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Aims. We aimed to investigate child mortality, perinatal morbidities and congenital anomalies born by women with substance misuse during or before pregnancy (DP or BP). Methods. Taiwan Birth Registration from 2004 to 2014 linking Integrated Illicit Drug Databases used to include substance misuse participates. Children born by mothers convicted of substance misuse DP or BP were the substance-exposed cohort. Two substance-unexposed comparison cohorts were established: one comparison cohort selected newborns from the rest of the population on a ratio of 1:1 and exact matched by the child's gender, child's birth year, mother's birth year and child's first use of the health insurance card; another comparison cohort matched newborns from exposed and unexposed mothers by their propensity scores calculated from logistic regression. Results. The exposure group included 1776 DP, 1776 BP and 3552 unexposed individuals in exact-matched cohorts. A fourfold increased risk of deaths in children born by mothers exposed to substance during pregnancy was found compared to unexposed group (hazard ratio [HR] = 4.54, 95% confidence interval (CI): 2.07-9.97]. Further multivariate Cox regression models with adjustments and propensity matching substantially attenuated HRs on mortality in the substance-exposed cohort (aHR = 1.62, 95% CI: 1.10-2.39). Raised risks of perinatal morbidities and congenital anomalies were also found. Conclusions. Increased risks of child mortality, perinatal morbidities or congenital anomalies were found in women with substance use during pregnancy. From estimates before and after adjustments, our results showed that having outpatient visits or medical utilizations during pregnancy were associated with substantially attenuated HRs on mortality in the substance-exposed cohort. Therefore, the excess mortality risk might be partially explained by the lack of relevant antenatal clinical care. Our finding may suggest that the importance of early identification, specific abstinence program and access to appropriate antenatal care might be helpful in reducing newborn mortality. Adequate prevention policies may be formulated. [ABSTRACT FROM AUTHOR]

Aims: Although the relationship between attention-deficit/hyperactivity disorder (ADHD) and transport accidents has been shown, there is limited information on the relationship between medication and dose–response effects and transport accident risk. This study aims to determine whether young people with ADHD, including adolescents, are more prone to transport accidents than those without, and the extent to which methylphenidate (MPH) prescription in these patients reduces the risk. Methods: We identified 114 486 patients diagnosed with ADHD from Taiwan's National Health Insurance Research Database from 1997 to 2013. Using a Cox regression model, we compared the risk of transport accidents between ADHD and non-ADHD groups and estimated the effect of MPH on accidents. Furthermore, we applied a self-control case-series analysis to compare the risk of accidents during the medication periods with the same patients' non-medication periods. Results: Male ADHD patients had a higher risk of transport accidents than non-ADHD individuals (adjusted hazard ratio [aHR] = 1.24, [95% confidence interval (CI) 1.10–1.39]), especially for those comorbid with epilepsy, oppositional defiant disorder/conduct disorder (ODD/CD), and intellectual disabilities (ID). Female ADHD patients showed no relationship, except for comorbid with autism spectrum disorder (ASD) or ID. We found a reduced risk of transport accidents in patients with ADHD with MPH medication than those without MPH, with a plausible dose–response relationship (aHR of 0.23 to 0.07). A similar pattern was found in self-controlled case-series analysis. Conclusions: Male patients with ADHD, especially those comorbid with epilepsy, ODD/CD, or ID, were at high risk of transport accidents. Female patients, when comorbid with ASD or ID, also exhibited a higher risk of accidents. MPH treatment lowered the accident risk with a dose–response relationship. [ABSTRACT FROM AUTHOR]

