Dihydrocodeine for detoxification and maintenance treatment in individuals with opiate use disorders

BACKGROUND

Medical treatment and detoxification from opiate disorders includes oral administration of opioid agonists. Dihydrocodeine (DHC) substitution treatment is typically low threshold and therefore has the capacity to reach wider groups of opiate users. Decisions to prescribe DHC to patients with less severe opiate disorders centre on its perceived safety, reduced toxicity, shorter half-life and more rapid onset of action, and potential retention of patients. This review set out to investigate the effects of DHC in comparison to other pharmaceutical opioids and placebos in the detoxification and substitution of individuals with opiate use disorders.

OBJECTIVES

To investigate the effectiveness of DHC in reducing illicit opiate use and other health-related outcomes among adults compared to other drugs or placebos used for detoxification or substitution therapy.

SEARCH METHODS

In February 2019 we searched Cochrane Drugs and Alcohol's Specialised Register, CENTRAL, PubMed, Embase and Web of Science. We also searched for ongoing and unpublished studies via ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and Trialsjournal.com. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials that evaluated the effect of DHC for detoxification and maintenance substitution therapy for adolescent (aged 15 years and older) and adult illicit opiate users. The primary outcomes were abstinence from illicit opiate use following detoxification or maintenance therapy measured by self-report or urinalysis. The secondary outcomes were treatment retention and other health and behaviour outcomes.

DATA COLLECTION AND ANALYSIS

We followed the standard methodological procedures that are outlined by Cochrane. This includes the GRADE approach to appraise the quality of evidence.

MAIN RESULTS

We included three trials (in five articles) with 385 opiate-using participants that measured outcomes at different follow-up periods in this review. Two studies with 150 individuals compared DHC with buprenorphine for detoxification, and one study with 235 participants compared DHC to methadone for maintenance substitution therapy. We downgraded the quality of evidence mainly due to risk of bias and imprecision. For the two studies that compared DHC to buprenorphine, we found low-quality evidence of no significant difference between DHC and buprenorphine for detoxification at six-month follow-up (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.25 to 1.39; P = 0.23) in the meta-analysis for the primary outcome of abstinence from illicit opiates. Similarly, low-quality evidence indicated no difference for treatment retention (RR 1.29, 95% CI 0.99 to 1.68; P = 0.06). In the single trial that compared DHC to methadone for maintenance substitution therapy, the evidence was also of low quality, and there may be no difference in effects between DHC and methadone for reported abstinence from illicit opiates (mean difference (MD) -0.01, 95% CI -0.31 to 0.29). For treatment retention at six months' follow-up in this single trial, the RR calculated with an intention-to-treat analysis also indicated that there may be no difference between DHC and methadone (RR 1.04, 95% CI 0.94 to 1.16). The studies that compared DHC to buprenorphine reported no serious adverse events, while the DHC versus methadone study reported one death due to methadone overdose.

AUTHORS' CONCLUSIONS

We found low-quality evidence that DHC may be no more effective than other commonly used pharmacological interventions in reducing illicit opiate use. It is therefore premature to make any conclusive statements about the effectiveness of DHC, and it is suggested that further high-quality studies are conducted, especially in low- to middle-income countries.

The impact of alcohol use on tuberculosis treatment outcomes: a systematic review and meta-analysis

Alcohol use is associated with increased risk of developing tuberculosis (TB) disease, yet the impact of alcohol use on TB treatment outcomes has not been summarized. We aimed to quantitatively review evidence of the relationship between alcohol use and poor TB treatment outcomes. We conducted a systematic review of PubMed, EMBASE, and Web of Science (January 1980-May 2018). We categorized studies as having a high- or low-quality alcohol use definition and examined poor treatment outcomes individually and as two aggregated definitions (i.e., including or excluding loss to follow-up [LTFU]). We analyzed drug-susceptible (DS-) and multidrug-resistant (MDR-) TB studies separately. Our systematic review yielded 111 studies reporting alcohol use as a predictor of DS- and MDR-TB treatment outcomes. Alcohol use was associated with increased odds of poor treatment outcomes (i.e., death, treatment failure, and LTFU) in DS (OR 1.99, 95% CI 1.57-2.51) and MDR-TB studies (OR 2.00, 95% CI 1.73-2.32). This association persisted for aggregated poor treatment outcomes excluding LTFU, each individual poor outcome, and across sub-group and sensitivity analyses. Only 19% of studies used high-quality alcohol definitions. Alcohol use significantly increased the risk of poor treatment outcomes in both DS- and MDR-TB patients. This study highlights the need for improved assessment of alcohol use in TB outcomes research and potentially modified treatment guidelines for TB patients who consume alcohol.

