Sanju George

Fetal alcohol spectrum disorder(FASD)

Fetal alcohol syndrome (FAS)is the leading cause of mental retardation worldwide but is also the foremost preventable cause of neurobehavioral and developmental abnormalities. It is equally important to know spectrum of disorders due to maternal alcoholism during pregnancy such as Fetal alcohol spectrum disorder (FASD)in order to identify and treat affected child and family effectively. This article aims to create awareness among practising clinicians most of whom are only aware of phenotypical variant of FASD which is FAS.In this article we discuss those aspects of FASD relevant to the clinician such as: terminological ambiguity, assessment, diagnosis and prevention.

Social network support for individuals receiving opiate substitution treatment and its association with treatment progress.

Background/Aims: Social networks have been hypothesized to protect people from the harmful effects of stress, but may also provide dysfunctional role models and provide cues associated with drug use. This study describes the range, type and level of social support available to patients engaged in UK opiate substitution treatment (OST) programmes, and explores the association between network factors and continued use of illicit heroin. Methods: A cross-sectional survey of a randomly selected sample of OST patients (n = 118) utilised measures of current substance use and social network structure and support. Results: More than half of the participants had used heroin in the previous month, and most described networks that were both supportive and positive about treatment. Multivariate analysis showed that the substance use involvement of network members was higher in those patients still using heroin, even when other treatment factors were controlled for. Conclusion: There was a strong association between ongoing contact with other drug users and continued use of illicit heroin in this treatment sample. Whilst there is potential for the involvement of social networks in treatment, future research needs to ascertain the exact nature of the relationship between social support and drug use.

Sexual Dysfunctions in Male Opiate Users: A Comparative Study of Heroin, Methadone, and Buprenorphine

ObjectiveThe aim of this study was to compare sexual dysfunctions in male patients dependent on heroin and those on methadone or buprenorphine treatment for opiate dependence. MethodsNinety-one patients (30 in the heroin group, 33 in the methadone group, and 28 in the buprenorphine group) were recruited from outpatient attendees at a community drug team in Birmingham, UK. The “Loyola University Clinic-special history sheet for men” was administered to assess sexual functioning (self-reports), and the Brief Psychiatric Rating Scale was used to assess psychopathology. ResultsA wide range of sexual dysfunctions was reported by these patients (n=90): low sex drive (n=38; 41.8%), loss of sexual fantasy life (n=17; 18.7%), loss of morning erection (n=25; 27.5%), premature ejaculation (n=54; 59.3%), and ejaculation with soft penis (n=67; 73.6%). Fewer patients on buprenorphine (as compared with those on heroin and methadone) reported loss of sexual fantasy, loss of sexual desire, loss of erection with movement, premature ejaculation, and loss of angulation of penis (all P<0.05). ConclusionsThe results of this study indicate that sexual dysfunctions are common in male opiate misusers and that buprenorphine is significantly less likely than methadone or heroin to induce this side effect. Further research is needed to explore the pathophysiology and treatment implications of these findings. From a clinical perspective, it is imperative that patients misusing opiates and those treated with methadone or buprenorphine are routinely asked about their sexual functioning and appropriate investigations and treatment planned if indicated.

Review of Neuroendocrine Correlates of Chronic Opiate Misuse: Dysfunctions and Pathophysiological Mechanisms

