Elephants in the Room While the latest research may offer new insights into A&D, sometimes key messages from older pieces of work may be overlooked or taken for granted. This talk will explore some
elephants in the A&D consult room. I have thrown in a couple of pink elephants and a woolly mammoth for good
measure
Jeremy Hayllar
Seminar Series
11 May 2017
Weacknowledgethetradi1onalcustodiansofthelandonwhichwemeettodayandpayrespecttoElderspast,presentandemerging.WealsoextendthatrespecttootherAboriginaland/orTorresStraitIslanderswhoarejoiningusheretoday.
DavidRHorton,creator,©AboriginalStudiesPress,AIATSISandAuslig/Sinclair,Knight,Merz,1996.Viewaninterac1veversionoftheAIATSISmapwww.abc.net.au/indigenous/map/HeaderArtworkproducedforQueenslandHealthbyGilimbaa
Contents (seminar no 26!) Based on 17 Studies which have changed our work
• Social Relationships
• Opioid Dependence
• Substance education in young people
• The therapeutic relationship
• Amphetamine Use Disorder
• Alcohol Use Disorder
• Tobacco
Sources
• The idea and some material for this talk came from Drug and Alcohol Findings series ‘Old Gold’. (Edited by Prof Mike Ashton, supported by Alcohol
Research UK & the Society for the Study of Addiction and
advised by the National Addiction Centre. UK)
• https://findings.org.uk/ to subscribe to their regular emails / updates
‘Those who cannot remember the past are condemned to repeat it.’
George Santayana
War(s) on Drugs (WoD)
• 1914 Harrison Narcotics Tax Act
• 1919 18th amendment prohibited sale, manufacture, or transportation of alcohol (repealed 1933 21st amendment)
• 1937 Marijuana Tax act – (? To destroy hemp producers)
• 1968 Nixon formally declared WoD – eradication, interdiction and incarceration (‘fighting 2 enemies: blacks and the anti-war left aka hippies”) John Ehrlichman
• 1971 Nixon ‘drug abuse is public enemy number one’ re Vietnam. The press promoted the WoD – ignoring $$ to prevent new ‘addicts’ and rehab. to those already addicted.
• $51 billion pa spent by US to further WoD ‘which has failed’ Global Commission on Drug Policy 2011
To draw a parallel, many decades ago high mortality rates were
observed among infants in custodial care (i.e., orphanages), even
when controlling for pre-existing health conditions and medical
treatment [201–204]. Lack of human contact predicted mortality.
The medical profession was stunned to learn that infants would die without social interaction. This single
finding, so simplistic in hindsight, was responsible for changes in practice and policy that markedly decreased mortality rates in custodial care settings.
Contemporary medicine could similarly benefit from acknowledging
the data: Social relationships influence the health outcomes of
adults.
PLOS 1 2010
PLOS1 2010
Vietnam Veterans followed up 3 years after leaving Vietnam September 1971
• 2 Congressmen went to Vietnam 3/1971
• Discovered extensive heroin use in soldiers
• J Jaffe urged 1) D Defense UDS all returnees
• +ve result > withdrawal Rx before return
• 2) FU study 900/14,000 returnees 9/1971
• Randomly selected from total + a random selection of UDS positives returning
• May-Oct/1972 returnees interviewed
• Oct-Dec /1974 re-interviewed 617 returnees + 214 matched non veterans – 91% follow up
• While in Vietnam
– 85% were offered heroin
– 35% used heroin
– 19% became dependent (addicted)
– 73% who used >5x became dependent
Tested 5 pre-conceptions about
heroin use
1. Does heroin use progress rapidly to daily use and dependence?
2. Is heroin so much more pleasurable than other substances that it supplants them?
3. Is heroin addiction ~permanent without prolonged treatment?
4. Does maintaining recovery require abstinence?
5. Is heroin a major social problem?
Does heroin use progress rapidly to daily use and dependence?
Is heroin so much more pleasurable than other substances that it supplants them?
Is heroin addiction ~permanent without prolonged treatment?
Does maintaining recovery require abstinence?
Is heroin a major social problem?
Dr Marie Nyswander
• Early in 1964 methadone given to 2 patients with opioid dependence.
• Their behaviour changed dramatically, “they got up, got dressed and began going to night school”…
• MN described waiting in total terror every night for her charges to return to the ward.
• Despite temptations – people scoring drugs – the pair “went and got an ice cream”.