'What will it take': addressing alcohol use among people living with HIV in South Africa

Given that hazardous and harmful alcohol use has been identified as a significant barrier to adherence to antiretroviral therapy (ART) in South Africa, alcohol reduction interventions delivered within HIV treatment services are being investigated. Prior to designing and implementing an alcohol-focused screening and brief intervention (SBI), we explored patients’ perceptions of alcohol as a barrier to HIV treatment, the acceptability of providing SBIs for alcohol use within the context of HIV services and identifying potential barriers to patient uptake of this SBI. Four focus groups were conducted with 23 participants recruited from three HIV treatment sites in Tshwane, South Africa. Specific themes that emerged included: (1) barriers to ART adherence, (2) available services to address problematic alcohol use and (3) barriers and facilitators to delivering a brief intervention to address alcohol use within HIV care. Although all participants in the present study unanimously agreed that there was a great need for SBIs to address alcohol use among people living with HIV and AIDS, our study identified several areas that should be considered prior to implementing such a programme.

Electronic cigarettes: the solution or yet another phase of the tobacco epidemic?

Tobacco use is the single largest preventable cause of death globally. For years, the tobacco industry sought to create a tobacco product that is less controversial than conventional cigarettes. Electronic cigarettes were created out of the supposed need to supply consumers of tobacco products with a less harmful tobacco product. The question remains, is it really less harmful for consumers of traditional cigarettes and other tobacco products to switch to electronic cigarettes? This article takes a closer look at the overall harm in relation to benefits of using electronic cigarettes for the individual and public health and the unintended negative consequences the introduction of electronic cigarette has had on overall public health. Given the evidence that the use of electronic cigarettes is a gateway to the use of other tobacco products especially among adolescents, we view electronic cigarettes as having the potential to cause a rebound of the tobacco use glut which the global public health community has been succeeding in reversing. We therefore support the World Health Organization’s suggestion that electronic cigarettes should be regulated as other tobacco products since there is, as yet, no harmless tobacco product. In the same vein, we view the new Tobacco Products and Electronic Delivery Systems Bill seeking to regulate electronic cigarettes in South Africa as other tobacco products as a step in the right direction.

Addressing the intersection between alcohol consumption and antiretroviral treatment: needs assessment and design of interventions for primary healthcare workers, the Western Cape, South Africa

BACKGROUND

At the points where an infectious disease and risk factors for poor health intersect, while health problems may be compounded, there is also an opportunity to provide health services. Where human immunodeficiency virus (HIV) infection and alcohol consumption intersect include infection with HIV, onward transmission of HIV, impact on HIV and acquired immunodeficiency syndrome (AIDS) disease progression, and premature death. The levels of knowledge and attitudes relating to the health and treatment outcomes of HIV and AIDS and the concurrent consumption of alcohol need to be determined. This study aimed to ascertain the knowledge, attitudes and practices of primary healthcare workers concerning the concurrent consumption of alcohol of clinic attendees who are prescribed antiretroviral drugs. An assessment of the exchange of information on the subject between clinic attendees and primary healthcare providers forms an important aspect of the research. A further objective of this study is an assessment of the level of alcohol consumption of people living with HIV and AIDS attending public health facilities in the Western Cape Province in South Africa, to which end, the study reviewed health workers' perceptions of the problem's extent. A final objective is to contribute to the development of evidence-based guidelines for AIDS patients who consume alcohol when on ARVs. The overall study purpose is to optimise antiretroviral health outcomes for all people living with HIV and AIDS, but with specific reference to the clinic attendees studied in this research.

METHODS

Overall the research study utilised mixed methods. Three group-specific questionnaires were administered between September 2013 and May 2014. The resulting qualitative data presented here supplements the results of the quantitative data questionnaires for HIV and AIDS clinic attendees, which have been analysed and written up separately. This arm of the research study comprised two, separate, semi-structured sets of interviews: one face-to-face with healthcare workers at the same primary healthcare clinics from which the clinic attendees were sampled, and the other with administrators from the local government health service via email. The qualitative analysis from the primary healthcare worker interviews has been analysed using thematic content analysis.

