Misuse Problems Research Articles

Linking Profiles of Child Welfare Involved Caregivers to Severity of Substance Misuse and Aggressive Behavior

Research indicates that parental substance misuse and domestic violence are the most frequent reasons for involvement with the child welfare system. However, parents often do not receive adequate care due to multiple co-occurring issues such as substance misuse and mental health problems. Studies suggest that services must be tailored to their complex interrelated needs to improve outcomes. This can be a serious challenge to service providers due to the lack of information about behavioral health profiles of the caregivers who are at higher risk for further involvement with the child protection system. The purpose of this study was to identify subgroups of caregivers (N = 197) with similar profiles and examine who are at higher risk for further aggressive behavior and substance misuse using latent class analysis. Three distinct groups were identified: High Level of Emotional Problems; Moderate Level of Emotional Problems, and Minimal Emotional Challenges. The findings suggest that caregivers with High Level of Emotional Problems represent the most vulnerable population, and specific strategies should be developed to address their co-occurring needs.

Signpost to an Undiscovered Land

“What is the Alexander Technique?” Those of us who have studied or taught this work have all been asked this question and it is not easy to answer. In one sense, the answer is simple enough: the Alexander Technique is a way of learning to move and do things with less tension—we’ve seen the many videos and books that depict the Alexander Technique as a form of movement awareness that addresses the problem of misuse in action. The basic image is familiar to all of us: the student is asked to stand in front of a chair and to sit down. Pointing out how the student pulls his head back and arches his back, the teacher then asks him to pause before sitting down, and shows him how to direct the head and neck in order to reduce the harmful tension. By being shown how to perform the action more efficiently, to use the joints instead of muscle tension, the student learns to perform actions more effortlessly, and to notice the tensions and holdings that interfere with free and easy movement.

The influence of the built environment on drug misuse and abuse

Drug misuse and overdoses (DMO) continue to rise in the United States and around the world. As the COVID-19 pandemic lockdown brought America to a standstill, the drug overdose epidemic took a sharp turn for the worse. Poorly built environments have been said to pose greater risks for substance use. The inequitable race and socioeconomic status distribution of the built environment might be tipping drug overdose and deaths toward minority populations. This review examined the contribution of the built environment to drug misuse and overdose to identify further research and policy needs. Databases like PubMed and Google Scholar were searched for peer-reviewed empirical studies in the English language published from 2010 to March 2021. MeSH search terms were built environment, overdose, drug, and drug overdose. Using the PRISMA flow diagram of article selection, title, and abstract screening plus text narrative synthesis of included articles were done. The built environment features making it more conducive to initiating and maintaining DMO included disinvestment, geographical context (urban versus rural), spatial characteristics of the built environment, easy access to drugs, low access to interventions, and built-environment-associated environmental and social stressors. Built environment features play some roles in drug misuse problems. Policies and programs are needed that place the built environment at the centre of health, drug overdose prevention, and harm reduction, provide increased treatment facilities for addicted persons, ensure stricter opioid prescription measures, and address poverty as well as hopelessness due to disinvestment.

Evaluation of an infographic: prescription drug misuse among older adults in Saskatchewan

ABSTRACT Background Misuse of prescription drugs leads to morbidity and mortality. Prescription drug misuse among older adults over the age of 60 years is an understudied area which needs attention and one of the best methods to spread awareness is through infographics. The main objective of this study was to develop and evaluate an infographic on the extent of prescription drug misuse problems among older adults over the age of 60 years in Saskatchewan, Canada. Methods A mixed-method approach was used for this study which involved an online survey and development of an infographic. The survey was administered between October and November 2022. Survey participants were asked about their drug use habits. An infographic was created based on the results. Two focus groups which consisted of seven individuals were carried out to evaluate the infographic over Zoom. Questions were asked based on three themes (content, presentation, and reflection). Results Data from the focus group was used to revise the infographic. The majority of participants in the focus group indicated that the infographic was useful in getting the message across to the public and would be beneficial in various health care settings.

