Letters to the Editor products: one opiate user mentioned five and another six different proprietary products that they had abused. In conclusion abuse of OTC medication was common among the group studied. None of the clients were referred primarily for problems related to OTC abuse and would not have voluntered the information unless specifically asked. Whether any client abused such medication during the treatment programme is not known. The clients studied were heavy intravenous drug users, often with a past history of poly-drug abuse. The survey gives no indication of the point in the users career at which these preparations were used. However, the relatively old average age of the clients (mean 26.8 years, range 20-49) and the high proportion who had used OTC medication in the previous 12 months suggest that their use was not just a passing experimental phase, but had been incorporated into their range of drug taking behaviour. Clients with problems related to primary OTC abuse rarely present to treatment agencies. The extent of OTC use in the community is unknown. OTC preparations have not been included in surveys of adolescent drug use/knowledge (Swadi, 1988; Wright & Pearl, 1990). However, there is no evidence of widespread abuse such as occured in the USA in the early 198O's (Lake & Quirk, 1984; Doughtery, 1982) nor of OTC stimulants being passed off as amphetamine or cocaine substitutes. Among the group studied these preparations do not have the same kudos as street amphetamines (even if they do have similar psychopharmacological effects). Many of the users had little difficulty in obtaining large quantities of various preparations, though it is notable (and encouraging) that some clients had recent difficulty in obtaining codiene linctus. The sale of these preparations is restricted to retail pharmacies and the majority of people probably use them sensibly. However, the poly-pharmacy inherent in many of these preparations, their potentially serious side-effects, abuse potential and ease of purchase argue for stricter controls on their availability. At the least there needs to be greater awareness among pharmacists and doctors of the abuse potential of these preparations. D. J. ARMSTRONG
DARTT, 20 Albion Street, Hull HUl 3TG
127
References CHAPLIN, S. (1984) Adverse reactions to sympathomimetics in cold remedies, Adverse Drug Reaction Bulletin, 107, pp. 396-399. DOUGHTERY, R. J. (1982) Pseudospeed, New York State Journal of Psychiatry, 1, pp. 74-75. GREENWOOD, J. (1983) The case against phenylpropanolamine, Pharmaceutical Journal, May 21. HARRISON, I. (1988) The sale of medicines liable to abuse, Pharmaceutical Journal, May 7, p. 600. JELLEY, T. M. (1987) Phensedyl abuse (letter), British Journal of Psychiatry, 151, pp. 418-419. LAKE, C . R. & QUIRK, R. S. (1984) CNS stimulants and
the look-alike drugs. Psychiatric Clinics of North America, 7, pp. 689-701. LoosMORE, S. & ARMSTRONG, D . J. (1990) Do-Do abuse, British Journal of Psychiatry, 157, pp. 278-281. PuGH, C. R. & HOWIE, S. M . (1986) Dependence on pseudoephidrine, (letter), British Journal of Psychiatry, 151, p. 789. SWADI, H . (1988) Drug and substance use among 3333 London adolescents, British Journal of Addiction, 83, pp. 935-942. WHrrEHOusE, A. M. & DUNCAN, J. M. (1987) Ephedrine psychosis rediscovered, British Journal of Psychiatry, 150, pp. 258-260. WRIGHT, J. D. & PEARL, L . (1990) Knowledge and
experience of young people regarding drug abuse 1969-1989, British Medical Journal, 300, pp. 99-103.
Morphine dispensing to long term problematic injectors SIR—In News and Notes of the January 1991 issue of BJA a single sentence in the review of my PhD thesis on the outcome of the Amsterdam morphine dispensing programme (in Dutch, with an English summary) may cause some misunderstanding. It says that the research project 'after a period of 43 months' reported 'a cautiously positive outcome, but six clients died... while four were not in contact with the programme at the time of death'. Allow me to make the following comments. The first part of this statement needs a bit more context for adequate interpretation and the second part is due to a misunderstanding, and thus not correct. Besides morphine, almost all of the patients in the Amsterdam morphine programme (a cohort of 37 very problematic injectors) also were prescribed a baseline dose of oral methadone. The methadone was meant to stabilize the patients and the injectable morphine was meant to meet the need for injections. The programme started in October 1983 and the patient group was completed in May 1985. The statement in News and Notes describes the status of the patient group in November 1989. Thus, the data on the mortality in the cohort represent not a 43-
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month follow-up, but rather a 49-72-month followup. Indeed, by November 1989 six patients were deceased; three had committed suicide, one had died of AIDS, one of pneumonia (not known was if this was HIV related) and one had died of lung cancer. The programme status of these patients at the time of death was as follows. Only one patient was not in contact with one of treatment modalities closely linked to the injectable dispensing programme at the time of death. Three patients were still in the oral methadone part of the programme; one patient died (because of AIDS) in the prison hospital being on oral methadone only, after having participated in the methadone-and-morphine part of the programme before going to prison; and one patient still was in the methadone-and-morphine part of the programme at the time of death. The single patient not in contact with the programme, left the morphine part of the programme very soon after intake. After that he participated for almost 2 years in the oral methadone part of the programme. At that time he stopped opiate use at all (including methadone), but he continued drinking alcohol excessively and was transferred to alcoholism treatment. He did not respond very well on this treatment and dropped out. One-and-a-half years later it was reported that he had committed suicide shortly before. This leads to two conclusions. First, a single patient died while in morphine maintenance. Sec-
ondly, two out of six patients died of 'drug-related causes' (suicide with an overdose of legal and illegal opiates, and with legal non-opiate drugs). One of the conclusions of the research on the programme said that in most cases, including the dropouts, the relationship of the clients with the medical system was strengthened. Drop-outs from the morphine programme continued participation in the methadone programme at the same dispensary. I am sorry that the concise English summary of the Dutch book on the Amsterdam morphine programme does not provide sufficient detailed information for unequivocal interpretation of the programme results. JACK DERKS
The Netherlands Institute of Mental Health, P.O. Box 5103, 3502 JC Utrecht, The Netherlands
References DERKS, J. (1990) Het Amsterdamse Morfine-verstrekkingsprogramma. Een longitudinaal onderzoek onder extreem problematische druggebruikers (The Amsterdam Morphine Dispensing Programme. A longitudinal study of extremely problematic drug addicts in an experimental Public Health Programme), NcGv, Utrecht, Ph.D. Thesis (Rijks Universiteit Utrecht; State University Utrecht, The Netherlands).