Although endocrine abnormalities are recognized in opiate users, very little is known about the range of hormones affected, their pathophysiology, and their clinical relevance. The primary aim of this study was to explore the effects of heroin misuse and methadone maintenance treatment on the human endocrine system. A literature search for relevant articles (in English) and appropriate cross-referencing of the following databases-Medline (1952-2002), Embase (1974-2002), and Psychlit (1980-2002)-was done. Two authors independently reviewed over 100 articles and summarized the key findings. Various endocrine abnormalities have been reported in these patients, which include abnormal adrenal metabolism and adrenal insufficiency; abnormalities in circadian rhythm of corticosteroid secretion; increased levels of Thyroxine (T4), Tri-iodothyronine (T3), and Thyroxine Binding Globulin (TBG), and reduced T3 uptake values; increased prolactin levels; insulin and glucose metabolism abnormalities similar to those seen in type 2 diabetes; reductions in testosterone levels; and abnormalities in Follicular Stimulating Hormone/Luteinising Hormone (FSH/LH) levels. Pathophysiological mechanisms postulated to explain these findings include: a direct action of heroin or methadone at the hypothalamic or pituitary level, a more peripheral action at the end organ level, or indirect action via hepatic and/or renal dysfunction. We conclude that many of the hypothalamic and anterior pituitary hormones are adversely affected in heroin misusers and methadone maintained patients. Clinicians need to be aware of these hormonal dysfunctions, their clinical presentations (or as side effects leading to treatment non-compliance), and management. Further research is needed to explore the prevalence, pathophysiology. and clinical implications of these neuroendocrine dysfunctions.

Pilot study of a social network intervention for heroin users in opiate substitution treatment: study protocol for a randomized controlled trial.

AbstractBackgroundResearch indicates that 3% of people receiving opiate substitution treatment (OST) in the UK manage to achieve abstinence from all prescribed and illicit drugs within 3 years of commencing treatment, and there is concern that treatment services have become skilled at engaging people but not at helping them to enter a stage of recovery and drug abstinence. The National Treatment Agency for Substance Misuse recommends the involvement of families and wider social networks in supporting drug users’ psychological treatment, and this pilot randomized controlled trial aims to evaluate the impact of a social network-focused intervention for patients receiving OST.Methods and designIn this two-site, early phase, randomized controlled trial, a total of 120 patients receiving OST will be recruited and randomized to receive one of three treatments: 1) Brief Social Behavior and Network Therapy (B-SBNT), 2) Personal Goal Setting (PGS) or 3) treatment as usual. Randomization will take place following baseline assessment. Participants allocated to receive B-SBNT or PGS will continue to receive the same treatment that is routinely provided by drug treatment services, plus four additional sessions of either intervention. Outcomes will be assessed at baseline, 3 and 12 months. The primary outcome will be assessment of illicit heroin use, measured by both urinary analysis and self-report. Secondary outcomes involve assessment of dependence, psychological symptoms, social satisfaction, motivation to change, quality of life and therapeutic engagement. Family members (n = 120) of patients involved in the trial will also be assessed to measure the level of symptoms, coping and the impact of the addiction problem on the family member at baseline, 3 and 12 months.DiscussionThis study will provide experimental data regarding the feasibility and efficacy of implementing a social network intervention within routine drug treatment services in the UK National Health Service. The study will explore the impact of the intervention on both patients receiving drug treatment and their family members.Trial registrationTrial Registration Number: ISRCTN22608399 ISRCTN22608399 registration: 27/04/2012Date of first randomisation: 14/08/2012

A cross-sectional study of problem gambling and its correlates among college students in South India.

Background In the Western world, a significant portion of college students have gambled. College gamblers have one of the highest rates of problem gambling. To date, there have been no studies on gambling participation or the rates of problem gambling in India. Aims This study evaluated the prevalence of gambling participation and problem gambling in college students in India. It also evaluated demographic and psychosocial correlates of gambling in that population. Method We surveyed 5784 college students from 58 colleges in the district of Ernakulam, Kerala, India, using cluster random sampling. Students completed questionnaires that addressed gambling, substance use, psychological distress, suicidality and attention-deficit hyperactivity disorder (ADHD). Results A total of 5580 completed questionnaires were returned, and while only 1090 (19.5%) college students reported having ever gambled, 415 (7.4%) reported problem gambling. Lotteries were the most popular form of gambling. Problem gamblers in comparison with non-gamblers were significantly more likely to be male, have a part-time job, greater academic failures, higher substance use, higher psychological distress scores, higher suicidality and higher ADHD symptom scores. In comparison with non-problem gamblers, problem gamblers were significantly more likely to have greater academic failures, higher psychological distress scores, higher suicidality and higher ADHD symptom scores. Conclusions This study, the first to look at the prevalence of gambling in India, found relatively low rates of gambling participation in college students but high rates of problem gambling among those who did gamble. Correlates of gambling were generally similar to those noted in other countries. Since 38% of college students who had gambled had a gambling problem, there is a need for immediate public health measures to raise awareness about gambling, and to prevent and treat problem gambling in this population. Declaration of interest S.G. was (until October 2014) a member of the UK Responsible Gambling Strategy Board, and authored the Royal College of Psychiatrists’ Faculty report FR/AP/01 Gambling: The Hidden Addiction – Future Trends in Addictions (2014). Copyright and usage

