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Ultram (tramadol HCL) was approved by the Food and Drug Administration in 1994 as a non-scheduled drug under the Controlled Substance Act. The non-scheduled status was contingent on the development and implementation of a comprehensive post-marketing surveillance program by an Independent Steering Committee external to Ortho-McNeil Pharmaceutical charged with monitoring abuse and recommending scheduling if unexpectedly high abuse occurred. The program developed by this committee was composed of a variety of studies, and the results of the first three years of the surveillance efforts revealed that the rate of Ultram abuse was low. At a meeting of the FDA in 1998 to reexamine the scheduling status of Ultram, it was recommended that the scope of the postmarketing surveillance program be broadened to include data on diversion. After a 1-year pilot study, by January 2002, a nationwide diversion survey was fully operational. This brief communication describes the experiences of this diversion study, and compares the findings on the diversion of Ultram and other tramadol HCL products with that of more widely abused drugs. Survey data suggest that the diversion of Ultram and other tramadol products is low, and overall, diversion investigators did not consider tramadol to be a problem in their respective jurisdictions.

Concern about abuse/dependence in chronic pain patients taking opioid analgesics may lead to undertreatment of pain, yet little is known about the prevalence of abuse/dependence in these patients and how it differs among analgesic agents. The objective of this study was to assess the prevalence of tramadol abuse compared to nonsteroidal anti-inflammatory drugs (NSAIDs) and hydrocodone-containing analgesics in patients with chronic noncancer pain (CNP). The study had three arms. The first arm consisted of subjects prescribed tramadol alone; the second of subjects randomized to either NSAIDs or tramadol; and the third of subjects randomized to hydrocodone or tramadol. Each investigator received two boxes of prescriptions randomized so that one in every four prescriptions was for tramadol. Upon deciding on the therapeutically appropriate arm, the physician selected the appropriate box, opened the next envelope and completed the enclosed prescription. After the initial randomization, physicians could prescribe whatever medication was therapeutically appropriate. A total of 11,352 subjects were enrolled. Up to nine interviews using a structured questionnaire were conducted over a 12-month period. An algorithm called the "Abuse Index" was developed to identify subjects who were abusing the drug. The primary components of the index were increasing dose without physician approval, use for purposes other than intended, inability to stop its use, and withdrawal. The percent of subjects who scored positive for abuse at least once during the 12-month follow-up were 2.5% for NSAIDs, 2.7% for tramadol, and 4.9% for hydrocodone. When more than one hit on the algorithm was used as a measure of persistence, abuse rates were 0.5% for NSAIDs, 0.7% for tramadol, and 1.2% for hydrocodone. Thus, the results of this study suggest that the prevalence of abuse/dependence over a 12-month period in a CNP population that was primarily female was equivalent for tramadol and NSAIDs, with both significantly less than the rate for hydrocodone.

Objective: Assess the validity of medical products reporting program (MEDWatch) reports of abuse/dependence and withdrawal associated with Ultram (tramadol). Methods: Reports of possible abuse/dependence or withdrawal associated with Ultram during 13 quarters following launch were spontaneously reported to the manufacturer Ortho-McNeil Pharmaceutical (OMP) and also solicited from 255 NIDA grantees and addiction treatment professionals by an Independent Steering Committee (ISC). Reports were classified by the ISC using DSM-IV criteria, by the Drug Safety and Surveillance (DSS) units of Robert Wood Johnson Pharmaceutical Research Institute (PRI) using World Health Organization Adverse Reaction Terms (WHOART) terms, and reported to the food and drug administration (FDA) via MEDWatch. Rates of abuse/dependence and withdrawal per 100 000 persons exposed were calculated separately for classifications made by the PRI and the ISC, and confidence intervals calculated to determine the degree to which they agreed. Results: For 681 reports submitted to PRI, confidence intervals of ISC ratings contained PRI ratings 12 of 13 times for abuse/dependence, and 12 of 13 times for withdrawal. For 242 reports submitted to the ISC, confidence intervals of ISC ratings contained PRI ratings 10 of 13 times for abuse/dependence, and 12 of 13 times for withdrawal. Proactive surveillance increased the total number of cases of abuse/dependence but not withdrawal. Many cases of withdrawal without signs or symptoms of abuse/dependence were identified. Conclusions: There was good/excellent concordance between MEDWatch and ISC classifications. Proactive surveillance increased cases of abuse/dependence but not withdrawal. Withdrawal with no signs or symptoms of dependence was common. More use of proactive surveillance is likely to improve assessments of public health risks associated with adverse events.

