an ordinary medical setting. The intervention is sometimes as brief as a doctor looking at the results of liver-function tests and telling a patient to cut down on his drinking. Many patients then decide to cut back—and do!
As brief interventions have evolved, they have become more structured. A physician may simply review the amount the patient drinks, or use a checklist to evaluate the extent of a drinking problem. The doctor then typically recommends and seeks agreement from the patient on a goal (usually reduced drinking rather than complete abstinence). More severe alcoholics would typically be referred out for specialized treatment. A range of options is discussed (such as attending AA, engaging in activities incompatible with drinking or using a self-help manual). A spouse or family member might be involved in the planning. The patient is then scheduled for a future visit, where progress can be checked. A case monitor might call every few weeks to see whether the person has any questions or problems.
The second most effective approach is motivational enhancement, also called motivational interviewing. This technique throws the decision to quit or reduce drinking—and to find the best methods for doing so—back on the individual. In this case, the therapist asks targeted questions that prompt the individual to reflect on his drinking in terms of his own values and goals. When patients resist, the therapist does not argue with the individual but explores the person’s ambivalence about change so as to allow him or her to draw his own conclusions: “You say that you like to be in control of your behavior, yet you feel when you drink you are often not in charge. Could you just clarify that for me?”
Miller’s team found that the list of most effective treatments for alcoholism included a few more surprises. Self-help manuals were highly successful. So was the community-reinforcement approach, which addresses the person’s capacity to deal with life, notably marital relationships, work issues (such as simply getting a job), leisure planning and social-group formation (a buddy might be provided, as in AA, as a resource to encourage sobriety). The focus is on developing life skills, such as resisting pressures to drink, coping with stress (at work and in relationships) and building communication skills.
These findings square with what we know about change in other areas of life: People change when they want it badly enough and when they feel strong enough to face the challenge, not when they’re humiliated or coerced. An approach that empowers and offers positive reinforcement is preferable to one that strips the individual of agency. These techniques are most likely to elicit real changes, however short of perfect and hard-won they may be.
Psychologist Stanton Peele first wrote about addiction in the classic Love and Addiction (with Archie Brodsky) in 1975. This summer, his latest book, 7 Tools to Beat Addiction will be published by Random House/Three Rivers Press.
Peele S. The Surprising Truth About Addiction. Psychology Today (2004) May-June: 43-46
Psychology Today, May-June 2004, pp. 43-46
The Surprising Truth About Addiction
Stanton Peele, North Arlington, NJ
Summary: More people quit addictions than maintain them, and they do so on their own. That's not to say it happens overnight. People succeed when they recognize that the addiction interferes with something they value—and when they develop the confidence that they can change.
Change is natural. You no doubt act very differently in many areas of your life now compared with how you did when you were a teenager. Likewise, over time you will probably overcome or ameliorate certain behaviors: a short temper, crippling insecurity.
For some reason, we exempt addiction from our beliefs about change. In both popular and scientific models, addiction is seen as locking you into an inescapable pattern of behavior. Both folk wisdom, as represented by Alcoholics Anonymous, and modern neuroscience regard addiction as a virtually permanent brain disease. No matter how many years ago your uncle Joe had his last drink, he is still considered an alcoholic. The very word addict confers an identity that admits no other possibilities. It incorporates the assumption that you can’t, or won’t, change.
But this fatalistic thinking about addiction doesn’t jibe with the facts. More people overcome addictions than do not. And the vast majority do so without therapy. Quitting may take several tries, and people may not stop smoking, drinking or using drugs altogether. But eventually they succeed in shaking dependence.
Kicking these habits constitutes a dramatic change, but the change need not occur in a dramatic way. So when it comes to addiction treatment, the most effective approaches rely on the counterintuitive principle that less is often more. Successful treatment places the responsibility for change squarely on the individual and acknowledges that positive events in other realms may jump-start change.
Consider the experience of American soldiers returning from the war in Vietnam, where heroin use and addiction was widespread. In 90 percent of cases, when GIs left the pressure cooker of the battle zone, they also shed their addictions—in vivo proof that drug addiction can be just a matter of where in life you are.
Of course, it took more than a plane trip back from Asia for these men to overcome drug addiction. Most soldiers experienced dramatically altered lives when they returned. They left the anxiety, fear and boredom of the war arena and settled back into their home environments. They returned to their families, formed new relationships, developed work skills.
