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Aim To evaluate the efficacy of nortriptyline (NOR) added to a multi-component smoking cessation intervention, which included cognitive–behavioural therapy (CBT) and provision of nicotine replacement therapy (NRT). Design Randomized controlled trial (RCT) comparing two study groups with blinded follow-up at 3, 6 and 12 months. Both groups received a multi-component smoking cessation intervention comprising two half-hour individual sessions of CBT and NRT with either active NOR or placebo. Setting Prisons in New South Wales (17) and Queensland (one), Australia. Participants A total of 425 male prisoners met inclusion criteria and were allocated to either treatment (n = 206) or control group (n = 219). Measurements Primary end-points at 3, 6 and 12 months were continuous abstinence, point prevalence abstinence and reporting a 50% reduction in smoking. Smoking status was confirmed by expired carbon monoxide, using a cut-point of ≤10 parts per million. Findings Participants' demographics and baseline tobacco use were similar in treatment and control groups. Based on an intention-to-treat analysis, continuous abstinence between the treatment and control groups was not significantly different at 3 months (23.8 versus 16.4%), 6 months (17.5 versus 12.3%) and 12 months (11.7 versus 11.9%). Conclusion Adding nortriptyline to a smoking cessation treatment package consisting of behavioural support and nicotine replacement therapy does not appear to improve long-term abstinence rates in male prisoners.

Aim To examine the safety and efficacy of modafinil (200 mg/day) compared to placebo in the treatment of methamphetamine dependence and to examine predictors of post-treatment outcome. Participants and design Eighty methamphetamine-dependent subjects in Sydney, Australia were allocated randomly to modafinil (200 mg/day) (n = 38) or placebo (n = 42) under double-blind conditions for 10 weeks with a further 12 weeks post- treatment follow-up. Measures Comprehensive drug use data (urine specimens and self-report) and other health and psychosocial data were collected weekly during treatment and research interviews at baseline, week 10 and week 22. Results Treatment retention and medication adherence were equivalent between groups. There were no differences in methamphetamine abstinence, craving or severity of dependence. Medication-compliant subjects tended to provide more methamphetamine-negative urine samples over the 10-week treatment period (P = 0.07). Outcomes were better for methamphetamine-dependent subjects with no other substance dependence and those who accessed counselling. There were statistically significant reductions in systolic blood pressure (P = 0.03) and weight gain (P = 0.05) in modafinil-compliant subjects compared to placebo. There were no medication-related serious adverse events. Adverse events were generally mild and consistent with known pharmacological effects. Conclusions Modafinil demonstrated promise in reducing methamphetamine use in selected methamphetamine-dependent patients. The study findings support definitive trials of modafinil in larger multi-site trials.

Aims To establish the feasibility of conducting a placebo-controlled clinical trial of dexamphetamine replacement therapy for cocaine dependence and to obtain preliminary data. Design Double-blind randomized placebo-controlled trial. Participants Thirty cocaine-dependent injecting drug users. Intervention Subjects were assigned randomly to receive 60 mg/day dexamphetamine ( n = 16) or placebo ( n = 14) for 14 weeks. Measurements Immunoassay and mass spectrometric techniques were used to identify cocaine metabolites in urine. Subjects were screened using the Composite International Diagnostic Interview and DSM-IV. The Opiate Treatment Index, Brief Symptom Inventory, Severity of Dependence Scale and visual analogue craving scales were used to collect pre- and post-self-report data. Findings Treatment retention was equivalent between groups; however, outcomes favoured the treatment group with no improvements observed in the placebo control group. The proportion of cocaine-positive urine samples detected in the treatment group declined from 94% to 56% compared to no change in the placebo group (79% positive). While the improvements were not significant between groups, within-group analysis revealed that the treatment group reduced self-reported cocaine use ( P = 0.02), reduced criminal activity ( P = 0.04), reduced cravings ( P < 0.01) and reduced severity of cocaine dependence ( P < 0.01) with no within-group improvements found in the placebo group. Conclusions A definitive evaluation of the utility of dexamphetamine in the management of cocaine dependence is feasible and warranted.

