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Our current approach to drug abuse — progress, problems, proposals
158 Journal of Clinical Forensic Medicine
Our current approach to drug abuse - progress, problems, proposals H. D. Kleber Colombia University,
New York, NY, USA
The author draws attention to drug abuse as a national critical problem linked to crime, violence, AIDS, health care costs etc. He goes on to assess current policies, progress and problems which include efforts in education and prevention programmes based locally and nationally. He compares widespread tobacco use amongst adolescents despite increased publicity about the dangers with making drugs legally available. The availability of alcohol and tobacco for adults and associated social attitudes makes it much more difficult to prevent their use by adolescents. The problems associated with legalisation are discussed in relation to use, crime, other social costs, adolescents and children. Consideration is given to proposals for expanded and enhanced treatment, improved prevention and the modification of existing laws. The author considers that the use of currently illicit drugs like marijuana for medical purposes should be a scientific and not a political question. A much larger investment in research for treatment and prevention is called for. This article is topical and will be of great interest to all professionals involved in coping with substance misuse, to the public, politicians and law enforcement agencies, all of whom are prone to making public pronouncements about the use and misuse of controlled substances. New England Journal of Medicine 1994; 330: 361-365
The battered woman syndrome: effects of severity and intermittence of abuse D. G. Dutton, S. Painter Universities of British Columbia
and Ottawa,
Canada
The authors review the various descriptions of the Battered Woman Syndrome, some divergent views, its effects, emotional responses and sequelae. 75 women (mean age 31.4 years) with a 6-month history of physical or emotional abuse were recruited via transition houses, court mandated programmes and newspaper advertisements. They were assessed by the Conflicts Tactics Scale (CTS) and Psychological Maltreatment of Women Inventory (PMWI) for intermittency and predictability of abuse. Factors such as power, attachment, self-esteem and trauma were also considered. A syndrome of three aspects ~ high rates of trauma symptoms, lowered self-esteem and heightened ‘paradoxical attachment’ to the batterer were confirmed. Criticism of the ‘cycle of violence’ aspect described by Walker is mentioned and the authors suggest that intermittence rather than cyclical abuse is a major element of post separation distress with battering. Strong relationships may develop in abusive situations and account for some women returning to abusers. There is much in this study to interest clinicians, social workers, the police and the legal profession, all of whom deal with this complex problem and who occasionally feel frustrated when women drop charges or return to the abuser. American Journal of Orthopsychiatry
1993; 63(4): 614-622
Esophageal foreign bodies as child abuse, potential fatal mechanisms K. B. Nolte University of New Mexico, Alberquerque,
NM, USA
This is a rare form of child abuse but the report of four recorded instances of non-fatal examples is mentioned. The author describes the case of 4) month-old infant with numerous coins stacked in the esophagus on two occasions. The first was thought to be consistent with the parent’s account of the contents of a ‘piggy bank’ spilled in the crib; the second, a month later, was fatal. Mechanisms unrelated
to the foreign bodies, aspiration of swallowed material, mechanical compression of the trachea or heart or occlusion by the introducing finger are considered. The author concludes that the combination of the two episodes is consistent with a ‘battered baby’ but speculates that the case may also represent Munchausen Syndrome by Proxy. Clinical forensic physicians, paediatricians, accident and emergency surgeons, radiologists and pathologists will find something of interest in this presentation. It is a salutary lesson which again emphasises the need for maintaining a high index of suspicion when dealing with commonplace to bizarre injuries to children, even when explanations by carers appear to be credible. American Journal of Forensic Medicine and Pathology 1993; 14(4): 3233326