Smoking is at the top of the charts in terms of difficulty of quitting. But the majority of ex-smokers quit without any aid––neither nicotine patches nor gum, Smokenders groups nor hypnotism. (Don’t take my word for it; at your next social gathering, ask how many people have quit smoking on their own.) In fact, as many cigarette smokers quit on their own, an even higher percentage of heroin and cocaine addicts and alcoholics quit without treatment. It is simply more difficult to keep these habits going through adulthood. It’s hard to go to Disney World with your family while you are shooting heroin. Addicts who quit on their own typically report that they did so in order to achieve normalcy.
Every year, the National Survey on Drug Use and Health interviews Americans about their drug and alcohol habits. Ages 18 to 25 constitute the peak period of drug and alcohol use. In 2002, the latest year for which data are available, 22 percent of Americans between ages 18 and 25 were abusing or were dependent on a substance, versus only 3 percent of those aged 55 to 59. These data show that most people overcome their substance abuse, even though most of them do not enter treatment.
How do we know that the majority aren’t seeking treatment? In 1992, the National Institute on Alcohol Abuse and Alcoholism conducted one of the largest surveys of substance use ever, sending Census Bureau workers to interview more than 42,000 Americans about their lifetime drug and alcohol use. Of the 4,500-plus respondents who had ever been dependent on alcohol, only 27 percent had gone to treatment of any kind, including Alcoholics Anonymous. In this group, one-third were still abusing alcohol.
Of those who never had any treatment, only about one-quarter were currently diagnosable as alcohol abusers. This study, known as the National Longitudinal Alcohol Epidemiologic Survey, indicates first that treatment is not a cure-all, and second that it is not necessary. The vast majority of Americans who were alcohol dependent, about three-quarters, never underwent treatment. And fewer of them were abusing alcohol than were those who were treated.
This is not to say that treatment can’t be useful. But the most successful treatments are nonconfrontational approaches that allow self-propelled change. Psychologists at the University of New Mexico led by William Miller tabulated every controlled study of alcoholism treatment they could find. They concluded that the leading therapy was barely a therapy at all but a quick encounter between patient and health-care worker in an ordinary medical setting. The intervention is sometimes as brief as a doctor looking at the results of liver-function tests and telling a patient to cut down on his drinking. Many patients then decide to cut back—and do!
As brief interventions have evolved, they have become more structured. A physician may simply review the amount the patient drinks, or use a checklist to evaluate the extent of a drinking problem. The doctor then typically recommends and seeks agreement from the patient on a goal (usually reduced drinking rather than complete abstinence). More severe alcoholics would typically be referred out for specialized treatment. A range of options is discussed (such as attending AA, engaging in activities incompatible with drinking or using a self-help manual). A spouse or family member might be involved in the planning. The patient is then scheduled for a future visit, where progress can be checked. A case monitor might call every few weeks to see whether the person has any questions or problems.
The second most effective approach is motivational enhancement, also called motivational interviewing. This technique throws the decision to quit or reduce drinking—and to find the best methods for doing so—back on the individual. In this case, the therapist asks targeted questions that prompt the individual to reflect on his drinking in terms of his own values and goals. When patients resist, the therapist does not argue with the individual but explores the person’s ambivalence about change so as to allow him or her to draw his own conclusions: “You say that you like to be in control of your behavior, yet you feel when you drink you are often not in charge. Could you just clarify that for me?”
Miller’s team found that the list of most effective treatments for alcoholism included a few more surprises. Self-help manuals were highly successful. So was the community-reinforcement approach, which addresses the person’s capacity to deal with life, notably marital relationships, work issues (such as simply getting a job), leisure planning and social-group formation (a buddy might be provided, as in AA, as a resource to encourage sobriety). The focus is on developing life skills, such as resisting pressures to drink, coping with stress (at work and in relationships) and building communication skills.
These findings square with what we know about change in other areas of life: People change when they want it badly enough and when they feel strong enough to face the challenge, not when they’re humiliated or coerced. An approach that empowers and offers positive reinforcement is preferable to one that strips the individual of agency. These techniques are most likely to elicit real changes, however short of perfect and hard-won they may be.