Esketamine combined with a mindfulness-based intervention for individuals with alcohol problems.

Alcohol use disorder (AUD) is a major public health issue, posing harmful consequences for individuals and society. Recent advances in addiction research have highlighted the therapeutic potential of ketamine-assisted therapy for AUD. However, the exact mechanisms underlying its effectiveness remain unknown. This double-blind, pilot study aimed to investigate esketamine combined with mindfulness-based intervention (MBI) to examine whether esketamine enhances engagement in MBI for individuals with alcohol misuse problems and whether enhanced engagement has any impact on alcohol-related outcomes. In all, 28 individuals with alcohol problems were randomly assigned to receive sublingual esketamine hydrochloride (AWKN002: 115.1 mg) or vitamin C (placebo) in an oral thin film and took part in 2 weeks of daily MBI. Participants were assessed on various self-report measures, including mindfulness, engagement in MBI (physical and psychological), alcohol cravings and consumption. Esketamine enhanced psychological engagement with a daily MBI, compared to placebo, and led to transient decreases in alcohol cravings. Esketamine also resulted in significantly greater mystical experiences and dissociative states compared to placebo. The findings suggest that esketamine may improve treatment outcomes when combined with mindfulness-based therapies through its ability to increase engagement with meditative practice.

Assessment of Automatic Thoughts and Self Esteem Among Substance Using Adults

Abstract: In order to better understand how altering one's ideas might improve one's self-esteem and help one cope with substance misuse issues, this study looked at the relationship between automatic thoughts and self-esteem in adult substance users. In order to participate in the study, a sample of 95 persons who use drugs filled out self-report questionnaires measuring their automatic thought patterns and self-esteem. The findings showed that among adults who use drugs, automatic thoughts and levels of self-esteem are significantly correlated. In particular, people with greater levels of self-esteem were more likely to report having good automatic thoughts, whereas people with lower levels of self-esteem were more likely to report having negative automatic thoughts. Additionally, the results indicated that treating and changing automatic negative beliefs could be a useful intervention technique for enhancing self-worth and supporting the treatment of substance misuse problems.

Midlife diseases of despair and cardiometabolic risk: testing shared origins in adolescent psychopathology.

Rising midlife mortality in the United States is largely attributable to 'deaths of despair' (deaths from suicide, drug poisonings, and alcohol-related diseases) and deaths from cardiometabolic conditions. Although despair- and cardiometabolic-related mortality are increasing concurrently, it is unclear whether they share common developmental origins. We tested adolescent psychopathology as a potential common origin of midlife diseases of despair and cardiometabolic risk. Participants (N = 4578) were from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative cohort followed from adolescence to early midlife. Adolescent psychopathology included depression, anxiety, eating disorders, PTSD, conduct disorder, and ADHD at ages 11-18. Diseases of despair (suicidality, substance misuse, pain, and sleep problems) and cardiometabolic risk (hypertension, hyperlipidemia, high-risk waist circumference, diabetes, and cardiovascular conditions) were multi-modally measured at ages 33-43. At midlife, adolescents who experienced psychopathology exhibited more indicators of despair-related diseases and cardiometabolic risk (IRRs = 1.67 [1.46-1.87] and 1.13 [1.04-1.21], respectively), even after accounting for demographics, adolescent SES, and adolescent cognitive ability. Associations were evident for internalizing and externalizing conditions, and in a dose-response fashion. In mediation analyses, low education explained little of these associations, but early-adult substance use explained 21.5% of psychopathology's association with despair-related diseases. Midlife despair-related diseases and cardiometabolic risk co-occurred within individuals (IRR = 1.12 [1.08-1.16]). Adolescent psychopathology accounted for 8.3% of this co-occurrence, and 16.7% together with adolescent SES and cognitive ability. Adolescent psychopathology precedes both diseases of despair and cardiometabolic risk. Prevention and treatment of psychopathology may mitigate multiple causes of poor midlife health, reducing premature mortality.

