Journal of the Royal
August 1992
435
Editorials
Medical education and substance abuse On 13 February 1991, the Sections of Epidemiology and Psychiatry organized an all day symposium on addictive behaviour due to the misuse of illegal drugs and alcohol. The issues addressed by a panel of distinguished contributors were those relating to public health concerns, treatment efficacy and the education of doctors. In the last two decades there has been increasing recognition of the immensity and range of problems caused by alcohol misuse and a radical change in thinking about them. The former stereotype of the alcoholic as a middle aged man, whose drinking behaviour is so excessive and addictive that recovery is difficult or even impossible with inevitable social deterioration has been challenged by the observations that alcohol causes problems across the age range, in all social classes and in women as well as men. Further, Ledermann's' observation that alcohol consumption has a continuous distribution in the general population with a skewed or approximately normal curve, backed up by data from population surveys has dispelled the myth that alcoholism is a disease affecting only a minority of vulnerable people with the vast majority of people being able to drink without harm. The alcohol dependence syndrome can develop in any person providing the duration and quantity of their consumption reaches a certain threshold, while alcohol related disability ranging from accidents and family difficulties to medical problems such as hepatic cirrhosis can occur with levels of consumption that do not induce dependence2'3. As well as personal and social factors unique to the individual, alcohol consumption is influenced by socio-economic factors, especially the cultural attitudes about alcohol prevalent in society and the cost and availability of alcohol. The cheaper relative to the cost of living and the more available alcohol is, the greater the consumption of the population and the higher the prevalence of problem drinking. Indeed there is compelling evidence that alcohol related harm is correlated with national alcohol consumption4. Finally, reviews of treatment efficacy indicate a much more favourable outcome with little difference between the effectiveness of the wide repertoire of treatments used. The seminal study by Orford and Edwards5 showing that brief structured advice was as effective as a more intensive standard treatment package in a specialist unit called in question the cost-effectiveness of specialist inpatient treatment programmes. At the same
time as the disease model was being questioned, the application of learning theory concepts derived from experimental psychology facilitated the development of the idea that problem drinking can be viewed as a learned behavioural disorder, influenced by a complex interaction of a range of personal, social, cultural and economic factors6.
In turn, this approach has encouraged more flexible treatment strategies, in particular the development of brief, 'minimal intervention' packages based on cognitive-behavioural principles, often with a large self-help component, which may be presented in the form of an instruction manual for the patient's use, for example the one used by Kisson-Singh et at7 in a study of media recruited problem drinkers. A major advantage of this approach is that it can be applied by non-specialists with appropriate training. It is just as well that such 'user friendly' minimal intervention packages are coming on stream, since the sheer size of the problem makes specialist treatment an impractical option. For example, it is estimated that the average health district in England and Wales has around 22000 heavy drinkers, of whom 7500 will admit to problem drinking. Only 1250 will be known to the helping agencies involved and 125 will be admitted to psychiatric hospitals. Hence, it is clear that alcohol problems can not be managed by specialists in clinical isolation. A community approach is an alternative and preferable option with 'grass roots' collaboration between the various health care, social work, voluntary and legal agencies involved8. Since the vast majority of the population are registered with GPs and consult from time to time, GPs are ideally placed to play a crucial role in early detection and management at a time in the evolution of the drinking behaviour when a health promotion or minimal intervention approach is likely to be most effective. However, the available evidence suggests serious deficiencies in both clinical skills and therapeutic commitment. Newly qualified doctors have been shown to be poor at taking alcohol histories9 and trainee psychiatrists also have difficulty with this basic skill'0. Yet, we know that a proper alcohol history can be taken in under 2 minutes in a general practice consultation" and in a hospital setting'2. A survey in Salford suggests that GPs tend to have negative attitudes about working with problem drinkers. Only 9% thought it rewarding work while 74% disagreed13. Anderson14 reports similar findings amongst GPs in the Oxford region; a relatively low level of therapeutic commitment as expressed by level of motivation to work with problem drinkers, lack of satisfaction in working with them and low self esteem about their own therapeutic competence. Clearly, medical educators at both undergraduate and postgraduate levels need to devise more effective training programmes. Ambivalence about one's own drinking behaviour, negative attitudes induced by the 'Skid Row' stereotype and lack of minimal intervention therapeutic skills leading to low levels of therapeutic commitment are issues that need to be tackled. At the February 1991 symposium Bruce Ritson reviewed the range of potential therapies, Alec Paton discussed the barriers to medical education about alcohol and Peter Anderson addressed the issue of training of primary care physicians. Their papers are published in this issue of the Journal.