Tramadol HCl, marketed as Ultram in the USA, was introduced as a non-scheduled drug in April 1995 based on the assumption that the risk of abuse was sufficiently low to warrant a non-scheduled status. However, approval was contingent upon the development of an innovative proactive surveillance program, to be overseen by an independent steering committee, which would detect unexpectedly high levels of abuse. The postmarketing surveillance program consisted of systematic collection and scientific evaluation of reports of suspected abuse in high-risk populations surveyed through an extensive key informant network of drug abuse specialists and all spontaneous reports of abuse received through the FDA MedWatch system. Methods to estimate the number of patients prescribed tramadol were also developed. Monthly rates of abuse were calculated as an index of the risk-benefit ratio (i.e., abuse cases per 100,000 patients prescribed the drug). The data for the 3 years since the drug was introduced show that the reported rate of abuse has been low. Although a period of experimentation seemed to occur in the first 18 months after its introduction--which reached a peak rate of approximately two cases per 100,000 patients exposed--during the 2 year period prior to June 1998, the reported rate of abuse has significantly (P = 0.011) declined, reaching levels of less than one case per 100,000 patients in the last 18 months. The overwhelming majority of abuse cases (97%) have been found to occur among individuals with a history of substance abuse and the abuse has been confined to isolated pockets around the country-notably none of which have significant populations of street drug abusers. Thus, the data support the decision not to schedule tramadol and, furthermore, suggest that a proactive post-marketing surveillance program can be successfully developed to effectively monitor abuse of new medications.

The effectiveness of a case management model in improving treatment access, retention, and outcomes was examined within a cohort of 360 intravenous drug users (IDUs) pursuing substance-abuse treatment through a central intake facility. IDUs were randomly assigned either to the case management group or to the comparison group. In the case managed condition, IDUs received assistance from their case manager in identifying and accessing needed services, including substance abuse treatment. In the comparison condition, IDUs received limited referral information for substance abuse treatment. Clients in the case managed group accessed substance abuse treatment in significantly greater numbers and more rapidly than clients in the comparison group. Case-managed clients also remained in substance abuse treatment nearly twice as long as did comparison group clients. Finally, case-managed clients showed better treatment outcomes including reduced alcohol and drug use.

This paper examines data on the question of possible differences between benzodiazepines in abuse liability and potential for causing physical dependence. The data on potential for causing physical dependence indicates that all benzodiazepines cause physical dependence and there is little evidence for substantial differences between them in this respect. The evidence for substantive differences between benzodiazepines with respect to abuse liability is reviewed: problems with methodology and with definitions make problematic the assertion of some authors that there are clinically meaningful differences in abuse liability. There is general agreement that all benzodiazepines have at least some abuse liability.

Poison Control Center (PCC) cases involving intentional ingestion, injection or inhalation of prescription opioids are a potentially valuable source of information on the abuse and misuse of these products. This study sought to validate PCC classifications of prescription opioid intentional exposure cases against clinical diagnostic criteria. 4,321 cases were reviewed. PCC-clinician concordance was good to excellent for Withdrawal, Abuse, and Suicide (kappa statistics: 0.73, 0.53, 0.48, respectively), but poor for Misuse and Intentional Unknown (Specific motive not known). Interrater reliability among clinicians was good (weighted kappa range: 0.56–0.68). Results demonstrate the degree of compatibility between PCC and standard nosologic classifications.

