Drug Dependence Unit Research Articles

Drug dependency units

Drug dependency units

Poppy tea drinking in East Anglia

Poppy tea drinking was a widespread traditional practice in the Fenlands of East Anglia during the nineteenth century. The subsequent social changes which led to greater integration of the area with the rest of the country may have contributed to a decline in the practice. In recent years poppy tea drinking has been revived within the illicit drug using community and a survey using a self-report questionnaire was carried out among patients attending the Cambridge Drug Dependency Unit. Forty-three patients admitted to drinking poppy tea, usually during the summer months and on an intermittent basis. The potency of the infusion varied and was unpredictable but in general was low. Although poisoning from herbicides and pesticides was seen as the main risk, it is in the main perceived by drug users as a harmless secondary activity existing alongside the more regular and more potent drugs of misuse.

Monitoring HIV trends in injecting drug users

To examine the incidence and prevalence of HIV infection, we studied a large sample of intravenous drug users (IVDUs) attending a drug dependency unit in Rome over the period 1985-1989. The annual prevalence of HIV antibodies remained stable over the 5-year period. However, a seroconversion study conducted on 302 subjects consistently attending the same facility showed a continued occurrence of HIV seroconversion, although the incidence declined from 8.9 per 100 person-years in 1985-1987 to 5.3 per 100 person-years in 1987-1989. The cumulative incidence of HIV seropositivity, estimated by the Kaplan-Meier survival technique, was higher in female than in male IVDUs. The findings show that the use of both incidence and prevalence data to monitor the trend of HIV infection allows a better understanding of the current viral spread among IVDUs.

Some reflections on dynamics and dilemmas in a DDU

Some difficulties in the management of addiction in a Drug Dependence Unit are discussed. Staff time with clients on prescribed methadone is dominated by enquiries into covert drug abuse and they must contend with passive aggression and denial. Dependency issues, to which the DDU may contribute, arise with chronic clients. Psychodynamic themes, even where identified as important, are difficult to follow through and link to outcome. There are inherent constraints in a medical model of management addressing behaviours which are as much the property of social context as of definable individual psychopathology. The AIDS crisis may bring new funds but also new pressures: DDUs may come to be judged essentially by their ability to shield the general population from HIV. This would have implications for the ethos of individual treatment and for team make-up.

Creating a new drug service in Edinburgh.

After one year Edinburgh's Community Drug Problem Service has shown that if psychiatric services offer consultation and regular support for drug users many general practitioners will share the care of such patients and prescribe for them, under contract conditions, whether the key worker is a community psychiatric nurse or a drug worker from a voluntary agency. This seems to apply whether the prescribing is part of a "harm reduction" strategy over a long period or whether it is a short period of methadone substitution treatment. Given the 50% prevalence of HIV infection among drug users in the Edinburgh area and the fact that only half of them have been tested for seropositivity, the health and care of this demanding group of young people with a chaotic lifestyle are better shared among primary care, community based drug workers, and specialist community drugs team than treated exclusively by a centralised hospital drug dependency unit. As the progression to AIDS is predictable in a larger proportion of drug users who are positive for HIV, there is an even greater need for coordinated care between specialists and community agencies in the near future.

Abuse of Benzodiazepines

To the Editor.— The recent article by Woods et al1presented a good literature review of benzodiazepine use and abuse based on the reinforcing model of behavioral pharmacology. However, some of the conclusions and recommendations in the article created a sense of unease in those of us who work in a tertiary referral facility and regularly see patients suffering from iatrogenically fostered benzodiazepine dependence. Woods et al1concluded that there is virtually no recreational or inappropriate use of benzodiazepines among patients for whom these drugs are prescribed and that psychological dependence is not a substantial risk of benzodiazepine therapy. A collection of seven cases at our institution that documented alprazolam dependence as defined byDSM-III(revised) criteria for psychoactive substance dependence was reported recently.2Between 1986 and 1988, two hundred ninety-three patients were treated in our Alcoholism and Drug Dependence Unit who were diagnosed as having benzodiazepine

The role of the satellite clinic in reaching intravenous drug users at risk from HIV

The arrival of HIV has challenged the traditional services for intravenous drug users providing the impetus to re-examine working practices. Only 10% of intravenous drug users attend hospital based treatment centres offering out-patient programmes based on reducing doses of oral methadone with an ultimate goal of abstinence (Hartnoll et al, 1985), yet for public health programmes designed to limit the spread of HIV it is important to increase the contact between high-risk groups and health professionals. Satellite clinics originally introduced to provide low cost help for drug users at a more local level may also be effective as a means of reaching intravenous drug users at high risk of HIV who would otherwise not be exposed to treatment and health education. Strang has described how a satellite clinic may be established with few resources, with staff who can be supervised by more senior workers at a central site (Strang & Creed, 1985). In this study the client groups of a satellite clinic and a conventional drug dependency unit were compared in order to characterise the clientele of the satellite clinic and to discover whether it was indeed fulfilling a useful role in terms of attracting such high-risk individuals for treatment.

