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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jsat.2008.09.007 Byline: Gayle Ridge, Michael Gossop, Nicholas Lintzeris, John Witton, John Strang Keywords: Methadone; Buprenorphine; Prescriptions; Patient preference; Patient attitude; Clinical decisions Abstract: The study investigates patient preferences and beliefs and treatment program factors related to the decision to prescribe either buprenorphine or methadone to opiate-dependent patients. The sample (N = 192) was recruited from 10 addiction treatment services in London. Data were collected by means of a single structured interview conducted with patients commencing a treatment episode at the participating agencies. Data on patient demographics, beliefs, attitudes, and preferences were collected using a structured interview. Data regarding treatment goals and prescribed medication were collected from interviews with clinical staff. Oral methadone had a higher preference rating than buprenorphine. Clinical prescribing practices were influenced by patient preferences (both positive and negative), by prior treatment experiences, and by current treatment goals. Patient preferences and beliefs about opioid agonist medications served as an important influence upon clinical prescribing practices. The odds of being prescribed buprenorphine were three times greater among those patients who reported a preference for buprenorphine. The odds of receiving a prescription for methadone were about twice as great among those for whom methadone was the more preferred medication. Preferences were related to previous treatment experiences with these opioid agonists, and for patients in both groups, personal experience was the most important source of information about the treatment options. Buprenorphine was more likely to be prescribed for short-term detoxification and methadone for maintenance treatment. Author Affiliation: National Addiction Centre, Maudsley Hospital/Institute of Psychiatry, King's College, London SE5 8AF, UK Article History: Received 7 May 2008; Revised 18 September 2008; Accepted 19 September 2008

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jsat.2008.08.002 Byline: Jennifer Bearn (a)(b), Anshul Swami (a), Duncan Stewart (b), Catherine Atnas (b), Lisa Giotto (b), Michael Gossop (a)(b) Keywords: Opiate; Detoxification; Acupuncture; Withdrawal; Craving Abstract: It was hypothesized that auricular acupuncture would lead to reduced severity of opiate withdrawal symptoms and craving when provided as an adjunct to methadone detoxification. The study used a randomized, placebo-controlled study design. The sample consisted of 83 drug misusers who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for opiate dependence. Daily measures of withdrawal severity and craving were taken using the Short Opiate Withdrawal Scale and an eight-item craving questionnaire. Urine screening was used as an objective assessment of treatment adherence. The study hypothesis was not confirmed. Auricular acupuncture had no effect upon withdrawal severity or craving when provided as an adjunct to a standard methadone detoxification treatment. The results are consistent with the findings of other studies that failed to find any effect of acupuncture in the treatment of drug dependence. The failure to find any clinical gains from the adjunctive use of auricular acupuncture during detoxification from opiates raises concerns about the widespread acceptance of this intervention. Author Affiliation: (a) Wickham Park House (Drug Dependence Unit), Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, UK (b) National Addiction Centre, Institute of Psychiatry, London SE5 4AF, UK Article History: Received 27 March 2008; Revised 16 July 2008; Accepted 23 August 2008

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.addbeh.2006.11.019 Byline: Duncan Stewart (a), Michael Gossop (b), Katia Trakada (b) Keywords: Parents; Children; Treatment; Outcomes; Women Abstract: Relatively little is known about the treatment of drug dependent parents. This study of drug misusers (n =1075) investigates the involvement of parents with treatment services, childcare arrangements before and during treatment, and outcomes at 1-year follow up. Almost half the sample (46%) were parents. Women were more likely to be responsible for the care of children. Parents, and especially women, who looked after children, were less likely to receive residential treatment. Illicit drug use and psychiatric symptoms were reduced at 1 year. Outcomes did not differ by gender or parenting status, but there was an interaction effect for psychiatric symptoms: for women, looking after children during treatment was associated with less improvement in psychiatric symptoms at follow up. Such women face special difficulties in access to services and would benefit if treatment services were able to offer improved access and childcare support. Author Affiliation: (a) Research Development and Statistics, Home Office, 2 Marsham Street, London SW1P 4DF, UK (b) National Addiction Centre, Institute of Psychiatry, 4 Windsor Walk, London SE5 8AF, UK