Psychologist Stanton Peele first wrote about addiction in the classic Love and Addiction (with Archie Brodsky) in 1975. This summer, his latest book, 7 Tools to Beat Addiction will be published by Random House/Three Rivers Press.
Peele S. The Surprising Truth About Addiction. Psychology Today (2004) May-June: 43-46
Cannabis not implicated in stroke in adolescents.
Cerebellar Infarction in Adolescent Males Associated With Acute MarijuanaUse. Geller T, Loftis L, Brink DS. Pediatrics (2004) 113;4:365-370
Dear Colleagues,
This item provides no evidence that cannabis causes stroke. The authorsclaim it is a possibility but their evidence persuades to the contrary viewon my reading. They even quote the various known 'neuroprotective' andpositive therapeutic effects of cannabis.
In one of the three adolescent stroke cases the authors 'could not get anadequate history of pattern of use' and this patient had negative THCfindings 3 days after supposedly substantial use of the drug. This isinconsistent with my experience as THC remains detectable for many days andsometimes weeks after use. Yet we are quoted a source citing it as apossibility to have a negative qualitative THC finding 3 days after exposure(? a small quantity consumed or ? false negative result). They state thatthe annual rate of stroke in children is approximately 60 per million(regardless of cannabis use). Clearly in late teens there will be aproportion (in fact, an increasing proportion) who happen to be usingcannabis.
In order to test a hypothesis that cannabis leads to stroke, it would beappropriate to look at the many 'natural experiments' where cannabis use hasgained popularity (eg. Jamaica, Greece, Australia). I am not aware of anysuch associations being shown. These authors can only find eight otherliterature references to stroke in young cannabis users and they state thatmost are isolated case reports with some being 'more convincing thanothers'. In addition, it would appear that two of them are by these sameauthors reporting one of these exact same cases.
These authors have been conservative and comprehensive in their descriptionsbut have jumped to a conclusion that cannabis use can cause hypotension and'possibly vasospasm .. resulting in cerebellar ischemia'. This is despitetheir stating that 'The neuropharmacologic literature regarding THCgenerally describes neuroprotective effects . as well as therapeutic effectsincluding analgesia, ocular hypotension and antiemesis. In a rat model offocal cerebral ischemia, synthetic cannabinoid agonists have been reportedto reduce infarct volume'. So it is even conceivable that cannabis mightbenefit stroke victims in certain circumstances.
Thus there is no strong theoretical reason to suppose that cannabis wouldcause stroke and these cases do not argue for it in any scientific wayeither. Casual or coincident use of cannabis in teenagers with other rareillnesses can hardly be taken as evidence of causation.
As ever, this item will be used by those opposing rational drug laws todemand that prohibition is needed more than ever. Yet this very reportcomes from the United States (St Louis, Missouri) where cannabis use andpossession are still severely prosecuted, with very little benefit, itseems, to those intended to be protected such as the tragic cases of theyoung men described in this report. A recent report showed littledifference in cannabis use between San Francisco and Amsterdam wherepolicies are almost opposite.
A report in the Courier Mail (p3, 5/5) stated that "all had apparently beenbinge smoking" which was incorrect (two had possibly been 'binge smoking'while no history was available for the third who may have used no cannabisat all). It also stated that 'the drug has been found to trigger "brainattacks" in teenagers'. This is also inconsistent with my reading of thearticle and shows that the journalist did not read it very carefully.
comments by Andrew Byrne ..
Geller T, Loftis L, Brink DS. Cerebellar Infarction in Adolescent MalesAssociated With Acute Marijuana Use. Pediatrics (2004) 113;4:365-370
Dear Colleagues,
This item provides no evidence that cannabis causes stroke. The authorsclaim it is a possibility but their evidence persuades to the contrary viewon my reading. They even quote the various known 'neuroprotective' andpositive therapeutic effects of cannabis.
In one of the three adolescent stroke cases the authors 'could not get anadequate history of pattern of use' and this patient had negative THCfindings 3 days after supposedly substantial use of the drug. This isinconsistent with my experience as THC remains detectable for many days andsometimes weeks after use. Yet we are quoted a source citing it as apossibility to have a negative qualitative THC finding 3 days after exposure(? a small quantity consumed or ? false negative result). They state thatthe annual rate of stroke in children is approximately 60 per million(regardless of cannabis use). Clearly in late teens there will be aproportion (in fact, an increasing proportion) who happen to be usingcannabis.