Paper arising from joint meeting of Sections of Epidemiology and Psychiatry, 13 February 1991
0141-0768/92
080435-02/$02.00/0 © 1992 The Royal Society of Medicine
436
Journal of the Royal Society of Medicine Volume 85 August 1992
Though misuse of illegal drugs differs from that of alcohol by type of client group, extent of criminal involvement and the HIV question, there are many commonalities in terms of addictive behaviour, dependence, substance related harm and approaches to prevention, harm reduction and therapy as well as negative medical attitudes. Michael Gossop reviewed treatment and outcome at the February 1991 symposium and his paper is published in this issue of the Journal. The work of Ilana Glass15, who also spoke at the symposium, indicates that medical training in the management of drug misusers is also in a state of disarray with limited teaching time in an already overcrowded curriculum, negative attitudes often based on inaccurate perceptions of outcome, lack of therapeutic commitment and deficient basic patient management skills; yet another challenge facing medical education. George W Fenton Ninewells Hospital Dundee DD1 9SY References 1 Ledermann S. Alcool, alcoolisme, alcoolisation. Paris: Presses Universitaires de France, 1956 2 Edwards G, Gross M. Alcohol dependence; provisional description of a clinical syndrome. BMJ 1976;i:1058-61 3 Edwards G, Gross M, Keller M, Moser J, Room M, eds. Alcohol related disabilities. World Health Organisation Offset Publication No 32. Geneva: WHO, 1977
Philosophy of medicine: alternative or scientific It seems that 'alternative', 'complementary', 'unconventional' or 'fringe' medicine is currently enjoying something of a boom - being a regular feature of the media output, and having penetrated into every pharmacist's shop. Consultations with 'irregular' practitioners are now commonplace among the trendy middle-classes and seem to be spreading. And yet at the same time 'scientific' medicine goes from strength to strength with enormous public interest in the wonders of modern therapy. How can we explain this paradox, and what is the relationship between alternative and scientific medicine? The best perspective can be derived from history. It was around the middle ofthe 19th century that the practice of medicine evolved into its present diseasebased system. Each disease category was (ideally) based upon the identification of an underlying pathological lesion, by the art of eliciting physical signs, and with the ultimate arbiter of a postmortem
examination'. The philosophy of pathological medicine went through several stages bringing us up to the present day. Firstly, there developed an awareness of natural remission. It was realized that many illnesses were self-limiting and the body had powers to cure itself
4 Kendell R. Alcoholism: a medical or a political problem? BMJ 1979;i:367-71 5 Orford J, Edwards G. Alcoholism: a comparison of treatment and advice, with a study of the influence of marriage. London: Oxford University Press, 1977 6 Heather N, Robertson I. Problem drinking The new approach. London: Penguin Books, 1985 7 Kisson-Singh J, Heather N, Fenton GW. Assisted natural recovery from alcohol problems. Br J Addict 1990;85:1177-85 8 Orford J. Alcohol problems in the community. In: Bennett DH, Freeman HL, eds. Community psychiatry. Edinburgh: Churchill Livingstone, 1991 9 Barrison IJ, Viola L, Murray-Lyon IM. Do housemen take an adequate drinking history? BMJ 1980:281:1040 10 Farrell MP, David AS. Do psychiatric registrars take a proper drinking history? BMJ 1988;296:395-6 11 Wiseman SM, McCarthy SN, Mitcheson MC. Assessment of drinking problems in general practice. J R Coll Gen Pract 1986;36:407-8 12 Rowland N, Maynard A, Beveridge A, Kennedy P, Wintergill W, Stone W. Doctors have no time for alcohol screening. BMJ 1987;295:95-6 13 Clement S. The Salford Experiment: an account of the community alcohol team approach. In: Stockwell T, Clement S, eds. Helping the problem drinker: new initiatives in community care. London: Croom Helm, 1987 14 Anderson P. Managing alcohol problems in general practice. BMJ 1985;290:1873-5 15 Glass IB, Strang J. Professional training in substance abuse: the UK experience. In: Glass IB, ed. The international handbook of addiction behaviour. London: Tavistock/Routledge, 1991
