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working group were unable to discern any effect from the1974 reorganisation on the development of teamwork and, bythese tokens, it seems unlikely that any legislative or similarmeasures could help at present. Presumably the call forchanges at that level will come eventually, when enoughcommunity nurses and doctors are convinced of their need.Meanwhile, any unifying influences should be cultivated,and the professional bodies must play a substantial part.
NATURAL HISTORY OF OPIATE ADDICTION
WHAT happens to opiate addicts in the long term? Whatproportions can be expected to go on using opiates, die ofcauses related to their addiction, switch over to alcoholism, orquit the drug habit? Does opiate maintenance perpetuatedrug use or save lives? These are important questions both fordaily clinical work and for national treatment policies. Littleis known on any of these issues, and follow-up research onaddicts is notoriously difficult to mount. A recent Americanreport is therefore welcome, even if it provides only hintsrather than firm answers. Musto and Ramos’ have boldlyexploited the research opportunity provided by recordsderived from a morphine maintenance clinic which operatedin New Haven, Connecticut, from 1918 to its forced closurein 1920. They obtained particulars on ninety-one patients, allaged over 21 at the time of original registration. Patientsreceived from the clinic an average daily dose of 460 mgmorphine sulphate. They came predominantly from poorareas of the city and many had a petty criminal background.Follow-up was entirely by recordsearch. Death certificates
were traced for 44% of the ninety-one subjects, and the searchwas limited to Connecticut death registrations. Given that thegreat majority of subjects would be expected to have died bythe time that the search was conducted in 1978, this lowtracing rate must limit any interpretation which can be put onthe findings. The bias which may have been introduced bylosing to follow-up the geographically more mobile sector ofthe study population is not adequately discussed. Despite thisshortcoming, the study certainly provides some interestinghints. The mean age at death for forty subjects was 55-9 9years, or 13 years earlier than would be expected in thegeneral base population. This life expectation probably didnot, though, deviate from that which would have been
expected in the particular socioeconomic group from whichthe sample was drawn. As for the recorded reasons for death,there were enhanced rates for a number of causes commonlyassociated with poverty and social handicap: tuberculosis, forinstance, accounted for 10% of deaths versus 3% in the State’sgeneral White population. Alcoholism accounted for 5% ofdeaths versus less than 1 % expectation, and suicide 307o versus1% expectation. Only three subjects dying before 1937 weredescribed on the death certificate as addicts, and none wereso described after 1937.Musto and Ramos interpret their results as giving support
to the belief that many people will mature out of addictioneven without the aid of treatment. They further conclude thataddiction (or having been an addict) is not necessarilyassociated with greatly enhanced expectations of prematuredeath. The evidence does not suggest that the closure of theNew Haven clinic in 1920 was followed by an epidemic of
1. Musto DF, Ramos MR. Notes on American medical history- a follow-up study of theNew Haven morphine maintenance clinic of 1920 N Engl Med 1981; 304:1071-77.
suicide or overdose. These findings are obviously rooted in aparticular historical and social context. Even so, and despitethe incompleteness of the death-search information, the
findings fit in with other reports which suggest that the adage"once an addict, always an addict" is not in accord with thefacts. A 7-year British follow-up of a representative sample ofone hundred and twenty-six heroin addicts showed, for
instance, that forty subjects were off opiates at the end of thisperiod and and of these thirty-three had, at the time of
interview, been abstinent for over 2 years. An Americanstudy of soldiers who had become addicted in Vietnam foundthat only 2 - 5% were still taking opiates 2 years after
returning to the U.S.A.3Given that many addicts will attain stable abstinence and
that the older pessimism is unjustified, it becomes importantto understand the process by which abstinence is attained andthe contribution which treatment (including maintenancetreatment) may make to this result.4 A superficial reading ofthe Musto and Ramos report would be that closing that clinicdid not lead to disaster and that London in the 1980s shouldconsider following the example of New Haven in the 1920sand shut down the British maintenance programme. Mustoand Ramos themselves do not draw such intemperateconclusions, but we should accept the reminder that we knowvery little about how opiate maintenance influences thenatural history of addiction among the urban British opiateusers of the 1980s.
A LEGAL INTERVENTION
A sudden legal process culminating in a judgment by theCourt of Appeal on Aug. 7 (see p. 413) has disquieted thosewho believe that the treatment or non-treatment of childrenborn with extreme handicap is best determined withoutintervention of law. In the past the law has seldom becomeinvolved, but it is now responding to vigorous questions frompeople convinced that every effort must be made to supporteven the most severely damaged infant. The chief
imponderable has always been the degree of disability thechild, the parents, and the community might eventually haveto sustain. For neural-tube defects, criteria may be applied topredict the minimum handicap; and that may be so bad thatmost doctors would advise against supportive care. Forinfants with all degrees of Down syndrome, many parentshave attested to a happy life for the child and a rewardingchallenge for themselves. The new legal decision apparentlymeans that parents of a child with Down syndrome do nottherefore have the choice of accepting medical advice whichwould lead to early death. What would be a court’s judgmenton the treatment of an infant with severe spina bifida andhydrocephalus? In the present atmosphere of search andlitigate, it may not be long before this question is put to thetest. It may be necessary to inflict this instant extra distress onstricken patients if long-existing practices are to be publiclyand effectively examined. Those reformists with the
strongest sense of rectitude will accept nothing less thanthe discounting of parents’ wishes and the suppression, ifnecessary by the law of murder, of what they see as
presumptuous medical advice.
2. Stimson GV, Oppenheim E, Thorley A. Seven-year follow-up of heroin addicts druguse and outcome. Br Med J 1978; i: 1190-92
3. Robins LN, Davis DH, Goodwin DW Drug use by US army enlisted men in Vietnama follow-up on their return home Am J Epidemiol 1974; 99: 223-47
4. Wille R. Cessation of opiate dependence- processes involved in achieving abstinence
Br J Addict 1978; 73: 381-84