‘The great unmentionable’: Exploring the pleasures and benefits of ecstasy from the perspectives of drug users

There is limited evidence about the prevalence of mental illness and substance misuse comorbidity (comorbidity) and its current management. This hampers service development in the UK. We measured the prevalence of comorbidity in community mental health teams (CMHTs) and drug and alcohol services in four urban UK centres. We also described the patterns of comorbidity, assessed the health and social care needs of patients and described current management.

Among CMHT patients, 44% report past year problem drug use and/or harmful alcohol use. The majority of drug (74.5%) and alcohol patients (80.6%) had a past year psychiatric disorder. In each population most comorbid patients exhibit multiple disorders and have greater community care needs than non-comorbid patients. Comorbid status did not restrict access to interventions provided through the patient's allocated service, but joint management between services was uncommon.

Resources need to be deployed to enable substance misuse services to provide evidence-based interventions to a higher proportion of comorbid patients. The treatment need of comorbid CMHT patients are likely to be best met by mainstream mental health services. However, CMHTs need to develop these competencies through staff training and research into the effectiveness of novel interventions tailored to UK service contexts.     

‘All suffering together’: student drinkers’ experiences of alcohol hangover

Background: There is a pervasive norm of drinking to intoxication among young people in many affluent countries, despite recent falls in overall alcohol consumption. Students’ accounts of their experiences of alcohol hangovers have not been explored in any depth, which is surprising given the high rates of heavy episodic drinking amongst this group. This study investigated student drinkers’ lay health beliefs about alcohol hangovers, considering the role of hangovers in student drinking culture and the implications for safer drinking initiatives.

Method: The present study involved a Thematic analysis of semi-structured individual interviews with 23 students aged 18 to 29 (8 women and 15 men) at a university in South West England about their thoughts, feelings and experiences regarding hangovers and drinking.

Results: Hangovers were relatively frequent events for most participants, associated with heavy drinking and producing unpleasant physical and psychological effects. Participants employed a range of strategies to minimise the effects of hangovers although very few considered reducing their alcohol consumption. A key negative aspect of hangovers involved low mood and social isolation, in contrast to the positive experience of shared collective suffering that strengthened social bonds in participants’ friendship groups.

Conclusions: Collective periods of shared suffering formed a valued aspect of participants’ hangover experiences, strengthening group identity and linking to the culture of heavy drinking. It is important to acknowledge positive as well as negative aspects of students’ views on hangovers in public health guidance on young adults’ alcohol consumption.     

Heroin uncertainties: Exploring users’ perceptions of fentanyl-adulterated and -substituted ‘heroin’

BackgroundThe US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30–50X more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as ‘heroin’ and to observe the drugs and their use.MethodsA team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n = 38) qualitative interviews with persons who use heroin.Results(1) The composition and appearance of heroin changed in the last four years; (2) heroin is cheaper and more widely available than before; and (3) heroin ‘types’ have proliferated with several products being sold as ‘heroin’. These consisted of two types of heroin (alone), fentanyl (alone), and heroin–fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl’s presence, followed by taste, solution appearance and powder color. This paper presents a new ‘heroin’ typology based on users’ reports.ConclusionMassachusetts’ heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users’ discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations.     

Four groups of illicit substance users amongst the adult ‘hidden’ non-problematic community

This paper describes and distinguishes between adult drug users’ perceptions of their own drug use. Focusing on ‘non-problematic’ (non-addicted) users over the age of 25 amongst a non-agency attending population, the paper delineates adult drug users as a group, using qualitative data from a three-year investigation. Interviewees were located utilizing a combination of snowball and opportunistic sampling, gaining privileged access to a hidden network of drug users. Open ended qualitative interviews explored personal histories of substance use over time, covering patterns and perceptions of use. Four distinct groups of adult ‘non-problematic’ users are identified, each having different purposes, approaches to and understandings of their own drug use, and thus experiencing the phenomenon in fundamentally different ways. The identified groups are presented and discussed in terms of furthering research understanding of this group of illicit substance users. Implications for future research are discussed.     