RESULTS

The key capacity gaps for nurses include the definition of different patterns and volumes of alcohol consumption, resultant health outcomes and how to answer patient questions on alcohol consumption while on antiretroviral treatment. Not only did the counsellors lack knowledge regarding alcohol abuse and its treatment, but they were also they were unclear on their role and rights in relation to their patients. Doctors highlighted the need for additional training for clinicians in diagnosing alcohol use disorders and information on the pharmacological interventions to treat alcoholism.

CONCLUSION

Pertinent knowledge regarding patient alcohol consumption while taking ARVs needs to be disseminated to primary healthcare workers.

The state of interventions to address substance-related disorders in South African workplaces: implications for research, policy, and practice

Substance abuse in South Africa is highly prevalent and continues to be a major cause of mortality and a risk factor for both communicable and non-communicable diseases. The employer costs associated with substance abuse remain high owing to rising health costs, accidents, absenteeism, and workers’ compensation claims placing the organisation and its employees at risk for harm. This article describes the status of current policy, prevention, and treatment interventions to address substance abuse in the South African workplace. Key issues highlighted are the need for research into the extent and impact of substance abuse in the South African workforce, the promotion of substance abuse policies that are comprehensive in nature, and the need to upscale prevention and treatment initiatives through a move away from a traditional labour approach to addressing substance-related disorders in the workplace to the adoption of a more public health approach. Cost-effectiveness of substance abuse interventions is explored alongside the importance of ensuring that employers, practitioners, and other role players engage with the evidence of what works using international standards as the basis.

Restricting or banning alcohol advertising to reduce alcohol consumption in adults and adolescents

BACKGROUND

Alcohol is estimated to be the fifth leading risk factor for global disability-adjusted life years. Restricting or banning alcohol advertising may reduce exposure to the risk posed by alcohol at the individual and general population level. To date, no systematic review has evaluated the effectiveness, possible harms and cost-effectiveness of this intervention.

OBJECTIVES

To evaluate the benefits, harms and costs of restricting or banning the advertising of alcohol, via any format, compared with no restrictions or counter-advertising, on alcohol consumption in adults and adolescents.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register (May 2014); CENTRAL (Issue 5, 2014); MEDLINE (1966 to 28 May 2014); EMBASE (1974 to 28 May 2014); PsychINFO (June 2013); and five alcohol and marketing databases in October 2013. We also searched seven conference databases and www.clinicaltrials.gov and http://apps.who.int/trialsearch/ in October 2013. We checked the reference lists of all studies identified and those of relevant systematic reviews or guidelines, and contacted researchers, policymakers and other experts in the field for published or unpublished data, regardless of language.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), controlled clinical trials, prospective and retrospective cohort studies, controlled before-and-after studies and interrupted time series (ITS) studies that evaluated the restriction or banning of alcohol advertising via any format including advertising in the press, on the television, radio, or internet, via billboards, social media or product placement in films. The data could be at the individual (adults or adolescent) or population level.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included one small RCT (80 male student participants conducted in the Netherlands and published in 2009) and three ITS studies (general population studies in Canadian provinces conducted in the 1970s and 80s).The RCT found that young men exposed to movies with a low-alcohol content drank less than men exposed to movies with a high-alcohol content (mean difference (MD) -0.65 drinks; 95% CI -1.2, -0.07; p value = 0.03, very-low-quality evidence). Young men exposed to commercials with a neutral content compared with those exposed to commercials for alcohol drank less (MD -0.73 drinks; 95% CI -1.30, -0.16; p value = 0.01, very-low-quality evidence). Outcomes were assessed immediately after the end of the intervention (lasting 1.5 hours), so no follow-up data were available. Using the Grading of Recommendations Assessment, Development and Evaluation approach, the quality of the evidence was rated as very low due to a serious risk of bias, serious indirectness of the included population and serious level of imprecision.Two of the ITS studies evaluated the implementation of an advertising ban and one study evaluated the lifting of such a ban. Each of the three ITS studies evaluated a different type of ban (partial or full) compared with different degrees of restrictions or no restrictions during the control period. The results from the three ITS studies were inconsistent. A meta-analysis of the two studies that evaluated the implementation of a ban showed an overall mean non-significant increase in beer consumption in the general population of 1.10% following the ban (95% CI -5.26, 7.47; p value = 0.43; I(2) = 83%, very-low-quality evidence). This finding is consistent with an increase, no difference, or a decrease in alcohol consumption. In the study evaluating the lifting of a total ban on all forms of alcohol advertising to a partial ban on spirits advertising only, which utilised an Abrupt Auto-regressive Integrated Moving Average model, the volume of all forms of alcohol sales decreased by 11.11 kilolitres (95% CI -27.56, 5.34; p value = 0.19) per month after the ban was lifted. In this model, beer and wine sales increased per month by 14.89 kilolitres (95% CI 0.39, 29.39; p value = 0.04) and 1.15 kilolitres (95% CI -0.91, 3.21; p value = 0.27), respectively, and spirits sales decreased statistically significantly by 22.49 kilolitres (95% CI -36.83, -8.15; p value = 0.002). Using the GRADE approach, the evidence from the ITS studies was rated as very low due to a high risk of bias arising from a lack of randomisation and imprecision in the results.No other prespecified outcomes (including economic loss or hardship due to decreased alcohol sales) were addressed in the included studies and no adverse effects were reported in any of the studies. None of the studies were funded by the alcohol or advertising industries.

