Should ethanol be scheduled as a drug of high risk to public health?

Six criteria described in the New Zealand Misuse of Drugs Act and used by the Expert Advisory Committee on Drugs (EACD) for determining the risk of a drug to public health were examined in relation to ethanol, using gamma-hydroxybutyric acid (GHB) as a comparator drug. GHB is an ideal candidate for use as a comparator because it is a sedative substance very similar to ethanol and has been previously investigated by the EACD using these six criteria. GHB was subsequently classified as a Class B1 drug under the Misuse of Drugs Act, that is, as a prohibited drug of high risk to public health. The dangerousness level of ethanol was found to be at least similar to that of GHB in this analysis. This highlights a major discrepancy in public policy.

What is the cost-effectiveness of hepatitis C treatment for injecting drug users on methadone maintenance in New Zealand?

The cost-effectiveness of hepatitis C virus (HCV) anti-viral therapy for injecting drug users (IDUs) on methadone maintenance is important because the majority have chronic infections that remain untreated. Cost-effectiveness analysis examines the costs of treatment compared with the benefits, which in this study are defined as savings in life. The cost-effectiveness of treatment for HCV infection is investigated for Mäori and non-Mäori IDUs on methadone maintenance therapy (MMT) in New Zealand. Markov models are used to model cohorts of IDUs, changes in their health states and the effects of MMT and anti-viral therapy on morbidity and mortality. Comparisons were made between conventional combination therapy (COT) and combination therapy with pegylated interferon. Sensitivity analysis is used to model cost-effectiveness of treatment under varying assumptions of progression of liver disease and compliance with treatment. The cost-effectiveness of MMT alone was estimated at 25397 dollars per life year saved (LYS) for non-Mäori men and 25035 dollars for non-Mäori women IDUs (costs and benefits discounted at 3%). The incremental effects of providing COT to all eligible patients were to save extra years of life, as well as to involve additional costs of anti-viral therapy. Analysis of both the incremental costs and benefits showed that a policy of providing COT to all patients meeting treatment criteria would have similar cost-effectiveness to MMT alone. Costs per LYS were estimated to be lower for Mäori for both men and women, reflecting ethnic differences in mortality. Cost-effectiveness was found to improve if the average age of stabilizing on MMT could be lowered by 5 years from the current average age of 31 years to age 26. Cost-effectiveness of the new treatment with pegylated interferon and ribavirin was found to be similar to that of COT because the increased LYS were offset by expected higher costs of the new pharmaceuticals. Sensitivity analysis showed that anti-viral treatment remained cost-effective under varying assumptions of the rate of disease progression and compliance with treatment.

Clinician beliefs and practices related to increasing responsivity to the needs of Maori with alcohol and drug problems.

Culturally responsive treatments are often cited as essential for successfully addressing substance use-associated problems in indigenous and other ethnic groups. However, there has been little investigation of the support for this assertion among alcohol and drug-user treatment workers, or how it might translate into clinical practice. The current paper reports on the results of a survey of the New Zealand alcohol and drug-user treatment field, which canvassed these issues. Eighty-six percent of respondents advocated adjustment of clinical practice when working with Maori. Two key strategies were referral to specialist Maori groups or individuals and/or contacting/meeting with whanau (family). Comparisons were made between respondents who referred clients on and those who provided intervention themselves. Implications of results, limitations and future research are discussed.

A randomized controlled trial of motivational enhancement therapy (MET) for mild to moderate alcohol dependence.

OBJECTIVE: This study was designed to conduct a randomized controlled trial of motivational enhancement therapy (MET) with two control conditions: nondirective reflective listening (NDRL) and no further counseling (NFC); and to conduct this study in a sample of patients with a primary diagnosis of mild to moderate alcohol dependence, in a "real-life" clinical setting. METHOD: Patients with mild to moderate alcohol dependence were recruited, assessed and treated at the Community Alcohol and Drug Service of Christchurch, New Zealand. All patients received a feedback/education session before randomization to either four sessions of MET, four sessions of NDRL, or NFC. Outcome data on 122 subjects (57.4% men) were obtained 6 months following the end of treatment, by an interviewer who was blind to the treatment condition. The primary drinking outcome was unequivocal heavy drinking, defined as drinking 10 or more standard drinks six or more times in the follow-up period. Global assessment scale (GAS) measured general personal/social functioning. RESULTS: Of patients treated with MET, 42.9% showed unequivocal heavy drinking compared with 62.5% of the NDRL and 65.0% of the NFC groups (p = .04). No significant differences were found for GAS score according to treatment condition. CONCLUSIONS: In patients with mild to moderate alcohol dependence, MET is more effective for reducing unequivocal heavy drinking than either a feedback/education session alone or four sessions of NDRL. MET can be considered an effective "value added" counseling intervention in a real-life clinical setting. In patients with mild to moderate alcohol dependence, nondirective reflective listening provides no additional advantage over a feedback/education session alone.