Purpose The analgesic Tramadol HCl (Ultram™) was approved in 1994 as a non-scheduled drug under the CSA provided that a novel risk-management program would be developed by an Independent Steering Committee (ISC). The risk-management program began in 1995 with the launch of Ultram, and has been modified over the past decade to accommodate Ultracet (Ultram and acetaminophen) in 2001 and generic tramadol in 2002. This provided a unique opportunity to study the potential changes in abuse as the generic and combination products became available. Methods To proactively detect cases of abuse and diversion, the ISC developed a comprehensive questionnaire which was completed quarterly by an extensive network of drug abuse experts (n = 309) and police agencies (n = 100) who were asked to indicate how many diversion cases involving Ultram, Ultracet, and generic tramadol were identified during the preceding 3 months and what were the ten most commonly diverted drugs in their catchment area during that period. Results and Conclusions The data generated demonstrate that the abuse of tramadol remained very low despite new branded and generic formulations. Contrary to the hypothesis that cheaper generic drugs would lead to higher rates of abuse, we found no increase in abuse with the introduction of generic tramadol. Ultracet abuse rates, unlike those found with other widely used hydrocodone and oxycodone combination products, have been even lower than that observed for tramadol. Since the FDA has now mandated that proactive risk-management plans be implemented for new drugs, the tramadol risk-management plan may be useful as a prototypic model which can be modified to accommodate other drugs with abuse potential. Copyright © 2005 John Wiley & Sons, Ltd.

In 1994, the Drug Abuse Advisory Committee (DAAC) of the Food and Drug Administration (FDA) concluded that Ultram® (tramadol hydrochloride) could be marketed as an analgesic drug without scheduling under the Controlled Substances Act based upon extensive pre-clinical, clinical and European epidemiological data. However, to guard against unexpectedly high levels of abuse in the United States, the DAAC recommended that an independent steering committee (ISC) be appointed to proactively monitor abuse/dependence. In the event that high rates of abuse were found, this ISC was given the authority to immediately recommend to the FDA that Ultram® be scheduled. In the course of the surveillance project, the ISC received reports of withdrawal following abrupt discontinuation of Ultram® and in some instances, following dose reductions. In most cases, the withdrawal symptoms consisted of classical opioid withdrawal, but in some cases were accompanied by withdrawal symptoms not normally observed in opiate withdrawal, such as hallucinations, paranoia, extreme anxiety, panic attacks, confusion and unusual sensory experiences such as numbness and tingling in one or more extremities. Withdrawal symptoms of either type were one of the more prevalent adverse events associated with chronic Ultram® use, comprising nearly 40% of all adverse events reported with Ultram®. Most of these consisted of typical opiate withdrawal symptoms, but 1 in 8 cases presented as atypical. These results indicate that physicians and other healthcare professionals need to be aware of the potential of Ultram® to induce withdrawal of the classical opioid type, and that atypical withdrawal may also occur.

This article describes a 300-bed substance abuse treatment program that is part of a continuum of care focused on preventing drug and criminal recidivism in substance abusing criminals incarcerated in Dallas County, Texas. It is the product of a joint effort of the judiciary, the Dallas County Supervision and Corrections Department, the State of Texas Criminal Justice Division, and Interventions Co., a not-for-profit treatment provider. The program is rooted in over 25 years of treatment experience and incorporates therapeutic community (TC) technology combined with 12-Step programming, behavior modification, job training (having a job is required for graduation), educational, and medical/psychiatric elements. Treatment is conceived as part of a continuum of care to provide substantial and sustained support for the inmate in the difficult process of adapting to the community post incarceration. Treatment plans are individualized and are based on an extended workup in which the individual's status in a number of domains is assessed. Specialized services, such as transportation and childcare, facilitate recovery. Once in the community, urine monitoring, groups, and counseling continue. The program is beginning its fourth year of operation and approximately 600 inmates have started the program. A formal evaluation is in process.

In a one year study, 130 methadone maintained subjects with a six month history of good treatment performance were assigned randomly to an experimental condition of one monthly non-random urine screen, one monthly counseling session, one monthly doctor visit, two times per month methadone pick up, a quarterly true random urine screen and participation in a diversion control program or to a control condition of staying under standard conditions for six months and then being transferred to the experimental condition for six months. Results of urine screens and scores on the Addiction Severity Index (ASI) at entrance and six month intervals showed no differences between groups. Three out of four subjects completed the year in good standing. Subject satisfaction was such that the IRB judged that return to standard conditions would be a hardship. Experimental conditions were cheaper such that resources freed up could be applied to the HIV epidemic.