AUTHORS' CONCLUSIONS

There is a lack of robust evidence for or against recommending the implementation of alcohol advertising restrictions. Advertising restrictions should be implemented within a high-quality, well-monitored research programme to ensure the evaluation over time of all relevant outcomes in order to build the evidence base.

Hazardous and harmful use of alcohol and/or other drugs and health status among South African patients attending HIV clinics

There is growing recognition of the influence of substance use, particularly alcohol use, on HIV disease progression. This study investigated how hazardous/harmful use of alcohol and drugs impacts the health status of 1503 patients attending HIV clinics. Of the sample, 37 % indicated hazardous/harmful drinking and 13 % indicated a drug problem. Hazardous/harmful use of alcohol and drugs was significantly related to health status, with participants using substances more likely to have TB-positive status (χ(2) = 4.30, p < 0.05), less likely to be on ARVs (χ(2) = 9.87, p < 0.05) and having lower CD4 counts (t = 4.01, p < 0.05). Structural equation modelling confirmed the centrality of hazardous/harmful use of alcohol as a direct and indirect determinant of disease progression. Based on these findings it is recommended that patients attending HIV clinics be routinely screened for problematic alcohol and/or drug use, with strong emphasis on ensuring ARV adherence in those with problematic alcohol use.

Identifying perceived barriers to monitoring service quality among substance abuse treatment providers in South Africa

BACKGROUND

A performance measurement system is planned for South African substance abuse treatment services. Provider-level barriers to implementing these systems have been identified in the United States, but little is known about the nature of these barriers in South Africa. This study explored the willingness of South African substance abuse treatment providers' to adopt a performance measurement system and perceived barriers to monitoring service quality that would need to be addressed during system development.

METHODS

Three focus group discussions were held with treatment providers from two of the nine provinces in South Africa. These providers represented the diverse spread of substance abuse treatment services available in the country. The final sample comprised 21 representatives from 12 treatment facilities: eight treatment centres in the Western Cape and four in KwaZulu-Natal. Content analysis was used to extract core themes from these discussions.

RESULTS

Participants identified barriers to the monitoring of service quality that included outdated modes of collecting data, personnel who were already burdened by paperwork, lack of time to collect data, and limited skills to analyse and interpret data. Participants recommended that developers engage with service providers in a participatory manner to ensure that service providers are invested in the proposed performance measurement system.

CONCLUSION

Findings show that substance abuse treatment providers are willing to adopt a performance measurement system and highlight several barriers that need to be addressed during system development in order to enhance the likelihood that this system will be successfully implemented.

A preliminary investigation of the AUDIT and DUDIT in comparison to biomarkers for alcohol and drug use among HIV-infected clinic attendees in Cape Town, South Africa

OBJECTIVE

There is growing concern about the effect of substance use on HIV treatment outcomes. The study objectives included: (i) evaluating whether the use of validated questionnaires (AUDIT and DUDIT) provide useful and consistent information of alcohol and drug consumption when compared with the use of biomarkers of alcohol in (urine and hair) and drugs in (urine) and (ii) assessing the feasibility of using self-report measures compared with urine and hair tests.

