Archive for the ‘Drugs and drugs policy’ Category

The lost child

Thursday, March 5th, 2009

 

There’s an mildly interesting spat in the press at the moment and, being about drugs, is just about within my remit.  Novelist Julie Myerson has written a book The Lost Child, which weaves two stories.  The first is about Mary Yelloly, a girl who died of tuberculosis in the 1820s leaving a  album of precocious watercolours; the second about her son, whom she and her husband threw out of their house aged 18 because of his fondness for cannabis and the ensuing family disruption.

Given that young people in crisis usually do better with more, rather than less, support, can this really have  been the only appropriate course of action?  Teenagers are often pretty foolish (but not me obviously) and most of them see sense fairly quickly.  Mark Twain captures this process nicely:

When I was a boy of 14, my father was so ignorant I could hardly stand to have the old man around. But when I got to be 21, I was astonished at how much the old man had learned in seven years

Myerson said in her initial interviews that her son had consented to be written about, an assertion that he has since disputed.  It’s hard to see the justification for writing about one’s family in this way as Jake, her son, has now had his business widely aired and will have to live with the consequences, whilst someone else takes the literary acclaim.  Myerson has said that her motivation for publication was to help other people in a similar situation, but does this wash?  Or is it that Myserson has fallen for the narcissistic trap that befalls so many celebrities: the notion that they are different to the rest of us and so important that we, their people, cannot possibly not wish to know.

Why I had to write the book about my son’s drug trauma Guardian 1 March 2009
Terence Blacker: Writers should spare their families Independent 3 March 2009
How could any mother throw her son out of the house for smoking dope – and then profit by writing a book about it? The Daily Mail 5 March 2009 (I’ve included this as a link, but for some reason the tone of it makes me feel really cross)

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Update: if I’d have known how big this story was going to be, I probably wouldn’t have bothered posting about it.  Today in the Guardian This is an emergency Jonathan Myerson justifies his and his wife’s decision to publish.  This now has the air of an unseemly family squabble; Myerson’s tone reminds me of Reefer Madness

If anyone else has an opinion about this, please leave a comment below

Ecstasy and Jacqui Smith

Sunday, February 22nd, 2009

There’s been a fuss in the press and in Parliament this month following a report on ecstasy from the Advisory Council for the Misuse of Drugs (ACMD) and a similarly themed article in Journal of Psychopharmacology by ACMD chairman.

The ACMD’s report made an evidence based recommendation that ecstasy be downgraded to ‘Class B’.  With ‘A’ being the worst, illegal drugs are graded in terms of their harmfulness which informs their illegalness.  The ACMD judged ecstasy not sufficiently harmful either at a personal or societal level to warrant inclusion with the Class A big boys (heroin etc.); alas the UK Home Secretary has chosen to ignore this advice, as she did with similar advice regarding cannabis

At almost the same time David Nutt, chairman of AMCD, wrote an article entitled Equasy – An overlooked addiction with implications for the current debate on drug harms.  In it he makes up an addiction, to that of equine sports, which has a similar hazard rate to ecstasy use and draws parallels between attitudes to ecstasy use and those to horse riding. Given the subsequent fallout, it’s as if he engineered the reaction specifically to illustrate his point.

Here’s Professor Nutt:

‘The general public, especially the younger generation, are disillusioned with the lack of balanced political debate about drugs’

And Jacqui Smith

I’m sure most people would simply not accept the link that he makes up in his article between horse riding and illegal drug taking.  For me that makes light of a serious problem, trivialises the dangers of drugs, shows insensitivity to the families of victims of ecstasy and sends the wrong message to young people about the dangers of drugs.

(Smith’s thought process: I find what you say unspeakable, therefore it’s unsayable, therefore you are wrong)

Nutt’s article is sensible and clearly reasoned about the risks we take in our society and how our judgement of them is informed by society’s wider stance on whether they are worthy or not.  In the case of horse riding it’s thumbs up, and ecstasy, thumbs down.  Maybe on balance this is how it should be but Smith’s retort is knee-jerk and lacks nuance or any intellectual flexibility.  A thoughts comes to mind: sometimes, during a particularly exasperating consultation, I say something like ‘look, people come here and ask me what I think.  So I tell them and then it’s up to them to go away and consider what I’ve said and whether they agree with me about the best way forward or not; sometimes they decide to do what I think is a good idea, and sometimes they don’t’.   This, perhaps, is how David Nutt and the Advisory Council for the Misuse of Drugs must feel.

