'Addiction' supplement December 2002. "Treatment of marijuana disorders". Edited by Michael L. Dennis and Thomas F. Babor.
Dear Colleagues,
This edition of Addiction on cannabis is most unusual in several respects, for a scientific journal. Least controversial is that 'cannabis', the normal scientific term, is used interchangeably with the American intrusive term 'marijuana' which should probably now be avoided in serious research writing. Further, some authors appear to assume that cannabis use automatically warrants the term 'disorder' and still further that this is requires treatment in a high proportion of cases. This Addiction 'special issue' was 'made possible by the Center for Substance Abuse Treatment (CSAT) ... US Department of Health and Human Services'. This sort of patronage of a scientific journal is unusual in my experience. I do not know whether 'special editions' or 'supplements' as such are peer reviewed in the normal way.
The two introductory pieces, each including the contributing 'guest editors' (one being a regular Addiction regional editor), repeatedly emphasise the importance and prevalence of cannabis problems and thus the crucial place of good research and translating this into clinical practice. One can only agree. It is only in the third last paragraph of these 15 pages that they concede that existing treatment for cannabis dependence is associated with smaller reductions in drug use than with other drugs, and, especially in adolescents and young adults "in some cases actually increase their [cannabis] use". This important latter statement is written in parentheses for no syntactical reason that I could detect.
Quite rightly, emphasis is given by the authors to the age of first use of cannabis and the likelihood of problems in later life. They state rather cumbersomely: "The likelihood of having tobacco or alcohol problems is highest (39% and 45% respectively) for adolescents who first tried these substances prior to age 15 and the rates decline with later onset. ... For cannabis and other drugs there is a very different pattern: the rate of problems is more than 60% among people who first used prior to age 15. Although the rates decline in the older onset age cohorts, they never fall below 50% for a given substance. (The two exceptions to this pattern are cocaine and heroin, which have a high risk of problems regardless of the age of first use)."
These authors make a bold statement, then contradict it parenthetically for two of the most troublesome drugs in that country. "Never" usually means 'never'. But not, evidently, when followed by a sentence put in parentheses. This subject is too important to use less-than-accurate unscientific or ill defined language. We should use clear, correct and importantly, unemotional language when addressing one of the major problems facing modern society, being drug use in young people. We know that a scientific approach to any subject is more likely to result in optimal outcomes ... be it drug treatment, population control, HIV/AIDS, malaria programs or other endeavours. There are a number of important inconsistencies in this issue of Addiction.
There appear to be unwritten assumptions about cannabis use and its dangers in a section entitled "Beyond Benign Neglect". Referring to those in whom treatment was 'mandated', the authors state: "Even those who are not cannabis-dependent demonstrate a wide range of functional impairment (eg. missing work, school, fighting, arrests, injuries) that varies with their frequency of using cannabis use." Apart from awkward English, this would seem to imply that cannabis use is often associated with delinquency and perhaps (but without any references) in a *causative* manner.
These authors detail the widespread availability, relative cheapness and strength of cannabis in America, but there is only passing reference to the failure of legal sanctions to keep the drug out of the reaches of young people. It is a serious oversight to ignore good research from Holland, a comparable western country which has had virtually legal availability of cannabis for adults for over a generation. I cannot imagine any reason why serious, experienced researchers and commentators would choose to neglect such a major source of evidence on cannabis harms.
There is still a major problem with terminology when some authors consider cannabis use needful of treatment may consist of only weekly drug use episodes. True cannabis dependence is a problem and certainly needs all of our efforts as professionals in the field. But some would consider a program which sought to address once weekly cannabis use in teenagers as rather 'low-priority' in the scheme of drug related harms, and when compared against the major problems of hepatitis C, overdose, depression and dependence (not to mention bush fires and terrorism).
Dennis and colleagues describe the Cannabis Youth Treatment (CYT) experiment in the first research report in this Addiction supplement. They randomly assigned young people referred from a variety of agencies to be treated with one of five behavioural therapies including CBT and family therapy. But when describing 'existing practice' for 150,000 adolescents treated in 1998, it is stated that half used the drug only weekly. It is hard to take the rest of their work seriously when they are 'treating' a large proportion of young people who may not qualify for a DSM IV category for either abuse or dependence.
Dennis and co-authors stress that they were anxious to be able to generalise their results to the American community. It is disappointing, therefore, that they excluded 44% of 1250 referrals on a number of criteria. These included those who (i) had used other drugs/alcohol to a significant degree (ii) had a substantial medical or psychological diagnosis, (iii) were intellectually impaired, (iv) had a severe conduct disorder or impending incarceration, (v) lacked an available English speaking parent. Another 15% declined to be involved while over half of those accepted felt that they did not need treatment for cannabis use. About two thirds were coerced by the American judicial system making the results less meaningful scientifically in other jurisdictions such as Canada, UK or Australia. Fully 80% did not view their cannabis use as 'a problem'. Only 45% were classified as cannabis dependent, yet we are given the intriguing information that this figure rises to 76% if the parents' opinions are included (!).
Self report of cannabis use in the previous month at intake, three and six months was 83%, 59% and 58%. On-site urine testing performed at the same intervals was positive for 76%, 68% and 71%. These hardly give rise to great optimism for the five programs being trialed. Nor is any statistical significance given for these modest and seemingly unimpressive, if downward, trends. No explanation is given for the remarkable finding that up to a quarter of the enrolled subjects were not actually using cannabis at or near the start of 'treatment' by either self report or urine test.
Therapy sessions were taped and reviewed with which some may find a fundamental ethical discomfort. Retention is incompletely reported, eg. 81% completed 2 months or more of a 3 month program (mean 80 days). The average stay in a 5-6 week treatment was 43 days which seems unlikely if not impossible unless there were 'overstayers'. To the credit of these researchers, it appears that over 90% of subjects were interviewed at 3, 6, 9 and 12 months using various extensive means of contact.
With high expectations I read on to find that these researchers, who repeatedly stressed the importance of their work, give no outcome results despite their comparative 'manual' intervention 'treatment phase' ending over two years ago. They whet our appetite by stating that after some preliminary results reported here, "more will be forthcoming in the coming years". Of the copious references fully 37 are from these authors themselves and their own institutions, showing their publishing prowess and perhaps also just how small the cannabis 'treatment' field actually is.
In this special issue of Addiction there follows a series of 6 "research reports", mostly from the same stable of authors as the initial report and involving one or both guest editors. These mostly document various aspect of the conduct of the same study of 600 American teenagers who chose to use cannabis and came to attention of the treatment fraternity. Once again, the wider field is not always considered in most of these, notably the item on costs which omits to compare the cost of legal sanctions which are the primary option used in some countries for drug control amongst their citizenry. The second part of this Supplement is devoted to the Marijuana Treatment Project looking at long term cannabis users and three treatment interventions. Sadly, this is just a description of the trial (including an interesting 'delayed treatment control') but again, no outcome results!