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.addbeh.2005.12.002 Byline: David Best, Victoria Manning, Michael Gossop, Samantha Gross, John Strang Keywords: Excessive drinking; Illicit drugs; Delinquency; Schools; Truancy Abstract: The study investigates excessive drinking and associations with other problem behaviours in 2078 school students aged 14-16 years in seven London secondary schools. Using a cross-sectional design, a self-completion questionnaire assessed lifetime and recent (past month) alcohol and drug consumption, attitudes to alcohol use education, alcohol-related problems, psychological problems, educational aspirations, truancy, and delinquent behaviour. Excessive drinking was operationally defined as 10 or more units of alcohol per drinking occasion. At least one episode of excessive drinking was reported by 32% of the sample, with 10% reporting five or more episodes. Excessive drinking was positively associated with frequency of cigarette smoking, use of cannabis, positive attitudes towards illicit drugs, low educational aspirations, higher depression scores, frequent truancy, and involvement in delinquent behaviours. Excessive drinking is a problematic behaviour in its own right but it is also a marker for other problem behaviours, including illicit drug misuse and delinquency. Understanding and responding to alcohol misuse among adolescents requires attention to psychological, social and developmental factors other than alcohol consumption alone. Author Affiliation: National Addiction Centre/Institute of Psychiatry, PO Box 48, Addiction Sciences Building, 4 Windsor Walk, Denmark Hill, London, SE5 8AF, United Kingdom

Changes in caseload and in the provision of counseling and comprehensive services were examined among 27 outpatient methadone programs across England between 1995 and 1999. The number of patients treated at the programs doubled during this time and average waiting times increased. More patients presented for treatment with alcohol and stimulant problems, dual diagnosis, and involvement in the Criminal Justice System. Provision of individual counseling and comprehensive services was high at both points, although services for family/relationship problems were reduced at followup. Changes were reported in disciplinary procedures. Drug positive urine tests were more likely to result in loss of patient privileges, and there was a significant increase in discharges for breaking program rules, missing appointments, and consuming alcohol. The study allows only tentative conclusions to be drawn, but these changes may be indicative of increased pressures placed on the programs and their staff. Keywords: Methadone; Comprehensive services; Counseling: Discharge

Diamorphine, with a 129-year history, is one of the longest established medications. In British medicine, diamorphine is sometimes used as a maintenance treatment for opiate addiction but is also routinely used in clinical practice to treat a number of general medical conditions. These ways of using diamorphine are very different but are often confused by observers of the British system. Although the routine clinical use of diamorphine in medicine is unique to the United Kingdom (UK), in other countries there is little awareness of this very British practice. Diamorphine is used in hospitals, primary care settings, and hospices. It may be administered by different routes, including oral, intramuscular, intravenous, subcutaneous, inhaled, epidural, and intrathecal routes. Among its most important medicinal uses is the treatment of severe and/ or intractable pain. Discussion of the medical uses of diamorphine is often confused by entanglement of medical practice and illicit drug abuse problems. This article summarizes the history, regulation, and uses of diamorphine in the UK.

This paper investigates alcohol outcomes and heavy drinking among 418 drug misusers from the National Treatment Outcome Research Study who completed followup interviews at 1, 2, and 4-5 years. About a quarter of the sample were drinking heavily at intake. Alcohol consumption at followup was predicted by drinking prior to intake, and about a quarter of those who were classified as alcohol abstainers, medium-level drinkers, or heavy drinkers at intake, remained in the same drinking category at all assessment points. Drinking outcomes were not related to opioid use. Heavy drinkers at followup were more likely to be using non-opioid drugs. The poor drinking outcomes are a matter for concern. Drug misusers with concurrent alcohol problems may require special treatment provision. The extent of heavy drinking among drug misusers both before and after treatment indicates a need to develop and strengthen programs and interventions to tackle alcohol-related problems in this patient group. Keywords: Drug misuse; Alcohol outcomes; Heavy drinking; Treatment

Few studies have investigated methadone treatment of opiate dependent patients in primary health care settings. Using a prospective cohort design, the study investigated outcomes at 1 and 2 years for 240 patients treated by general practitioners (n = 79) or drug clinics (n = 161) at sites across England. Mean daily methadone dose for both groups was 50 mg. Reductions in illicit drug use, injecting, sharing injecting equipment, psychological and physical health problems, and crime, were found in both groups at follow-up. Patients treated in general practitioner (GP) settings reported less frequent benzodiazepine and stimulant use, and fewer psychological health problems at follow-up. Alcohol use outcomes were poor for both groups. Differences in treatment practices were found for GPs and clinics. Results show substantial reductions in a range of problems behaviours, among unselected samples of opiate dependent patients treated in GP and in clinic settings, which are sustained to 1-year and 2-year follow-up. Keywords: General practice; Methadone; Treatment outcomes

