Reply to Wodak

© 2004 Society for the Study of Addiction doi:10.1111/j.1360-0443.2004.00824.x

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, 1062–1066

Blackwell Science, Ltd

Oxford, UK

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0965-2140© 2004 Society for the Study of Addiction

99Letter to the Editor

Letter to the EditorLetter to the Editor

Letters to the Editor

BEHAVIORAL AUTARCESIS—REPRISE

Our research team has borrowed ‘autarcesis’ as a

loan-word

from general epidemiology. Without apology, weextended the reach of the underlying concept to encom-pass behaviors that might function as a shield (prevent-ing or delaying onset of the first chance to try a drug), aswell as behaviors that might function by strengtheningresistance to consume the drug once the youth experi-ences a chance to try the drug. Of course, some behaviorsmight serve both a shielding function as well as aresistance-strengthening function.

As an aid to research on these ‘

autarceologic

’ functionsof behavior with respect to youthful drug-taking, weoffered two distinctive statistical indicators of impact.With respect to the shielding function, behavioral autar-cesis should be manifest in a reduced unconditional risk(or hazard) of experiencing the first chance to try a drug,or in a delayed onset of the first chance to try the drug.With respect to the resistance-strengthening function,behavioral autarcesis should be manifest in a reducedconditional risk (or hazard) of actually consuming thedrug once the first chance to try the drug has occurred,or in an increased lag time from first chance to try thedrug until first actual consumption of the drug.

Interested readers will find more details on the conceptof behavioral autarcesis in two recent publications, one ofwhich appeared in

Addiction

(Chen

et al

. 2004b). Theother article has appeared in the

American Journal of Epi-demiology

(Chen

et al

. 2004a)Our concept of behavioral autarcesis follows the

contours of the original epidemiological concept of autar-cesis in that the separable shielding and resistance-strengthening functions are not at all specific withrespect to the properties of the

agent

under study. Rather,autarcesis refers to a

non-specific

shielding or resistance-strengthening function – i.e. a function that is manifest inrelation to different types of agents, and unlike theresistance engendered via the mechanism of an agent-induced antibody, autarcesis is not specific to a singlespecies or subspecies of agent. As such, the shieldingfunction of an intact epidermis is effective against a broadrange of ambient pathogens. In contrast, inoculationagainst smallpox has little or nothing to do with shielding

or strengthening resistance against cholera. In sum,autarcesis by definition generally is non-specific withrespect to the agent under study.

In addition, our concept of behavioral autarcesis com-plements the concepts of alternative reinforcers within ayouth’s behavioral repertoire, which may compete withthe reinforcing functions of drug-taking, once drug-taking starts, and thereby help to reduce or retard theoccurrence of drug dependence syndromes. The evidencethat behavior is functioning as an alternative reinforcercannot be seen until after drug use starts. In contrast, theevidence that behavior has an autarceologic function isseen before the individual-level reinforcing functions ofdrug-taking can be observed. That is, it is in the run-up tothe first chance to try a drug that we see behavior func-tioning as a shield (against the first chance to try a drug),or as a resistance-strengthener once the drug exposureopportunity has occurred (Johanson

et al

. 1996).The comments by Professors Moos and Mäkelä

(Mäkelä 2004; Moos 2004) seem to reflect a misunder-standing of these clear and distinctive features of the non-specific shielding and resistance-strengthening functionsof behavior with respect to the first chance to try a drugand the transition from first chance to first actual use of adrug. It is possible that the misunderstanding is the faultof my research team. Perhaps we did not explain our-selves clearly enough. But it is possible that somethingelse was at work when they decided to resist the introduc-tion of terms that were new to them. Unless I have readthese comments incorrectly, the authors have asked the

Addiction

readers to draw up sides, and to join with themin resisting the alien introduction of a concept.

My own preference is to urge

Addiction

readers to thinkfor themselves, and to use the concepts of autarcesis andbehavioral autarcesis if these concepts serve well inresearch on the earliest stages of youthful drug involve-ment. If they do not serve well, then by all means, inves-tigators should fall back on the more familiar and genericterms such as risk factor and protective factor. From myown perspective, the term ‘risk factor’ and the term ‘pro-tective factor’ have become too general and diffuse inmeaning to serve useful scientific functions. These termshave lost their original meanings via over-extension(Anthony & Van Etten 1998). In contrast, the value of a


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concept like behavioral autarcesis may rest in its specific-ity of meaning, and in the corresponding statistical indi-cators for the separable shielding functions andresistance-strengthening functions of behavior. Time willtell us whether the concept has value. Enquiring mindsneed no authorities to tell them what to do, no matter howdistinguished or experienced the authorities might be.