(1978). Treatment Goals for Substance Abusers. The American Journal of Drug and Alcohol Abuse: Vol. 5, No. 3, pp. 299-305.

Medical histories, neurological examinations and electroencephalograms of 25 methadone-maintained subjects were compared with those of 25 abstinent controls. Comparisons on all measures failed to show significant differences between groups. The incidence of abnormalities was low for all subjects. None of the observed conditions appeared to involve methadone in their etiology.

This report examines heroin use careers within a sample of 147 Black male heroin addicts and their nonaddicted friends. Based on the extent of their heroin use, subjects were classified into the following subgroups: "light" experimenters, "moderate" experimenters, "heavy" experimenters, and addicts. Our findings indicate that no single career line of pattern characterizes all heroin users. While some users quickly progress from initiation to heroin to regular, intermittent use or "chipping" to daily heroin use and physical dependence, others are deflected at various points along the way. In this report we describe some of the sociobehavioral processes or career contingencies associated with movement from one level of heroin use to the next.

A review of scientific and clinical evidence indicates: (1) benzodiazepines have an abuse liability and can cause physical dependence, (2) abuse liability is of a lower order of magnitude than that associated with common intoxicants such as barbiturates, opioids or stimulants, (3) sustained, exclusive use of benzodiazepines for inducing intoxication occurs but, it is infrequent, (4) benzodiazepines tend to be secondary drugs to a preferred primary intoxicant; in experimental paradigms normals prefer placebo to benzodiazepines, (5) susceptibility to physical dependence varies widely as low doses are sufficient to produce it in some but very high multiples are not sufficient to produce it in many others, (6) factors predisposing to physical dependence are: total lifetime dose, previous exposure to drugs cross-tolerant, such as alcohol or barbiturates, concomitant severe medical/psychiatric problems, and severe persisting stress. Individual susceptibility to abuse and to become dependent on benzodiazepines should be investigated much more vigorously than it has heretofore.

Plasma testosterone levels were measured in a group of 13 men maintained on acetylmethadol for treatment of opiate dependence. Prior to acetylmethadol administration, plasma testosterone levels were within normal adult ranges. Four hours following ingestion of acetylmethadol, plasma testosterone levels were significantly depressed and continued to fall 7-9 hr after drug administration. Plasma testosterone levels remained low 24-25 hr after the drug was taken, but, 48 hr following drug, plasma testosterone levels rose to values approximating those prior to drug. Depression of plasma testosterone levels following acetylmethadol ingestion was not only statistically but also biologically significant, since in many patients the levels were below the normal range for adult males.

To determine whether family, peer, and school variables are associated with divergent heroin-use patterns or career outcomes, we interviewed 183 black male heroin addicts, experimenters, and non-heroin users from Chicago's south side. While subgroup differences on socio-familial variables generally were not statistically significant, we did observe a number of trends in the expected direction. For example, addicts were more likely than experimenters or nonusers to come from broken homes, to have friends who were involved in serious types of drug use and other illegal activities, and to drop out of high school. At the same time, the pervasiveness of some of our measures of “social disharmony” across the sample suggests that, at least in some inner-city black neighborhoods, these patterns are perhaps becoming the norm.

Patients applying for treatment to the State of Illinois' Chicago Central Intake Facility were interviewed to assess their service needs and treatment expectations; a subgroup was reinterviewed after 4 months. Patients were classified as long-term opioid-dependent, short-term opioid-dependent, or as polydrug nonopioid dependent abusers. We found high levels of housing, employment, and legal needs among all subgroups at both first and second interviews. There were significant differences between drug-use groups in reasons for seeking treatment; opioid-dependent groups gave drug-related reasons more frequently while polydrug abusers cited legal reasons. Length of time patients remained in treatment was not related to service needs.

