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B3: 11 Referral and
Shared Care HO2
Shared Care in the Management of Alcohol & Other
Drug-Related Disorders:
A Review of the Literature
Jan Copeland (PhD)
Prepared as part of the Mental Health Shared Care Network
Commitment to Divisions of General Practice
February 1998
Integration Support and Evaluation
Resource Unit
School of Community Medicine, University of New South Wales
Funded by the Commonwealth Department of Health and Family Services, GP Branch
Acknowledgement:
The earlier drafts of this document were reviewed by Jonine Penrose-Wall, Prof Mark
Harris (Integration SERU) and Prof Ian Webster (Reference Group to the Mental Health
Shared Care Network). Layout and typsetting by Jane Drury.
TABLE OF CONTENTS
I
1
INTRODUCTION................................................................................................................................................... 3
THE EPIDEMIOLOGY OF SUBSTANCE USE DISORDERS ........................................................................... 4
THE GENERAL PRACTITIONER AND SUBSTANCE USE DISORDERS ...................................................... 5
MODELS OF SHARED CARE SUBSTANCE USE DISORDERS .................................................................... 6
ASSESSMENT OF ALCOHOL AND OTHER DRUG-RELATED DISORDERS .............................................. 8
Motivation ........................................................................................................................................................ 8
Social and Lifestyle Factors ........................................................................................................................... 9
2
ALCOHOL ABUSE/DEPENDENCE .................................................................................................................. 10
Assessment .................................................................................................................................................. 10
Brief and Early Intervention .......................................................................................................................... 10
Detoxification ................................................................................................................................................ 11
3
OPIOID ABUSE/DEPENDENCE ....................................................................................................................... 13
Assessment .................................................................................................................................................. 13
Detoxification and Abstinence Orientated Interventions ............................................................................. 13
Replacement Pharmacotherapies ............................................................................................................... 14
I
4
CANNABIS ABUSE/DEPENDENCE ................................................................................................................. 17
Brief Interventions ......................................................................................................................................... 17
Adolescents .................................................................................................................................................. 18
5
HYPNO-SEDATIVE ABUSE/DEPENDENCE ................................................................................................... 19
Interventions with General Practitioners ...................................................................................................... 19
Benzodiazepine Dependence ...................................................................................................................... 19
Management of Benzodiazepine Withdrawal ............................................................................................. 20
Benzodiazapine use among IDU ................................................................................................................. 21
6
CONCLUSION..................................................................................................................................................... 22
REFERENCES .................................................................................................................................................... 24
CHAPTER 2
CHAPTER
1
INTRODUCTION
Given the prevalence of alcohol and other drug abuse/dependence disorders, and the high
levels of hazardous substance use in the community, coupled with the low levels of specialist
help-seeking by this group there is an urgent need for the general medical practitioners to
detect and intervene with at-risk patients and to develop shared care relationships with a variety
of specialist agencies. This review of the literature examines the current policy and practice
environment of the management of substance use disorders in the context of the role of
general medical practitioners in shared management relationships with specialist alcohol and
other drug service providers.
The published literature was searched electronically using the terms: substance use disorder,
alcohol, drugs, opiates, hypnosedatives, benzodiazepines, general practitioner, physician,
shared care, treatment, and intervention. The electronic databases consulted included
Excerpta Medica/EMBASE, MEDLINE, Current Contents/Clinical Medicine and psycLIT. Only
English language articles were included in the review, which comprises 102 items. While the
majority of papers were peer-reviewed articles, the "grey literature" of government reports,
technical reports, and practice manuals have been included where the authors are of sufficient
eminence in the field to warrant their consideration. As there is a paucity of literature addressing
shared care of substance use disorders, guidelines from the literature on the primary
management issues for general practitioners have been included, to assist in building GPs'
confidence in the shared management of such patients.
The review is presented in a number of sections. These include:

an epidemiological overview of substance use disorders in Australia

the general practitioner and substance use disorders

models of shared care

general assessment issues

alcohol abuse/dependence

opioid abuse/dependence

cannabis abuse/dependence

hypno-sedative abuse/dependence, and

evaluation issues in shared care of substance use disorders.
The terms substance use disorders, substance abuse/dependence, and alcohol and other drug
problems are used interchangeably throughout the review.
3
THE EPIDEMIOLOGY OF SUBSTANCE USE DISORDERS
It has long been established that drug abuse leads to significant direct and indirect costs for the
Australian community. Collins and Lapsley (1996) estimated the total tangible and intangible
social costs of drug abuse in Australia in 1992 was $AU18,845 million, of which tobacco
accounted for 67%. This represented a 26.5% increase from the 1988 figures. A recent
national review of the quantifiable drug-caused morbidity and mortality in Australia has revealed
that in 1992 hazardous and harmful alcohol use caused the loss of 3,660 lives and 55,450
person-years of life before 70 years at an average of 15.2 years of life lost per death. Among
active tobacco smokers the figures were 18, 920 deaths and 88, 266 person years of life lost at
an average of 4.7 years of life lost per death. Among illicit drug users for the same year there
were 488 deaths and 17,899 person-years lost at an average of 36.7 years of life lost per death
(English, Holman, Milne et al., 1995).
A number of epidemiological surveys of psychiatric morbidity have demonstrated that alcohol
abuse/dependence is the most common lifetime diagnosis, and most frequent co-morbid
diagnosis in the community. The 1992 National Comorbidity Survey in the United States of
America (US) gathered data on 8,098 15 to 54 year olds in the noninstitutionalised civilian
population using the Composite Diagnostic Interview (Kessler, McGonagle, Zhao et al., 1994).
They reported that 35.4 % of males and 17.9% of females had a lifetime diagnosis of any
substance abuse/dependence. The figures for a current 12 month diagnosis were 16.1% and
6.6% respectively. The next most common lifetime disorder was any affective disorder with a
prevalence of 14.7% for men and 23.9% for women. This study further examined treatment
seeking and reported that only 8.4% of the sample with one substance related diagnosis had
ever sought treatment at a substance abuse facility, with the figure rising to 14.8% for those
with three or more mental disorders.
The earlier US Epidemiologic Catchment Area study of 20, 291 community and institutional
population members further noted that among those with a mental disorder, the odds ratio of
having some substance use disorder was 2.7. That is, people with any mental disorder are
almost three times as likely to also have substance use disorder than those in the community
with no mental disorder. Further, for those with either an alcohol or a drug disorder, the odds of
having the other disorder were seven times greater than the rest of the population without either
an alcohol or a drug disorder. It therefore appears that having one substance use disorder
greatly increases the odds of having a co-morbid substance use disorder. Among those with an
alcohol disorder, 37% had a co-morbid mental disorder. The highest mental-substance use
disorder co-morbidity rate was found for those with drug (other than alcohol) disorders, among
whom more than half (53%) were found to have another mental disorder (Regier, Farmer, Rae
et al., 1990). Aspects of these finding have been replicated in a small South Australian study
(Clayer, McFarlane, Czechowicz and Wright, 1991) and in the 1986 Christchurch Psychiatric
Epidemiology Study (Wells, Bushnell, Hornblow et al., 1989).
The most frequent measure of the patterns of alcohol and other drug use in Australia is the
National Drug Strategy Household Survey. The 1995 survey of 3,850 personal interviews
revealed that 76% of the population aged 14 years or more are current drinkers, with just over
half of those drinking at least weekly (Commonwealth of Australia, 1996). According to National
Health and Medical Research Council guidelines 33% of women and 28% of men were
drinking at hazardous levels and 12% of women compared to 13% of men were drinking at
harmful levels in 1995. Overall males aged 14-24 years and females aged 20-24 years were
more likely to be drinking to excess than any other age group. Nearly half of all current drinkers
had deliberately attempted to reduce their alcohol consumption in the past year, with more than
a third of these doing so for health reasons (Commonwealth of Australia, 1996).
CHAPTER 2
A companion survey of 2,993 Aboriginal and Torres Strait Islander (ATSI) peoples living in
urban areas nationally, revealed that a smaller proportion of ATSI peoples drank alcohol (62%)
compared with the general population living in urban areas (72%). Among those ATSI peoples
who do drink, however, 68% usually consume harmful quantities of alcohol (Commonwealth of
Australia, 1994).
The 1995 National Drug Strategy Household Survey further reported that 39% of the population
aged more than 14 years had tried at least one illicit drug, and 17% had used one in the past 12
months. Cannabis accounted for the bulk of this group. Only 4% of the population had used
any illicit drug, apart from cannabis, in the previous twelve months (Commonwealth of
Australia). Illicit drug experimentation and use is more widespread among the urban ATSI
community than among the general urban community with 50% having tried at least one illicit
drug. The bulk of this was accounted for by cannabis with 48% having tried cannabis and 22%
being regular users, however six per cent were current users of at least one other illicit drug
(Commonwealth of Australia, 1994).
THE GENERAL PRACTITIONER AND SUBSTANCE USE DISORDERS
General practitioners are the first point of contact for people with a variety of mental health
problems, including substance abuse/dependence and disorders. Approximately 30% of
hospital admissions and up to 20% of patients presenting in primary care settings have alcohol
or other drug related problems (Williams, Burns and Morey, 1978; Burns, Hanratty, Reznik et
al., 1987). Authors such as Rush, Ellis, Crowe and Powell (1994) have made good arguments
for improved involvement of GPs in their patients’ alcohol and other drug use problems. These
include:

most adults visit a GP at least once a year, thus providing scope for opportunistic
interventions;

patients believe that GPs have legitimate reasons for asking about their lifestyle, such as
alcohol and other drug use (Sanson-Fisher, Webb & Reid, 1986; Swift, Copeland & Hall,
1996) ;