Aims: Attention-deficit/hyperactivity disorder (ADHD) is associated with a higher risk of burn injury than in the normal population. Nevertheless, the influence of methylphenidate (MPH) on the risk of burn injury remains unclear. This retrospective cohort study analysed the effect of MPH on the risk of burn injury in children with ADHD. Method: Data were from Taiwan's National Health Insurance Research Database (NHIRD). The sample comprised individuals younger than 18 years with a diagnosis of ADHD (n = 90 634) in Taiwan's NHIRD between January 1996 and December 2013. We examined the cumulative effect of MPH on burn injury risk using Cox proportional hazards models. We conducted a sensitivity analysis for immortal time bias using a time-dependent Cox model and within-patient comparisons using the self-controlled case series model. Results: Children with ADHD taking MPH had a reduced risk of burn injury, with a cumulative duration of treatment dose-related effect, compared with those not taking MPH. Compared with children with ADHD not taking MPH, the adjusted hazard ratio for burn injury was 0.70 in children taking MPH for <90 days (95% confidence interval (CI) 0.64–0.77) and 0.43 in children taking MPH for ≥90 days (95% CI 0.40–0.47), with a 50.8% preventable fraction. The negative association of MPH was replicated in age-stratified analysis using time-dependent Cox regression and self-controlled case series models. Conclusion: This study showed that MPH treatment was associated with a lower risk of burn injury in a cumulative duration of treatment dose-related effect manner. [ABSTRACT FROM AUTHOR]

Background: Naltrexone has considerable potential in helping to prevent relapse in heroin dependency. A longer-lasting formulation for naltrexone treatment is desirable to further reduce non-adherence and relapse during treatment of opiate dependence.Aims: To evaluate the safety and effectiveness of a 6-month naltrexone implant in reducing opioid use after in-patient treatment.Method: A group of 56 abstinence-oriented patients who completed in-patient treatment for opioid dependence were randomly and openly assigned to receive either a 6-month naltrexone implant or their usual aftercare. Drug use and other outcomes were assessed at 6-month follow-up.Results: Patients receiving naltrexone had on average 45 days less heroin use and 60 days less opioid use than controls in the 180-day period (both P<0.05). Blood tests showed naltrexone levels above 1 ng/ml for the duration of 6 months. Two patients died, neither of whom had received an implant.Conclusions: Naltrexone implant treatment safely and significantly reduces opioid use in a motivated population of patients. [ABSTRACT FROM AUTHOR]

Background: Treatments in different settings have different costs. A dilemma arises if expensive treatments lead to better outcomes.Aims: To investigate conflicts between the priorities of cost minimisation, clinical effectiveness, and cost-effectiveness in the detoxification of opiate addicts.Method: Cost and clinical effectiveness were examined using published outcome data. The main outcome measures were: achieving a drug-free state on completion of detoxification; the economic costs of treatment.Results: In terms of simple cost, in-patient detoxification is much more expensive than out-patient treatment (ratio, 24:1). With adjustment for successful outcome, the costs are almost identical (ratio, 0.9:1). Comparison of specialist and general psychiatry in-patient settings showed that even when adjusted for clinical outcomes, the specialist setting is more costly (ratio, 1.9:1), although the outcomes are better.Conclusions: Naïve adherence to cost and cost-containment considerations is dangerous. Discussion of treatment costs is misleading if not informed by, and adjusted for, evidence of effectiveness. This is especially important where marked differences in outcome between treatment options exist. [ABSTRACT FROM AUTHOR]

Background Many people with substance use disorders are vulnerable to other psychiatric disorders and present to addiction treatment services with comorbid psychiatric symptoms. Aims To describe the prevalence of recent psychiatric treatment and current psychiatric symptoms and explore links between substance misuse, personal! social functioning and symptom severity. Method Subjects were 1075 adults recruited to the National Treatment Outcome Research Study (NTORS), of whom 90% were opiate-dependent. Psychiatric symptoms at intake were recorded using sub-scales from the Brief Symptom Inventory. Results Recent psychiatric treatment was reported by one in five subjects. Psychiatric symptom levels were high and females had elevated scores on all scales. Symptoms were elevated among opiate users who were also frequent users of benzodiazepines, alcohol and, in particular, stimulants. Gender, physical health, drug dependence and personal relationship problems were more powerful predictors of psychiatric symptoms than substance use. Conclusions Addictions service providers should be vigilant to psychiatric problems among their clients at intake to treatment. Psychiatric symptoms are more closely linked to polydrug use than to opiate use in this population. [ABSTRACT FROM AUTHOR]