Considering the widespread use of cannabis and its propensity to cause problems in some users, especially young people, research of this nature is very important. However it is most unusual to publish details and proposals in peer reviewed journals before results are collated. Surely it is putting the cart before the horse - especially when some such programs have shown little, or even negative impact on drug use in the past. Some of the subjects are probably normal adolescents and the chance of 'treatment' improving their outcomes is simply not a consideration. The decision to omit the "no treatment" or 'control' option for treatment interventions was taken for stated reason that "past studies have shown consistently that untreated or minimally treated adolescents become worse or fail to improve". Many would disagree with this deduction and some may even find it spurious. Without controls the rigour of any study is reduced, which is very disappointing for a large, prospective intervention such as this.
comments by Andrew Byrne ..
citations:
Dennis M, Titus JC, Diamond G, Donaldson J, Godley SH, Tims FM, Webb C, Kaminer Y, Babor T, Roebuck MC, Godley MD, Hamilton N, Liddle H, Scott CK & CYT Steering Committee. The Cannabis Youth Treatment (CYT) experiment: rationale, study design and analysis plans. Addiction (2002) 97 (Suppl )1 16-34
Stephens RS, Babor TF, Kadden R, Miller M. Marijuana Treatment Project (MTP). Addiction (2002) 97 (Supp )1 109-124
11 October 2002
Young Australian visits Mayo Clinic in 1924. Lost letters found!
In 1924, my 24 year old maternal grandfather was asked to accompany a family friend to the Mayo Clinic in Rochester, Minnesota. Australian doctors advised the trip for an illness plaguing his friend, Bill Treloar of Tamworth, NSW.
Drs William and Charles Mayo were among the first to use a team approach in medical treatment. Having pioneered the medical specialties and the sharing of medical records, the Mayo Clinic's fame had spread, even downunder.
The young Australians' trip of 5 months took in Tahiti, California, Rochester, New York and London, returning via Suez and Perth. The letters excerpted below lay ignored for almost 80 years until I sought them from my uncle Bill Gracie in Muwillumbah, near the Queensland border. A bank teller, Harry Gordon Gracie later became ANZ manager in the Riverina, Hunter and New England regions. The letters are addressed to his family in Artarmon, just north of the Sydney Harbour Bridge (which had yet to be built). They will interest modern medicos, being a young man's observations of a famous medical institution in a period of great change in our profession.
Hotel Campbell, Rochester, Minnesota
23 Sept 1924
My dear mother,
Rochester, Minnesota is where the Mayo Bros are and where I hope Bill will get fixed up. The first part of our long journey from Sydney now over, we are resting for a little while. Bill is attending the clinic, so far with good results. He was up at the Clinic again this morning and when he returned we took a car without a driver to see the sights around the town. The total cost for the hire of a Ford Coupe, nearly new was 9/- so we consider that is dirt cheap.
The Mayo Clinic here just keeps the town. It is a marvellous place with 300 doctors employed all under the direct control of the Mayos. The people flock to them in thousands every day. The town lists its population at 13,000 while there are always at least 25,000 in the place. Of course it is full of hotels and hospitals and cripples of all sorts abound. It is a pitiful sight to stand outside the clinic and watch the hundreds pouring in and out, the whole time suffering from every known form of disease - and some, I suppose, unknown. And they line up in queues to wait their turn. It puts one in mind of Hickson's Mission but on a much larger scale.
The American scenery is very fine their cities large and convenient - their people are all only too willing to explain anything to you and take you about when you come to their home town. But everything in the place is artificial. They talk and think of nothing else but the almighty $ and the shortest way to pack up a stack of them. There is nothing substantial about the places we have so far seen in San Francisco and Los Angeles. They are all jerrybuilt homes and buildings, put up in quick time.
We are both well. Bill is brighter than previously by a long way - while I have put on 5lbs since leaving Sydney!
Often I would give a pound for a long iced lager. One can get lots of spirits in this place - and good stuff too I believe - but not for me, thanks! Everyone laughs at the Prohibition laws here and they drink hard.
[and a subsequent letter ...] after a little over a week Bill is ever so much better - the doctors have now finished their examinations of him. They put him on a diet and he finishes the course today. On Friday next he goes back to the Clinic and has his final instructions. We are hoping to leave then to continue our trip on to Buffalo and New York.
Yesterday called into a stud farm of Holstein cattle owned by the State Hospital. It is a wonderful affair. The patients are all mental cases and they milk 150 cows twice a day by hand. The milk is used in the hospitals around. The bails are enormous as they bail all the cows at the same time and they always go to the same bail. Their milk is tested every time. Last night I went to a village dance in town with some girls from the hotel. They are nurses from the clinic. Bill went to bed.
We have just about seen all there is to see in this place as an old chap who devotes his life to wheeling patients about for the love of it has taken a great fancy to us. Johnny McBride, the "Angel of the Wheelchairs" at Rochester has shown us all over the town. One day he took us to the basement of the Colonial Hospital and from there through a subway to the Kahler Hotel. We went up to the top and saw all over the city from the 14th floor. The Kahler is a combination affair. The basement is set apart for nurses, rest rooms, etc. The first floor is lobby and offices the next six are hotel then to the roof is hospital. In a corner of the roof garden are four operating theatres and while we were up there one of the theatres was in full swing and was full of doctors watching the operation. From the roof we went back to the basement and then more subways to the Damon Hotel across the street. It is practically wholly devoted to hospital uses. More subways from there to the Clinic which is 3 blocks away from the Colonial Hospital where we entered so you can imagine how far we travelled underground.
In Italy all roads lead to Rome but in Rochester all subways lead to the Clinic. From the Clinic I went to St Mary's Hospital by jitney. This is the largest surgical hospital in the world under one roof. You can imagine the size of the place when there are fourteen operating theatres in it. They are all fitted with a gallery for onlookers and the largest of these theatres has a gallery built of marble leading up from the main floor and operating table, that will hold 240 people - and which cost $60,000. One doctor alone did 20 goitre operations in a single day.
St Mary's is run by Catholic sisters and it is here the Mayos' do all their own operations. In fact they refuse to operate elsewhere. They are Protestants but when they first commenced practice in this place these Sisters helped them so much that they stick to them now.
Then there is Worrell Hospital where a lot of the X ray work is done and also the contagious diseases. There are 9,000 cases in one month of one disease alone. These are only a few of the hospitals that keep this place alive. There are also the Curie, Samaritan, Zambro and many others. In fact the town is full of hospitals, drug stores (as they call chemists shops) and undertakers ... not forgetting hotels.
The country around here is the best and prettiest we have yet seen in the States and the weather is all one could wish for.
We are having a great time here and Bill is the best he has yet been although he still has to keep to the vegetarian diet. He does not think he is coming home with me but will stay in England for 3 or 4 months and then come home.
[and a subsequent letter after reaching London ...] I am having a good time here in London but Bill is in dock again. It is nothing serious but he was not improving as rapidly as he thought he should. He attributed it to the old trouble with his nose and so saw a specialist here who advised an operation to remove a septum from the back of his nose. This prevented the normal use of his nostrils and matter was being swallowed and perhaps poisoning his stomach. He went into a private hospital on Sunday last and was operated on last Monday morning. He was pretty sick for a couple of days but yesterday and today has been as fit again as ever. He thinks so too which makes a lot more noise than what I think as now it is only a matter of his mind over his ailment. Hospitals do not exist in the heart of London and I have a long way to go to see him.
Yesterday we had a London fog. It is all we have heard of it and more. To see anything you have to get right on top of it. I went out to lunch at 1.45 and the street lights were on and also the electric signs and the lights of vehicles. It was just like night with gusts of the soupy stuff called fog all around. Bill has been advised to get out of the cities until his nose is quite healed again so he will not now come to Paris with me but go straight to Cornwall. I shall join him down there after seeing Paris and the battlefields of Flanders and Belgium. I will then stay in Cornwall for Xmas and N. Year and come back to London to catch the "Ormonde" on 3rd.