without medical intervention - this led to the era of 'therapeutic nihilism'. Secondly, there occurred the development of objectively effective treatments: initially the invention of general anaesthesia and aseptic surgery, and during the 20th century a vast armamentarium of therapeutic drugs. Only much more recently have we reached the third stage: a realization of the vital role ofthe placebo. The placebo effect was found to be, overall, the major element in therapy, and virtually the only cause of effective therapy in the pre-modern era2. It is difficult to overestimate the importance of this shattering insight. From now onwards, doctors can no longer assume that a specific effect is due to a specific treatment - it might equally be a non-specific result of the therapeutic relationship. Objective evidence for effective therapy is of two kinds. The first is the 'miracle cure', when effectiveness is not in doubt among rational and informed parties. These are treatments which improve a predictably bad prognosis: a previously fatal disease is no longer fatal, a drug has a quick and dependably curative effect in all patients, surgery restores anatomical normality etc. The second kind of objective evidence is necessary when prognosis is unpredictable, and a group of patients must be studied under scientific conditions. The upshot is the double-blind, randomized controlled trial, which is a technique for quantifying natural remissions and the placebo effect in order to differentiate them from specific treatment.
0141-0768/92 080436-03/$02.00/0 © 1992 The Royal Society of Medicine
August 1992
435
Editorials
Medical education and substance abuse On 13 February 1991, the Sections of Epidemiology and Psychiatry organized an all day symposium on addictive behaviour due to the misuse of illegal drugs and alcohol. The issues addressed by a panel of distinguished contributors were those relating to public health concerns, treatment efficacy and the education of doctors. In the last two decades there has been increasing recognition of the immensity and range of problems caused by alcohol misuse and a radical change in thinking about them. The former stereotype of the alcoholic as a middle aged man, whose drinking behaviour is so excessive and addictive that recovery is difficult or even impossible with inevitable social deterioration has been challenged by the observations that alcohol causes problems across the age range, in all social classes and in women as well as men. Further, Ledermann's' observation that alcohol consumption has a continuous distribution in the general population with a skewed or approximately normal curve, backed up by data from population surveys has dispelled the myth that alcoholism is a disease affecting only a minority of vulnerable people with the vast majority of people being able to drink without harm. The alcohol dependence syndrome can develop in any person providing the duration and quantity of their consumption reaches a certain threshold, while alcohol related disability ranging from accidents and family difficulties to medical problems such as hepatic cirrhosis can occur with levels of consumption that do not induce dependence2'3. As well as personal and social factors unique to the individual, alcohol consumption is influenced by socio-economic factors, especially the cultural attitudes about alcohol prevalent in society and the cost and availability of alcohol. The cheaper relative to the cost of living and the more available alcohol is, the greater the consumption of the population and the higher the prevalence of problem drinking. Indeed there is compelling evidence that alcohol related harm is correlated with national alcohol consumption4. Finally, reviews of treatment efficacy indicate a much more favourable outcome with little difference between the effectiveness of the wide repertoire of treatments used. The seminal study by Orford and Edwards5 showing that brief structured advice was as effective as a more intensive standard treatment package in a specialist unit called in question the cost-effectiveness of specialist inpatient treatment programmes. At the same
time as the disease model was being questioned, the application of learning theory concepts derived from experimental psychology facilitated the development of the idea that problem drinking can be viewed as a learned behavioural disorder, influenced by a complex interaction of a range of personal, social, cultural and economic factors6.
