Richard Hammersley

Ranking the harm of non-medically used prescription opioids in the UK

A panel of nine experts applied multi-criteria decision analysis (MCDA) to determine the relative overall harm to users and harms to others of street heroin (injected and smoked) and eleven non-medically used prescription opioids. The experts assessed harm scores for each of the 13 opioids on each of 20 harm criteria, weighted the criteria and explored the resulting weighted harm scores for each opioid. Both forms of heroin scored very high: overall harm score of 99 for injected heroin and 72 for smoked heroin on a scale of 0-100. The main feature that distinguishes both forms of street heroin use is that their harm to others is more than five times that of the other eleven opioids. The overall harm score of fentanyl (including injection of fentanyl extracted from patches) and diamorphine (medically prescribed form of heroin) was 54 and 51, respectively, whereas that of orally used opioids ranged from 32 (pethidine) to 11 (codeine-containing pharmaceuticals). Injected street heroin, fentanyl and diamorphine emerged as most harmful to users, with the latter two very low in harm to others. Pethidine, methadone, morphine and oxycodone are also low in harm to others, while moderate in harm to users. We conclude that the overall harms of non-medically used prescription opioids are less than half that of injected street heroin. These data may give a basis for precautionary regulatory measures that should be considered if the rising trend in non-medical use of prescription opioids were to become evident in the UK.

Aspartame Sensitivity? A Double Blind Randomised Crossover Study

Background Aspartame is a commonly used intense artificial sweetener, being approximately 200 times sweeter than sucrose. There have been concerns over aspartame since approval in the 1980s including a large anecdotal database reporting severe symptoms. The objective of this study was to compare the acute symptom effects of aspartame to a control preparation. Methods This was a double-blind randomized cross over study conducted in a clinical research unit in United Kingdom. Forty-eight individual who has self reported sensitivity to aspartame were compared to 48 age and gender matched aspartame non-sensitive individuals. They were given aspartame (100mg)-containing or control snack bars randomly at least 7 days apart. The main outcome measures were acute effects of aspartame measured using repeated ratings of 14 symptoms, biochemistry and metabonomics. Results Aspartame sensitive and non-sensitive participants differed psychologically at baseline in handling feelings and perceived stress. Sensitive participants had higher triglycerides (2.05 ± 1.44 vs. 1.26 ± 0.84mmol/L; p value 0.008) and lower HDL-C (1.16 ± 0.34 vs. 1.35 ± 0.54 mmol/L; p value 0.04), reflected in 1H NMR serum analysis that showed differences in the baseline lipid content between the two groups. Urine metabonomic studies showed no significant differences. None of the rated symptoms differed between aspartame and control bars, or between sensitive and control participants. However, aspartame sensitive participants rated more symptoms particularly in the first test session, whether this was placebo or control. Aspartame and control bars affected GLP-1, GIP, tyrosine and phenylalanine levels equally in both aspartame sensitive and non-sensitive subjects. Conclusion Using a comprehensive battery of psychological tests, biochemistry and state of the art metabonomics there was no evidence of any acute adverse responses to aspartame. This independent study gives reassurance to both regulatory bodies and the public that acute ingestion of aspartame does not have any detectable psychological or metabolic effects in humans. Trial Registration ISRCTN Registry ISRCTN39650237

The Executive Dysfunctions Most Commonly Associated with Multiple Sclerosis and Their Impact on Occupational Performance

Introduction: The relationship between executive dysfunction and functional status in people with multiple sclerosis (MS) is not fully understood. This study attempts to provide empirical evidence of the executive dysfunctions most commonly associated with MS and to develop an understanding of the impact of this on occupational performance. Method: This cross-sectional study explores the relationships between an MS group (n = 69) and a healthy control group (n = 30) using the Behavioural Assessment of Dysexecutive Syndrome and the Dysexecutive Questionnaire. Results: More than a third of people with MS experienced some impairment of executive function sufficient to interfere with occupational performance. The most commonly occurring problems included planning, problem solving, behavioural regulation, lack of insight, apathy and lack of motivation. Executive function deficits were evident from the early stages of the disease, although participants with a secondary progressive form of MS appeared to demonstrate greater difficulties. Conclusion: While the Behavioural Assessment of Dysexecutive Syndrome may reliably identify the presence of executive dysfunction within this clinical population it does not inform clinicians of the impact on occupational performance. Self-reported executive function demonstrates heightened awareness of occupational performance deficits and may lead to more accurate reporting of executive dysfunction. The impact of depression, fatigue and anxiety, however, requires further investigation.