Bill is slowly improving I think but will take some time to regain his normal health and I do not think he will return much before our summer next year, 1925.
View full text of Harry's letters here
Drs William and Charles Mayo were among the first to use a team approach in medical treatment. Having pioneered the medical specialties and the sharing of medical records, the Mayo Clinic's fame had spread, even downunder.
The young Australians' trip of 5 months took in Tahiti, California, Rochester, New York and London, returning via Suez and Perth. The letters excerpted below lay ignored for almost 80 years until I sought them from my uncle Bill Gracie in Muwillumbah, near the Queensland border. A bank teller, Harry Gordon Gracie later became ANZ manager in the Riverina, Hunter and New England regions. The letters are addressed to his family in Artarmon, just north of the Sydney Harbour Bridge (which had yet to be built). They will interest modern medicos, being a young man's observations of a famous medical institution in a period of great change in our profession.
Hotel Campbell, Rochester, Minnesota
23 Sept 1924
My dear mother,
Rochester, Minnesota is where the Mayo Bros are and where I hope Bill will get fixed up. The first part of our long journey from Sydney now over, we are resting for a little while. Bill is attending the clinic, so far with good results. He was up at the Clinic again this morning and when he returned we took a car without a driver to see the sights around the town. The total cost for the hire of a Ford Coupe, nearly new was 9/- so we consider that is dirt cheap.
The Mayo Clinic here just keeps the town. It is a marvellous place with 300 doctors employed all under the direct control of the Mayos. The people flock to them in thousands every day. The town lists its population at 13,000 while there are always at least 25,000 in the place. Of course it is full of hotels and hospitals and cripples of all sorts abound. It is a pitiful sight to stand outside the clinic and watch the hundreds pouring in and out, the whole time suffering from every known form of disease - and some, I suppose, unknown. And they line up in queues to wait their turn. It puts one in mind of Hickson's Mission but on a much larger scale.
The American scenery is very fine their cities large and convenient - their people are all only too willing to explain anything to you and take you about when you come to their home town. But everything in the place is artificial. They talk and think of nothing else but the almighty $ and the shortest way to pack up a stack of them. There is nothing substantial about the places we have so far seen in San Francisco and Los Angeles. They are all jerrybuilt homes and buildings, put up in quick time.
We are both well. Bill is brighter than previously by a long way - while I have put on 5lbs since leaving Sydney!
Often I would give a pound for a long iced lager. One can get lots of spirits in this place - and good stuff too I believe - but not for me, thanks! Everyone laughs at the Prohibition laws here and they drink hard.
[and a subsequent letter ...] after a little over a week Bill is ever so much better - the doctors have now finished their examinations of him. They put him on a diet and he finishes the course today. On Friday next he goes back to the Clinic and has his final instructions. We are hoping to leave then to continue our trip on to Buffalo and New York.
Yesterday called into a stud farm of Holstein cattle owned by the State Hospital. It is a wonderful affair. The patients are all mental cases and they milk 150 cows twice a day by hand. The milk is used in the hospitals around. The bails are enormous as they bail all the cows at the same time and they always go to the same bail. Their milk is tested every time. Last night I went to a village dance in town with some girls from the hotel. They are nurses from the clinic. Bill went to bed.
We have just about seen all there is to see in this place as an old chap who devotes his life to wheeling patients about for the love of it has taken a great fancy to us. Johnny McBride, the "Angel of the Wheelchairs" at Rochester has shown us all over the town. One day he took us to the basement of the Colonial Hospital and from there through a subway to the Kahler Hotel. We went up to the top and saw all over the city from the 14th floor. The Kahler is a combination affair. The basement is set apart for nurses, rest rooms, etc. The first floor is lobby and offices the next six are hotel then to the roof is hospital. In a corner of the roof garden are four operating theatres and while we were up there one of the theatres was in full swing and was full of doctors watching the operation. From the roof we went back to the basement and then more subways to the Damon Hotel across the street. It is practically wholly devoted to hospital uses. More subways from there to the Clinic which is 3 blocks away from the Colonial Hospital where we entered so you can imagine how far we travelled underground.
In Italy all roads lead to Rome but in Rochester all subways lead to the Clinic. From the Clinic I went to St Mary's Hospital by jitney. This is the largest surgical hospital in the world under one roof. You can imagine the size of the place when there are fourteen operating theatres in it. They are all fitted with a gallery for onlookers and the largest of these theatres has a gallery built of marble leading up from the main floor and operating table, that will hold 240 people - and which cost $60,000. One doctor alone did 20 goitre operations in a single day.
St Mary's is run by Catholic sisters and it is here the Mayos' do all their own operations. In fact they refuse to operate elsewhere. They are Protestants but when they first commenced practice in this place these Sisters helped them so much that they stick to them now.
Then there is Worrell Hospital where a lot of the X ray work is done and also the contagious diseases. There are 9,000 cases in one month of one disease alone. These are only a few of the hospitals that keep this place alive. There are also the Curie, Samaritan, Zambro and many others. In fact the town is full of hospitals, drug stores (as they call chemists shops) and undertakers ... not forgetting hotels.
The country around here is the best and prettiest we have yet seen in the States and the weather is all one could wish for.
We are having a great time here and Bill is the best he has yet been although he still has to keep to the vegetarian diet. He does not think he is coming home with me but will stay in England for 3 or 4 months and then come home.
[and a subsequent letter after reaching London ...] I am having a good time here in London but Bill is in dock again. It is nothing serious but he was not improving as rapidly as he thought he should. He attributed it to the old trouble with his nose and so saw a specialist here who advised an operation to remove a septum from the back of his nose. This prevented the normal use of his nostrils and matter was being swallowed and perhaps poisoning his stomach. He went into a private hospital on Sunday last and was operated on last Monday morning. He was pretty sick for a couple of days but yesterday and today has been as fit again as ever. He thinks so too which makes a lot more noise than what I think as now it is only a matter of his mind over his ailment. Hospitals do not exist in the heart of London and I have a long way to go to see him.
Yesterday we had a London fog. It is all we have heard of it and more. To see anything you have to get right on top of it. I went out to lunch at 1.45 and the street lights were on and also the electric signs and the lights of vehicles. It was just like night with gusts of the soupy stuff called fog all around. Bill has been advised to get out of the cities until his nose is quite healed again so he will not now come to Paris with me but go straight to Cornwall. I shall join him down there after seeing Paris and the battlefields of Flanders and Belgium. I will then stay in Cornwall for Xmas and N. Year and come back to London to catch the "Ormonde" on 3rd.
Bill is slowly improving I think but will take some time to regain his normal health and I do not think he will return much before our summer next year, 1925.
Submitted by Andrew Byrne ..
View full text of Harry's letters here
1 July 2002
Benzodiazepine addiction - trial of 2 methods of treatment from Finland
Treatment of out-patients with complicated benzodiazepine dependence: comparison of two approaches. Vorma H, Naukkarinen H, Sarna S, Kuoppasalmi K. Addiction (2002) 97: 851-859
Dear Colleagues,
These authors randomised 76 benzodiazepine dependent patients to receive 'traditional' dose taper treatment or an experimental protocol involving fixed rates of withdrawal and psychosocial supports.
The patients presented to four addiction clinics in Finland with the experimental condition being implemented by one such clinic. This presumably entailed some patients having their treatment moved and standardised to the experimental protocol.
