VIEWPOINT * POINT DE VUE
We should consider
some
Wte shoul consider somie new approaches
to addiction
Paul Devenyi, MD, FRCPC
A lthough I have spent almost 30 years practising addiction medicine and now hold strongly biased views on the subject, I entered the field purely by accident. Unlike some colleagues who chose this specialty, I never had any personal problems with alcohol and drugs, nor did anyone in my close circle of family and friends. In the early 1960s I was not entirely happy as a solo general practitioner in Hamilton, Ont., and when the local Addiction Research Founda-
tion (ARF) branch advertised a part-time clinic position, I thought this type of work might provide an interesting diversion. I applied and got the job. I found the clinical issues related to alcoholism fascinating we hardly dealt with other types of substance abuse in those days - and got hooked. In 1965, I gave up my private practice and joined the ARF full time. Later, I took a leave of absence to complete specialty training in internal medicine and then returned to the ARF and worked in various clinical positions. I was named head of medical services in the early 1 980s. Although I was never a rePaul Devenyi is an internist practising in Don Mills, Ont. 344
CAN MED ASSOC J 1992; 147 (3)
Ifirmly believe that in most biomedical scientific fields research is the cornerstone of progress, but I do not think addiction research is one of the fields.
searcher, I was always on the fringes of research. I collaborated with numerous scientists on various projects and copublished some clinical studies, as well as reviews of my own - about 60 papers in all. I became an academic internist by virtue of my university appointment and, in addition to a primary involvement with addiction medicine, practised general internal medicine through a cross appointment to one of Toronto's teaching hospitals. I taught bedside clinical medicine and trained residents in addiction medicine. In 1990, when the ARF decided to undertake a major reorganization and change of direction, I chose to take early retirement. Since then I have been practising private addiction medicine as a consultant.
When I first got involved in treating alcoholism, a relatively new book was regarded as an instant classic in the field. The Disease Concept of Alcoholism, written by one of the most influential practitioners of the field, Dr. E.M. Jellinek,' eloquently argued in favour of regarding alcoholism as a legitimate disease. In the early '60s, it would have been heretical for addiction specialists to believe otherwise. Since then, however, considerable debate has taken place about the disease concept. These arguments are still going on. The disease concept did have a positive impact because it made chemical dependency a respectable health problem, one that no longer had to be denied, covered up or masked by another diagnosis for purposes of hospital admisLE le' AOUJT 1992
I stillfind alcoholism and substance abuse big and elusive mysteries. Why do some people begin, and especially why do they repeat and sustain, the substance-abusing behaviour despite its adverse consequences?
sion or insurance coverage. Its major drawback was, and still is, that it creates the false impression that it is "treatable" - it places the onus of recovery more on healers than on patients. That is why I do not favour the disease concept. I prefer to regard substance abuse as a problem from which recovery is possible rather than as a treatable disease. The difference is not purely semantic. Although alcoholism and drug dependence often create disease, I do not consider them diseases in the traditional sense. But neither do I subscribe to the antiquated position that they are signs of moral or character weaknesses. While there is an element of selfinfliction involved, substance abuse happens to people more by chance than by choice. Having said that, I still find alcoholism and substance abuse big and elusive mysteries. Why do some people begin, and especially why do they repeat and sustain, the substance-abusing behaviour despite its adverse consequences? Although much has been written about basic personality characteristics or genetic factors underlying addictions,2,3 I remain unconvinced. I believe that circumstantial and environmental influences exert the strongest effects in somewhat of a chance fashion. In spite of thousands of publications based on observation, speculation and scientific experimentation, in 1992 we are no closer to understanding the roots of addictive behaviour than we AUGUST 1, 1992
