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This study investigated causes and manner of drug-related fatalities recorded in 2000 in the United Kingdom, measuring the 'masked' manner of death in cases typically recorded as overdose. A retrospective cohort study was used of 1037 cases of accidental drug-related fatalities reported by coroners in England and Wales to the National Programme of Substance Abuse Deaths. Whilst 802 cases were identified as direct acute overdose, representing 77% of the total accidental deaths, 23% of 'overdose' fatalities were caused by asphyxiation (7%), drug-related medical conditions (7%), non-drug-related conditions (4%), traumatic accidents (3%) and infections (2%). Younger people show higher risk of overdose and asphyxiation; older people show higher risk from pre-existing medical conditions. This study not only confirmed the high risk of overdose associated with heroin and polydrug use, but it also identified other high fatality risk factors for heroin/morphine users such as contracting an acute infection leading to septicaemia or endocarditis, or contracting a chronic infection such as HIV, HBV or HCV. In contrast, stimulants particularly featured in traumatic accidents, with amphetamine use most associated with cardio-vascular fatality. These findings highlight the 'masked' manner of death in cases commonly recorded as overdose and demonstrate the need for a more-detailed and systematic method of recording drug-related deaths in order to inform drug education and harm reduction strategies. [ABSTRACT FROM AUTHOR]

Objectives: MDAI (5,6-methylenedioxy-2-aminoindane; 6,7-dihydro-5H-cyclopenta[f][1,3]benzodioxol-6-amine; 'sparkle'; 'mindy') is a psychoactive substance, sold primarily over the Internet and in 'head' shops as a 'legal high'. Synthesised and used as a research chemical in the 1990s, MDAI has structural similarities to MDMA (3,4-methylenedioxy-N-methylamphetamine) and shares its behavioural properties. Recreational use of MDAI appears to have started in Europe around 2007, with a noticeable increase after 2009 in the UK and other countries. Calls to National Poisons Information Services started in 2010, although there were few presentations to emergency departments by patients complaining of undesirable physical and psychiatric effects after taking MDAI. Recreational use of this drug has been reported only occasionally by online user fora. There is little scientifically based literature on the pharmacological, physiological, psychopharmacological, toxicological and epidemiological characteristics of this drug., Methods: Recent literature (including 'grey') was searched to update what is known about MDAI, especially on its toxicity., Results: The resultant information is presented, including on the first three UK deaths involving MDAI use in 2011 and 2012. 'Serotonin syndrome' appears to be a possible factor in these fatalities., Conclusion: It is vital that any other cases, including non-fatal overdoses, are documented so that a scientific evidence base can be established for them., (Copyright © 2013 John Wiley & Sons, Ltd.)

5-MeO-DALT (N,N-diallyl-5-methoxytryptamine) is a psychoactive substance, sold primarily over the Internet as a 'research chemical' or 'plant food'. Although details for the synthesis of this tryptamine have been available since 2004, its use as a hallucinogenic drug has been reported only occasionally in on-line user fora. It is controlled in only a few countries world-wide. There is little scientifically-based literature on the pharmacological, physiological, psychopharmacological, toxicological and epidemiological characteristics of 5-MeO-DALT. Here we review what is known about these aspects. We also report what we believe to be the first death involving the use of this substance. The case involved a man in his mid-20s who died in mid-2010. The coroner concluded that the deceased "died from injuries sustained after being hit by a lorry whilst under the influence of 5-MeODALT". It is critical that any other cases, including non-fatal instances, are documented so that a scientific evidence-base can be established for this drug., (Copyright © 2012 Elsevier Inc. All rights reserved.)

