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 Oxford Specialist
Handbooks
Addiction
Medicine
Second Edition
Edited by

John B. Saunders E. Jane Marshall

Professor and Consultant Physician in Consultant Psychiatrist, Alcohol Service,
Internal Medicine and Addiction Medicine, South London and Maudsley National
University of Queensland, University of Health Service Trust and the National
Sydney, and St. John of God Health Care, Addiction Centre, Institute of Psychiatry,
Wesley Health Care, and South Pacific King’s College London, UK
Private Hospital, Sydney, Australia
Walter Ling
Katherine M. Conigrave Integrated Substance Abuse Program
Professor in Addiction Medicine and (ISAP), School of Medicine, University
Public Health, Sydney Medical School, of California at Los Angeles (UCLA),
University of Sydney, and Addiction and formerly Commissioner for
Specialist Royal Prince Alfred Hospital, Narcotics and Dangerous Drugs
Sydney, Australia Commission, Los Angeles, CA, USA

Noeline C. Latt Susumu Higuchi

Addiction Medicine Specialist, Royal Director, National Hospital
North Shore Hospital, and Sydney Medical Organization Kurihama Medical and
School, University of Sydney, Australia Addiction Center and Director of the
World Health Organization (WHO)
David J. Nutt Collaborating Centre on Research and
Training of Alcohol-​Related Problems,
Professor of Psychopharmacology,
Kanagawa, Japan
Division of Brain Science, Department
of Medicine, Hammersmith Hospital,
Imperial College London, UK, and
Founding Chair of DrugScience, UK

With a Foreword by Karl Mann

1
1
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 v

Preface

Origin of this handbook

This Oxford Specialist Handbook Addiction Medicine is the result of many
years, preparation by a group of colleagues who have been clinicians, teach-
ers, and researchers in the addictive disorders field for many years. The
present edition replaces the first edition, which was published in 2009. That
had its origins in a series of lecture notes produced for the University of
Sydney more than 30 years ago and clinical protocols developed separately
and in collaboration by the authors and constantly updated over this time.
The scope of the second edition has been expanded in several ways. It
now includes the behavioural addictions such as gambling and gaming and
includes a broader range of psychoactive substances. It aims to be interna-
tional in scope. The editors are drawn from the United Kingdom, Australia,
United States of America, and Japan and there are contributing authors
from 25 countries worldwide.
Our aim continues to be to offer a contemporary, broadly based, and
clinically grounded text that summarizes the scientific basis and the practice
of addiction medicine.

Evidence and practice

Evidence-​based practice continues to increase in impact and there is an
expectation that the approaches made in management of addictive disor-
ders and the selection of medications, therapies, and overall strategy are
based on scientific data from controlled clinical trials and other relevant
studies. This applies in addiction medicine as much as it does in any other
field of healthcare. We recognize, however, that as in other areas the scien-
tific evidence base is not comprehensive, particularly when a person with an
addictive disorder has different co-​morbidities or when standard treatment
approaches have been exhausted, or simply where the evidence base does
not exist.
Our approach to the second edition has been to draw upon the follow-
ing sources:
1. Current guidelines developed according to prevailing international
standards for clinical guidelines and which include guidelines published
by the World Health Organization, government departments of health
and human services (e.g. from the US, UK, Australia, Japan, Germany,
France, Sweden, and other Nordic countries) and those produced by
relevant professional organizations, academies, and associations, which
have been based on systematic reviews of the literature and undergone
extensive processes of validation.
2. Publically accessible scientific evidence on the efficacy of treatment
(with an emphasis on systematic reviews, meta-​analyses, and
vi PREFACE

randomized controlled trials), supplemented by other scientifically valid

clinical, psychometric, and epidemiological studies.
3. The clinical practice and experience of the authors, ensuring that the
recommendations are appropriate to many clinical practice settings and,
where there is an absence of evidence from scientific studies, that the
material published here represents a distillation of practice which we
consider to have international relevance and to be effective and safe.
It should be emphasized that in clinical practice, decisions need to be made
often in the absence of scientific evidence. This may be simply because
there is none or, very typically, the clinical situation develops beyond what
scientific evidence exists or could ever realistically be expected to exist. In
clinical practice, the focus is on the individual (or it may be on a couple, a
family, or a group) and individuals and groups of individuals are infinitely
variable. Scientific data will never exist to cover the multiple variations and
eventualities in terms of comorbid disorders, previous treatment expe-
rience, lack of response to an approved treatment, individual patient or
family preference, and some of the unknowns such as vital diagnostic or
background information not being available at the time the clinical decision
has to be made. These are the realities of the clinical life and in producing
this handbook we recognize these as realities. Clinical practice is not merely
the application of the evidence base to a particular person. Rather, the evi-
dence base informs and guides clinical practice.

Who is this book for?

This handbook is intended as a concise and practical guide for students and
practitioners of medicine, nursing, psychology, and other health profession-
als whose work brings them into contact with people with addictive dis-
orders. In particular, it is designed for students and post-​graduate trainees
and fellows in addiction medicine, internal medicine, psychiatry, emergency
medicine, pain management, gastroenterology, and general medical (fam-
ily physician) practice. We believe it will be useful and relevant to nurses,
particularly those working as specialists in addictive disorders, clinical psy-
chologists, psychologists and counsellors, and social workers and for staff in
specialist multidisciplinary agencies which provide help, support, and treat-
ment for people with addictive disorders.

Why is this book important?

Alcohol and other substance use rank among the five top risk factors con-
tributing to the global burden of disease. In recent years, there has been a
rapid increase in non-​substance forms of addiction such as gambling, inter-
net gaming, and various other behavioural or ‘process’ addictions. In Asia
and several other parts of the world, these latter disorders represent the
biggest burden of ill health and social problems of any of the addictions.
Substance use disorders can cause, mimic, underlie, or complicate a large
number of medical and psychiatric conditions. All addictive disorders can
 PREFACE vii

cause immense personal suffering as well as harm and costs to families,

communities, and society as a whole. Often this is not recognized. People
with addictive disorders may be reticent about revealing their substance use
and may not see its relevance. The fact that many patients use more than
one substance, sometimes multiple substances and sometimes a substance
used in combination with a behavioural addiction, further adds to the com-
plexity. Making a correct diagnosis of an addictive disorder can greatly facili-
tate management, often avoid unnecessary tests and procedures, shorten
hospital stays, and make both the clinician’s and the patient’s life easier.
The ability to diagnose addictive disorders and initiate appropriate manage-
ment is a responsibility for all health professionals. Historically, however,
most have not been confident in their ability to diagnose and manage these
disorders, as they have often been omitted from student and postgradu-
ate courses. Recent years have seen the development of a comprehen-
sive knowledge base and an understanding of the skill set and professional
practice behaviour necessary for good professional practice in this field.
Addiction medicine now has a range of approaches that compare in their
effectiveness with those in other areas of medicine.

What is covered?
This handbook provides a practical guide to the management of people with
addictive disorders. The first chapters provide important background infor-
mation and summarize the overall principles of diagnosis and management.
There follow several chapters on specific types or groups of psychoactive
substance. The nature of the substances, their pharmacological properties,
and the clinical syndromes that result are described, together with specific
guidance on diagnosis and management which takes into account both their
generic addictive properties and their specific pathophysiological ones. The
latter part of the book is devoted to the management of specific groups of
patients and people seen in specific settings, together with an account of
relevant medicolegal and ethical issues. Following the main text, the final
chapter comprises a series of practical tools, such as questionnaires, which
assist in systematic clinical practice.
The handbook provides detailed guidelines on how to elicit a history
of substance use and other addictive activities, together with ways of
diagnosing the core clinical syndromes and the physical, psychiatric, and
social disorders that may flow from them. It includes practical guides to
brief intervention, management of intoxication, withdrawal management
(‘intoxication’), pharmacotherapies, and psychological therapies aimed at
relapse prevention, together with an account of support approaches and
the principles and practice of self-​help.
viii