were 30 years ago. Today, I somewhat cynically wonder if we ever will be, and whether continued research into the origins of chemical dependency is an' exercise in futility. I firmly believe that in most biomedical scientific fields research is the cornerstone of progress, but I do not think addiction research is one of the fields. I am, of course, familiar with the argument that research does not have to be immediately and practically relevant to be valuable in the long run. But this principle, while absolutely true in many fields of scientific endeavour, also serves as a convenient escape clause for the unproductive and self-serving scientist. There have not been, and I do not believe there ever will be, major scientific breakthroughs in the addiction field. This applies to both causation and treatment. Sure, we have gained an increasing body of knowledge over the years and there have been advances in the management of some medical complications alcoholic liver disease, for instance, or withdrawal symptoms. However, I do not think there has been any fundamental change in the last 30 years in how we approach addictive behaviour. If we do things better today than a generation ago, it is not so much because of more knowledge coming out of research laboratories, but because of better public awareness, more experience, better and more recovery facilities,
and better and more people providing assistance. Having spent more than 25 years at the ARF, I could not write this without reflecting on that organization. The ARF was born because of the vision, wisdom and persistence of one man, David Archibald. In 1949 he was able to persuade the Ontario government to fund an organization to deal with alcoholism. The ARF would later become involved in dealing with other addictions, and in the ensuing 40 years became perhaps the world's leading institution dealing with addiction issues. As is often the case, it was appreciated much more nationally and internationally than it was locally. Although "research" was prominently displayed in the ARF's name, it managed to keep a healthy balance between patient care, research and education, even though it underwent several "identity crises." Nonetheless, under Archibald's leadership the foundation remained a dynamic and stimulating institution with high staff morale and a continued sense of purpose. I thoroughly enjoyed the Archibald years - I probably would not have stayed in the field after my initial explorations had it not been for the ARF's excellent overall atmosphere at the time. As the organization grew, it became increasingly politicized and bureaucratized and eventually Archibald was replaced. Although many good things have continued CAN MED ASSOC J 1992; 147 (3)
345
I think Ontario should open medical wards dedicated to addiction medicine in several of its hospitals.
to occur at the ARF and even though it attracted some highprofile people to its staff, doubts about its function started to emerge in recent years. Was the ARF still doing its job effectively? In these days of health care austerity, are Ontario taxpayers get-
ting their money's worth? (The current annual budget is about $40 million.) After a management consultant's report was released in 1989, the ARF hired a new administration, which decided to make major changes in the organization and its direction. In my opinion, the fundamental philosophy pronounced by the "new ARF" was a mistake. It emphasized research and development, and subordinated patient care to research. It should be the other way around. I do not believe addiction research will ever produce revolutionary discoveries and think that the foundation, when mapping its future directions, should have emphasized expanded patient care and education. Perhaps it should have changed its name to Addiction Recovery Foundation. For better or worse, the new leaders chose another course. It remains to be seen whether the hoopla surrounding the new direction really means substantial changes, and not just grandiose statements that involve little more than a reshuffling of administrative structure. I do want the ARF to succeed. It nurtured me and my interest in this field, and I am proud 346
CAN MED ASSOC J 1992; 147 (3)
that the things I learned about addiction were learned during many years of experience there. During my 30 years, "treatment" did not change much. Because substance abuse is a selfinduced process, we are still trying to persuade patients to stop the abuse. Beyond the management of withdrawal and physical complications, I do not like to call our interventions "treatment." It is more humble and more appropriate to talk about assisted recov-
ery.4 Basically, we still appeal to the patient's ability to recover those who have the motivation and capacity to recover will do so. There is evidence that many people recover spontaneously, without any therapy. However, others have the perceived or real need for assistance, which may come from peer support, lay counselling or professional intervention. The value of these supports should not be underestimated; for many, this external assistance is a key ingredient of the recovery process. But how extensive (and expensive) is the required recovery assistance? Recently, the notion developed that inpatient programs involving an arbitrarily determined 1- to 3-month stay are the best form of "treatment." In Canada, few of these programs are available and most have long waiting lists; in the US they mushroomed into a profitable industry. They range from modest clinical facilities to resort-like retreats, and their methods range
