- Email: [email protected]
ASSESSING HEROIN ADDICTION
244
Letters
to
the Editor
ASSESSING HEROIN ADDICTION to time casualty officers and general practitioners are confronted by patients who claim to be addicts, and who ask for help. The help asked for may be in the form of a request for heroin to abort withdrawl symptoms or for direction to a centre for more comprehensive treatment of the addiction. Casualty officers at Lambeth and St. Thomas’ Hospitals are given the following list of instructions:
possible in
our cramped, antiquated building, with many consultants using each ward and with training responsibilities to both postgraduate and undergraduate students, we wonder whether similar solutions may be possible elsewhere if the
nroblem is viewed afresh.
SIR,-From time
1. Ascertain that the patient is a heroin addict; generally they are untruthful. Look for multiple antecubital puncture marks, abscess sites, and signs of old and recent thromboses of arm veins. 2. Check for signs of withdrawal (see accompanying table). 3. If withdrawal signs are present, administer methadone (’ Physeptone ’), preferably in the form of the linctus. Initially, give 10 mg. of methadone. If the patient vomits, this 10 mg. of methadone can be given by subcutaneous injection. If, after 1-2 hours withdrawal signs persist, another 10-20 mg. may be given. This treatment should carry the patient over about 12 hours. (The next dose, if necessary, 12 hours later, should be 20 mg., preferably orally.) 4. Refer the patient to a treatment centre, preferably near where he lives. (See list of treatment centres.) 5. Admit if general physical condition requires.
The table referred to in (2) is from an article by Blachly.l Briefly, 3-4 hours after the last dose of heroin, withdrawal signs consist of craving and anxiety. At about 8 hours added signs are restlessness, yawning, perspiration, lacrimation, and rhinorrhcea. At about 12 hours these signs are increased in intensity and in addition there is mydriasis, gooseflesh, muscle twitching, aching bones and muscles, hot and cold flushes, and anorexia. The list of treatment centres referred to in (4) have now
been announced bv the Ministrv of Health. Hospitals,
Lambeth and St. Thomas’ London S.E.
JULIUS MERRY.
Queen Elizabeth Hospital for Children, London E.2.
WITHDRAWAL FITS
SIR,-Dr. Merry’s
visiting of adults in hospital, it is unfortunate that our colleagues at the Infirmary at Leeds have not explicitly excluded children’s wards and hospitals from their recommendations, since we find that their letter (Jan. 6, p. 44) is already being misinterpreted. Some older children undoubtedly gain in independence from the challenge of admission to hospital, and a good hospital can sometimes be a refuge from a bad home, but there is now overwhelming evidence that some younger children are seriously harmed by separation from their parents, with effects that may persist for years. Though long separations are more damaging, quite short periods of separation in strange surroundings can have surprisingly large effects; for children under four, and certainly for those between six months and two years, nothing less than persuading the mother to live in and share in the care of the child, when this is possible, seems likely to avert the harmful consequences in many instances. Now that this knowledge is available to us, we believe there can be no case at all for any general limitations on visiting of children by their parents. When lately we studied this issue, as members of a subcommittee representing the medical, surgical, and psychiatric departments of this hospital, we came to the conclusion that while unrestricted visiting of children by their parents posed very real problems for all hospital staff, especially the nursing staff, the majority of doctors and nurses at all levels coped with these difficulties willingly. Indeed, to facilitate such visiting, without overburdening the nursing staff, our medical advisory committee has not only rearranged the use of the wards by medical staff and postgraduate and undergraduate students, to reduce the total numbers entering each ward, but has recommended that rounds and examinations should, as far as possible, be confined to limited periods. This seems to us to put priorities in the right order. If this approach to the problem is 1.
Blachly,
P. H.
Am. J. Psychiat. 1966, 122, 742.
comments
(Jan. 13,
p.
96)
on
withdrawal
fits in association with non-barbiturate hypnotic drugs are most pertinent, and I can endorse his experience of unexpected withdrawal fits in heroin addicts who had not disclosed the extent of their hypnotic-drug misuse. Indeed this was the cause of death of at least one London heroin addict,! whilst another I recently encountered developed serial fits, and required transfer to an intensive-care unit before they were controlled. Abrupt withdrawal of non-barbiturate hypnotics may also lead to a tremulous drug-withdrawal psychosis, clinically indistinguishable from delirium tremens.2 Addiction to both barbiturate and non-barbiturate hypnotic drugs is very much more common than is generally realised, and, since the patient usually fails to disclose the habit, it is frequently unrecognised.3 Chronic hypnotic-drug intoxication leads to mental depression, episodic ataxia and agitation, " blackouts " with falls, and a variety of symptoms which may mimic various medical, neurological, or psychiatric disorders.4 The occurrence of otherwise unexplained fits or delirium (especially developing 2-4 days after admission to hospital or some other event associated with drug deprivation) should always raise the possible diagnosis of undisclosed drug addiction. I. PIERCE JAMES. London S.E.26.