Prison: shield from threat, or threat to survival? M. Ross, A. B. Grossman, S. Murdoch et al. Bradford, London, Leeds and Liverpool, UK An outbreak of hepatitis B in a UK prison led to the recognition of inmates with HIV infection. Although the authors’ experience is principally in West Yorkshire they contend that it is probably representative of national conditions. There is published and unpublished evidence of the wide divergence of the pattern of provisions for opiate dependent subjects in the prison medical service compared with that of drug dependency clinics in the NHS. Figures are quoted of over 10% of adult men, 6% of young men and 24% of sentenced prisoners being addicted to hard drugs. In prisons, heroin is said to be widely available at prices varying from O-f5 per gram (about f80/gram outside prison). The prison medical service’s failure to implement Department of Health recommended treatment programmes is criticised. Internally distributed Home Office guidelines for treatment of drug abusers in prison are claimed actually to breach standards of professional ethical care. The authors prospectively monitored two drug misusers and the ethics and outcomes are discussed. A call is made for prominent organisations to enquire into the failure to control heroin misuse in prisons. The article is of great interest to the profession and public and is apposite in the light of publication of the guidelines of the Home Office Working Group on substance misusers in police custody and the BMA/Association of Police Surgeons report on ‘Health Care of Detainees in Police Stations’ (see Book Review). British Medical Journal 1994; 308: 109221095
Accuracy among dentists experienced in forensic odontology in establishing identity G. Ekstrom, T. Johnsson, H. Borrnan University
of Goteborg,
Goteborg,
Sweden
The aim of the study was to investigate the accuracy of 17 experienced forensic odontologists identifying individuals from ante- and postmortem radiographs, the time interval varying from one to several years between and dental conditions varying from nil to complicated therapy such as crowns, bridgework and root fillings. On first evaluation, only 1 observer combined all radiographs correctly and all solved 13 of the 31 cases, while on second evaluation 4 observers combined all radiographs correctly. The authors admit that their study was unrealistic in some respects. Mainly bite wing radiographs were used, these having the disadvantage of not providing the information about the roots and surrounding bone. Future difficulties are indicated, e.g. no therapy because of improved dental health and replacement of amalgam by tooth-coloured restorations without radiographic contrast. They recommended that forensic work be performed by 2 collaborating odontologists ~ one examining and the other checking and making notes, and only experienced and fully qualified experts should carry out person identification by dental characteristics. Pathologists and odontologists will note the importance
Our current approach to drug abuse - progress, problems, proposals H. D. Kleber Colombia University,
New York, NY, USA
The author draws attention to drug abuse as a national critical problem linked to crime, violence, AIDS, health care costs etc. He goes on to assess current policies, progress and problems which include efforts in education and prevention programmes based locally and nationally. He compares widespread tobacco use amongst adolescents despite increased publicity about the dangers with making drugs legally available. The availability of alcohol and tobacco for adults and associated social attitudes makes it much more difficult to prevent their use by adolescents. The problems associated with legalisation are discussed in relation to use, crime, other social costs, adolescents and children. Consideration is given to proposals for expanded and enhanced treatment, improved prevention and the modification of existing laws. The author considers that the use of currently illicit drugs like marijuana for medical purposes should be a scientific and not a political question. A much larger investment in research for treatment and prevention is called for. This article is topical and will be of great interest to all professionals involved in coping with substance misuse, to the public, politicians and law enforcement agencies, all of whom are prone to making public pronouncements about the use and misuse of controlled substances. New England Journal of Medicine 1994; 330: 361-365
The battered woman syndrome: effects of severity and intermittence of abuse D. G. Dutton, S. Painter Universities of British Columbia
and Ottawa,
Canada
The authors review the various descriptions of the Battered Woman Syndrome, some divergent views, its effects, emotional responses and sequelae. 75 women (mean age 31.4 years) with a 6-month history of physical or emotional abuse were recruited via transition houses, court mandated programmes and newspaper advertisements. They were assessed by the Conflicts Tactics Scale (CTS) and Psychological Maltreatment of Women Inventory (PMWI) for intermittency and predictability of abuse. Factors such as power, attachment, self-esteem and trauma were also considered. A syndrome of three aspects ~ high rates of trauma symptoms, lowered self-esteem and heightened ‘paradoxical attachment’ to the batterer were confirmed. Criticism of the ‘cycle of violence’ aspect described by Walker is mentioned and the authors suggest that intermittence rather than cyclical abuse is a major element of post separation distress with battering. Strong relationships may develop in abusive situations and account for some women returning to abusers. There is much in this study to interest clinicians, social workers, the police and the legal profession, all of whom deal with this complex problem and who occasionally feel frustrated when women drop charges or return to the abuser. American Journal of Orthopsychiatry