Previous: Cannabis and Jacqui Smith

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Links

Press
Jacqui Smith slaps down drugs adviser for comparing ecstasy to horse riding Guardian February 9 2009
Drugs adviser says sorry over ecstasy article Guardian February 10 2009
Home secretary accused of bullying drugs adviser over comments about ecstasy BMJ February 13 2009

Blogs
Taking ecstasy no more dangerous than riding a horse? - Before you take that pill
(note this statement as an example of relativism: ‘…something creepy about comparing deaths from drug use and horseback riding. I mean horseback riding is a healthy and uplifting activity, while drug usage, even if it doesn’t kill you, drags you down into lower levels of spiritual and mental functioning’
Psychiatrist Says Ecstasy Less Harmful Than Horse Riding, Controversy Ensues - Furious Seasons

Other
Horizon: Britain’s most dangerous drugs

Psychiatry in the news 17 February 2009 – cannabis special

Tuesday, February 17th, 2009

The Government this week launched an advertisement campaign aimed at teenage dabblers in cannabis.  It’s costing £2.2 million, and focuses on the unpleasant side effects of the drug. 

Watch the Ad 
Read a scathing review and some interesting comments

I don’t know who makes these things, but if teenagers today are anything like they were in my day (we didn’t have a VHS video recorder until I was fifteen, to put this in some sort of context) then being sick is actually an essential part of a recreational experience and therefore welcomed.  This advertisement will act, if anything, as a recruitment drive.

I’ve just discovered this documentary on cannabis, which looks interesting.

Riding on the back of this, TV doctor Mark Porter writes in the Times Cannabis and the risks: facts you need to know 

I wrote a post on cannabis ages ago called Cannabis and Jacqui Smith

I’m ashamed to admit that I find it difficult to understand how fearful we should be, doctors and public alike, of cannabis: does it really make otherwise healthy people psychotic? If so how many? Is it really getting stronger?  Didn’t smoking it used to be fun?  Expect a posting on this when time allows.

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Financial Times has an article about Psychiatry as New York’s counter-cyclical industry.  I’ve been saying this to my friends for a lark for a while (someone making conversation: ‘how’s your job’ me: ‘great, I get paid the same and everythings cheaper’ etc.) but thought that I should stop as I was clearly going to get lynched.

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Trainee psychiatrists charged £175 to query exam results (by RCPsych)
Boo!  Hiss!

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The Times has an article about children with an increasing number of psychiatric classifications Children suffering multiple behaviour problems ASD and ADHD apparently children today are getting ‘alphabet diagnoses’ because of their multiple behaviour problems. 

The reasons for this appear complex, but to my mind has something to do with our willingness to view everything in the light of ‘disorders’, rather than through a lens that would reveal more straightforward processes….

Your thoughts as ever are very welcome.

Liver Transplants ‘furious row’

Sunday, February 15th, 2009

There’s an article in the Observer today talking about a ‘furious’ row that has broken out concerning the number of transplant livers that are being provided to alcoholics with liver disease.

According to Associated Press, figures released by UK health minister Ann Keen showed that the number of liver transplant cases involving damage caused by alcohol has risen rose 94 in 1997/98 to 151 in 2007/08 – increasing from 14% to 23% of the number treated annually over that period. Overall 1,300 people suffering from alcoholic liver disease have received new livers since 1997/98 – 18% of the total number of patients benefiting from the transplants. The Observer quotes the an outraged mother whose unfortunate daughter died and donated her organs and who said how she finds it ‘offensive that one in four of the livers donated go to alcoholics’.

Feelings about this obviously run high in some quarters. The subtext is that people with alcohol problems are deserving of their fate and that by giving a transplant liver to an alcoholic doctors are depriving a much more worthy recipient; a small child whose mother has terminal cancer perhaps. There is certainly a risk that someone who is an alcohol will knacker the second the same way as they did the first, but it’s not evident from the figures reported if non-alcoholics have lost out, or indeed the underlying reason why more transplant operations have taken place on such patients, beyond the obvious possibilities that there are more alcoholic cirrhosis patients or that surgeons are more willing to give them the benefit of the doubt.

I don’t think as a doctors we can afford to be picky or judgemental about our patients. As a profession plenty of our patients have done things that have not turned out to be in their best interests, be it smoking, drinking, a sexual oversight, or climbing up a tree. Some of these society is more tolerant of than others but most pay their taxes and have families who care about them. An alcoholic’s situation is often framed as one of a lack of self control, and subsequent disapproval follows from this ‘failure’. However many factors* have been implicated in alcohol abuse only some of which can be shoehorned into this narrow view.

Rather than get exercised about the care being given to people with alcohol problems, who some presumably think should be let rot, what we need more is a frank discussion about the way alcohol pervades our lives, the forces that drive this and the ways we all collude into making this so. But kicking your local alcoholic on the way to work is like shooting the messenger.

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Check out Alcohol Action Necessary

Guardian article /Press Association / Daily Mail / Telegraph

Alcohol: the world’s favourite drug by Griffith Edwards is recommended to the interested reader

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*The aetiology of alcohol dependence has biological, psychological and social factors. Birth trauma, abandonment by parents, death of parent, death of sibling, sexual or emotional abuse in childhood, broken families, genetics, personality traits of novelty seeking and impulsivity and biochemical factors have all been implicated.