Foreword

Addictions are highly prevalent. They cause harm to the afflicted and their
families and are costly to society. While the clinical symptomatology in peo-
ple suffering from addictions is similar around the world, treatment and pre-
vention are not. Research in recent years has provided enormous progress
in our understanding of these disorders resulting in a multitude of new evi-
dence-based treatments. However, most conditions remain under-served
and treatment approaches vary substantially around the world. All of these
facts call for an up-to-date and universal appraisal of the current situation.
A comprehensive overview on emerging strategies would be instrumental
in this and could help to meet the actual challenges.
The Oxford Specialist Handbook—Addiction Medicine provides such a
global perspective. The editors and authors are eminent researchers and
clinicians in our field. They come from a large variety of areas such as
Australia, Asia, Europe, and North America. While the first edition of the
textbook in 2009 already provided a very broad view on addictions and
ways of dealing with them, the revised version gives an update of current
concepts and newly emanating strategies. Important extensions have been
made providing several new chapters and incorporating new fields such as
gambling and gaming as examples for behavioural addictions. The handbook
now also includes evidence-based recommendations from the most recent
clinical guidelines from around the world.
Prof. John Saunders of Sydney and Queensland Universities and his col-
leagues are to be congratulated for their enormous efforts. Their book
Addiction Medicine gives the necessary detail to understand and respond to
actual problems in an individual patient. The long standing teaching experi-
ence of most of its authors has resulted in a text which is well structured
and easy to read and thus offers information not only to the professional
but also to the patient and his or her family and to others in search of some
quick and valid information on the troublesome but also fascinating field of
addiction.

Karl Mann, MD
Emeritus Professor of Addiction Research
Central Institute of Mental Health
Medical Faculty Mannheim
University of Heidelberg
Germany
 ix

Contents

Acknowledgements xi
Editors and authors xii
Contributors xv
Symbols and abbreviations xxiii

1 The nature of addictive disorders    1

2 Epidemiology and prevention    7
3 Pharmacology and pathophysiology   31
4 The scope of intervention   55
5 Establishing the diagnosis   67
6 Acute care   85
7 Ongoing management of substance use disorders 103
8 Tobacco 119
9 Alcohol 151
10 Cannabis 235
11 Opioids 249
12 Pain and opioids 295
13 Benzodiazepines and the other sedative-​hypnotics 307
14 Psychostimulants 327
15 Hallucinogens and dissociative drugs 355
16 Other drugs 363
17 Polysubstance use 391
18 Injecting drug use 407
19 Gambling 427
20 Gaming 441
21 Other addictive disorders 449
22 Psychiatric co-​morbidity 461
x CONTRIBUTORS

23 Specific clinical situations 483

24 Special populations 493
25 Substance use and specific healthcare settings 545
26 Legal and ethical issues 563
27 Resources 589

Index 629
 xi

Acknowledgements

In presenting this handbook to our colleagues and students, we would in

turn like to thank our own teachers. We wish to dedicate this handbook to
those who helped influence and shape our own professional careers, includ-
ing Griffith Edwards, Alex Paton, David Graham-​Smith, Markku Linnoila,
Boris Tabakoff, Harding Burns, Norman Sartorius, and Harold Kalant.
We would like to acknowledge the contribution of our colleagues in
reviewing and helping finalize parts of this book, and in particular, Robert
Batey, Glenys Dore, Anne Lingford Hughes, Martin Raw and Carina Walters.
We would particularly like to highlight and acknowledge the key role
played by Corinne Lim, Editorial Officer, throughout the preparation of
this book.
xii

Editors and authors

Professor John B. Saunders MA, MB BChir, MD, FRCP, FRACP, FAChAM,

FAFPHM is a Professor and Consultant Physician in Internal Medicine and
Addiction Medicine, with appointments at the University of Queensland and
University of Sydney in Australia, and with several private hospital groups.
He graduated in pharmacology and then medicine from the University of
Cambridge, and undertook specialist medical training in internal medicine,
gastroenterology, and addiction medicine. His career as a clinician, service
director, researcher, and academic in addictive disorders extends back over
40 years, and he has extensive clinical experience in hospital and community
settings. He has been a member of many state and federal Australian gov-
ernment committees, including the Australian National Council on Drugs
(2001–​2007). He has worked with the World Health Organization since
1981 and was responsible for developing the AUDIT Questionnaire. He is
a member of the WHO’s Expert Advisory Panel on Substance Abuse and
the ICD​11 Substance-​Related and Addictive Disorders Workgroup. He
has published four books and over 330 scientific papers, reviews, and book
chapters. He is an ISI highly cited scientist.
Professor Katherine M. Conigrave MB BS (Hons), PhD, FAFPHM,
FAChAM is Senior Staff Specialist in Addiction Medicine and Public Health
Medicine at Royal Prince Alfred Hospital and Concord Hospital in Sydney,
Australia, where she provides clinical care in out-​patient, general hospi-
tal, and residential detoxification and rehabilitation settings. She has been
involved for many years in training medical and other health professionals
through Sydney Medical School, University of Sydney, and through training
sessions for practising health professionals. Professor Conigrave’s research
has a focus on detection and early intervention for alcohol problems, and
on improving implementation of evidence-​based practice in prevention and
treatment of substance use disorders. Over the past 15 years, Professor
Conigrave has also worked in partnership with Aboriginal communities in
urban, regional, and remote Australia. She has over 100 peer-​reviewed
academic publications, has received the Senior Scientist Award for the
Australasian Professional Society for Alcohol and Other Drugs, and has
acted as a consultant to the World Health Organization on alcohol screen-
ing and brief intervention. She is on the Editorial Advisory Boards of Alcohol
and Alcoholism, and of Addiction Science & Clinical Practice.
Dr Noeline C. Latt MBBS, MPhil, MRCP, FAChAM is a Senior Staff
Specialist in Addiction Medicine at Royal North Shore Hospital, Clinical
Lecturer at the University of Sydney, and a Foundation Fellow of the
Chapter of Addiction Medicine, Royal Australasian College of Physicians.
She is a Physician and Addiction Medicine Specialist with extensive experi-
ence in clinical pharmacology and internal medicine. After a period as a
medical director in the Pharmaceutical Industry, she became a Specialist
in Addiction Medicine at Westmead Hospital and as Director of the Ryde
and Hornsby Drug & Alcohol Service she developed a drug and alcohol unit
offering consultation liaison services and teaching programmes in alcohol
 EDITORS AND AUTHORS xiii

and substance use disorders. Her research interests have focused on plate-
let monoamine oxidase activity, and treatment of alcohol and substance use
disorders, alcoholic liver disease and hepatitis C in injecting drug users, and
substance-​induced psychosis.
Professor David J. Nutt MA, MB BChir, DM, FRCP, FRCPsych,
FMedSci is Consultant Psychiatrist and the Edmund J. Safra Professor of
Neuropsychopharmacology in the Division of Brain Science, Department
of Medicine, Hammersmith Hospital, Imperial College London. Here he
uses a range of brain imaging techniques to explore the causes of addiction
and other psychiatric disorders and to search for new treatments. He has
published over 400 original research papers, a similar number of reviews
and book chapters, eight government reports on drugs, and 28 books,
including one for the general public, Drugs: Without the Hot Air, that won the
Transmission Prize in 2014. He is currently the President of the European
Brain Council and Founding Chair of DrugScience (formerly the Independent
Scientific Committee on Drugs (ISCD)). Previously he has been president
of the British Association of Psychopharmacology, the British Neuroscience
Association, and the European College of Neuropsychopharmacology. He
broadcasts widely to the general public both on radio and television. In
2010, The Times Eureka science magazine voted him one of the 100 most
important figures in British science, and the only psychiatrist in the list. In
2013, he was awarded the John Maddox Prize from Nature/​Sense about
Science for standing up for science.
Dr E. Jane Marshall MB BCh BAO MRCP (Ireland) FRCPsych is a
Consultant Psychiatrist in Alcohol Services at the South London and
Maudsley NHS Foundation Trust and Senior Lecturer in the Addictions
at the National Addiction Centre, Institute of Psychiatry, King’s College
London. She trained in Psychiatry at St Patrick’s Hospital, Dublin, and St
Bartholomew’s and the Maudsley Hospitals in London. Her clinical work
is currently focused on a specialist out-​patient and in-​patient alcohol ser-
vice, and also a service for addicted healthcare professionals. She is lead
clinician for the MSc programme in Addiction at the Institute of Psychiatry.
Research interests include the evaluation of treatment for alcohol prob-
lems in specialist and generalist settings and, in particular, and treatment for
addicted healthcare professionals. Dr Marshall acts as a medical supervisor
and examiner for the General Medical Council and as a medical advisor
for the General Dental Council. Within the Royal College of Psychiatrists
she is Co-​Director of Flexible Training, and a member of the executive
committee of the Faculty of the Addictions and Psychiatrists’ Support
Service Committee. Dr Marshall has contributed to national guidelines, and
has been a member of a number of Working Parties, including the Royal
College of Physicians Working Party on Alcohol in the General Hospital
(2001); an Alcohol Concern Research Forum (2002); and a Department of
Health Working Group on Alcohol-​related Brain Damage (2007).
Professor Walter Ling, MD, is Professor of Psychiatry and the Founding
Director of the Integrated Substance Abuse Programs (ISAP) at UCLA,
one of the foremost substance abuse research groups in the US. He is
board certified in neurology and psychiatry, is active in research and clinical
work, and has been listed in ‘Best Doctors in America’. Dr Ling’s research
in opiate pharmacotherapy provided pivotal information for the approval
xiv EDITORS AND AUTHORS

