Addiction, culture and family therapy strategies.

Τhis update reviews the empirical evidence supporting the use of couple and family therapies in managing families affected by addiction, both adolescent and adult populations. A particular focus of the paper is the need for a "culturally competent" strategy in assessing and treating target families.

Fatal antidepressant overdose among drug abusers and non-drug abusers.

OBJECTIVE: This study examined the predictors, extent and pattern of fatal antidepressant overdose (FAO) in all psychoactive drug-related deaths and compared these in drug abusers and non-drug abusers. METHOD: Inquest data on 491 psychoactive drug-related cases in England and Wales were analysed. We examined predictors of FAO relative to other drug-related deaths in drug abusers and non-abusers using logistic regression, and compared the relative fatality of different antidepressant classes using the Proportionate Fatality Index (PFI). RESULTS: The overall FAO prevalence ratio was 10% (male = 7.1%, female = 18.5%). FAO was twice as likely to occur among cases aged 45 years and over than in younger cases (MOR = 2.6, 95% CI = 1.4-4.9), and eight times more likely to occur in cases with no history of drug abuse (MOR = 8.2, 95% CI = 4.0-18.4). Ingestion of prescribed antidepressants is the only common predictor of FAO among drug abusers and non-abusers, and co-ingestion of a combination of antidepressants of two different classes is a potent risk for FAO in the cases studied. CONCLUSION: The results highlight the need to develop appropriate therapeutic strategies for managing treatment-resistant depression.

Methadone-related deaths: data from 18 coroners' jurisdictions in England.

This paper examines the methadone-related deaths (MRD) among entire cases of inquest on drug-related cases in 18 coroners' jurisdictions in England which were entered on the National Programme on Substance Abuse Deaths during a six-month period in 1997. In 154 deaths methadone, either prescribed or not prescribed, was reported to be the substance directly implicated in the death of 40 individuals. The MRD between the prescribed and non-prescribed cases were compared in respect to various demographic variables and associated risks. The main findings reported are that the majority of deaths in this sample were in cases where methadone had not been prescribed (72%) and that there was a significant difference in age between the methadone prescribed (median = 22 years) and non-prescribed groups (median = 37 years) (Mann-Whitney U = 57.5, p = 0.01). Also significant differences amongst the two groups in respect of the coroners' verdicts are reported. The authors suggest more stringent controls around the prescription and dispensing of methadone, along with measures to alert the population at risk of the hazards of using methadone in a non-controlled fashion.

Drug abuse-related mortality: a study of teenage addicts over a 20-year period.

BACKGROUND: There is growing concern about increase in illicit drug use and associated fatalities in young people. METHOD: This longitudinal analysis of successive cohorts of addicts in England and Wales aged 15-19 years followed up over a 20-year period covering 1974 to 1993 (1) investigated trends in all-causes mortality; (2) examined teenage-specific mortality, i.e. deaths during ages 15-19 years; (3) determined excess teenage-specific mortality; and (4) identified the main underlying causes of teenage-specific death in this population. The main outcome measures were overall mortality rates, teenage-specific mortality and standardised mortality ratios calculated for four 5-year (period) successive cohorts. RESULTS: Overall mortality rate in the study population (N = 9491) was 4.7/1000 person-years. The median age at death was 23 years (semi interquartile range = 3), with the majority (91.3%) of deaths occurring between ages 15 and 29 years. Excess teenage-specific mortality in the population was 10.7 in males and 21.2 in females (general population = 1), and increase in excess mortality in both sexes was evident in the last 5-year period of study. The majority of deaths (64.3%) resulted from accidental poisoning. Methadone and heroine/morphine accounted for about two-thirds of accidental poisoning deaths, while suicide accounted for 11.4% of teenage-specific deaths. CONCLUSIONS: It is strongly recommended that treatment services should be more responsive to the need for careful prescribing, dispensing and administration of substitute medication to teenage addicts in their care. The development of needs-led, case-sensitive treatment services for young addicts is indicated.

Suicide among drug addicts in the UK.