In order to test a hypothesis that cannabis leads to stroke, it would beappropriate to look at the many 'natural experiments' where cannabis use hasgained popularity (eg. Jamaica, Greece, Australia). I am not aware of anysuch associations being shown. These authors can only find eight otherliterature references to stroke in young cannabis users and they state thatmost are isolated case reports with some being 'more convincing thanothers'. In addition, it would appear that two of them are by these sameauthors reporting one of these exact same cases.
These authors have been conservative and comprehensive in their descriptionsbut have jumped to a conclusion that cannabis use can cause hypotension and'possibly vasospasm .. resulting in cerebellar ischemia'. This is despitetheir stating that 'The neuropharmacologic literature regarding THCgenerally describes neuroprotective effects . as well as therapeutic effectsincluding analgesia, ocular hypotension and antiemesis. In a rat model offocal cerebral ischemia, synthetic cannabinoid agonists have been reportedto reduce infarct volume'. So it is even conceivable that cannabis mightbenefit stroke victims in certain circumstances.
Thus there is no strong theoretical reason to suppose that cannabis wouldcause stroke and these cases do not argue for it in any scientific wayeither. Casual or coincident use of cannabis in teenagers with other rareillnesses can hardly be taken as evidence of causation.
As ever, this item will be used by those opposing rational drug laws todemand that prohibition is needed more than ever. Yet this very reportcomes from the United States (St Louis, Missouri) where cannabis use andpossession are still severely prosecuted, with very little benefit, itseems, to those intended to be protected such as the tragic cases of theyoung men described in this report. A recent report showed littledifference in cannabis use between San Francisco and Amsterdam wherepolicies are almost opposite.
A report in the Courier Mail (p3, 5/5) stated that "all had apparently beenbinge smoking" which was incorrect (two had possibly been 'binge smoking'while no history was available for the third who may have used no cannabisat all). It also stated that 'the drug has been found to trigger "brainattacks" in teenagers'. This is also inconsistent with my reading of thearticle and shows that the journalist did not read it very carefully.
comments by Andrew Byrne ..
Geller T, Loftis L, Brink DS. Cerebellar Infarction in Adolescent MalesAssociated With Acute Marijuana Use. Pediatrics (2004) 113;4:365-370
Nicotine without soot, etc. Can it be safer to chew?
Chewing tobacco - is it better than smoking?
http://bmj.bmjjournals.com/cgi/content/full/328/7444/885
.
http://www.nytimes.com/2004/04/06/health/06ESSA.html
Dear Colleagues,
Two recent items have focussed on reduced tobacco harms. A BMJ article has looked at the logic in cutting down the numbers of cigarettes smoked, reduced-tar products, switching to pipes or cigars, use of ‘smokeless tobacco’, use of nicotine replacement while still smoking and finally, the use of oral tobacco wads (‘snus‘) as used in Sweden.
This article opens the possibility that some effort to reduce harms may inadvertently do the opposite. ‘Low tar’ cigarettes are in general also ‘low nicotine’ products, so people might even smoke increased numbers of cigarettes, or inhale more deeply in an effort to get more nicotine. Likewise, cutting the number of cigarettes may lead to deeper inhalations and thus potentially more harmful smoke exposure.
Dr Sally Satel, in an opinion piece in the New York Times supports the harm minimization benefits of ‘snus’ which she believe should be a choice for smokers. Despite an incidence of oral cancer, the overall risks are apparently much lower than the many dangers faced by tobacco smokers. Satel quotes enviable statistics from Sweden where the product takes up half the market. It is banned in most other countries.
It would seem that at the very least we should support limited availability of the product to examine it acceptability, benefits and dangers in the Australian situation. I vote that NSW be first to lift the current ban on wad tobacco and carefully investigate the consequences.
comments by Andrew Byrne ..
http://bmj.bmjjournals.com/cgi/content/full/328/7444/885
.
http://www.nytimes.com/2004/04/06/health/06ESSA.html
Dear Colleagues,
Two recent items have focussed on reduced tobacco harms. A BMJ article has looked at the logic in cutting down the numbers of cigarettes smoked, reduced-tar products, switching to pipes or cigars, use of ‘smokeless tobacco’, use of nicotine replacement while still smoking and finally, the use of oral tobacco wads (‘snus‘) as used in Sweden.