of buprenorphine and naltrexone. His current focus of research includes

abuse and dependence on methamphetamine, cocaine, heroin, and pre-
scription opiates; opiate-​induced hyperalgesia, treatment of pain in opiate-​
maintained patients, including those treated with buprenorphine, and the
role of buprenorphine in the management of pain in these patients. Dr Ling
is a fellow of the American Academy of Neurology; he has served as
Commissioner for the Narcotics and Dangerous Drugs Commission, Los
Angeles County, California; and a consultant on narcotics for the World
Health Organization, the United Nations, and the U.S. Department of
State. As Principal Investigator of NIDA’s Clinical Trial Network’s Pacific
Region Node, Dr Ling has extended ISAP’s research beyond the US to
China, Southeast Asia and the Middle East.
Professor Susumu Higuchi, MD, PhD is Director of the National Hospital
Organization Kurihama Medical and Addiction Center and Director of the
World Health Organization (WHO) Collaborating Centre on Research and
Training of Alcohol-​Related Problems in Yokosuka, Japan. He has principally
worked on genetics and clinical studies of alcohol use disorders, especially
on the implications of genetic variations of alcohol-​metabolizing enzymes
on pharmacokinetic and pharmacodynamic effects, organ damage, and
alcohol-​use disorders. He has published more than 220 scientific papers in
well-​recognized international journals, and more than 400 papers in domes-
tic journals. He is President of the International Society for Biomedical
Research on Alcoholism (ISBRA), congress president in 2014, a director
of the International Society of Addiction Medicine, and President of the
Japanese Society of Alcohol-​Related Problems. For the past decade, he has
worked on alcohol policy and programmes, and has served as chair or a
member of many committees of the Japanese government. He has contrib-
uted to WHO initiatives to reduce global alcohol-​related harm as a member
of the WHO Expert Advisory Panel and a delegate of the Japanese govern-
ment to the World Health Assembly and other WHO meetings. Clinically,
he has been the leading psychiatrist in the field of alcohol dependence and
behavioural addiction, especially Internet addiction in Japan.
 xv

Contributors

Professor Peter Anderson Dr James Bell

Professor, Substance Use Consultant Physician, Addictions
Policy and Practice, Institute of Clinical Academic Group, Kings
Health and Society, Newcastle Health Partners, London, UK
University, UK Chapter 12: Pain and opioids
Chapter 2: Epidemiology and
prevention Associate Professor Renee
Bittoun
Associate Professor Sawitri Associate Professor, Sydney
Assanangkornchai Medical School, Faculty of
Associate Professor, Epidemiology Medicine, University of Sydney;
Unit, Faculty of Medicine, Prince Director, Smoking Cessation
of Songkla University, Songkhla, Unit, and Smokers Clinics, Brain
Thailand and Mind Research Institute,
Chapter 4: The scope of intervention; Camperdown, NSW, Australia
Chapter 24: Special populations Chapter 8: Tobacco
Associate Professor Tatiana Associate Professor
Balachova Yvonne Bonomo
Associate Professor of Pediatrics, Associate Professor and Consultant
University of Oklahoma Health Physician in Addiction Medicine,
Sciences Center, Department St Vincent’s Hospital Melbourne,
of Pediatrics and the Center and Departments of Medicine
on Child Abuse and Neglect, and Paediatrics, University of
University of Oklahoma, Melbourne, VC, Australia
Oklahoma City, USA Chapter 24: Special populations
Chapter 24: Special populations
Dr Henrietta Bowden-​Jones
Professor Robert Batey Consultant Psychiatrist, Director
Professor in Hepatology and and Lead Clinician, National
Addiction Medicine, University Problem Gambling Clinic and
of Sydney and Flinders University Honorary Senior Lecturer, Division
South Australia; Consultant of Brain Science, Imperial College,
Physician, Department of London, UK
Medicine, Alice Springs Hospital, Chapter 19: Gambling
Australia
Chapter 9: Alcohol; Dr Jonathan Brett
Chapter 11: Opioids; Consultant in Clinical
Chapter 18: Injecting drug use Pharmacology, Toxicology and
Addiction Medicine, Royal Prince
Dr Jenny Bearn Alfred Hospital and Clinical
Consultant in Addiction Psychiatry, Lecturer, University of Sydney;
Maudsley Hospital, South London Sydney, NSW, Australia
and Maudsley NHS Foundation Chapter 16: Other drugs;
Trust, UK Chapter 25: Substance use and spe-
Chapter 16: Other drugs cific healthcare settings
xvi CONTRIBUTORS

Dr Adam Brodie Professor H. Valerie Curran

Consultant Addiction Psychiatrist, Professor of Psychopharmacology,
Clinical Director Addictions (NHS Clinical Psychopharmacology Unit,
Lanarkshire), Coathill House, Brain Sciences, University College
Coatbridge, UK London, UK
Chapter 16: Other drugs Chapter 10: Cannabis
Professor Katherine Professor Louisa
M. Conigrave Degenhardt
Professor in Addiction Medicine NHMRC Principal Research Fellow
and Public Health, Sydney and Professor, National Drug
Medical School, University of and Alcohol Research Centre,
Sydney, and Addiction Medicine University of New South Wales,
Specialist, Royal Prince Alfred Sydney, NSW, Australia
Hospital, Sydney, Australia Chapter 2: Epidemiology and
Chapter 2: Epidemiology and prevention
prevention; Chapter 8: Tobacco;
Chapter 9: Alcohol; Associate Professor
Chapter 11: Opioids; Glenys Dore
Chapter 16: Other drugs; Clinical Director and Senior Staff
Chapter 18: Injecting drug use; Specialist Psychiatrist, Northern
Chapter 24: Special populations; Sydney Drug & Alcohol Service,
Chapter 26: Legal and ethical and Clinical Associate Professor,
issues University of Sydney, Sydney
Medical School -​Northern; Royal
Professor Jason P. Connor North Shore Hospital, Sydney,
Professor of Clinical Psychology, NSW, Australia
Discipline of Psychiatry and Chapter 5: Establishing the diag-
Centre for Youth Substance nosis; Chapter 6: Acute care;
Abuse Research, The University Chapter 14: Psychostimulants;
of Queensland, Royal Brisbane Chapter 22: Psychiatric co-​morbidity;
and Women’s Hospital, QLD, Chapter 24: Special populations;
Australia Chapter 26: Legal and ethical issues
Chapter 17: Polysubstance use
Professor Colin Drummond
Professor Ilana B. Crome Professor of Addiction Psychiatry,
Emeritus Professor of Addiction Addictions Department, National
Psychiatry, Keele University, Addiction Centre, Institute
UK; Honorary Consultant of Psychiatry, Psychology and
Psychiatrist, South Staffordshire Neuroscience, King's College
and Shropshire Healthcare NHS London, South London and
Foundation Trust, Staffordshire, Maudsley NHS Foundation
UK; Honorary Professor, Trust, UK
Queen Mary University, Chapter 9: Alcohol
London, UK; Senior Research
Fellow, Imperial College
London, UK
Chapter 24: Special populations
 CONTRIBUTORS xvii