We studied 108 heroindependent patients who had been “stabilized” on methadone, i.e., had no change in methadone dose for at least 2 weeks. With respect to their methadone detoxification regimen, 65 of the study patients preferred physician reg- ulation and 43 study patients preferred self-regulation. Half of each group was randomly assigned to self- or physician regulation. Twenty-five of the 108 patients reached abstinence following a regimen which lasted 22 weeks; there was no statistically significant difference in proportion of subjects reaching abstinence from any of the four study groups. We observed no differences in treatment retention, symptom severity, frequency of urines positive for morphine or quinine, or psycho- social functioning. Study subjects preferring self-regulation had statistically signif- icant increases in the number of dose raises. We conclude that there is no evidence to support the belief that physician regulation is superior to self-regulation in opioid detoxification regimens.

We conducted a pilot study to ascertain the potential toxicity and possible efficacy of delta 9-tetrahydrocannabinol (THC) at the oral dose of 5 mg/m2. Over one third of the study population, which consisted of 25 patients, reported significant dysphoric reactions. Four patients (16 per cent) elected not to take THC rather than experience loss of motivation which interfered with their professional life. Paradoxically, on eight occasions nausea seemed to worsen with THC. After the first administration of THC, 18 patients (72 per cent) described less nausea and only two individuals (8 per cent) noted complete resolution of nausea. Two patients reported worsening of their nausea. Eighteen patients noted less vomiting (69 per cent) after the first administration of THC and four patients (15 per cent) reported completed resolution of their vomiting. By the third administration of THC, one of 14 patients (7 per cent) and two of 14 (14 per cent) noted complete alleviation of nausea and vomiting, respectively. Patients who scored high on the Brief Psychiatric Rating Scale, who reported euphoria, or who had psychogenic nausea and vomiting were most likely to have a favorable antiemetic response. The results of this pilot study suggest that orally administered THC is a toxic but transiently effective antiemetic when administered at 5 mg/m2.

Of 186 narcotics addicts admitted to a hospital ward for withdrawal, 33 volunteered for treatment with cyclazocine. Twenty months later 33% (11) of the patients given cyclazocine were in an abstinence-aftercare treatment, as compared to 8.5% of those not receiving the drug. When all treatment modalities are considered (abstinence-aftercare, therapeutic communities, and methadone maintenance) 57.5% (19) of patients given cyclazocine remained in some form of treatment as compared to 32% of those who did not take cyclazocine.Patient acceptance of cyclazocine was high in spite of frequent side effects. Tolerance developed rapidly and there was no evidence of serious toxicity. Tentatively, cyclazocine appears useful in the treatment of narcotics addicts voluntarily seeking abstinence.

Previous studies have provided strong evidence to support the concepts that in the rat histamine is the chemical mediator of gastric acid secretion and that histamine plays an essential role in the pathogenesis of stress ulcers. The present experiments indicate that the role of histamine in the pathogenesis of stress ulcers in rats is probably mediated through stimulation of gastric acid secretion. In particular, we found a strong negative correlation between intragastric pH and the incidence of stress ulcers. Furthermore, intragastric administration of Basaljel® (a nonabsorbable antacid) afforded significant protection against stress ulcers without preventing the sharp increase in histidine decarboxylase activity in response to stress.

Gastric secretions of 12 fasting male subjects between the ages 20 and 27 years were collected by continuous manual syringe aspiration for two hours. In seven trials, the subjects rested for one hour and did mental arithmetic during the second hour. In seven other trials, the arithmetic hour preceded the rest hour. The mean milliequivalents of HCl secreted during the 14 arithmetic hours was significantly different from the mean milliequivalents secreted during the 14 rest hours (one tailed t= 2.28; p < .05). The volume of juice secreted during the arithmetic hour also decreased (one tailed t= 2.35; p < .05).