Dole and Nyswander 1970
• Original Model MMT (22 patients in JAMA) – High dose – Intense rehabilitation – Extended duration of treatment
• Then modified from MMT to “abstinence from all opioids including methadone”
• “I watched in despair as opinionated theorists
distorted a patient-orientated, individualised treatment, lowered the dosage and punished the addicts for failure” Prof Vincent Dole 1992
Harm Reduction (Pillar 3)
• Informing Australian drug policy since 1980s
• Economics a strong case – yet often politics / prejudice wins the argument
• NSP - $27 ROI per $1 spent (ROI Report 2 2009)
– $27 million pa invested saving $1.3 billion 2000-2009
• OTP – $12 ROI per $1 spent (NIDA)
• MSIC- $658K -> $32 ROI per $1 spent (SAHA 2008)
• Prison NSP / OTP
• Naloxone distribution (400 trained, 95 scripts, 5 ODs. ROI
€62,500 for HHS (drugnet Ireland 2017)
Government Annual Spend on Substance related issues (2010, Ritter)
Total $1.609.6 (millions)
• $1,031.8 Law Enforcement (64.1%)
• $361.8 Treatment services (22.5%)
• $156.8 Prevention services (9.8%)
• $36.1 Harm Reduction (2.2%)
• $23.1 Other (1.4%)
Rotterdam Education Department Drug education in young people
• Orthodoxy: tell kids of dangers and they will abstain
• Sample schools total 1034 pupils, 14-16 years
• 3 ‘drug education’ regimes + control
• 1st 2 a ‘one shot’ approach to ‘innoculate’ kids
– 1) ‘Mild horror’
– 2) Remedy knowledge deficiencies
• 3) 10/52 I hour classes for pupils to discuss problems of adolescence with their usual teacher
• 4) no intervention – control group
de Haes and Schuurman 1975
• Regular self reports, before, at 2/52 and 3/12
• At 3 months none in group 2 (the remedy knowledge group) had retained anything
• No approach deterred those already using (mainly THC)
• Non-users: the ‘mild horror’ approach 7.3% v 4.6% controls and 2.6% of the unfocused personal group had gone on to use
Drug education in young people
• Warning kids of dangers may itself be dangerous • 180° to the prevailing wisdom – parents scared about drugs expected their kids to respond the same way
The Boot Camp approach…
In 1993, "A good counselor needed a loud voice and an arsenal of four-letter words”
Bill Miller
Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles. Miller
and Rollnick JCCP 1993
• Drinker’s Check list recruited heavy drinkers
• 2 hour assessment session with
• a) immediate or b) 6/52 later feedback
• Group a) reduced alcohol 27% over next 18/12
• Next examined 2 ways of giving feedback – either directive /confrontational or empathic
• Empathic approach gave slight reduction in drinking
• Looking at the individual counseling sessions: the more confrontational, the more drinking I year later!
The attitudes of helping agents towards the alcoholic client: the influence of experience, support, training
and self esteem. Cartwright. Addiction 1980
• Total 187 A&D workers followed up for 6/12
• Group a) had summer school 1/52
• Group b) had counselling course 1/52
• Group c) A&D research methods teaching 1/52
• 61% did all 3 questionnaires
• Support and experience seemed the major factors increasing commitment, more than formal education / personality / work place
UK and US posters re changes in portion sizes
since the 1950s.
Theresa M Marteau et al. BMJ 2015;351:bmj.h5863
©2015 by British Medical Journal Publishing Group
n = 42 oral amphetamine users
Detailed MH and AOD history
Hospitalized for violence, suicide attempts, and requests for police protection.
12 reported being chased by a gang
10 persecution of other kinds
Majority following prolonged drug use
‘Amphetamine Psychosis’ Connell 1958
Daimler Landaulette 1954
‘Amphetamine Psychosis’ Connell 1958
9 (21%) developed psychotic reactions after a single dose or a large dose divided over a three-day period.
- 77% recovered in six to seven days.
Treatment should be ‘ withdrawal of the drug and appropriate sedation’.
If symptoms persist beyond a few weeks reassess for a possible underlying illness and hence consider trial of treatment with an anti psychotics
A Long Term Study of Sons of Alcoholics
MARC A. SCHUCKIT, M.D. 1995
• Genes & environment interact in complex ways
• 453 men followed prospectively from 1975
• Only 3 lost to follow-up!