GPs are viewed as credible sources of information on such matters (Moore, Makkai &
McAllister 1989; Copeland, 1995);

the prevalence of substance use disorders in the population is high; and

low cost detection efforts and brief, effective interventions and other forms of assistance
are available.
While there is a great deal of scope for the involvement of GPs in managing their patients’
problematic alcohol and other drug use, evidence suggests that opportunities for such
intervention are not often taken up (Brown, Carter & Gordon, 1987; Clement, 1986; Deehan,
Taylor and Strang, 1997; Flaherty & Flaherty, 1983; Reid, Webb, Hennrikus et al., 1986;
Rowland, Maynard, Beveridge et al., 1987). Australian surveys of recent medical graduates
report that they possess barely adequate knowledge and skills in relation to the detection and
management of alcohol and other drug related problems (Roche, Parle, Saunders & Stubbs,
1993) and have little confidence in the efficacy of early and brief interventions (Roche, Parle,
Stubbs, Hall & Saunders, 1995).
5
A survey of 211 GPs on the Central Coast of New South Wales supports this view. It found
93% of respondents saw themselves as having a role in alcohol and other drug issues but
predominantly in detection and referral (Edwards, Roche, Gill et al., 1996). Only 28% of GPs
surveyed were willing to provide home detoxification and 19% were willing to provide
methadone maintenance with many citing the need for support and training in order to feel
confident in providing such interventions. Regarding knowledge and attitudes, while most GPs
felt confident in dealing with smoking issues, there were significant gaps in knowledge and
confidence concerning the management of illicit drug using patients with more than half of the
respondents reporting they were the most "difficult" group of patients to work with as they were
unmotivated to change. The survey further reported that GPs beliefs in the effectiveness of
interventions was not consistent with current best practice. Almost all believed that Alcoholics
Anonymous and residential rehabilitation were effective but only around one half believed
methadone was effective. Less than a quarter of GPs endorsed controlled drinking as an
effective intervention (Edwards et al., 1996).
It appears, therefore, that GPs see themselves as having a role in the detection and
management of their patient's substance use issues but demonstrate significant gaps in their
knowledge and confidence in general. This is particularly so with moving beyond assessment
and referral to the management of illicit drug use by their patients.
In addition to education and training issues, GPs such as MacQueen (1997) highlight more
practical barriers to undertaking alcohol and other drug work. He points out that there is little or
no accredited and remunerated training for GPs in substance use disorders. Further, the length
of consultation required for assessment, induction to methadone maintenance, and the
management of polydrug use or psychiatric co-morbidity makes it an extremely stressful and
an uneconomic undertaking for GPs. A final issue raised by MacQueen was the paucity of
clinically-orientated research and publication in the addiction field to assist the busy clinician to
readily incorporate best practice interventions.
Despite these concerns, a model of shared care between drug specialists and GPs in
Edinburgh has led to a great increase in the number of services available to this group with
70% of Edinburgh's GPs now prescribing for around 1200 drug users (Greenwood, 1996). This
model has led to a marked shift away from injecting drug use and towards oral pharmaceutical
drugs, with a drop in HIV rates among new referrals to shared care from 21% to 8%
(Greenwood, 1996).
MODELS OF SHARED CARE SUBSTANCE USE DISORDERS
From the available literature it is not possible to recommend a model of shared care for alcoholdependent patients that has a sound empirical basis as the issue is largely unresearched.
Reports such as the Joint Consultative Committee in Psychiatry's 1997 Primary Care
Psychiatry - The Last Frontier (RACGP) suggests a variety of models of shared care in mental
health that are worthy of consideration in the alcohol and other drugs field. These include:

attachment of a self-employed or publicly funded AOD specialist to one or more general
practices either sharing management responsibility for those patients or receiving referrals;

employment of an AOD specialist by a GP practice for one or more sessions providing a
specific service requested upon referral;

a shared base model of service where practitioners are co-located but may not collaborate
beyond referral;
CHAPTER 2

liaison and consultative models where there is a regularised link between GPs and AOD
specialists with the GP maintaining primary management responsibility with the specialist
serving as a consultant, supporter and educator;

other liaison models, such as, case conferencing to ensure a multidisciplinary approach
with group practice GPs, and models of improved liaison that focus on expediting referral
and discharge information;

and other models such as GP training to improve skills and confidence; reducing barriers
between specialist and generalist services and enhancing networking possibilities.
A general reference of relevance to communication issues highlighted in models of shared care
is that of Stoeckle, Ronan, Emanuel and Ehrlich (1997). This review discusses manners and
courtesies for the shared care of patients within and across health care agencies.
Regarding allied health professionals and GPs, Bray and Roger (1995) reported a pilot
demonstration project that linked psychologists and family physicians to improve the care of
patients with alcohol and other drug problems. Ten pairs of psychologists and family physicians
in rural Texas and Wyoming received training in establishing appropriate linkages.
Unfortunately, inadequate evaluation information was provided to adequately assess the
efficacy of that model.
In the United Kingdom there are models of shared care that have been developed by clinical
nurse specialists within community drug and alcohol services. These involve practice visits by
the specialist nurses to assist GPs to update their skills in substance use disorders and also in
dealing with occasionally chaotic, demanding and verbally agressive patients. The model
involves the development of a contract between the client, the GP and the community team
clearly specifying their roles and responsibilities (King, 1997). This model has not been formally
evaluated although GPs are reported to be participating and outcomes for some clients to have
improved.
The most promising model in the current climate would appear to be the liaison and
consultative model with the GP assessing and managing the bulk of patients with alcohol
related problems and then referring for joint management the alcohol dependent clients or
those with complicating physical, psychological or social factors. As Farrell and Gerada (1997)
point out, the frequently complex clinical and social needs of substance dependent patients and
the growing number of adolescents and those with problems related to drugs other than alcohol
and opiates means that specialist services have a critical training and management role. The
issues to be addressed by the literature include deciding how new patients are best matched
with service providers, the on-going management of long-term patients, and the integration of
health and social welfare needs of this patient group. The formalising of such a model and a
rigorous outcomes-based evaluation is urgently required to address the significant gaps in the
literature.
One of the principal barriers to maximising shared care of patients is GP/health system
communication. A European electronic data interchange has been developed to enable shared
care participants to intergrate medical records information (Branger, van't Hooft and van der
Wouden (1995)). The adaption and evaluation of such a system would be a valuable tool to
enhance communication between Australian GPs who almost all now use computer-based
record systems.
7
ASSESSMENT OF ALCOHOL AND OTHER DRUG-RELATED DISORDERS
It is clear that there are high levels of substance use-problems in the community and that
patients expect their medical practitioner to be involved in all aspects of health promotion and
disease prevention. This raises the vexed question of how best should GPs intervene. The
following literature review is based on clinical literature relevant to GP management of patients
with essentially uncomplicated substance use disorders. The literature highlights the
assessment, detoxification, brief intervention strategies and other management approaches
within major drug classes that GPs manage.
In general, assessment is a purposeful process with a number of functions. It enables the
clinician to gather information relevant to the selection of treatment goals and strategies; it
facilitates the development of rapport (provided the clinician is empathic and non-judgemental);
and provides an opportunity for personalised feedback on their substance use that will give
patients an opportunity to develop their own motivation to change (Mattick & Karvis, 1993). The
principal areas to be briefly canvassed below include: quantity, frequency, and chronicity of
current substance use pattern; presence of adverse physical, psychological and social
sequelae of substance use including dependence; motivation to change; history of previous
detoxifications, where relevant; and lifestyle and social factors conducive to or unfavourable to
making changes in their current patterns of substance use.
The assessment of motivation to change and lifestyle and social factors are similar across all
substances that GPs manage.
Motivation
A popular model for measuring motivation is the “stages of change model” provided by
Prochaska and DiClemente (1986). It includes a pre-contemplation stage or "happy users", a
contemplative or "ambivalent" stage, an action phase "ready to quit or cut down", maintenance
"enduring change", and relapse "old habits die hard". People rarely move through the stages in
a linear fashion. The kinds of questions that might be useful in assessing stage of change
include: "How interested are you in changing your drinking now?" and "what would you be
prepared to do to make solve this cannabis problem now?" and "how confident are you that you
can achieve this?" By contrast, the traditional view of motivation suggested that it was fixed and
immutable. Miller and Rollnick (1991) developed a technique known as motivational
interviewing to help patients explore and resolve their ambivalence about their behaviour. As
described by the authors, the key principles of motivational interviewing include:

regard patient's substance use as a personal choice;

let the patient decide how much of a problem they have and what needs to be done about
it;

avoid confrontation or labelling; and

encourage the patient to see the contrast between their own substance use and their
beliefs about alcohol and other drugs.
The relevant interviewing strategies are further discussed by Litt, Ali & White (1993):

express empathy;

ask open-ended questions;

listen reflectively;

ask about the good things and less good things about their substance use;

use affirmation by supporting patients positive statements regarding change;

elicit the patients concerns; and
CHAPTER 2

summarise and re-frame the patients' concerns.
Patients are more likely to change their behaviour when their alcohol and other drug use is
responsible for their presenting symptoms or other problems; they see the connection; they
believe that things will get better if they change; and they believe that they can change.
Social and Lifestyle Factors
While there are structured interviews that incorporate these issues that will be briefly mentioned
in the following substance specific sections, the domains of interest are the same with varying
degrees of emphasis depending on the legal status of the drug. These include:

vocational and financial status;

family background including family history of substance use, whether they are currently in a
supportive relationship and whether that person also has alcohol and other drug problems,
dependent children, and presence of domestic violence;

presence of additional problems such as childhood sexual abuse or recent sexual assault;
psychiatric co-morbidity;

legal problems;

blood-borne disease risk-taking behaviours; and

interests and hobbies to be built on.
9
CHAPTER
2
ALCOHOL ABUSE/DEPENDENCE
Thorley (1980) proposed a model which described alcohol related problems in three
overlapping areas: intoxication, regular use and dependence. Regular alcohol use is rarely
considered a clinical problem unless it exceeds the National Health and Medical Research
Council's Guidelines (Pols & Hawks, 1987). Intoxication has been defined as greater than 80g
for men and greater than 60g for women on a single drinking occasion. This level of alcohol
intake has variable manifestations across individuals, particularly where that person is alcohol
dependent. The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition
(American Psychiatric Association 1994) defines alcohol intoxication by the presence of
clinically significant maladaptive behavioural and psychological changes immediately following
ingestion of alcohol and accompanied by at least one of six objective signs such as unsteady
gait or nystagmus. Dependence should be suspected where patients are regularly drinking,
greater than 100g/day for men or greater than 80g/day for women.
Assessment
A recent Australian review by Dawe and Mattick (1997) provides an overview of relevant
screening tests for assessing alcohol abuse/dependence. These include, the Alcohol Use
Disorders Identification Test (Saunders, Aasland, Babor et al., 1993), the Comprehensive
Drinker Profile (Miller and Marlatt, 1984) and the Severity of Alcohol Dependence
Questionnaire (Stockwell, Sittharthan, McGrath et al., 1994). A medical assessment of a heavy
drinking patient should also include assessment of blood pressure, cholesterol levels and liver
function and, where suspected, referred for a formal assessment of alcohol-related brain injury.
Brief and Early Intervention
In general practice, most success will be achieved when the intervention is focussed on
patients who are having problems associated with intoxication and regular use rather than
dependence. As previously discussed when patient concern is linked with a GP's enquiry about
related factors such as alcohol use, their receptiveness to modify their behaviour is enhanced.
Contrary to the belief of some GPs, they can be effective change agents. Recent evidence has
demonstrated the effectiveness of GPs and other health professionals in reducing hazardous
alcohol consumption (see reviews such as Kahan, Wilson and Becker, 1995; and large scale
trials such as Project TrEAT by Fleming, Barry, Manwell et al., 1997). There are a number of
additional reasons why GPs should focus on early and brief interventions. These include:

they are more realistic, efficient and flexible in that they are consistent with the time
constraints of general practice, they are more cost-effective than alternative strategies
(Finney & Monahan, 1996), and enable more patients to be assisted;

most of the morbidity associated with alcohol use related to hazardous use is not alcohol
dependence and modifying drinking will resolve many of these conditions such as
heartburn, hypertension, diarrhoea and anxiety (Maheswaran, Beevers & Beevers, 1992);
and

brief interventions have been found to be acceptable to both physicians and patients,
especially if there is emphasis on a patient-centred, non-judgemental approach (Richmond
& Webster, 1985).
The successful components of a brief intervention by a GP with people with drinking problems
include (Kahan et al., 1995):
CHAPTER 2

screening for the presence of problem drinking using simple tools such as the question
"Have you ever felt you had a problem with alcohol?". Instruments such as the CAGE, that
was developed for use by primary physicians, are also very useful (Lawner, Doot, Gausas
et al., 1997; Samet, Rollnick & Barnes, 1996). As previously mentioned, the slightly longer
AUDIT is also a highly specific and sensitive instrument for the detection of current alcohol
problems in general practice (e.g. Tzelepis, 1994). Patients who demonstrate alcohol
dependence should be advised to abstain and offered referral to a more intensive
intervention;

informing patients on the safe levels of drinking and providing comparative feedback on
their reported consumption patterns compared with the community norms for their age and
gender;

reviewing the health effects of alcohol;

counselling the patient to set a goal such as abstinence or reduction to two drinks three
nights a week;

providing tips of cutting down such as delaying first drink, only one per hour, dilute with
mixer, sips slowly, and alternate with non-alcoholic spacer;

asking patients to keep a daily record of drinking related behaviour;

providing a pamphlet on health effects of alcohol and tips on cutting down; and

providing feedback of regular monitoring of blood pressure and liver function tests where
relevant.
Additional components of patient care might be to identify high risk situations for the patient and
work through a range of practical methods to cope and enlist any social support that they may
have to assist in the maintenance of behaviour change.
Detoxification
Australian guides to home detoxification are available such as Saunders, Ward and Novak
(1996) for an outline of appropriate monitoring and use of pharmacotherapy, and a general and
detoxification guide by Frank and Pead (1995). A brief review of detoxification has been
developed by Hall & Zador (1997). Finally, NSW health has in press detoxification guidelines.
It will be particularly helpful for GPs to assess symptoms of dependence when a patient who
has a history of sustained and heavy alcohol use wishes to abstain from alcohol. There are four
factors that predict the likely severity of the alcohol withdrawal syndrome. They are:

past history of withdrawal symptoms, particularly delirium tremens;

long history of regular heavy alcohol use, although there is not a linear relationship between
consumption levels and experience of withdrawal;

presence of concomitant physical or psychological illness, injury, pregnancy, or recent
surgery; and

use of other psychotropic drugs, particularly CNS depressants.
Provided none of these indicators are present the GP may chose to offer home detoxification.
Additional factors should be in place for a successful home detoxification. These include:

patient's agreement with the treatment;

no history of previously failed attempts at home detoxification;

appropriate home supervision in a physically and psychologically safe environment with no
other alcohol and other drug use. This supervision includes an awareness of the symptoms
11
that require medical attention, clear information on how to contact the GP and emergency
services; and