Associate Professor Gerald Professor Wayne Hall

F. X. Feeney Director, University of Queensland
Consultant Physician and Centre for Youth Substance Abuse
Medical Director, Alcohol and Research and the University
Drug Assessment Unit, Princess of Queensland Centre Clinical
Alexandra Hospital and the Research, The University of
Centre for Youth Substance Queensland, Brisbane, QLD,
Use Research, The University Australia; and National Addiction
of Queensland, Brisbane, QLD, Centre, King’s College London, UK
Australia Chapter 2: Epidemiology and
Chapter 17: Polysubstance use prevention
Dr Emily Finch Associate Professor
Clinical Director and Consultant Takayuki Harada
Addiction Psychiatrist, South Associate Professor, Department
London and Maudsley NHS of Psychology, Faculty of Human
Foundation Trust, and Addictions Sciences, Mejiro University,
Clinical Academic Group, Tokyo, Japan
London, UK Chapter 21: Other addictive
Chapter 26: Legal and ethical issues Disorders
Mr Bradley Freeburn Professor Susumu Higuchi
Drug and Alcohol and Mental Director, National Hospital
Health Unit, Aboriginal Medical Organization Kurihama Medical
Service, Redfern, NSW, Australia and Addiction Center and Director
Chapter 24: Special populations of the World Health Organization
(WHO) Collaborating Centre on
Dr Sanju George Research and Training of Alcohol-​
Consultant in Addiction Psychiatry, Related Problems, Kanagawa, Japan
Birmingham and Solihull Mental Chapter 19: Gambling
Health NHS Foundation Trust, Chapter 20: Gaming
Birmingham, UK; and now Senior Chapter 21: Other addictive disorders
Consultant in Psychiatry, Rajagiri
Hospital, Aluva, Kerala, India Dr Ralph Hingson
Chapter 19: Gambling Director, Division of Epidemiology
and Prevention Research, National
Professor Paul Haber Institute on Alcohol Abuse and
Clinical Director, Drug Health Alcoholism, National Institutes of
Services, Sydney Local Health Health, Bethesda, MD, USA
District; Professor and Head, Chapter 26: Legal and ethical issues
Discipline of Addiction Medicine,
Sydney Medical School, University Professor Kazutaka Ikeda
of Sydney, Camperdown, NSW, Professor, Addictive Substance
Australia Project, Tokyo Metropolitan
Chapter 18: Injecting drug use Institute of Medical Science,
Tokyo, Japan
Chapter 3: Pharmacology and
pathophysiology
xviii CONTRIBUTORS

Dr Marianne Jauncey Professor Michael Levy

Medical Director, Sydney Medically Professor, Medical School,
Supervised Injecting Centre, NSW, College of Medicine, Biology and
Australia Environment, Australian National
Chapter 24: Special populations University, Acton, ACT, Australia
Chapter 24: Special populations
Associate Professor
Stephen Jurd Ms Corinne Lim
Consultant Psychiatrist and Editorial Officer, ‘Addiction
Associate Professor, Discipline of Medicine’; formerly The Australian
Psychological Medicine, Sydney Financial Review, Fairfax Media
Medical School, University of Limited, Australia
Sydney, and Director of Training Chapter 24: Special populations
in Psychiatry, Macquarie Hospital,
North Ryde, NSW, Australia Professor Walter Ling
Chapter 7: Ongoing management of Integrated Substance Abuse
substance use disorders Program (ISAP), School of
Medicine, University of California
Ms Shivani R. Khan at Los Angeles (UCLA), and
Pre-​doctoral Fellow, Department formerly Commissioner for
of Epidemiology, College of Public Narcotics and Dangerous Drugs
Health and Health Professions & Commission, Los Angeles,
College of Medicine, University of CA, USA
Florida, Gainesville, FL, USA Chapter 14: Psychostimulants
Chapter 16: Other drugs
Professor Anne
Dr Yasunobu Komoto Lingford-​Hughes
Chief of Psychiatry, National Professor of Addiction Biology,
Hospital Organization, Kurihama Centre for Neuropsycho­
Medical and Addiction Center, pharmacology, Division of Brain
Yokosuka City, Japan Sciences, Department of Medicine,
Chapter 19: Gambling Imperial College London, UK
Chapter 22: Psychiatric co-​morbidity
Dr Noeline C. Latt
Addiction Medicine Specialist, Dr E. Jane Marshall
Royal North Shore Hospital and Consultant Psychiatrist, Alcohol
Sydney Medical School, University Studies Services, South London
of Sydney, NSW, Australia and Maudsley National Health
Chapter 5: Establishing the Service Trust and the National
diagnosis; Chapter 6: Acute Addiction Centre, Institute
care; Chapter 9: Alcohol; of Psychiatry, King’s College
Chapter 11 Opioids; London, UK
Chapter 13: Benzodiazepines Chapter 6: Acute care;
and the other sedative-​hypnotics; Chapter 9: Alcohol
Chapter 23: Specific clinical
situations; Chapter 26: Legal and
ethical issues
 CONTRIBUTORS xix

Professor Ross McCormick Professor David J. Nutt

Consultant in Addiction Medicine, Professor of Psychopharmacology,
and Associate Dean (Postgraduate Division of Brain Science,
Studies), Faculty of Medical and Department of Medicine,
Health Sciences, University of Hammersmith Hospital, Imperial
Auckland, New Zealand College London, UK, and Founding
Chapter 24: Special populations Chair of DrugScience (formerly
the Independent Scientific
Ms Satoko Mihara Committee on Drugs), UK
Chief, Department of Clinical Chapter 3: Pharmacology and
Psychology, National Hospital pathophysiology; Chapter 9: Alcohol;
Organization Kurihama Chapter 10: Cannabis;
Medical and Addiction Center, Chapter 11: Opioids;
Kanagawa, Japan Chapter 13: Benzodiazepines
Chapter 21: Other addictive and the other sedative-​hypnotics;
disorders Chapter 14: Psychostimulants;
Chapter 15: Hallucinogens and disso-
Professor Hisatsugu Miyata
ciative drugs; Chapter 19: Gambling
Professor, Department of
Psychiatry, Jikei University School Dr Sally Porter
of Medicine, Tokyo, Japan Regional Clinical Director, Turning
Chapter 8: Tobacco Point Substance Misuse Services,
Croydon, UK
Dr Hideki Nakayama
Chapter 26: Legal and ethical issues
Chief of Psychiatry, National
Hospital Organization Kurihama Professor Richard Saitz
Medical and Addiction Center, Chair, Professor of Community
Yokosuka, Japan Health Sciences and Medicine,
Chapter 20: Gaming Department of Community
Dr Tim Neumann Health Sciences, Boston University
Schools of Public Health and
Senior Specialist, Department of
Medicine, Boston, MA, USA
Anaesthesiology and Intensive
Chapter 9: Alcohol;
Care Medicine,
Chapter 25: Substance use and spe-
Charité-​Universitätsmedizin Berlin,
cific healthcare settings
Germany
Chapter 25: Substance use and Dr Hiroshi Sakuma
specific healthcare settings Chief of Psychiatry, National
Dr Daisuke Nishizawa Hospital Organization Kurihama
Addictive Substance Project, Tokyo Medical and Addiction Center,
Metropolitan Institute of Medical Kanagawa, Japan
Science, Tokyo, Japan Chapter 20: Gaming
Chapter 3: Pharmacology and Dr Taku Sato
pathophysiology Psychiatrist, National Hospital
Organization Kurihama Medical
and Addiction Center, Treatment
of Pathological Gambling and
Research Section, Kanagawa, Japan
Chapter 19: Gambling
xx CONTRIBUTORS