• FHP & FHN (positive and negative Family History)
• 40% of FHP were low responders v 10% FHN
• All patients (white males) were matched at ~20 yrs re alcohol consumption / employment / lack of MH issues
Z score – based on serum cortisol, subjective feeling of intoxication, body sway and other criteria predicted who became alcohol dependent
Essential elements of the syndrome might include:
• a narrowing in the repertoire of drinking behavior;
• salience of drink-seeking behaviour;
• increased tolerance to alcohol;
• repeated withdrawal symptoms;
• repeated relief or avoidance of withdrawal symptoms by
further drinking;
• subjective awareness of a compulsion to drink;
• reinstatement of the syndrome after abstinence
BMJ 1976
Edwards and Gross 1976 4 Features of withdrawal
Along with nausea, sweating and mood disturbance
Treatment of alcohol withdrawal – a comparison of 4 drugs Kaim et al Am J Psych 1969
• Placebo, chlordiazepoxide, thiamine, chlorpromazine, hydroxyzine for alcohol withdrawal in 537 Veterans
• Previous Rx barbiturates, reserpine, chlorpromazine
• BZD reduced seizures and progression to DTs
• Showed chlorpromazine increased seizures
• Placebo improved anxiety / tremor (not seizures / DTs)
• Used appropriate criteria to Dx withdrawal however did not control for severity
• By 1973 86/101 Veteran hospitals using BZD
for alcohol withdrawal
Treatment of alcohol withdrawal – a comparison of 4 drugs Kaim et al Am J Psych 1969
• ‘Tetraethylthiuram disulphide’ used for >100 years in rubber manufacture
• 80 years since potential recognised by Dr EE Williams Occupational Physician in USA 1937
• Rediscovered 1947 in Denmark
• 1952 first death from disulfiram / ethanol reaction (2gm, 1.5 gm, 1 gm, and 0.5gm)
• 4 hours later 1oz whisky...
Disulfiram treatment of alcoholism JAMA Fuller R et al 1986
• Multicentre study, 605 patients
• 250 mg v 1 mg tablets v placebo
• Counselling, voluntary AA
• Use of placebo, biological markers, urine testing, collaborative sources, survival analysis
• Only 20% adherence, no difference in TTA across 3 groups
• 1992 Study: supervised doses worked better!
Prevention of Alcohol Misuse: A Review of Health
Promotion Efforts among American Indians Philip May & James Moran 1995
Important concepts for providing health promotion services to this population are:
• cultural relevance must be carefully planned and monitored;
• individuals in the local community must be involved;
• the drunken Indian stereotype must be addressed;
• and community empowerment should be an important goal
1962
Smoking and Health RCP (81 pages)
1964
Smoking and Health 387 pages
The Woolly Mammoth!
Early 1950s
The mortality of doctors in relation to their
smoking habit at 50 years. Doll and Peto BMJ 2004
• 34,439 recruits, only 17% were lifelong non-smokers
• Effects seen from 4 years, 10, 20, 40 and 50 years
• 99.2% follow up – save those O/S or dereg’d
• By 2001 5,902 living, 25,346 (74%) died
• 98.9% cause of death was documented
• 11 categories of cause of death used
• ~25% of deaths from lung cancer
• 2 died from smoking in bed... ( cf Nina Simone 1959)!
The mortality of doctors in relation to their smoking habit at 50 years Doll and Peto BMJ 2004
• 1939 18 yr old conscripts given ample supplies of tobacco – establishing a generation with a heavy smoking habit from late adolescence (recall Qld prison service until ~3 years ago)
• Effects of smoking on mortality were grossly underestimated even in 1980s
• % of current smokers dying from smoking related disease vary from 50-66%
• Doll and Peto prefer to say half of smokers will die from smoking related disease
Tobacco messages
• Typical smoker loses 10-11 years of life expectancy
• After age 35, for each year of of smoking, the smoker loses 3 months of life expectancy
• Smoking is the single, largest avoidable cause of morbidity and mortality
• No safe threshold, dose response relationship
• Quitting at any age (the younger the better) soon produces measurable survival benefits
• Public health approaches understood very early
1961
Conclusions
• Harms of smoking well described late 50s early 60s
• Appreciate that the way we approach our patients today reflects much past trial and error
• Outcomes from MI similar to other current therapeutic approaches, as shown in Project Match (J Strang et al Cochrane 2011)
• The therapeutic alliance lies at the centre of the treatment process