1993; 63(4): 614-622
Esophageal foreign bodies as child abuse, potential fatal mechanisms K. B. Nolte University of New Mexico, Alberquerque,
NM, USA
This is a rare form of child abuse but the report of four recorded instances of non-fatal examples is mentioned. The author describes the case of 4) month-old infant with numerous coins stacked in the esophagus on two occasions. The first was thought to be consistent with the parent’s account of the contents of a ‘piggy bank’ spilled in the crib; the second, a month later, was fatal. Mechanisms unrelated
to the foreign bodies, aspiration of swallowed material, mechanical compression of the trachea or heart or occlusion by the introducing finger are considered. The author concludes that the combination of the two episodes is consistent with a ‘battered baby’ but speculates that the case may also represent Munchausen Syndrome by Proxy. Clinical forensic physicians, paediatricians, accident and emergency surgeons, radiologists and pathologists will find something of interest in this presentation. It is a salutary lesson which again emphasises the need for maintaining a high index of suspicion when dealing with commonplace to bizarre injuries to children, even when explanations by carers appear to be credible. American Journal of Forensic Medicine and Pathology 1993; 14(4): 3233326
Prison: shield from threat, or threat to survival? M. Ross, A. B. Grossman, S. Murdoch et al. Bradford, London, Leeds and Liverpool, UK An outbreak of hepatitis B in a UK prison led to the recognition of inmates with HIV infection. Although the authors’ experience is principally in West Yorkshire they contend that it is probably representative of national conditions. There is published and unpublished evidence of the wide divergence of the pattern of provisions for opiate dependent subjects in the prison medical service compared with that of drug dependency clinics in the NHS. Figures are quoted of over 10% of adult men, 6% of young men and 24% of sentenced prisoners being addicted to hard drugs. In prisons, heroin is said to be widely available at prices varying from O-f5 per gram (about f80/gram outside prison). The prison medical service’s failure to implement Department of Health recommended treatment programmes is criticised. Internally distributed Home Office guidelines for treatment of drug abusers in prison are claimed actually to breach standards of professional ethical care. The authors prospectively monitored two drug misusers and the ethics and outcomes are discussed. A call is made for prominent organisations to enquire into the failure to control heroin misuse in prisons. The article is of great interest to the profession and public and is apposite in the light of publication of the guidelines of the Home Office Working Group on substance misusers in police custody and the BMA/Association of Police Surgeons report on ‘Health Care of Detainees in Police Stations’ (see Book Review). British Medical Journal 1994; 308: 109221095
Accuracy among dentists experienced in forensic odontology in establishing identity G. Ekstrom, T. Johnsson, H. Borrnan University
of Goteborg,
Goteborg,
Sweden
The aim of the study was to investigate the accuracy of 17 experienced forensic odontologists identifying individuals from ante- and postmortem radiographs, the time interval varying from one to several years between and dental conditions varying from nil to complicated therapy such as crowns, bridgework and root fillings. On first evaluation, only 1 observer combined all radiographs correctly and all solved 13 of the 31 cases, while on second evaluation 4 observers combined all radiographs correctly. The authors admit that their study was unrealistic in some respects. Mainly bite wing radiographs were used, these having the disadvantage of not providing the information about the roots and surrounding bone. Future difficulties are indicated, e.g. no therapy because of improved dental health and replacement of amalgam by tooth-coloured restorations without radiographic contrast. They recommended that forensic work be performed by 2 collaborating odontologists ~ one examining and the other checking and making notes, and only experienced and fully qualified experts should carry out person identification by dental characteristics. Pathologists and odontologists will note the importance