Professor John B. Saunders Dr Iain Smith

Professor and Consultant Physician Consultant in Addiction Psychiatry,
in Internal Medicine and Addiction Kershaw Unit, Gartnavel Royal
Medicine, University of Queensland, Hospital, Glasgow, UK
University of Sydney, and St. John of Chapter 16: Other drugs
God Health Care, Wesley Health
Care, and South Pacific Private Professor Claudia Spies
Hospital, Sydney, NSW, Australia Professor, Department of
Preface; Chapter 1: The nature of Anaesthesiology and Intensive
addictive disorders; Chapter 3: Care Medicine, Charité-​
Pharmacology and pathophysiol- Universitätsmedizin Berlin, Germany
ogy; Chapter 4: The scope of Chapter 25: Substance use and spe-
intervention; Chapter 5: Establishing cific healthcare settings
the diagnosis; Chapter 6: Acute
Professor Tim Stockwell
care; Chapter 7: Ongoing man-
agement of substance use Director, Centre for Addictions
disorders; Chapter 9: Alcohol; Research of BC and Professor,
Chapter 10: Cannabis; Department of Psychology,
Chapter 11: Opioids; University of Victoria, BC, Canada
Chapter 13: Benzodiazepines Chapter 2: Epidemiology and prevention
and the other sedative-​hypnotics; Professor John Strang
Chapter 21: Other addictive disorders;
Professor of Addiction Psychiatry
Chapter 22: Psychiatric co-​morbidity;
and Head of Department, National
Chapter 23: Specific clinical situa-
Addiction Centre, Institute
tions; Chapter 25: Substance use
of Psychiatry, King’s College
and specific healthcare settings;
London, UK
Chapter 26: Legal and ethical issues
Chapter 18: Injecting drug use
Professor Andrew J. Saxon Dr Pierluigi Struzzo
Professor, Department of
General Practitioner, Head of
Psychiatry & Behavioural Sciences;
the Research and Innovation
Director, Addiction Psychiatry
Area of the Regional Centre for
Residency Program, University of
the Training in Primary Care,
Washington; WA, USA; Director,
Department of Life Sciences,
Center of Excellence in Substance
University of Trieste, Italy
Abuse Treatment and Education
Chapter 25: Substance use and spe-
(CESATE), VA Puget Sound Health
cific healthcare settings
Care System, Seattle, WA, USA
Chapter 11: Opioids Assistant Professor
Professor Janie Sheridan Catherine Woodstock Striley
Assistant Professor, Department
Professor, School of Pharmacy and
of Epidemiology, College of Public
Centre for Addiction Research,
Health and Health Professions,
Faculty of Medical and Health
College of Medicine, University of
Sciences, The University of
Florida, Gainesville, FL, USA
Auckland, New Zealand
Chapter 16: Other drugs
Chapter 16: Other drugs
 CONTRIBUTORS xxi

Professor David Taylor Professor Kim Wolff

Director of Pharmacy and Professor in Addiction Science,
Pathology, South London and King’s College London, Institute
Maudsley NHS Foundation Trust, of Pharmaceutical Science,
Pharmacy Department, Maudsley London, UK
Hospital, London, UK Chapter 24: Special populations
Chapter 16: Other drugs
Professor George Woody
Associate Professor Peter Professor, Department of
Thompson Psychiatry, University of
Senior Staff Specialist, Emergency Pennsylvania and Treatment
Medicine, and Associate Research Institute, Philadelphia,
Professor, Rural Clinical School, PA, USA
Rockhampton, QLD, Australia Chapter 11: Opioids
Chapter 6: Acute care
Professor Nicholas Zwar
Dr Sue Wilson Professor of General Practice,
Senior Research Fellow, Centre School of Public Health and
for Neuropsychopharmacology, Community Medicine, University
Division of Brain Sciences, Imperial of New South Wales, Sydney,
College London, UK NSW, Australia
Chapter 23: Specific clinical situations Chapter 8: Tobacco
Dr Adam R. Winstock
Consultant Psychiatrist and
Addiction Medicine Specialist,
South London and Maudsley NHS
Trust; Senior Lecturer, King’s
College London, UK
Chapter 15: Hallucinogens
and dissociative drugs;
Chapter 16: Other drugs
 xxiii

Symbols and abbreviations

5HIAA 5-​hydroxyindoleacetic acid

5HT 5-​hydroxytryptamine (serotonin)
AA Alcoholics Anonymous
Ab antibody
ACE angiotensin-​converting enzyme
ADH antidiuretic hormone
ADHD attention deficit hyperactivity disorder
ADIS Alcohol and Drug Information Service, Australia
AFP alpha-​fetoprotein
Ag antigen
AIDS acquired immune deficiency syndrome
ALP alkaline phosphatase
ALT alanine aminotransferase
Anti-​HBc anti-​hepatitis B core antibody
Anti-​HBe anti-​hepatitis B e antibody
Anti-​HBs anti-​hepatitis B surface antibody
Anti-​HCV hepatitis C antibody
APTT activated partial thromboplastin time
ARND alcohol-​related neurodevelopment disorder
ASI Addiction Severity Index
ASPD antisocial personality disorder
ASSIST Alcohol, Smoking and Substance Involvement
Screening Test
AST aspartate aminotransferase
ATS amphetamine-​type stimulants
AUD alcohol use disorder
AUDIT Alcohol Use Disorders Identification Test
AWS Alcohol Withdrawal Scale
BAC blood alcohol concentration
BAP British Association of Psychopharmacology
BBV blood-​borne virus
BP blood pressure
xxiv SYMBOLS AND ABBREVIATIONS

BWS Benzodiazepine Withdrawal Scale

CAGE acronym for four alcoholism screening questions
CAL chronic airways limitation (also known as COPD)
CB1 cannabinoid receptor type 1
CB2 cannabinoid receptor type 2
CBD cannabidiol
CBT cognitive behavioural therapy
CCF congestive cardiac failure
CDT carbohydrate deficient transferrin
CIDI Composite International Diagnostic Interview
CIWA-​Ar Clinical Institute Withdrawal Assessment for
Alcohol-​revised
CIWA-​B Clinical Institute Withdrawal Assessment for
Benzodiazepines
CK-​MB creatine kinase isoenzyme
C-​L consultation-​liaison
CNS central nervous system
CO carbon monoxide
COMT catechol-​O-​methyltransferase
COPD chronic obstructive pulmonary disease
CPK creatine phosphokinase
CRP C-​reactive protein
CT computed tomography
CVS cardiovascular system
CXR chest X-​ray
DA dopamine
DALY disability-​adjusted life year
DD differential diagnosis
DDS Delirium Detection Scale
DIS Diagnostic Interview Schedule
DNA deoxyribonucleic acid
DSM-​IV Diagnostic and Statistical Manual, 4th edition
DSM-​5 Diagnostic and Statistical Manual, 5th edition
DTs delirium tremens
DVLA Driver and Vehicle Licensing Agency (UK)
ECG electrocardiogram
 SYMBOLS AND ABBREVIATIONS xxv

ECHO echocardiogram
ED emergency department
EDOU emergency department observation unit
EEG electroencephalogram
EMR Eastern Mediterranean region
ERCP endoscopic retrograde cholangiopancreatography
ESR erythrocyte sedimentation rate
EU European Union
EUC electrolytes, urea, and creatinine
FAE fetal alcohol effects
FAS fetal alcohol syndrome
FASD fetal alcohol spectrum disorder
FBC full blood count
FCTC World Health Organization Framework Convention
on Tobacco Control
FLAGS Feedback, Listen, Advice, Goals, Strategies (acronym
for core elements of brief intervention)
fMRI functional magnetic resonance imaging
FTQ Fagerström tolerance questionnaire
GABA gamma aminobutyric acid
GAD generalized anxiety disorder
GCS Glasgow coma scale
GDP gross domestic product
GGT gamma-​glutamyl transferase
GHB gamma hydroxybutyrate
GI gastrointestinal
GIT gastrointestinal tract
GP general practitioner
HADS Hospital Anxiety and Depression Scale
Hb haemoglobin
HBcAb hepatitis B core antibody
HBeAg hepatitis B e antigen
HBsAg hepatitis B surface antigen
HBV hepatitis B virus
Hct haematocrit
HCV hepatitis C virus
xxvi SYMBOLS AND ABBREVIATIONS