a commitment by the medical practitioner to be available to prescribe and monitor
pharmacotherapy.
Where patients are not appropriate for home detoxification they should be referred to alcohol
and other drug specialist services where shared care arrangements may be made for the GP
supervision of any ongoing pharmacotherapy and psychosocial support.
CHAPTER 3
CHAPTER
3
OPIOID ABUSE/DEPENDENCE
In 1995 opioid overdose deaths accounted for 8% of male and 5% of female deaths among
young adults between the ages of 15 and 44 years (Hall & Darke, 1997). The rate per 100,000
of the adult population aged 15 to 44 years dying from opioid overdose has significantly
increased from 1.07 in 1970 to 6.70 in 1995. Despite the recent media portrayal of the naive
user succumbing to a "bad" batch of heroin, the average age at death has increased from 24.2
years in 1979 to 30.1 years in 1995 (Hall & Darke, 1997). Zador, Sunjic & Darke (1996)
reported that 80% of heroin-related deaths in NSW during 1992 were classified as due to
dependence. While increased heroin purity and availability has played a role in the rising
mortality rate, the concomitant use of alcohol and benzodiazepines are highly significant factors
in fatal heroin overdose (Darke, Ross & Hall, 1996).
Assessment
The core principles of assessment as previously described alcohol dependence apply to the
assessment of a patient presenting with a history of opioid use. However, Edwards et al. (1996)
reported that GPs felt particularly pessimistic about their effectiveness with illicit drug users and
their knowledge of withdrawal syndromes was particularly weak.
Three standardised instruments that are particularly valuable in the formal assessment of
opiate dependence are the Severity of Opiate Dependence Scale (SODQ), The Severity of
Dependence Scale (SDS) and the Opiate Treatment Index (OTI), with each serving a different
purpose. The SODQ (Sutherland, Edwards, Taylor et al., 1986) is a 21 item assessment of
opiate dependence that does not yet have a defined cut-off point for dependence. The SDS
(Gossop, Darke, Griffiths et al., 1995) is an extremely useful clinical instrument comprising only
5 items, it can be used to assess dependence on a variety of illicit drugs and has been
standardised on Australian samples. A longer instrument that is designed to assess all relevant
aspects of an opiate users’ lifestyle is the OTI (Darke, Ward, Hall, et al., 1991). This examines
drug use, BBV risk-taking behaviour, social functioning, criminality, health status and
psychological functioning. It is ideal for GPs to assess patients at baseline and follow-up in
treatment outcome studies.
Detoxification and Abstinence Orientated Interventions
The opioid withdrawal syndrome is rarely life-threatening or associated with significant
disturbances of mental state, however, completion of withdrawal is difficult for most patients.
People with opiate dependence usually have a great deal of knowledge about their drug of
choice, but conversely there is a great deal of inaccurate street mythology regarding the
process of withdrawal. The onset of heroin withdrawal is between 8 and 12 hours following the
13
last dose, and 24 to 48 hours for methadone. The duration of physical heroin withdrawal is 5-7
days and 5 to 21 days for methadone.
Patients requesting supervised opiate withdrawal but reluctant to enter a specialist service
should have an accurate drug history taken by their GP. It is common for illicit opiate using
patients to have current poly drug dependence, particularly alcohol (49%) and cannabis (40%)
and to have significant psychiatric co-morbidity (Darke & Ross, 1997). Should the patient
demonstrate poly drug dependence they should be strongly advised by the GP to have an
inpatient detoxification.
In addition to careful history taking and clarification of motivation and social support for
detoxification, patients should also have a full medical examination, including hepatitis B & C,
HIV, and cardiovascular screening. Detoxification is not recommended during pregnancy with
methadone maintenance being the therapy of choice (Mattick & Hall,1993). The opiate
withdrawal syndrome can be monitored using a brief instrument such as the 10 item Short
Opiate Withdrawal Scale (Gossop, 1990). The critical feature in opiate withdrawal is supportive
care since psychological factors such as fear and anxiety play a major role in successful
withdrawal. The patient should have an appropriate environment that is relatively stress free. A
support person should be available to provide relief of physical symptoms (e.g. by using hot
packs and massage) and to take over the patient's everyday responsibilities for the withdrawal
period. Symptomatic pharmacotherapy for opioid withdrawal include anti-emetics, non-opiate
analgesics, anti-inflammatories, anti-diarrhoeals, and partial alpha andrenergic agonists.
Methadone or buprenorphine may also be used to assist withdrawal. Guides such as Frank
and Pead (1995) and Mattick and Hall (1993) provide guidelines for symptomatic
pharmacotherapies. GPs have a home detoxification guide available by Saunders, Ward and
Novak (1996) which includes opiate detoxification.
It should be understood that detoxification as a stand-alone process is not a treatment for
opiate dependence. Studies such as the Drug Abuse Reporting Program (DARP) found that
there was no discernible advantage in detoxification compared with no treatment (Sells,
Dwayne, Joe et al., 1976).
The Quality Assurance Project reviewing interventions for opioid dependence concluded that
drug free treatments have limited value for this group of patients (Mattick & Hall, 1993). They
concluded that outpatient drug free treatments are of doubtful value for the majority of people
with opiate dependence and that the therapeutic community approach is only effective for that
small group of patients who are attracted to such a long-term intervention (where a stay of at
least three months and preferably a year is necessary before significant rehabilitation is
observable). Further, there is no evidence that self-help groups or cognitive behavioural
interventions alone are an effective treatment for opiate dependent patients.
Replacement Pharmacotherapies
Methadone maintenance
Methadone maintenance is the best researched in a range of options to meet the needs of the
opiate dependent patient and is the only intervention that has been demonstrated to possess
clear effectiveness beyond no-treatment, drug-free treatment and placebo in randomised
controlled trials (Mattick & Hall, 1993). The benefits of methadone include:

cross-tolerance to other opioids;

longacting (24 hours);

prevents or reverses opioid withdrawal

high doses provide opioid blockade; and

it is administered orally.
CHAPTER 3
The indications for methadone include:

patients who exhibit evidence of recent opiate use or of withdrawal symptoms. People who
display evidence of opiate dependence and request entry to methadone should be assisted
to do so by their GP;

methadone may also be appropriate for some patients who use opiates who do not
demonstrate opiate dependence but who are at serious risk of infection with blood borne
viruses, pregnant women, have medical conditions requiring stabilisation, or are at serious
risk of relapsing to dependent use;

factors such as psychiatric co-morbidity and age should not be used as exclusion criteria
(consent from the court may be required for a patient under 16 years);

methadone is particularly suitable for patients who have not been successfully assisted by
drug free treatments.
The contraindications to methadone maintenance include:

patients unwilling to go onto a pharmacotherapy; and

patients with a very short and irregular history of opiate use should be encouraged to try
drug free treatments, as should patients with a primary alcohol dependence.
The 1997 National Policy on Methadone (Commonwealth of Australia, 1997) clearly states the
recommended procedures regarding the assessment and induction of patients onto
methadone maintenance, the guidelines for dosing and monitoring, management of special
client groups, and issues concerning initial and ongoing training of prescribers. Two further
recommended guides for methadone prescribers include the Methadone Prescribers' Manual
for General Practitioners (Gill, Pead & Mellor, 1992) and Key Issues in Methadone
Maintenance (with a new edition to be published shortly) by Ward, Mattick & Hall (1992).
Given the significant growth of methadone maintenance by GPs and community pharmacists it
is vital that there be adequate training in concert with process and outcome monitoring for this
expanding service sector.
Buprenorphine
This long acting mixed opioid agonist-antagonist is currently being trialed in Australia. This
pharmacology appears to make buprenorphine safer in overdose and less likely to be diverted
onto the illicit market. These factors appear to make it preferable to methadone, as it is also
easier to withdraw patients from buprenorphine and requires less frequent oral dosing. A
combination of buprenorphine and naloxone has also been recently introduced in New Zealand
to minimise misuse.
LAAM
Levomethadyl acetate is a synthetic opioid analgesic related to methadone. The major
advantage of LAAM over methadone is that it has a half-life of 92 hours compared with 24-36
hours for methadone. There is reasonable evidence to suggest that the efficacy of LAAM is at
least equivalent to methadone. LAAM has recently been approved for use by the USA Food
and Drug Administration and a trial is shortly to commence in Australia.
Naltrexone
This long acting (up to 72 hours) opioid antagonist has recently attracted significant media
attention. It blocks both the analgesic and euphoric effects of opiates, and has only minor side
15
effects. There is reasonable research evidence to support its efficacy when taken regularly but
patients have to be highly motivated, and preferably supervised to ensure that they take their
doses regularly for it to be a useful pharmacotherapy.
CHAPTER 4
CHAPTER
4
CANNABIS ABUSE/DEPENDENCE
Despite early research which concluded that cannabis was not a drug of dependence,
experimental, clinical and observational research on animals and studies of humans who
chronically use cannabis have since provided increasing evidence of its dependence potential
(Swift, Hall & Copeland, in press).
Cannabis is the most widely used illicit drug in Australia and other Western countries (Donnelly
and Hall, 1994). The prevalence of cannabis dependence/abuse has been estimated from a
number of large scale epidemiological studies. The recent US National Comorbidity Survey
reported cannabis abuse/dependence figures of 4.2% for the entire sample using DSM-3R
criteria, and 9.1% among those who had tried cannabis at least once. The results from this
survey ranked cannabis dependence as approximately as common as panic disorder and
generalised anxiety disorder (Kessler et al., 1994). The 1995 Australian National Household
Survey reports that 31% of the Australian population had ever tried marijuana, with 28% of 1419 year olds reporting current use. Such widespread use of cannabis may have important
public health implications for heavy, chronic users of the drug. This is especially so as
dependence is a problem not only in itself, but because it also increases the risk of adverse
health consequences (Hall, Solowij and Lemon, 1994).
There has been a significant rise in the demand for treatment for cannabis dependence in the
last few years, with some states in the US now reporting that more than half of their treatment
population are requesting assistance for cannabis dependence.
Brief Interventions
Despite the demand for services among people who use cannabis, there is little agreement
among service providers as to whether this group requires assistance, or what type of
intervention might be most appropriate. Approaches to intervention have been eclectic, ranging
from those based on smoking cessation, because of similarities in the context of use (Jones,
1984), to the 12 step (e.g., Narcotics Anonymous) approaches derived from current practices in
the alcohol area (Miller & Gold, 1989; Zweben & O'Connell, 1992). Controlled evaluations of
these interventions have been rare.
There have been only three controlled studies investigating the efficacy of interventions for
cannabis. The first was a small (n=22) clinical trial of aversion therapy and "self-management
counselling", which was used to reinforce the aversive stimuli (Smith, Schmeling and Knowles,
1988). The most extensive studies have been conducted by Stephens, Roffman and
colleagues, who have conducted two large randomised controlled trials of their interventions.
The first study investigated the efficacy of a brief cognitive behavioural intervention and a longer
social skills intervention (Stephens, Roffman & Simpson, 1993; 1994). Eighty eight percent of
the sample exhibited clinical levels of cannabis abuse. They found no difference between the
17
two interventions, while both groups reported a decrease in days of cannabis use and mean
number of cannabis related problems at twelve month follow-up compared with pre-treatment.
More recently, Stephens, Roffman, Cleaveland, Curtin and Wertz (1994) reported the results of
a randomised controlled trial with 291 people allocated to either a wait-list control condition, a
brief two session intervention based on motivational interviewing principles, or a more extensive
14 session relapse prevention intervention based on a cognitive-behavioural approach. Of the
same sample, 98% met DSM-3R criteria for cannabis dependence. There was no difference
between either treatment group at follow-up on any outcome index. This has important
implications if an effective brief intervention may be provided in place of a more intensive,
costlier intervention.
Adolescents
Given the high levels of cannabis use among young people, many GPs are approached by
concerned parents about the cannabis use of their adolescent children. While there has been
no research into this issue specifically, two separate bodies of literature contain suggestions for
an appropriate approach. The first concerns interventions with one or more members of the
target person's social network in order to facilitate his or her entry into treatment. The second
includes research on the efficacy of brief interventions specifically tailored to engage with, and
facilitate increased readiness for change in, untreated alcohol dependent persons or substance
dependent individuals.
Szapocznik and colleagues (1988) developed an effective intervention, Strategic
Structural-Systems Engagement, delivered by telephone to a family member of adolescent
substance abusers. These researchers reported that 93% of targeted adolescents agreed to
come in to a clinic with their families for an intake meeting. More recently, Garrett and
colleagues (1997) reported on the effectiveness of the Albany-Rochester Interventional
Sequence for Engagement (ARISE), a three-stage graduated continuum of strategies derived
from family and systems theory. Their first stage involves telephone coaching with the
concerned person, where the therapeutic intention is to turn the caller's concern into motivation
and skill to intervene. The efficacy data from these and related approaches converge to offer
promise for reaching and facilitating treatment entry of targeted individuals through
interventions with one or more family members, friends, or other social network members.
An approach using engagement and motivation enhancement techniques appears to be
particularly appropriate to adolescents, who are at relatively early stages of cannabis
use/abuse, and usually do not perceive a need for change. The perception among young
people of their cannabis use is frequently at odds with that of their families, carers, or friends. It
may be most appropriate for the GP to assist the parent to talk to the young person in an
unemotional way about their attitudes to and experiences with cannabis and provide them with
factual information regarding the harms associated with cannabis use. This approach uses the
carer's concern to draw the young person into identifying any concerns they may have
regarding their cannabis use and moving them towards making changes in that use. It may
also alleviate the parent's concern that experimentation with cannabis use is a major threat to
the well-being of their child.
CHAPTER 5
CHAPTER
5
HYPNO-SEDATIVE ABUSE/DEPENDENCE
The benzodiazepines are among the most widely used prescription medications. They have
largely replaced the barbiturates because they: (1) are more effective in alleviating anxiety and
stress responses; (2) have fewer and less severe side effects; (3) are much safer in overdose;
(4) are less liver toxic and do not interact as seriously with other drugs; and (5) are believed to
be less liable to induce dependence (Lader, 1983).
An estimated 9.2 million benzodiazepine prescriptions were dispensed in Australian retail
pharmacies in 1991 (Mant, Whicker, McManus et al., 1992). Despite this figure, there has been
a reduction in the proportion of patients receiving a prescription for a psychotropic drug since
the 1970s - with anxiolytic and hypnotic agents having a rate of 4.4% (Bridges-Webb, Britt,
Miles et al., 1992). The 1995 National Drug Strategy Household Survey, however, reported that
only 3% of that sample had tried tranquillisers for non-medical purposes and 0.6% had used
them in this way in the last twelve months (Commonwealth of Australia, 1996).
Interventions with General Practitioners
A controlled trial of educational visiting to improve GP benzodiazepine prescribing has been
conducted in Australia (de Burgh, Mant, Mattick et al., 1995). An approximately representative
sample of 286 GPs was allocated to an intervention or control group and rates of
benzodiazepine prescriptions were derived from two comprehensive self-report surveys seven
months apart. Two months following the first survey the intervention group received an
educational visit and supporting material from a doctor or pharmacist, ostensibly unconnected
to the previous survey. The overall benzodiazepine prescribing rate fell by 23.7 per cent from
the first to the second survey. Anxiety and insomnia diagnosis rates also declined from 4.7 to
3.8 per 100 encounters. A linear regression model that focused on initial prescriptions for new
insomnia diagnoses showed a statistically significant treatment effect after controlled for
relevant confounding variables and clustering effects, but this was not found for new anxiety
diagnoses. The authors conclude that while academic detailing or practice visiting enjoy
positive outcomes, they are resource intensive and they suggest that such interventions be
targeted carefully. Drugs such as the benzodiazepines, where there is public and professional
pressure to reduce prescribing, self-monitoring alone may be sufficient to improve prescribing
practices of GPs (Burgh, Mant, Mattick et al., 1995).
Benzodiazepine Dependence
Since the 1980s it has been recognised that there exists a benzodiazepine (BZD) withdrawal
and dependence syndrome even within therapeutic dose ranges (Lader, 1983; Tyer, Owen &
Dawling, 1983). Further side effects include amnesia and other cognitive impairments,
disinhibition, psychomotor impairment, overdose and polydrug abuse (de Burgh, Mant, Mattick
et al., 1995). A recent Australian study of 31,256 patients in general practice found that
19
receiving a benzodiazepine prescription was associated with presenting with insomnia (unlike
anxiety which was more likely to be managed without pharmacotherapy), being female, being
older, being an established patient of a practice, and attending a GP working in a busy innercity practice (Mant, Mattick, de Burgh et al., 1995). A similar Spanish study of 68 general
practices reported that, in general, GPs had accurate knowledge regarding the therapeutic
indications for BZDs, but that they were less aware of the withdrawal and dependence issues
(Boixet, Battle & Bolibar, 1996). Using external validity checks on the self-reported BZD
prescribing rates, the authors found GPs underestimated their prescribing rates by more than
50%. Boixet and colleagues (1996) called for more accurate information on BZDs be provided
to GPs and that alternatives to their prescription should be emphasised in medical education.
A brief (30 item) scale called the Benzodiazepine Dependence Questionnaire (BDEPQ) has
been developed in Australia (Baillie & Mattick, 1996). This scale has three subscales: general
dependence, pleasant effects of BZD, and perceived needs. These provide more clinically
relevant information that the purely physical dependence symptoms measured in previous
scales (e.g. Tyrer, Murphy & Riley, 1990).
Management of Benzodiazepine Withdrawal
The abstinence syndrome after benzodiazepine use is variable in nature, severity and duration.
In rare cases, discontinuation can lead to full tonic-clonic seizures and even death (Miller &
Greenblatt, 1996). Much more commonly, a true withdrawal reaction is characterised by such
symptoms as sensitivity to light and sound, headaches, palpitations, diaphoresis and dysphoria.
The correlation between BZD dose and duration of use to the incidence and severity of BZD
withdrawal remains to be precisely quantified. A review of the controlled studies of long-term
therapeutic doses of BZD indicated that nearly 50% of patients ingesting a BZD for an average
of three years will experience a minor withdrawal syndrome upon BZD discontinuation.
Following discontinuation of the short and long acting BZDs, minor withdrawal reactions usually
begin within one and five days respectively. Symptoms gradually disappear over two to four
weeks. The rate of severe withdrawal symptoms in this group is 2 to 5%. Studies of high dose
BZD use indicate a significant risk of severe withdrawal reactions upon abrupt discontinuation
of BZD (Alexander & Perry, 1991).
There are a number of guides to the management of benzodiazepine withdrawal:

Alexander, B. & Perry, P.J. (1991). Detoxification from benzodiazepines: schedules and
strategies. Journal of Substance Abuse Treatment, 8(1/2), 9-17.

