time or another. Obviously, many of the estimated 81 million drinking Americans who are not alcoholics may have many other problems related to alcohol, yet short of alcoholism, but chronic alcoholism itself extracts a ter¬ rible toll. It would seem not only appropriate, but urgent, to at¬ tempt to identify ways of determining in advance that one person in ten who is at risk of becoming an alcoholic if he drinks. Since the dose/time relationship extends as many as 5 to 30 years before alcoholism is recognizable in most alcoholics, if one could identify a person at greater risk, that person could be educated and observed before and during his alcohol use so as to detect when a problem be¬ gins to occur and try to nip it in the bud. This could sec¬ ondarily prevent (or treat or rehabilitate early) much al¬ coholism. However, there appears to be a subgroup of alcoholics who are subject to very early dependence, within days or weeks. Informal polls of groups of alcoholics consistently show that 20% to 30% believe that they became an al¬ coholic the first time they ever became drunk. If this is true, the total drinking population contains a risk group of 2% to 3% who may become alcoholic on first, or very early, exposure to alcohol. In this group, genetic/biochemical features or an addictive personality or both may produce a very low/short dose/time relationship susceptibility. This theory should be tested widely. If it is found to be true, it becomes a matter of greatest urgency to attempt to de¬ velop some method of predicting who these 2% to 3% are and then to attempt to prevent these individuals from ever getting drunk the first time. Prevention of psychoactive drug use (such as alcohol) is in the same category of difficulty as prevention of sexual activities or eating. Nonetheless, the consequences of al¬ coholism are so grave to the individual and to society as to suggest that an urgent program be initiated to determine those individuals at greatest initial drinking risk and, once this group is identified, to engage in the strongest form of primary preventive medicine with them. George D. Lundberg, MD Editorial Board, JAMA at
Susceptibility
to
Dependence
on
Alcohol
Primary and Secondary Prevention It is
generally estimated that 90 million Americans drink alcohol and that approximately 9 million of these may be considered alcoholics (or "problem drinkers"). Thus, the risk factor of becoming an alcoholic, if one drinks, would appear to be one in ten. The ghastly toll of alcohol abuse can be measured in terms of many billions of dollars of annual economic loss, a status of being the No. or 4 in the killer of adults United States, participating in countless accidents, homocides, suicides, other violent crimes against persons, and in broken homes, and causing multisystem organ damage. Many of these effects do not require that chemical dependence has been established. However, dependence on alcohol is one of the principal hazards of alcohol use. What governs the likelihood of a given person becoming an alcoholic if he or she begins to drink? The three principal theories that treat the issue of susceptibility to chemical dependence are as follows: 1. Psychological.\p=m-\Manypeople believe that there is such a thing as an "addictive personality"—a person who is prone to become psychologically dependent on almost anything pleasurable that happens—eating, gambling, booze, sex, heroin, or whatever. 2. Genetic/Biochemical.—Others believe that everyone is born with a certain biochemical propensity to be suscep¬ tible or resistant to chemical dependence on any agent that is capable of causing dependence. 3. Dose/Time Relationships.—Still others believe that with agents capable of causing physical dependence, no matter who you are, if you take one or more of these agents in high enough doses for a long enough period of time, you will become dependent. There appears to be good reason to believe in all three theories in certain individuals and settings. They are not mutually exclusive. A key point appears to be the extent to which the psychological and genetic/biochemical factors predispose to susceptibility or resistance. Varying time/dose relationships participate in this equation, which may be unique to each individual in relation to each drug in a kind of continuum. Following the prohibition debacle, it generally has been believed that the elimination of availability of alcohol, al¬ though theoretically sound as a preventive approach, is unwise, unlikely to succeed, often counterproductive, and thus should not be promulgated. Since alcohol is freely available, therefore, it is likely that most people will use it 3
Address editorial communications to the 535 N Dearborn St, Chicago 60610
Editor,
one
Detoxification of Heroin Addicts In the current issue of the Archives of General Psychiatry (32:909, 1975), Razani et al describe a method for detoxification of heroin addicts in which patients have ac-
tive, though limited, control of the frequency of methadone hydrochloride administration during their detoxification. On demand, in any 12-hour period, patients are able to receive up to four oral doses of 5 mg of methadone at intervals of at least one hour. If a patient requests more than the four doses allowed in any 12-hour period, a physician is called and the need for additional methadone is evaluated.
Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 05/29/2015
studied on a ward for acute psychiatric et Razani al achieved impressive results with this problems, 26 of 30 patients were "satisfied" or "very satistechnique: fied," 4 were "neutral," and 4 were "dissatisfied." Average length of stay in a hospital was nine days, including a three-day observation period after detoxification. No patient required longer than seven days for detoxification, and of greatest note was the mean total amount of meth¬ adone hydrochloride consumed, 83.5 mg. The ordinary physician-controlled methadone detoxification, scheduled over a seven-day period, requires the administration of ap¬ proximately 180 mg. Generalization from this clinical report is quite limited. The number of patients included in the study was small and the selection process nonspecific. Razani et al state that their subjects were patients whose habits were heavier than other patients who were detoxified in a nonmedical residen¬ tial detoxification center. In addition, no attempt was made to assign patients randomly to standard detoxification tech¬ niques, nor was naloxone (Narcan) testing employed to quantitate the degree of opiate dependence. But the article by Razani and co-workers adds to the growing list of clinical reports indicating that an active rather than a passive role on the part of the heroin addict undergoing detoxification has desirable consequences. Re¬ duction in amount of medication required, avoidance of the manipulative efforts of the addict, reduction in amount of physician time, and avoidance of the errors inherent in in¬ terpreting the often equivocal physical signs of the absti¬ nence syndrome are among the benefits of this approach. Clinical experience suggests that self-regulation is not desirable for every patient undergoing detoxification. Many prefer standard approaches, in which the patient appears to feel less anxiety with the physician in control. Thus, selfregulation is properly viewed as one possible approach to detoxification. The wise clinician will choose the approach most appropriate for each patient. In a field so frequently dominated by sterotypical thinking, it is encouraging to see In 30
patients
development of flexible approaches of opiate detoxification.
to
the difficult
problem
Edward C. Senay, MD, Director Drug Abuse Programs
Chicago
Adequacy of Dialysis enter into the making of Sometimes decisions. when the alternative many therapeutic to benefit is certain death, the decision is simplified. The public or private sector of our humane society will assist the threatened individual. Life must be preserved at all costs. But, even in desperate situations, cost becomes an important decisional factor, if a choice exists between two or more life-sustaining measures. Decisions then have to be made on the basis of comparative cost, and this is no simple
Cost/benefit considerations often
matter,
as
is well illustrated in the treatment of renal fail-
ure.
Hemodialysis and renal transplantation often compete for priority of choice in advanced renal failure. Each of these two treatment modalities carries its own complex of costs and benefits. The benefits of renal transplantation are obvious. Patients with successfully grafted kidneys do not depend on a machine\p=m-\apsychological bonus of no small moment. They have greater freedom from dietary restraints, freedom of mobility, fuller recovery of libido and fertility, and they are practically free of such complica¬ tions as anemia, peripheral neuropathy, and renal os-
teodystrophy.
With such benefits accruing from renal transplantation, why should we be concerned with hemodialysis as an al¬ ternative? Why choose a therapy that enforces a tedious
machine-dominated routine,
a
therapy complicated by
os¬
neurologic, hématologie, and cardiovascular distur¬ bances ? Why incur such costs ? The answer lies partly in the costs of renal transplanta¬ tion—operative mortality, graft rejection, repeat surgery, lifelong expensive medication—but, more important, in its associated logistic problems, which are tremendous. Indeed, the problem of organ availability accounts to a great extent for the fact that fewer patients (13,086 as of May 1, 1975) in this country have had renal transplantation than are now undergoing long-term hemodialysis (14,129 as of April 1, 1975). Even if we assume—the assumption is not unreason¬ able—that many of the logistic difficulties will be over¬ come and more cadaver kidneys will become available, we can still expect that within a few years, tens of thousands will be receiving long-term dialysis therapy. Clearly, there is a need for assessing the adequacy of this therapy, its costs and benefits, so as to ensure its optimal use. The recently published Proceedings of the Conference on Adequacy of Dialysis,1 sponsored by the National Institutes of Health, provides the background for such an assessment.