HCV Ab anti-​hepatitis C antibody

HDL high-​density lipoprotein
HDV hepatitis D virus
HIV human immunodeficiency virus
HoNOS Health of the Nation Outcome Scales
h hour(s)
ICD ​10 International Classification of Diseases, 10th
revision
IDU injecting drug user
IgG immunoglobulin G
IgM immunoglobulin M
IM intramuscular
INR international normalized ratio
IV intravenous
IU international units
IUGR intra-​uterine growth retardation
K, Special K ketamine
kg kilogram(s)
L litre(s)
LDL low-​density lipoprotein
LFT liver function test
LSD lysergic acid
MAOI monoamine oxidase inhibitor
mcg microgram(s)
MCV mean corpuscular volume
MDMA methylenedioxymethamphetamine
MEOS microsomal ethanol oxidizing system
min minute(s)
mL millilitre(s)
mmHg millimetres of mercury
MRI magnetic resonance imaging
MRSA meticillin-​resistant Staphylococcus aureus
MSE Mental State Examination
NA Narcotics Anonymous
NAD nicotinamide adenine dinucleotide (oxidized form)
 SYMBOLS AND ABBREVIATIONS xxvii

NADH nicotinamide adenine dinucleotide (reduced form)

NARS Nicotine Assisted Reduction to Stop
NaSSA noradrenaline and specific serotonergic agent
ng nanograms(s)
NMDA N-​methyl-​D-​aspartate
NMS neuroleptic malignant syndrome
nocte at night
NRT nicotine replacement therapy
NSAID non-​steroidal anti-​inflammatory drug
OCD obsessive–​compulsive disorder
OST opioid substitution treatment
OTC over-​the-​counter
PAT Paddington alcohol test
PAE prenatal alcohol exposure
PCP phencyclidine
PCR polymerase chain reaction
PET positron emission tomography
PFC prefrontal cortex
PMA para-​methoxyamphetamine
PO per oral (orally)
PPP purchasing power parity
PRN pro re nata (as required)
PTSD post-​traumatic stress disorder
RASS Richmond Agitation-​Sedation Scale
RIMA reversible inhibitor of monoamine oxidase A
RNA ribonucleic acid
RTA road traffic accidents
SAD social anxiety disorder
SADQ Severity of Alcohol Dependence Questionnaire
SAM substance abuse module
SC subcutaneous
SCAN Schedules for Clinical Assessment in
Neuropsychiatry
SDS Severity of Dependence Scale
sec second(s)
xxviii SYMBOLS AND ABBREVIATIONS

SF14, SF36, SF96 quality of life questionnaires

SIDS sudden infant death syndrome
SE side effects
SL sublingual
SNRI serotonin and noradrenaline reuptake inhibitor
SNS social networking service
SODQ Severity of Opiate Dependence Questionnaire
SSRI selective serotonin reuptake inhibitor
STI sexually transmitted infection
t½ half-​life
TB tuberculosis
TCA tricyclic antidepressant
TFT thyroid function test
THC tetrahydrocannabinol
TIA transient ischaemic attacks
TSH thyroid-​stimulating hormone
TTFC time to first cigarette
TWEAK Tolerance, Worried, Eye-​opener, Amnesia, K/​
Cut-​down
UN United Nations
UNODC United Nations Office on Drugs and Crime
VDRL venereal diseases research laboratory test for
syphilis
VSM volatile solvent misuse
VTA ventral tegmental area
WBC white blood cell count
WE Wernicke’s encephalopathy
WHO World Health Organization
WPR Western Pacific Region
Exploring the Variety of Random
Documents with Different Content
 APRIL 15. (Wednesday.)
About noon to-day a well-disposed healthy lad of seventeen years
of age was employed in unhaltering the first pair of oxen of one of
the waggons, in doing which he entangled his right leg in the rope.
At that moment the oxen set off full gallop, and dragged the boy
along with them round the whole inclosure, before the other negroes
could succeed in stopping them. However, when the prisoner was
extricated, although his flesh appeared to have been terribly
lacerated, no bones were broken, and he was even able to walk to
the hospital without support. He was blooded instantly, and two
physicians were sent for by express. At two o’clock he was still in
perfect possession of his senses, and only complained of the
soreness of his wounds: but in half an hour after he became
apoplectic; sank into a state of utter insensibility, during which a
dreadful rattling in his throat was the only sign of still existing life,
and before six in the evening all was over with him!

APRIL 17.
Pickle had accused his brother-in-law, Edward the Eboe, of having
given him a pleurisy by the practice of Obeah. During my last visit I
had convinced him that the charge was unjust (or at least he had
declared himself to be convinced), and about six weeks ago they
came together to assure me, that ever since they had lived upon the
best terms possible. Unluckily, Pickle’s wife miscarried lately, and for
the third time; previously to which Edward had said, that his wife
would remain sole heiress of the father’s property. This was enough
to set the suspicious brains of these foolish people at work; and to-
day Pickle and his father-in-law, old Damon, came to assure me, that
in order to prevent a child coming to claim its share of the
grandfather’s property, Edward had practised Obeah to make his
sister-in-law miscarry; the only proof of which adduced was the
above expression, and the woman’s having miscarried “just
according to Edward’s very words!” To reason with such very absurd
persons was out of the case. I found too, that the two sisters were
quarrelling perpetually, and always on the point of tearing each
other’s eyes out. Therefore, as domestic peace “in a house so
disunited” was out of the question, I ordered the two families to
separate instantly, and to live at the two extremities of the negro
village; at the same time forbidding all intercourse between them
whatsoever: a plan, which was received with approbation by all
parties; and Edward moved his property out of the old man’s house
into another without loss of time. Among other charges of Obeah,
Pickle declared, that his house having been robbed, Edward had told
him that Nato was the offender; and in order to prove it beyond the
power of doubt, he had made him look at something round, “just
like massa’s watch,” out of which he had taken a sentee (a
something) which looked like an egg; this he gave to Pickle, at the
same time instructing him to throw it at night against the door of
Nato’s house; which he had no sooner done and broken the egg,
than the very next day Nato’s wife Philippa “began to bawl, and
halloo, and went mad.” Now that Philippa had bawled and hallooed
enough was certainly true; but it was also true that she had
confessed her madness to have been a trick for the purpose of
exciting my compassion, and inducing me to feed her from my own
table. Yet was this simple fellow persuaded that he had made her go
mad by the help of his broken egg, and his old fool of a father-in-law
was goose enough to encourage him in the persuasion.

APRIL 19. (Sunday.)