Treatment provision for gambling disorder in Britain: call for an integrated addictions treatment and commissioning model

Treatment provision for individuals with gambling problems in Britain is at best inadequate. Here we call for gambling treatment provision to be integrated into mainstream drug and alcohol services, and for its commissioning responsibilities to fall under local public health departments.

'I saved a life': a heroin addict's reflections on managing an overdose using 'take home naloxone'.

Research shows that most heroin addicts, at some point in their drug using careers, accidentally overdose and that accidental overdose is the most common cause of death in this group. As most such overdoses are witnessed by other drug users or their carers, it is argued that providing ‘take home naloxone’ (a fast-acting opiate antagonist) to them (as potential witnesses to an overdose) can save lives. Despite the robust evidence base to support the feasibility and effectiveness of this strategy, its integration into clinical practice in the UK is still very limited. Here, we report the case of a heroin addict who used his take home naloxone to manage an overdose and thereby saved a life. Through this account, we hope to raise clinicians’ awareness of this simple yet life-saving intervention. We will also briefly discuss the evidence base for take home naloxone with particular reference to the UK and will also give some practical guidance to clinicians on prescribing take home naloxone.

'You never told me I would turn into a gambler': a first person account of dopamine agonist--induced gambling addiction in a patient with restless legs syndrome.

Dopaminergic agents are commonly used and effective treatments for restless legs syndrome (RLS), a disabling sensorimotor disorder. Less known are some of the potentially disabling side effects of these treatments, particularly iatrogenic gambling addiction, as is described here. Here the authors present a 62-year-old man, with a 20–year history of RLS, who developed gambling addiction while on dopaminergic treatment. He was not forewarned of this side effect, nor was he ever screened for gambling behaviours prior to or during treatment. Eight months after discontinuation of dopaminergic treatment and after 10 sessions of cognitive–behavioural therapy for gambling addiction, his gambling behaviours have partially resolved. To our knowledge, this is the first ever first person account of this condition. To prevent the devastating consequences of gambling addiction or to minimise its impact by early intervention, the authors call for clinicians involved in treatment of RLS to follow these simple measures: screen patients for gambling behaviours prior to the onset and during dopaminergic treatment; forewarn patients of this potential side effect; and if patients screen positive, refer them to specialist gambling treatment services, in addition to making necessary changes to their medication regime.

Up yours: smuggling illicit drugs into prison.

A significant proportion of patients who are heroin-dependant and receiving treatment in the community serve prison sentences at some point in their lives, meaning their treatment continues “on the inside”. Although prison inmates are promised the same quality of care as they would get “on the outside”, this is not always the case. Some drawbacks of the drug treatments offered in prisons can lead to people smuggling drugs into prisons. The present work describes how a patient, who is heroin dependant and attending a community drug and alcohol team for methadone maintenance treatment, smuggled methadone and heroin into prison, his reasons for doing that, his personal description of the extent of drug use in prisons and finally what can be done to stop it from treatment and policy perspectives. Drug misuse is common in prisons. Much more can be done at treatment and policy levels to prevent people smuggling drugs into prison.