2-DPMP (desoxypipradrol, 2-benzhydrylpiperidine, 2-phenylmethylpiperidine) and D2PM (diphenyl-2-pyrrolidin-2-yl-methanol, diphenylprolinol) are psychoactive substances, sold primarily over the Internet and in 'head' shops as 'legal highs', 'research chemicals' or 'plant food'. Originally developed in the 1950s for the treatment of narcolepsy and ADHD, 2-DPMP's use soon became very limited. Recreational use of 2-DPMP and D2PM appears to have started in March 2007, but only developed slowly. However, in the UK their popularity grew in 2009, increasing rapidly during summer 2010. At this time, there were many presentations to UK Emergency Departments by patients complaining of undesirable physical and psychiatric effects after taking 2-DPMP. In spring 2011 there were similar presentations for D2PM. Recreational use of these drugs has been reported only occasionally in on-line user fora. There is little scientifically-based literature on the pharmacological, physiological, psychopharmacological, toxicological and epidemiological characteristics of these drugs. Here we describe what is known about them, especially on their toxicity, including what we believe to be the first three deaths involving the use of 2-DPMP in August 2010. There are no international controls imposed on 2-DPMP or D2PM. However, a ban on their UK importation was imposed in November 2011 and they became Class C drugs on 13 June 2012. It is critical that any other cases, including non-fatal overdoses, are documented so that a scientific evidence-base can be established for them., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: International media have been reporting about fatalities allegedly related to mephedrone, a popular recreational stimulant, but now a proportion of them have been confirmed. We aimed here at analyzing information relating to the circumstances of mephedrone-related deaths in the United Kingdom., Methods: Descriptive analysis of information was mainly extracted from the UK National Programme on Substance Abuse Deaths database. With an average annual response rate of 95%, UK National Programme on Substance Abuse Deaths receives information from coroners on drug-related deaths among both addicts and nonaddicts in the United Kingdom, the Channel Islands, and the Isle of Man., Results: So far, 128 alleged mephedrone-associated fatalities have been reported; mephedrone was identified at postmortem in 90 cases; inquests have been concluded in 69 cases, 62 of which are analyzed here. Typical mephedrone victims were young (mean age, 28.8 years), male, and with a previous history of drug misuse. There was a notable number (18 cases [29%], 11 being from hanging) of deaths involving self-harm. Mephedrone alone was identified at postmortem on 8 occasions (13% of the inquests' sample)., Conclusions: Present mortality data may suggest a significant level of caution when ingesting mephedrone. Limitations include an inability to determine the exact extent of risks associated with mephedrone consumption.

Objective: Phenazepam (fenazepam; 7-bromo-5-(2-chlorophenyl)-1,3-dihydro-2H-1,4-benzodiazepin-2-one; PNZ, 'Bonsai') is a benzodiazepine developed in the former Soviet Union during the 1970s to treat neurological disorders, epilepsy, and alcohol withdrawal syndrome. Its recreational use appears to have increased over recent years. Because of the lack of accessible data on this substance, it is important that information is made available to health professionals., Methods: A literature search was conducted in relevant databases (Medline, Toxbase, PsychInfo, etc.), grey literature (using Google Scholar) and Internet sites to identify key data on phenazepam, including epidemiology such as availability, price, supply sources, confiscations, and health-related problems., Results: Information from these sources indicates the potential for serious adverse health consequences for this drug when taken recreationally and that its use is spreading in the USA and Europe. Although first use was reported in the UK in October 2009, major concerns in the UK arose in summer 2010 when individuals across Britain were admitted to hospital following overdose. Nine UK fatalities were reported in which phenazepam was detected in post mortem toxicology but not implicated in death. The first UK death directly involving phenazepam was notified in July and the second in November 2011., Conclusions: This paper summarises the key information about phenazepam abuse and health problems of which health professionals, especially those in Emergency Departments, should be aware and presents new information in respect of fatalities caused by the drug., (Copyright © 2012 John Wiley & Sons, Ltd.)