Associations between recorded loneliness and adverse mental health outcomes among patients receiving mental healthcare in South London: a retrospective cohort study

PurposeLoneliness disproportionately affects people with mental disorders, but associations with mental health outcomes in groups affected remain less well understood.MethodA cohort of patients receiving mental healthcare on 30th June 2012 was assembled from a large mental health records database covering a south London catchment area. Recorded loneliness within the preceding 2 years was extracted using natural language processing and outcomes were measured between 30th June 2012 until 30th December 2019, except for survival which applied a censoring point of 6th December 2020 according to data available at the time of extraction. The following mental healthcare outcomes: (i) time to first crisis episode; (ii) time to first emergency presentation; (iii) all-cause mortality; (iv) days active to service per year; and (v) face-to-face contacts per year.ResultsLoneliness was recorded in 4,483 (16.7%) patients in the study population and fully adjusted models showed associations with subsequent crisis episode (HR 1.17, 95% CI 1.07–1.29), emergency presentation (HR 1.30, 1.21–1.40), days active per year (IRR 1.04, 1.03–1.05), and face-to-face contacts per year (IRR 1.28, 1.27–1.30). Recorded loneliness in patients with substance misuse problems was particularly strongly associated with adverse outcomes, including risk of emergency presentation (HR 1.68, 1.29–2.18) and mortality (HR 1.29, 1.01–1.65).ConclusionPatients receiving mental healthcare who are recorded as lonely have a higher risk of several adverse outcomes which may require a need for higher service input.

Therapist-Level Moderators of Patient-Therapist Match Effectiveness in Community Psychotherapy

Based on patient-reported outcomes data analyzed at the provider level, there is evidence that psychotherapists can possess effectiveness strengths and weaknesses when treating patients with different presenting concerns. These within-therapist differences hold promise for personalizing care by prospectively matching patients to therapists’ historical effectiveness strengths. In a double-masked randomized controlled trial (RCT; NCT02990000), such matching outperformed pragmatically determined usual case assignment—which leaves personalized, measurement-based matching to chance—in naturalistic outpatient psychotherapy (Constantino et al., JAMA Psychiatry 78:960–969, 2021). Demonstrating that personalization can be even more precise, some research has demonstrated that the strength of this positive match effect was moderated by certain patient characteristics. Notably, though, it could also be that matching is especially important for some therapists to achieve more effective outcomes. Examining this novel question, the present study drew on the Constantino et al. (JAMA Psychiatry 78:960–969, 2021) trial data to explore three therapist-level moderators of matching: (a) effectiveness “spread” (i.e., greater performance variability across patients’ presenting problem domains), (b) overestimation of their measurement-based and problem-specific effectiveness, and (c) the frequency with which they use patient-reported routine outcomes monitoring in their practice. Patients were 206 adults, randomized to the match or control condition, treated by 40 therapists who were crossed over conditions. The therapist variables were assessed at the trial’s baseline and patients’ symptomatic/functional impairment and global distress were assessed regularly up to 16 weeks of treatment. Hierarchical linear models revealed that only therapist effectiveness spread significantly moderated the match effect for the global distress outcome; for therapists with more spread, the match effect was more pronounced, whereas the match effect was minimal for therapists with less effectiveness spread. Notably, two therapist-level covariates unexpectedly emerged as significant moderators for the symptomatic/functional impairment outcome; for clinicians who consistently treated patients with higher versus lower average severity levels and who relatedly treated a higher proportion of patients with primary presenting problems of substance misuse or violence, the beneficial match effect was even stronger. Thus, measurement-based matching may be especially potent for therapists with more variable effectiveness across problem domains, and who consistently treat patients with more severe presenting concerns or with particular primary problems, which provides further precision in conceptualizing personalized care.