seous,
Although data for complete analysis are as yet unavailable, they offer enough material for planning future clinical trials and for providing guidelines to studies aimed at clari¬
fying relationships between end-stage uremic lesions and the variables of dialysis therapy. Based on available knowl¬ edge of uremic complications and those of dialysis (dis¬ cussed at length in the Proceedings), these guidelines in¬ clude recommendations for patient selection in experimental studies, appropriate statistical methods, eval¬ uation of neurologic, skeletal, hématologie, and cardio¬ vascular changes in response to dialysis, nutritional eval¬ uation, and quantification of therapy in research protocols. This is indeed a big order. Its delivery will be awaited with great interest. Samuel Vaisrub, MD Senior Editor
FA, Krueger KK: Proceedings of the Conference of Dialysis, suppl 2. Berlin, Springer-Verlag, 1975.
1. Gotch quacy
Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 05/29/2015
on
Ade-
Susceptibility
to
Dependence
on
Alcohol
Primary and Secondary Prevention It is
generally estimated that 90 million Americans drink alcohol and that approximately 9 million of these may be considered alcoholics (or "problem drinkers"). Thus, the risk factor of becoming an alcoholic, if one drinks, would appear to be one in ten. The ghastly toll of alcohol abuse can be measured in terms of many billions of dollars of annual economic loss, a status of being the No. or 4 in the killer of adults United States, participating in countless accidents, homocides, suicides, other violent crimes against persons, and in broken homes, and causing multisystem organ damage. Many of these effects do not require that chemical dependence has been established. However, dependence on alcohol is one of the principal hazards of alcohol use. What governs the likelihood of a given person becoming an alcoholic if he or she begins to drink? The three principal theories that treat the issue of susceptibility to chemical dependence are as follows: 1. Psychological.\p=m-\Manypeople believe that there is such a thing as an "addictive personality"—a person who is prone to become psychologically dependent on almost anything pleasurable that happens—eating, gambling, booze, sex, heroin, or whatever. 2. Genetic/Biochemical.—Others believe that everyone is born with a certain biochemical propensity to be suscep¬ tible or resistant to chemical dependence on any agent that is capable of causing dependence. 3. Dose/Time Relationships.—Still others believe that with agents capable of causing physical dependence, no matter who you are, if you take one or more of these agents in high enough doses for a long enough period of time, you will become dependent. There appears to be good reason to believe in all three theories in certain individuals and settings. They are not mutually exclusive. A key point appears to be the extent to which the psychological and genetic/biochemical factors predispose to susceptibility or resistance. Varying time/dose relationships participate in this equation, which may be unique to each individual in relation to each drug in a kind of continuum. Following the prohibition debacle, it generally has been believed that the elimination of availability of alcohol, al¬ though theoretically sound as a preventive approach, is unwise, unlikely to succeed, often counterproductive, and thus should not be promulgated. Since alcohol is freely available, therefore, it is likely that most people will use it 3
Address editorial communications to the 535 N Dearborn St, Chicago 60610
Editor,
one
Detoxification of Heroin Addicts In the current issue of the Archives of General Psychiatry (32:909, 1975), Razani et al describe a method for detoxification of heroin addicts in which patients have ac-
tive, though limited, control of the frequency of methadone hydrochloride administration during their detoxification. On demand, in any 12-hour period, patients are able to receive up to four oral doses of 5 mg of methadone at intervals of at least one hour. If a patient requests more than the four doses allowed in any 12-hour period, a physician is called and the need for additional methadone is evaluated.
Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 05/29/2015
studied on a ward for acute psychiatric et Razani al achieved impressive results with this problems, 26 of 30 patients were "satisfied" or "very satistechnique: fied," 4 were "neutral," and 4 were "dissatisfied." Average length of stay in a hospital was nine days, including a three-day observation period after detoxification. No patient required longer than seven days for detoxification, and of greatest note was the mean total amount of meth¬ adone hydrochloride consumed, 83.5 mg. The ordinary physician-controlled methadone detoxification, scheduled over a seven-day period, requires the administration of ap¬ proximately 180 mg. Generalization from this clinical report is quite limited. The number of patients included in the study was small and the selection process nonspecific. Razani et al state that their subjects were patients whose habits were heavier than other patients who were detoxified in a nonmedical residen¬ tial detoxification center. In addition, no attempt was made to assign patients randomly to standard detoxification tech¬ niques, nor was naloxone (Narcan) testing employed to quantitate the degree of opiate dependence. But the article by Razani and co-workers adds to the growing list of clinical reports indicating that an active rather than a passive role on the part of the heroin addict undergoing detoxification has desirable consequences. Re¬ duction in amount of medication required, avoidance of the manipulative efforts of the addict, reduction in amount of physician time, and avoidance of the errors inherent in in¬ terpreting the often equivocal physical signs of the absti¬ nence syndrome are among the benefits of this approach. Clinical experience suggests that self-regulation is not desirable for every patient undergoing detoxification. Many prefer standard approaches, in which the patient appears to feel less anxiety with the physician in control. Thus, selfregulation is properly viewed as one possible approach to detoxification. The wise clinician will choose the approach most appropriate for each patient. In a field so frequently dominated by sterotypical thinking, it is encouraging to see In 30
patients
development of flexible approaches of opiate detoxification.
to
the difficult
problem
Edward C. Senay, MD, Director Drug Abuse Programs
Chicago
Adequacy of Dialysis enter into the making of Sometimes decisions. when the alternative many therapeutic to benefit is certain death, the decision is simplified. The public or private sector of our humane society will assist the threatened individual. Life must be preserved at all costs. But, even in desperate situations, cost becomes an important decisional factor, if a choice exists between two or more life-sustaining measures. Decisions then have to be made on the basis of comparative cost, and this is no simple
Cost/benefit considerations often
matter,
as
is well illustrated in the treatment of renal fail-
ure.
Hemodialysis and renal transplantation often compete for priority of choice in advanced renal failure. Each of these two treatment modalities carries its own complex of costs and benefits. The benefits of renal transplantation are obvious. Patients with successfully grafted kidneys do not depend on a machine\p=m-\apsychological bonus of no small moment. They have greater freedom from dietary restraints, freedom of mobility, fuller recovery of libido and fertility, and they are practically free of such complica¬ tions as anemia, peripheral neuropathy, and renal os-
teodystrophy.
With such benefits accruing from renal transplantation, why should we be concerned with hemodialysis as an al¬ ternative? Why choose a therapy that enforces a tedious
machine-dominated routine,
a
therapy complicated by
os¬
neurologic, hématologie, and cardiovascular distur¬ bances ? Why incur such costs ? The answer lies partly in the costs of renal transplanta¬ tion—operative mortality, graft rejection, repeat surgery, lifelong expensive medication—but, more important, in its associated logistic problems, which are tremendous. Indeed, the problem of organ availability accounts to a great extent for the fact that fewer patients (13,086 as of May 1, 1975) in this country have had renal transplantation than are now undergoing long-term hemodialysis (14,129 as of April 1, 1975). Even if we assume—the assumption is not unreason¬ able—that many of the logistic difficulties will be over¬ come and more cadaver kidneys will become available, we can still expect that within a few years, tens of thousands will be receiving long-term dialysis therapy. Clearly, there is a need for assessing the adequacy of this therapy, its costs and benefits, so as to ensure its optimal use. The recently published Proceedings of the Conference on Adequacy of Dialysis,1 sponsored by the National Institutes of Health, provides the background for such an assessment.
seous,
Although data for complete analysis are as yet unavailable, they offer enough material for planning future clinical trials and for providing guidelines to studies aimed at clari¬
fying relationships between end-stage uremic lesions and the variables of dialysis therapy. Based on available knowl¬ edge of uremic complications and those of dialysis (dis¬ cussed at length in the Proceedings), these guidelines in¬ clude recommendations for patient selection in experimental studies, appropriate statistical methods, eval¬ uation of neurologic, skeletal, hématologie, and cardio¬ vascular changes in response to dialysis, nutritional eval¬ uation, and quantification of therapy in research protocols. This is indeed a big order. Its delivery will be awaited with great interest. Samuel Vaisrub, MD Senior Editor
FA, Krueger KK: Proceedings of the Conference of Dialysis, suppl 2. Berlin, Springer-Verlag, 1975.
1. Gotch quacy
Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 05/29/2015
on
Ade-