Addiction

readers who are interested in the history ofideas may wish to review the story of the French Acad-emy and its resistance to new concepts and words that didnot originate in the French royal court. For example,according to Rosenberg (2003), members of the Acad-emy did everything in their power to suppress publicationof Antoine Furetière’s unsanctioned dictionary of newterms in 1690, and to assert an exclusive authority overthe French language. (The more things change, the morethey remain the same.)

Autarcesis is not a ‘newly hatched’ term, and for along time this epidemiological concept has been used todistinguish specific from non-specific mechanisms ofshielding against infection and resistance-strengtheningvia mechanisms that are not specific to an individualagent of disease. What is new, is the insight that behaviormight serve this non-specific autarceologic function withrespect to prevention of youthful drug-taking, eithershielding against the first chance to try a drug (in a non-specific way) or strengthening resistance against tryingthe drug once the opportunity has occurred (again, in anon-specific way). Time and usage, not the voice ofauthority

ex cathedra

, will teach us whether autarcesisand behavioral autarcesis can aid in the conceptualiza-tion and completion of research on the earliest stages ofyouthful drug involvement.

Can we apply the concept of behavioral autarcesisand try to build behavioral shields that will effectivelydelay the first exposure to a chance to try tobacco, alco-hol, or an illegal drug? Will preventive interventions tostrengthen these behavioral shields be as effective as pre-ventive interventions to strengthen resistance when thefirst chance to try a drug is encountered? These arequestions that do not emerge when we constrain ourthinking within the conventional realm of ‘risk and pro-tective factors,’ but they are questions that can andshould be answered in new research on youthful druginvolvement.

JAMES C. ANTHONY

Department of EpidemiologyMedical SchoolMichigan State UniversityEast LansingMI 48824USAE-mail: [email protected]

References

Anthony, J. C. & Van Etten, M. L. (1998) Epidemiology and itsrubrics. In: A. Bellack & M. Hersen, eds.

Comprehensive ClinicalPsychology

, Vol. 1, pp. 355–390. Oxford, UK: Elsevier.Chen, C.-Y., Dormitzer, C. D., Bejerano, J. & Anthony, J. C.

(2004a) Religiosity and the earliest stages of adolescent druginvolvement in seven countries of Latin America.

AmericanJournal of Epidemiology

159

, 1180–1188.Chen, C.-Y., Dormitzer, C., Gutierrez, U., Vittetoe, K., Gonzales,

G. & Anthony, J. C. (2004b) The adolescent behavioral reper-toire as a context for drug exposure: behavioral autarcesis atplay.

Addiction

,

99

, 897–906.Johanson, C. E., Duffy, F. F. & Anthony, J. C. (1996) Associations

between drug use and behavioral repertoire in urban youths.

Addiction

,

91

, 523–534.Mäkelä, K. (2004) Is ‘autarcesis’ the Emperor’s new clothes? A

comment on Chen

et al.

(2004)

Addiction

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99

, 923.Moos, R. (2004) Protection from etymologic infection.

Addiction

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, 923–924.Rosenberg, D. (2003) Louis-Sébastien Mercier’s New Words.

Eighteenth-Century Studies

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36

, 367–386.


Oxford, UK

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FOOTNOTES TO HALL (2004)

Professor Wayne Hall [1] has done the field a great ser-vice by summarizing his major achievements in heroinresearch in Australia over a period of eleven years. Hiscontribution is remarkably impressive by any reckoning.However, there appear to be some areas where a correc-tion may be required.

Professor Hall discusses a body of work that identifiedincreasing heroin use and adverse consequences of her-oin use in parts of Australia beginning in the early 1990s.He states (p 563) that this author [2] ‘predicted that themost likely effect of the decline in heroin price and puritythat we reported was a reduction [italics in original] inheroin overdose deaths and crime’.

These were not my views at the time [2], nor have theybecome my views since. The reference Professor Hall cited[2] does not state or even imply these views. Rather, Iargued against the assumption that a fall in the streetprice of illicit drugs inevitably results in increased con-sumption, citing the example of a considerable decline inthe estimated number of cocaine users in the UnitedStates in 1980s-1990s at a time when street cocaineprices dropped substantially. I also speculated that socialfactors, such as youth unemployment, educationalopportunities and attitudes of young people to instantgratification, may be more important determinants ofillicit drug use than price and purity.