BACKGROUND: The extent of suicide among addicts in the UK has not been sufficiently examined. AIMS: To examine suicide trends among registered addicts in the UK over a 25-year period. METHOD: We quantified suicide using International Classification of Diseases (ICD) external death codes E950-959, calculated annual age-standardised suicide rates, standardised mortality ratios (SMRs) and described trends in methods of suicide and drug overdose suicides in five successive cohorts of registered addicts. RESULTS: Male and female suicide rates are 69.0 and 44.8 per 100,000 person-years, respectively. There was a consistent decline in suicide rate throughout the 25-year period. Among males, the SMR for suicide declined from 17.2 in 1968-1972 to 4.4 in 1988-1992 (SMR ratio = 3.9, 95% CI = 2.5-6.1); among females it declined from 52.6 to 11.3 in the same period (SMR ratio = 4.7, 95% CI = 1.9-10.8). Drug overdose was the most common method of suicide, accounting for 45% of cases. Significant increase in antidepressant (percentage difference = 23.5%, 95% CI = 15.2-31.8) and methadone (percentage difference = 11.0%, 95% CI = 0.5, 21.5) overdose in 1988-1992 compared with 1968-1972 was reported. CONCLUSIONS: The findings confirm that addicts are still at higher risk of suicide than the general population and that prescribed drugs, notably antidepressants and methadone, influence this heightened risk.

Guiding principles of drug demand reduction: an international response.

BACKGROUND: The 20th century has seen the globalisation and homogenisation of substance misuse problems, blurring traditional boundaries between producer and consumer countries and forcing the international community to consider new responses to substance misuse. AIMS: To highlight the importance of the principles of illicit drug demand reduction and related activities in tackling global drug problems and to discuss the commitment made by United Nations (UN) Member States at the highest political level towards meeting the objectives set in their Declaration on the Guiding Principles. METHOD: A review of international responses to substance misuse. RESULTS: Traditionally, the focus has been on reducing the supply of controlled drugs, while maintaining adequate supplies of narcotic and psychotropic drugs for clinical and scientific purposes. However, it has become apparent that supply reduction in isolation is insufficient and demand reduction is now receiving greater emphasis--culminating in the UN General Assembly adopting the Declaration on the Guiding Principles of Demand Reduction in 1998. CONCLUSIONS: This declaration offers a genuinely holistic approach to the complexities of substance misuse. To be successful, it requires the commitment of governments at the highest level and the willing participation of small communities.

Mortality of drug addicts in the United Kingdom 1967-1993.

BACKGROUND: Mortality in specified clinical populations has often been regarded as a measure of treatment effectiveness. This study examined time trends in mortality of drug addicts in the UK notified to the Home Office over a 27-year period. METHODS: The study was a longitudinal analysis of routine mortality data of a population of newly notified addicts from 1967 to 1993. Altogether, 92 802 addicts were newly notified during the study period, and they accounted for 687 673 person-years of observation. The main outcome measures were age-specific all-causes mortality; drug-related mortality; and age- and sex-specific standardized mortality ratios (SMR) 1967-1993. RESULTS: There were significant differences in death rates between the periods 1967-1976 (19/1000 person-years) and 1984-1993 (10.5/1000 person-years). Excess deaths were significantly higher among the 1967-1976 cohorts than in the 1984-1993 cohorts (SMR ratio = 1.80, 95% CI: 1.64-1.97). The majority of deaths were drug-related, with those aged <45 years more likely to die of a drug-related cause than those older (OR = 6.29, 95% CI: 4.97-7.96). CONCLUSIONS: It appears that service provision has some impact on all-causes mortality among opiate addicts. As services improved, there was a corresponding decline in mortality rates during the study period. Further preventive measures, however, should be devised to reduce drug-related deaths.

Developing a quality of care index for outpatient methadone treatment programmes.