Perception of risk of HIV infection by injecting drug users and effects on medical clinic attendance.

One hundred and sixty two injecting drug users attending two London clinics were asked if they thought that they were at risk from HIV infection. Thirty-one thought it was likely that they had been exposed to HIV, and these subjects had injected drugs for longer, were more likely to have shared needles and syringes in the last year, to have used dealer's equipment and to have shared with someone from abroad. They also had more male sexual partners and were more likely to have resorted to prostitution. There was no evidence that perception of risk influenced subjects in their intention to attend a medical clinic, and subjects who attended the medical clinic did not differ significantly from others attending the drug dependency unit.

Screening medical patients for alcoholism with the MMPI: A comparison of seven scales

Seven alcoholism scales for the MMPI were evaluated for effectiveness in screening medical patients. Sensitivity and specificity were assessed by use of five contrast samples: (1) 736 inpatients from an alcohol and drug dependence unit; (2) 4,923 unselected medical outpatients; (3) 7,044 selected medical outpatients; (4) 214 psychiatric inpatients; and (5) 1,408 contemporary normal persons. None of these scales can be recommended for use in screening medical patients. However, endorsement of MMPI item 215 should lead to further evaluation because classification was more accurate with this single item than with any of the scales evaluated.

Current status of opiate dependence

Summary The historical aspects of opiate dependence in the United Kingdom have been briefly reviewed. Recent practice is governed by the 1971 Misuse of Drugs Act . There is a legal obligation for medical practitioners in the UK to notify individuals they find to be addicted to opiate drugs, to the Chief Medical Officer of the Home Office. Official statistics (collected by the Home Office) provide a broad impression of the trend of opiate related problems and represent the tip of the iceberg in their attempt to quantify the problem in the UK. Local variations, as well as rapid changes in the availability of drugs in any particular location, make it essential to study the incidence of drug problems in relatively small areas. A broad range of prescribed opioid drugs can lead to dependence; however the majority of patients seen in drug dependency units are addicted to heroin bought as a powder at ‘street level'. Those who become dependent on opiate drugs tend to be young adults, males outnumbering females two to one; they would appear to be from all social classes. Whilst most individuals presenting at DDUs will be unemployed and have criminal records, this is not an invariable stereotype. Damage associated with opiate dependence can be divided into social, mental and physical spheres. Social harm is most obvious in the realms of d deterioration in personal relationships, conflict with the Law and difficulty in sustaining employment. Physical harm relates closely to the method of administration of the drug, intravenous opiate addicts being at particular risk of developing hepatitis and HIV infection; opiate addicts show high incidence of venereal infection. Mental harm includes deterioration of personality and depression. Psychotic illnesses as a response to opiate dependence are unlikely to occur. Repeated administration of opiates leads to a rapid build-up of tolerance, and a well-recognized abstinence syndrome will occur when such drugs are withdrawn abruptly. Withdrawal can be managed using methadone linctus by mouth as a substitute drug. It is essential to treat psychological dependence, once physical aspects of withdrawal are under control. Children born to mothers addicted to opiates are likely to show withdrawal symptoms and will require special attention during the neonatal period. Studies of the longer term prospects of opiate addicts suggest that, in the course of a 10-year period, approximately 20% will die, 40% will survive showing a marked increase in their stability and decrease in their drug misuse, and the remaining 40% are likely to spend increasing periods in custody or survive as a result of repeated episodes of treatment. This account of opiate dependence concentrates heavily on the current situation in the UK, drawing deliberately on recent studies, as opiate dependence is a rapidly changing problem, many aspects of which will be specific to the community within which it occurs. The principles of management tend to remain the same whatever the setting.

Monitoring the demand for treatment by problem drug takers: a case study of a London drug dependency unit.

SummaryReliable, up‐to‐date information on drug misuse is essential for planning and evaluating service provision, both for administrators and for those who provide a service. This paper presents routine monitoring of a treatment agency as a tool that can play an important part in achieving this goal. The characteristics of routine monitoring are described. A case study is then presented, using the example of an inner London DDU. This illustrates that whilst a snapshot of the profile of an agency's clientele can be useful in raising questions about needs and forms of support, of far greater value, especially for planning purposes, is continuous information on how the characteristics of clients and the pattern of demand on the service change over time. Not only does this reflect changing service needs at the agency concerned, hut can also, when taken in conjunction with other sources of information, be valuable as an indicator of trends in the wider community and as a pointer to service needs in the future. In this example, there were marked changes over 4 years, with an increasing proportion of the client group being older chronic heroin users who had been in and out of treatment before. Other changes included a fall in the proportion of new clients, an increase in the delay between first opiate use and first demand for treatment, and important changes in the route of administration. The paper concludes with an assessment of the value and limitations of single case routine monitoring.