There was daily or binge drinking in about 30% of subjects. About half had used 40mg diazepam equivalent daily or more. Patients used sedatives for an average of 7 years and over 80% had previously tried to quit. About one in seven had used recreational drugs in the previous year. 80% of each group has a current axis I disorder (anxiety, depression, alcohol abuse). Two thirds had a personality disorder, leaving only 5-10% without a formal psychiatric diagnosis. There were no significant differences between the randomized groups.
The experimental plan included a fixed diazepam or equivalent taper based on the patient's dose and proportionate reductions of about one tenth each week. The time taken for tapering was thus longer for higher doses. They also included a drug/alcohol diary, video film on withdrawals, sleep advice, printed material on reductions, 'assessment of benzodiazepine functions' and relaxation exercises. About a third of subjects in each group was prescribed fluoxetine for depression. 'Control' treatment involved traditional sedative reductions, 'supervised by a physician'.
Subjects had monthly urine and/or blood drug screens plus interviews including an AUDIT questionnaire after abstinence was attained, or at 12 months, where possible.
Judging by abstinence or 12 months of treatment attendance the experimental group had a 46% completion rate while the control group yielded 70%, a significant difference. One subject who had been accepted but dropped out, committed suicide some months later. The authors state that if they excluded patients who did not participate in treatment or left treatment 'for reasons unrelated to the treatment' the differences become insignificant. [But if patients did not participate in the treatment as offered, then would normally be considered 'failures' in any fair assessment of an experimental intervention.]
The reductions in benzo use were impressive, all tending to be better in the 'control' taper group (but apparently not significantly). Fully 27% achieved abstinence in the control group, 13% in the experimental. There were reductions in overall benzo use by 45-80% across the groups. One in six subjects demonstrated no reductions over 12 months despite the treatment interventions. It would appear that all of the patients were followed up at some point, a remarkable feat for benzo users, or any drug treatment subjects.
This study tells us that trying to standardise an approach to treatment in a way which is not based on sound research findings does not lead to improvements in outcomes. Indeed, it may be that the lack of prescribing flexibility even reduced successes for some patients in this difficult area.
Unlike heroin addiction, there is still no 'gold standard' treatment for tranquillizer addiction. But despite this, most in the field seem to approve some degree of diazepam (or similar) prescribing with reductions as tolerated in a setting of medical care and psychosocial supports. These authors did not use diazepam in every case, nor do they describe supervised or daily dosing which is now recommended in certain unstable cases (see Strang J. UK Dependency Treatment Guidelines 1999 p31-33).
comments by Andrew Byrne ..
4 April 2002
Urine testing in treatment - how often?
Fellous J, Lowenstein W, Gourarier L, Bonan B, et al. Relevance of urinalysis monitoring of methadone maintenance patients: a clinical-biological agreement on 41 patients. Addiction Biology (2000) 5:313-318
This interesting report from a Paris addiction treatment service tells us much about good medical treatment with methadone as well as showing the benefits and limitations of urine drug testing in the clinical environment. These researchers reiterate that urine testing should never be used punitively but more as a clinical guide or reminder. They state that such testing is 'still used by some as a disciplinary measure despite recommendations of clinicians and epidemiologists'. 'It should not be performed as a repressive imposition which will probably lead drug abusers to falsify their urine samples' (6 references given).
The study's sub-group of the clinic population comprised 41 long term methadone maintenance treatment (MMT) patients with mean age 33, 57% male, 92% injectors. Dose ranges were also typical with 90% receiving between 30 and 120mg daily (mean dose 72mg). 5% were prescribed in excess of 120mg. The overall clinic's annual retention rate appeared to be a staggering 96%.
All patients had at least one test every 2 months during the 12 months of the trial which examined results in comparison with clinical history given to health professionals. The simplified addiction severity measure used self-report of drug use and medical/social consequences. There was a 'very poor agreement' with urine test results. The authors conclude that urine test results should be used as a surveillance to alert the physician to early relapse and to schedule earlier consultations for action to be taken such as dose adjustment, counselling, etc.
This report underlines that urine testing has still not been proven to have any effect on the outcomes of treatment or prevention, despite popular belief of a therapeutic benefit from such surveillance. Urine testing, as long as it is (1) supervised (witnessed and/or temperature tested) and (2) tested by reliable and sensitive methods and (3) used without any threats of adverse consequences on treatment - is an accurate way of determining a subject's recent intake of drugs. This provides evidence for research into medical, legal or epidemiological aspects of psychoactive drug use. It probably also has a place in improving clinical outcomes but this remains to be proven by comparative research.
I was intrigued to learn this week that the Australian Health Insurance Commission has increased from 21 to 36 the maximum rebateable number of urine toxicology tests per annum. Why ever would they fund additional tests per year when there is no evidence that they are of any benefit? Could politics have influenced matters?
comments by Andrew Byrne ..
further references:
Chutuape MA, Silverman K, Stitzer ML. Effects of urine testing frequency on outcome in a methadone take-home contingency program. D&A Dependence 62 (2001) 69-76
Chermack ST, Roll J, Reilly M, Davis L, Kilaru U, Grabowski J. Comparison of patient self-report and urinalysis results obtained under naturalistic methadone maintenance conditions. D&A Dependence (2000) 59:43-49
Ditton J, Cooper GAA, Scott KS et al. Hair testing for 'ecstasy' (MDMA) in volunteer Scottish drug users. Addiction Biology (2000) 5:207-213
This interesting report from a Paris addiction treatment service tells us much about good medical treatment with methadone as well as showing the benefits and limitations of urine drug testing in the clinical environment. These researchers reiterate that urine testing should never be used punitively but more as a clinical guide or reminder. They state that such testing is 'still used by some as a disciplinary measure despite recommendations of clinicians and epidemiologists'. 'It should not be performed as a repressive imposition which will probably lead drug abusers to falsify their urine samples' (6 references given).
The study's sub-group of the clinic population comprised 41 long term methadone maintenance treatment (MMT) patients with mean age 33, 57% male, 92% injectors. Dose ranges were also typical with 90% receiving between 30 and 120mg daily (mean dose 72mg). 5% were prescribed in excess of 120mg. The overall clinic's annual retention rate appeared to be a staggering 96%.
All patients had at least one test every 2 months during the 12 months of the trial which examined results in comparison with clinical history given to health professionals. The simplified addiction severity measure used self-report of drug use and medical/social consequences. There was a 'very poor agreement' with urine test results. The authors conclude that urine test results should be used as a surveillance to alert the physician to early relapse and to schedule earlier consultations for action to be taken such as dose adjustment, counselling, etc.
This report underlines that urine testing has still not been proven to have any effect on the outcomes of treatment or prevention, despite popular belief of a therapeutic benefit from such surveillance. Urine testing, as long as it is (1) supervised (witnessed and/or temperature tested) and (2) tested by reliable and sensitive methods and (3) used without any threats of adverse consequences on treatment - is an accurate way of determining a subject's recent intake of drugs. This provides evidence for research into medical, legal or epidemiological aspects of psychoactive drug use. It probably also has a place in improving clinical outcomes but this remains to be proven by comparative research.