This article opens the possibility that some effort to reduce harms may inadvertently do the opposite. ‘Low tar’ cigarettes are in general also ‘low nicotine’ products, so people might even smoke increased numbers of cigarettes, or inhale more deeply in an effort to get more nicotine. Likewise, cutting the number of cigarettes may lead to deeper inhalations and thus potentially more harmful smoke exposure.
Dr Sally Satel, in an opinion piece in the New York Times supports the harm minimization benefits of ‘snus’ which she believe should be a choice for smokers. Despite an incidence of oral cancer, the overall risks are apparently much lower than the many dangers faced by tobacco smokers. Satel quotes enviable statistics from Sweden where the product takes up half the market. It is banned in most other countries.
It would seem that at the very least we should support limited availability of the product to examine it acceptability, benefits and dangers in the Australian situation. I vote that NSW be first to lift the current ban on wad tobacco and carefully investigate the consequences.
comments by Andrew Byrne ..
Complications from Pittsburgh rapid opioid detox series.
Unexpected Delirium During Rapid Opioid Detoxification (ROD), Golden SA, Sakhrani DL. Journal of Addictive Diseases 2004 23;1:65-74
Dear Colleagues,
This is one of the very few descriptions of a series of rapid opioid detoxification (ROD) cases. Many such reports have been anecdotal, coronial or selected cases, and thus of limited scientific value. This Pittsburgh series is drawn from 20 consecutive patients ‘requesting’ rapid detoxification with an appraisal of their outcomes and complications. Some of these complications are very worrying, and they are not infrequent. Five patients (25%) developed delirium and had to have the procedure abandoned. One of the 5 patients who developed delirium had to be treated in intensive care for hypotension. Another had bradycardia, a problems also reported by the Spanish group with most experience in this area (Seaone et al.). One further patient of this twenty refused to take the naltrexone on day two. Thus an early relapse rate of 30% may be indicated. The average hospital stay was 6 days.
Even though the follow up is patchy (it only lasted for ‘the study period’, the length of which was not stated), at least 4 (20%) cases had to be readmitted for further detoxification (‘traditional’, not ‘ROD’) in the immediate post-treatment period at the same institution while others treated lived at some distance and could not be followed up at all.
These results are extremely poor compared with other reports, but they would appear to be influenced by very high rates of depression, anxiety and other co-morbid conditions, notably the use of benzodiazepines and other drugs in combination with opiates. Also, it is hardly surprising that the patients who were being forcibly reduced from methadone would not do well with an abstinence based treatment.
According to some experts, rapid opioid detoxification is most likely to prove appropriate for a group of addicts who (1) are pure opiate users, (2) do not suffer severe Axis II disorders, (3) who have had beneficial periods of abstinence in the past, (4) who suffer particularly severe EARLY withdrawal symptoms with traditional detoxification AND (5) who are competently assessed as being currently 'equipped' for abstinence. Importantly, this means that it is not a sufficient criterion for rapid detox to just ‘not want methadone’. Similarly, few diabetics would choose insulin treatment unless there were no simpler alternative.
comments by Andrew Byrne ..
Citation:
Golden SA, Sakhrani DL. Unexpected Delirium During Rapid Opioid Detoxification (ROD). Journal of Addictive Diseases 2004 23;1:65-74
Dear Colleagues,
This is one of the very few descriptions of a series of rapid opioid detoxification (ROD) cases. Many such reports have been anecdotal, coronial or selected cases, and thus of limited scientific value. This Pittsburgh series is drawn from 20 consecutive patients ‘requesting’ rapid detoxification with an appraisal of their outcomes and complications. Some of these complications are very worrying, and they are not infrequent. Five patients (25%) developed delirium and had to have the procedure abandoned. One of the 5 patients who developed delirium had to be treated in intensive care for hypotension. Another had bradycardia, a problems also reported by the Spanish group with most experience in this area (Seaone et al.). One further patient of this twenty refused to take the naltrexone on day two. Thus an early relapse rate of 30% may be indicated. The average hospital stay was 6 days.