Detectability of cannabinoids in the serum samples of cannabis users: Indicators of recent cannabis use? A follow-up study

Forensic toxicologists are frequently required to predict the time of last cannabis consumption. Several studies suggested the utility of minor cannabinoids as indicators of recent cannabis use. Because several factors influence blood cannabinoid concentrations, the interpretation of serum cannabinoid concentrations remains challenging. To assess the informative value of serum cannabinoid levels in cannabis users (in total N = 117 patients, including 56 patients who stated an exact time of last cannabis use within 24 h before blood sampling), the detectability of cannabinoids, namely, delta-9-tetrahydrocannabinol (delta-9-THC), 11-hydroxy-delta-9-THC, 11-nor-9-carboxy-delta-9-THC, cannabichromene (CBC), cannabidiol (CBD), cannabinol (CBN), cannabidivarin, tetrahydrocannabivarin, cannabigerol (CBG), cannabicyclol, delta-8-THC, tetrahydrocannabinolic acid A, cannabichromenic acid, cannabidiolic acid (CBDA), cannabigerolic acid, cannabicyclolic acid (CBLA), 11-nor-9-carboxy-THCV (THCVCOOH), and 11-nor-CBN-9-COOH, was investigated. Excluding CBDA and CBLA, all investigated cannabinoids were detected in at least one analyzed sample. The interval between cannabis consumption and sample collection (reported by the patients) was not correlated with cannabinoid concentrations. Minor cannabinoids tended to be more easily detected in samples obtained shortly after consumption. However, some samples tested positive for minor cannabinoids despite an interval of several hours or even days between consumption and sampling (according to patients' statements). For instance, CBC, CBG, THCVCOOH, CBD, and CBN in certain cases could be detected more than 24 h after the last consumption of cannabis. Thus, findings of minor cannabinoids should always be interpreted with caution.     

‘Peer’ work as precarious: A qualitative study of work conditions and experiences of people who use drugs engaged in harm reduction work

In this study, we examine the qualitative accounts of people who use drugs engaged in ‘peer’ work in harm reduction settings across British Columbia, Canada. We found peer work was precarious, characterized by nonstandard or casual work arrangements, high job instability and insecurity, insufficient wages, and limited social benefits. Participants were reluctant to exercise their rights or negotiate work conditions, such as higher wages or more consistent work, out of fear of job loss. However, the flexibility of peer work was beneficial for some in that it worked within their life circumstances and provided a low-barrier entry into the labor market. If inequities in peer work are perpetuated, unrecognized and unaddressed, precarious work conditions may continue to undermine the potential benefits of harm reduction work for organizations, peer workers and the people to whom they engage with and support. This study adds people who use drugs to the many social groups that are impacted by precarious work conditions globally.     

‘Vaping and fidget-spinners’: A qualitative,longitudinal study of e-cigarettes in adolescence

BackgroundWe see the contours of a cigarette-free adolescent cohort in Norway. Simultaneously, increasing use of vaping devices among adolescents internationally, and in the US in particular, has evoked fear of a new nicotine-addicted generation. This longitudinal study explores the vaping phenomenon in a context where nicotine e-liquid is still prohibited.MethodsData are from longitudinal, qualitative interviews with a sizable sample of 12-17 year olds (118 8^th graders from 6 schools/classes at baseline). Four follow-ups were conducted from 2015 to 2019 (a total of 50 semi-structured group and 175 individual interviews). The interviews were coded using HyperResearch software and thematically analysed in the light of actor network and interaction ritual theory.ResultsGradual and collective shifts in vaping practices and in the symbolic meaning of vaping were observed in three phases. First, in 8^th grade, few had tried to vape, even if several were curious about this novel invention, practice and the available flavours. Second, after 9^th grade, one in three reported personal use. They emphasised harmlessness, coolness, performance and accessibility online. However, by the end of middle school, a third phase became visible; vaping had lost status and was described as ‘childish’ and unpopular. Interviewees repeated the lack of relevance in high school, comparing e-cigarettes with the fidget-spinner and reserving vaping for kids and addicted adult smokers. The analysis displays a systematic pattern in which adolescents account for vaping as a time-limited trend.ConclusionE-cigarettes were devalued from novelty and transgression to childish and uninteresting within the same sample over a four-year period. In conclusion, e-cigarettes in the sample represented fashionable experimentation rather than steady user patterns.     

