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Biomedical subjects

J R Caplehorn

Publications and source records attributed to J R Caplehorn.

At least 19 recordsLinked to original sources
PubMed1999

Mortality associated with New South Wales methadone programs in 1994: lives lost and saved.

OBJECTIVES: To estimate the effects of methadone programs in New South Wales on mortality. DESIGN AND CASES: Retrospective, cross-sectional study of all 1994 New South Wales coronial cases in which methadone was detected in postmortem specimens taken from the deceased. Cases were people we identified as patients in NSW methadone maintenance programs or those whose deaths involved methadone syrup diverted from maintenance programs. OUTCOME MEASURES: Relative risks of fatal, accidental drug toxicity in the first two weeks of treatment and later; the number of lives lost as a result of maintenance treatment; preadmission risks and the number of lives saved by maintenance programs, calculated from data from a previous study. RESULTS: There was very close agreement between this study's classifications and official pathology reports of accidental drug toxicity. The relative risk (RR) of fatal accidental drug toxicity for patients in the first two weeks of methadone maintenance was 6.7 times that of heroin addicts not in treatment (95% CI RR, 3.3-13.9) and 97.8 times that of patients who had been in maintenance more than two weeks (95% CI RR, 36.7-260.5). Despite 10 people dying from iatrogenic methadone toxicity and diverted methadone syrup being involved in 26 fatalities. In 1994, NSW maintenance programs are estimated to have saved 68 lives (adjusted 95% CI, 29-128). CONCLUSIONS: In 1994, untoward events associated with NSW methadone programs cost 36 lives in NSW. To reduce this mortality, doctors should carefully assess and closely monitor patients being admitted to methadone maintenance and limit the use of takeaway doses of methadone.

Adult↗
PubMed1998

Staff attitudes and retention of patients in methadone maintenance programs.

A study was made of the effect of staff commitment to abstinence-oriented policies on retention of patients in methadone maintenance. Staff working in six public methadone programs in Sydney, Australia, were surveyed in 1989 and 1992 using the Abstinence Orientation Scale. The association of the clinics' median Abstinence Orientation scores with the time in treatment of a random sample of their 1988-1989 admissions was summarised using Cox regression. Patients' risk of discharge increased by a factor of three with every one unit increase in the clinics' median Abstinence Orientation scores, (RR 3.4, 95% CI 2.3-5.0). Abstinence-oriented policies were shown to disadvantage ex-prisoners.

Adult↗
PubMed1998

Deaths in the first two weeks of maintenance treatment in NSW in 1994: identifying cases of iatrogenic methadone toxicity.

A study was undertaken to estimate the frequency of iatrogenic methadone toxicity in the first 2 weeks of maintenance treatment in NSW. Cases were identified from a list of all 1994 methadone-associated deaths using data on methadone patients held by the NSW and Queensland Health Departments. The likely causes of death were determined from data collected from coronial files. A forensic toxicologist experienced in the area gave an independent opinion. Of the 14 deaths in the first 2 weeks of maintenance, at least 10 were primarily caused by the toxic effects of methadone prescribed by NSW doctors. The rate of fatal iatrogenic methadone toxicity was 2.2 per thousand admissions to maintenance. Victims of fatal iatrogenic toxicity often displayed signs of methadone intoxication in the days before their death. They invariably died several hours after taking the fatal dose, usually after seeming to go to sleep. Often friends or family were concerned about their welfare, were unable to rouse them from their "sleep" and frequently reported the deceased was "snoring" loudly for some time before their demise. The author recommends that patients entering methadone maintenance should be informed of the risks and should be required to give written consent to treatment. To prevent fatal methadone toxicity, patients should receive daily medical assessment during the first 1-2 weeks of maintenance.

Journal Article↗
PubMed1997

Measuring and comparing the attitudes and beliefs of staff working in New York methadone maintenance clinics.

Scales measuring commitment to abstinence-oriented policies, attitudes to drug addiction, and knowledge of methadone maintenance were refined and tested in a survey of staff working in 14 New York maintenance programs. Confirmatory factor analysis established the validity of a 9-item Abstinence Orientation Scale and a 6-item Disapproval of Drug Use Scale. Scores on the two scales and Knowledge scores were highly correlated. There were highly significant differences in the mean Abstinence Orientation scores of the administrative and better qualified clinical staff on the one hand and the less qualified staff on the other. Senior staff generally rejected abstinence-oriented policies while nurses and counselors tended to support them.

Adult↗
PubMed1997

High serum carcinoembryonic antigen concentration in patients with colorectal liver metastases is associated with poor cell-mediated immunity, which is predictive of survival.