What Is Already Known About This Subject: Dihydrocodeine (DHC) is an opioid analgesic sometimes prescribed as an alternative to other medications (e.g. methadone and buprenorphine) for opioid misuse. Its effectiveness is, however, still controversial. DHC prescription rates seem to be related to levels of DHC fatalities, possibly in relation to levels of disregard of the availability of supervised or interval dispensing of opioids, but no large-scale analysis of DHC fatalities has been carried out. We analysed here involvement of DHC in fatalities that occurred between 1997 and 2007 among individuals with a history of opiate/opioid misuse reported to the National Programme on Substance Abuse Deaths (np-SAD)., What This Study Adds: DHC, either alone or in combination, was identified in 584 fatalities. Typical cases identified were males in their early thirties. In accidental overdoses, DHC, which had been prescribed to 45% of the victims, was typically identified in combination with other drugs, such as heroin/morphine, methadone and hypnotics/sedatives. Both paracetamol and antidepressants were more typically identified in combination with DHC in suicides. Opiate/opioid misusers should be educated about risks associated with polydrug intake and prescribers should carefully consider a pharmacological intervention alternative to DHC (e.g. methadone, buprenorphine) when managing and treating opiate addiction., Aims: Although its effectiveness is somewhat controversial, it appears that dihydrocodeine (DHC) is still prescribed in the UK as an alternative to both methadone and buprenorphine for the treatment of opiate addiction., Methods: Data covering the period 1997-2007 voluntarily supplied by coroners were analysed. All cases pertaining to victims with a clear history of opiate/opioid misuse and in which DHC, either on its own or in combination, was identified at post-mortem toxicology and/or implicated in death, were extracted from the database., Results: Dihydrocodeine, either alone or in combination, was identified in 584 fatalities meeting the selection criteria. In 44% of cases it was directly implicated in the cause of death. These cases represented about 6.8% of all opiate/opioid-related deaths during this period. Typical DHC cases identified were White males in their early thirties. Accidental deaths (96%) were likely to involve DHC in combination with other psychoactives, mainly heroin/morphine, hypnotics/sedatives and methadone. Both paracetamol and antidepressants were found in proportionately more suicide cases than in accidental overdoses. DHC had been prescribed to the decedent in at least 45% of cases., Conclusions: Opiate/opioid misusers should be educated about risks associated with polydrug intake. More in particular, co-administration of DHC with heroin, methadone and benzodiazepines may increase the risk of accidental fatal overdose. Prescribers should carefully consider pharmacological intervention alternative to DHC (e.g. methadone, buprenorphine) when managing and treating opiate addiction. More resources are required to do prospective research in this area., (© 2011 The Authors. British Journal of Clinical Pharmacology © 2011 The British Pharmacological Society.)

Background: Recently, those substances deriving from the active ingredient of the Khat plant, cathinone, have been rising in popularity. Indeed, 4-methylmethcathinone (mephedrone; 'meow meow' and others) has been seen by some as a cheaper alternative to other classified recreational drugs., Aims: We aimed here at providing a state-of-the-art review on mephedrone history and prevalence of misuse, chemistry, pharmacology, legal status, product market appearance, clinical/management and related fatalities., Methods: Because of the limited evidence, some of the information here presented has been obtained from user reports/drug user-orientated web sites. The most common routes for mephedrone recreational use include insufflation and oral ingestion. It elicits stimulant and empathogenic effects similar to amphetamine, methylamphetamine, cocaine and MDMA. Due to its sympathomimetic actions, mephedrone may be associated with a number of both physical and psychopathological side effects. Recent preliminary analysis of recent UK data carried out in 48 related cases have provided positive results for the presence of mephedrone at postmortem., Discussion and Conclusions: Within the UK, diffusion of mephedrone may have been associated with an unprecedented combination of a particularly aggressive online marketing policy and a decreasing availability/purity of both ecstasy and cocaine. Mephedrone has been recently classified in both the UK and in a number of other countries as a measure to control its availability. Following this, a few other research psychoactives have recently entered the online market as yet unregulated substances that may substitute for mephedrone. Only international collaborative efforts may be able to tackle the phenomenon of the regular offer of novel psychoactive drugs.