Professor Hall also comments [1] that ‘a heroin trialcame to be seen by some advocacy groups as the only wayto reduce the steeply rising rate of opioid overdose deaths.’I have been very closely involved in advocacy for a herointrial in Australia from 1991, when I suggested a herointrial to a committee that subsequently adopted the idea as

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one of their recommendations [3]. I have been closelyinvolved in advocacy for a heroin trial ever since. I amunaware of any significant advocate for a heroin trialwho discounted the paramount importance of consider-able expansion of methadone maintenance treatment aspart of a comprehensive range of strategies to reduce her-oin overdose deaths. I can, no doubt, be justly accused ofmany failings. But, as countless observers will attest, afailure to consistently and strenuously advocate for vig-orous expansion (and improvement) of methadone main-tenance treatment is not one of my shortcomings. Thecase for a heroin trial in Australia has strengthenedgreatly since 1991 and so too has the case for expansionand enhancement of methadone treatment.

ALEX WODAK

Alcohol and Drug ServiceSt Vincent’s HospitalDarlinghurstNSW 2010AustraliaE-mail: [email protected]

References

1 Hall, W. (2004) The contribution of research to Australianpolicy responses to heroin dependence 1990–2001: a per-sonal retrospection.

Addiction

,

99

, 560–569.2 Wodak, A. (1997) We lose 500 young each year.

SydneyMorning Herald

, 28 January 1997, p. 14.3 Legislative Assembly for the ACT Select Committee on, HIV

and Illegal Drugs and Prostitution (1991)

Second InterimReport: A Feasibility Study on the Controlled Availability of Opio-ids.

Canberra: Legislative Assembly for the Australian CapitalTerritory.


Oxford, UK

ADDAddiction




REPLY TO WODAK

Dr Wodak rejects my interpretation of his prediction(Wodak 1997) that the ‘most likely effect of the declinein heroin price and purity that we reported was a reduc-tion in heroin overdose deaths and crime’. He claimsthat: ‘These were not my views at the time, nor havethey become my views since.’ I am puzzled how he rec-onciles this assertion with the following statements inhis letter:

‘If drug users switched from injecting to other routes of administration, overdose deaths and new hepatitis C cases would tumble. A fall in street price of drugs would probably mean less crime (and ultimately lower insurance premiums and fewer prison cells). These are more important outcomes than the possibility of an increase in the number of drug users, which may not even happen.’

Second, Dr Wodak takes my assertion that ‘a herointrial came to be seen by some advocacy groups as the onlyway to reduce the steeply rising rate of opioid overdosedeaths’ as a criticism of his views. It was not. It was par-ent groups who claimed that a heroin trial was the onlyway to reduce overdose deaths. This can be discovered byanyone who reads the media’s coverage of the heroin trialdebate in the popular press.

WAYNE HALL

Office of Public Policy and EthicsInstitute for Molecular BioscienceUniversity of QueenslandSt LuciaQld 4072AustraliaE-mail: [email protected]

Reference

Wodak, A. (1997) We lose 500 young each year.

SydneyMorning Herald

, 28 January 1997, p. 14.


Oxford, UK

ADDAddiction


99Letter

Letter to the Editor

Letter to the Editor

HIGHLY ACTIVE ANTIRETROVIRAL THERAPY AMONG HIV-INFECTED PEOPLE WITH ALCOHOL AND SUBSTANCE MISUSE PROBLEMS: THE IMPACT OF SUBSTANCE ABUSE TREATMENT

The aims of a recent study published in

Addiction

were ‘toexamine the association of substance abuse treatmentwith the uptake adherence and virological response tohighly active antiretroviral therapy (HAART), amongHIV infected people with alcohol and other substanceabuse problems’ (Palepu

et al

. 2004). In this article theauthors report that substance abuse treatment was foundto be associated with the receipt of HAART, however, itwas not found to be associated with adherence, or HIVviral load suppression. They go on to suggest that effortsto maximize the effect of substance abuse treatment pro-grams on adherence to antiretrovirals and HIV treatmentoutcomes among HIV infected people with alcohol anddrug problems, merit further examination in clinicaltrials.

We would like to draw your attention to an article byClarke

et al

. (2002) which examines the use of directlyobserved therapy (DOT) for injecting drug users with HIVinfection. This prospective observational study was con-ducted in order to determine the efficacy of directlyobserved antiretroviral therapy, which was provided inconjunction with daily-observed methadone mainte-


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nance therapy. The authors report that at 48 weeks,51% of antiretroviral-experienced patients and 65% ofantiretroviral-naïve patients had achieved maximumviral suppression.

This study was conducted in a methadone mainte-nance treatment clinic where patients are required toattend daily until stable with respect to their drug use.Patients are dispensed all medications on site underobservation and are also offered continued counselling,social support, as well as regular psychiatric and medicalreviews. A liaison service also operates between this ser-vice and the department of genitourinary medicine andinfectious diseases at the regional hospital where themainstay of treatment for HIV positive patients isprovided.