BACKGROUND: Carcinoembryonic antigen (CEA) inhibits lymphocyte function and patients with cancer have lower cell-mediated immunity (CMI) than the normal population. To test this association an investigation was made of the relationship between CMI score, CEA level and survival. METHODS: CEA level, CMI score and other variables were compared with the survival time of 109 patients with colorectal liver metastases using Cox regression analysis. RESULTS: There was a significant association between CMI and CEA categories (P = 0.04, chi 2 test). The odds of patients with normal CMI having a CEA level in the upper quartile observed for all patients were 22 per cent of those of patients with depressed CMI (odds ratio 0.22 (95 per cent confidence interval (c.i.) 0.03-0.90), mid-P corrected). The median survival time of patients with normal CMI scores was 943 days compared with 488 days for those with depressed CMI (P = 0.03, log rank test; P = 0.04, Peto). The mortality risk of patients with normal CMI at entry to the study was, in the first 2 years of treatment, 40 per cent of that of patients with depressed CMI (95 per cent c.i. for relative risk 0.20-0.82, Cox regression). CONCLUSION: In patients with colorectal hepatic metastases, CMI is predictive of survival and a raised serum CEA level is associated with depressed CMI.

Adult↗
PubMed1996

Methadone maintenance and addicts' risk of fatal heroin overdose.

An admission cohort of 296 Australian methadone maintenance patients was followed over 15 years. The relative risks of death in and out of maintenance were calculated for two age groups, 20-29 and 30-39 years. Heroin addicts in both age groups were one-quarter as likely to die while receiving methadone maintenance as addicts not in treatment. This is because they were significantly less likely to die by heroin overdose or suicide while in maintenance. Methadone maintenance had no measurable effect on the risk of death through nonheroin overdose, violence or trauma, or natural causes. A meta-analysis showed the reduction in overall mortality was consistent with the results of cohort studies conducted in the United States, Sweden, and Germany. The combined results of the five studies again indicated that methadone maintenance reduced addicts' risk of death to a quarter, RR 0.25 (95% CI 0.19 to 0.33).

Accidents↗
PubMed1996

Attitudes and beliefs of staff working in methadone maintenance clinics.

Two attitudinal scales measuring commitment to abstinence-oriented treatment policies and disapproval of illicit drug use were derived from a survey of 90 staff working in 10 public methadone maintenance clinics in Sydney, Australia. The two scales were shown to be valid constructs by confirmatory factor analysis and to be internally reliable and to have high test-retest reliability. The factors underlying the two scales were highly correlated (r = .77), indicating support for policies that enforce abstinence and limit the duration of maintenance is highly associated with personal disapproval of drug use. There was no significant correlation between staff's knowledge of the benefits of methadone maintenance and their support for abstinence-oriented policies.

Attitude↗
PubMed1996

Physicians' attitudes and retention of patients in their methadone maintenance programs.

A study was undertaken to investigate the influence of methadone prescribers' commitment to abstinence-oriented policies on retention in their maintenance programs. Two hundred and eighty patients recently enrolled in single-person, private methadone programs were interviewed and followed for 8 years. The prescribing physicians' scores on an Abstinence Orientation Scale, derived from an independent sample of methadone program staff, were significantly associated with their patients' risk of premature discharge. The influence of program orientation on retention was greater the higher the maximum dose of methadone. More attention should be paid to the effect of staff attitudes and beliefs on the effectiveness of maintenance treatment.

Adult↗
PubMed1995

The Quality in Australian Health Care Study.

A review of the medical records of over 14,000 admissions to 28 hospitals in New South Wales and South Australia revealed that 16.6% of these admissions were associated with an "adverse event", which resulted in disability or a longer hospital stay for the patient and was caused by health care management; 51% of the adverse events were considered preventable. In 77.1% the disability had resolved within 12 months, but in 13.7% the disability was permanent and in 4.9% the patient died.

Adolescent↗
PubMed1995

A simple and effective way to reduce postoperative pain after laparoscopic cholecystectomy.

The aims of this study were to see if laparoscopic cholecystectomy is associated with a similar postoperative pain pattern to gynaecological laparoscopy and to see whether the use of a suprahepatic suction drain makes recovery from laparoscopic cholecystectomy more comfortable. After routine laparoscopic cholecystectomy and insertion of a suprahepatic suction drain, patients were randomized to suction or no suction on the drain. The time course of the severity of wound, abdominal and shoulder tip pain was assessed by visual analogue scales administered in the morning and afternoon of the first 3 postoperative days. The control group had a high incidence of shoulder tip pain similar to that after gynaecological laparoscopy. Patients in the treatment group reported significantly less shoulder tip pain than the control group (O.R. 0.16, 95% CI, 0.06-0.40). There was a tendency for the treatment group to report reduced abdominal and, to a lesser extent, wound pain. The authors recommend suprahepatic suction as a simple and more effective way to improve patient comfort after laparoscopic cholecystectomy.