from respectable professional assistance to quackery. The patients often do not know the difference, at least until they arrive. I won't elaborate on the issue of Canadian patients being channelled by local brokers into American facilities at Ontario taxpayers' expense because CMAJ has already done that.5 The Ontario government is now clamping down on this practice. Still, the issue should not be whether to pay American centres, and how much, but whether the lengthy residential programs are necessary, regardless of whether they are in Canada or elsewhere. They can reach only a limited number of patients, they are expensive, and there is no good evidence that they are more effective than outpatient interventions. Many of these institutions provide impressive recovery statistics, but it is well known that the coexistence of two eventsentering the treatment centre and recovering from addiction - does not prove cause-and-effect relationship. These patients may have been ready to recover at that particular point of their lives, no matter what "treatment" they received. Distinguished British researchers supplied evidence years ago that brief outpatient interventions are just as effective as intensive inpatient programs.6 The ARF experience and position is more or less similar. I think that patients wishing and attempting to recover from substance depenLE I"' AOOT 1992
dence must ultimately win (or lose) the battle on their home turf, not in the artificial environment of an institution or resort, simply because there are too many potential patients and too few facilities. Assuming that professional assistance is of value, but that the intensity of intervention may not be a major factor, I would urge the government to channel funds into outpatient recovery facilities that can reach numerous patients, not into expensive residential programs that are available only to a few. The inpatient facilities we need are ones that supply shortterm hospital treatment through pharmacologic interventions or for medical complications. For many years the ARF ran a 20-bed medical ward, which is being abandoned during the current reorganization. Perhaps it is a reasonable decision not to operate a minihospital that is surrounded by a nonhospital environment. I think, however, that Ontario should open medical wards dedicated to addiction medicine in several of its hospitals. The patients to be admitted - those with delirium tremens, other forms of severe or complicated withdrawal, severe alcoholic liver disease, intravenous users' endocarditis, et cetera - would be admitted and cared for by our hospitals anyway. However, they are scattered around the medical services among other patients who have strokes, bleeding ulcers and heart failure. In that mixed environment, addicted patients' medical issues are addressed, but their addictions may not be. On a ward dedicated to addiction treatment there would be a better chance that patients can be channelled into a recovery outpatient program after their medical problems have been treated. These wards would also be a good teaching ground for house staff. Creating them would not be expensive. These patients already AUGUST 1,1992
exist in the hospital system, and THERAPEUTIC INDEX the allocation of space for an adINDEX THERAPEUTIQUE diction ward would require only a reshuffling of existing resources, not the creation of new ones. Restoration of health is a requisite initial step in the recovery process of addicted patients who Analgesic have medical problems. Beyond Toradol 288, 289, 362 the medical ward, I would concentrate on outpatient recovery assistance. Once a patient is on the Angiotensin converting enzyme inhibitor right track, I think even the busi- Prinivil 356, 357, 358, Inside Back Cover est family practitioner could be Vasotec 298, 354, 355 part of the follow-up and support process. Our therapeutic techniques for substance abusers may Antianginal agent not be very good, but assisting Transderm-Nitro 348, Outside Back Cover those who have the desire and capability of recovery is a merciAntihistamine ful act that is often successful. There will always be people Benadryl 292, 293, 338 who use mind-altering chemical substances. Thus, treatment issues, or more correctly, recovery- Antihypertensive agent assistance issues, will always be Cardizem SR 282, 349 with us. When we talk about prevention, we are talking about mini- Anti-inflammatory agent mizing the number of people who Surgam SR 329, 330 become chemically dependent. This is not a matter of clinical practice, but of social engineering. Bronchial anti-inflammatory agent It involves politics, economics, so- Tilade 296, 297, 361 ciology, law enforcement and, most of all, education. Cholesterol-lowering agent I thank Joyce Reeves for her help with
Mevacor
304, 353
this manuscript.
