be prevented if the "good guys and gals" were armed and ready to defend themselves and that "some of us would rather be judged by 12 than carried by 6." I am concerned that this is the kind of attitude that may end up transforming Canada into the battle zone of the inner cities of the United States, that bastion of arms-carrying populist militarism. What will stop this endless cycle of violence from escalating out of control (as in Los Angeles) if we allow ourselves to become armed vigilantes that "have access to a firearm to back up our constitutional rights"? Shabbir M.H. Alibhai Richmond Hill, Ont.

Giving patients a choice I read with interest the article by Evelyn Shapiro, Robert B. Tate and Ellen Tabisz entitled "Waiting times for nursing-home placement: the impact of patients' choices" (Can Med Assoc J 1992; 146: 1343-1348). The study showed that patients and families often prefer ethnoreligious nursing homes. It would be useful to survey their satisfaction with the various types of placement. One senses that there may be differences, but is this, in fact, true? One of the difficulties with allowing patients and their families a choice is the pressure placed on them to accept a nursing home that is not their first choice. There must be many factors that might influence them to accept other homes or to stand firm for their home of first choice. To enter temporarily a nursing home that is not the first choice with subsequent transfer when a place is available in the preferred home entails the stress of two moves. Among patients SEPTEMBER 15,1992

and their families in this situation there is also a perception that low priority will be given to the transfer. Indeed, with the great demand for beds a nursing home may be pressured to accept patients from hospitals or the community before those from other nursing homes. I believe that the system in Manitoba, though not perfect, is very humane and compassionate. It attempts at least to give patients and their families some choice and to allow patients to end their lives in a culturally sensitive and ethnoreligiously appropriate institution. For many, such an environment is important. I recall the days of my early training when patients were pressured into entering homes that were not culturally sensitive. I also recall that patients were pressured into accepting the first available bed in a nursing home, even though their spouse might already have been admitted to a different home. Not only is this harsh for the individuals involved, but also it is difficult for their families. Manitoba's present system seems fairer: it can deal with patients requiring differing levels of care within the same institution, and it has a large proportion of ethnoreligious homes. It would be a pity to see these choices curtailed or secularized. Michael Szul, MD St. Joseph's Health Centre Toronto, Ont.

[The first author responds:] Dr. Szul's letter highlights the dilemma facing policymakers. On the one hand, physicians and hos-

pital administrators are complaining to government and the media about the number of short-term beds occupied for a long time by people awaiting transfer to a longterm care facility. On the other hand, satisfying the desire for only one transfer and for admission to an ethnoreligious nursing home for the reasons so well outlined by

Szul increases the waiting time in the short-term hospital bed. How should the government resolve this dilemma? Evelyn Shapiro, MA Professor Department of Community Health Sciences Faculty of Medicine University of Manitoba Winnipeg, Man.

Psychosis with Vicks Formula 44-D abuse r~. David Francis Craig's report of psychosis resulting from abuse of Vicks Formula 44-D (Can Med Assoc J 1992; 146: 1199-1200) attributed the symptoms to phenylpropanolamine abuse. Dextromethorphan is mentioned briefly, although the patient consumed 2400 mg/d. In our opinion the role of dextromethorphan should have been given more consideration. Although early studies of dextromethorphan abuse' found the drug to be devoid of addictive properties, later case reports gave a different account of its effects.2-4 When it is consumed in large doses (more than 600 mg/d) abusers experience drug effects similar to those of phencyclidine: dissociative symptoms such as hallucinations and perceptual alterations, along with physiologic manifestations such as dilated pupils, tachycardia and hypertension. Some of the case reports5'6 recount a brief psychotic episode with spontaneous remission after 3 to 4 days. Our current knowledge of the metabolism of dextromethorphan enables us to understand these effects. Dextromethorphan is metabolized by the liver cytochrome P-450 2D6 enzyme to dextrorphan, which has mild to moderate affinity for the phencyclidine recognition site in the ligand channel D

CAN MED ASSOC J 1992; 147 (6)