This article describes the development and evaluation of a psychometric instrument for assessing quality of care in outpatient methadone substitution therapy (MST) programmes. The instrument, termed the Quality of Care Index-1 (QCI-1), is a seven-item scale evaluated in two studies. Its psychometric properties are consistently acceptable across both studies. The QCI-1 reveals three distinct quality criteria relevant to the condition of the patients in methadone treatment. These are drug use hygiene, sharing of injecting equipment and partner's drug use status.

Subjective sleep-wake parameters in treatment-seeking opiate addicts.

We investigated subjective sleep parameters and sleep difficulties of opiate addicts undertaking methadone detoxification and identified their sleep profile. Using the St Mary's Sleep Questionnaire, we compared the subjective sleep parameters of 27 consecutively consenting patients (16 males, 11 females) with a mean age of 33 years (S.D. = 7.5) undertaking in-patient methadone detoxification with those of 26 drug-free controls (9 males, 17 females) with a mean age of 35 years (S.D. = 8.0). Our findings reveal that subjective sleep parameters of opiate addicts and controls are quantitatively and qualitatively different. The patients are more likely than controls to report difficulty initiating sleep (OR = 5.42; 95% CI = 1.43, 20.47); difficulty maintaining sleep (OR = 16.50; 95% CI = 3.81, 71.47); inadequate sleep quality (OR = 8.56; 95% CI = 2.04, 35.81); and inadequate sleep quantity (OR = 9.00; 95% CI = 2.49, 32.57).

The opiate addiction test: a clinical evaluation of a quick test for physical dependence on opiate drugs.

1. Mydriasis (pupil dilation) in response to conjunctivally applied naloxone hydrochloride has been demonstrated using an innovative electronic binocular pupillometer in 40 opiate dependent patients, on maintenance methadone treatment. 2. No pupillary response to naloxone was seen when an identical procedure was carried out in a control population of 12 healthy volunteers. 3. After a baseline measurement of pupil size, two drops of naloxone hydrochloride were instilled into the conjunctival sac of one eye. Serial binocular pupillometry was then carried out at 5, 10, 15, 20, 25, 30, 35, 40 and 45 min post-instillation. 4. Discriminant analysis between the control and patient groups showed that the false negative rate (error of misclassification to the wrong population) was lowest (20%) at 40 min post-eyedrop instillation, with no false positives in the control group. 5. The study has therefore shown an improvement in the previously reported false negative rate (25%) [1,2], of the conjunctival naloxone test of opiate dependence, with the use of our innovative electronic binocular pupillometer.

Clonidine is not a useful adjunct to methadone gradual detoxification in opioid addiction.

BACKGROUND: The role of clonidine in the management of opioid-dependent individuals undergoing gradual detoxification. METHOD: A double-blind placebo-controlled trial was conducted on 86 voluntary in-patients (59 male, 27 female) aged 18-47 years, at a specialist drug-dependence treatment unit. Patients entered the trial when on 40 mg of methadone daily or less, and were randomised to receive incremental doses of clonidine (increasing from 0.2 mg daily to 1.2 mg daily) during a 14-day period of gradual methadone detoxification and for four weeks thereafter. Blood pressure was monitored and severity of opioid abstinence was assessed by questionnaire and by clinical examination. RESULT: Half the subjects were withdrawn or defaulted from the trial by the end of two weeks, those receiving clonidine earlier than those receiving dummy medication (9 of the former and only one of the latter because of systemic hypotension). Similar proportions of subjects completed detoxification in the two groups. In those who completed detoxification, clonidine did not significantly reduce either the symptoms or objective signs of opioid withdrawal. CONCLUSIONS: These findings suggest that clonidine has no place as an adjunct to a programme of gradual opioid detoxification.

A comparison of drug-related problems in London Accident and Emergency Departments 1975-1982.

Drug-related incidents dealt with by ten Accident and Emergency departments in Greater London during July 1982 were compared with those obtained from an identical survey in 1975. The number of incidents remained high, but there was a significant reduction in them and in the number of drug dependent attenders, compared with 1975: hypnotic drugs were used in a significantly smaller percentage of drug overdoses, but there was increased use of minor tranquillisers. The possibility of using A & E departments to monitor drug misuse on a Regional basis is discussed.