“And massa,” said Bridget, the doctoress, this morning, “my old
mother a lilly so-so to-day; and him tank massa much for the good
supper massa send last night; and him like it so well.—Laud! massa,
the old lady was just thinking what him could yam (eat) and him no
fancy nothing; and him could no yam salt, and him just wishing for
something fresh, when at that very moment Cu-bina come to him
from massa with a stewed pig’s head so fresh: it seemed just as if
massa had got it from the Almighty’s hands himself.”
 APRIL 22.
Naturalists and physicians, philosophers and philanthropists, may
argue and decide as they please; but certainly, as far as mere
observation admits of my judging, there does seem to be a very
great difference between the brain of a black person and a white
one. I should think that Voltaire would call a negro’s reason “une
raison très particulière.” Somehow or other, they never can manage
to do anything quite as it should be done. If they correct themselves
in one respect to-day they are sure of making a blunder in some
other manner to-morrow. Cubina is now twenty-five, and has all his
life been employed about the stable; he goes out with my carriage
twice every day; yet he has never yet been able to succeed in
putting on the harness properly. Before we get to one of the
plantation gates we are certain of being obliged to stop, and put
something or other to rights: and I once remember having laboured
for more than half an hour to make him understand that the
Christmas holidays came at Christmas; when asked the question, he
always hesitated, and answered, at hap-hazard, “July” or “October.”
Yet, Cubina is far superior in intellect to most of the negroes who
have fallen under my observation. The girl too, whose business it is
to open the house each morning, has in vain been desired to unclose
all the jalousies: she never fails to leave three or four closed, and
when she is scolded for doing so, she takes care to open those three
the next morning, and leaves three shut on the opposite side.
Indeed, the attempt to make them correct a fault is quite fruitless:
they never can do the same thing a second time in the same
manner; and if the cook having succeeded in dressing a dish well is
desired to dress just such another, she is certain of doing something
which makes it quite different. One day I desired, that there might
be always a piece of salt meat at dinner, in order that I might be
certain of always having enough to send to the sick in the hospital.
In consequence, there was nothing at dinner but salt meat. I
complained that there was not a single fresh dish, and the next day,
there was nothing but fresh. Sometimes there is scarcely anything
served up, and the cook seems to have forgotten the dinner
altogether: she is told of it; and the next day she slaughters without
mercy pigs, sheep, fowls, ducks, turkeys, and everything that she
can lay her murderous hands upon, till the table absolutely groans
under the load of her labours. For above a month Cubina and I had
perpetual quarrels about the cats being shut into the gallery at
nights, where they threw down plates, glasses, and crockery of all
kinds, and made such a clatter that to get a wink of sleep was quite
out of the question. Cubina, before he went to rest, hunted under all
the beds and sofas, and laid about him with a long whip for half an
hour together; but in half an hour after his departure the cats were
at work again. He was then told, that although he had turned them
out, he must certainly have left some window open: he promised to
pay particular attention to this point, but that night the uproar was
worse than ever; yet he protested that he had carefully turned out
all the cats, locked all the doors, and shut all the windows. He was
told, that if he had really turned out all the cats, the cats must have
got in again, and therefore that he must have left some one window
open at least. “No,” he said, “he had not left one; but a pane in one
of the windows had been broken two months before, and it was
there that the cats got in whenever they pleased.” Yet he had
continued to turn the cats out of the door with the greatest care,
although he was perfectly conscious that they could always walk in
again at the window in five minutes after. But the most curious of
Cubina’s modes of proceeding is, when it is necessary for him to
attack the pigeon-house. He steals up the ladder as slily and as
softly as foot can fall; he opens the door, and steals in his head with
the utmost caution; on which, to his never-failing surprise and
disappointment, all the pigeons make their escape through the open
holes; he has now no resource but entering the dove-cot, and
remaining there with unwearied patience for the accidental return of
the birds, which nine times out of ten does not take place till too late
for dinner, and Cubina returns empty-handed. Having observed this
proceeding constantly repeated during a fortnight, I took pity upon
his embarrassment, and ordered two wooden sliders to be fitted to
the holes. Cubina was delighted with this exquisite invention, and
failed not the next morning to close all the holes on the right with
one of the sliders; he then stepped boldly into the dove-cot, when to
his utter confusion the pigeons flew away through the holes on the
left. Here then he discovered where the fault lay, so he lost no time
in closing the remaining aperture with the second slider, and the
pigeons were thus prevented from returning at all. Cubina waited
long with exemplary patience, but without success, so he abandoned
the new invention in despair, made no farther use of the sliders, and
continues to steal up the ladder as he did before. A few days ago,
Nicholas, a mulatto carpenter, was ordered to make a box for the
conveyance of four jars of sweetmeats, of which he took previous
measure; yet first he made a box so small that it would scarcely hold
a single jar, and then another so large that it would have held
twenty; and when at length he produced one of a proper size, he
brought it nailed up for travelling (although it was completely
empty), and nailed up so effectually too, that on being directed to
open it that the jars might be packed, he split the cover to pieces in
the attempt to take it off. Yet, among all my negroes, Nicholas and
Cubina are not equalled for adroitness and intelligence by more than
twenty. Judge then what must be the remaining three hundred!

APRIL 23.
In my medical capacity, like a true quack I sometimes perform
cures so unexpected, that I stand like Katterfelto, “with my hair
standing on end at my own wonders.” Last night, Alexander, the
second governor, who has been seriously ill for some days, sent me
word, that he was suffering cruelly from a pain in his head, and
could get no sleep. I knew not how to relieve him; but having
frequently observed a violent passion for perfumes in the house
negroes, for want of something else I gave the doctoress some oil of
lavender, and told her to rub two or three drops upon his nostrils.
This morning, he told me that “to be sure what I had sent him was a
grand medicine indeed,” for it had no sooner touched his nose than
he felt some-thing cold run up to his forehead, over his head, and all
the way down his neck to the back-bone; instantly, the headach left
him, he fell fast asleep, nor had the pain returned in the morning.
But I am afraid, that even this wonderful oil would fail of curing a
complaint which was made to me a few days ago. A poor old
creature, named Quasheba, made her appearance at my breakfast
table, and told me, “that she was almost eighty, had been rather
weakly for some time past, and somehow she did not feel as she
was by any means right.”
“Had she seen the doctor? Did she want physic?”
“No, she had taken too much physic already, and the doctor would
do her no good; she did not want to see the doctor.”
“But what then was her complaint?”
“Oh! she had no particular complaint; only she was old and
weakly, and did not find herself by any means so well as she used to
be, and so she came just to tell massa, and see what he could do to
make her quite right again, that was all.” In short, she only wanted
me to make her young again!

APRIL 24.
Mr. Forbes is dead. When I was last in Jamaica, he had just been
poisoned with corrosive sublimate by a female slave, who was
executed in consequence. He never was well afterwards; but as he
lived intemperately, the whole blame of his death must not be laid
upon the poison.

APRIL 30.
A free mulatto of the name of Rolph had frequently been
mentioned to me by different magistrates, as remarkable for the
numerous complaints brought against him for cruel treatment of his
negroes. He was described to me as the son of a white ploughman,
who at his death left his son six or seven slaves, with whom he
resides in the heart of the mountains, where the remoteness of the
situation secures him from observation or control. His slaves, indeed,
every now and then contrive to escape, and come down to
Savannah la Mar to lodge their complaints; but the magistrates,
hitherto, had never been able to get a legal hold upon him. However,
a few days ago, he entered the house of a Mrs. Edgins, when she
was from home, and behaving in an outrageous manner to her
slaves, he was desired by the head-man to go away. Highly
incensed, he answered, “that if the fellow dared to speak another
word, it should be the last that he should ever utter.” The negro
dared to make a rejoinder; upon which Rolph aimed a blow at him
with a stick, which missed his intended victim, but struck another
slave who was interposing to prevent a scuffle, and killed him upon
the spot. The murder was committed in the presence of several
negroes; but negroes are not allowed to give evidence, and as no
free person was present, there are not only doubts whether the
murderer will be punished, but whether he can even be put upon his
trial.