I was intrigued to learn this week that the Australian Health Insurance Commission has increased from 21 to 36 the maximum rebateable number of urine toxicology tests per annum. Why ever would they fund additional tests per year when there is no evidence that they are of any benefit? Could politics have influenced matters?
comments by Andrew Byrne ..
further references:
Chutuape MA, Silverman K, Stitzer ML. Effects of urine testing frequency on outcome in a methadone take-home contingency program. D&A Dependence 62 (2001) 69-76
Chermack ST, Roll J, Reilly M, Davis L, Kilaru U, Grabowski J. Comparison of patient self-report and urinalysis results obtained under naturalistic methadone maintenance conditions. D&A Dependence (2000) 59:43-49
Ditton J, Cooper GAA, Scott KS et al. Hair testing for 'ecstasy' (MDMA) in volunteer Scottish drug users. Addiction Biology (2000) 5:207-213
12 December 2001
Does case management work? Journal article.
Rosen A, Teesson M. Does case management work? The evidence and the abuse of evidence-based medicine. ANZJ Psych 2001 35;6:731-746
Dear Colleagues,
This paper is long and complex, but its essence seems to be that to in order to be effective, 'case management' needs to be used for high risk subjects and only when implemented by professionals in the field. As a working definition, case management might be termed: "active and assertive community treatment" or better still: "patient care co-ordinated by a single professional using a multi-disciplinary approach". With minor changes, this is believed to apply to dependency matters just as it does to community psychiatry where most of the current evaluative research has been done. More than twelve randomised controlled studies comparing case management with 'standard therapy', from a variety of countries - including Australia - contributed to a Cochrane database on the subject.
Some have considered case management (CM) as a 'motherhood' subject, ineligible of criticism or modification. So much so that I once considered it an imaginary concept, like Falstaff's "honour" monologue. But as long as it is seen in concert with good quality medical care it is a useful way of examining and implementing psychosocial supports.
If not by name, case management comes naturally to GPs since this is just what they do as a matter of course. Hospital specialists and clinic based health workers may have more clearly demarcated duties and thus be less likely to address a patient 'holistically'. It is still possible, however, for any health professional to take the time to examine various aspects of the patient's life and coordinate an approach to address those areas needing attention. It is sometimes straightforward but at other times the high risk areas need to be teased out of a difficult presentation by subjects who may be 'in denial' or unable to recognise the issues themselves due to the circumstances.
Of fundamental importance is the aspect of medical treatment and its quality in relation to the current evidence base. Addiction treatment is in these respects possibly even clearer than in community mental health. There is some debate as to who is responsible for appropriate medical care. Courts generally find that it is the doctor who is responsible for inadequate medical care. It might be argued, however, that other health care workers are almost equally responsible in matters of diagnosis and treatment, despite sometimes their having no training in therapeutics. The doctor may not always be involved in the first instance. Thus to this point others must take the responsibility for assessments and treatment given (or not given). In the community it is normally the patient who decides when to go to the doctor (or the dentist, or the hairdresser for that matter). But in the health care system, there often needs to be a key worker who does significantly more than a travel clerk booking a ticket on request.
comments by Andrew Byrne ..
References:
Pringle JL, Edmondston LA et al. The Role of Wrap Around Services in Retention and Outcome in Substance Abuse Treatment: Finding From the Wrap Around Service Impact Study. Addictive Disorders Their Treat (2002) 1;4:109-118
Dear Colleagues,
This paper is long and complex, but its essence seems to be that to in order to be effective, 'case management' needs to be used for high risk subjects and only when implemented by professionals in the field. As a working definition, case management might be termed: "active and assertive community treatment" or better still: "patient care co-ordinated by a single professional using a multi-disciplinary approach". With minor changes, this is believed to apply to dependency matters just as it does to community psychiatry where most of the current evaluative research has been done. More than twelve randomised controlled studies comparing case management with 'standard therapy', from a variety of countries - including Australia - contributed to a Cochrane database on the subject.
Some have considered case management (CM) as a 'motherhood' subject, ineligible of criticism or modification. So much so that I once considered it an imaginary concept, like Falstaff's "honour" monologue. But as long as it is seen in concert with good quality medical care it is a useful way of examining and implementing psychosocial supports.
If not by name, case management comes naturally to GPs since this is just what they do as a matter of course. Hospital specialists and clinic based health workers may have more clearly demarcated duties and thus be less likely to address a patient 'holistically'. It is still possible, however, for any health professional to take the time to examine various aspects of the patient's life and coordinate an approach to address those areas needing attention. It is sometimes straightforward but at other times the high risk areas need to be teased out of a difficult presentation by subjects who may be 'in denial' or unable to recognise the issues themselves due to the circumstances.
Of fundamental importance is the aspect of medical treatment and its quality in relation to the current evidence base. Addiction treatment is in these respects possibly even clearer than in community mental health. There is some debate as to who is responsible for appropriate medical care. Courts generally find that it is the doctor who is responsible for inadequate medical care. It might be argued, however, that other health care workers are almost equally responsible in matters of diagnosis and treatment, despite sometimes their having no training in therapeutics. The doctor may not always be involved in the first instance. Thus to this point others must take the responsibility for assessments and treatment given (or not given). In the community it is normally the patient who decides when to go to the doctor (or the dentist, or the hairdresser for that matter). But in the health care system, there often needs to be a key worker who does significantly more than a travel clerk booking a ticket on request.
comments by Andrew Byrne ..
References:
Pringle JL, Edmondston LA et al. The Role of Wrap Around Services in Retention and Outcome in Substance Abuse Treatment: Finding From the Wrap Around Service Impact Study. Addictive Disorders Their Treat (2002) 1;4:109-118
11 November 2001
Addiction journal goes 'troppo con molto prezzo'.
Dear Colleagues,
The (UK) Society for the Study of Addiction has sent out a somewhat apologetic note with the normal subscription notice this month. Under the name of Christine Godfrey, SSA President, we are informed of the excellent news that all members, for the yearly rate of 75 pounds or US$150 will now receive 4 copies of Addiction Biology in addition to the 12 issues of Addiction and special 'supplements' each year. For an additional 12 pounds, we are told that members can also have on-line access. For us in the distant antipodes, where mails take up to six weeks, this on-line bonus is indeed welcome.
The management is to be congratulated for these moves. That said, similar promises have been made in the past. In March 1998 Addiction's blue cover proudly announced "available online". But it wasn't. Not to me, anyway. I know as I tried all year unsuccessfully punching passwords and down-loading software to make it all happen. To this day, the cover bears that same caption 'AVAILABLE ONLINE'. Apparently it can be down-loaded by enterprising librarians and other institutional subscribers. My library did not seem able to do so.
Another enticing piece nearly 5 years ago, in May 1997 was entitled: "Join the Society for the Study of Addiction" ... "A World Wide Web site is under development and it is proposed in the near future to set up an Internet bulletin board for members to exchange ideas and request information. These are exciting times for the Society ... ". [Vol 92(5) p636]. I should have contained my excitement since recent editions still state the same! "A World Wide Web site is under development and it is proposed in the near future ...". [Vol 96 (10) p1530]. One is tempted to wonder whether the Society is really serious about encouraging debate.
Addiction once devoted a column to ME! But rather than robust academic discourse it was a clumsy attempt at 'ad hominem' sarcasm following a critical letter on 'decrimalization'. In fact it was hard to understand the meaning of the swagger by Susan Savva in 'News and Notes', but she was clearly enjoying herself at my expense [Vol 95 p1875-6]. Interestingly, the British government seems not to agree with her line of argument as they are now making minor cannabis possession a non-arrestable offence.
On even more serious matters, I have written to the editor, sub-editors and other esteemed members at various times in recent years about the pressing need to improve the quality of methadone and other treatments in the UK and Australia. I pointed out that the Journal had not broached this issue, nor what might be done about it. I was politely told that this issue was being looked into and that a piece was proposed.