Identifying Subgroups of Youth Suicide Decedents Based on Clinical Profiles of Psychiatric and Medical Diagnoses: A Latent Class Analysis

PurposeTo identify risk subgroups of youth suicide decedents using demographic and clinical psychiatric and medical diagnostic profiles to inform tailored youth suicide prevention efforts. MethodsThis study linked Ohio Medicaid and death certificate data for Medicaid enrolled youth aged 8–25 years who died by suicide between January 1, 2010, and December 31, 2020 (N = 511). Latent class analysis was used to identify distinct clinical risk subgroups. ResultsThree latent classes were identified. Internalizing problems were common across all classes, but especially prevalent in class 1, the High Internalizing + Multiple Comorbidities group (n = 152, 30%). A prior history of suicidal behavior was confined to class 1 decedents, who were otherwise characterized by substance misuse, and multiple psychiatric and medical comorbidities. Class 2 decedents, the Internalizing + Externalizing group (n = 176, 34%), were more often younger, male, Black, and unlikely to have a history of substance misuse. Decedents in class 3, the Internalizing + Substance Misuse group (n = 183, 36%), were more often older and likely to have a history of substance misuse, but unlikely to exhibit other externalizing problems. DiscussionInternalizing psychopathology is particularly common among youth who die by suicide, with comorbid externalizing psychopathology, substance misuse, and medical problems contributing to youth suicide risk. Because less than a third of youth who die by suicide have a prior history of recognized suicidal thinking or behavior, universal screening for youth suicide risk should be considered, particularly in younger children, and efforts to integrate suicide prevention in traditional health care settings should be prioritized.

Misuse of Consumer Personal Data Through Illegal Fintech Peer To Peer Lending

This research examines the misuse of consumer personal data through illegal Fintech Peer To Peer Lending. The aim of this research is to determine aspects related to Peer-to-peer lending Fintech Companies with a focus on the problem of misuse of consumer data. By providing an in-depth overview of forms of data misuse, as well as analyzing the legal responsibilities of illegal peer to peer lending fintech providers who are involved in misuse of consumer data. The research focus based on the background in this research is; 1) What are the forms of misuse of consumer data through illegal fintech peer to peer lending according to decision number; 438/Pid.Sus/2020/PN Jkt.Utr. 2) What is the legal responsibility of individuals managing illegal peer to peer lending fintech who misuse consumer personal data according to Decision Number; 438/Pid.Sus/2020/PN Jkt.Utr. This research uses a type of normative juridical research using qualitative methods and analytical descriptive approaches. So that the analysis can be carried out, the author first collects materials that are appropriate to the legal issue to be studied. The research results show that illegal fintech operators often misuse consumer data by involving third parties who do not have official certification, giving rise to intimidation, threats and defamation of consumers. In addition, the practice of requesting consumer consent to access personal data in violation of certain regulations was also exposed. The conclusion of this research confirms that this act can be subject to criminal sanctions as stated in the court decision. It is hoped that legal enforcement of this practice can be an effective step to protect consumer data and prevent abuse in the peer-to-peer lending fintech industry. Keywords: Misuse of personal data; illegal fintech peer-to-peer lending; positive law in Indonesia.

HEAVY DRINKING, MENTAL HEALTH PROBLEMS AND RECOVERY IN OLDER ADULTS: EXPLORING SUPPORT NEEDS

Abstract Many older adults who consume alcohol at harmful levels experience mental health problems. Common life events such as retirement, bereavement, and declining health, can contribute to anxiety and depression, with alcohol consumption being used as a coping mechanism. Tailored support is crucial to address the unique needs of older adults facing both alcohol misuse and mental health problems. These patients often fall into gaps between services (family practice/alcohol/mental health), which are unable to meet their complex support needs. This qualitative study aimed to understand the lived experiences of older adults with co-occurring heavy drinking and mental health problems, support received and unmet needs. We conducted semi-structured interviews with 14 older adults living in the North of England (completed Summer 2023). Thematic analysis and constant comparison were employed in data analysis. Findings highlighted the importance of age-tailored initiatives such as access to mental health support while actively drinking, supervised detoxification, increased peer support and services that are age inclusive and friendly. Risk factors such as grief, loneliness, financial problems and undiagnosed trauma in older adults contributed to development of these conditions. Older adults need services to work together, integrated around patient needs and addressing heavy drinking and mental health concerns at the same time. Future research should focus on improving mental health literacy and, developing holistic and preventive interventions to address risk factors for co-occurring alcohol and mental health problems in older adults.