During the past 20 years or so, more has become known about the properties of khat, its pharmacology, physiological and psychological effects on humans. However, at the same time its reputation of social and recreational use in traditional contexts has hindered the dissemination of knowledge about its detrimental effects in terms of mortality. This paper focuses on this particular deficit and adds to the knowledge-base by reviewing the scant literature that does exist on mortality associated with the trade and use of khat. We sought all peer-reviewed papers relating to deaths associated with khat. From an initial list of 111, we identified 15 items meeting our selection criteria. Examination of these revealed 61 further relevant items. These were supplemented with published reports, newspaper and other media reports. A conceptual framework was then developed for classifying mortality associated with each stage of the plant's journey from its cultivation, transportation, consumption, to its effects on the human body. The model is demonstrated with concrete examples drawn from the above sources. These highlight a number of issues for which more substantive statistical data are needed, including population-based studies of the physiological and psychological determinants of khat-related fatalities. Khat-consuming communities, and health professionals charged with their care should be more aware of the physiological and psychological effects of khat, together with the risks for morbidity and mortality associated with its use. There is also a need for information to be collected at international and national levels on other causes of death associated with khat cultivation, transportation, and trade. Both these dimensions need to be understood.

Background: Although the move to smoke-free hospital settings is generally a popular initiative, it may be a more challenging and controversial issue in mental health care. A survey was carried out to investigate differences in attitudes between clinical staff in psychiatric and general medical settings to smoke-free policy and intervention., Method: The sample comprised 2574 NHS staff working in two Acute Hospital Trusts and one Mental Health Trust in England. Attitudes were examined on two factors: health care settings as smoke-free environments and the role of staff in stop smoking intervention., Results: The findings indicated that attitudes on the two factors were only moderately correlated. Psychiatric staff expressed significantly less favourable attitudes than general staff to smoke-free health care settings and also to the role of staff in stop smoking intervention. The largest difference between the settings concerned the implementation of smoking bans. While approximately 1 in 10 staff in the general setting disagreed with a smoking ban in their wards or clinics, nearly one in three psychiatric staff was against such a ban in their setting., Conclusions: Staff attitudes need to be carefully considered, particularly in psychiatric settings, in attempts to implement smoke-free policies in health care settings.

Objective: The data on England and Wales voluntarily supplied by Coroners to the National Programme on Substance Abuse Deaths for the August 1996-December 2002 time frame were analyzed., Methods: All cases in which at least one analgesic- and cough suppressant-opioid other than heroin/morphine, methadone or buprenorphine was identified were extracted from the database. We hypothesized that: a) populations of addicts and non-addicts presented differences in patterns of drugs involved; and b) within the population of addicts and non-addicts, intentional and non-intentional deaths presented different patterns of substance consumption., Results: A total of 2024 deaths related to selected opioids, either alone or in combination, were included in the analysis. Typically, non-addicts were older than 45 and died as a result of intentional poisoning whilst majority of addicts were young, males and victims of accidental deaths. In about 93% of cases the selected opioids were reported in combination with another substance. Most frequently identified narcotics were propoxyphene, codeine and dihydrocodeine. Co-proxamol, Co-codamol and Co-dydramol were typically prescribed for non-addicts, whilst dihydrocodeine was mostly given to addicts. In non-addicts, alcohol was mostly represented in accidental deaths and antidepressants were typically represented in intentional deaths. Conversely, illicit drugs and hypnotics/sedatives were typically reported in addicts' accidental deaths., Conclusions: The present report constitutes the largest available collection of analgesic- and cough suppressant-opioid mortality data in the UK. Users should be educated about risks associated with polydrug misuse.

Purpose: Only a few formal assessments of websites with drug-related contents have been carried out. We aimed here at fostering collection and analysis of data from web pages related to information on consumption, manufacture and sales of psychoactive substances., General Methods: An 8-language, two-engine, assessment of the information available in a purposeful sample of 1633 unique websites was carried out., Findings: A pro-drug and a harm reduction approach were evident, respectively, in 18% and 10% of websites accessed. About 1 in 10 websites offered either psychoactive compounds for sale or detailed data on drugs' synthesis/extraction procedures. Information on a number of psychoactive substances and on unusual drugs' combinations not found in the Medline was elicited., Conclusions: This represents the first review which is both comprehensive and multilingual of the online available information on psychoactive compounds. Health professionals may need to be aware of the web being a new drug resource for information and possibly purchase.