Social and cultural factors pertaining to neuroses and psychosomatic illnesses were reviewed. An attempt was made to define terms and to suggest which of a large number of possibilities might be relevant variables in the mental health equation. Cultural, sub-cultural, and small and large group systems were selected. It was concluded, on the basis of present knowledge, that there is probably a significant amount of cultural invariance i.e., the same basic syndromes occur in widely different settings but are modified by them in form and course. Subcultural variables contribute more to variance than culture. Some forms of behavior disorders such as drug addiction, alcoholism, and the sociopathies are strongly influenced by the sub-cultural system. Small group systems, particularly the family, are major sources of variance in questions of both psychologic and somatic disease. Prevention and treatment will benefit from a more comprehensive framework than we have had heretofore. An emerging general systems theory would seem to fit this need. It was suggested that today's professional role allocations for treatment and research of psychosomatic and psychoneurotic disorders are artificial and that new professional roles must be created if we are to achieve our ultimate goals.

Discussion and conclusionThis method offers several significant advantages over those described previously. The simplicity of the technique permits an experienced operator to immobilize an animal in approximately 30 to 45 seconds. Only 2 hours are required to produce lesions, offering further saving of time. Apparently this rapid production of lesions represents a synergistic effect of the dual stresses employed. We believe that the mode of restraint also contributes to the improved results obtained. This method obviates additional environmental variables that may be difficult to control, e.g., increased temperature, as with plaster of paris immobilization (5); pain, as with nailing the paws to a board (1); or ingestion of sharp metal fragments, as with wire screen immobilization(3). Furthermore, use of the plastic box permits immobilization in a relatively uniform volume. Bonfils and Lambling, on the basis of studies in a large series of animals, described a linear inverse relationship between incidence ...

In this paper we report our experience with 24 cases in which there was a homicide or homicides committed in association with use of large amounts of psychoactive drugs. Many, if not most of these homicides, would not have occurred without drug effects, for frequently there was evidence of grossly illogical thinking in close temporal association with use of intoxicants and in many cases there was no previous history of violence, no evidence of premeditation, no plan to avoid arrest and little or no discernible motivation. Usually there were multiple losses or other severe stress in the lives of the persons committing the homicide in the months preceding the crime. The stress increase was accompanied by increased and extraordinary intake of psychoactive substances. We theorize that high doses of psychoactive drugs impaired severely the brain systems upon which the mental functions of reality testing and judgment depend. Drug induced impairment of reality testing and judgment is frequently uncritically equated with hallucinations, disorientation, changes in time perception or other drug induced mental phenomena. Impairment of reality testing and judgment are basic criteria for linking drug effects with the behavior of homicide in the cases reviewed.

Clinical impressions, reinforced by reports in both professional journals and the lay press, suggested that use and abuse of minor tranquilizers and sedative-hypnotics was extensive among patients in our drug treatment clinics and required some change in our policies. We surveyed a randomly selected national sample of methadone program physicians and found they shared our assumptions concerning the use of these drugs. A pilot program of urine screening for the presence of adjunctive drugs was completed, and we found the incidence of use to be below expected levels, except for opiates and alcohol. These results suggest we should reconsider plans to alter clinic policies concerning the regulation of these substances. A rigorous examination of serum and/or urine in a national research program to determine both the incidence of adjunctive drug use by clients in drug treatment programs and correlations of such data with national surveys would be an expensive undertaking, but would provide a more rational basis for policy making at both local and national levels.

Diagnostic pupillography, under blind conditions, produced constrictions greater than 0.75 mm in 25 opioid addicts and no change or dilation in 82 others. Placebo use produced no constrictions in 99 subjects. Methadone test dose pupillography provides significant information useful in diagnosing opioid dependence and is more acceptable to addicts than naloxone testing.

Summary Ophthalmic instillation of naloxone into the conjunctival sac of one eye can elicit bilateral mydriasis in volunteers maintained on daily methadone. Unlike previous reports, signs of a generalized withdrawal syndrome were recorded. Anisocoria was noted in one of the patients but both pupils were dilated relative to baseline. The conclusion drawn was that the ophthalmic naloxone test can elicit a generalized withdrawal syndrome and should not be used routinely to detect the presence of opiate dependence.

This paper reviews the world literature on methadone. Methadone has been used in hundreds of thousands of patients, in disparate social, economic, cultural, and geographic situations; it has been evaluated in scores of studies. The large majority of evaluations demonstrate that opioid use, criminality, and general health status are affected positively in many addicts. Smaller gains in job and family functions are noted. Alcoholism and multiple drug use complicate treatment for some addicts. Despite the positive data, public opinion remains negative about this treatment. The use of methadone in withdrawal from opioid dependence and in pregnancy complicated by opioid dependence is discussed.