FLUORIDATED SCHOOL MILK ?
OVERVISITING OF HOSPITAL PATIENTS ?
SiR,-Whatever the arguments in favour of restricting
A. C. R. SKYNNER V. A. J. SWAIN. WINIFRED F. YOUNG.
SiR,-The suggestions of Dr. Davis (Jan. 13, p. 93) and Dr. Sinclair (Jan. 20, p. 147) for fluoridated milk and sweets,
respectively, are worth more investigation-if not for the reasons they advocate, most of which have been often and thoroughly refuted. The Federation Dentaire Internationale,5 in July last year, adopted a new policy towards the use of milk, sugar, and other vehicles as alternatives to water. For example: " Only in exceptional instances where the dairy industry is well developed and the distribution systems are highly organised can milk be considered as a suitable alternative vehicle. Sugar, considered to be the main dental caries culprit, has not been tested and exploration of its usefulness as a vehicle should be expedited." While this policy is mainly concerned with areas where there is no piped water-supply, it also approves the use of alternative vehicles " where the communal water supply is not being fluoridated ". Communal water is the preferred vehicle, and tablets, lozenges, or drops are the next choice, in view of the limited experience with other vehicles. Wellington, New Zealand, thoroughly considered treating its municipal milksupply, which was exceptionally suitable, before deciding on the water-supply as the vehicle. Generally, the saving in chemicals will not offset the greater cost of administration and lesser efficacy. New Zealand has also used its highly organised child and baby care clinics to promote the use of fluoride tablets in areas with unfluoridated water such as Nelson, where, however, only 17% of the children were found by the M.O.H. to be consuming their tablets. Fluoride sweets might be more readily consumed, but overdose could not be prevented by Restricted sale or a sugar satiety as Dr. Sinclair suggests. child-proof home dispenser might be effective. 1. 2.
3. 4. 5.
James, I. P. Br. J. Addict. Alcohol, 1967, 62, 391. James, I. P. Am. J. Psychiat. 1963, 119, 880. Lancet, 1962, ii, 1368. James, I. P. Med. J. Aust. 1962, ii, 277. Int. dent. J. 1967, 17, 782.
Letters
to
the Editor
ASSESSING HEROIN ADDICTION to time casualty officers and general practitioners are confronted by patients who claim to be addicts, and who ask for help. The help asked for may be in the form of a request for heroin to abort withdrawl symptoms or for direction to a centre for more comprehensive treatment of the addiction. Casualty officers at Lambeth and St. Thomas’ Hospitals are given the following list of instructions:
possible in
our cramped, antiquated building, with many consultants using each ward and with training responsibilities to both postgraduate and undergraduate students, we wonder whether similar solutions may be possible elsewhere if the
nroblem is viewed afresh.
SIR,-From time
1. Ascertain that the patient is a heroin addict; generally they are untruthful. Look for multiple antecubital puncture marks, abscess sites, and signs of old and recent thromboses of arm veins. 2. Check for signs of withdrawal (see accompanying table). 3. If withdrawal signs are present, administer methadone (’ Physeptone ’), preferably in the form of the linctus. Initially, give 10 mg. of methadone. If the patient vomits, this 10 mg. of methadone can be given by subcutaneous injection. If, after 1-2 hours withdrawal signs persist, another 10-20 mg. may be given. This treatment should carry the patient over about 12 hours. (The next dose, if necessary, 12 hours later, should be 20 mg., preferably orally.) 4. Refer the patient to a treatment centre, preferably near where he lives. (See list of treatment centres.) 5. Admit if general physical condition requires.
The table referred to in (2) is from an article by Blachly.l Briefly, 3-4 hours after the last dose of heroin, withdrawal signs consist of craving and anxiety. At about 8 hours added signs are restlessness, yawning, perspiration, lacrimation, and rhinorrhcea. At about 12 hours these signs are increased in intensity and in addition there is mydriasis, gooseflesh, muscle twitching, aching bones and muscles, hot and cold flushes, and anorexia. The list of treatment centres referred to in (4) have now
been announced bv the Ministrv of Health. Hospitals,
Lambeth and St. Thomas’ London S.E.
JULIUS MERRY.
Queen Elizabeth Hospital for Children, London E.2.