METHOD

Participants were HIV positive patients attending an HIV community health clinic in Kraaifontein, Cape Town. Hair and urine samples were collected and analysed for alcohol, in Fatty Acid Ethyl Esters (FAEE) and in Ethyl Glucuronide and (EtG), and drugs. Biological markers were compared with self-report measures of alcohol and drug consumption in terms of sensitivity, specificity. Forty-three participants completed the self-report measures, while 30 provided hair and urine samples.

RESULTS

On the AUDIT, 18 (41.9%) participants screened positive for harmful and hazardous drinking and 13 (30.2%) participants on the DUDIT screened positive for having a drug-related problem. Two of 30 participants (7%) tested positive for alcohol abuse on FAEE analysis. For EtG, 6 of 24 (25%) participants tested positive for alcohol abuse. On hair drug analysis, all 30 participants tested negative for cannabis, amphetamines, opiates, cocaine, PCP and methaqualone. On the urinalysis, 1 of 30 participants tested positive for cannabis and everyone tested negative for all other drugs included in the screening.

CONCLUSION

Substance use among patients attending HIV clinics appears to be a problem, especially alcohol. Self-report measures seem to be a more cost effective option for screening of alcohol and drug abuse in resource poor settings.

Cocaine treatment admissions at three sentinel sites in South Africa (1997-2006): findings and implications for policy, practice and research

BACKGROUND

Accurate prevalence data on cocaine use, that points to where problems exist and the extent of these problems, is necessary to guide the formulation of effective substance abuse policy and practice. The purpose of this study was to provide surveillance information about the nature and extent of problematic cocaine use in South Africa.

METHODS

Data were collected between January 1997 and December 2006 on admissions for drug abuse treatment through a regular monitoring system involving 56 drug treatment centres and programmes in Cape Town, Gauteng Province (Johannesburg and Pretoria) and the Eastern Cape every six months as part of the South African Community Epidemiology Network on Drug Use (SACENDU). A one-page form was completed by treatment centre personnel to obtain demographic data, the patients' primary and secondary substances of abuse, the mode, frequency and age of first use of substance, and information on prior treatment.

RESULTS

Treatment indicators point to a significant increase in cocaine related admissions over time in all sites, but with substantial inter-site variation, particularly in recent years. The data indicate high levels of crack cocaine use and high levels of daily usage among patients, most of whom were first time admissions. Patients with cocaine related problems continue to be predominantly male, with a mean age of around 30 years. Substantial changes in the racial profile of patients have occurred over time. Poly drug use is high with cocaine often used with alcohol, cannabis and other drugs.

CONCLUSION

These trends point to the possibility of cocaine use becoming a serious health and social issue in South Africa and demonstrate the utility of continued monitoring of cocaine treatment admissions in the future. They also highlight the need to address cocaine use in national and provincial policy planning and intervention efforts. In terms of treatment, the findings highlight the need to ensure that treatment practitioners are adequately trained to address stimulant problems, poly drug use, and HIV and other risk behaviour related to crack cocaine use. Possible gaps in access to treatment by certain sectors of the population should be addessed as a matter of urgency.

Profile of drinking behaviour and comparison of self-report with the CAGE questionnaire and carbohydrate-deficient transferrin in a rural Lesotho community