Referrals to a Scottish drug dependence unit. A descriptive study.

The social and demographic characteristics, drug history and current levels of drug taking, drug-related illnesses, and criminal records of a one year cohort of attenders at the Southern General Hospital are described. The findings are compared with those of previous studies at the same clinic; made when methadone was prescribed for a limited period in reducing dosage and when this policy was being replaced by one of the use opiate-free drugs to cover withdrawal.

Intervjuundersökning av opiatmissbrukande kvinnor—metoder och metodproblem

Bergstrom, M. & Nilsson, K.: Interview study of female opiate addicts—methodological problems. Nordisk Psykologi, 1987, 39 (2), 127–141. This paper is based on a follow-up study of 68 female opiate addicts, treated at the Drug Dependence Unit at St. Lars hospital, Lund, Sweden, between 1970 and 1978. A semistructured interview guide containing questions about social circumstances, interpersonal and intrapsychic conditions has been used. The paper describes the research methodology and discusses the problems connected with an interview study based on persons with experience of heavy drug addiction.

Substance dependence and chronic pain: Profile of 50 patients treated in an alcohol and drug dependence unit

Fifty adult patients with chronic pain and substance dependence were admitted to an inpatient unit for treatment of addiction without primary emphasis on treatment of pain. As a group they had received considerable medical attention for their pain, but relatively little for their addictions. When compared with a group of general medical patients, the study population showed MMPI evidence of considerably more psychopathologic characteristics. MMPI data and family histories of substance dependence did not differentiate the study group from a comparable group in a Pain Management Center.

The influence of psychological factors on the opiate withdrawal syndrome.

Psychological and drug-related variables and their effect on the severity of withdrawal symptoms were examined in a group of addicts being withdrawn from opiates on an in-patient drug dependence unit. Two psychological factors--neuroticism and the degree of distress expected by the patient--were related to subsequent severity of symptoms. Both are anxiety-related, and may serve to amplify withdrawal symptoms. Surprisingly, drug dose was unrelated to symptom severity.

Activities of Daily Living in Psychiatry (Developing an Approach to Drug Dependence)

Many different treatment approaches have been tried with drug dependent patients, ranging from psychotherapy to behaviour therapy. This article examines a set of new groups run in an in-patient drug dependence unit, as established by two occupational therapists and a social worker. The approach particularly incorporates cognitive therapy as described by Aaron Beck. These sessions have further prompted and supported the work being developed by other disciplines, based on gaining and improving the survival skills for addicts. The article outlines methods used to orientate the individual towards community-based living with emphasis on practical skills. A broad description of these groups is given with the initial findings.

Prescribing methadone for the opiate addict: A problem of dosage conversion

This study examines the relationship between self-reported use of opiates and the dose of oral methadone found to be needed on admission to an inpatients drug dependence unit. The sample consisted of all opiate addicts admitted in a 12-month period. For methadone addicts there was a close relationship between the two dose measures: for heroin addicts there was no relationship. Users of illicit heroin who generally state doses in ‘grammes’, reported a mean daily dose of 312.5 mg, but needed only 43 mg of oral methadone. Mean values for methadone addicts were 56 mg self-reported use, and 49 mg needed on the drug unit. Some of the reasons for the discrepancy in the two doses for the heroin addicts are discussed and clinical implications with regard to prescribing for opiate addicts are drawn.

Drug dependence units in England and Wales. The results of a national survey.

Drug dependence units (DDUs) form the cornerstone of government policy response to problem drug taking. Yet we know surprisingly little about the facilities that they can provide and what treatment policies they adopt. This paper constitutes a modest attempt to fill some of the gaps in our knowledge and points to the need to base future policy recommendations on detailed empirical research.

The Piccadilly drug scene.

SummaryA participant observation study of the Piccadilly drug scene is described. A thriving market in diverted illicit drugs exists around this area, much of it an overspill from Drug Dependency Units and general practitioner prescribing. The economic organization of this market is described, the role of the dealers and runners, and the characteristics of the buyers. The nature and origins of the Piccadilly subculture are discussed, and its functional meaning. Public Health implications are also considered.

Assessment of an Urgent Admission Procedure to an In‐Patient Drug Dependence Unit

SummaryAn Urgent Admission Procedure has recently been introduced in the In‐patient Drug Dependence Unit. No difference in effectiveness (in terms of duration of stay of patients) is found when compared with the lengthier Normal Admission Procedure. However, those Urgent Admission patients who did not complete their drug withdrawal failed at an earlier stage of the withdrawal phase. Certain issues concerning the interpretation of the findings, the introduction of this scheme, its apparent benefits and the limitations of the research design are discussed. It is suggested that there is a need for such a service.