In turn, this approach has encouraged more flexible treatment strategies, in particular the development of brief, 'minimal intervention' packages based on cognitive-behavioural principles, often with a large self-help component, which may be presented in the form of an instruction manual for the patient's use, for example the one used by Kisson-Singh et at7 in a study of media recruited problem drinkers. A major advantage of this approach is that it can be applied by non-specialists with appropriate training. It is just as well that such 'user friendly' minimal intervention packages are coming on stream, since the sheer size of the problem makes specialist treatment an impractical option. For example, it is estimated that the average health district in England and Wales has around 22000 heavy drinkers, of whom 7500 will admit to problem drinking. Only 1250 will be known to the helping agencies involved and 125 will be admitted to psychiatric hospitals. Hence, it is clear that alcohol problems can not be managed by specialists in clinical isolation. A community approach is an alternative and preferable option with 'grass roots' collaboration between the various health care, social work, voluntary and legal agencies involved8. Since the vast majority of the population are registered with GPs and consult from time to time, GPs are ideally placed to play a crucial role in early detection and management at a time in the evolution of the drinking behaviour when a health promotion or minimal intervention approach is likely to be most effective. However, the available evidence suggests serious deficiencies in both clinical skills and therapeutic commitment. Newly qualified doctors have been shown to be poor at taking alcohol histories9 and trainee psychiatrists also have difficulty with this basic skill'0. Yet, we know that a proper alcohol history can be taken in under 2 minutes in a general practice consultation" and in a hospital setting'2. A survey in Salford suggests that GPs tend to have negative attitudes about working with problem drinkers. Only 9% thought it rewarding work while 74% disagreed13. Anderson14 reports similar findings amongst GPs in the Oxford region; a relatively low level of therapeutic commitment as expressed by level of motivation to work with problem drinkers, lack of satisfaction in working with them and low self esteem about their own therapeutic competence. Clearly, medical educators at both undergraduate and postgraduate levels need to devise more effective training programmes. Ambivalence about one's own drinking behaviour, negative attitudes induced by the 'Skid Row' stereotype and lack of minimal intervention therapeutic skills leading to low levels of therapeutic commitment are issues that need to be tackled. At the February 1991 symposium Bruce Ritson reviewed the range of potential therapies, Alec Paton discussed the barriers to medical education about alcohol and Peter Anderson addressed the issue of training of primary care physicians. Their papers are published in this issue of the Journal.
Paper arising from joint meeting of Sections of Epidemiology and Psychiatry, 13 February 1991
0141-0768/92
080435-02/$02.00/0 © 1992 The Royal Society of Medicine
436
Journal of the Royal Society of Medicine Volume 85 August 1992
Though misuse of illegal drugs differs from that of alcohol by type of client group, extent of criminal involvement and the HIV question, there are many commonalities in terms of addictive behaviour, dependence, substance related harm and approaches to prevention, harm reduction and therapy as well as negative medical attitudes. Michael Gossop reviewed treatment and outcome at the February 1991 symposium and his paper is published in this issue of the Journal. The work of Ilana Glass15, who also spoke at the symposium, indicates that medical training in the management of drug misusers is also in a state of disarray with limited teaching time in an already overcrowded curriculum, negative attitudes often based on inaccurate perceptions of outcome, lack of therapeutic commitment and deficient basic patient management skills; yet another challenge facing medical education. George W Fenton Ninewells Hospital Dundee DD1 9SY References 1 Ledermann S. Alcool, alcoolisme, alcoolisation. Paris: Presses Universitaires de France, 1956 2 Edwards G, Gross M. Alcohol dependence; provisional description of a clinical syndrome. BMJ 1976;i:1058-61 3 Edwards G, Gross M, Keller M, Moser J, Room M, eds. Alcohol related disabilities. World Health Organisation Offset Publication No 32. Geneva: WHO, 1977