Alcohol: action necessary

Sunday, August 31st, 2008

The other night I tried to get a cup of tea in Hoxton at nine thirty pm only to be told to piss off by a spotty barman who was so rushed off his feet that he could barely be bothered to look up from his fashion magazine. There was no end of exotic cocktails on offer, but seemingly no demand or no desire to serve me something less intoxicating.

It often seems to me in London that we don’t like non or even moderate drinkers. On at least one occasion I’ve taken to hiding pints of beer under my seat, bought for me despite my protestations that I didn’t want a fourth a fifth or a sixth. We’re suspicious of the sober as if they don’t they want to have fun. Or perhaps jealous of how they can have fun without the lubricant we need? Save tea, there’s nothing else which glues British society together like alcohol. New addition to the family: let’s wet the babies head; someone died: let’s drown our sorrows. Any excuse will do. As Reverend Sidney Smith said:

What two ideas are more inseparable than beer and Britannica?

I am not, of course, against having fun. But with alcohol we’ve been sold a sort of fun without due consideration for the harm it does to the individual or wider society. There appears to be no objective appraisal of the dangers of drinking large amounts of alcohol, and a blindness to the sheer horror of town centres rendered no-go areas to families every night of the week due to alcohol fuelled antics. When it comes to alcohol, threats are downplayed and benefits lauded.

Indeed, next time someone boasts to you ‘I was so drunk that I could hardly stand’, take a step back and think about what a bizarre statement this really is, and how we can arrived at a place where this is regarded as an achievement. Generally people like to boast about their abilities like how many hot dogs they can eat, or Munroes they’ve bagged, yet with alcohol it’s the opposite – how much you can’t do. And we all laugh along. It’s clear that excess drinking isn’t just about the behaviour of individuals, but occurs within a social and economic context.

Supermarkets are selling alcoholic drinks at prices cheaper than bottled water. Bars are vertical drinking establishments, intoxicating people to the point of unconsciousness, before ejecting them (sometimes rather forcefully in my experience) onto the street for the ambulances to scrape up. The Government finds itself conflicted – it makes money from taxes on alcoholic drinks but also finances the NHS. Famously, before the 2001 election the Labour Government sent out a text message to its young supporters encouraging them to vote Labour on the basis of a relaxation of the licensing laws. In a way so are psychiatrists; if you guys didn’t drink so much booze quite few of us wouldn’t be needed….

Here are some facts, gleaned from Institute of Alcohol Studies factsheets:

  • There are significantly more premises licensed to sell alcohol than 20 years ago. The licensed capacity of premises in the centre of Manchester increased by 242% between 1996 and 1999. This expansion has led to more competition,including heavy discounting, which is associated with binge drinking and increased drunkenness.
    (Interim Analytical Report. Strategy Unit Alcohol Harm Reduction Project. Strategy Unit 2003)
  • Between 1980 and 2003 the price of alcohol increased by 24% more than prices generally. However, households’ disposable income increased by 91% in real terms over the same period, making alcohol 54% more affordable in 2003 than in 1980 (Statistics on alcohol: England, 2004. Department of Health. Office for National Statistics Statistical Bulletin, 17 September 2004)
  • In 2001, £36,636,000,000 was spent on alcohol, equivalent to 5.8% of all consumer expenditure.
  • Britons spend around £17 billion in pubs each year. In 2002, the nightclub market was worth £1.7 billion.
  • In comparison, Britons spent £7.2 billion on activities such as going to the cinema, theatre, museum and bingo combined. £7.4 billion was spent on gambling in 2002.
    Source for above three
  • The Strategy Unit calculated that for England and Wales the costs of some but not all adverse consequences of alcohol consumption to be in the region of £20 billion.
    Strategy Unit: Alcohol Misuse: How much does it cost? September 2003
  • Of the 580 deaths in drink drive accidents in 1996, 59 per cent were drivers or riders over the limit and 41per cent were innocent victims.
    (Tomorrow’s roads: safer for everyone. The Government’s road safety strategy and casualty reduction targets for 2010. DETR March 2000)
  • Up to 1,000 young people a week suffer serious facial injuries as a result of drunken assaults. 18,000 young people are scarred for life each year.
    (D Campbell. Name Your Poison. The Guardian 8 June 1998. Cited in ‘Taking Stock:What do we know about violence? ESRC Violence Research Programme HMSO 1998)

And I haven’t even touched here on the damage done to individual families and health by dependence and overconsumption.

I’m rather hoping that someone is going to do something about this soon. There’s a lot that can be addressed if the Government and local councils have the stomach for it. Reining back the number of licensed premises, reducing the duty free allowance are two. An important step one was illustrated to my way home on the tube the other week (my bike is broken), when I saw this advertisement:

Advertising’s aim is to sell more alcoholic drinks. Otherwise producers would spend their money on something else. You can see that is says in very small letters that we are recommended to drink responsibly. In much bigger letters the advertisement wishes to plant in our minds that drinking Gordon’s Gin is for the exceptional and those aspiring to greatness. Other advertisements for other drinks show attractive people leading desirable lifestyles. There has been concern that these advertisements disproportionately influence the young.