“You’re all going to hate the word ‘recovery’ by the end of this”: Service users’ views of measuring addiction recovery

Abstract

Aims: To explore how service users’ views of measuring addiction recovery differ from those of service providers. Methods: Five focus groups conducted in two English cities with (i) people currently using Class A drugs (n?=?6); (ii) people currently using alcohol (n?=?12); (iii) individuals in residential detoxification (n?=?12); (iv) individuals in residential rehabilitation (n?=?7); and (v) people who defined themselves as ex drug or alcohol users (n?=?7). Each focus group reviewed 76 measures of recovery previously identified by senior service providers. Findings: Service users identified multiple problems with the 76 measures. Difficulties could be categorized as expecting the impossible of service users; the dangers of progress; the hidden benefits of negative outcomes; outcomes that negate the agency in recovery; contradictory measures; failure to recognise individual differences; entrenched vulnerabilities; the misattribution of feelings and behaviours; and inappropriate language. Conclusions: Service users experience recovery as a process and personal journey that is often more about ‘coping’ than ‘cure’. Involving service users in designing measures of recovery can lessen the likelihood that researchers develop assessment tools that use inappropriate, contradictory or objectionable outcomes, and ambiguous and unclear language. People who have experienced drug or alcohol problems can highlight important weaknesses in dominant recovery discourses.     

A qualitative study exploring patients’ experiences regarding insulin pump use

Background

Diabetes is a threat to peoples’ lives around the world, particularly in the Middle East. Medicine misuse and poor glycaemic control are prevalent among patients with type 2 diabetes, especially insulin-dependent patients (Alsairafi et al., 2016). With advances in medical technology, insulin pumps became a treatment option for patients with type 1 diabetes and those with insulin-dependent type 2 diabetes. However, use of these devices is still lacking in Kuwait, particularly in patients with type 2 diabetes. Information on how patients manage these devices and their efficacy and safety from the perspectives of patients is also lacking (Alsaleh et al., 2016).

Struggling to achieve a ‘normal life’: A qualitative study of Vietnamese methadone patients

Background:Methadone maintenance treatment, initially introduced in Vietnam for HIV harm reduction, has marked a significant switch in the country’s drug policy – from addiction as a moral issue to addiction as a brain disease. After the some initial outstanding achievements, the programme is facing a high dropout rate that threatens both goals of HIV prevention and drug treatment. This sociological study, as part of an HIV intervention research project, explores the challenges and opportunities that individuals who use drugs are faced with in relation to addiction treatment.Methods:A qualitative study among drug users with and without methadone maintenance treatment experiences recruited by peer outreach workers. We conducted 58 in-depth interviews and 2 focus groups between 2016 and 2017.Results:The start of treatment brought about significant feelings of success as heroin use was no longer compulsive. However, being in treatment programmes is also challenging with respect to continuing the recovery process. Barriers to retention include a popular fear of methadone as another harmful drug, a feeling of dependence related to the current practices of methadone treatment programmes and a poor therapeutic relationship. In the face of such challenges, the two major motivations that keep patients in care come from the desire to completely break up with heroin and the pursuit of family happiness.Conclusion:The current practices of methadone programmes pose challenges to patients’ recovery efforts from addiction and threaten treatment retention. Prompt interventions are needed to help Vietnam attain its objective of providing better care for larger vulnerable populations.     