Even though the follow up is patchy (it only lasted for ‘the study period’, the length of which was not stated), at least 4 (20%) cases had to be readmitted for further detoxification (‘traditional’, not ‘ROD’) in the immediate post-treatment period at the same institution while others treated lived at some distance and could not be followed up at all.
These results are extremely poor compared with other reports, but they would appear to be influenced by very high rates of depression, anxiety and other co-morbid conditions, notably the use of benzodiazepines and other drugs in combination with opiates. Also, it is hardly surprising that the patients who were being forcibly reduced from methadone would not do well with an abstinence based treatment.
According to some experts, rapid opioid detoxification is most likely to prove appropriate for a group of addicts who (1) are pure opiate users, (2) do not suffer severe Axis II disorders, (3) who have had beneficial periods of abstinence in the past, (4) who suffer particularly severe EARLY withdrawal symptoms with traditional detoxification AND (5) who are competently assessed as being currently 'equipped' for abstinence. Importantly, this means that it is not a sufficient criterion for rapid detox to just ‘not want methadone’. Similarly, few diabetics would choose insulin treatment unless there were no simpler alternative.
comments by Andrew Byrne ..
Citation:
Golden SA, Sakhrani DL. Unexpected Delirium During Rapid Opioid Detoxification (ROD). Journal of Addictive Diseases 2004 23;1:65-74
Cannabis not implicated in stroke in adolescents.
Cerebellar Infarction in Adolescent Males Associated With Acute Marijuana Use. Geller T, Loftis L, Brink DS. Pediatrics (2004) 113;4:365-370
Dear Colleagues,
This item provides no evidence that cannabis causes stroke. The authors claim it is a possibility but their evidence persuades to the contrary view on my reading. They even quote the various known ‘neuroprotective’ and positive therapeutic effects of cannabis.
In one of the three adolescent stroke cases the authors ‘could not get an adequate history of pattern of use’ and this patient had negative THC findings 3 days after supposedly substantial use of the drug. This is inconsistent with my experience as THC remains detectable for many days and sometimes weeks after use. Yet we are quoted a source citing it as a possibility to have a negative qualitative THC finding 3 days after exposure (? a small quantity consumed or ? false negative result). They state that the annual rate of stroke in children is approximately 60 per million (regardless of cannabis use). Clearly in late teens there will be a proportion (in fact, an increasing proportion) who happen to be using cannabis.
In order to test a hypothesis that cannabis leads to stroke, it would be appropriate to look at the many ‘natural experiments’ where cannabis use has gained popularity (eg. Jamaica, Greece, Australia). I am not aware of any such associations being shown. These authors can only find eight other literature references to stroke in young cannabis users and they state that most are isolated case reports with some being ‘more convincing than others’. In addition, it would appear that two of them are by these same authors reporting one of these exact same cases.
These authors have been conservative and comprehensive in their descriptions but have jumped to a conclusion that cannabis use can cause hypotension and ‘possibly vasospasm .. resulting in cerebellar ischemia’. This is despite their stating that ‘The neuropharmacologic literature regarding THC generally describes neuroprotective effects … as well as therapeutic effects including analgesia, ocular hypotension and antiemesis. In a rat model of focal cerebral ischemia, synthetic cannabinoid agonists have been reported to reduce infarct volume’. So it is even conceivable that cannabis might benefit stroke victims in certain circumstances.
Thus there is no strong theoretical reason to suppose that cannabis would cause stroke and these cases do not argue for it in any scientific way either. Casual or coincident use of cannabis in teenagers with other rare illnesses can hardly be taken as evidence of causation.
As ever, this item will be used by those opposing rational drug laws to demand that prohibition is needed more than ever. Yet this very report comes from the United States (St Louis, Missouri) where cannabis use and possession are still severely prosecuted, with very little benefit, it seems, to those intended to be protected such as the tragic cases of the young men described in this report. A recent report showed little difference in cannabis use between San Francisco and Amsterdam where policies are almost opposite.
A report in the Courier Mail (p3, 5/5) stated that “all had apparently been binge smoking” which was incorrect (two had possibly been ‘binge smoking’ while no history was available for the third who may have used no cannabis at all). It also stated that ‘the drug has been found to trigger “brain attacks” in teenagers’. This is also inconsistent with my reading of the article and shows that the journalist did not read it very carefully.
comments by Andrew Byrne ..