DARTT, 20 Albion Street, Hull HUl 3TG
127
References CHAPLIN, S. (1984) Adverse reactions to sympathomimetics in cold remedies, Adverse Drug Reaction Bulletin, 107, pp. 396-399. DOUGHTERY, R. J. (1982) Pseudospeed, New York State Journal of Psychiatry, 1, pp. 74-75. GREENWOOD, J. (1983) The case against phenylpropanolamine, Pharmaceutical Journal, May 21. HARRISON, I. (1988) The sale of medicines liable to abuse, Pharmaceutical Journal, May 7, p. 600. JELLEY, T. M. (1987) Phensedyl abuse (letter), British Journal of Psychiatry, 151, pp. 418-419. LAKE, C . R. & QUIRK, R. S. (1984) CNS stimulants and
the look-alike drugs. Psychiatric Clinics of North America, 7, pp. 689-701. LoosMORE, S. & ARMSTRONG, D . J. (1990) Do-Do abuse, British Journal of Psychiatry, 157, pp. 278-281. PuGH, C. R. & HOWIE, S. M . (1986) Dependence on pseudoephidrine, (letter), British Journal of Psychiatry, 151, p. 789. SWADI, H . (1988) Drug and substance use among 3333 London adolescents, British Journal of Addiction, 83, pp. 935-942. WHrrEHOusE, A. M. & DUNCAN, J. M. (1987) Ephedrine psychosis rediscovered, British Journal of Psychiatry, 150, pp. 258-260. WRIGHT, J. D. & PEARL, L . (1990) Knowledge and
experience of young people regarding drug abuse 1969-1989, British Medical Journal, 300, pp. 99-103.
Morphine dispensing to long term problematic injectors SIR—In News and Notes of the January 1991 issue of BJA a single sentence in the review of my PhD thesis on the outcome of the Amsterdam morphine dispensing programme (in Dutch, with an English summary) may cause some misunderstanding. It says that the research project 'after a period of 43 months' reported 'a cautiously positive outcome, but six clients died... while four were not in contact with the programme at the time of death'. Allow me to make the following comments. The first part of this statement needs a bit more context for adequate interpretation and the second part is due to a misunderstanding, and thus not correct. Besides morphine, almost all of the patients in the Amsterdam morphine programme (a cohort of 37 very problematic injectors) also were prescribed a baseline dose of oral methadone. The methadone was meant to stabilize the patients and the injectable morphine was meant to meet the need for injections. The programme started in October 1983 and the patient group was completed in May 1985. The statement in News and Notes describes the status of the patient group in November 1989. Thus, the data on the mortality in the cohort represent not a 43-
128
Letters to the Editor
month follow-up, but rather a 49-72-month followup. Indeed, by November 1989 six patients were deceased; three had committed suicide, one had died of AIDS, one of pneumonia (not known was if this was HIV related) and one had died of lung cancer. The programme status of these patients at the time of death was as follows. Only one patient was not in contact with one of treatment modalities closely linked to the injectable dispensing programme at the time of death. Three patients were still in the oral methadone part of the programme; one patient died (because of AIDS) in the prison hospital being on oral methadone only, after having participated in the methadone-and-morphine part of the programme before going to prison; and one patient still was in the methadone-and-morphine part of the programme at the time of death. The single patient not in contact with the programme, left the morphine part of the programme very soon after intake. After that he participated for almost 2 years in the oral methadone part of the programme. At that time he stopped opiate use at all (including methadone), but he continued drinking alcohol excessively and was transferred to alcoholism treatment. He did not respond very well on this treatment and dropped out. One-and-a-half years later it was reported that he had committed suicide shortly before. This leads to two conclusions. First, a single patient died while in morphine maintenance. Sec-
ondly, two out of six patients died of 'drug-related causes' (suicide with an overdose of legal and illegal opiates, and with legal non-opiate drugs). One of the conclusions of the research on the programme said that in most cases, including the dropouts, the relationship of the clients with the medical system was strengthened. Drop-outs from the morphine programme continued participation in the methadone programme at the same dispensary. I am sorry that the concise English summary of the Dutch book on the Amsterdam morphine programme does not provide sufficient detailed information for unequivocal interpretation of the programme results. JACK DERKS
The Netherlands Institute of Mental Health, P.O. Box 5103, 3502 JC Utrecht, The Netherlands
References DERKS, J. (1990) Het Amsterdamse Morfine-verstrekkingsprogramma. Een longitudinaal onderzoek onder extreem problematische druggebruikers (The Amsterdam Morphine Dispensing Programme. A longitudinal study of extremely problematic drug addicts in an experimental Public Health Programme), NcGv, Utrecht, Ph.D. Thesis (Rijks Universiteit Utrecht; State University Utrecht, The Netherlands).