Commonwealth of Australia. (1991). Guidelines for the Prevention and Management of
Benzodiazepine Dependence. Australian Government Publishing Service: Canberra.

Devenyi, P. & Saunders, S.J. (1986). Physicians' Handbook for Medical Management of
Alcohol and Drug-Related Problems. Addiction Research Foundation and Ontario Medical
Association: Toronto.
The specific principles of such management include taking a careful history from the patient to:

assess the underlying psychological disorder for which the BZD was being taken;

ascertain any polydrug abuse/dependencies. BZD misuse is frequently a complicating
factor of other drug withdrawal and vice versa. Such patients do not appear to do any
differently to other detoxifying patients. If a person is detoxifying from both alcohol and
BZD, maintain the BZD dose through the alcohol detoxification first and then commence
BZD tapering;

estimate the duration and dosage of BZD. If the patient has been taking short-acting BZD
then he or she will need to be converted to an equivalent dose of a long-acting BZD and

ascertain a history of previous severe BZD withdrawal symptoms, dosage >100mgs/day of
diazepam equivalent or a history of epilepsy. Where any of these are present the patient
CHAPTER 5
will require a tapering regime as described in the references above in addition to Harrison,
Busto, Naranjo et al., (1984). In tapering regimes psychological withdrawal symptoms tend
to peak in the range of 25% of the initial dose and physical symptoms at 12.5-25%.
Over the course of the withdrawal it is essential that patients receive supportive and empathic
care and are frequently monitored and reassured. Where anxiety and hyperadrenergic
symptoms predominate in the withdrawal, beta adrenergic blocking agents such as propanolol
40 to 160 mgs per day may be effective additions to the treatment if they are not, otherwise,
contraindicated (Devenyi & Saunders, 1986).
Benzodiazapine use among IDU
A significant sub-group of benzodiazepine-seeking patients that requires particular attention are
injecting drug using (IDU) patients. Recent research has reported that the use of
benzodiazepines among IDU is a major clinical problem, being linked to a higher risk of HIV
infection, psychopathology, poorer health and social functioning, and a greater risk of heroin
overdose than other injecting drug users (Darke, Hall, Ross et al., 1992; Darke, Swift, Hall et
al., 1994). International and Australian research has demonstrated a preference for
flunitrazepam, diazepam and temazepam among these groups and a meaningful difference in
their likelihood of being injected. It is recommended, therefore, these particular
benzodiazepines should be prescribed with great caution to this group (Darke, Ross & Hall,
1995; Navaratnum & Foong, 1990). Australian research has also reported the lowest
preference for nitrazepam and a small likelihood of nitrazepam injection among IDU, and
recommend its prescription if benzodiazepines are unavoidable among this group (Darke, Ross
& Hall, 1995).
21
CHAPTER
6
CONCLUSION
The prevalence of alcohol and other drug abuse/dependence disorders, and the high levels of
hazardous substance use in the community, coupled with the low levels of specialist helpseeking by this group highlight the urgent need for improved skills and confidence among
general medical practitioners to detect and intervene with at-risk patients.
In addition to improved training and professional and personal support for GPs to work with
patients suffering alcohol and other drug related problems, there is an urgent need to develop
and evaluate models of shared care between general medical practitioners and a variety of
specialist agencies.
While much lip service is paid to the importance of evaluation, it is frequently glossed over or ill
conceived in the provision of funding for health services generally and related research, in
particular. As previously discussed there are a number of professional and institutional barriers
to the successful shared care of alcohol and other drug affected patients between general
medical practitioners and specialist alcohol and other drug practitioners. Recent studies have
examined referral patterns for mental health problems by GPs and have highlighted the belief
among this group that the only condition best referred to a non-professional counsellor was
alcohol and substance abuse problems (Ogden and Pinder, 1997). This underlying belief that
professionals have little to offer substance dependent patients is consistent with the reports of
poor diagnostic accuracy of the syndrome among GPs (Fitzpatrick, Meaney and Casey (1997)
and their poor understanding of the extant research literature on best practice (Roche, Parle,
Saunders et al., 1993).
There is clearly a great deal of work to be done in the areas of GP training and the
development and evaluation of shared care models in the addictions field. General practitioner
training has been demonstrated to have a positive impact on diagnostic accuracy (Mehler,
McClellan, Lezotte et al., 1995). A well-developed international medical education model for
prevention and treatment of alcohol-related problems has been developed by Murray and
Fleming (1996). This trainer-development approach has two main components. The first is a
curriculum made up of 19 teaching modules - each containing learning objectives, an
educational plan, participant handouts, exercises, slides and a bibliography. Core
competencies are identified and the content areas include the latest research on epidemiology,
screening, assessment, brief intervention techniques, adverse health effects of alcohol use,
emerging pharmacotherapies and medical detoxification. The second component of the model
is an intensive five-day course for medical school faculty that uses interactive teaching
strategies, including learner-centred teaching, competency-based teaching, facilitator-team role
modelling, group interaction, role plays, videotapes and case studies. The evaluation of the
model includes pre- and six-month post-course questionnaires and interviews concerning
content knowledge and the educational experiences of the participants. In addition to their selfperceived interest and competencies in a range of clinical areas related to alcohol
abuse/dependence were assessed. While this model appears to be useful, the weak
evaluation component makes it difficult to assess the value of the technique for Australian
undergraduate and postgraduate medical training.
CHAPTER 6
The development of such models linked with evaluation would make a significant contribution
to the reduction of alcohol and other drug related harms among the community. These issues
are further discussed along with the core models of shared care programs, in a handbook for
Divisions on currently accepted practice, “From Projects to Programs Sharing Mental Health
Care Vol 2 The Management of Alcohol and Other Drug Disorders” (Copeland and PenroseWall 1998) produced by the Integration Support and Evaluation Resource Unit.
23
REFERENCES
Alexander, B. & Perry, P.J. (1991). Detoxification from benzodiazepines: schedules and
strategies. Journal of Substance Abuse Treatment, 8, 9-17.
American Psychiatric Association. (1994). The Diagnostic and Statistical Manual of mental
Disorders Fourth Edition. American Psychiatric Association: Washington, DC.
Baillie, A.J. & Mattick, R.P. (1996). The Benzodiazepine Dependence Questionnaire:
development, reliability and validity. British Journal of Psychiatry, 169, 276-281.
Boixet, M., Batlle, E., & Bolibar, I. (1996). Benzodiazepines in primary health care:a survey of
general practitioner prescribing patterns. Addiction, 91, 549-556.
Branger, P., van't Hooft, A., & van der Wouden, H.C. (1995). Coordinating shared care using
electronic data interchange. Medinfo, 8, 1669.
Bray, J.H. & Rogers, J.C. (1995). Linking psychologists and family physicians for collaborative
practice. Professional Psychology, Research and Practice, 26(2), 132-138.
Bridges-Webb, , C., Britt, H., Miles, D.A., Neary, S., Charles, C., & Traynor, V. (1992). Morbidity
and treatment in general practice in Australia 1990-1991. Medical Journal of Australia,
157(Supplement), S1-S56.
Brown, R.L., Carter, W.B. & Gordon, M.J. (1987). Diagnosis of alcoholism in a simulated