Philosophy of medicine: alternative or scientific It seems that 'alternative', 'complementary', 'unconventional' or 'fringe' medicine is currently enjoying something of a boom - being a regular feature of the media output, and having penetrated into every pharmacist's shop. Consultations with 'irregular' practitioners are now commonplace among the trendy middle-classes and seem to be spreading. And yet at the same time 'scientific' medicine goes from strength to strength with enormous public interest in the wonders of modern therapy. How can we explain this paradox, and what is the relationship between alternative and scientific medicine? The best perspective can be derived from history. It was around the middle ofthe 19th century that the practice of medicine evolved into its present diseasebased system. Each disease category was (ideally) based upon the identification of an underlying pathological lesion, by the art of eliciting physical signs, and with the ultimate arbiter of a postmortem
examination'. The philosophy of pathological medicine went through several stages bringing us up to the present day. Firstly, there developed an awareness of natural remission. It was realized that many illnesses were self-limiting and the body had powers to cure itself
4 Kendell R. Alcoholism: a medical or a political problem? BMJ 1979;i:367-71 5 Orford J, Edwards G. Alcoholism: a comparison of treatment and advice, with a study of the influence of marriage. London: Oxford University Press, 1977 6 Heather N, Robertson I. Problem drinking The new approach. London: Penguin Books, 1985 7 Kisson-Singh J, Heather N, Fenton GW. Assisted natural recovery from alcohol problems. Br J Addict 1990;85:1177-85 8 Orford J. Alcohol problems in the community. In: Bennett DH, Freeman HL, eds. Community psychiatry. Edinburgh: Churchill Livingstone, 1991 9 Barrison IJ, Viola L, Murray-Lyon IM. Do housemen take an adequate drinking history? BMJ 1980:281:1040 10 Farrell MP, David AS. Do psychiatric registrars take a proper drinking history? BMJ 1988;296:395-6 11 Wiseman SM, McCarthy SN, Mitcheson MC. Assessment of drinking problems in general practice. J R Coll Gen Pract 1986;36:407-8 12 Rowland N, Maynard A, Beveridge A, Kennedy P, Wintergill W, Stone W. Doctors have no time for alcohol screening. BMJ 1987;295:95-6 13 Clement S. The Salford Experiment: an account of the community alcohol team approach. In: Stockwell T, Clement S, eds. Helping the problem drinker: new initiatives in community care. London: Croom Helm, 1987 14 Anderson P. Managing alcohol problems in general practice. BMJ 1985;290:1873-5 15 Glass IB, Strang J. Professional training in substance abuse: the UK experience. In: Glass IB, ed. The international handbook of addiction behaviour. London: Tavistock/Routledge, 1991
without medical intervention - this led to the era of 'therapeutic nihilism'. Secondly, there occurred the development of objectively effective treatments: initially the invention of general anaesthesia and aseptic surgery, and during the 20th century a vast armamentarium of therapeutic drugs. Only much more recently have we reached the third stage: a realization of the vital role ofthe placebo. The placebo effect was found to be, overall, the major element in therapy, and virtually the only cause of effective therapy in the pre-modern era2. It is difficult to overestimate the importance of this shattering insight. From now onwards, doctors can no longer assume that a specific effect is due to a specific treatment - it might equally be a non-specific result of the therapeutic relationship. Objective evidence for effective therapy is of two kinds. The first is the 'miracle cure', when effectiveness is not in doubt among rational and informed parties. These are treatments which improve a predictably bad prognosis: a previously fatal disease is no longer fatal, a drug has a quick and dependably curative effect in all patients, surgery restores anatomical normality etc. The second kind of objective evidence is necessary when prognosis is unpredictable, and a group of patients must be studied under scientific conditions. The upshot is the double-blind, randomized controlled trial, which is a technique for quantifying natural remissions and the placebo effect in order to differentiate them from specific treatment.
0141-0768/92 080436-03/$02.00/0 © 1992 The Royal Society of Medicine