Patterns of alcohol use and misuse among elderly rest home residents in Christchurch.

AIMS: To determine the prevalence of alcohol use and misuse among elderly rest home residents in Christchurch. METHODS: A cross-sectional prevalence survey was conducted among 175 residents aged 65 years and over, randomly selected from 30 rest homes in Christchurch, in 1998. Hazardous patterns of alcohol consumption in the past twelve months were determined by the Alcohol Use Disorders Identification Test (AUDIT) questionnaire, and alcohol dependence in the past 12-months and lifetime was determined by a strctured clinical interview using DSM-IV criteria. RESULTS: Of 246 eligible participants, 175 (71.1%) residents were interviewed, 115 women and 60 men, mean age, 82.6 years (SD=7.8) compared with 83.2 years (SD=6.3) for non-participants. The prevalence of hazardous patterns of alcohol consumption in the past twelve months by the AUDIT (cut-off score 8) was 5.1% (95% CI = 1.8-8.4). According to DSM-IV criteria, the prevalence of lifetime alcohol dependence was 20.5% (95% CI = 13.5-27.6) and for the past twelve months was 0.5% (95% CI = 0-1.7). The prevalence of lifetime alcohol dependence was significantly higher in men 36.7% (95% CI = 23.2-50.1) than women 12.2% (95% CI = 5.6-18.8) (p = 0.0001). CONCLUSIONS: In spite of advanced age, a small proportion of elderly rest home residents consumed quantities of alcohol that put them at risk of future damage to physical or mental health. Lifetime prevalence of alcohol dependence was comparable to the general population estimates and was higher in men than women.

A preventive ethics approach to methadone maintenance programmes.

In New Zealand opioid users obtain their drugs by extraction from codeine-based products, prescribed medication and poppies (in season) as geographical isolation and efficient border protection mean that street heroin is expensive and irregularly available. Hospital run methadone programmes have a virtual monopoly on the provision of opioid substitution programmes leaving clients with limited options if they want to leave methadone programmes. This leads to high client retention rates and provides an opportunity to explore the characteristic conflict that occurs between clients and providers of these programmes. Methadone providers are open to charges of paternalism as they exercise power in what they perceive as the best interests of their clients. Paternalism can be justifiable in treatment where a patient faces serious risks that can be reliably predicted, where these risks are irreversible and where patients have impairment in their autonomy. There may be a degree of impaired autonomy in clients entering a Methadone Maintenance Programme (MMP) as a product of the desperate circumstances of clients on entry to the programme and as a result of opioid dependency. However the risks of not participating in the programme cannot be reliably predicted for an individual client and the impairment in autonomy is of a temporary nature, making paternalism unjustifiable in these programmes. It is suggested that paternalism may be more than a perception in methadone programmes and that it may contribute to conflict between providers and clients. Aspects of MMPs that may indicate paternalism are: confusion between the long term and short term aims of the programmes, assumptions regarding client autonomy on entry and after clients stabilise on the programme, confusion over the application of harm minimisation aims and the inflexibility and social invasiveness of programmes. Preventative ethics is a process whereby programme structures are examined to identify and eliminate those which may lead to unacceptable treatment for clients. This paper examines aspects of MMPs that have the appearance of paternalism and suggests a number of programme design strategies that might assist in eliminating unjustifiable paternalism from MMPs.

A profile of alcohol and drug clients in New Zealand: results from the 1998 national telephone survey.

AIMS: To describe the profile of clients seen across the broad spectrum of dedicated alcohol and drug treatment services in New Zealand. METHODS: 217 randomly selected alcohol and drug treatment workers in New Zealand were interviewed by telephone, yielding a randomly selected sample of 291 clients. Workers were asked to identify the age, gender, ethnicity, main substance use problem and geographical location of clients. RESULTS: 60% of clients were male, 28% were Maori, the mean age was 31 years and the largest group of clients were seen for alcohol related issues (45%), followed by cannabis (27%) and opioids (17%). None of these variables differed significantly across residential/non-residential services. Significant trends to emerge were: that Maori clients were more likely to live rurally and to be in treatment for cannabis use, women were more likely to be in treatment for benzodiazepine use and less likely for cannabis use, opioid users were more likely to be seen at Crown Health Enterprise funded services, and cannabis users were (on average) younger than other clients, while alcohol users were older. CONCLUSIONS: Alcohol and drug treatment services are dominated by clients seeking assistance with alcohol and cannabis use problems. Women are not under-represented in this population. Maori are over-represented. This contrasts with the absence of Asian clients and an under-representation of Pacific Island clients. There are some significant variations in the types of drugs used by different demographic treatment seeking populations. In contrast, client differences across treatment settings are minimal.