Abdominal Pain↗
PubMed1995

Methadone maintenance and the likelihood of risky needle-sharing.

Survey data were used to study the association of methadone maintenance and needle-sharing. An ordinal scale of HIV risk was derived from the number of persons from whom subjects reported accepting a used needle and syringe in the 6 months prior to interview. The odds of respondents in methadone maintenance being in the higher risk group were half those of daily heroin users not in treatment for all three transitions in a four-level ordinal scale of risk (OR 0.55, 95% CL 0.33 to 0.90, ordinal logistic regression). This association disappeared when methadone patients who had not injected in the month prior to interview were excluded from the analysis. Subjects' knowledge concerning HIV and AIDS had no measurable association with the outcome. It is concluded that methadone maintenance reduces heroin addicts' risk of infection with HIV by reducing the likelihood of their injecting drugs rather than by changing their injecting behavior.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Retention in methadone maintenance and heroin addicts' risk of death.

A long-term follow-up was made of a cohort of 307 heroin addicts admitted into a high-dose, Australian methadone maintenance programme in the early 1970s. Using data from clinic records, official death records and methadone treatment histories, it was found that subjects were nearly three times as likely to die outside of methadone maintenance as in it (95% CI RR 1.45 to 5.61). Data were further analyzed using Cox regression to investigate the association of maximum daily methadone dose and a change in clinic policy with retention in maintenance treatment. It is estimated that subjects given a maximum daily dose of 80 mg were nearly twice as likely to be discharged during the first three years of maintenance as those given 120 mg (95% CI RR 1.3 to 2.2). The estimated median time in maintenance for subjects given a maximum dose of 120 mg was 1150 days while for 80 mg it was 660 days. It is further estimated that the change in clinic policy from abstinence to indefinite maintenance reduced to one-third subjects' risk of leaving after three years' of treatment (95% CI RR 0.19 to 0.54). It is concluded that, in order to minimize heroin addicts' risk of death, they should be offered indefinite, high-dose methadone maintenance.

Adolescent↗
PubMed1994

The effect of intake procedures on performance in methadone maintenance.

The effect of assessment and intake procedures on the outcome of methadone maintenance treatment was investigated in a natural experiment in which a single methadone clinic admitted 89 patients by a rapid intake procedure, and 74 patients who had been on a waiting list and underwent formal assessment interviews. Outcome measures were frequency of illicit drug use as detected by urine tests, and risk of dropping out or being expelled from treatment. Subjects admitted after prolonged, formal assessment were more likely to be expelled, and were more than twice as likely to leave during the first 400 days of maintenance treatment (95% Cl relative risk 1.1 to 5.2). The odds of formally assessed subjects using heroin in the first 6 months of treatment were twice those of the rapid intake group (95% Cl odds ratio 1.5 to 2.2). The formal assessment process deterred half the initial applicants, yet seems to have either selected individuals with a worse prognosis or to have had a negative effect on in-treatment performance.

Female↗
PubMed1994

CEA reduction after cryotherapy for liver metastases from colon cancer predicts survival.

Serum carcinoembryonic antigen (CEA) levels in 33 Australian patients with hepatic metastases from colorectal cancer were measured before and after treatment with hepatic cryotherapy and intra-arterial chemotherapy. Pre-operative and monthly postoperative CEA measurements were made and the lowest postoperative reading was recorded as a percentage fall from the pre-operative level. There was a highly significant association between the maximum percentage fall in CEA and survival. A 50% increase in the maximum percentage fall in CEA level was associated with one-tenth the risk of death (95% CI RR 0.03 to 0.32, Cox regression). It is estimated that an increase in the maximum percentage fall in CEA of 50% from 25 to 75% was associated with an increase in the median survival from 240 days to over 2 years.

Antineoplastic Agents↗
PubMed1994

A comparison of abstinence-oriented and indefinite methadone maintenance treatment.

Advantage was taken of a natural experiment to compare the outcome of abstinence-oriented and indefinite methadone maintenance. Subjects assigned to an abstinence-oriented program were significantly more likely than those assigned to indefinite maintenance to use heroin (OR 1.3) and amphetamines (OR 2.8) during the first 2 years of methadone treatment but less likely to use benzodiazepines (OR 0.7). Subjects discharged from the abstinence-oriented program were significantly more likely to relapse and return to maintenance treatment (RR, first 6 months, 4.2). The abstinence-oriented program was also less able to attract heroin addicts into maintenance treatment.

Adult↗