Geller T, Loftis L, Brink DS. Cerebellar Infarction in Adolescent Males Associated With Acute Marijuana Use. Pediatrics (2004) 113;4:365-370
Dear Colleagues,
This item provides no evidence that cannabis causes stroke. The authors claim it is a possibility but their evidence persuades to the contrary view on my reading. They even quote the various known ‘neuroprotective’ and positive therapeutic effects of cannabis.
In one of the three adolescent stroke cases the authors ‘could not get an adequate history of pattern of use’ and this patient had negative THC findings 3 days after supposedly substantial use of the drug. This is inconsistent with my experience as THC remains detectable for many days and sometimes weeks after use. Yet we are quoted a source citing it as a possibility to have a negative qualitative THC finding 3 days after exposure (? a small quantity consumed or ? false negative result). They state that the annual rate of stroke in children is approximately 60 per million (regardless of cannabis use). Clearly in late teens there will be a proportion (in fact, an increasing proportion) who happen to be using cannabis.
In order to test a hypothesis that cannabis leads to stroke, it would be appropriate to look at the many ‘natural experiments’ where cannabis use has gained popularity (eg. Jamaica, Greece, Australia). I am not aware of any such associations being shown. These authors can only find eight other literature references to stroke in young cannabis users and they state that most are isolated case reports with some being ‘more convincing than others’. In addition, it would appear that two of them are by these same authors reporting one of these exact same cases.
These authors have been conservative and comprehensive in their descriptions but have jumped to a conclusion that cannabis use can cause hypotension and ‘possibly vasospasm .. resulting in cerebellar ischemia’. This is despite their stating that ‘The neuropharmacologic literature regarding THC generally describes neuroprotective effects … as well as therapeutic effects including analgesia, ocular hypotension and antiemesis. In a rat model of focal cerebral ischemia, synthetic cannabinoid agonists have been reported to reduce infarct volume’. So it is even conceivable that cannabis might benefit stroke victims in certain circumstances.
Thus there is no strong theoretical reason to suppose that cannabis would cause stroke and these cases do not argue for it in any scientific way either. Casual or coincident use of cannabis in teenagers with other rare illnesses can hardly be taken as evidence of causation.
As ever, this item will be used by those opposing rational drug laws to demand that prohibition is needed more than ever. Yet this very report comes from the United States (St Louis, Missouri) where cannabis use and possession are still severely prosecuted, with very little benefit, it seems, to those intended to be protected such as the tragic cases of the young men described in this report. A recent report showed little difference in cannabis use between San Francisco and Amsterdam where policies are almost opposite.
A report in the Courier Mail (p3, 5/5) stated that “all had apparently been binge smoking” which was incorrect (two had possibly been ‘binge smoking’ while no history was available for the third who may have used no cannabis at all). It also stated that ‘the drug has been found to trigger “brain attacks” in teenagers’. This is also inconsistent with my reading of the article and shows that the journalist did not read it very carefully.
comments by Andrew Byrne ..
Geller T, Loftis L, Brink DS. Cerebellar Infarction in Adolescent Males Associated With Acute Marijuana Use. Pediatrics (2004) 113;4:365-370
1 May 2004
American Psychiatric Association, 2004 Annual Meeting, "Dissolving the Mind-Brain Barrier"
1-6 May 2004
Psychotherapy and Psychopharmcotherapy. Dissolving the Mind-Brain Barrier. New York. 157th annual Meeting.
Dear Colleagues,
I have had an opportunity to review the enormous 'proceedings summary' for this conference given to me by one of the large group of Australian psychiatrists who attended. It consisted of 370 pages of very small print! Like all big scientific conferences these days, nobody could attend all the parallel sessions and it is hard to imagine that they could not have been pared down for relevance, quality and length. Regarding addiction related presentations there was a mixture and these also varied in quality. In our field we are used to being left to the end of days, following the other more 'mainstream' topics.