Optimal treatment for Maori with alcohol and drug-use-related problems: an investigation of cultural factors in treatment.

There is an increasing emphasis on taking account of the diversity of social, psychological, and cultural factors in the assessment and treatment of alcohol and drug-use-related problems. In New Zealand the increasing use of customary Maori values, beliefs, and practices in the treatment of Maori with alcohol and drug-use-related problems has also been accompanied by the adaptation and integration of Western approaches to fit contemporary Maori sociocultural needs. This paper reports on an investigation of cultural factors and cultural identity in the alcohol and drug-user treatment of a clinical sample of Maori. The essential finding was a very high endorsement of the importance of cultural factors in treatment--irrespective of age, gender, mood, level of dependence, previous admissions, cultural connectedness, or whether they were treated in a Maori dedicated program or not. A significant number believed that a sense of belonging to an Iwi (tribe), identifying as a Maori and having pride in being Maori were also important in the recovery/healing process. The findings of this study support the need to investigate the relationship between specific "cultural factors" and other clinical components of effective treatment for Maori.

Increasing diagnosis of nicotine dependence in adolescent mental health patients.

OBJECTIVE: The aim of this study was to investigate the routine recording patterns of patients' smoking by clinical staff of an adolescent mental health service over a 3-year period. METHOD: A systematic examination of the clinical files of all patients who underwent an initial assessment or reassessment at the Youth Specialty Service (Mental Health; YSS) over a 2-month period (1 April-31 May) was carried out in 1996, 1997 and 1998. A range of data were collected including: demographics; diagnoses; amount of total information recorded and history of nicotine dependence. RESULTS: A stable historical record of cigarette smoking in the region of 30-40% across the 3 years sampled was found, but the rate of formal diagnosis of nicotine dependence rose from 3.6% in 1996 to 26.3% in 1998. This rise was in the context of relative stability over this time period of: size of reports and relevant sections (alcohol and drug history, cigarette smoking history); three other key diagnoses, major depression, conduct disorder and alcohol dependence; and demographic data. The rise in rate of diagnosis proceeded specific discussion within the clinical team about nicotine dependence. CONCLUSIONS: Adolescent mental health settings are a key venue to address heavy and potentially chronic cigarette smoking, but nicotine dependence has been traditionally a neglected diagnosis in mental health patients. The rate of diagnosis is likely to rise when specific discussion is undertaken within clinical teams.

The Cartwright Report ten years on: the obligations and rights of health consumers and providers.

It is ten years since the Cartwright report was published, three years since the code of health and disability services consumers' rights was promulgated and two years since the code came into force which makes it due for review next year. This paper reviews the issues identified by Cartwright and the effect that her investigation into the "Unfortunate Experiment" has had on the provision of health services. Issues of clinical freedom, peer supervision and informed consent are discussed in relation to the Health and Disability Commissioner Act, the Privacy Act and concepts of partnership in health care. Some comments on the present state of the relationships between consumers and providers in the health system are included.

A clinical sample of Maori being treated for alcohol and drug problems in New Zealand.

AIMS: To document key clinical characteristics of a group of Maori being treated for alcohol and drug problems; compare the characteristics of Maori accessing dedicated Maori alcohol and drug treatment services with Maori accessing non-dedicated services; and investigate these clinical characteristics in relation to patient satisfaction. METHODS: A sample of 105 Maori with alcohol and drug problems, accessing the range of treatment services in the Canterbury area, undertook a semi-structured interview. RESULTS: Overall this sample of Maori were socially disadvantaged. Their main drug of use was alcohol, followed by cannabis, opioids and sedatives/hypnotics. There were no significant differences between the subjects who attended Maori dedicated services and those who attended non-dedicated Maori services in terms of demographic variables, alcohol and drug use history, current level of dependence, or anxiety/depression state. Subjects in dedicated Maori services were more likely to have had greater than 21 days of treatment compared to those in non-dedicated Maori services and were more likely to have been to their home marae than those in non-dedicated services. In multivariate analysis, Maori in dedicated Maori services were significantly more likely to be satisfied with treatment than those in non-dedicated services (odds ratio = 5.5, 95% confidence interval = 1.81-16.78). CONCLUSION: Further research is required to investigate the relationship between high patient satisfaction by Maori with alcohol and drug problems attending dedicated Maori treatment services, treatment effectiveness and the components of dedicated Maori services that may contribute to higher retention rates, greater patient satisfaction and increased positive treatment outcome.