Innovative analysis of diazepam, zolpidem and their main metabolites in human urine by micelle-to-solvent stacking in capillary electrophoresis

Diazepam and zolpidem are the most widely used medications for managing insomnia. However, significant concerns regarding the potential risks of misuse and abuse problems arose in many literatures. While urine analysis is a valuable diagnostic tool, a challenge arises from the fact that some parent drugs may remain undetectable in urine. This necessitates concurrent monitoring of their metabolites. Here, we described an innovative on-line sample preconcentration technique known as micelle to solvent stacking (MSS) for the analysis of diazepam, zolpidem, and their main metabolites in urine. Several key parameters warrant further discussion to optimize the MSS model, enhancing its performance in terms of sensitivity and resolution. After optimizing the conditions, we conducted a validation test, achieving high correlation coefficients (greater than 0.9977) for intra-day and inter-day regression lines. Additionally, both the relative standard deviation (RSD) and relative error (RE) remained below 6.10% and 12.55%, respectively. The limits of detection (LODs, S/N = 3) for all five analytes ranged from 2.0 to 56 ng/mL. Compared to the conventional capillary zone electrophoresis method, this new approach exhibited remarkable sensitivity enhancements, ranging from 123 to 235-fold. Upon applying this method to actual urine samples from patients, we successfully detected nordiazepam, zolpidem, and its metabolites. This simple and sensitive approach has promising applications in supporting patient medication safety and bolstering forensic investigations.

Physicians' perception about predictors of opioid abuse in patients with chronic non-cancer pain: a Delphi study.

Opioids are being prescribed widely, and increasingly, for the treatment of chronic non-cancer pain (CNCP). However, several side effects are associated with mid- and long-term opioid use and, for certain patients, with the risk of problematic opioid use. The aim of this study is to know the perception of the physicians about which variables could be associated with increased risk of patients with CNCP developing a problem of abuse or misuse of the prescribed opioid medication. Twenty-nine physicians with experience in CNCP pain management and opioids prescription participated in a two-round Delphi study focused on the risk factors for opioid misuse and abuse. The variables that reached consensus regarding their relationship with the increased risk of suffering a problem of opioid abuse or misuse were: (1) Experiencing pain on a daily basis, (2) previous use of high-dose opioids, (3) generalized anxiety, (4) hopelessness, (5) benzodiazepine intake, (6) use of opioids for reasons other than pain, (7) family problems, family instability or family breakdown, and (8) having access to several opioid prescribers. The only variable that reached consensus regarding it not being associated to a possible risk of abuse or misuse was having mild pain intensity (0-4 on a NRS-11). This study provides useful information that could help make decisions about the use of opioids for CNCP treatment and prevent future difficulties. Prospective studies testing the relationship of the variables that reached consensus with the risk of opioid misuse and abuse are warranted. This study shows the variables of CNCP that the professional must take into account in order to avoid possible problems when prescribing opioids.

Misuse of State Property in The Form of State-Owned Houses

The management of class III state houses begins with the transfer of status of class II state houses to class III state houses, transfer of rights, lease purchase agreements, and transfer of property rights. This study aims to determine the process of managing class III state houses and the problem of misuse of state property in the form of class III state houses. This study uses a descriptive qualitative research method with a case study approach. Data collection techniques were carried out through interviews and documentation. The results showed that a lack of internal control could cause the problem of abuse of country houses. The solution to these problems is following up with applicable regulations and strengthening the internal control system. This research implies that it becomes the basis for compiling clear and detailed guidelines or guidelines on the management of class III state houses. These guidelines will assist the authorities in establishing rules that are more transparent, accountable, and efficient in managing these state houses.

What interventions should we implement in England's mental health services? The mental health implementation network (MHIN) mixed-methods approach to rapid prioritisation.