This paper aims to: (1) profile the drinking behaviour of a rural Lesotho community facing relocation; (2) compare the following measures of hazardous drinking in this community: quantity/frequency self-report, the CAGE questionnaire and carbohydrate-deficient transferrin (CDT) levels; (3) describe community awareness of, and attitude towards, treatment services. As part of a larger baseline survey of community health status, households in 29 villages in Lesotho were randomly sampled. Consenting adults (n = 348) participated in a face-to-face interview about alcohol use, which included the CAGE. Blood was taken from participants for CDT determination. Fifty-three per cent of men (37/69) and 19% of women (53/279) reported drinking alcohol. Thirty-six per cent of men (25/69) and 9% of women (25/279) were classified as hazardous drinkers defined as drinking 350 g (males) or 225 g (females) of alcohol/week, or 'engaged in bouts of heavy drinking 1 to 2 days a month or more during the past 12 months'. Hazardous drinkers were significantly more likely to be male and older, but did not differ from the rest of the sample on marital status. Using hazardous drinking as the standard, CAGE (score > or = 2) had a positive predictive value (PPV) of 75% for men and 62% for women. The parameters for CDT must be interpreted with caution as the cut-offs for hazardous drinking, especially for women's drinking, were lower than the usual cut-offs in published CDT studies. However, the high specificities for CDT in men (100%; 19/19) and in women (77%; 110/142) are consistent with other studies, but the low PPV of 14% (5/37) for men and women combined suggests that CDT is not effective as a predictor of hazardous drinking in this population. There was high awareness of available treatment services among participants, and most believed treatment to be beneficial. Overall, the study provides a comprehensive baseline profile of drinking behaviour in this community, but did not show the CAGE questionnaire or CDT profile to be useful in in this community.

To what extent does South African mental health and substance abuse research address priority issues?

OBJECTIVE

To investigate the extent to which South African mental health research addresses priority issues.

DESIGN

Cross-sectional survey of conference presentations.

SETTING

The most recent conferences of the following professional societies: the Epidemiological Society of Southern Africa, the Psychological Society of South Africa, the Society of Psychiatrists of South Africa, and the South African Association for Child and Adolescent Psychiatry and Allied Disciplines.

MAIN OUTCOME MEASURES

Whether the presentations addressed priority areas as defined in the list 'Selected priority areas of research' compiled by the Mental Health and Substance Abuse Thrust of the Medical Research Council, and if so which priority areas were addressed.

RESULTS

There were 627 presentations, with 267 (43%) on mental health or substance abuse. Seventy-eight papers (29%) reported original research in a priority area identified by the Medical Research Council. Of these, 73 (94%) were on mental health and 5 (6%) were on substance abuse. Of the 73 papers on mental health, 33 (45%) addressed topics in health problem research, 7 (10%) aetiology research, 22 (30%) intervention research, and 11 (15%) operational and health systems research.

CONCLUSION

Much South African mental health research does not address priority issues. There is a particular dearth of research addressing substance abuse research priorities. Funding mechanisms and research capacity development initiatives could help to rectify the situation.

Performance of the Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3) in an informal settlement area in South Africa

OBJECTIVE

To investigate the performance of the Xhosa Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3) in a community study of African children and adolescents in Khayelitsha, a largely informal settlement area in Cape Town, South Africa.

METHOD

A cross-sectional community study of 500 youths aged 6 to 16 years was undertaken using a systematic sampling strategy based on random starting points in the community. Three trained Xhosa-speaking lay interviewers administered the DISC-2.3 to youths and their parents in their homes. Additional questions included degree of impairment, selected risk factors, and service use.

RESULTS

The administration of the Xhosa DISC-2.3 in an informal settlement area was both feasible and acceptable to respondents. Psychiatric disorder with impairment was recorded for 76 (15.2%) of the children and adolescents. Consultation had been sought in only 20 cases, mostly from medical doctors, except for 3 who had attended indigenous healers. Rates of disorder were significantly higher among respondents who were living in unserviced areas or who came from homes where food was needed.

CONCLUSIONS

The DISC is a potentially useful instrument even in the presence of major constraints on conducting epidemiological research.

Seasonal variation of suicide in South Africa

Seasonal trends in South African suicide incidence were investigated with a view to ascertaining whether they are consistent with those in the northern hemisphere regarding: (1) the existence of the expected pattern; (2) this pattern being more pronounced for less urbanized groups; and (3) the presence of a secondary fall peak for youth and females. Log-linear modelling was performed to investigate the effect of month and relevant demographic variables on the suicide counts. The 16,389 nationally registered suicide deaths during 1980-1989 were analysed. The expected pattern, with a peak in the spring (that is, in September/October) or summer and a trough in winter, was present. This pattern was more pronounced for a sub-group that is less urbanized and for another sub-group with a relatively low standard of living. The secondary peak in autumn was not present for youth or females. In the northern hemisphere, this secondary peak has been ascribed to sociodemographic factors associated with the commencement of the academic year and (for females) bioclimatic factors associated with gender-specific biological circannual rhythms. The fact that the academic year commences in summer in South Africa indicates that the present findings are consistent with the former explanation.