Conceiving of addicted pleasures: A ‘modern’ paradox

Drawing on research with people who inject drugs in London, UK, this article will explore how participants conceived of pleasure, and try to understand some of the tensions that ensued. There is a strong sense in participants’ accounts that drug use is at points pleasurable but it should not, or rather, could not be conceived of in this way. As such, the article will reflect on several situations in which pleasure came up during fieldwork but was quickly redirected towards addiction using terms such as ‘denial’. Trying to make sense of this seemingly paradoxical dynamic, in which pleasure can be addictive, but addiction cannot be pleasurable, I turn to some of the practices that actively keep pleasure and addiction apart, indeed, in some areas of the addiction sciences, antithetical. That is, a singular account of pleasure is produced as freely chosen (of the ‘free’ subject) in opposition to the determined nature of addiction (of the automated brain or object). These realities materialise in participants’ accounts, but due to their constructed nature they also collapse and multiply. This ‘hybridisation’ is what Bruno Latour refers to as the paradox of the Moderns. Considering pleasure, however, as both natural and cultural, it is better conceived of as always in tension, expressed by participants as ‘mixed feelings’, ‘love/hate’, ‘sweet and sour’, ‘good things and bad things’. Against a backdrop of neglect, especially within the context of injecting drug use, such conceptualisation can help acknowledge pleasure where it is least conceivable and yet perhaps has the most to offer.     

A comparison of ‘Integrin’ and ‘Tacitin’ in the treatment of anxiety neurosis in general practice

Summary

A double-blind trial was carried out in general practice over a 4-week period on 76 patients with anxiety neurosis to compare the efficacy of ‘Integrin’ (oxypertine) with that of ‘Tacitin’ (benzoctamine hydrochloride). A standard daily dose of 30?mg. of either drug was used. Patients were assessed on a modified Hamilton Anxiety Scale. Changes in total score and in specific scores for anxious and for depressed mood were examined. Both agents produced a highly significant improvement and were equally effective. Side-effects were acceptably low in both.     

Visuospatial memory impairments in users of MDMA (‘ecstasy’)

Rationale Previous studies have presented conflicting findings regarding visuospatial span deficits in MDMA (ecstasy) users, possibly attributable to a lack of distinction between simple visuospatial span and visuospatial working memory span. Both draw upon central executive processing, while the latter also involves concurrent goal-orientated visuospatial processing.Objectives This study compared visuospatial working memory span for MDMA users and controls. An additional concurrent task also loading on the central executive tested for inter-group differences related to central executive workload.Method MDMA user group (25 current users, 10 previous users and 18 non-users) was between-participants, and dual task condition (concurrent alphabetic generation, random letter generation, and no dual task) was within-participants. The visuospatial working memory task required participants to serially recall a spatial sequence while simultaneously completing a visual judgement task, and was completed on its own and under dual task conditions.Results Overall, non-users performed significantly better than both MDMA user groups. However, contrary to expectation, the performance decrement among users was no worse with concurrent random generation than under control conditions. Analyses controlling for background variables and the use of other drugs in the previous 3 months showed that the main effect of MDMA remained significant following control for intelligence, alcohol, amphetamines and cocaine, among other potential confounds. Unclear results were found following control for cannabis use.Conclusions The MDMA users experienced deficits in visuospatial working memory span. The lack of interaction between dual task condition and user group may be due to inter-group differences in central executive utilisation under different task conditions.     