Although HAART has been a major breakthrough inthe treatment of patients with HIV, many studies reportthat adherence remains a barrier to successful antiretro-viral therapy, as rates of

>

95% are necessary in order forit to be effective. Patients have been reported to offer arange of reasons for non-adherence, and one of the mostfrequently reported is that they simply forget (Bartlett2002). Other additional barriers to adherence ofteninclude substance misuse, depression, other psychiatricdisorders, regime complexity, and side-effects. Consistentparticipation in methadone maintenance therapy hasalready been shown to be associated with a higher prob-ability of antiretroviral use and, among antiretroviralusers, more consistent use of antiretrovirals (Sam-bamoorthi

et al

. 2000).In the above treatment setting, many of these barriers

to the adherence of HAART are also addressed, and thisin conjunction with DOT appears to be effective, andshould therefore be considered a potential option for pro-viding HAART to this group of patients.

JACINTA O’SHEA & EAMON KEENAN

South Western Area Health BoardAIDS/Drugs ServiceBridge HouseCherry Orchard HospitalBallyfermotDublin 10EireE-mail: [email protected]

References

Bartlett, J. A. (2002) Addressing the challenges of adher-ence.

Journal of Acquired Immune Deficiency Syndrome

,

29

,s2–10.

Clarke, S., Keenan, E., Ryan, M., Barry, M. & Mulcahy, F.(2002) Directly observed antiretroviral therapy for injec-tion drug users with HIV infection.

AIDS Reader

,

12

, 305–316.

Palepu, A., Horton, N. J., Tibbetts, N., Meil, S. & Samett, J. H.(2004) Uptake and adherence to highly active antiretroviraltherapy among HIV-infected people with alcohol and othersubstance use problems: the impact of substance abuse treat-ment.

Addiction

,

99

, 361–368.Sambamoorthi, U., Warner, L. A., Crystal, S. & Walkup, J.

(2000) Drug abuse, methadone treatment, and health serviceuse among injection drug users with AIDS.

Drug and AlcoholDependence

,

60

, 77–89.


Oxford, UK

ADDAddiction


99Original Article

Letter

to the EditorLetter to the Editor

AMAZING GOOD NEWS

I read the statement by Steve Burdette in his letterrecently published in

Addiction

(Burdette, 2004) that‘patient’s will never cease to amaze health-care pro-viders’ and agreed with him but for different reasons.Although Dr Burdette’s letter highlighted how damag-ing substance misuse can be, I rarely read of the posi-tive ways patients can ‘amaze health-care providers’once they enter treatment programmes. The verymorning I read Dr Burdette’s letter I saw a patient inthe clinic who made me realise why I entered thisfield and also why hope and optimism must never belost.

When I first met Hannah (pseudonym) in April 2003she was in a very sorry state. She was injecting anythingup to 2 g of heroin per day intravenously into her neck,breast and genital areas and funding her habit by work-ing in massage parlours.

She described a familiar and tragic background his-tory: a childhood she was unwilling to talk about,repeated contacts with the criminal justice systeminvolving prison sentences, poly substance misuse andfailed relationships, always with heroin-using malepartners. I started her on a methadone maintenanceregime and she was quickly titrated in the communityto 70 mg of methadone on a supervised consumptionbasis.

I reviewed her two months later. She had stoppedusing all illicit drugs and had ceased working in massageparlours. More impressively she had started working fulltime as a machine operator.

Three months later Hannah came to see me in theclinic and announced she was getting engaged to herpartner who had never used drugs. She was enjoyingwork, had bought a house and had reduced her metha-done down to 50 mg per day without any relapse intoheroin dependence. She wanted to continue reducing hermethadone down herself.

I reviewed Hannah at the end of April 2004, 12months after her first presentation. She has reduceddown to 10 mg methadone without any problems andhas started her own business with her fiancé. There is no

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evidence of illicit drug use and she has just discoveredthat she is hepatitis C negative. She was overjoyed when Iasked her permission to write this letter.

I accept that such miraculous transformations arerare. I find satisfaction in the small improvements in thelives of our patients that can occur with relatively littleinput. However, I would like to issue a challenge to anyhealth-care provider: is there any other treatment inter-vention to be found in medicine that is so cheap but canhave such an enormous impact on a patient’s physical,psychological and social health? That is why I love work-ing in this field.

NAV AHLUWALIA

Consultant in Substance MisuseRotherham Community Drug TeamMedway House, 1–3 Chatham StreetRotherhamUKE-mail: [email protected]

Reference

Burdette, S. (2004) Patients never cease to amaze.

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