patient encounter by primary care physicians. Journal of Family Practice, 25, 259-264.
Burns, F.H., Hanratty, S.J., Reznik, R. & Saunders, J.B. (1987). Prevalence of "at risk" drinkers
presenting at general medical settings. Proceedings of the 9th International IFNGO, Hong
Kong.
Clayer, J.R., McFarlane, A.C., Czechowicz, A.S., & Wright, W. (1991). Mental Health in the
Riverland: A Report of the Findings of the 1991 "Prevalence of Mental Illness, Associated
Disability and Needs in the Riverland Study. Mental Health Research and Evaluation Centre,
South Australian Health Commission: Adelaide.
Clement, S. (1986). The identification of alcohol-related problems by general practitioners.
British Journal of Addiction, 81, 257-264.
Collins, D.J. & Lapsley, H.M. (1996). The Social Costs of Drug Abuse in Australia in 1988 and
1992. National Campaign Against Drug Abuse Monograph Series No. 30. Australian
Government Publishing Service: Canberra.
Copeland, J. (1995). A Qualitative Study of Self-Managed Change in Substance Dependence
Among Women. National Drug and Alcohol Research Centre Technical Report 24.
Commonwealth Department of Human Services and Health (1995). Review of Methadone
Treatments in Australia. Final Report. Coopers and Lybrand Health and Community Services
Division: Sydney.
Commonwealth of Australia (1991). Guidelines for the Prevention and Management of
Benzodiazepine Dependence. Australian Government Publishing Service: Canberra.
REFERENCES
Commonwealth of Australia (1994). National Drug Strategy Household Survey. Urban
Aboriginal and Torres Strait Islander Supplement. Australian Government Publishing Service:
Canberra.
Commonwealth of Australia (1994a). Better Health Outcomes for Australians: National Health
Goals, Targets and Strategies for Better Health Outcomes into the Next Century. Australian
Government Publishing Service: Canberra.
Commonwealth of Australia (1996). National Drug Strategy Household Survey. Survey Report
1995. Australian Government Publishing Service: Canberra.
Commonwealth of Australia (1996a). National Alcohol Action Plan 1995-1997. Australian
Government Publishing Service: Canberra.
Commonwealth of Australia (1997). National Policy on Methadone Treatment. Australian
Government Publishing Service: Canberra.
Coyle, D., Godfrey, C., Hardmann, G., & Raistruck, D. (1994). Costing Substance Misuse
Services. YARTIC Occasional Paper 5. Centre for Health Economics, University of York:
Heslington.
Darke, S. (1992). The measurement of outcome in opiate treatment evaluation studies. Drug
and Alcohol Review, 11, 169-174.
Darke, S., Hall, W., Ross, M.W. & Wodak, A. (1992). Benzodiazepine use and HIV risk-taking
behaviour among injecting drug users. Drug and Alcohol Dependence, 31, 31-36.
Darke, S. & Ross, J. (1997). Polydrug dependence and psychiatric comorbidity among heroin
injectors. Drug and Alcohol Dependence, 48, 135-141.
Darke, S., Ross, J., & Hall, W. (1995). Benzodiazepine use among injecting heroin users. The
Medical Journal of Australia, 162, 645-647.
Darke, S., Ross, J., & Hall, W. (1996). Overdose among heroin user in Sydney, Australia: I.
Prevalence and correlates of non-fatal overdose. Addiction, 91, 405-411.
Darke, S., Swift, W., Hall, W., & Ross, M.W. (1994). HIV risk-taking and psychosocial
correlates of benzodiazepine use among methadone maintenance clients . Drug and Alcohol
Dependence, 34, 67-70.
Darke, S., Ward, J., Hall, W., Heather, N., & Wodak, A. (1991). The Opiate Treatment Index
(OTI) Manual. Technical Report Number 11. National Drug and Alcohol Research Centre:
Sydney.
Dawe, S. & Mattick, R.P. (1997). Review of Diagnostic Screening Instruments for Alcohol and
Other Drug Use and Other Psychiatric Disorders. Australian Government Publishing Service:
Canberra.
de Burgh, S., Mant, A., Mattick, R.P., Donnelly, N., Hall, W., & Bridges-Webb, C. (1995). A
controlled trial of educational visiting to improve benzodiazepine prescribing in general practice.
Australian Journal of Public Health, 19, 142-148.
25
Deehan, A., Taylor, C., & Strang, J. (1997). The general practitioner, the drug misuser, and the
alcohol misuser: major differences in general practitioner activity, therapeutic commitment, and
"shared care" proposals. British Journal of General Practice, 47, 705-709.
Devenyi, P. & Saunders, S.J. (1986). Physicians' Handbook for Medical Management of
Alcohol and Drug-Related Problems. Addiction Research Foundation and Ontario Medical
Association: Toronto.
Dixon, B.R. & Bouma, G.D. (1984). The Research Process. Oxford University Press:
Melbourne.
Donnelly, N. & Hall, W. (1994) Patterns of cannabis use in Australia. NCADA Monograph
No27. Australian Government Publishing Service: Canberra.
Edwards, C., Roche, A., Gill, A., Polkinghorne, H., Evershed, K. & Mant, A. (1996). General
Practitioner Drug and Alcohol Needs Assessment. Central Coast Health Service: Gosford.
English, D.R., Holman, C.D.J., Milne, E., Winter, M.G., Hulse, G.K., Codde, J.P., Bower, C.I.,
Corti, B., de Klerke, N., Knuiman, M.W., Kurinczuk, J.J., Lewin, G.F., & Ryan , G.A. (1995). The
Quantification of Drug Caused Morbidity and Mortality in Australia. Commonwealth Department
of Human Services and Health. Australian Government Publishing Service: Canberra.
Farrel, M. & Gerada, C. (1997). Drug misuers: whose business is it? British Medical Journal,
315, 559-560.
Finney, J.W. & Monahan, S.C. (1996). The cost-effectiveness of treatment for alcohol: a
second approximation. Journal of Studies on Alcohol, 57, 229-243.
Fitzpatrick, D.G., Meaney, A.M., & Casey, P.R. (1997). Diagnostic accuracy of psychiatric
disorders in primary care. Primary Care Psychiatry, 3, 95-99.
Flaherty, J.A. & Flaherty, E.G. (1983). Medical students' performance in reporting alcohol
related problems. Journal of Studies on Alcohol, 44, 1083-1087.
Fleming, M.F., Barry, K.L., Manwell, L.B., Johnson, K., & London, R. (1997). Brief physician
advice for problem alcohol drinkers. A randomized controlled trial in community-based primary
care practices. Journal of the American Medical Association, 277, 1039-1045.
Frank, L. & Pead, J. (1995). New Concepts in Drug Withdrawal: A Resource Handbook. The
University of Melbourne: Melbourne.
Gossop, M. (1990). The development of a short opiate withdrawal scale (SOWS). Addictive
Behaviors, 15, 487-490.
Gossop, M., Darke, S., Griffiths, P., Hando, J., Powis, B., Hall, W., & Strang, J. (1995). The
Severity of Dependence Scale (SDS): psychometric properties of the SDS in English and
Australian samples of heroin, cocaine and amphetamine users. Addiction, 90, 607-614.
Greenwood, J. (1996). Six years experience of sharing the care of Edinburgh's drug users.
Psychiatric Bulletin, 20, 8-11.
Hall, H., & Shiell, A. (1993). Health Outcomes: A Health Economics Perspective. Centre for
Health Economics Research and Evaluation Discussion Paper Series No. 19. Centre for Health
Economics Research and Evaluation, Westmead Hospital, University of Sydney: Sydney.
Hall, W. & Zador, D. (1997). The alcohol withdrawal syndrome. Lancet, 349, 1897-1900.
REFERENCES
Hall, W., Solowij, N. & Lemon, J. (1994) The health and psychological consequences of
marijuana use. NCADA Monograph No. 25. Australian Government Publishing Service:
Canberra.
Harrison, M., Busto, U., Naranjo, C. A., Kaplan, H.L., & Sellers, E.M. (1984). Diazepam tapering
in detoxification for high-dose benzodiazepine abuse. Clinical Pharmacology and Therapeutics,
36, 527-533.
Hawe, P., Degeling, D., & Hall, J. (1992). Evaluating Health Promotion. Maclennan and Petty:
Sydney.
Joint Consultative Committee in Psychiatry (1997). Primary Care Psychiatry - The Last Frontier.
A National Mental Health Strategy Project. A Draft Report for Discussion. Royal Australian
College of General Practitioners: Sydney.
Kahan, M., Wilson, L., & Becker, L. (1995). Effectiveness of physician-based interventions with
problem drinkers: a review. Canadian Medical Association Journal, 152, 851-859.
Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen
H-U., & Kendler, K.S. (1994). Lifetime and 12-month prevalence of DSM-IIIR psychiatric
disorders in the United States. Archives of General Psychiatry, 51, 8-19.
King, L. (1997). Structured GP liaison for substance misuse. Nursing Times, 93, 30-31.
Lader, M. (1983). Dependence on Benzodiazepines. Journal of Clinical Psychiatry, 44, 121127.
