New Treatments for Addiction: Behavioural, Ethical,Legal and Social Questions: Harwood & T. G. Myers eds (Book review)

This book is an exemplar of what the National Academy of Science does so well: to assemble a cast of very wellinformed and clever experts; to ask them to think hard and critically about an important issue over a substantial period of time; and to seek a consensus, if possible and failing that, to identify the critical issues on which wellinformed people disagree and to specify the evidence that has the greatest epistemic leverage in resolving disagreements.

Improving family functioning and child outcome in methadone maintained families: the Parents Under Pressure programme

Twelve families responded to posters displayed in a methadone clinic for inclusion in a pilot study assessing the viability and potential utility of an intensive, multi-component family-focused intervention, the Parents Under Pressure programme. The programme was designed to improve child behaviour, decrease parental stress and improve family functioning in methadone-maintained families by targeting affect regulation, mood, views of self as a parent, drug use and parenting skills. Nine of the families completed the programme delivered in their homes; eight were recontacted at 3 months. Each family reported significant improvements in three domains: parental functioning, parent - child relationship and parental substance use and risk behaviour. In addition to the changes in family functioning, the majority of families reported a decrease in concurrent alcohol use, HIV risk-taking behaviour and maintenance dose of methadone. The families reported high levels of satisfaction with the programme. It is recommended that future studies include independent measures (e.g. behavioural observations) of child outcome and parental functioning. The results were optimistic and provided the impetus to evaluate the treatment programme using a randomized controlled trial.

A randomized controlled trial of a nurse-administered educational intervention for improving cancer pain management in ambulatory settings

The persistence of negative attitudes towards cancer pain and its treatment suggests there is scope for identifying more effective pain education strategies. This randomized controlled trial involving 189 ambulatory cancer patients evaluated an educational intervention that aimed to optimize patients' ability to manage pain. One week post-intervention, patients receiving the pain management intervention (PMI) had a significantly greater increase in self-reported pain knowledge, perceived control over pain, and number of pain treatments recommended. Intervention group patients also demonstrated a greater reduction in willingness to tolerate pain, concerns about addiction and side effects, being a "good" patient, and tolerance to pain relieving medication. The results suggest that targeted educational interventions that utilize individualized instructional techniques may alter cancer patient attitudes, which can potentially act as barriers to effective pain management. (C) 2003 Elsevier Ireland Ltd. All rights reserved.

Children and war

Children bear disproportionate consequences of armed conflict. The 21st century continues to see patterns of children enmeshed in international violence between opposing combatant forces, as victims of terrorist warfare, and, perhaps most tragically of all, as victims of civil wars. Innocent children so often are the victims of high-energy wounding from military ordinance. They sustain high-energy tissue damage and massive burns - injuries that are not commonly seen in civilian populations. Children have also been deliberately targeted victims in genocidal civil wars in Africa in the past decade, and hundreds of thousands have been killed and maimed in the context of close-quarter, hand-to-hand assaults of great ferocity. Paediatricians serve as uniformed military surgeons and as civilian doctors in both international and civil wars, and have a significant strategic role to play as advocates for the rights and welfare of children in the context of the evolving 'Laws of War'. One chronic legacy of contemporary warfare is blast injury to children from landmines. Such blasts leave children without feet or lower limbs, with genital injuries, blindness and deafness. This pattern of injury has become one of the post-civil war syndromes encountered by all intensivists and surgeons serving in four of the world's continents. The continued advocacy for the international ban on the manufacture, commerce and military use of antipersonnel landmines is a part of all paediatricians' obligation to promote the ethos of the Laws of War. Post-traumatic stress disorder remains an undertreated legacy of children who have been trapped in the shot and shell of battle as well as those displaced as refugees. An urgent, unfocused and unmet challenge has been the increase in, and plight of, child soldiers themselves. A new class of combatant comprises these children, who also become enmeshed in the triad of anarchic civil war, light-weight weaponry and drug or alcohol addiction. The International Criminal Court has outlawed as a War Crime, the conscription of children under 15 years of age. Nevertheless, there remain more than 300 000 child soldiers active and enmeshed in psychopathic violence as part of both civil and international warfare. The typical profile of a child soldier is of a boy between the ages of 8 and 18 years, bonded into a group of armed peers, almost always an orphan, drug or alcohol addicted, amoral, merciless, illiterate and dangerous. Paediatricians have much to do to protect such war-enmeshed children, irrespective of the accident of their place of birth. Only by such vigorous and maintained advocacy can the world's children be better protected from the scourge of future wars.

Reasons for cannabis use in men with and without psychosis

Psychoses are relatively low prevalence disorders that have a disproportionately negative impact on individuals and society. Cannabis use is one factor that can exacerbate the negative consequences associated with psychotic disorders. Relatively few studies have examined the effects or reasons for using cannabis self-reported by individuals with psychosis. The present study is the first known to compare directly such factors in individuals with and without psychosis, within a single study. At baseline and follow-up participants with psychosis most commonly reported using cannabis for positive mood alteration (36% and 42%), coping with negative affect (27% and 29%) and for social activity reasons (38% and 29%). The control group most commonly reported using cannabis for relaxation (34% and 43%) and social activity reasons (49% and 51%). Participants with psychosis were less likely to report relaxation as the most important effect after use ( 27%) or expect it at follow-up ( 49%) compared to the control group (53% and 70%). In both groups, addiction and positive affect enhancement were the composite variable scores correlated most consistently with concurrent amount and frequency of use.