All I have seen to date has been a somewhat pompous and contradictory editorial on the possible mischief attended by harm reduction, "quo vadis", by a savant from Montreal. It stated magnanimously that when given properly, methadone treatment 'worked' and was not questioned by leaders in the field. The author then proceeded to question agonist treatments (!). Two recent letters-in-reply were politely critical ... personally, I find it hard to be polite about curbs on simple measures which save lives.
Despite all, I will probably be renewing my subscription to this venerable organ which is nearly into its hundredth year.
comments by Andrew Byrne ..
The (UK) Society for the Study of Addiction has sent out a somewhat apologetic note with the normal subscription notice this month. Under the name of Christine Godfrey, SSA President, we are informed of the excellent news that all members, for the yearly rate of 75 pounds or US$150 will now receive 4 copies of Addiction Biology in addition to the 12 issues of Addiction and special 'supplements' each year. For an additional 12 pounds, we are told that members can also have on-line access. For us in the distant antipodes, where mails take up to six weeks, this on-line bonus is indeed welcome.
The management is to be congratulated for these moves. That said, similar promises have been made in the past. In March 1998 Addiction's blue cover proudly announced "available online". But it wasn't. Not to me, anyway. I know as I tried all year unsuccessfully punching passwords and down-loading software to make it all happen. To this day, the cover bears that same caption 'AVAILABLE ONLINE'. Apparently it can be down-loaded by enterprising librarians and other institutional subscribers. My library did not seem able to do so.
Another enticing piece nearly 5 years ago, in May 1997 was entitled: "Join the Society for the Study of Addiction" ... "A World Wide Web site is under development and it is proposed in the near future to set up an Internet bulletin board for members to exchange ideas and request information. These are exciting times for the Society ... ". [Vol 92(5) p636]. I should have contained my excitement since recent editions still state the same! "A World Wide Web site is under development and it is proposed in the near future ...". [Vol 96 (10) p1530]. One is tempted to wonder whether the Society is really serious about encouraging debate.
Addiction once devoted a column to ME! But rather than robust academic discourse it was a clumsy attempt at 'ad hominem' sarcasm following a critical letter on 'decrimalization'. In fact it was hard to understand the meaning of the swagger by Susan Savva in 'News and Notes', but she was clearly enjoying herself at my expense [Vol 95 p1875-6]. Interestingly, the British government seems not to agree with her line of argument as they are now making minor cannabis possession a non-arrestable offence.
On even more serious matters, I have written to the editor, sub-editors and other esteemed members at various times in recent years about the pressing need to improve the quality of methadone and other treatments in the UK and Australia. I pointed out that the Journal had not broached this issue, nor what might be done about it. I was politely told that this issue was being looked into and that a piece was proposed.
All I have seen to date has been a somewhat pompous and contradictory editorial on the possible mischief attended by harm reduction, "quo vadis", by a savant from Montreal. It stated magnanimously that when given properly, methadone treatment 'worked' and was not questioned by leaders in the field. The author then proceeded to question agonist treatments (!). Two recent letters-in-reply were politely critical ... personally, I find it hard to be polite about curbs on simple measures which save lives.
Despite all, I will probably be renewing my subscription to this venerable organ which is nearly into its hundredth year.
comments by Andrew Byrne ..
10 October 2001
Comparison of urine toxicology with self-report.
Chermack ST, Roll J, Reilly M, Davis L, Kilaru U, Grabowski J. Comparison of patient self-report and urinalysis results obtained under naturalistic methadone maintenance conditions. D&A Dependence (2000) 59:43-49
Dear Colleagues,
'Confidential' comparisons of urine testing with self-report outside the clinical setting have shown close accuracy (Darke 1998). However, when responses are given to clinicians in the naturalistic setting, as this study finds, they are less likely to be as accurate, at least this is so in the clinic setting where treatment termination based on such results is possible. It is the experience of most who work in the behavioural area that self report is less accurate than objective findings. This probably applies to weight reduction programs, ("the scales are wrong, doctor"), smoking cessation, etc. Urine toxicology always introduces some tension, just like the scales, but it should never cause treatment to be terminated and *taken alone* such testing should not cause patients' treatment schedules to be altered. The most serious consequence of a positive test should be a counselling visit in which 'punishment' should not be an issue.
Despite the lack of surprise in these overall results, it is always gratifying to have ones own experiences documented in a careful scientific study.
These results are hard to generalise to other practices since the patients were all male, ex-service personel, aged 50.4 years (mean) and three quarters were African American.
These authors use exhaustive statistical analysis comparing urine tests results (EMIT tests for opiates and cocaine) and a structured ASI (addiction severity index) including questions on drug use in the previous 30 days. These showed a degree of concordance, but not nearly as much as previous reports of confidential studies where the information was assured to be kept private from treating doctors. What a remarkable state of affairs when patients are apparently afraid for their own doctor to know more about their case!
Comments by Andrew Byrne ..
Dear Colleagues,
'Confidential' comparisons of urine testing with self-report outside the clinical setting have shown close accuracy (Darke 1998). However, when responses are given to clinicians in the naturalistic setting, as this study finds, they are less likely to be as accurate, at least this is so in the clinic setting where treatment termination based on such results is possible. It is the experience of most who work in the behavioural area that self report is less accurate than objective findings. This probably applies to weight reduction programs, ("the scales are wrong, doctor"), smoking cessation, etc. Urine toxicology always introduces some tension, just like the scales, but it should never cause treatment to be terminated and *taken alone* such testing should not cause patients' treatment schedules to be altered. The most serious consequence of a positive test should be a counselling visit in which 'punishment' should not be an issue.
Despite the lack of surprise in these overall results, it is always gratifying to have ones own experiences documented in a careful scientific study.
These results are hard to generalise to other practices since the patients were all male, ex-service personel, aged 50.4 years (mean) and three quarters were African American.
These authors use exhaustive statistical analysis comparing urine tests results (EMIT tests for opiates and cocaine) and a structured ASI (addiction severity index) including questions on drug use in the previous 30 days. These showed a degree of concordance, but not nearly as much as previous reports of confidential studies where the information was assured to be kept private from treating doctors. What a remarkable state of affairs when patients are apparently afraid for their own doctor to know more about their case!
Comments by Andrew Byrne ..
2 April 2001
Addiction: April 2001
Editorial and debate on injectable methadone by Zador. Addiction (2001) 96:547-553.
Zador's perfectly sensible description on the prescribing of injectable methadone by British doctors is challenged by others on some of the most spurious grounds. Both Malcolm Lader and Jerome Jaffe state that it is medico-legally fraught, being non-evidence based medicine. But they ignore the 'out' that this treatment may be the only reasonable alternative for certain heroin dependent folk in whom other treatments have proven unsuccessful or unacceptable. In such a case it may be possible be prove medical negligence by NOT continuing such apparently effective treatment. This may also be the case in a small number of previous trial subjects in Queensland who were given this treatment some years ago. Much treatment given by doctors currently is not strictly evidence based, such as antibiotics for 'bronchitis'.
Jaffe goes through several possible reasons why such prescribing is not appropriate (cost, political acceptability, evidence base) yet he accepts that research might show that it could be so! He even uses the old peccadillo about supplying alcohol to alcoholics and tobacco to smokers 'all paid for indefinitely by the taxpayers'. Of course these drugs ARE CURRENTLY made available by all our governments at reasonable cost to all addicts, and to the very great benefit of the public purse through taxes. It is unusual for this respected researcher to inject such irrelevancies into this otherwise very serious discussion.