It’s hard to miss the parallels with the advertisement of tobacco products, which have been banned for the past few years. Alcohol advertisements should be banned also.

More information:

Today Programme report0814 23 July 2008 - UK hospital admissions due to alcohol have increased markedly compared to 13 years ago.

Alcohol: The world’s favourite drug Griffith Edwards

Understanding and modifying the impact of parents’ substance misuse on children
Advan. Psychiatr. Treat., Mar 2007; 13: 79 – 89

Alcohol’s damaging effect on the brain
Alcohol Alert Vol 63 October 2004

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‘Roid Rage

Wednesday, August 13th, 2008

Stop Press:
Discussion (and speculation) about Olympic doping including 100m/200m results
Science of Sport
Steroid Nation

I was listening on the radio just now about UK medal hopes at the Beijing Olympics. It seems we’re doing quite well. Unfortunately I have an anti-talent at sports; at primary school I would only be picked second last if my brother beat me to the wooden spoon. Many years later I lived with a girl and she would watch football on our ancient TV, whilst I sat in my room with the door shut reading ‘The Road to Wigan Pier’.

What’s more my bag is the speculation about the scale of abuse of performance enhancing drugs and their psychiatric sequelae. There are a number of substances used by athletes in order to improve performance. and of these the most common are anabolic steroids.

In the UK anabolic steroids are class C drugs and can be sold only by pharmacists with a doctor’s prescription (most often for hypogonadism). It’s legal to possess or import steroids as long as they’re for personal use, but possession or importing with intent to supply is illegal and could lead to 14 years in prison and an unlimited fine. A UK government source states that in 2003 300,000 steroid tablets were seized.

Use of anabolic steroids in the UK is suspected to be widespread and is not just the preserve of elite athletes; in a survey of 687 students at a British college the overall rate of current or previous use was 2.8% (4.4% in males, 1.0% in females) and, of these, 56% had first used anabolic steroids at the age of 15 or younger. A BMA report in 2002 found that as many as half of the members of dedicated bodybuilding gyms admitted to taking anabolic agents, and that steroid use ran as high as 13% even in some high street fitness centres.

Anabolic steroids are synthetic derivates of the hormone testosterone and allow the user to increase both the frequency and intensity of workouts, in addition to increasing muscle capacity, reducing body fat, increasing strength and endurance, and hastening recovery from injury. Users have varied aims. The majority may wish to enhance their physical appearance in order to achieve a ‘perfect body’, whilst a smaller proportion have experienced physical or sexual abuse, and are trying to increase their muscle size to protect themselves. A further group (possibly between 5 and 10%) includes people who have a form of body dysmorphic disorder (sometimes called ‘reverse anorexia nervosa’), in which they believe that they look small and weak, even if they are large and muscular (Brower et al, 1991).

The steroids are taken orally, or by intramuscular injection and according to a number of regimes – ‘stacking’, ‘cycling’ and ‘pyramiding’.

Misusers of anabolic steroids subjectively report significantly more fights, verbal aggression and violence towards their significant others during periods of use compared with periods of nonuse. Other work has suggested that adolescents who abuse anabolic steroids have nearly triple the incidence of violent behaviour. Clinical presentations include grandiose and paranoid delusional states that often occur in the context of a psychotic or manic episode. Symptoms usually resolve in a few weeks if steroid use is discontinued, although may persist for as long as a month even if adequately treated with antipsychotics.

Steroid users have been shown to have a higher prevalence of cluster B (histrionic, narcissistic, antisocial and borderline) personality traits than community controls . Self report questionnaires and informant histories have been used to retrospectively assess the personality type of anabolic steroid misusers before their first use. Such work suggests that they start out with personalities similar to those of non-using bodybuilders, but develop abnormal personality traits that could be attributed to steroid misuse.

A study involving 41 steroid-using bodybuilders used structured interviews to measure affective symptoms according to DSM–III–R criteria. They identified 5 participants (12.2%) who met the criteria for a manic episode during steroid exposure; a further 8 (19.5%) only narrowly missed the diagnosis. Significantly more participants developed a full affective syndrome during periods of steroid exposure (22%) than non-exposure (5%), and 10 were ‘stacking’ when they experienced manic symptoms.
Symptoms of steroid withdrawal include mood disorders (with suicidal depression as the most life threatening complication), apathy, feelings of anxiety, difficulty in concentrating, insomnia, anorexia, decreased libido, fatigue, headache, and muscle and joint pain. It is difficult to distinguish symptoms that may be physical in origin from those more psychological. Observing oneself to lose muscle mass, strength, performance and confidence after cessation of steroid use has a powerful negative effect on mood, and this may lead to a strong desire to take steroids again.

