Editor's note

The co-morbidity of a concurrent substance use disorder and a non-substance major psychiatric disorder is quite common. Yet there is very little data available to inform the clinician as to what treatment(s) might be best for this particular group of patients with this particular set of substance abuse plus non-substance psychiatric co-morbidity. In general, the limited research available, consensus recommendations and clinical experiences all suggest that integrated treatment, i.e. treatment by the same group of providers that addresses both the substance misuse and the other major mental illness is most effective. However, there are exceptions to this rule and providers must be flexible and offer a combination of services regarding what works best in treating the mental disorder plus what works best in the treatment of the specific substance abuse disorder. While on the surface this appears to be logical and pragmatic, this kind of reasoning does not always work. For example, there is some evidence that lithium is less effective in people with bipolar disorder complicated by substance abuse than it is in bipolar disorder alone. Furthermore, some pharmacological agents used to treat some psychiatric disorders have an increased liability for abuse and dependency, suggesting greater caution in using these interventions when substance abuse is a comorbid issue. The most efficacious treatment approach is probably integrated multi-modal treatment which involves the same group of caregivers providing treatment to both the mental illness and the substance misuse disorder.

In his preface, Ed Day highlights that this book originated in articles written in the peer-reviewed psychiatry literature for a generic audience of consultant psychiatrists. This stimulated me to think whether the book will serve as a useful tool for my generic psychiatry colleagues. Our paths frequently cross as in our daily professional lives we constantly encounter problems relating to problematic drug or alcohol use. I am convinced that this book is a ‘must have’ for every consultant psychiatrist. However, the value of this book is for a much wider audience. I reflected upon how it would feel to be a junior doctor considering a career in addiction psychiatry. Would this book reassure me that it is possible to pursue a fulfilling career in providing professional, evidence-based clinical care to people whose drug use has become a problem to themselves, their families and wider society? Without doubt I am sure that it does have the potential to fulfil such a function. There are few books that offer both a wide scope (breadth) and an exhaustive reservoir of knowledge (depth) by combining the current evidence base with diverse expert clinical knowledge and experience. This book has managed to achieve these aims in a style that is readable, engaging, yet authoritative

There is another readership, however, to whom I would unreservedly recommend this book, namely that of my own professional peoplegroup, primary care clinicians. One of the chapters alludes to the recent growth in primary-care-based drug treatment and another points out that, although psychiatry services for those with mental ill-health and drug dependence are largely separate, in primary care such comorbid conditions are managed by the same clinician. If primary care has traditionally offered the drug treatment field strengths of pragmatism and integrated clinical care for those with comorbid conditions, then there is much that we can receive in return from our colleagues in specialist addiction psychiatry services. This book offers us an authoritative collection of the evidence, and I would like it to sit on the bookshelves of all my primary care colleagues who have clinical responsibility for those who use drugs in a problematic fashion.

Historical overview of policy developments and evolution of treatment services

We will begin by summarising key policy developments in England and the resulting addiction treatment services, with specific focus on the socalled ‘British system’ (Spear, 2005). Although this summary provides a chronological account of the evolution of Britain's drug policies (Box 2.1), it is recommended that it be read in conjunction with two key references: Strang & Gossop (2005a,b) and Spear (2002). Space precludes detailed descriptions of the socio-political context within which the various British drug policies have developed, although it is worth noting that dramatic and unplanned shifts in policy have often been the result of a combination of changing political ideals, social structures and medical ideologies, rather than the consequence of any better understanding of addiction.

The 18th and 19th centuries

Although the origins of the British system are often traced to the Rolleston Report of 1926 (Ministry of Health, 1926), Berridge (2005) describes three systems that existed in Britain in the 18th and 19th centuries: the lay or commercial control system, the pharmaceutical control system and the medico-penal system. During the 18th and initial part of the 19th centuries, opium was freely available in pharmacies, grocers and other general stores. There was no regulation on its sale or purchase and, like alcohol, it was marketed just as any other product, i.e. subject to a lay or commercial control system.

There have been huge changes in the treatment of addictive behaviours in the past 30 years. The steady development of a scientific evidence base and fluctuating levels of political interest in the topic have led to an evolving and increasingly complex treatment system in the UK and other wealthy countries.