Suicide in South Africa. An analysis of nationally registered mortality data for 1984-1986

Nationally registered suicide mortality data for South Africa (1984-1986) were analysed. There were 5448 deaths (1.3%) due to suicide in this period. Proportional mortality and mean annual suicide mortality rates were highest for whites, followed by Asians and then coloureds. The proportional mortality for blacks was similar to that of coloureds. Suicide was relatively prominent as a cause of death for Asian females (15-24 years). For whites, the most commonly used method of suicide was firearms. Except for coloured females, hanging was the most common method used for the other population groups. Political, economic, and religious factors may account for some of the differences. Cultural factors may explain the findings for young Asian females. There is a need for strict gun control legislation.

Assessment of alcohol-screening instruments in tuberculosis patients

SETTING

Two samples of hospitalised tuberculosis (TB) patients were randomly selected.

OBJECTIVE

To evaluate the usefulness of two alcohol-use screening instruments (AUDIT and CAGE).

DESIGN

A cross-sectional analytic study was conducted with 122 patients (61 Coloured and 61 African).

RESULTS

In the coloured group, AUDIT and CAGE identified 57% and 62% of patients respectively as scoring above the cut-off points for possible alcohol misuse. In the African group, AUDIT and CAGE identified 36% and 31% of patients respectively as scoring above the cut-off points. Rates for risky drinking found in community-based studies were lower than those found in this study for the Coloured sample. The male African group's CAGE result for alcohol misuse (17/46; 37%) is similar to the CAGE finding for African male mineworkers (33%), also findings from a community study in African males (34-37%). Both instruments were in agreement with each other for both groups. Slight to substantial agreement was observed between the instruments and other assessments of alcohol misuse (ward sister's perception, patient's file, self-perception and communal drinking), as well as between these assessments, for both groups.

CONCLUSION

Screening instruments such as AUDIT and CAGE can play a useful role in describing alcohol misuse among TB patients and in facilitating intervention programmes.

Why the gap? Practice and policy in civil commitment hearings

The failure of civil commitment procedures to meet statutory requirements is one of the more reliable findings in the applied social sciences. Most states now require specific legal procedures and behavioral standards for involuntary hospitalization. Nonetheless, empirical studies have demonstrated that commitment hearings are rarely adversarial and clinical concerns continue to take precedence over legal issues. These findings are analyzed in the context of three related issues: the grounds for commitment that are used in civil commitment hearings, the particular difficulties of recommitment hearings, and the shortcomings of the national policy of deinstitutionalization. The authors conclude that a primary cause of the gap between legal standards and actual practice is the absence of viable, less restrictive alternatives to inpatient treatment.

Length of hospitalization and outcome of commitment and recommitment hearings

Despite extensive legislative reformulation of civil commitment procedures, empirical studies have shown that civil commitment hearings continue to be largely nonadversarial. The authors observed all civil commitment hearings during a three-month period at a large state hospital in Virginia and examined the characteristics of patients and the actions of attorneys, clinical examiners, and judges as a function of the length of time the patient had been in the hospital. The analysis revealed that as the length of a patient's hospitalization increased, the hearings became shorter and less adversarial; patients tended to show fewer signs of acute psychiatric illness and more signs of chronic schizophrenia. The implications of these findings for civil commitment policy are discussed.

Why the gap? Practice and policy in civil commitment hearings

The failure of civil commitment procedures to meet statutory requirements is one of the more reliable findings in the applied social sciences. Most states now require specific legal procedures and behavioral standards for involuntary hospitalization. Nonetheless, empirical studies have demonstrated that commitment hearings are rarely adversarial and clinical concerns continue to take precedence over legal issues. These findings are analyzed in the context of three related issues: the grounds for commitment that are used in civil commitment hearings, the particular difficulties of recommitment hearings, and the shortcomings of the national policy of deinstitutionalization. The authors conclude that a primary cause of the gap between legal standards and actual practice is the absence of viable, less restrictive alternatives to inpatient treatment.