So, you’re all asking yourself, what’s FP’s advice? Listen to Noam Chomsky:

‘Take, say, sports — that’s another crucial example of the indoctrination system, in my view. For one thing because it … offers people something to pay attention to that’s of no importance; that keeps them from worrying about things that matter to their lives that they might have some idea of doing something about. And in fact it’s striking to see the intelligence that’s used by ordinary people in [discussions of] sports [as opposed to political and social issues

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Sources for this posting:

General

I have leant very heavily on Anabolic androgenic steroids: what the psychiatrist needs to know

This BBC Ethics page has a concise summary of the arguments for and against use of performance enhancing drugs in sport

The talk to Frank site anabolic steroids page

News reports:

Steroids a dangerous new trend BBC February 2 2004

BBC 8 June 2006 Body builder misuse alarm

BBC 11 April 2002 Steroid misuse widespread

Radio programmes (I can’t get these to work, but perhaps you can…)

BBC Radio 4 Diet and Drugs 24 April 2002

BBC Radio 4 The Long View 14 October 2003

Woman’s hour East German doping 7 November 2005

Yemen – country of khat

Monday, August 4th, 2008

Background

What’s it like Man?

Drawbacks

Khat and the Psychiatrist

Socio-economics

What to do?

In the UK

Khat and The Frontier Psychiatrist

Links

 

Yemen has been in the news recently, due to its deteriorating security situation. I’ve long had a fascination with the Middle East, and this country is known not just for its fantastic architecture, but also for its people’s fondness for chewing khat.

Background

Khat (Catha edulis) is a slow growing evergreen shrub that grows wild in countries bordering the Red Sea and along the East coast of Africa. Its appeal is that chewing its fresh leaves and tops leads the user toward a state of amphetamine-like euphoria and stimulation. There are several names for the plant, depending on its origin: chat, qat, qaad, jaad, miraa, mairungi, cat and catha. In most of the Western literature, and this posting, it is referred to as khat.

The habit of khat chewing probably predates the use of coffee, but it has become increasingly popular of late and it is estimated that three quarters of Yemeni adults chew the leaves each afternoon, with a similar social role to that of tea, cigarettes or alcohol. Khat chewing commands a dominant place in social functions and its use so widespread that withdrawal from khat can result in social isolation.

What’s it like Man?

Yemeni homes are constructed specially to provide a warm reception room for khat chewing. For the urban chewer, khat sessions usually begin soon after lunch with men and women meeting separately; the habit is mostly practiced by males.

Drs Wijdan Luqman and T. S. Danowski describe the drug’s effects:

The chewing session starts with slightly euphoric behaviour and a friendly sense of humour. The leaves are plucked off the twigs, chewed, and stored against one or the other cheek. The mixture of saliva and extract from the leaves is swallowed. As new leaves are taken, the cheek bulges out. The euphoric effects appear shortly after the chewing begins ….. The session and the friendly atmosphere last about 2 h. These are followed by a mood of zeal that lasts another 2 h, and during this interval current subjects and problems are discussed. This in turn is supplanted by a serious mood and may be accompanied by irritability.

They also note:

The act of communal chewing promotes interpersonal interactions. For example, as passengers on public transport we observed spontaneous eruptions of group conversations among previously-mute Yemenis once khat chews began.

Writing in the guardian in 2001 Brian Whitaker is a bit more poetic

As you approach cruising altitude, the brain slips into overdrive and you discover that you’re one of the most intelligent and articulate people in the world. Thoughts have never been so clear, nor have ideas flowed so freely. No matter how difficult the problem, by the end of the session you will have either dreamed up a solution or decided that it’s not worth bothering about.

And writing in his book ‘Eating the flowers of paradise’ (buy Amazon Waterstones), Kevin Rushby makes the experience sound positively transcendental:

I passed the hours listening to the gentle lubalub of the hookah and whispered conversations about dead poets and fine deeds. In Sana’a, khat governs. Each day at three, climbing the steps to a smoky room with a bundle under the arm; then closing the door to the outside world, choosing the leaves, gently crushing them with the teeth and waiting for the drug to take effect. No rush, just a silky transition, scarcely noticed, and then the room casts loose its moorings.

In rural areas the chewing of khat starts soon after breakfast, and continues throughout the day, with the children also participating. The stimulant effect is said to lighten the daily tasks. In these poorer regions food may be lacking and the khat decreases the need for meals; on the other hand such is the appeal of the plant that people will sometimes forgo buying food for khat.

Drawbacks

Yemem’s people can spend about one-quarter to one-third of their cash income on the plant. This report has a teacher spending 44% of his salary on khat. As discussed in the Yemen Times the cultivation of khat is extremely widespread, and there is concern due to 80% of Yemen’s water being used for khat growing. One reason for khat’s popularity with farmers is the high income it provides, which can be five times that of that from growing coffee or fruit. A wikipedia source states that increasing demand has lead to the area on which khat is cultivated growing from 8,000 hectares to 103,000 hectares from 1970 to 2000.

Chronic khat chewing can cause hypertension in young adults, with a spontaneous regression once consumption ceases. Khat’s tannins may lead to gastritis, stomatitis, oesophagitis, and peridontal disease. The tannic acids produced are also thought to be hepatotoxic. There are also concerns about the pesticides used in khat cultivation.