Even some of the general lectures/workshop titles were very esoteric. 'Music and the mind: Beethoven'; 9/11 Research: Reviews; 'Surviving Jock Culture'; 'Why does the human brain become addicted'; 'The brain in love'; 'Better Sex: Naturally'; 'Postwar mental health services'; 'Leash on life: Human attachment to animals'; 'Detection of Malingering'; 'Juvenile Justice . Jazz and Blues'; 'Sexual satisfaction . in Orthodox Jewish Women'; 'The sissy duckling . gender variance'; 'Psychotherapy in Asian women'; 'Gayness and God'; 'Modafinil treatment of chronic shift work sleep disorder'; 'Food and drug cravings: metaphor or common mechanism?' . I could go on . Yoga techniques, show biz, teaching, forensic psychiatry, twin studies, topiramate for alcoholism, terrorism, PTSD, AA, ADD, etc, etc, etc.
From the program, there was still plenty for the 'bread-and-butter' psychiatry issues of anxiety, depression and psychoses, as behoves such a large conference. We forget just how 'big' psychiatry is in the United States. While it is exceptional for Australians to have a psychiatrist, it is almost compulsory for middle class Americans.
Regarding addiction, there were a number of papers, many authored by well known researchers and clinicians but on a surprisingly limited range of subjects. These mostly revolved around the newfound availability of buprenorphine for maintenance of opioid addiction in office based practice. When properly used, such work can be enormously professionally rewarding . and prescribing opioids to addicts is something American doctors have been largely banned from doing since the 1920s. Also, uniquely in the US, pharmacists are barred from administering methadone in the treatment of addiction. Buprenorphine (mostly in combination with naloxone) has been made available on a 'waiver' prescription system under the Drug Addiction Treatment Act of 2000 from certified doctors as outpatient management. This is without the normal addiction clinic requirements for supervised administration, counselling, urine testing, etc. Medication can be prescribed for up to six months on one prescription, including repeats or 'refills'.
There were also numerous papers on cocaine and cannabis, with uniquely American flavours, and thus often of limited relevance to normal medical practice in other countries.
Nowhere was there mention of the current uncomfortable conundrum of doctors sometimes prescribing the second best drug for arbitrary regulatory reasons. Methadone is the recommended maintenance drug for pregnant addicts, yet it is not available in some states and is very limited in the others. Methadone is also more effective than buprenorphine for those with high tolerance. Trials often show better outcomes for methadone so it should be the first line drug in some or even most patients. One could understand this being omitted by the authors in the section sponsored by drug companies. Yet it is not mentioned in the many other free papers, as far as I could determine.
Many of the most prominent personalities of drug research in the US were represented here, including names like Ling, Kosten, Kleber, Galanter, McNicholas, Volkow, Rounseville, Portnoy, Tsuang, O'Brien, Millman, McLellan and Bankole Johnson.
Some of their views were controversial, others questionable, such as the claim that methadone should be avoided in HIV cases because of its supposed negative effect on the immune system. The myths of buprenorphine being easier to withdraw from and having less dependence features were also resurrected by some contributors. Buprenorphine withdrawals have no better success than methadone withdrawals. Nobody ever mentions the rather important fact that there are simply no long-term safety data on buprenorphine, especially in combination with naloxone. Indeed, the manufacturer seems not to be sponsoring any such research currently.
It was gratifying to find so many papers on nicotine dependence. In my view psychiatrists have a much wider community responsibility than immediate patient care. It is tragic that is has taken so long for them to realise what psychiatrist Marie Nyswander wrote about 50 years ago . that treating addicts with psychotherapy was fraught with frustration without using maintenance pharmacotherapy for appropriate cases. And with such therapy it can be enormously rewarding for doctor and patient as addicts put their often considerable talents towards normal life issues rather than constantly procuring drugs.
There were only small contributions from overseas including adolescent psychiatry (one from ANU and another from the UK). There was also a reference in Walter Ling's insightful paper on treating chronic pain in maintenance patients. He quoted some important work from Adelaide researchers on the subject of induced hyperalgesia in such patients and the need for different approaches for the future as there will be so many more such patients. Australia has contributed much to the field of psychiatry (eg. a Melbourne doctor first devised lithium treatment).
It is a shame that more prominence was not given to a RCT by Bankole Johnson in which he measured quality of life in alcoholics given topiramate, a new drug used for cravings and/or relapse prevention. There was a significant positive effect. So now we have at least four drugs in this class: naltrexone, acamprosate, ondansetron and topiramate. The latter two could only be used off-label in Australia and thus should probably only be prescribed in specialist or research settings. The first two should be familiar to all Australia doctors who come into contact with alcoholics - and who doesn't?
Comments by Andrew Byrne ..
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