Lawner, K., Doot, M., Gausas, J., Doot, J., & See, C. (1997). Implementation of CAGE alcohol
screening in a primary care practice. Family Physician, 29(5), 332-335.
Litt, J.C.B., Ali, R., & White, J. (1993). Dealing With Alcohol Problems in General Practice.
Flinders University Press: Adelaide.
Lockyer, J., El-Guebaly, N., Simpson, E., Gromoff, B. et al., (1996). Standardized patients as a
measure of change in the ability of family physicians to detect and manage alcohol abuse.
Academic Medicine, 71(Supp 1), S1-S3.
MacQueen, A.R. (1997). Why general practitioners might avoid drug and alcohol work. Drug
and Alcohol Review, 16(4), 429-431.
Maheswaran, R., Beevers, M., & Beevers, D.G. (1992). Effectiveness of advice to reduce
alcohol consumption in hypertensive patients. Hypertension, 19, 79-84.
Mant, A., Mattick, R.P., de Burgh, S., Donnelly, N., & Hall, W. (1995). Benzodiazepine
prescribing in general practice: dispelling some myths. Family Practice, 12, 37-43.
Mant, A., Whicker, S.D., McManus, P., Birkett, D.J., Edmonds, D., & Drummond, D. (1993).
Benzodiazepine utilisation in Australia:report from a new pharmacological database. Australian
Journal of Public Health, 17, 345-349.
Mattick, R.P. & Hall, W. (Eds.) (1993). A Treatment Outline for the Approaches to Opioid
Dependence: Quality Assurance Project. National Drug Strategy Monograph Series No. 21.
Australian Government Publishing Service: Canberra.
27
Mattick, R.P. & Karvis, T.J. (Eds.) (1993). An Outline for the Management of Alcohol Problems:
Quality Assurance Project. National Drug Strategy Monograph Series No. 20. Australian
Government Publishing Service: Canberra.
Mehler, P.S., McClellan, M.D., Lezotte, D., Casper, E., & Gabow, P.A. (1995). Improving
identification of and intervention for alcoholism. Western Journal of Medicine, 163, 335-340.
Miller, L.G. & Greenblatt, D.J. (1996). Benzodiazepine discontinuation syndromes. In C.R.
Schuster and M.J. Kuhar (Eds.) Pharmacological Aspects of Drug Dependence: Toward an
Integrated Neurobehavioral Approach. Springer-Verlag: Berlin.
Miller, W.R. & Marlatt, A. (1984). Manual for the Comprehensive Drinker Profile, Brief Drinker
Profile and Follow-up Drinker Profile. Psychological Assessment Resources Inc: Florida.
Miller, W.R. & Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change
Addictive Behavior. Guilford Press: New York.
Moore, R., Makkai, T., & McAllister, I. (1989). Perceptions and Patterns of Drug Use. National
Campaiagn Against Drug Abuse: Canberra.
Murray, M. & Fleming, M. (1996). Prevention and treatment of alcohol-related problems: an
international medical education model. Academic Medicine, 71, 1204-1210.
Navaratnum, V. & Foong, K. (1990). Opiate dependence - the role of benzodiazepines. Current
Medical Research Opinion, 11, 620-630.
Ogden, J. & Pinder, K. (1997). Mental health referral a matter for consensual guidelines.
Primary Care Psychiatry, 3, 31-36.
Pols,R. & Hawks, D. (1987). Is There a Safe Level of Drinking for Men and Women?
Recommendations regarding drinking. Australian Government Publishing Service: Canberra.
Prochaska, J.O. & DiClemente, C.C. (1986). Towards a comprehensive model of change. In
W.R. Miller & N. Heather (eds.), Treating Addictive Behaviors: Processes of Change, 3-27.
Plenum Press: New York.
Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z., Keith, S.J., Judd, L.L., & Goodwin, F.K.
(1990). Comorbidity of mental disorders with alcohol and other drug abuse. Journal of The
American Medical Association, 264, 2511-2518.
Reid, A.L.A., Webb, G.R., Hennrikus, D., Fahey, P.P. & Sanson-Fisher, R.W. (1986). Detection
of patients with high alcohol intakes by general practitioners. British Medical Journal, 293, 735737.
Richmond, R. & Webster, I.W. (1985). A smoking cessation program for use in general
practice. Medical Journal of Australia, 142, 190-194.
Roche, A.M., Parle, M.D., Saunders, J.B. & Stubbs, J.M. (1993). Drug and Alcohol Related
Knowledge and Attitudes of Family Medicine Programme Trainees. A report prepared for the
Royal Australian College of General Practitioners: Sydney.
Roche, A.M., Parle, M.D., Stubbs, J.M., Hall, W. & Saunders, J.B. (1995). Management and
treatment efficacy of drug and alcohol problems: What do doctors believe? Addiction, 90, 13571366.
REFERENCES
Rowland, N., Maynard, A., Beveridge, A., Kennedy, P., & Wintersgill, W. (1987). Doctors have
no time for alcohol screening. British Medical Journal, 295, 95-96.
Rush, B., Ellis, K., Crowe, T.G., & Powell, L.Y. (1994). How general practitioners view drug use.
Clearing up the confusion. Canadian Family Physician, 40, 1570-1579.
Samet, J.H., Rollnick, S., & Barnes, H. (1996). Beyond CAGE: a brief clinical approach after
detection of substance use. Archives of Internal Medicine, 156, 2287-2293.
Sanson-Fisher, R.W., Webb, G.R., & Reid, A.L.A. (1986). The role of the medical practitioner
as an agent for disease prevention. Better Health Commission: Looking to Better Health, 3,
201-212.
Sansone, J. (1994). Health Outcomes: The Current Focus. Australian Health Outcomes
Clearing House, Australian Institute of Health and Welfare: Canberra.
Saunders, J.B., Aasland, O.G., Babor, T.F., de le Fuente, J.R. & Grant, M., (1993).
Development of the Alcohol Use Disorders Identification Test (AUDIT). WHO collaborative
project on early detection of persons harmful alcohol consumption - II, Addiction, 88, 791-804.
Saunders, J.B., Ward, H., & Novak, H. (1996). Guide to Home Detoxification. Central Sydney
Area Health Service: Camperdown.
Sells, S.B., Dwayne, D., Joe, G.W., Demaree, R.G., Savage, L.J., & Lloyd, M.R. (1976). A
national follow-up study to evaluate the effectiveness of drug abuse treatment. A report of
cohort 1 of the DARP 5 years later. American Journal of Drug and Alcohol Abuse, 3, 407-411.
Single, E. & Rohl, T. (1997). The National Drug Strategy: Mapping The Future. A report
commissioned by the Ministerial Council on Drug Strategy: Canberra.
Stockwell, T., Sittharthan, T., McGrath, D., & Lang, E. (1994). The measurement of alcohol
dependence and impaired control in community samples. Addiction, 89, 167-174.
Stoeckle, J.D., Ronan, L.J., Emanuel. L.L. & Ehrlich, C.M. (1997). A manual of manners and
courtesies for the shared care of patients. The Journal of Clinical Ethics, 8(1), 22-33.
Sutherland, G., Edwards, G., Taylor, C., Phillips, G., Gossop, M., Brady, R. (1986). The
measurement of opiate dependence. British Journal of Addiction, 81, 479-484.
Swift, W., Copeland, J., & Hall, W. (1995). Characteristics and Treatment Needs of Women
with Alcohol and Other Drug Problems:Results of an Australian National Survey. National Drug
Strategy Research Report Series, Report no. 7. Australian Government Printing Service:
Canberra.
Swift, W., Hall, W., & Copeland, J. (in press). Patterns and correlates of cannabis dependence
among long-term users in Sydney, Australia. Psychology of Addictive Behaviours.
Thorley, A. (1980). Medical responses to problem drinking. Medicine 3rd series, 35, 1816-1822.
Tyer, P., Owen, R., & Dawling, S. (1983). Gradual withdrawal of diazepam after long-term
therapy. Lancet, 1402-1406.
29
Tyrer, P., Murphy, S., & Riley, P. (1990). The Benzodiazepine Withdrawal Symptom
Questionnaire. Journal of Affective Disorders, 19, 53-61.
Tzelepis, A. (1994). Screening with the Alcohol Use Disorders Identification Test (AUDIT) in an
inner city population. Journal of General Internal Medicine, 9(10), 550-553.
Wells, J.E., Bushnell, J.A., Hornblow, A.R., Joyce, P.R., & Oakley-Browne, M.A. (1989).
Christchurch Psychiatric Epidemiology Study, Part 1: Methodology and lifetime prevalence for
specific psychiatric disorders. Australian and New Zealand Journal of Psychiatry, 23, 315-326.
Wesson, D.R. (1995). Detoxification from Alcohol and Other Drugs. US Department of Health
and Human Services: Rockville.
Williams, A.T., Burns, F.H., & Morey, S. (1978). Prevalence of alcoholism in a Sydney teaching
hospital. Medical Journal of Australia, 156, 43-48.
World Health Organisation (1993). Assessing the Standards of Care in Substance Abuse
Treatment. WHO: Geneva.
Zador, D., Sunjic, S., & Darke, S. (1996). Heroin-related deaths in New South Wales, 1992:
toxicological findings and circumstances. Medical Journal of Australia, 164, 204-207.