Khat and the Psychiatrist

There is debate as to whether khat is able to produce dependence with some researchers saying that the dependence effects are psychological. There is also debate as to whether a withdrawal syndrome exists. Physical withdrawal symptoms have been documented and may consist of lethargy, mild depression, slight trembling and recurrent bad dreams. Discontinuation results in improvement of sleep and appetite, and fewer constipation problems.

According to the WHO expert committee on drug dependence khat chewing can induce two kinds of psychotic reactions. First, a manic illness with grandiose delusions and second, a schizophreniform psychosis with persecutory delusions associated with mainly auditory hallucinations, fear and anxiety, resembling amphetamine psychosis.

Psychotic reactions to chewing khat are rare, probably due to the physical limits of leaf chewing. When seen they are related to chewing large amounts. Symptoms resolve when the khat is withdrawn and anti-psychotics are not usually needed. Khat psychosis may be accompanied by depressive symptoms and sometimes by violent reactions. It has been argued that khat chewing might exacerbate symptoms in patients with pre-existing psychiatric disorder.

Socio-economic effects

The habit of Khat chewing does manifest a number of socio-economic problems. Khat chewing leads to loss of work hours, decreased economic production, malnutrition and diversion of money in order to buy further khat. Family life is harmed because of neglect, dissipation of family income and inappropriate behaviour and khat is quoted as a factor in one in two divorces in Djibouti. Acquisition of funds to pay for khat may lead to criminal behaviour and even prostitution.

On the other hand there are a lot of benefits from the Yemeni’s love of khat and a lot of people clearly enjoy its use. The crop generates wealth for its cultivators and the need for a rural workforce has stabilized the rate of rural to urban migration. It has positive psychological effects too and many people report that it leads them to be more creative. Its energizing effects benefit the elderly especially and it serves as a medium for social discourse.

What to do?

Attempts have been made to control the use of the drug but with little success. In 1957 the Adeni political party instigated a ban, but such was the political turmoil over this issue that the party collapsed the following year. Many people complain that Yemeni authorities are not committed to combating the use of khat because the crop is such a moneymaker for senior officials and influential tribal leaders.

In contrast to Yemen, in Saudi Arabia use of the plant is completely banned and there are harsh penalties in place. One less severe approach would be to treat khat like tobacco in the West, with information campaigns about its drawbacks and restrictions on its use.

In the UK

In recent years as a result of air transport, the consumption of fresh khat leaves has expanded considerably and khat is readily and legally available in the UK. It has been estimated that about 7000 kg of khat pass through Heathrow Airport each week from where it is distributed into the UK and into other European countries.

There have been calls for it to be banned and the BBC reported Faisa Mohammed, chair of the Bromley-based Somali Well Women Project, saying that the abuse of khat was damaging many Somali families in Britain.

Back home the men were the breadwinners but they came to Britain without jobs and took up khat, which has become an addiction. They chew all night and during the day they can’t do anything.

Your correspondent’s humbling experience

As khat is legal in the UK I thought that it might make for a distracting afternoon to try to purchase some. Living near Whitechapel, as I do, I hung outside a semi-reputable Somali shop until I plucked up the courage to go in.

‘Hello, I was wondering if you sold khat’ I said. ‘You know, that plant you can chew’

‘No we don’t and I don’t approve of it’.

I panicked and told the shop keeper that I was a medical student doing a project on khat and I was trying to buy some for ‘research purposes’

Then the shopkeeper’s friend came in and starting to tell me about all the bad things that have happened to the Somali society in the UK thanks to khat, chiefly men ignoring their families and jobs in order to chew the stuff. He thought it should be banned.

Duely chastened I left.

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Links for this article:

Adverse effects of khat: A review Advances in Psychiatric Treatment (2003), vol. 9, 456–463 – a really great review – full text available for free!

The impact of qat chewing on health: A re-evaluation by Nageeb Hassan, Abdullah Gunaid and Iain Murray-Lyon British-Yemini Society

Al-Bab.com qat page

Pages about the Middle East run by the Guardian’s Middle East Editor Brian Whitaker

The Curse of Yemen Ian Black Guardian August 12 2008

Here’s Kevin Rushby’s book again:

Also:

Lonely Plant Yemen page

High in hell An Esquire article by Kevin Fedarko September 1 2006

That darned khat Village Voice article 14 November 2006

The Curse of Yemen Guardian 12 August 2008

Alcoholism and diagnostic creep (starring Kirstin Davis)

Sunday, June 15th, 2008

Kirstin Davis has been annoying me this morning.  The doctors’ on call room here is full of celebrity magazines; they’re always a few weeks old and these ones have a lot about the new Sex and the City movie.  Here are some of the headlines:

Now Magazine 26 May 2008

Kristin: ‘I’m a recovering alcoholic’

Q: You admitted to suffering from alcoholism in your twenties.  Is there any truth in the rumours that you relapsed and went back to rehab?
A: I haven’t had a drink for 20 years now.  I haven’t kept it a secret but people don’t really know about it*