References
Corticosteroid for nasal use Nasacort
278, 360
1. Jellinek EM: The Disease Concept of Alcoholism, Hillhouse Pr, New Haven,
Conn, 1960 2. Goodwin DW: Alcoholism and Heredity. Arch Gen Psychiatry 1979; 36: 57-61 3. Gordis E, Tabakoff B, Goldman D et al: Finding the Gene(s) for Alcoholism. JAMA 1990; 263: 2094-2095 4. Mulford HA: Treating alcoholism versus accelerating the natural recovery process; A cost benefit comparison. J StudAlcohol 1979; 40: 505-512 5. Korcok M: US cash registers humming as Canadian patients flock south. Can Med Assoc J 1991; 144: 745-747 6. Edwards G, Orford J, Egert S et al: Alcoholism: A controlled trial of "treatment" and "advice." J Stud Akcohol 1 977; 38: 1004- 103 1
Histamine HI receptor antagonist Reactine 314, 359 Seldane 303, 355
Histamine H2 receptor antagonist Pepcid
350, 351, Inside Front Cover
Peristaltic stimulant 280, 352
Senokot/S
Urinary antibacterial agent Noroxin
284, 352
CAN MED ASSOC J 1992; 147 (3)
347
We should consider
some
Wte shoul consider somie new approaches
to addiction
Paul Devenyi, MD, FRCPC
A lthough I have spent almost 30 years practising addiction medicine and now hold strongly biased views on the subject, I entered the field purely by accident. Unlike some colleagues who chose this specialty, I never had any personal problems with alcohol and drugs, nor did anyone in my close circle of family and friends. In the early 1960s I was not entirely happy as a solo general practitioner in Hamilton, Ont., and when the local Addiction Research Founda-
tion (ARF) branch advertised a part-time clinic position, I thought this type of work might provide an interesting diversion. I applied and got the job. I found the clinical issues related to alcoholism fascinating we hardly dealt with other types of substance abuse in those days - and got hooked. In 1965, I gave up my private practice and joined the ARF full time. Later, I took a leave of absence to complete specialty training in internal medicine and then returned to the ARF and worked in various clinical positions. I was named head of medical services in the early 1 980s. Although I was never a rePaul Devenyi is an internist practising in Don Mills, Ont. 344
CAN MED ASSOC J 1992; 147 (3)
Ifirmly believe that in most biomedical scientific fields research is the cornerstone of progress, but I do not think addiction research is one of the fields.
searcher, I was always on the fringes of research. I collaborated with numerous scientists on various projects and copublished some clinical studies, as well as reviews of my own - about 60 papers in all. I became an academic internist by virtue of my university appointment and, in addition to a primary involvement with addiction medicine, practised general internal medicine through a cross appointment to one of Toronto's teaching hospitals. I taught bedside clinical medicine and trained residents in addiction medicine. In 1990, when the ARF decided to undertake a major reorganization and change of direction, I chose to take early retirement. Since then I have been practising private addiction medicine as a consultant.
When I first got involved in treating alcoholism, a relatively new book was regarded as an instant classic in the field. The Disease Concept of Alcoholism, written by one of the most influential practitioners of the field, Dr. E.M. Jellinek,' eloquently argued in favour of regarding alcoholism as a legitimate disease. In the early '60s, it would have been heretical for addiction specialists to believe otherwise. Since then, however, considerable debate has taken place about the disease concept. These arguments are still going on. The disease concept did have a positive impact because it made chemical dependency a respectable health problem, one that no longer had to be denied, covered up or masked by another diagnosis for purposes of hospital admisLE le' AOUJT 1992
I stillfind alcoholism and substance abuse big and elusive mysteries. Why do some people begin, and especially why do they repeat and sustain, the substance-abusing behaviour despite its adverse consequences?
sion or insurance coverage. Its major drawback was, and still is, that it creates the false impression that it is "treatable" - it places the onus of recovery more on healers than on patients. That is why I do not favour the disease concept. I prefer to regard substance abuse as a problem from which recovery is possible rather than as a treatable disease. The difference is not purely semantic. Although alcoholism and drug dependence often create disease, I do not consider them diseases in the traditional sense. But neither do I subscribe to the antiquated position that they are signs of moral or character weaknesses. While there is an element of selfinfliction involved, substance abuse happens to people more by chance than by choice. Having said that, I still find alcoholism and substance abuse big and elusive mysteries. Why do some people begin, and especially why do they repeat and sustain, the substance-abusing behaviour despite its adverse consequences? Although much has been written about basic personality characteristics or genetic factors underlying addictions,2,3 I remain unconvinced. I believe that circumstantial and environmental influences exert the strongest effects in somewhat of a chance fashion. In spite of thousands of publications based on observation, speculation and scientific experimentation, in 1992 we are no closer to understanding the roots of addictive behaviour than we AUGUST 1, 1992