Trauma in the childhood stories of people who have injected drugs

Abstract Aim: To document childhood trauma in the life stories of people who have injected drugs. Method: Fifty-five participants (38 m, 17 f) recruited via Scottish recovery networks, who had injected drugs in the previous five years, were interviewed by peer researchers using the Life Story method. Results: Remembered childhood trauma included persistent violence, repeated sexual abuse, neglect and traumatic bereavements. Many traumas were related to adult alcohol use. Few participants told of no trauma, some of severe trauma contributing to subsequent drug problems, some recounted stories including traumatic events, but not linked to later drug problems. A few told of initial severe behavioural problems leading to trauma for the child and to drug problems. Drug problems followed trauma by various routes, without straightforward cause and effect: direct use of drugs as avoidant coping; juvenile heavy recreational use that escalated; forming relationships in mid to late teens with criminals. For men, this involved enmeshment in drug dealing, crime and prison. Some women formed relationships with men who injected drugs, who often introduced them to drugs, and some of whom were violently abusive. Heroin injecting was an effective means of blotting out distressing thoughts and feelings. Although, childhood stories also contained positive memories, factors that might have promoted resilience were rarely mentioned. Conclusions: Severe childhood trauma was common and gravitated people towards problem drug use via various pathways. Participants had often normalised the problems and did not remember adult help. Parental alcohol use contributed to trauma. Addiction services need to be more trauma minded.

Food choice by people with intellectual disabilities at day centres : a qualitative study

People with intellectual disabilities experience a range of health inequalities. It is important to investigate possible contributory factors that may lead to these inequalities. This qualitative study identified some difficulties for healthy eating in day centres. (1) Service users and their family carers were aware of healthy food choices but framed these as diets for weight loss rather than as everyday eating. (2) Paid carers and managers regarded the principle of service user autonomy and choice as paramount, which meant that they felt limited in their capacity to influence food choices, which they attributed to the home environment. (3) Carers used food as a treat, a reward and for social bonding with service users. (4) Service users’ food choices modelled other service users’ and carers’ choices at the time. It is suggested that healthy eating should be made more of a priority in day care, with a view to promoting exemplarily behaviour that might influence food choice at home.

How to measure mood in nutrition research.

Mood is widely assessed in nutrition research, usually with rating scales. A core assumption is that positive mood reinforces ingestion, so it is important to measure mood well. Four relevant theoretical issues are reviewed: (i) the distinction between protracted and transient mood; (ii) the distinction between mood and emotion; (iii) the phenomenology of mood as an unstable tint to consciousness rather than a distinct state of consciousness; (iv) moods can be caused by social and cognitive processes as well as physiological ones. Consequently, mood is difficult to measure and mood rating is easily influenced by non-nutritive aspects of feeding, the psychological, social and physical environment where feeding occurs, and the nature of the rating system employed. Some of the difficulties are illustrated by reviewing experiments looking at the impact of food on mood. The mood-rating systems in common use in nutrition research are then reviewed, the requirements of a better mood-rating system are described, and guidelines are provided for a considered choice of mood-rating system including that assessment should: have two main dimensions; be brief; balance simplicity and comprehensiveness; be easy to use repeatedly. Also mood should be assessed only under conditions where cognitive biases have been considered and controlled.

Constraint theory: A cognitive, motivational theory of dependence

Aims: A new theory of substance dependence is presented that models dependence as the absence of cognitive constraints on substance use. Methods: (1) Critical review of the predominant paradigm that assumes that substance dependence is a pathological state fundamentally caused by the neuropsychopharmacological effects of drugs (NPP paradigm) identified four counter-factual assumptions. Contrary to the NPP paradigm: (I) dependence can occur on a-typical substances and other things; (II) dependence is a complex, gradated phenomenon, not a state; (III) heavy protracted substance use can occur without dependence; and (IV) NPP interventions against dependence have not worked other than as drug substitutes. (2) Reconceptualisation of dependence as substance use with few cognitive, behavioural or social constraints. (3) Development of an exhaustive list of constraints on substance use with a panel of experts, achieving theoretical saturation. (4) Modelling of dependence, specifically to explain why socioeconomic deprivation is correlated with substance dependence. Results: Fifteen common constraints are described, which prevent most substance users becoming dependent. People in more socioeconomically deprived conditions tend to have fewer constraints. Similarities between Constraint Theory and previous sociological and social cognitive theories are discussed. Conclusions: Constraint theory describes the known nature of substance dependence better than theories from the NPP paradigm. Conceptualising dependence as an absence of constraints shows promise as a theory of addiction and fits with existing knowledge about what works to prevent and treat substance dependence.

Barriers to Increasing the Physical Activity of People with Intellectual Disabilities.