This book has been complied from articles written for the journal Advances in Psychiatric Treatment, a key resource to support continuing professional development in psychiatry. The journal first appeared in September 1994, and has focused on topics such as physical methods of treatment, psychosocial treatments, sub-specialties of psychiatry (such as addiction psychiatry) and issues concerning the management of clinical services. The aim has always been to publish useful articles for trained consultant psychiatrists who may, however, have completed their training some years before. It has assumed that readers are familiar with conventional basic terminology and have considerable clinical experience, but may have no expert knowledge in the subject of a particular article.

This book is made up of 20 articles that have appeared in APT over the past 10 years, and two newly commissioned chapters. Several articles have been extensively updated by the original author to take into account new developments in the field. Each chapter therefore provides continuing medical education with an emphasis on the practical implications of the subject. They are factual, lucid and informative, with clear information and techniques that can be used in everyday practice. The book is written by practising clinicians for practising clinicians. It highlights and references upto- date evidence, but its main aim is to synthesise this into information that is useful in clinical practice. Thus, this book has much to offer the specialist, but also the general psychiatrist, psychiatric nurse or general practitioner who is interested in the area.

The book covers ‘mainstream’ areas within the substance misuse treatment field, but also broadens its scope to less commonly discussed, but no less important, topics. Chapters 1 and 6, by Jason Luty, provide an analysis of the evidence supporting the range of pharmacological and non-pharmacological approaches to drug and alcohol misuse in enough detail to comfortably guide non-specialists managing individuals with such problems.

It is difficult accurately to estimate the prevalence of high-risk drug use during pregnancy for a variety of reasons: feelings of shame, denial and stigma experienced by the drug user, lack of awareness among professionals in antenatal services, the presence of comorbid psychiatric disorders, and sociocultural barriers that prevent a thorough assessment. However, we know that about one-third of drug users in treatment in the UK are female, and over 90% of these women are of childbearing age (15–39 years). A number of large surveys of drug use in different populations conducted in the USA provide a further insight. For example, the National Pregnancy and Health Survey gathered self-report data from a sample of 2613 women whose babies were delivered in 52 urban and rural hospitals during 1992 (National Institute of Drug Abuse, 1996). Over 5% of those who gave birth during the study period had used illicit drugs while they were pregnant, with 2.9% using cannabis and 1.1% using cocaine at some point in their pregnancy (compared with 20% smoking tobacco and 18.5% drinking alcohol). A further report combined 2 years of US National Household Survey data (1994 and 1995) for women and girls 15–44 years old and found that 9.3% reported current use of illicit drugs, with 2.3% doing so while pregnant. The problem is therefore a significant one, particularly as it has implications for both mother and child.

The effects of psychoactive drugs have been closely linked to all forms of literature for as long as humans have been writing, but a review of the subject is currently very topical. Although the problems of alcohol have long been a theme covered by authors, other drugs have not been as well represented in mainstream publishing until the past few decades. However, the escalation of the drug problem in the Western world has had an influence on popular fiction and led to a rekindling of interest in an older literature that explored these themes. The work of the 19th-century Romantics and of the Beat Generation and counter-culture of the 1960s has been developed by the ‘chemical generation’, with ecstasy (methylenedioxymethamphetamine (MDMA)) joining the opiates, cocaine, cannabis, lysergic acid diethylamide (LSD) and amphetamines as a backdrop to popular fiction.

Writers and alcohol

Alcohol, in particular, has been strongly linked to creativity, and John Sutherland, a professor of English literature in London and a self-confessed ‘recovering drunk’, has written extensively in this area. His book Last Drink to LA (Sutherland, 2001)1 provides some literary signposts on the path to understanding alcohol addiction and describes his own experiences at Alcoholics Anonymous (AA). Through his attendance at AA meetings, Sutherland has come to see addicts primarily as storytellers, believing that ‘telling tales (most of them tall, many of them self-serving) is one of the few things that booze makes you good at’ (Sutherland, 2001: p. 73).

Analysis of the lives of many famous writers reveals evidence of heavy alcohol consumption, mental illness, physical disease, family breakdown, suicide and premature death (Post, 1994).