were 30 years ago. Today, I somewhat cynically wonder if we ever will be, and whether continued research into the origins of chemical dependency is an' exercise in futility. I firmly believe that in most biomedical scientific fields research is the cornerstone of progress, but I do not think addiction research is one of the fields. I am, of course, familiar with the argument that research does not have to be immediately and practically relevant to be valuable in the long run. But this principle, while absolutely true in many fields of scientific endeavour, also serves as a convenient escape clause for the unproductive and self-serving scientist. There have not been, and I do not believe there ever will be, major scientific breakthroughs in the addiction field. This applies to both causation and treatment. Sure, we have gained an increasing body of knowledge over the years and there have been advances in the management of some medical complications alcoholic liver disease, for instance, or withdrawal symptoms. However, I do not think there has been any fundamental change in the last 30 years in how we approach addictive behaviour. If we do things better today than a generation ago, it is not so much because of more knowledge coming out of research laboratories, but because of better public awareness, more experience, better and more recovery facilities,
and better and more people providing assistance. Having spent more than 25 years at the ARF, I could not write this without reflecting on that organization. The ARF was born because of the vision, wisdom and persistence of one man, David Archibald. In 1949 he was able to persuade the Ontario government to fund an organization to deal with alcoholism. The ARF would later become involved in dealing with other addictions, and in the ensuing 40 years became perhaps the world's leading institution dealing with addiction issues. As is often the case, it was appreciated much more nationally and internationally than it was locally. Although "research" was prominently displayed in the ARF's name, it managed to keep a healthy balance between patient care, research and education, even though it underwent several "identity crises." Nonetheless, under Archibald's leadership the foundation remained a dynamic and stimulating institution with high staff morale and a continued sense of purpose. I thoroughly enjoyed the Archibald years - I probably would not have stayed in the field after my initial explorations had it not been for the ARF's excellent overall atmosphere at the time. As the organization grew, it became increasingly politicized and bureaucratized and eventually Archibald was replaced. Although many good things have continued CAN MED ASSOC J 1992; 147 (3)
345
I think Ontario should open medical wards dedicated to addiction medicine in several of its hospitals.
to occur at the ARF and even though it attracted some highprofile people to its staff, doubts about its function started to emerge in recent years. Was the ARF still doing its job effectively? In these days of health care austerity, are Ontario taxpayers get-
ting their money's worth? (The current annual budget is about $40 million.) After a management consultant's report was released in 1989, the ARF hired a new administration, which decided to make major changes in the organization and its direction. In my opinion, the fundamental philosophy pronounced by the "new ARF" was a mistake. It emphasized research and development, and subordinated patient care to research. It should be the other way around. I do not believe addiction research will ever produce revolutionary discoveries and think that the foundation, when mapping its future directions, should have emphasized expanded patient care and education. Perhaps it should have changed its name to Addiction Recovery Foundation. For better or worse, the new leaders chose another course. It remains to be seen whether the hoopla surrounding the new direction really means substantial changes, and not just grandiose statements that involve little more than a reshuffling of administrative structure. I do want the ARF to succeed. It nurtured me and my interest in this field, and I am proud 346
CAN MED ASSOC J 1992; 147 (3)
that the things I learned about addiction were learned during many years of experience there. During my 30 years, "treatment" did not change much. Because substance abuse is a selfinduced process, we are still trying to persuade patients to stop the abuse. Beyond the management of withdrawal and physical complications, I do not like to call our interventions "treatment." It is more humble and more appropriate to talk about assisted recov-
ery.4 Basically, we still appeal to the patient's ability to recover those who have the motivation and capacity to recover will do so. There is evidence that many people recover spontaneously, without any therapy. However, others have the perceived or real need for assistance, which may come from peer support, lay counselling or professional intervention. The value of these supports should not be underestimated; for many, this external assistance is a key ingredient of the recovery process. But how extensive (and expensive) is the required recovery assistance? Recently, the notion developed that inpatient programs involving an arbitrarily determined 1- to 3-month stay are the best form of "treatment." In Canada, few of these programs are available and most have long waiting lists; in the US they mushroomed into a profitable industry. They range from modest clinical facilities to resort-like retreats, and their methods range