Jaffe writes for three pages, his arguments sounding more like those of a politician or a journalist-with-a-mission. He implies that the issue is enormously complex which is simply not the case. This prescribing is either defensible as good medical practice, or it is not. If it MIGHT be, we need more research. Simple!
The limited research that does exist is virtually all encouraging. Prescribing injectables to addicts appears to 'work' in a similar manner to oral methadone, and it may do so in some patients who fare poorly with existing treatments, thus enshrining it as ethical, if of uncertain application.
The article by Strang and Sheridan on relative dosing practices between private and public sectors in England is also of interest (Addiction (2001) 96:567-576).
These authors have conducted yet another elegant and useful study documenting the poor quality of care received by English dependent patients on methadone under the NHS. It is possible that private doctors also are guilty of giving poor treatment but these surveys did not question concurrent prescription of stimulants, or if they did we are not enlightened on the findings. Some private practices are notorious for multiple, gross over-prescribing, including stimulants and one was even the subject of an episode of "The Bill" a few years back.
Since supervised consumption, even in new patients, is exceptional in England, it is not possible to know how much methadone in private of public sector was actually consumed. It is certain, however, that some public sector patients received markedly inadequate doses.
As they point out, there are weaknesses to the study, but one strength is that it is clearly shows that the mean dose of oral methadone in public patients is around 50mg daily, a finding which is consistent with other British reports. As Strang's own guidelines point out, effective doses are usually in the range of 60mg to 120mg daily with only a small proportion of patients requiring more or less than this range. Even allowing for some patients on reducing doses, a mean dose of 50mg would imply that more than half of these patients may be receiving inadequate and therefore ineffective doses. This regrettable situation is still not acknowledged by the authors despite the unfolding tragedy which is dependency treatment in England and Wales in recent years.
Editorial by Juan Negrete, Montreal. Addiction (2001) 96:543-5
This is intriguingly slanted piece heaps scorn on the large proportion of the professional community which perceives benefits in harm reduction principles. The author fails to carefully define what he means by harm reduction which makes his article almost worthless.
It outlines an unscientific and near hysterical viewpoint on harm reduction, a policy most now consider close to 'motherhood' and which has been shown to save countless lives in its various implementations.
Juan Negrete criticises supporters of harm reduction in a most unflattering manner. He says that harm reductionists' aims towards improving methadone treatment only make it easier to get by removing barriers. But he fails to accept that like every other medical intervention, methadone treatment and any variations on its implementation, are subject to rigorous evaluation and hence improvements should only follow normal research findings, not the arbitrary views of any individual parties.
Negrete roundly criticises the Swiss heroin trial, but accepts that if benefits were found, he would review his opinion. How elegantly he contradicts himself, since only by running such a trial could benefits be demonstrated? And they were! The outcomes clearly showed that among 1146 treatment refractory patients there were very high retention rates and low mortality rates along with benefits regarding employment and housing. It is inescapable that this treatment attracted large numbers of otherwise 'treatment-refractory' patients into treatment and kept them alive over the three years of the trial. Is preventing death a 'benefit to patients'?
After faintly praising methadone treatment, Negrete says that maintenance therapies are 'irreversible' and he implies that they prevent addicts attaining drug free status. But people come off methadone successfully all the time! His emotive terminology reveals his clear unhappiness with the field: "harm reduction ideologues"; "compulsive toxicophilia" (is this English?); "drug reward slavery"; [addicts are] "much diminished human beings"; "primitive self-centredness of their pursuit"; "well meaning harm reduction workers who do not assign much importance to the problem of addiction". These are not the usual terms of clear scientific writing and if applied to those dependent on legal drugs would be considered offensive and outrageous by many such people.
It is surprising to find such items in 'Addiction', the world's oldest scientific journal on dependency.
Comments by Andrew Byrne ..
1 January 2001
"Confessions of an English Opium-Eater" (Thomas de Quincey)
Written in 1821, this is an intense and pertinent portrayal of narcotic dependence from the addict's viewpoint. De Quincey addresses the constant conflict between intoxication and abstinence. Similar sentiments are related by our patients today, but rarely with as much eloquence and insight as Thomas De Quincey. This classic work is essential reading for all involved in drug and alcohol studies and who admire beautiful language.
With so many patients now on maintenance programs (mostly methadone), and illicit opioids still ubiquitous, it is timely to re-examine this work, probably the oldest account of its kind in English.
The 'Confessions' presents us with several episodes in the author's life. He recounts privileged public school days, subsequent hostile truancy, still later poverty in London squats and, some years afterward, a comfortable country existence. But this story is not just biographical. The disparate scenes each place his drug-taking into vivid context.
As a 36-year-old addict, the writer states that his drug of choice was laudanum (tincture of opium), a medicine first prescribed him for recurrent dyspepsia aged 28. It was then that he also discovered its pleasurable qualities. He consumed up to 320 grains of opium daily, equal to around 20g of raw opium, a large, but not unbelievable quantity. Though he claims to have given up opium, history tells us that he continued heavy use for another 35 years. He did not live long enough to 'enjoy' the discovery of heroin and the hypodermic needle.
The original 'Confessions' was published as a series of articles in the "London Magazine" in 1821. Some parts had been written previously, and the series may have been pieced together hastily out of financial necessity. The author pleads for patience, explaining that his prose follows his own train of thought so closely that it sometimes may appear wandering or disjointed. The American author, William Burroughs suffered the same 'malady', (and possibly for the same reason) but, far from craving his readers' indulgence, he has capitalized on it and has made it his trade-mark.
De Quincey apologises needlessly for his narrative style. Seemingly embroidered or wordy descriptions are well balanced by other elegantly succinct poetic portraits.
"Thou only givest these gifts to man; and thou hast the keys of Paradise, oh, just, subtle, and mighty opium!" Every page of this work contains language of beauty, humanity and frequently, humour.
The subject of this book was taboo at the time of writing, and the very title would have shocked its public. It was then widely believed that Europeans could not become addicted to opium.
As well as 'Preliminary Confessions', he writes chapters on the pleasures and the pains of opium. He affirms his belief in the unique healing powers of the drug, and the benefits of doctor's prescriptions which contain opium. De Quincey reveals that he used opium only intermittently for several years, before developing a daily proclivity. He took it regularly before going to the Covent Garden opera. A proportion of today's narcotic users employ the drug to enhance other pleasurable activities.
Based on personal knowledge as well as information from apothecaries he patronized, De Quincey correctly deduces that opium addiction was extremely widespread in Regency England. He expresses some remorse over his addiction, but devotes much space to explaining his extenuating personal circumstances. Unlike simple pleasure seekers, the reader is told, he took it initially for medical reasons. He also compares it with the pernicious effects of alcohol. He identifies some other prominent opium users: first mentioned is the poet laureate and playwright, Thomas Shadwell (1642-92), a confirmed addict. Of his own contemporaries, he identifies Samuel Taylor Coleridge, William Wilberforce, Dr Abernethy, and several others in public life.
He revised and enlarged the confessions 35 years later, as if to prove opiate addiction and longevity are not mutually exclusive. Most modern editions give some passages from the revisions, but wisely keep the original as a discrete work. The revisions are longer than the entire original work. Although some central issues are clarified in the revisions, other tangential ones are drawn out and examined in excruciating detail.