No association between novelty seeking and the type 4 dopamine receptor gene (DRD4) in two New Zealand samples.

OBJECTIVE: In 1986 and 1987, Cloninger postulated the existence of the heritable behavioral trait of novelty seeking and its putative underpinnings in the dopaminergic systems of the ventral midbrain. Two widely reported studies found significant associations between novelty seeking and the type 4 dopamine receptor gene (DRD4), although a more recent study did not. The authors' objective was to investigate this association in two New Zealand samples. METHOD: The authors studied two nonoverlapping samples: subjects in a depression treatment trial (N = 86) and subjects from 14 pedigrees dense with alcoholism (N = 181). DRD4 genotyping was based on a standard protocol. RESULTS: Novelty seeking and DRD4 were not statistically associated. CONCLUSIONS: In these samples, there was no suggestion that the DRD4 polymorphism contributed to individual differences in the behavioral trait of novelty seeking.

The pattern of intravenous drug use and associated criminal activity in patients on a methadone treatment waiting list.

Sixty-four patients on the Christchurch Methadone Treatment Programme waiting list were questioned on their drug-use behaviour, criminal activity and sources of income, both legal and illegal, for the preceding 7 days. Opioids used included morphine sulphate tablets, methadone and opium poppies, while other drugs used included tranquillizers, cannabis and alcohol. A significant minority were prescribed opioids. The mean cost of drugs used in 7 days across all subjects was 882 dollars. The mean financial gain from criminal sources for the same period was 1079 dollars and was derived from drug-related crime, property crime and prostitution. Few gender differences were found relating to criminal activity or drug use. The majority of the sample were on unemployment benefits of varying types while a minority were in paid employment. Those in paid employment did not earn significantly less from criminal activity, nor did they spend significantly less on drug use than did those not in paid employment. An important implication of these findings is that untreated opioid users are a substantial financial burden to the community, strongly supporting the argument for greater treatment provision.

Increased requests for help by problem gamblers: data from a gambling crisis telephone hotline.

AIM: A report on the rate and profile of calls received by a national gambling telephone hotline for a twelve month period covering six month periods before and after the opening of New Zealand's second casino located in Auckland. METHODS: Data collected by the hotline for normal counselling purposes during the year ended July 31, 1996 were collated and analysed for trends, gambler profiles and reported problem gambling modes. RESULTS: New first time callers accessing the hotline service during the period comprised 732 problem gamblers and 604 significant others of problem gamblers ( 1,336 new callers in total). Numbers of these new callers contacting the service increased from 510 in the first six months to 826 for the second similar period. Problem gamblers and significant others of problem gamblers reported relatively specific problem modes, rather than generalised problem gambling behaviour. Reported problem modes were track (horse and dog) racing comprising 25% of problem modes, video gambling machines ('poker' machines) 49%, casinos 24% and other modes 2%. New callers increased by 62% in the second half of the year. Casinos increased from 7% of reported problems in the six months prior to the opening of the Auckland casino, to 34% of reported problems for the six months following. Seventy three percent of problem gambler callers were forty years of age or younger, with 15% under 25 years of age. Most problem gambler callers were male (70%), while most significant other callers were male (77%). Maori problem gambler callers comprised 24% of all gamblers and 35% of female problem gambler callers. CONCLUSIONS: Increased use of the gambling crisis hotline by new callers coincided with increased availability of gambling opportunities, particularly gambling machines and a casino, and increased gambling turnover figures. Gambling machines appear to be over represented in reported problems, while reported casino gambling problems increased quickly with availability of the second casino. Maori callers, particularly female Maori, are high users of the gambling crisis hotline.

Temperament and substance abuse in schizophrenia: is there a relationship?