from respectable professional assistance to quackery. The patients often do not know the difference, at least until they arrive. I won't elaborate on the issue of Canadian patients being channelled by local brokers into American facilities at Ontario taxpayers' expense because CMAJ has already done that.5 The Ontario government is now clamping down on this practice. Still, the issue should not be whether to pay American centres, and how much, but whether the lengthy residential programs are necessary, regardless of whether they are in Canada or elsewhere. They can reach only a limited number of patients, they are expensive, and there is no good evidence that they are more effective than outpatient interventions. Many of these institutions provide impressive recovery statistics, but it is well known that the coexistence of two eventsentering the treatment centre and recovering from addiction - does not prove cause-and-effect relationship. These patients may have been ready to recover at that particular point of their lives, no matter what "treatment" they received. Distinguished British researchers supplied evidence years ago that brief outpatient interventions are just as effective as intensive inpatient programs.6 The ARF experience and position is more or less similar. I think that patients wishing and attempting to recover from substance depenLE I"' AOOT 1992
dence must ultimately win (or lose) the battle on their home turf, not in the artificial environment of an institution or resort, simply because there are too many potential patients and too few facilities. Assuming that professional assistance is of value, but that the intensity of intervention may not be a major factor, I would urge the government to channel funds into outpatient recovery facilities that can reach numerous patients, not into expensive residential programs that are available only to a few. The inpatient facilities we need are ones that supply shortterm hospital treatment through pharmacologic interventions or for medical complications. For many years the ARF ran a 20-bed medical ward, which is being abandoned during the current reorganization. Perhaps it is a reasonable decision not to operate a minihospital that is surrounded by a nonhospital environment. I think, however, that Ontario should open medical wards dedicated to addiction medicine in several of its hospitals. The patients to be admitted - those with delirium tremens, other forms of severe or complicated withdrawal, severe alcoholic liver disease, intravenous users' endocarditis, et cetera - would be admitted and cared for by our hospitals anyway. However, they are scattered around the medical services among other patients who have strokes, bleeding ulcers and heart failure. In that mixed environment, addicted patients' medical issues are addressed, but their addictions may not be. On a ward dedicated to addiction treatment there would be a better chance that patients can be channelled into a recovery outpatient program after their medical problems have been treated. These wards would also be a good teaching ground for house staff. Creating them would not be expensive. These patients already AUGUST 1,1992
exist in the hospital system, and THERAPEUTIC INDEX the allocation of space for an adINDEX THERAPEUTIQUE diction ward would require only a reshuffling of existing resources, not the creation of new ones. Restoration of health is a requisite initial step in the recovery process of addicted patients who Analgesic have medical problems. Beyond Toradol 288, 289, 362 the medical ward, I would concentrate on outpatient recovery assistance. Once a patient is on the Angiotensin converting enzyme inhibitor right track, I think even the busi- Prinivil 356, 357, 358, Inside Back Cover est family practitioner could be Vasotec 298, 354, 355 part of the follow-up and support process. Our therapeutic techniques for substance abusers may Antianginal agent not be very good, but assisting Transderm-Nitro 348, Outside Back Cover those who have the desire and capability of recovery is a merciAntihistamine ful act that is often successful. There will always be people Benadryl 292, 293, 338 who use mind-altering chemical substances. Thus, treatment issues, or more correctly, recovery- Antihypertensive agent assistance issues, will always be Cardizem SR 282, 349 with us. When we talk about prevention, we are talking about mini- Anti-inflammatory agent mizing the number of people who Surgam SR 329, 330 become chemically dependent. This is not a matter of clinical practice, but of social engineering. Bronchial anti-inflammatory agent It involves politics, economics, so- Tilade 296, 297, 361 ciology, law enforcement and, most of all, education. Cholesterol-lowering agent I thank Joyce Reeves for her help with
Mevacor
304, 353
this manuscript.
References
Corticosteroid for nasal use Nasacort
278, 360
1. Jellinek EM: The Disease Concept of Alcoholism, Hillhouse Pr, New Haven,
Conn, 1960 2. Goodwin DW: Alcoholism and Heredity. Arch Gen Psychiatry 1979; 36: 57-61 3. Gordis E, Tabakoff B, Goldman D et al: Finding the Gene(s) for Alcoholism. JAMA 1990; 263: 2094-2095 4. Mulford HA: Treating alcoholism versus accelerating the natural recovery process; A cost benefit comparison. J StudAlcohol 1979; 40: 505-512 5. Korcok M: US cash registers humming as Canadian patients flock south. Can Med Assoc J 1991; 144: 745-747 6. Edwards G, Orford J, Egert S et al: Alcoholism: A controlled trial of "treatment" and "advice." J Stud Akcohol 1 977; 38: 1004- 103 1
Histamine HI receptor antagonist Reactine 314, 359 Seldane 303, 355
Histamine H2 receptor antagonist Pepcid
350, 351, Inside Front Cover
Peristaltic stimulant 280, 352
Senokot/S
Urinary antibacterial agent Noroxin
284, 352
CAN MED ASSOC J 1992; 147 (3)
347