De Quincey remains one of the great wordsmiths, and this well-forged story gives a personal aspect to one of mankind's most ancient activities, the pursuit of pleasure from drugs. [De Quincey, T. Confessions of an English Opium-Eater. Penguin English Library 1972, edited with an introduction by Alethea Hayter. First published in the "London Magazine", 1821]
With so many patients now on maintenance programs (mostly methadone), and illicit opioids still ubiquitous, it is timely to re-examine this work, probably the oldest account of its kind in English.
The 'Confessions' presents us with several episodes in the author's life. He recounts privileged public school days, subsequent hostile truancy, still later poverty in London squats and, some years afterward, a comfortable country existence. But this story is not just biographical. The disparate scenes each place his drug-taking into vivid context.
As a 36-year-old addict, the writer states that his drug of choice was laudanum (tincture of opium), a medicine first prescribed him for recurrent dyspepsia aged 28. It was then that he also discovered its pleasurable qualities. He consumed up to 320 grains of opium daily, equal to around 20g of raw opium, a large, but not unbelievable quantity. Though he claims to have given up opium, history tells us that he continued heavy use for another 35 years. He did not live long enough to 'enjoy' the discovery of heroin and the hypodermic needle.
The original 'Confessions' was published as a series of articles in the "London Magazine" in 1821. Some parts had been written previously, and the series may have been pieced together hastily out of financial necessity. The author pleads for patience, explaining that his prose follows his own train of thought so closely that it sometimes may appear wandering or disjointed. The American author, William Burroughs suffered the same 'malady', (and possibly for the same reason) but, far from craving his readers' indulgence, he has capitalized on it and has made it his trade-mark.
De Quincey apologises needlessly for his narrative style. Seemingly embroidered or wordy descriptions are well balanced by other elegantly succinct poetic portraits.
"Thou only givest these gifts to man; and thou hast the keys of Paradise, oh, just, subtle, and mighty opium!" Every page of this work contains language of beauty, humanity and frequently, humour.
The subject of this book was taboo at the time of writing, and the very title would have shocked its public. It was then widely believed that Europeans could not become addicted to opium.
As well as 'Preliminary Confessions', he writes chapters on the pleasures and the pains of opium. He affirms his belief in the unique healing powers of the drug, and the benefits of doctor's prescriptions which contain opium. De Quincey reveals that he used opium only intermittently for several years, before developing a daily proclivity. He took it regularly before going to the Covent Garden opera. A proportion of today's narcotic users employ the drug to enhance other pleasurable activities.
Based on personal knowledge as well as information from apothecaries he patronized, De Quincey correctly deduces that opium addiction was extremely widespread in Regency England. He expresses some remorse over his addiction, but devotes much space to explaining his extenuating personal circumstances. Unlike simple pleasure seekers, the reader is told, he took it initially for medical reasons. He also compares it with the pernicious effects of alcohol. He identifies some other prominent opium users: first mentioned is the poet laureate and playwright, Thomas Shadwell (1642-92), a confirmed addict. Of his own contemporaries, he identifies Samuel Taylor Coleridge, William Wilberforce, Dr Abernethy, and several others in public life.
He revised and enlarged the confessions 35 years later, as if to prove opiate addiction and longevity are not mutually exclusive. Most modern editions give some passages from the revisions, but wisely keep the original as a discrete work. The revisions are longer than the entire original work. Although some central issues are clarified in the revisions, other tangential ones are drawn out and examined in excruciating detail.
De Quincey remains one of the great wordsmiths, and this well-forged story gives a personal aspect to one of mankind's most ancient activities, the pursuit of pleasure from drugs. [De Quincey, T. Confessions of an English Opium-Eater. Penguin English Library 1972, edited with an introduction by Alethea Hayter. First published in the "London Magazine", 1821]
17 October 2000
Hulse et al. omit deaths in naltrexone report.
re: Hulse GK, Basso MR. Reassessing naltrexone maintenance as a treatment for illicit heroin users. Drug Alcohol Review 1999 18:263-269
Comment letter published D&A Review 2000 19;3:347
[Note: no reply published from original authors]
Dear Editor,
I support the authors' contention that naltrexone be judged using the same criteria as other treatments to enable fair comparisons of outcomes.
It is self-evident that stricter acceptance criteria will yield lower apparent 'success' rates, but that these will not alter actual patient outcomes. Clinical trials are rarely directly comparable so one of the tasks of clinicians is to determine the significance of each addition to the scientific literature. For dependency treatments this is not difficult since the aims of treatment are relatively straightforward and can be verified by simple means.
Hulse and Basso have reported detailed outcomes of a naltrexone treatment trial using two criteria for reporting six month follow-up details. Despite using tables and text to illuminate these outcomes, they place these results out of clinical context by omitting the two deaths which were previously reported from this cohort [Hulse G. Naltrexone - Defining a framework for use. Australian Professional Society on Alcohol and other Drugs (APSAD) Newsletter 'Summer' 1998, p4].
Mortality is the most fundamental end point in any treatment trial. To ignore, omit or mis-state deaths or other end points makes interpretation of data impossible and is inappropriate in balanced scientific writing.
A comparison of methadone and naltrexone in dependency management should be rigorous and impartial. After twenty years and over 500 peer-reviewed papers demonstrating the benefits of methadone, there has been only very limited research favouring naltrexone treatment in heroin addicts in the same time period. Few if any accredited addiction treatment services use naltrexone as a first line drug although it shows promise in certain selected groups and is effective in alcoholism.
The authors of all scientific research studies should be scrupulous in all reporting, lest they be seen as advocates for particular causes instead of maintaining the detachment which is essential in ethical research.
Yours faithfully,
Andrew Byrne ..
Comment letter published D&A Review 2000 19;3:347
[Note: no reply published from original authors]
Dear Editor,
I support the authors' contention that naltrexone be judged using the same criteria as other treatments to enable fair comparisons of outcomes.
It is self-evident that stricter acceptance criteria will yield lower apparent 'success' rates, but that these will not alter actual patient outcomes. Clinical trials are rarely directly comparable so one of the tasks of clinicians is to determine the significance of each addition to the scientific literature. For dependency treatments this is not difficult since the aims of treatment are relatively straightforward and can be verified by simple means.
Hulse and Basso have reported detailed outcomes of a naltrexone treatment trial using two criteria for reporting six month follow-up details. Despite using tables and text to illuminate these outcomes, they place these results out of clinical context by omitting the two deaths which were previously reported from this cohort [Hulse G. Naltrexone - Defining a framework for use. Australian Professional Society on Alcohol and other Drugs (APSAD) Newsletter 'Summer' 1998, p4].
Mortality is the most fundamental end point in any treatment trial. To ignore, omit or mis-state deaths or other end points makes interpretation of data impossible and is inappropriate in balanced scientific writing.
A comparison of methadone and naltrexone in dependency management should be rigorous and impartial. After twenty years and over 500 peer-reviewed papers demonstrating the benefits of methadone, there has been only very limited research favouring naltrexone treatment in heroin addicts in the same time period. Few if any accredited addiction treatment services use naltrexone as a first line drug although it shows promise in certain selected groups and is effective in alcoholism.
The authors of all scientific research studies should be scrupulous in all reporting, lest they be seen as advocates for particular causes instead of maintaining the detachment which is essential in ethical research.
Yours faithfully,
Andrew Byrne ..
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