Background: General psychiatrists have recently been encouraged to provide treatment to heroin addicts, including in-patient detoxification. No comparison has previously been made of specialist versus general psychiatric in-patient care.Method: During a randomised study of cue exposure, 186 opiate addicts were also randomised to either specialist in-patient (DDU; n = 115) or general psychiatric (GEN; n = 71) wards in the same hospital.Results: From pre-treatment (post-randomisation) onwards, patient outcomes differed across the two in-patient settings. Of the original randomised sample, significantly more DDU than GEN subjects accepted their randomisation (100 v. 77%), were subsequently admitted (60 v. 42%), and completed in-patient detoxification (45 v. 18%). Of patients admitted, more DDU than GEN patients completed detoxification (75 v. 43%). During seven-month follow-up, of those 43 patients who reached the end of treatment, significantly more ex-DDU than ex-GEN subjects were opiate-free.Conclusions: From pre-treatment onwards, significant differences in process and outcome were found after allocation to treatment on either DDU or GEN. Further randomised studies are required to replicate and explain these findings. [ABSTRACT FROM AUTHOR]

Background: This study investigates patterns of qat use among 207 Somalis living in London.Method: Subjects were recruited using privileged access interviewing. Somalian interviewers were recruited who shared the same culture as the subjects. Data were collected by means of a structured interview.Results: One hundred and sixty-two subjects (78%) had used qat. The majority (76%) used more qat than in Somalia. Some users reported moderate dependence; a minority reported severe problems. Adverse psychological effects included sleep problems, anxiety and depression. Medical problems associated with qat use were rare.Conclusions: Qat users who continue to use this drug when it is transplanted from a traditional context may experience difficulties. Qat use can also be seen as playing a positive role in supporting the cultural identity of the Somalian community. Severe problems were rarely reported. Qat consumption should be considered when addressing health-related topics with patients from those communities in which qat use is common. [ABSTRACT FROM AUTHOR]

This paper presents an approach to estimating the prevalence of cocaine use, based upon a new ratio estimation technique. This method can be applied to random samples of overlapping populations for which no sampling frames exist. When the ratio estimation method is applied to the two study samples (drawn from populations of people using cocaine and people using heroin) the ratio of cocaine users to heroin users (C/H) was 1.55, with a 95% confidence interval of +/- 0.48. Such estimates should be applied with caution. However, if used with reference to national estimates of about 75,000 heroin users, application of the present estimate suggests that there may be about 116,000 cocaine users in the UK. [ABSTRACT FROM AUTHOR]

We contacted and interviewed 150 cocaine users in south London community settings. Most were taking cocaine regularly, but not daily, and in substantial doses. Three main routes of administration were used: smoking (40%), intranasal (32%), and injecting (24%). Injectors reported having used cocaine more frequently, in higher doses and for longer periods of time. Despite their frequent and extensive use of cocaine, the overall level of dependence was low for the great majority of the sample. Two-thirds (66%) of the full sample (and two-thirds (65%) of the crack smokers) reported only minor signs of dependence during the year prior to interview. Route of drug administration was related to severity of dependence. Cocaine taken by injection was associated with the highest levels of dependence; intranasal use was associated with the lowest levels, and crack smoking was intermediate between the two. There had been substantial changes in the initial route by which cocaine was used, with a clear trend away from injection on the first occasion of use. Those who first used cocaine before 1986 were more likely to have used the drug either intranasally or by injection. Cocaine users who first tried the drug after 1987 were increasingly likely to take it by smoking crack. Women and black (predominantly Afro-Caribbean) subjects were more evident in this sample of cocaine users than has previously been reported in many UK studies. [ABSTRACT FROM AUTHOR]

This study investigates sex differences in patterns of drug taking and related injecting and sexual behaviour among 355 patients attending a London community drug team. The majority of cases attending the service presented with heroin problems. Men were more likely to use heroin by injection and women were more likely to use heroin by inhaling/smoking ('chasing the dragon'); there was no sex difference in the overall incidence of needle sharing. The delay between first use of the problem drug and first presentation to services was the same for both men and women. Women were more likely to have a sexual partner who was a drug user and to be living with another user than men. This closer social attachment to other drug users was seen as presenting a high risk factor for women with regard to prognosis and treatment. [ABSTRACT FROM AUTHOR]

