‘Addiction’: November 2004. A few seasonal observations.
# “Moo Joose” controversy.
# Addiction treatment compliance.
# Long-acting injectable ‘depot’ buprenorphine.
# Brief interventions on the web; twin study on alcoholism; ketamine brain damage; cannabis psychosis book review.
On the eve of a century of publication, this issue demonstrates the best and worst features of Addiction. The content of individual issues sometimes reveals editorial shortcomings and apparent inconsistencies yet an examination of a whole year’s titles would leave little doubt as to this journal’s editorial policy directions. These are well known to regular readers. On the positive side, the issue maintains an elegantly balanced dual thematic ‘leitmotif’, this month being a combination of modern approaches to alcohol policy and compliance to pharmacotherapy treatment for alcohol and drug problems. Authors represented in November include such luminaries as Anderson, Berridge, Bigelow, Caswell, Curran, Hickman, Kleber, Klingermann, Petry, Rhodes, Saunders, Tsuang and West. It is to Griffith Edwards’ credit that few other scientific journals in the world could boast such a line-up of experts in the one monthly edition. Clearly Addiction has the confidence of those in the research field.
The ‘Moo Joose’ (alcoholic flavoured milk) story is an example of how an important and topical subject should NOT be dealt with. Where there is clearly a divergence of opinion the case should be made with commentaries from the protagonists and experts but here we have only one side of the matter as so often happens in Addiction. Mr Aldred and his Alcohol and Drug Foundation (Queensland) are roundly criticised in the item as having changed their view on this product as a result of influence from the alcohol industry. However, they were not asked by Addiction to provide a comment (personal communication, 14/12/04). Nor, it appears, was the alcohol industry or government.
While many of us may agree with aspects of Munro’s critical report, it is hardly useful to have our own misgivings repeated by experts who have little more information than we do ourselves. And sadly, it is nothing novel for the beverage industry to chalk up another victory regarding alcohol marketing, against the advice of public health experts. The invited commentaries are therefore not balanced, nor are all the facts yet to come in on the matter, as pointed out in one frank review by Virginia Berridge. To her credit, she points out that Munro’s item raises as many questions as it answers. Yet editor Edwards, perhaps in hasty indignation, allows this antipodean tabloid teacup tempest to dominate his ‘scientific’ journal (items 2 to 9). So much for his maxim of encouraging ‘robust debate between people of goodwill’.
‘Moo Joose’ may be novel, and the final outcome possibly instructive but there are also matters of major moment from closer to home needing to be covered. Edwards has still not addressed the scandalously low standard of dependency treatment given by many of his British colleagues to hapless addicts in England. Details of this have been documented in the small print of his own journal many times over the years. I understand from impeccable sources that the average methadone dose prescribed in the UK is around 37mg daily, and further, that the most commonly prescribed daily dose is 30mg! These facts may partially explain why maintenance treatments have such a poor reputation in the UK. The official UK guidelines state that 60mg is the usual effective minimum.
While on this subject, it is hard to understand how Professor Weiss from Harvard could possibly omit methadone compliance and retention in his item (No 10) entitled ‘Adherence to pharmacotherapy in patients with alcohol and opioid dependence’. [Addiction (2004) 99: 1382-92]. Could it be that Addiction does not want to ‘offend’ by mentioning methadone at all? (shades of ‘Don’t mention the war!’).
Perhaps the most interesting item was the evaluation of an injected depot formulation of buprenorphine against placebo comparison. In an experimental in-patient detoxification setting, Sigmon, Bigelow and colleagues found few differences in responses over 6 weeks between those given the active opioid and those given placebo (my more complete summary elsewhere).
Perhaps the wisest commentary is last, the second ‘letter to the editor’ (actually an invited commentary) being from Herbert Kleber who has been around a long time and seen much come and go. Despite accepting some potential benefits, he also expresses concerns about depot and implanted medications, detailing the disadvantages. These include costs, painful administration, infections and a lack of ability to adjust the dose. Some, such as depot injections, do not allow removal but commit the patient to weeks or months of treatment. It reminded me of a Sydney University professor who was given an injection of procaine penicillin, having omitted to mention his life-long allergy. He apparently spent the next fortnight going in and out of anaphylaxis, needing adrenalin and cortisone treatment. I note with concern that in Sigmon’s trial they did not give a test dose of buprenorphine so allergies, although unusual with pure opioids, would not be have been detected until after a depot injecting was given. Depot preparations usually include numerous other chemicals (to delay absorption, preservatives, stabilizers, etc).
An extraordinary item on time-frames in Swiss alcohol and drug clinics tries to tease differences between social times and clock times (Klingermann & Schibili).
Kypri, Saunders and colleagues take alcohol brief interventions to the web, reporting benefits on both drinking and personal problems which declined with time in university students with hazardous drinking.
Liu, Tsuang and colleagues provide yet another examination of the huge Vietnam war era twin register to determine genetic influences on the age of onset of alcohol dependence.
There is an item on the long-term effects of ketamine, a sometimes popular illicit psychodelic anaesthetic agent. The authors find that there are some transient and other more long-lived side effects from heavy ketamine use, warning that users and potential users should be aware of such effects on memory and subjective experience. As usual with such items, there is no comparison with subjects who drink alcohol to excess, nor the degree of harms or benefits resulting from the illicit status of the drug in most countries.
David M. Fergusson gives an erudite book review on ‘Marijuana and Madness’, quoting some authoritative reports favouring causation as well as one discounting it. Recent writings on the subject make it clear that cannabis still may actually cause some cases of schizophrenia, but at most it could only account for a very small proportion of the total number of cases (well under 10% and possibly as low as 2%. Thus only with a massive increase in cannabis use could changes in prevalence be detectable in mental health statistics. For a comprehensive review of the current evidence see the current Drug and Alcohol Review which contains several relevant items.
Finally come two informative items pertaining to our most destructive drug, tobacco. Aspects of nicotine replacement and bupropion are examined from a general medical practice angle as well as certain gender differences in treatment response.
This is the second last edition under the editorship of Griffith Edwards. On 1st January 2005 he becomes “Commissioning editor“ - whatever that may mean. We are assured by Robert West, the new editor, that there will be more of the same.
comments by Andrew Byrne FAChAM ..