Pregnant injecting drug users were randomly assigned to: (i) individually receive a six-session cognitivebehavioural intervention in addition to their usual methadone maintenance treatment (intervention condition (I) ( n = 40)); or (ii) their usual methadone maintenance treatment only (control condition (C) ( n = 40)). There was no change in drug use per se in either group after the intervention. However, at 9-month follow-up the I group had significantly reduced some HIV risk-taking behaviours (in particular injecting risk behaviours). The I group reduced the needle risk associated both with "typical" use (drug use in the month before interview) and "binge" use (drug use in the month nominated as the heaviest month of drug use in the previous 6 months). The intervention had no effect on sexual risk behaviours. The finding of reduced injecting risk behaviour following the six-session intervention suggests that such an intervention may be of benefit for individuals persisting with injecting risk behaviours despite methadone maintenance treatment and the availability of sterile injection equipment.

In a controlled evaluation of general practitioner (GP)-based brief intervention, 378 excessive drinkers identified opportunistically by screening in 40 group practices in metropolitan Sydney were assigned to groups receiving: (i) a five-session intervention by the GP (the Alcoholscreen Program); (ii) a single session of 5 minutes' advice by the GP plus a self-help manual (minimal intervention); (iii) an alcohol-related assessment but no intervention; (iv) neither intervention nor assessment. Among all patients allocated to receive it, the Alcoholscreen Program did not result in a significantly greater reduction in consumption at follow-up than control conditions but patients offered Alcoholscreen reported a significantly greater reduction in alcohol-related problems in the period to 6 months follow-up. A greater proportion of patients who returned for the second Alcoholscreen visit were drinking below recommended levels at follow-up than in the remainder of the sample. There was no evidence that minimal intervention or alcohol-related assessment were effective in reducing alcohol consumption or problems. Implications for further research into GP-based brief interventions are discussed.

We examined the explanations given by a sample of 1245 injecting drug users in Sydney, Australia for accepting used injection equipment. Factor analysis of these reasons revealed three dimensions of sharing: not caring when withdrawing or intoxicated, unavailability of equipment, and not seeing it as high risk or ease of injecting. The most common reasons given were difficulty in obtaining sterile equipment (73% of cases), the dangers not seeming so important when in withdrawal (40%) and sharing being something done with friends or lovers (31%). Most common reasons for not sharing were related to health issues (91% citing AIDS and 67% hepatitis). These data suggest that interventions target provision of sterile equipment, and education which highlights risk situations such as intoxication and withdrawal.

Data are presented on the patterns of drug use and HIV risk-taking of daily amphetamine and opioid injectors among 1245 injecting drug users who were interviewed in Sydney in 1989. About one-third of the sample had injected amphetamines during a typical month of injecting, and 12% were using amphetamines on a daily basis. Daily amphetamine injectors were younger, less well educated, and less likely to have engaged in drug treatment, but they were no more likely than daily opioid users to have shared injection equipment or to have engaged in other behaviour likely to transmit HIV. Although there seemed to be no special cause for concern about HIV risk-taking among amphetamine injectors, there was nonetheless a high prevalence of sharing injecting equipment, with over half of daily amphetamine and heroin injectors having shared in the past several months. In addition, approximately a third of amphetamine injectors were injecting on a daily basis, a pattern of use which increases the risk of developing a severe dependence syndrome, and of experiencing an amphetamine-induced psychosis.

This article presents a new instrument with which to assess the effects of opiate treatment. The Opiate Treatment Index (OTI) is multi-dimensional in structure, with scales measuring six independently measured outcome domains: drug use; HIV risk-taking behaviour; social functioning; criminality; health; and psychological adjustment. Psychometric properties of the Index are excellent, suggesting that the OTI is a relatively quick, efficient means of obtaining reliable and valid data on opiate users undergoing treatment over a range of relevant outcome domains.

Summary Using a standarised questionnaire we interviewed 156 patients with newly-diagnosed alcoholic liver disease to establish whether they had been advised in the past to reduce their alcohol consumption and if they had been referred for treatment of an alcohol problem. A detailed assessment of their lifetime alcohol intake and severity of alcohol dependence was also undertaken. Most patients has a long history of excessive drinking (mean duration 17.3 years), yet only 69 (44%) said thay they had been advised by their general practitioners to reduce or stop drinking. This was corroborated by a review of a case records. Only 35 patients (22%) had been referred to a hospital clinic and 16 (10%) had attended an alcoholism counselling service or Alcoholics Anonymous. Patients who had received some intervention had a relatively higher mean daily alcohol intake and were more severely dependent on alcohol. These results suggest that most patients who develop alcoholic liver disease escape detection for many years because they have a relatively mild alcohol dependence syndrome. To limit the increasing morbidity from alcoholic liver disease emphasis must be placed on trying to identify and treat a broader spectrum of excessive drinkers than has been the case hitherto.