{nb the other four headlines were Cynthia: ‘I’ll wed my lesbian lover’, SJP: ‘I’ll miss Carrie’ and Kim ‘My tomboy keeps me young’}

Reveal Magazine 24 – 30 May 2008

‘I’m not ashamed to be an alcoholic’

‘Her co-stars may be toasting the release of the new Sex and the city movie with champagne, but Kristin Davis won’t be joining them
The star, who plays Charlotte in the New York-based sitcom, hasn’t drunk alcohol in more than 20 years because she had a drink problem.
She says ‘I’m an alcoholic, but I haven’t kept it a secret.  I’ve been sober for a really long time now’

She certainly doesn’t look like an alcoholic to me.  Davis is 43, and since you can legally drink at 21 in the USA this didn’t provide her with much of a window of opportunity to get really stuck in.  Neither article gives us much in the way of details as to what Davis got up to whilst she was a boozing.

Some more digging revealed this interview from the Guardian in 2002:

‘To the outside world, I was a good girl. But I drank a lot, which was rebellious because my parents didn’t drink at all. In the South, pretty much everybody drinks. There was always lots of alcohol, lots of access to alcohol, people sitting around every night with a Mint Julep, or whatever.’ …. At high school, it was just crazy. We’d all be behind the gym drinking, about 20 people passing around bourbon or whatever.’

Throughout our conversation, Davis has been sipping water, but she refuses my offer of wine: ‘No, I’ve been sober a long time.’ Did she end up having problems with alcohol? ‘Oh yes.’ I didn’t know that. ‘Not many people do. There’s this whole thing in America about talking about all your addictions and problems and I’m not really into that**. But it’s not like I want to keep it a secret either.’ What happened? ‘Oh, nothing that bad. I just realised that drinking was counterproductive to what I was trying to do. Acting is very difficult in weird ways. You’d have to get to class by 8am, work all day, rehearse all night, and it’s not really good to do when you’re hung over. I’d wanted to be an actress my whole life, that was my goal, that was all I cared about. Something had to go, so I chose drinking to go.’ Has it been difficult? ‘Oh yeah. Sometimes it would be nice to just have some red wine with dinner, but it’s not worth the risk. I have a great life, a great situation. Why would I want to risk self-destructive behaviour? Even though I might not, I might , do you know what I’m saying? You just never know.’

So, in summary Davis drank a lot whilst she was a rebellious student but then she realized that hangovers weren’t compatible with having a career and making something of yourself.  So she stopped.  Um, I did that too (without actually stopping mind).  Does that mean that I’m an alcoholic too?  ’Alcoholic’ is a poorly defined term, and this is where the confusion may lie.  But if by alcoholic Davis means ‘alcohol dependent’ she’s stretching it rather thin.  If a psychiatrist were to do this, this would be an example of criterion or diagnostic creep, where a previously well defined syndrome widens to include experiences that were previously thought to be a part of normal experience.  Has Davis actually seen a doctor, or is she a self-appointed recovering alcoholic?  PTSD is often accused of criterion creep and this can occur easily for psychiatric syndromes, where the aetiology is unknown.

Why has Davis appropriated the language of psychiatry and addiction to explain her own reaction to what many people would consider a normal stage of many people’s lives?  Perhaps as a way to draw attention to herself, to explain other failings in her life about which we know nothing, or so that she may permanently have one foot in Parsonssick role.  My esteemed colleague, on call with me today, ‘Dr Cynic’ is proposing that Davis is so boring that her alcoholic ploy is a way to spice herself up in the eyes of her public.

For what it’s worth, ICD-10 requires that three of the following criteria be experienced or exhibited at some time during the last year for a diagnosis of dependence:

A strong desire or sense of compulsion to take the substance

Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use

Physiological withdrawal state when substance use has ceased or been reduced, as evidenced by either of the following: the characteristic withdrawal syndrome for the substance or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms

Evidence of tolerance, such that increased doses of psychoactive substance are required to achieve effects originally produced by lower doses

Progressive neglect of alternative pleasures or interests because of psychoactive substance use and increased amount of time necessary to obtain or take the substance or to recover from its effects.

Persisting with substance use despite clear evidence of overly harmful consequences (physical or mental)

For an interesting account of the effect of alcohol and other drugs on society try the following two books by Griffith Edwards:

Matters of Substance – Why Everyone’s a User

Alcohol: the World’s favourite drug

*It’s certainly out of the bag now – I don’t think that talking to NOW magazine is a very effective way of keeping a low profile on this one.

** So what are you doing talking about it here then?

Psychiatric domestos?

Sunday, April 13th, 2008

 

Before the advent of antipsychotic medication the treatments available to the psychiatrist were, with the exception of ECT, ineffective.  Things changed in 1950 when chlorpromazine was first synthesised; now for the first time people working with the mentally ill had a way of improving the previously pretty dismal outcome for sufferers of schizophrenia.  As discussed by Trevor Turner, this also improved the respectability of the psychiatric profession and provided the basis of an aetiological theory for psychotic illness. 