Relapse is a central problem in the treatment of addictive behaviour, and a specific problem in the out-patient treatment of the opiate withdrawal syndrome. This study investigated factors associated with relapse among 42 opiate addicts receiving out-patient detoxification treatment at a London drug-dependence clinic. All subjects completed a questionnaire about their social, psychological, and environmental circumstances in the week before interview, and were interviewed within the first two weeks of the programme. Forty per cent had lapsed to illicit heroin abuse within the previous week. Interpersonal factors and drug-related cues were associated with lapse to opiate use. Most subjects encountered a range of high-risk situations, such as regularly meeting other drug users and being offered drugs, and persistent negative mood states. [ABSTRACT FROM AUTHOR]

A study of 50 opiate addicts attending a London service for treatment of drug dependence found that 47 subjects had previously made at least one attempt at self-detoxification. These subjects reported 212 previous attempts. Although 30 subjects reported having managed to complete at least one attempt, the success rate per episode was low (24%). One of the most commonly reported methods, used by 28 subjects, involved an abrupt cessation of opiates ('cold turkey'). Of the drugs used in their attempts at self-detoxification, benzodiazepines were reported by 24 subjects and opiates by 20. Practical strategies such as distraction and avoidance were also used. Self-help detoxification materials for opiate addicts might be useful. [ABSTRACT FROM AUTHOR]

This paper presents data from the first British prospective study to investigate relapse among opiate addicts after treatment. Eighty subjects were followed up over the six-month period immediately after discharge from treatment and were interviewed on several occasions. Large numbers of subjects used opiates within a very short time after discharge; 71% used them within the first six weeks. However, this first lapse to opiate use did not herald a full-blown relapse to dependent use. There was a gradual increase in the number of abstinent subjects, with 45% abstinent and living in the community at the six-month point. The practical and theoretical implications may be regarded as broadly encouraging. [ABSTRACT FROM AUTHOR]

This study investigates and compares the responses of 132 opiate addicts to a 10-day or a 21-day in-patient oral methadone withdrawal regime. For both groups, symptom severity (on the Opiate Withdrawal Scale) steadily increased through the methadone withdrawal phase, and peaked near the point of completion of the prescribed drug, declining slowly thereafter. Patients on the 10-day programme reported significantly higher peak withdrawal scores than those on the 21-day programme. Although the proportions who completed detoxification were similar, there was a significantly higher drop-out rate immediately after detoxification for the 10-day group. The possible benefits and handicaps of the two withdrawal schedules are considered and recommendations are proposed for further refinement of the present widely adopted approach. [ABSTRACT FROM AUTHOR]

Seventy-eight opiate abusers were followed up after successful in-patient detoxification in order to examine renewed opiate use. The greatest number of initial lapses occurred within a week of subjects leaving in-patient treatment. Eleven categories of lapse precipitant were identified: cognitive, mood, external, withdrawal, interpersonal, leaving a protected environment, drug availability, drug-related cues, craving, priming, and social pressure. Cognitions, negative moods and external events emerged as the most commonly mentioned factors; these often occurred together, either in clusters or in a sequence. Implications of these results for models of relapse and for treatment approaches are discussed. [ABSTRACT FROM AUTHOR]

A group of 24 opiate addicts admitted to an in-patient drug dependence unit received either electrostimulation or graduated oral methadone withdrawal. Addicts treated with electrostimulation showed high levels of withdrawal symptoms during the first week of treatment: these reached a peak on Day 3. In this respect electrostimulation was markedly inferior to methadone withdrawal treatment. However, although progressive methadone withdrawal quickly reduced symptoms to a moderate or low level, there was no reduction in symptomatology as late as one month after admission (i.e. after ten days without methadone). The implications of these findings are discussed. [ABSTRACT FROM AUTHOR]

Addicts who use illicit drugs despite receiving a maintenance prescription present a difficult management problem for drug dependence clinics. This study looks at a small group of such addicts and at their response to the provision of a temporary increase in their prescribed opiates. The results indicate that this increase led to a reduction in illicit drug use and to improvements in social functioning. These and other findings are discussed. It is suggested that clinics should be more prepared to consider such temporary increases, but the need for careful monitoring and for the involvement of more than one member of the treatment team is stressed. [ABSTRACT FROM AUTHOR]