843

olism: co-segregation of oxidative 0of the glutamate-NMDA (N-methdemethylation with debrisoquin hyyl-D-aspartate) receptor complex.7 droxylation. Clin Pharmacol Ther 1985; Dextrorphan had the same effects 38: 618-624 as phencyclidine in animal studies of drug self-administration and of [The author responds.] discrimination paradigms.8 A factor in the extent of metabolism of Drs. Schadel and Sellers raise a dextromethorphan is the genetic very interesting hypothesis, about polymorphism of cytochrome which I am not in a position to P-450 2D6: 7% to 10% of Cauca- comment. At Sellers' suggestion I sians lack the enzyme and cannot attempted to contact the patient. metabolize dextromethorphan to However, I learned that she is out dextrorphan, whereas in others of the country and cannot be there is extensive metabolism.9 reached. We predict that the patient described in the report is an ex- David Francis Craig, MD, FRCPC professor of psychiatry tensive metabolizer of dextro- Assistant Faculty of Medicine methorphan. There was thus sub- Memorial University of Newfoundland stantial conversion to dextror- St. John's, Nfld. phan, which accounted for the phencyclidine-like effects.

Mordecai Schadel, MD Edward M. Sellers, MD, PhD Clinical Research and Treatment Institute Addiction Research Foundation Departments of pharmacology, medicine and psychiatry University of Toronto Toronto, Ont.

References 1. Isbell H, Fraser HF: Actions and addiction liabilities of dromoran derivatives in man. J Pharmacol Exp Ther 1953;

106: 524-530 2. Dodds A, Revai E: Toxic psychosis due to dextromethorphan [C]. Med J Aust 1967; 2:231 3. McCarthy JP: Some less familiar drugs of abuse. Med J Aust 1971; 2: 10781081 4. Fleming PM: Dependence on dextromethorphan hydrobromide [C]. BMJ 1986; 293: 597 5. Orell MW, Campbell PG: Dependence on dextromethorphan hydrobromide [C]. Ibid: 1242-1243 6. Bornstein S. Czermak M, Postel J: A propos d'un cas d'intoxication medicamenteuse volontaire au bromhydrate de dextromethorphane. Ann Med Psychol (Paris) 1968; 1: 447-451 7. Tortella FC, Pellicano M, Bowery NG: Dextromethorphan and neuromodulation: old drug coughs up new activities. TIPS 1989; 10: 501-507 8. Szekely JI, Sharpe LG, Jaffe JH: Induction of phenycylidine-like behavior in rats by dextrorphan but not dextromethorphan. Pharmacol -Biochem Behav 1991; 40: 381-386 9. Schmid B, Bircher J, Preisig R et al: Polymorphic dextromethorphan metab844

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The Toronto Free Hospital for Consumptive Poor I was formerly medical director of the Canadian Tuberculosis Association, now the Lung Association, and was responsible for the national program against tuberculosis. The article by Peter Wilton (Can Med Assoc J 1992; 146: 1812-1814) is a fascinating review of the activities of the National Sanitarium Association, as the Toronto Free Hospital for Consumptive Poor called itself. This title was a source of some annoyance to the other tuberculosis associations in Canada, because the Toronto organization continued to call itself "national" even though it was a local constituent of the national body, the Canadian Tuberculosis Association. I cannot agree with Wilton's statement that "there is some doubt that the painful procedure [induction of pneumothorax] provided any benefit."' In selected cases of pulmonary tuberculosis in which no pleural adhesions had developed, pneumothorax short-

ened the time in a sanitarium by a year or more and resulted in arrest of the disease in a very high proportion of cases. Pneumothorax induction was not painful, nor was the pneumothorax itself I know because I had a pneumothorax for 3 years with a successful result - I am alive nearly 50 years later. I also did thousands of pneumothorax "refills" for my patients, who all agreed that the procedure was painless. C. William L. Jeanes, MD Consultant Tropical Health and Quarantine Bureau of Communicable Disease Epidemiology Laboratory Centre for Disease Control Department of National Health and Welfare Ottawa, Ont.

Mandatory drug testing: Boon for public safety or launch of a witch-hunt? T would like to correct a significant error of fact in this arti..Lcle, by Richard Sutherland (Can Med Assoc J 1992; 146: 1215-1220). The substance of the quotations attributed to Jim Britton (who is not an employee of Imperial Oil Limited) as they relate to the company's employee-assistance program is incorrect. Our comprehensive program is alive and well and continues to provide a confidential counselling service to all employees and their families. Furthermore, there never was a "huge meeting" planned to approve the program, nor was a meeting "scrapped" because of the Exxon Valdez incident. Alcohol and drug testing is but one component of a wideranging policy that reflects Imperial Oil's commitment to the health and safety of its employees and the public and to environmental protection. In our compaLE 15 SEPTEMBRE 1992