Objective: The study investigates levels of affiliation with AA and beliefs about the organization and its philosophy among a cohort of alcoholics entering a UK (non-AA) alcohol treatment service. Method: A total of 150 consecutive admissions (75% men) were interviewed by an independent researcher within 5 days of their entry into a residential alcohol treatment unit. Results: Although about three quarters of these patients had previously attended AA meetings, levels of affiliation were low, with only 16% having worked any of the Twelve Steps. Previous AA attenders were more likely to be older, drinking greater daily quantities prior to treatment and to have first sought alcohol treatment at a younger age. Roughly equal groups expressed 'positive,' 'neutral' and 'negative' current attitudes towards AA (38%, 36% and 26%, respectively). Each of these three AA-attitude groups expressed greater endorsement of 'Personal Responsibility' steps than of 'Higher Power mediated' steps. Conclusions: Few participants were universally negative to AA or the Twelve Steps--most regarded some of the steps as positive, but many rejected those referring to a Higher Power. Most also regarded some aspects of the organization and its philosophy worthwhile, with attitudes spread across the continuum of opinion. As AA remains one of the most widely sought forms of help for alcohol problems, a clearer understanding is needed of its impact on patients and the appropriateness of its integration within substance misuse programs which are not explicitly Twelve Step in orientation. (J. Stud. Alcohol 64: 257-261, 2003), THERE ARE MORE THAN 3,000 AA meetings each week in the UK, approximately 500 in London (personal communication with the AA General Service Board). AA is built around a program [...]

One hundred and eight opiate addicts attending an in-patient opiate treatment unit were interviewed, using a mixed quantitative-qualitative approach, to investigate their experiences of witnessing overdoses, the associated interpretations and perceived cause of the overdose. Poly drug use and frequency of witnessed overdose was high among the sample. Use of 14 different combinations of drugs were reported, 8 of which involved the use of alcohol, and 7 benzodiazepines. Perceived cause of overdose involved attributions relating to the use of alcohol, in particular strong lager, small quantities of heroin and low levels of current opiate tolerance. Peer initiated resuscitation techniques revealed a range of responses from the probably valuable (recovery position, summon ambulance, administer naloxone) to the ineffective or frankly harmful (injecting with salt solution, immersing in a cold bath). The findings highlight the need for an overdose prevention program during in-patient detoxification and rehabilitation.

This article evaluates the effectiveness of illicit drug use treatment programs. The authors, examining changes in clients who received treatment, maintain clients who abused drugs demonstrated reduced drug use, whereas alcoholics did not reduce their drinking intake, however, psychological and health problems were reduced among both groups.

Few studies have reported changes in rates of overdose after drug misuse treatment. This paper investigates changes in non-fatal overdose between treatment intake and 1 year follow-up among a sample of 753 clients recruited to the National Treatment Outcome Research Study (NTORS). A relatively high rate of overdose (15%) was reported during the 3 months prior to treatment. Variables predictive of overdose at intake to treatment included injecting, frequency of benzodiazepine and cocaine use, quantity of alcohol consumption, and levels of anxiety. At 1 year follow-up, the rate of non-fatal overdose had fallen to 6%. Reduced rates of non-fatal overdose were found for clients treated in both residential and community treatment settings. Reductions in overdose were linked to improvements in frequency of drug use and lower rates of injecting. Clients who overdosed at follow-up showed no improvements in their substance use, except for frequency of crack cocaine use. The risk of non-fatal overdose at 1 year was associated with injecting and multiple drug use. These findings support the view that treatment can play an important role in reducing deaths among drug misusers. Keywords: Non-fatal overdose; Treatment outcome

This article investigates patterns of drinking and drinking outcomes among 753 drug-misusing clients recruited to the National Treatment Outcome Research Study (NTORS). More than one third of those who were drinking at intake reported problematic or highly problematic patterns of alcohol consumption. About one third of the sample were abstinent from alcohol at intake and at follow-up. Some improvements in drinking behavior were found at 1-year follow-up, especially among the heaviest and most problematic drinkers. Improvements were specifically related to patterns of preintake drinking behavior. The majority of clients made little change to their pattern of pretreatment drinking behavior and the continued heavy drinking of many drinkers at follow-up is a disappointing finding. Drinking problems have been given insufficient attention in the treatment of illicit substance misuse problems, and efforts should be made to develop and strengthen the assessment and treatment of drinking problems among drug misusers.

Route of administration is significant in the understanding of drug addiction and related problems. A study researched patterns of consumption and cocaine-related problems among users in Sao Paulo. Crack cocaine users had more social and health problems and more involvement in crime than intranasal users. Their greater involvement in prostitution places them at higher risk from HIV infection and other sexually transmitted diseases.