In a study of male addicts attending a London drug dependence unit, it was found that convicted addicts tended to score more highly on measures of hostility than non-convicted subjects. The differences in hostility between the convicted and non-convicted groups were most clearly seen on the violent crimes variable, although addicts convicted of drug-possession and of non-drug crimes were also more hostile than non-convicted subjects. It is suggested that hostility acts as a personality factor which predisposes the individual towards criminal behaviour, and that the more hostile subjects may also be more likely to be apprehended and convicted. [ABSTRACT FROM AUTHOR]

Although a number of studies have suggested that hostility and drug dependence may be related, there are few systematic studies of this issue. Using the Hostility and Direction of Hostility Questionnaire, the present study compares several drug-dependent groups of patients. Results showed that the intravenous in-patient group was more hostile on several variables than their out-patient counterparts, and also more hostile than an oral in-patient group. Barbiturate abusers were found to have high levels of hostility; amphetamine abusers were the least hostile group, and narcotic dependent patients were intermediate between the two. Correlations between scales of the HDHQ were all positive, and most were both high and statistically significant, suggesting that hostility represents a relatively generalized trait in drug-dependent subjects. The results are discussed both in terms of patient selection factors--the differential pressures on different types of patients, and in terms of direct drug effects. It is suggested that the hostility of drug-dependent patients may represent an important problem of personal functioning and may require special attention in treatment programmes. [ABSTRACT FROM AUTHOR]

This study compares the withdrawal responses of methadone and heroin addicts during a ten-day in-patient detoxification programme with methadone. Contrary to suggestions in the literature, the methadone group reported more severe withdrawal symptoms during both the acute withdrawal phase and the recovery phase. There were no differences between the two groups in onset or duration of symptoms. Whereas there may be reasons to favour methadone as a maintenance drug, its use may lead to difficulties during withdrawal. [ABSTRACT FROM AUTHOR]

The article discusses developments in the government's response to drug abuse problems in Great Britain. The author notes the Maudsley Relapse Project is a study about the return to opiate use of a group of addicts who have been successfully withdrawn from opiates. He adds one particular interest of the project is a previously unreported tendency for substantial numbers of subjects to move towards abstinence during the first six months after leaving treatment. He stresses the treatment program maximizes the chances of success and treatment needs to be extended after discharge from hospital.

A response by John Strang and Michael Gossop to a letter to the editor about their article on methadone withdrawal in the May 1991 issue is presented.

Aims: We aimed to investigate child mortality, perinatal morbidities and congenital anomalies born by women with substance misuse during or before pregnancy (DP or BP)., Methods: Taiwan Birth Registration from 2004 to 2014 linking Integrated Illicit Drug Databases used to include substance misuse participates. Children born by mothers convicted of substance misuse DP or BP were the substance-exposed cohort. Two substance-unexposed comparison cohorts were established: one comparison cohort selected newborns from the rest of the population on a ratio of 1:1 and exact matched by the child's gender, child's birth year, mother's birth year and child's first use of the health insurance card; another comparison cohort matched newborns from exposed and unexposed mothers by their propensity scores calculated from logistic regression., Results: The exposure group included 1776 DP, 1776 BP and 3552 unexposed individuals in exact-matched cohorts. A fourfold increased risk of deaths in children born by mothers exposed to substance during pregnancy was found compared to unexposed group (hazard ratio [HR] = 4.54, 95% confidence interval (CI): 2.07-9.97]. Further multivariate Cox regression models with adjustments and propensity matching substantially attenuated HRs on mortality in the substance-exposed cohort (aHR = 1.62, 95% CI: 1.10-2.39). Raised risks of perinatal morbidities and congenital anomalies were also found., Conclusions: Increased risks of child mortality, perinatal morbidities or congenital anomalies were found in women with substance use during pregnancy. From estimates before and after adjustments, our results showed that having outpatient visits or medical utilizations during pregnancy were associated with substantially attenuated HRs on mortality in the substance-exposed cohort. Therefore, the excess mortality risk might be partially explained by the lack of relevant antenatal clinical care. Our finding may suggest that the importance of early identification, specific abstinence program and access to appropriate antenatal care might be helpful in reducing newborn mortality. Adequate prevention policies may be formulated.