© 2016 John Wiley & Sons Ltd Accessible summary: We talked to people with intellectual disabilities and their carers about being healthy. Sometimes it was difficult for people with intellectual disabilities to take part in activities that would help keep them healthy. Being active is not just about doing special sports and activities. It can be part of everyday life. People with intellectual disabilities could become more active and be healthier with help from their carers. Abstract: Background: The prevalence of obesity, inactivity and related morbidity and mortality is higher amongst people with intellectual disabilities than in the population in general, an issue of global concern. This research examined the perspectives of people with intellectual disabilities and their carers, on exercise and activity. Materials and Methods: Qualitative data were collected via interviews and a focus group with people with intellectual disabilities and their paid and family carers, recruited via state-funded community-based day centres in Scotland. Results: Three barriers hindered service users with intellectual disabilities from regular involvement in physical activity: (i) acceptance of an inactive lifestyle by carers; (ii) restrictions on activity due to paid carer preferences and resource limitations; (iii) communication issues between family carers and paid carers. Barriers were based on assumptions made by paid and family carers, so there is potential to increase activity by changing attitudes, improving communication and reconceptualising activity as integral to everyday living, rather than as additional exercise requiring special resources. Conclusions: Carers should be supported to promote physical activity in a variety of ways to enhance the motivation of service users, to encourage them to engage with physical activity as an integral part of a healthy lifestyle and to transfer this to their lives beyond day care.

Commentary on Hyggen (2012): Subtle perils of large general population surveys

Jessor & Jessor [1] found that cannabis use was associated with less conformist attitudes. Hyggen [2] also found that people who admit to using cannabis in the past year value work a little less, and proposes that cannabis use in Norway remains relatively rare, hence still deviant, unlike countries such as the United Kingdom [3,4]. Norwegian prevalence is approximately average for Europe [5], and 60% of Hyggen’s sample had been exposed to, or used, cannabis at some time, which suggests normalization in Norway as well. Therefore, reduced work commitment is unlikely to be due to an a-motivated subculture, although perhaps it could be due to people whose life values extend beyond work to leisure and family, because being a parent and alcohol use also reduced work commitment; or might it be due to the effects of cannabis, for cause is implied in the paper’s title? In fact, Hyggen’s results are too weak to support a relationship of any consequence. 1 Figure 1 exaggerates the difference in work commitment (no real zero on axis, no error bars), which is actually only 0.4 units on a scale with unknown variance, having a range from 1 (strongly disagree) to 5 (strongly agree). If this is correct, then involved cannabis users agree slightly, albeit significantly, less with work commitment statements, but the average remains on the ‘more committed’ half of the scale. 2 For the between-groups analyses there were only 63 (4%) ‘involved’ cannabis users who differ on work commitment from the other groups. Moreover, the data were weighed for analysis by means unspecified. Weighting tends to exaggerate the impact of smaller groups in multivariate analyses, and there is also the potential for systematic response bias in a group of only 63 subjects. 3 The regression analysis fails to consider the probable effect size in the real world. The R is about 0.07, meaning that the entire model predicts only about 3% of the variance in work commitment scores. That a tiny relationship is statistically significant is a consequence of the large sample size, not of the importance of the relationship. 4 Both ‘cannabis use’ and ‘work commitment’ are selfreport variables which could covary because of reporting biases, such as that the same people may be more willing to admit more unconventional/less socially acceptable values in surveys. 5 Use in previous 12 months is a very weak index of ‘cannabis use’, ranging from daily users to people who had had one puff at a party. Hyggen’s approach is not unusual, and illustrates some of the pitfalls of using epidemiological methods to research psychological constructs and social factors: (i) to hurry to the complex—and ‘significant’—statistical analyses without lingering carefully enough on basic descriptive statistics; (ii) to make category mistakes in interpreting variables derived from questionnaire answers. This is the equivalent of eating the menu in a restaurant (confusing the sign with the signified in semiotic terminology), by treating how people answer questions as uncomplicated representations of their thoughts and behaviour. Similar difficulties pervade the more influential literature on cannabis and psychosis: (iii) fishing expeditions seem acceptable if the findings conform to contemporary prejudices. In the epidemiology of drugs this means that any association between illicit drug use and some harm will be accepted relatively uncritically, as here; (iv) ignoring problems of small subsamples and small effects. In epidemiological research on physical disease, the reasonably safe assumption is made that disease mechanisms are relatively invariant across people and unaffected by participants’ volition. It may be appropriate, then, to compare a small group of people with a disease to a much larger group without disease. When, as here, assignment to the small group is based instead on subjective answers to questionnaire items, then such comparisons need to be approached with caution. (v) In the interests of brevity, drug use questions in general surveys are often excessively attenuated to the point that no useful quantity–frequency data are available. (vi) Again for brevity, surveys often focus on worrisome behaviours without contextualizing them within lifestyle. Cannabis and alcohol ‘involvement’ might indicate stress, anxiety, depression and reduced work ethic, or might indicate a work–life balance involving leisure and socialization: there is no way to tell.