Cocaine now occupies an established place in the British illicit drug scene. The available data point to London and several other metropolitan areas as core centers of the problem. Smokable cocaine (crack) represents a notable and worrying new feature of cocaine use in the 1990s. There remain substantial gaps in knowledge about the natural history of cocaine problems in Britain. This review addresses the prevalence and problems associated with cocaine in Britain and includes a brief summary of the effects of the drug and the development and distribution of illicit cocaine products in Britain. Following discussion of the prevalence of cocaine use and associated problems, the orientation of existing services toward cocaine users is described and future challenges for responding effectively to cocaine users in need of treatment services are identified.

Opioid substitution with oral methadone is the most widely implemented treatment for heroin dependence. In Britain, a complex array of specialist and generic health care services have evolved to deliver this treatment modality. Several minority aspects of British substitution practices receive enduring international interest, including the use of heroin itself as a substitute and the prescribing of methadone in an injectable form. This paper focuses on six linked dimensions that characterize substitution services: (1) treatment providers and settings, (2) prescribing regimes and treatment goals, (3) substitute drugs, (4) dose administration, (5) dose levels, and (6) substitute formulations. Against a background of increasing central and local accountability for the quality and efficiency of specialist providers and critical attention toward their effectiveness, the strengths and weaknesses of the British approach are considered and key issues and future directions are discussed.

In a randomized double-blind study, the clinical efficacy of methadone vs. methadone and guanfacine was assessed in terms of evolution of opioid withdrawal symptoms during inpatient defoxification. A total of 144 patients were included and randomly allocated to three different treatment groups: methadone alone, and two combined treatment schedules (methadone plus 3 or 4 mg of guanfacine). No differences were observed among the three groups with regard to retention rate throughout the study period. Both therapies, methadone and methadone plus guanfacine, determined a slight increase in withdrawal scores when methadone was discontinued. However, guanfacine was unable to effectively control methadone-associated withdrawal symptoms. These results indicate that guanfacine does not effectively reduce the opioid withdrawal symptoms. Keywords--opiate withdrawal; methadone; guanfacine; heroin addiction; treatment-efficacy.

A two-day training course for Employment Service staff to recognize drug and alcohol problems in clients and direct clients to more specialized organizations if required. The program helped boost the confidence of the staff and equipped them to tackle clients with drug and alcohol problems. The staff also exhibited willingness to deal with such clients.

This study investigated whether attributions of opiate addicts would predict both their ability to abstain from future use and their reactions to abstinence violations. Measures of generalized beliefs about responsibility for positive and negative outcomes and specific attributions about relapse episodes were elicited from 80 addicts at the time of admission for inpatient detoxification and treatment. Addicts who at admission attributed to themselves greater responsibility for negative outcomes and who attributed relapse episodes to more personally controllable factors were subsequently (at 6-month follow-up) more likely either to be completely abstinent or to contain the effects of temporary lapses into opiate use., The role of attributions in predicting drug abstinence and violations by opiate addicts was studied. In-patients were interviewed prior to detoxification to determine data on attributions of positive and negative outcomes. Follow-up interviews after six months showed that relapses are common and are attributed to opiate availability, boredom, dishonesty, social pressures and withdrawal symptoms. Better personal responsibility and control of negative outcomes are valuable in abstinence maintenance.

Statistical analysis of patterns of alcohol abuse, delinquency, substance abuse, and truancy among school-going teenagers in the United Kingdom is presented.

A sample consisting of six hundred and forty-one heroin users was studied to determine the type and extent of changes in route of drug administration especially among continuing heroin users after treatment. The results suggest that the transitions that take place in the routes of administration represent an important measure of outcome and should be incorporated in the treatments for heroin users.

An investigation on the frequency of adverse cocaine reactions and associated factors among regular cocaine misusers, in Sao Paulo, Brazil is presented. The extent to which adverse reactions are related to the drugs, its pattern of consumption, individual characteristics, and environment factors are discussed.

In a cohort study comprising 189 nonspecialist drug workers, who work with drug and alcohol misusers, levels of therapeutic commitment have bearing on the direct effects of self esteem, situational constraints, role support, and role security. Furthermore, working with drug users and education on drug-related issues indirectly influence therapeutic commitment.

Links between social networks of drug users and criminal activity are investigated. It is proved that these networks are long-term barriers to rehabilitation.

This article evaluates the success rate of self-detoxification methods. The authors, questioning methadone maintenance patients, maintain the majority of the patients had attempted self-detoxification, however, any success was short lived.

A new study investigates the treatment outcomes of stimulant misusers recruited to the National Treatment Outcome Research Study of drug abusers in the UK.