Community pharmacists’ perspectives about the sustainability of professional pharmacy services: A qualitative study

ObjectivePharmacists have been increasing patient-focused care through the implementation and provision of professional services. However, there is a lack of evidence on how to achieve long-term sustainability of the service once it is implemented. A framework identifying the factors affecting the sustainability of professional pharmacy services was developed. The objectives of this study were to explore the experiences of community pharmacists providing professional services to contextualize and assess the applicability in practice of the sustainability framework.MethodsA qualitative study was undertaken across Australia. Community pharmacists were identified using snowball sampling. Data were collected through semistructured interviews. Eighteen interviews were conducted and analyzed using framework methodology in NVivo 12 (QSR International).ResultsA range of major sustainability factors was identified and organized in social, economic, and environmental domains. In the social domain, most of the interviewees stated the importance of motivating staff to increase service promotion and patients’ demand. Most of the participants emphasized that having an adequate number of trained staff is required to enhance and maintain services over time. The perceived reluctance of some patients to spend more time than usual at the community pharmacy was another factor highlighted as affecting service sustainability. In the economic domain, the concern about lack of remuneration for service provision was highlighted by most of the interviewees. Having economic support was seen as essential for achieving sustainable services. In the environmental domain, the necessity of government recognition of the pharmacists’ role and value to the health care system was identified as a new key sustainability driver.ConclusionThe applicability of the framework for the sustainability of professional services was evaluated in practice. The identified factors will guide pharmacists to maintain implemented services and achieve their sustainability. Future research should focus on designing a tool to measure the sustainability of pharmacy services.     

A comparative controlled study of tiaprofenic acid (‘Surgam’) and naproxen in the treatment of rheumatoid arthritis

Summary

Tiaprofenic acid and naproxen were compared using a randomized double-blind, double-placebo crossover method in 32 hospital out-patients with rheumatoid arthritis. Patients received 200?mg tiaprofenic acid 3-times daily or 250?mg naproxen twice daily, each for a 2-week period with no initial or between-treatment washout periods. The results of objective and subjective assessments before and after treatments indicated that, overall, both anti-inflammatory drugs were equally effective and tolerated. Patient preference comparisons of the two treatment periods suggest that for some patients tiaprofenic acid will be a useful addition to this group of drugs.     

The effect of pimozide on variable-interval performance: A test of the ‘anhedonia’ hypothesis of the mode of action of neuroleptics

A quantitative behavioural test system based on Herrnstein's (1970) equation was used to test a prediction derived from the anhedonia hypothesis of neuroleptic action, that pimozide should increase the value of the behavioural parameter K _H (the reinforcement frequency needed to maintain the half-maximal response rate in variable-interval schedules). On the basis of theoretical considerations, it was shown that the equation implies that a drug which exerts such an effect on K _H must have a more profound suppressant effect on performance maintained by low reinforcement frequencies than on performance maintained by high reinforcement frequencies. Fifteen rats were trained under variable-interval 10-s and variable-interval 100-s schedules, and the effect of pimozide (0.125, 0.25, 0.33, and 0.5 mg/kg) was tested on performance maintained under each schedule. The drug suppressed performance maintained under both schedules in a dose-dependent manner, and there was no tendency for the drug to exert a greater effect on performance maintained under the lower reinforcement frequency. These results do not provide any evidence that the effect of pimozide on variable-interval performance is due to an anti-hedonic effect; rather, they are compatible with the hypothesis that pimozide impairs the capacity to respond.     

Comparison of ‘Duphalac’ and ‘irritant’ laxatives during and after treatment of chronic constipation : a preliminary study

Summary

A multi-centre trial was carried out to compare the effectiveness in the treatment of chronic constipation of a lactulose preparation (‘Duphalac’) and ‘irritant’ laxatives containing senna, anthraquinone derivatives or bisacodyl. The results, in 164 patients, indicate that the lactulose preparation was more effective than the ‘irritant’ laxatives. By Day 7, 58 % of the lactulose-treated group were passing a normal stool whereas only 42 % of the patients receiving an ‘irritant’ laxative did so at the same stage in treatment. The lactulose preparation was shown to have a persistent ‘carry-over’ effect, and this effect was seen in significantly more patients receiving ‘Duphalac’ than in the ‘irritant’ laxative group.