MAY 1. (Friday.)
This morning I signed the manumission of Nicholas Cameron, the
best of my mulatto carpenters. He had been so often on the very
point of getting his liberty, and still the cup was dashed from his lips,
that I had promised to set him free, whenever he could procure an
able negro as his substitute; although being a good workman, a
single negro was by no means an adequate price in exchange. On
my arrival this year I found that he had agreed to pay £150 for a
female negro, and the woman was approved of by my trustee. But
on enquiry it appeared that she had a child, from which she was
unwilling to separate, and that her owner refused to sell the child,
except at a most unreasonable price. Here then was an
insurmountable objection to my accepting her, and Nicholas was told
to his great mortification, that he must look out for another
substitute. The woman, on her part, was determined to belong to
Cornwall estate and no other: so she told her owner, that if he
attempted to sell her elsewhere she would make away with herself,
and on his ordering her to prepare for a removal to a neighbouring
proprietor’s, she disappeared, and concealed herself so well, that for
some time she was believed to have put her threats of suicide into
execution. The idea of losing his £150 frightened her master so
completely, that he declared himself ready to let me have the child
at a fair price, as well as the mother, if she ever should be found;
and her friends having conveyed this assurance to her, she thought
proper to emerge from her hiding-place, and the bargain was
arranged finally. The titles, however, were not yet made out, and as
the time of my departure for Hordley was arrived, these were
ordered to be got ready against my return, when the negroes were
to be delivered over to me, and Nicholas was to be set free. In the
meanwhile, the child was sent by her mistress (a free mulatto) to
hide some stolen ducks upon a distant property, and on her return
blabbed out the errand: in consequence the mistress was committed
to prison for theft; and no sooner was she released, than she
revenged herself upon the poor girl by giving her thirty lashes with
the cattle-whip, inflicted with all the severity of vindictive malice.
This treatment of a child of such tender years reduced her to such a
state, as made the magistrates think it right to send her for
protection to the workhouse, until the conduct of the mistress should
have been enquired into. In the meanwhile, as the result of the
enquiry might be the setting the girl at liberty, the joint title for her
and her mother could not be made out, and thus poor Nicholas’s
manumission was at a stand-still again. The magistrates at length
decided, that although the chastisement had been severe, yet
(according to the medical report) it was not such as to authorise the
sending the mistress to be tried at the assizes. She was accordingly
dismissed from farther investigation, and the girl was once more
considered as belonging to me, as soon as the title could be made
out. But the fatality which had so often prevented Nicholas from
obtaining his freedom, was not weary yet. On the very morning,
when he was to sign the title, a person whose signature was
indispensable, was thrown out of his chaise, the wheel of which
passed over his head, and he was rendered incapable of transacting
business for several weeks. Yesterday, the titles were at length
brought to me complete, and this morning put Nicholas in
possession of the object, in the pursuit of which he has experienced
such repeated disappointments. The conduct of the poor child’s
mulatto mistress in this case was most unpardonable, and is only
one of numerous instances of a similar description, which have been
mentioned to me. Indeed, I have every reason to believe, that
nothing can be uniformly more wretched, than the life of the slaves
of free people of colour in Jamaica; nor would any thing contribute
more to the relief of the black population, than the prohibiting by
law any mulatto to become the owner of a slave for the future. Why
should not rich people of colour be served by poor people of colour,
hiring them as domestics? It seldom happens that mulattoes are in
possession of plantations; but when a white man dies, who happens
to possess twenty negroes, he will divide them among his brown
family, leaving (we may say) five to each of his four children. These
are too few to be employed in plantation work; they are, therefore,
ordered to maintain their owner by some means or other, and which
means are frequently not the most honest, the most frequent being
the travelling about as higglers, and exchanging the trumpery
contents of their packs and boxes with plantation negroes for stolen
rum and sugar. I confess I cannot see why, on such bequest being
made, the law should not order the negroes to be sold, and the
produce of the sale paid to the mulatto heirs, but absolutely
prohibiting the mulattoes from becoming proprietors of the negroes
themselves. Every man of humanity must wish that slavery, even in
its best and most mitigated form, had never found a legal sanction,
and must regret that its system is now so incorporated with the
welfare of Great Britain as well as of Jamaica, as to make its
extirpation an absolute impossibility, without the certainty of
producing worse mischiefs than the one which we annihilate. But
certainly there can be no sort of occasion for continuing in the
colonies the existence of do-mestic slavery, which neither
contributes to the security of the colonies themselves, nor to the
opulence of the mother-country, the revenue of which derived from
colonial duties would suffer no defalcation whatever, even if neither
whites nor blacks in the West Indies were suffered to employ slaves,
except in plantation labour.

MAY 2.
I gave my negroes a farewell holiday, on which occasion each
grown person received a present of half-a-dollar, and every child a
maccaroni. In return, they endeavoured to express their sorrow for
my departure, by eating and drinking, dancing and singing, with
more vehemence and perseverance than on any former occasion. As
in all probability many years will elapse without my making them
another visit, if indeed I should ever return at all, I have at least
exerted myself while here to do everything which appeared likely to
contribute to their welfare and security during my absence. In
particular, my attorney has made out a list of all such offences as are
most usually committed on plantations, to which proportionate
punishments have been affixed by myself. From this code of internal
regulations the overseer is not to be allowed to deviate, and the
attorney has pledged himself in the most solemn manner to adhere
strictly to the system laid down for him. By this scheme, the negroes
will no longer be punished according to the momentary caprice of
their superintendent, but by known and fixed laws, the one no more
than the other, and without respect to partiality or prejudice.
Hitherto, in everything which had not been previously deter mined
by the public law, with a penalty attached to the breach of it, the
negro has been left entirely at the mercy of the overseer, who if he
was a humane man punished him slightly, and if a tyrant, heavily;
nay, very often the quantity of punishment depended upon the time
of day when the offence was made known. If accused in the
morning, when the overseer was in cold blood and in good humour,
a night’s confinement in the stocks might be deemed sufficient;
whereas if the charge was brought when the superior had taken his
full proportion of grog or sangaree, the very same offence would be
visited with thirty-nine lashes. I have, moreover, taken care to settle
all disputes respecting property, having caused all negroes having
claims upon others to bring them before my tribunal previous to my
departure, and determined that from that time forth no such claims
should be enquired into, but considered as definitively settled by my
authority. It would have done the Lord Chancellor’s heart good to
see how many suits I determined in the course of a week, and with
what expedition I made a clear court of chancery. But perhaps the
most astonishing part of the whole business was, that after
judgment was pronounced, the losers as well as the gainers declared
themselves perfectly satisfied with the justice of the sentence. I
must acknowledge, however, that the negro principle that “massa
can do no wrong,” was of some little assistance to me on this
occasion. “Oh! quite just, me good, massa! what massa say, quite
just! me no say nothing more; me good, massa!” Then they thanked
me “for massa’s goodness in giving them so long talk!” and went
away to tell all the others “how just massa had been in taking away
what they wanted to keep, or not giving them what they asked for.”
It must be owned that this is not the usual mode of proceeding after
the loss of a chancery suit in England. But to do the negroes mere
justice, I must say, that I could not have wished to find a more
tractable set of people on almost every occasion. Some lazy and
obstinate persons, of course, there must inevitably be in so great a
number; but in general I found them excellently disposed, and being
once thoroughly convinced of my real good-will towards them, they
were willing to take it for granted, that my regulations must be right
and beneficial, even in cases where they were in opposition to
individual interests and popular prejudices. My attorney had
mentioned to me several points, which he thought it advisable to
have altered, but which he had vainly endeavoured to accomplish.
Thus the negroes were in the practice of bequeathing their houses
and grounds, by which means some of them were become owners
of several houses and numerous gardens in the village, while others
with large families were either inadequately provided for, or not
provided for at all. I made it public, that from henceforth no negro
should possess more than one house, with a sufficient portion of
ground for his family, and on the following Sunday the overseer by
my order looked over the village, took from those who had too much
to give to those who had too little, and made an entire new
distribution according to the most strict Agrarian law. Those who lost
by this measure, came the next day to complain to me; when I
avowed its having been done by my order, and explained the
propriety of the proceeding; after which they declared themselves
contented, and I never heard another murmur on the subject. Again,
mothers being allowed certain indulgences while suckling, persist in
it for two years and upwards, to the great detriment both of
themselves and their children: complaint of this being made to me, I
sent for the mothers, and told them that every child must be sent to
the weaning-house on the first day of the fifteenth month, but that
their indulgences should be continued to the mothers for two
months longer, although the children would be no longer with them.
All who had children of that age immediately gave them up; the rest
promised to do so, when they should be old enough $ and they all
thanked me for the continuance of their indulgences, which they
considered as a boon newly granted them. On my return from
Hordley, I was told that the negroes suffered their pigs to infest the
works and grounds in the immediate vicinity of the house in such
numbers, that they were become a perfect nuisance; nor could any
remonstrance prevail on them to confine the animals within the
village. An order was in consequence issued on a Saturday, that the
first four pigs found rambling at large after two days should be put
to death without mercy; and accordingly on Monday morning, at the
negro breakfast hour, the head governor made his appearance
before the house, armed cap-a-pee, with a lance in his hand, and an
enormous cutlass by his side. The news of this tremendous
apparition spread through the estate like wildfire. Instantly all was in
an uproar; the negroes came pouring down from all quarters; in an
instant the whole air was rent with noises of all kinds and creatures;
men, women, and children shouting and bellowing, geese cackling,
dogs barking, turkeys gobbling; and, look where you would, there
was a negro running along as fast as he could, and dragging a pig
along with him by one of the hind legs, while the pigs were all
astonishment at this sudden attack, and called upon heaven and
earth for commiseration and protection,—

“With many a doleful grunt and piteous squeak,

Poor pigs! as if their pretty hearts would break!”

From thenceforth not a pig except my own was to be seen about

the place; yet instead of complaining of this restraint, several of the
negroes came to assure me, that I might depend on the animals not
being suffered to stray beyond the village for the future, and to
thank me for having given them the warning two days before. What
other negroes may be, I will not pretend to guess; but I am certain
that there cannot be more tractable or better disposed persons (take
them for all in all) than my negroes of Cornwall. I only wish, that in
my future dealings with white persons, whether in Jamaica or out of
it, I could but meet with half so much gratitude, affection, and good-
will.

THE END.
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