Setting mental health priorities helps researchers, policy makers, and service funders improve mental health services. In the context of a national mental health implementation programme in England, this study aims to identify implementable evidence-based interventions in key priority areas to improve mental health service delivery. A mixed-methods research design was used for a three step prioritisation approach involving systematic scoping reviews (additional manuscript under development), expert consultations and data triangulation. Groups with diverse expertise, including experts by experience, worked together to improve decision-making quality by promoting more inclusive and comprehensive discussions. A multi-criteria decision analysis (MCDA) model was used to combine participants' varied opinions, data and judgments about the data's relevance to the issues at hand during a decision conferencing workshop where the priorities were finalised. The study identified mental health interventions in three mental health priority areas: mental health inequalities, child and adolescent mental health, comorbidities with a focus on integration of mental and physical health services and mental health and substance misuse problems. Key interventions in all the priority areas are outlined. The programme is putting some of these evidence-based interventions into action nationwide in each of these three priority mental health priority areas. We report an inclusive attempt to ensure that the list of mental health service priorities agrees with perceived needs on the ground and focuses on evidence-based interventions. Other fields of healthcare may also benefit from this methodological approach if they need to make rapid health-prioritisation decisions.

Use of antibiotics in poultry and poultry farmers- a cross-sectional survey in Pakistan.

Antimicrobial resistance (AMR) which has been ascribed to be due to community carriage of antibiotic-resistant bacteria is highly prevalent in the WHO South-East Asia region. One of the major reasons for this is the misuse of antibiotics in animal farming practices and at the community level, which threatens both human and animal health. However, this problem of antibiotic misuse in poultry farms and in respective farmers is not well studied in countries like Pakistan. We conducted a cross-sectional study in rural Punjab to explore the current practices of antibiotic use in poultry and poultry farmers, associated factors, their healthcare-seeking behavior and biosecurity practices. In the context of antibiotic use for poultry, 60% comprised of Colistin sulfate and Amoxicillin trihydrate whereas Colistin is considered as the last resort antibiotic. In addition, the significant consumption of antibiotics in poultry farms (60%) and poultry farmers (50%) was without prescription by either human health physicians or veterinarians. Most of the farms (85%) had no wastewater drainage system, which resulted in the direct shedding of poultry waste and antibiotic residue into the surrounding environment. The lack of farmers' education, professional farm training and farming experience were the most significant factors associated with antibiotic use and knowledge of AMR. Our study findings show that it is necessary for an integrated AMR policy with the inclusion of all poultry farmers to be educated, a mass awareness program to be undertaken and that strict antibiotic usage guidelines be available to them. Such initiatives are also important to ensure food safety and farm biosecurity practices.

Improving the Interface Between Substance Misuse and Mental Health Services by Equipping Junior Doctors Working Within Mental Health Services, With Tools to Help Improve Competence in Assessment and Management of Dual Diagnosis(co-Occurrence of Substance Misuse and Mental Health problems)

AimsDual diagnosis (i.e. co-occurrence of substance misuse and mental health problems) is a norm rather a rarity making it vital for service users to receive high quality, patient focused and integrated care. That being said, patients with dual diagnosis often feel excluded from services with neither of the services taking overall responsibility. Lack of broad spectrum of expertise required to treat both conditions, has been identified as reason for gaps in service provision where NICE guidance emphasizes the need for staff training and supervision. This was highlighted during survey with doctors in LPT as baseline assessment to assess training needs. This project aims to upskill junior doctors in the assessment and management of patients with Dual Diagnosis by delivery of a training package to each round of junior doctors during the induction period. The training package includes an ebook as pre-requisite for attending induction followed by teaching and short video clip. The training module aims to:1)afford junior doctors the opportunity to assess and manage patients with dual diagnosis effectively. 2) minimise prescription errors, missed diagnosis and missed referrals to substance misuse services 3) improve compassion and reduce stigmaMethodsTraining package was delivered to new cohort of junior doctors Jan 2023during their induction period.We used pre teaching and post teaching questionnaires a means to measure the change in level of confidence that the junior doctors experienced across three domains: 1.Assessment of service users for substance misuse2.Using validated tools for screening of service users for substance misuse3.Making referrals to appropriate services using substance misuse pathway.Results14 responses have been collected from junior doctors to date.There was an improvement in level of confidence from across the three main domains.In carrying out assessment for substance misuse, 86% reported “somewhat confident” (after teaching) compared to 7.1% (before teaching).In using validated tools, 78% reported “somewhat confident” (after teaching) compared to 7.1% (before teaching).In making referral to substance misuse services, 64% “somewhat confident” (after teaching) compared to 14% (before teaching).ConclusionThe training package helped in improving the confidence level of junior doctors in carrying out assessment , using validated tools and making referral to substance misuse services. However, whether this translates to making them adept at assessment and management of substance misuse will need to be corroborated by measuring prescription errors and number of referrals to substance misuse services.

