SUBSTANCE ABUSE AND DEPENDENCE

SUBSTANCE ABUSE AND DEPENDENCE

Substance Abuse and Dependence An Introduction for the Caring Professions Edited by HAMID GHODSE DOUGLAS MAXWELL St George's Hospital and Medical School, London PETROLEUM (SPECIAL) TRUST FUND MACMILLAN

The Macmillan Press 1990 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 9HE. Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. First published 1990 by MACMILLAN PRESS LTD Houndmills, Basingstoke, Hampshire RG21 6XS and London Companies and representatives throughout the world ISBN 978-0-333-45859-4 ISBN 978-1-349-20859-3 (ebook) DOI 10.1007/978-1-349-20859-3 A catalogue record for this book is available from the British Library. This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. 8 7 6 5 4 3 2 05 04 03 02 01 00 99

Contents The contributors Acknowledgements IX xi Introduction H. Ghodse and D. Maxwell 1 Part 1. IDENTIFYING THE PROBLEM 1. What is Dependence? A. Johns Introduction The dependence syndrome Alternative models of habitual substance abuse A brief history of the concept of dependence The aetiology of dependence Conclusion 2. Effects of Drugs of Dependence S. Madden Tolerance and dependence Opioids Sedatives Stimulants Cannabis Hallucinogens Volatile inhalants Simple analgesics 5 5 10 12 13 16 28 30 30 31 35 40 45 47 50 51 v

VI Contents 3. Extent and Pattern of Drug Abuse and Dependence 53 S. Das Gupta Introduction 53 Enforcement statistics 55 Notification figures 56 Surveys of self-reported drug abuse in the general population 57 Special populations 61 Patterns of drug taking 63 Extent of abuse of specific drugs 64 Demographic characteristics 71 Problems related to drug use 74 Conclusions 76 4. Courses of Drug Use: The Concepts of Career and Natural History 80 J. Strang, M. Gossop and G. Stimson Introduction 80 The concept of career 83 The concept of natural history 84 The variability of the course 86 Natural patterns of cessation and recovery 87 Evidence for stages of dependence and orderly progression 88 Recreational and controlled use 90 Volition and attribution 91 Flow within treatment 92 Habit moderation and the malleability of behaviour 94 Part II. TREATMENT AND MANAGEMENT 5. Clinical Management 98 J.R. Morgan Treatment of overdosage and acute toxic reactions 98 Drug withdrawal 103 Maintenance of the drug-free state 122 Methadone maintenance 124 6. Psychological Treatments 131 M. Gossop and J. Strang Problem definition and treatment goals 131 Motivational interviewing and motivational milieu therapy 134 Compulsion as a central feature of dependence 136 Cue exposure 137 Intermediate goals 139 Relapse and survival 141 Preventing relapse 143 Conclusion 144

Contents 7. Psychosocial Interventions B. Wells Principles of intervention and treatment The priorities Goal setting Modes of intervention Conclusions VII 149 149 153 155 158 172 PART III. CLINICAL COMPLICATIONS OF SUBSTANCE ABUSE 8. Medical Complications of Substance Abuse 176 D. Maxwell Recognition of drug abuse 176 Multiple health problems associated with drug abuse 178 Serious infections in drug abusers 182 Medical complications related to the substance abused 196 9. Substance Abuse and Psychiatric Problems 204 J. Edeh Psychopathology complicating dependence on multiple drugs 204 Psychiatric complications of specific drugs 208 10. Problems of Maternal Substance Abuse 216 H. Ghodse Introduction 216 General effects 217 Pregnancy 218 Birth and the neonate 222 The child 224 Implications for treatment 227 PART IV. PREVENTIVE ISSUES AND LEGAL ASPECTS 11. Substance Abuse and Prevention Strategies 232 N. Dorn Introduction 232 Central government pump priming of local health and welfare responses 233 Needle exchange and HIV 235 Can harm minimisation have legal and social goals, as well as health goals? 236 Schools and the mass media 240 Conclusion 242

viii Contents 12. Drugs and the Law R. Farmer The origins of drug legislation in the United Kingdom The Misuse of Drugs Act 1971 The Mental Health Act 1983 Writing reports for the courts In the witness box Drug misuse and crime Drugs and the law in perspective Index 244 244 246 247 249 252 252 254 255

The Contributors S. DasGupta Consultant Psychiatrist, Drug Dependence Centre, StMary's Hospital, Praed Street, London W2 INY Nicholas Dorn Development Director, Institute of Study on Drug Dependence, 1-4 Hatton Place, London EClN 8ND James Edeh Senior Lecturer, Psychiatry of Addictive Behaviour, StGeorge's Hospital and Medical School, Cranmer Terrace, London SW17 ORE Roger Farmer Consultant and Honorary Senior Lecturer in Psychiatry, University College Hospital Drug Dependence Clinic, Hampstead Rd, London NWl 2L T Hamid Ghodse Professor and Director, Psychiatry of Addictive Behaviour, StGeorge's Hospital and Medical School, Cranmer Terrace, London SW17 ORE Michael Gossop Head of Research, Drug Dependence Clinical Research and Treatment Unit, The Maudsley Hospital, Denmark Hill, London SE5 8AZ Andrew Johns Senior Lecturer, Psychiatry of Addictive Behaviour, StGeorge's Hospital and Medical School, Cranmer Terrace, London SW17 ORE Spencer Madden Consultant in Charge, Mersey Regional Alcohol and Drug Dependence Unit, Countess of Chester Hospital, Liverpool Rd, Chester CH2 lbq IX

X The Contributors Douglas Maxwell Consultant Physician and Reader in Medicine, StGeorge's Hospital and Medical School, Cranmer Terrace, London SW17 ORE Judith R. Morgan Consultant Psychiatrist in Charge, St Giles Hospital, St Giles Rd, London SE5 7RN John Strang Director, Drug Dependence and Clinical Research Treatment Unit, Bethlem Royal Hospital, Monks Orchard Rd, Beckenham, KentBR33BX Gerry Stimson Senior Lecturer, Dept of Sociology, Goldsmith's College, New Cross, London SE14 6NW Brian Wells Consultant Psychiatrist in Charge, Drug Dependence Treatment Unit, St Stephen's Hospital, FulhamRd, London SWlO 9TH

Acknowledgements The editors wish to extend their sincere appreciation to all the contributors who have worked so hard to make this publication a reality. Despite the many demands upon them, they have been generous with their time, their enthusiasm and their many skills. We are also grateful to the publishers for their part in the production of this book and in particular to Mr David Grist for his patient co-operation. We should also like to thank Ms Melanie Sharp and Ms Cynthia Scott for their secretarial assistance. XI