The influence of temperament on substance abuse in schizophrenia is poorly understood, whereas it is known to play an important role in other clinical populations. In a sample of 28 male schizophrenics, Cloninger's dimensions of temperament were measured with the use of the Tridimensional Personality Questionnaire (TPQ). Levels of four commonly used substances were recorded. There was a significant correlation between the novelty-seeking dimension and past use of alcohol, cannabis, and caffeine and current use of caffeine and nicotine. There was no relationship between substance use and clinical symptoms or demographic variables. The possible implications of abnormal mean TPQ scores in the sample as well as a weak correlation between symptom patterns and TPQ scores are discussed. The findings suggest that novelty-seeking type behaviors contribute to substance use in schizophrenia.

Low persistence predicts relapse in alcohol dependence following treatment.

OBJECTIVE: To investigate the relationship between personality measures and alcohol dependence relapse in a treatment sample of men with alcohol dependence. METHOD: Alcohol dependent men (N = 87) without a primary diagnosis of antisocial personality disorder, recruited consecutively from a 3-week abstinence-focused therapeutic program, along with informants, completed the Structured Clinical Interview for DSM-III-R Personality Disorders (self-report questionnaire) (SCID-PQ) and the Tridimensional Personality Questionnaire (TPQ) and were followed-up for 6 months. Drinking outcomes were based on multiple sources of data and subjects categorized as relapsed or not. Personality was investigated according to traditional DSM-III-R/DSM-IV clusters, as well as conduct disorder and obsessionality separately, in addition to the four major temperament dimensions of the TPQ. RESULTS: Cluster B personality disorder symptoms, conduct disorder symptoms and novelty seeking were not associated with relapse. However, the temperament trait of persistence predicted relapse. CONCLUSIONS: Personality features associated with onset of alcohol dependence do not appear to be the same as those associated with relapse in a sample of alcohol dependent men that excludes severe antisocial personality disorder. It is speculated that what might be considered low motivation when applied to alcohol dependent patients who relapse following treatment, may in part reflect low persistence, a personality trait.

Cultural linkage: treating Maori with alcohol and drug problems in dedicated Maori treatment programs.

Maori are the indigenous people of New Zealand and suffer more health problems, including alcohol and drug-related problems, per head of population compared with the Pakeha (non-Maori) population. An initiative to develop dedicated Maori alcohol and drug user treatment programs, which offer "cultural linkage," is currently being undertaken. This initiative is based on the premise that addressing cultural needs makes alcohol and drug treatment more effective for Maori than mainstream programs which do not specifically address these special needs issues. As yet, there are no data from controlled studies which address this proposition. Key problems related to the development of "cultural linkage" programs in New Zealand are identified and solutions suggested along with future direction for research in this area.

Does depression predict relapse in the 6 months following treatment for men with alcohol dependence?

OBJECTIVE: To investigate whether depression measured at the time of treatment predicts relapse of alcohol dependence in the 6 months following treatment of alcohol-dependent men. METHOD: Ninety-three subjects with moderate-severe alcohol dependence (DSM-III-R), recruited from a 3-week, abstinence-focused therapeutic program, were assessed for current and lifetime major depression using the SCID-P and baseline depressive symptoms using the SCL-90, and then followed up for 6 months. Drinking outcomes were based on multiple sources of data. RESULTS: Relapse was not associated with either lifetime major depression, or baseline depressive symptoms; inadequate numbers of subjects with a current major depression precluded statistical analysis of this variable. CONCLUSIONS: Neither lifetime major depression, nor the degree of depressive symptoms in alcohol-dependent men at the time of treatment, compromise drinking outcomes in the 6 months following treatment.

Public knowledge and attitudes towards the use of alcohol and drinking guidelines.

AIMS: To investigate public knowledge and attitudes towards the use of alcohol with particular focus on drinking guidelines. METHOD: A telephone survey of 249 people randomly selected from the toll free area of Christchurch. RESULTS: Three key findings were (1) not one respondent was able to quote drinking guidelines that included quantities of alcohol per occasion or quantities of alcohol per week; (2) the majority of the public (74%) thought drinking guidelines were not publicised well enough; and (3) young men (18-24 years) were significantly more likely to state incorrectly that greater than six standard drinks is a safe amount of alcohol to consume on social occasions. CONCLUSIONS: More active promotion of drinking guidelines via the electronic and popular print media should be considered. Young men require particular attention related to drinking no more than six standard drinks per occasion of drinking as part of this initiative. Other studies targeting groups such as the more transient, different ethnic groups especially Maori and Pacific Islanders, health professionals and people with alcohol problems would be of interest, as well as a repeat of this study following an interim period in which active promotion of drinking guidelines is undertaken.