헌법제정권력: 갱신(更新) 중의 개념

The concept of constituent power is often invoked in jurisprudence and literature to account for the origin and supremacy of the constitution, the limits of constitutional amendment, and the basis of constitutional interpretation. Nevertheless, the concept of constituent power has been under criticism for quite some time, and there remains today some full-fledged arguments to dispense with it as a mythical concept, unnecessary or harmful. In order to answer the question of whether the concept of constituent power has meaning and value on the horizon of constitutional law scholarship today, it might be useful to confront these contemporary criticisms alongside a consideration of the history of the concept. A noteworthy point in the historical examination of the concept of constitutional power is the fact that Sieyès tried to distance the concept of constituent power from that of sovereignty. While Sieyès proposed ‘pouvoir constituant’ as a concept that expresses the ‘the political authority of the people’, he rejected the idea of sovereignty as a “monastic” and “colossal” that cannot give adequate explanatory function of modern form of political legitimacy. Carl Schmitt, on the other hand, who inherited the concept of constituent power from Sieyès but closely linked it to the concept of sovereignty, used the unmediated delegation of constituent power as a basis for justifying a transitional sovereign dictatorship that suspended all separation of powers. Contemporary critiques of the concept of constituent power take several forms. A positivist version suggests that the concept of constituent power as a immediate presence without representation, “das formlos Formende” is itself inconceivable. In addition, the concept reduces the question of validity and legitimacy of the legal order to the question of “who” created the constitution, while the circumstances regarding the enactment of a legal norm cannot be an independent, determinative basis for the obligation to obey the law. A normativist version argues that the concept of constituent power fails to explain coherently the problem of law's authority for it locates the source of law's authority outside the legal order. But as emphasized by Fuller and Dworkin, the authority of law is better explained by the internal morality of the legal order and this renders the concept of constituent power unnecessary. The former view contends that constitutions can only be justified in terms of their conformity to extralegal moral and practical considerations, and thus a concept of constituent power that centers on the question of “who” made them loses its importance. The latter view argues that constitutions can be justified through internal morality of the law itself, and thus the question of constitutional authority that locates the source of their authority outside the legal order is not raised in the first place. The view that the constituent power is “das formlos Formende”, the presence of the people without representation, however, may be just one interpretation of constituent power, but not the only one. Rather, Sieyès' concept which emphasizes the limited powers of the extraordinary representative in constitution-making, seems to be closely linked to considerations on the process of representation. In addition, understanding constitution-making power as extra-legal authority without any normative dimension or ‘plenitudo potestatis’, free of any legal constraints seems to be a distinctively Schmittian interpretation. It should not be overlooked that the concept of the constitution that the critiques presuppose underscores the meaning of positive ‘written’ constitution as a product of actual political processes. However, it is necessary to consider in a serious manner the problem of mystification and possible misuse of the concept of constitutional power that these criticisms highlight.

Reaching out to patients with alcohol and drug misuse problems.

Jeff Fernandez, Lead Alcohol and Drug Nurse, Alcohol and Drug Liaison Team, Royal Free Foundation Trust, London (jfernandez@nhs.net). The team was the Gold Award winner in the Gastrointestinal Nurse of the Year category in the BJN Awards 2023.