Hypertension in the coloured population of the Cape Peninsula

In a random sample of 976 coloured people 17.2% of men and 18.4% of women were hypertensive (greater than or equal to 160/95 mmHg or receiving medication). In the same population 35.6% of men and 24.7% of women suffered from total hypertension (greater than or equal to 140/90 mmHg). Men between 25 and 44 years had a markedly higher prevalence of hypertension than women of the same age. Above this age the situation was reversed. Correcting for under- and over-cuffing increased the mean pressures in men and decreased them in older women. Only 42.2% of hypertensive men and 69.9% of women were aware of their condition. Only 41.3% were on medication for it and a mere 16% had blood pressures below 160/95 mmHg. Hypertensives had significantly lower intakes of potassium, calcium, magnesium and saturated fat than normotensive subjects. Young hypertensives consumed more salt than older hypertensives. Both systolic and diastolic blood pressures were positively associated with alcohol consumption, smoking (in men), total serum cholesterol, low-density lipoprotein cholesterol, non-fasting triglyceride and uric acid levels. Hypertensive subjects were less educated and showed more type A coronary-prone behaviour than normotensives. A comparison of the prevalence of hypertension in the four South African ethnic groups is given.

Coronary risk factors in the coloured population of the Cape Peninsula

A cross-sectional study of risk factors for coronary heart disease (CHD) in a random sample of 976 coloured people revealed a population greatly at risk of CHD. The major reversible risk factors--hypercholesterolaemia, hypertension and smoking--were very common, with 56% of the men and 40% of the women smoking, 18% of both men and women being hypertensive and 17% of both sexes being hypercholesterolaemic. At high cut-off points 62,8% of the men and 59,4% of the women had at least one major reversible risk factor. At lower but real levels of risk, over 80% of the population was affected. Other risk factors such as inactivity, overweight, hyperuricaemia, hypertriglyceridaemia and a positive family history of CHD were all common in this population group. A 'protective' high-density lipoprotein cholesterol level of greater than or equal to 20% of the total serum cholesterol level was found in 74,5% of the men and 81,1% of the women. A comparison with available data on other South African population risk profiles shows marked differences. The need for preventive strategies in the coloured population is clear.

A retrospective study of head-injured children admitted to two hospitals in Cape Town

A retrospective study was undertaken to describe the patterns of head injury in children in the Cape Peninsula. Information was abstracted from Groote Schuur Hospital and Red Cross War Memorial Children's Hospital records for all children aged under 15 years admitted with head injury between July 1966 and June 1981. Data were collected on 1 820 admissions. There were significantly higher percentages of Coloureds and Blacks, males and children aged under 6 years in the sample than in the corresponding population of the Cape Peninsula. In children under 1 year old, fails accounted for approximately 70% of head injuries in all three race groups. In the 1-5-year age group, transport-related injuries were the most common cause of admission in Blacks (63,1%) and Coloureds (46,5%), but in Whites falls were still most common (58,2%). In the 6-14-year age group, transport-related accidents accounted for approximately 64% of head injuries in all three race groups. Pedestrian accidents were the commonest cause of admissions due to transport-related head injury. Severe or very severe concussive injuries, multiple injuries or death occurred more commonly in transport-related injuries than among those caused by falls or assault/abuse. Transport, falls and assault/abuse together accounted for 88,4% of all causes of head injury.

The causes of non-natural deaths in children over a 15-year period in greater Cape Town

This study was undertaken to describe the causes of non-natural death in children aged under 15 years in the Cape Peninsula. Information was abstracted from the official death register kept at the South African Police Mortuary in Cape Town for the period of 1 July 1966-30 June 1981. During the 15-year period 3 248 medicolegal autopsies were performed on children under 15 years of age who had died of non-natural causes. There were significantly higher percentages of Coloureds and Blacks, males, and children aged under 6 years in the sample than in the general population aged under 15 years in the Cape Peninsula. The majority of deaths (54,4%) were caused by road traffic injuries. Other important causes of deaths were burns (12,8%), drowning (11,0%), assault/abuse (5,4%) and poisoning (3,3%). Special attention was paid to the causes of fatal head injuries--head injury alone was given as the cause of death in 819 autopsies (25,2%). The majority of fatal head injuries (72,4%) were also caused by road traffic accidents. This study demonstrates the alarming number of deaths from non-natural causes among children aged under 15 years in the Cape Peninsula. The finding that more than half of these deaths were due to road traffic accidents indicates the impact that successful intervention could have.