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Press releases Saturday 12 January 2008

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(1) Should heroin be prescribed to addicts?
(2) People with dementia survive on average four and a half years after diagnosis
(3) Warning over severe weight loss caused by chewing gum

(1) Should heroin be prescribed to addicts?
(Head tp Head: Should heroin be precribed to addicts?)
Yes: http://www.bmj.com/cgi/content/full/336/7635/70
No: http://www.bmj.com/cgi/content/full/336/7635/71

In this week's BMJ experts debate whether heroin should be prescribed to addicts who are difficult to treat.

Maintenance treatment with heroin is appropriate for heroin misusers under certain circumstances, argue Jürgen Rehm from the Centre for Addiction and Mental Health in Toronto and Benedikt Fischer from the University of Victoria, British Columbia.

They point to trials in Switzerland, the Netherlands and Germany, which found heroin assisted maintenance treatment feasible and effective for those resistant to treatment. They also found it to be cost effective compared with methadone maintenance treatment.

In the UK, heroin has also been a treatment option for heroin misusers for several decades, but the practice remains controversial.

So, if maintenance treatment is generally justifiable, why should heroin not be used as one such pharmacological agent, they ask?

One reason that has been cited is safety, both for the patient and for the general public. Yet results from the Swiss studies show that mortality among patients in heroin assisted maintenance programmes is low, and lower than for patients in other maintenance programmes.

Overall, say the authors, we see no convincing reason why heroin assisted maintenance treatment should not be part of a comprehensive treatment system for opioid dependence.

But Neil McKeganey, Professor of Drug Misuse Research at the University of Glasgow argues that prescribing heroin to heroin addicts is treating the effects of misuse not the addiction.

The evidence in relation to heroin prescribing is far from conclusive, he says, while the cost of treating an addict with heroin is estimated to be three to four times that of treating an addict with methadone.

Prescribing heroin to heroin addicts is also a risky strategy, which could lead to massive pressure on doctors to prescribe increasing amounts of the drug.

Research has shown that with the right services in place it is possible to do more than simply stabilise addicts' continued drug use through the prescribing route, writes McKeganey. For example, a Scottish study found 29.4% of addicts who received residential rehabilitation were abstinent for at least 90 days compared with only 3.4% receiving methadone maintenance.

Other research has found that most addicts want services to help them become drug free. Health services therefore need to ensure that they are supporting addicts' attempts to become drug free, and they need to be extremely cautious about any extension of a policy that could be seen as a route to maintaining rather than reducing an individual's drug dependency, he concludes.

Contacts:
Jürgen Rehm, Chair, Centre for Addiction and Mental Health, Toronto, Canada
Email: jtrehm@aol.com
Neil McKeganey, Professor of Drug Misuse Research, University of Glasgow, Scotland
Email: n.mckeganey@lbss.gla.ac.uk
 

(2) People with dementia survive on average four and a half years after diagnosis
(Survival times in people with dementia: analysis from population based cohort study with 14 year follow-up)
http://www.bmj.com/cgi/content/full/bmj.39433.616678.25v1
(Editorial: Caring for people with dementia)
http://www.bmj.com/cgi/content/full/bmj.39429.434907.80v1

People with dementia survive an average of four and a half years after diagnosis, with age, sex, and existing disability all having an influence on life expectancy, finds a study published on bmj.com today.

The authors hope that these estimates will be of value to patients, carers, service providers, and policy-makers.

The number of people affected by dementia is estimated to double every 20 years to 81 million by 2040. Dementia is known to be associated with increased risk of death, but no estimate exists for actual survival with dementia in England and Wales. There is also considerable uncertainty about what influences survival.

So researchers set out to describe overall survival for people with dementia and to examine the association between factors which could affect survival.

The study involved over 13,000 individuals aged 65 years and above who were taking part in a population based study in England and Wales. Participants were assessed for dementia at regular intervals over a 14-year period 1991 to 2005.

Factors known to have an association with mortality, such as age, sex and marital status, accommodation type, education level, social class, self-reported health and disability were also recorded.

438 individuals developed dementia over the study period, of which 356 (81%) died.

Age, sex, and disability before onset all influenced survival independently.

There was nearly seven years difference in survival between the youngest and the oldest people with dementia (10.7 years for those aged 65-69 and 3.8 years for those aged 90 or over).

Average survival time from dementia onset to death was 4.1 years for men and 4.6 years for women.

There was around a three year reduction in survival between the most and least disabled at onset, suggesting that the frailer individuals are at higher risk, even after age is taken into account.

However, living in the community or residential home, marital status, and self-reported health were not associated with survival once other factors were taken into account.

Those with higher education had slightly shorter survival than those with lower education, but this did not reach statistical significance. Social class also showed no pattern

Knowing which factors influence the length of survival after onset of dementia is important, say the authors. These findings will be of value to patients, carers, service providers and policy-makers.

An accompanying editorial urges doctors to pay as much attention to strengths and retained abilities as they do deficits, dysfunction and disease when planning care and support for people with dementia.

Contact:
Carol Brayne, Professor of Public Health Medicine, Institute of Public Health, University of Cambridge, UK
Email: gm349@admin.cam.ac.uk 

(3) Warning over severe weight loss caused by chewing gum
(Lesson of the Week: Severe weight loss caused by chewing gum)
http://www.bmj.com/cgi/content/short/336/7635/96

In this week's BMJ, doctors warn of excess sorbitol intake, a widely used sweetener in "sugar-free" products such as chewing gum and sweets.

Sorbitol has laxative properties and is poorly absorbed by the small intestine.

Their advice follows the cases of two patients with chronic diarrhoea, abdominal pain and severe weight loss. Although extensive investigations were carried out, final diagnosis was only established after detailed analysis of eating habits.

On questioning, both patients admitted consuming substantial amounts of sugar-free gum and sweets.

The first patient (a 21 year old woman) chewed large amounts of sugar-free gum, accounting for a total daily dose of 18-20g sorbitol (one stick of chewing gum contains about 1.25g sorbitol). The second patient (a 46 year old man) reported chewing 20 sticks of sugar-free gum and eating up to 200g of sweets each day, which together contained around 30g sorbitol.

After both patients started a sorbitol free diet, diarrhoea subsided, normal bowel movements resumed and weight gain was achieved.

As possible side effects are usually found only within the small print on foods containing sorbitol, consumers may be unaware of its laxative effects and fail to recognise a link with their gastrointestinal problems, write the authors.

In conclusion, they say, our cases demonstrate that sorbitol consumption can cause not only chronic diarrhoea and functional bowel complaints but also considerable unintended weight loss (about 20% of usual body weight). Thus, the investigation of unexplained weight loss should include detailed dietary history with regard to foods containing sorbitol.

Contacts:
Juergen Bauditz or Herbert Lochs, Department of Gastroenterology, Hepatology and Endocrinology, University of Berlin, Germany, UK
Email: juergen.bauditz@charite.de 

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