Other medications followed in Chlorpromazine’s wake.  These have become known as the ‘typical‘ antipsychotics and examples are Haloperidol and fluphenazine.  Although good at reducing some of the symptoms of schizophrenia, they also produced some horrid side effects, most notably Parkinsonian symptoms and another movement disorder called tardive dyskinesia.  

In 1958 Clozapine was developed.  This was the first ‘atypical’ antipsychotic.  Its difference was that it wasn’t nearly such a good blocker of D2 receptors, but had more activity at many other receptors including dopamine D4.  It causes no tardive dyskinesia and leads to some improvement in schizophrenic negative symptoms.  Other atypical drugs have followed, these include Olanzapine, Quetiapine and Risperidone.  They too are less potent D2 receptor blockers, and are less likely to cause tardive dyskinesia.  These newer drugs are currently the most widely used, although there is research that they are no better than the older and cheaper drugs at improving patient outcome. 

Clozapine is the ‘psychiatric domestos’ of the title. It’s what psychiatrists use when all the other treatments of psychosis have failed and when it works it’s pretty impressive.  As a medication it’s not without a chequered past and during the 1970s it was withdrawn because of its association with neutropaenia (3% of patients) and agranulocytosis (0.8%); however it was reintroduced following a study which proved it was more effective than other antipsychotics.  Although it does not cause movement disorders, it does have a lot of other side effects, most notably hypersalavation, sedation and diabetes. Why it works more effectively than other drugs is unknown; although its action at D2 receptors is reduced, this still appears important.  No one has ever synthesised an antipsychotic with no D2 activity.  

So, these days, Clozapine is given to our most treatment resistant schizophrenic patients.  It’s an expensive operation.  Each patient requires strict monitoring including regular blood tests and there are dedicated ‘Clozapine clinics’.  I hope that within my lifetime we’ll look upon it as a hopelessly antiquated way to treat our most difficult patients, but for now its the best we’ve got in an area where the search for new medication is frustratingly slow.  

Drugs and leaders

Thursday, March 6th, 2008

There’s an Israeli academic who is speculating that the Old Testament’s Moses may have been under the influence of psychadelic drugs at the time of his writing the 10 commandments.  Benny Shanon is a professor of cognitive psychology at the Hebrew University of Jerusalem, says that these formed an integral part of the religious rites of Israelites in biblical times.  The article is in the Time and Mind journal of philosophy (I can’t find a link for this)

Given how speculative this is, it’s hardly worthy of comment and it’s more likely been said to get a bit of publicity and piss off a few religious leaders.  More interesting is the articles in the press about which of our current and former world leaders have been fond of recreational substances. 

In no particular order:

Boris Yeltsin – Distilled in 1938 Most celebrated incident was his failure to disembark from a plane to meet Albert Reynolds in Shannon Airport

Winston Churchill – The Winston Churchill Centre maintains that he was not an alcoholic but ‘dependent’, two states between which to differentiate would require a very fine pair of scales.  Probably wins the prize for the most quoted about the benefits of alcohol.  Try to Bessie Braddock, socialist member of parliament

George W. Bush – the current president has been arrested for driving under the influence and there is also speculation about his other drug use

Bill Clinton – "When I was in England, I experimented with marijuana a time or two, and I didn’t like it. I didn’t inhale and never tried it again."  Also known for his fondness of cigars…

David Cameron – Not strictly a leader, but he has been pressed at times to come clean about his drug use in the past.  He has refused to do so. 

Anthony Eden – British Prime Minister Anthony Eden was prescribed Benzedrine an amphetamine following damage to his bile duct during a gallstone operation.  It is widely reported across the internet that he ‘lived on benzedrine’ during the Suez crisis, but I can find no citation for this. 

John F Kennedy - is now known to have suffered from adrenal insufficiency.  His medical records have been made public and have detailed his use of hydrocortisone, testosterone, codeine, methadone, Ritalin, antihistamines, anti-anxiety drugs, barbiturates, and regular injections of Procaine to ease his back. Kennedy is described as being in almost constant pain in his last years by some sources, which seems in conflict with stories of his sexual adventures.  This article also suggests the the President smoked cannabis and took LSD

Adolf Hitlersaid to have received daily amphetamine injections from his personal physician. 

I’ve also written about the drug use of the current UK home secretary Jacqui Smith

How should we judge the behaviour of these men.  I would argue that if our leaders seek to leglisate against the public’s use of recreational drugs, then the hyprocrisy evident in their own use is very relevant, and cause for public interest.  We also have a right to be concerned if decisions being taken on our behalves are being taken by people who may be comprimized.  However maybe if we wish a great leader (I’m not counting Hitler here), we must appreciate that their greatness may come hand in hand with their flaws.

Here’s an interesting article on celebrity drug use.  If anyone has other examples of similar leaders please let me know.