WITHDRAWAL FITS
SIR,-Dr. Merry’s
visiting of adults in hospital, it is unfortunate that our colleagues at the Infirmary at Leeds have not explicitly excluded children’s wards and hospitals from their recommendations, since we find that their letter (Jan. 6, p. 44) is already being misinterpreted. Some older children undoubtedly gain in independence from the challenge of admission to hospital, and a good hospital can sometimes be a refuge from a bad home, but there is now overwhelming evidence that some younger children are seriously harmed by separation from their parents, with effects that may persist for years. Though long separations are more damaging, quite short periods of separation in strange surroundings can have surprisingly large effects; for children under four, and certainly for those between six months and two years, nothing less than persuading the mother to live in and share in the care of the child, when this is possible, seems likely to avert the harmful consequences in many instances. Now that this knowledge is available to us, we believe there can be no case at all for any general limitations on visiting of children by their parents. When lately we studied this issue, as members of a subcommittee representing the medical, surgical, and psychiatric departments of this hospital, we came to the conclusion that while unrestricted visiting of children by their parents posed very real problems for all hospital staff, especially the nursing staff, the majority of doctors and nurses at all levels coped with these difficulties willingly. Indeed, to facilitate such visiting, without overburdening the nursing staff, our medical advisory committee has not only rearranged the use of the wards by medical staff and postgraduate and undergraduate students, to reduce the total numbers entering each ward, but has recommended that rounds and examinations should, as far as possible, be confined to limited periods. This seems to us to put priorities in the right order. If this approach to the problem is 1.
Blachly,
P. H.
Am. J. Psychiat. 1966, 122, 742.
comments
(Jan. 13,
p.
96)
on
withdrawal
fits in association with non-barbiturate hypnotic drugs are most pertinent, and I can endorse his experience of unexpected withdrawal fits in heroin addicts who had not disclosed the extent of their hypnotic-drug misuse. Indeed this was the cause of death of at least one London heroin addict,! whilst another I recently encountered developed serial fits, and required transfer to an intensive-care unit before they were controlled. Abrupt withdrawal of non-barbiturate hypnotics may also lead to a tremulous drug-withdrawal psychosis, clinically indistinguishable from delirium tremens.2 Addiction to both barbiturate and non-barbiturate hypnotic drugs is very much more common than is generally realised, and, since the patient usually fails to disclose the habit, it is frequently unrecognised.3 Chronic hypnotic-drug intoxication leads to mental depression, episodic ataxia and agitation, " blackouts " with falls, and a variety of symptoms which may mimic various medical, neurological, or psychiatric disorders.4 The occurrence of otherwise unexplained fits or delirium (especially developing 2-4 days after admission to hospital or some other event associated with drug deprivation) should always raise the possible diagnosis of undisclosed drug addiction. I. PIERCE JAMES. London S.E.26.
FLUORIDATED SCHOOL MILK ?
OVERVISITING OF HOSPITAL PATIENTS ?
SiR,-Whatever the arguments in favour of restricting
A. C. R. SKYNNER V. A. J. SWAIN. WINIFRED F. YOUNG.
SiR,-The suggestions of Dr. Davis (Jan. 13, p. 93) and Dr. Sinclair (Jan. 20, p. 147) for fluoridated milk and sweets,
respectively, are worth more investigation-if not for the reasons they advocate, most of which have been often and thoroughly refuted. The Federation Dentaire Internationale,5 in July last year, adopted a new policy towards the use of milk, sugar, and other vehicles as alternatives to water. For example: " Only in exceptional instances where the dairy industry is well developed and the distribution systems are highly organised can milk be considered as a suitable alternative vehicle. Sugar, considered to be the main dental caries culprit, has not been tested and exploration of its usefulness as a vehicle should be expedited." While this policy is mainly concerned with areas where there is no piped water-supply, it also approves the use of alternative vehicles " where the communal water supply is not being fluoridated ". Communal water is the preferred vehicle, and tablets, lozenges, or drops are the next choice, in view of the limited experience with other vehicles. Wellington, New Zealand, thoroughly considered treating its municipal milksupply, which was exceptionally suitable, before deciding on the water-supply as the vehicle. Generally, the saving in chemicals will not offset the greater cost of administration and lesser efficacy. New Zealand has also used its highly organised child and baby care clinics to promote the use of fluoride tablets in areas with unfluoridated water such as Nelson, where, however, only 17% of the children were found by the M.O.H. to be consuming their tablets. Fluoride sweets might be more readily consumed, but overdose could not be prevented by Restricted sale or a sugar satiety as Dr. Sinclair suggests. child-proof home dispenser might be effective. 1. 2.
3. 4. 5.
James, I. P. Br. J. Addict. Alcohol, 1967, 62, 391. James, I. P. Am. J. Psychiat. 1963, 119, 880. Lancet, 1962, ii, 1368. James, I. P. Med. J. Aust. 1962, ii, 277. Int. dent. J. 1967, 17, 782.