'T's and B's' started to become widely used in Chicago in the early 1970s. Users reported an interaction between the two drugs which was expressed in slang terms such as 'Toms and Bettys', 'T'shirts and Blue Jeans.' By the late 1970s, T's and B's users occupied 10% of the treatment census in Chicago. Soft tissue damage was more pronounced with 'T's and B's' than with heroin and a number of serious medical complications were observed, e.g. pulmonary hypertension. The introduction of Talwin NX appears to have decreased greatly the use of T's and B's as demand for treatment for primary abuse of this combination is close to zero in 1983-84.

To determine whether early life-style variables (i.e., involvement in illicit drug use and other illegal activities) might be associated with subsequent patterns of heroin use, we conducted personal history interviews with 186 Black male heroin addicts, experimenters, and nonheroin users. Our findings indicate that patterns of heroin use should be viewed within the broader context of involvement in a deviant life-style. Addicts and heavy experimenters were more likely than moderate experimenters or nonheroin users to have been heavy users of illicit drugs such as marijuana, barbiturates, amphetamines, and codeine cough syrup and to have been involved in illegal activities such as drug dealing, property offenses, and violent crimes during or after leaving high school.

The majority of heroin addicts in Chicago meet at drug distribution sites called “copping areas.” One of these sites was selected to study the interactions of the heroin subculture with its host community. Awareness, attitudes, and actions of residents, business people, and police were surveyed. The findings in regard to community-police-addict interactions offer implications for the design of more effective community prevention and control programs.

The authors examined the relationship between depressive symptoms, drug-use pattern, and demographic variables in 432 substance abusers. Assessment was at intake and at 4 and 8 months. Depression was measured by using the Beck Depression Inventory, the Hamilton Rating Scale for Depression, and the Current and Past Psychopathology Scales. At intake 46% of the subjects reported moderate or high levels of depression on the Beck scale and 29% of subjects scored in the high or moderate range of depression on the Hamilton scale. After eight months, depression scores were significantly lower in all drug abuse groups. These reducations were not related to type or length of treatment.

A four-phase intervention model for containing localized heroin epidemics was tested in a black public housing project in Chicago where a heroin epidemic beginning in 1967 had produced approximately 50 new addicts by the end of 1971. The implementation of the intervention model is described in detail. Data are presented to show the impact of the program on heroin incidence and prevalence trends in the target community.

Clinical experience suggests that women seeking abortion inhibit, either partially or completely, the normal process of fantasy about the fetus. To study this phenomenon more systematically, we compared five categories of fantasies in women (N=28)who wanted to carry their pregnancies to term with similar data in women (N=18)who did not want to carry their pregnancies to term and were seeking therapeutic abortion. All women desiring term pregnancies reported fantasies in multiple categories, and none denied having any fantasies concerning their unborn child. Sixteen of eighteen women seeking therapeutic abortion denied fantasy in any of the five categories tested: sex of the child-to-be, personal qualities and achievement, name of child, eye color, and imagining holding and/or nurturing the child. The remaining two women reported only fantasies about the sex of the child. The data obtained in this study tentatively support the hypothesis that women seeking abortion inhibit the process of fantasy formation about the fetus within them.

CURRENTLY there appears to be some feeling in the behavioral science community that liberalization of laws will make psychiatry irrelevant in the abortion question. Hopefully this communication will demonstrate that we will continue to need the clinical insights we have gained in the last decade. Rationalization of abortion laws can mean that psychiatry will be able to contribute appropriately; that is, on the same consultative basis as for any other medical problem. Although legal aspects of abortion and questions such as frequency of suicide, general indications and outcome have received much attention in the literature, little attention has been given to the clinical process and the specific symptoms suffered by patients. No attention has been given to problems encountered by clinicians dealing with such patients in initial evaluative interviews. These aspects will form the substance of this paper. Clearly the involvement of the