Ethical issues in using a cocaine vaccine to treat and prevent cocaine abuse and dependence

A cocaine vaccine'' is a promising immunotherapeutic approach to treating cocaine dependence which induces the immune system to form antibodies that prevent cocaine from crossing the blood brain barrier to act on receptor sites in the brain. Studies in rats show that cocaine antibodies block cocaine from reaching the brain and prevent the reinstatement of cocaine self administration. A successful phase 1 trial of a human cocaine vaccine has been reported. The most promising application of a cocaine vaccine is to prevent relapse to dependence in abstinent users who voluntarily enter treatment. Any use of a vaccine to treat cocaine addicts under legal coercion raises major ethical issues. If this is done at all, it should be carefully trialled first, and only after considerable clinical experience has been obtained in using the vaccine to treat voluntary patients. There will need to be an informed community debate about what role, if any, a cocaine vaccine may have as a way of preventing cocaine addiction in children and adolescents.

Psychoanalytic perspectives on substance use and antisocial personality disorder

Psychoanalysis and related psychodynamic psychotherapies have historically had a limited engagement with substance use and antisocial personality disorders. This in part reflects an early preoccupation with 'transference neuroses' and in part reflects later de-emphasis of diagnosis and focus on therapeutic process. Nonetheless, psychoanalytic perspectives can usefully inform thinking about approaches to treatment of such disorders and there are psychoanalytic constructs that have specific relevance to their treatment. This paper reviews some prominent strands of psychoanalytic thinking as they pertain to the treatment of substance abuse and antisocial personality disorders. It is argued that, while Freudian formulations lead to a primarily pessimistic view of the prospect of treatment of such disorders, both the British object relations and the North American self psychology traditions suggest potentially productive approaches. Finally the limited empirical evidence from brief psycho dynamically informed treatments of substance use disorders is reviewed. It is concluded that such treatments are not demonstrably effective but that, since no form of psychotherapy has established high efficacy with substance use disorders, brief psychdynamic therapies are not necessarily of lesser value than other treatments and may have specific value for particular individuals and in particular treatment contexts.

Will nicotine genetics and a nicotine vaccine prevent cigarette smoking and smoking-related diseases?

This paper briefly explains why it would be unwise to use genetic and neurobiological knowledge to prevent cigarette smoking and tobacco-related disease. However implausible these uses may seem to those who are well informed about the genetics of tobacco use or tobacco-control policy, it is the preventive uses of genetic information and nicotine vaccines that most excite the interest of the media and the public. The major challenges that these approaches face need to be widely understood if we are to prevent these superfi cially attractive but controversial uses from undermining effective control policies and the development of better methods of helping smokers to quit.

Tooth wear: diet analysis and advice

Diet analysis and advice for patients with tooth wear is potentially the most logical intervention to arrest attrition, erosion and abrasion. It is saliva that protects the teeth against corrosion by the acids which soften enamel and make it susceptible to wear. Thus the lifestyles and diet of patients at risk need to be analysed for sources of acid and reasons for lost salivary protection. Medical conditions which put patients at risk of tooth wear are principally: asthma, bulimia nervosa, caffeine addiction, diabetes mellitus, exercise dehydration, functional depression, gastroesophageal reflux in alcoholism, hypertension and syndromes with salivary hypofunction. The sources of acid are various, but loss of salivary protection is the common theme. In healthy young Australians, soft drinks are the main source of acid, and exercise dehydration the main reason for loss of salivary protection. In the medically compromised, diet acids and gastroesophageal reflux are the sources, but medications are the main reasons for lost salivary protection. Diet advice for patients with tooth wear must: promote a healthy lifestyle and diet strategy that conserves the teeth by natural means of salivary stimulation; and address the specific needs of the patients' oral and medical conditions. Individualised, patient-empowering erosion WATCH strategies; on Water, Acid, Taste, Calcium and Health, are urgently required to combat the emerging epidemic of tooth wear currently being experienced in westernised societies.

The complexity of drinking: Interactions between the cognitive and behavioural determinants of alcohol consumption

This study expanded the earlier work conducted by this laboratory ( Hasking, P.A. and Oei, T.P.S. (2002a) . The differential role of alcohol expectancies, drinking refusal self-efficacy and coping resources in predicting alcohol consumption in community and clinical samples. Addiction Research and Theory , 10 , 465-494), by examining the independent and interactive effects of avoidant coping strategies, positive and negative expectancies and self-efficacy, in predicting volume and frequency of alcohol consumption in a sample of community drinkers. Differential relationships were found between the variables when predicting the two consumption measures. Specifically, while self-efficacy, seeking social support for emotional reasons and using drugs or alcohol to cope were independently related to both volume and frequency of drinking, complex interactions with positive and negative alcohol expectancies were also found. These interactions are discussed in terms of the cognitive and behavioural mechanisms thought to underlie drinking behaviour.

Comparative gene expression in brain regions of human alcoholics

The mesocorticolimbic system is the reward centre of the brain and the major target for drugs of abuse including alcohol. Neuroadaptive changes in this region are thought to underlie the process of tolerance and dependence. Recently, several research groups have searched for alcohol-responsive genes using high-throughput microarrays and well-characterized human post-mortem material. Comparison of data from these studies of cortical regions highlights the differences in experimental approach and selection of cases. However, alcohol-responsive gene sets associated with transcription, oxidative stress and energy production were common to these studies. In marked contrast, alcohol-responsive genes in the nucleus accumbens and the ventral tegmental area are primarily associated with changes in neurotransmission and signal transduction. These data support the concept that, within cortical regions, changes in gene expression are associated with alcoholism-related pathology. In the dopaminergic tract of the mesocorticolimbic system, alcohol-responsive gene sets suggest long-term neuroplastic changes in synaptic transmission.