In the last decade, a global trend of escalating ecstasy (MDMA, MDA, MDEA, MBDB) use was observed. Mentions on medical death certificates, last year's ecstasy use, number of drug offenders, seizures, prices and dosage levels figures were used for this descriptive and correlational study. Figures (1994-2003) were taken from the UK General Mortality Registers, from the Home Office Statistical Bulletins, from the British Crime Survey and from those reported to both the National Crime Intelligence and Forensic Science Services. A total of 394 ecstasy deaths mentions were here identified from the UK; in 42% of cases ecstasy was the sole drug mentioned. Overall, number of fatalities showed a year-per-year increase and positively correlated with: prevalence of last year's use (p < 0.01); number of offenders (p < 0.01) and number of seizures (p < 0.01) but negatively correlated with ecstasy price (p < 0.05). Price negatively correlated with: prevalence of last year's use (p < 0.001) and number of seizures (p < 0.01); but positively correlated with average MDMA dosage per tablet (p < 0.01). MDA, MDEA and MBDB accounted for a significant proportion of tablets only up to 1997, but not afterwards. Increasing production with a concomitant decrease in ecstasy price may have facilitated an increase in consumption levels and this, in turn, may have determined an increase in number of ecstasy deaths mentions. Only medical death certificates and not coroners' reports at the end of their inquests were here analysed; no data were available in respect of other drugs use and toxicology results.

Buprenorphine safety in overdose has been debated recently, but no mortality data related to this compound from the UK have been published. To gather together all of the buprenorphine mortality figures, a number of different sources have been checked. To inform on buprenorphine safety issues, accessible information related to its availability indicators (i.e. prescriptions; seizures) data for the 1980-2002 time frame have been sought. In the UK, during this period, buprenorphine was mentioned in 43 fatalities. Typically, victims were males in the 25-44 age group. In 12 cases (28% of total), a verdict of suicide was given. Buprenorphine was detected on its own in seven cases; more frequently, it was found together with benzodiazepines and other opiates. Large quantities of buprenorphine were prescribed both in England in 1985-1989 and in 1991-1992 in Scotland, where seizures reached their highest levels. Buprenorphine prescriptions seemed to peak again after 1999, when high dose buprenorphine formulations entered the UK market. No positive correlation was found between the number of buprenorphine deaths over the years and either buprenorphine dispensings/prescriptions or seizures. However, an increase in buprenorphine-related deaths since 1999 was identified and this may be an issue which should be carefully monitored over the next few years., (Copyright (c) 2005 John Wiley & Sons, Ltd.)

Methadone is a synthetic opioid, used both as an analgesic in severe pain relief and now mainly in the treatment of opiate dependence. Such use of the drug has increased as its advantages have become widely recognized. There are undesirable outcomes from its greater use, including a substantial market in diverted methadone and a high number of deaths where the drug has been implicated. It is important to understand how and why methadone causes death so that such fatalities can be minimized, and to disseminate such information. This paper presents an overview of the chief effects of methadone on the human body, considering its metabolism, drug interactions and tolerance. The principal mechanisms by which methadone causes death are discussed: respiratory depression, aspiration of vomit, pulmonary oedema, bronchopneumonia, cardiac problems and renal failure. Many such deaths are preventable, if drug interactions and polydrug use are avoided, its longer period of metabolism and individuals' tolerance levels are considered. It is hoped that this paper will (a) help guide health professionals in their management and treatment of patients participating in methadone treatment programmes, and (b) provide some basic information for those dealing with individuals who have consumed methadone., (2004 John Wiley & Sons, Ltd.)

Background: Deaths from antidepressants continue to account for a substantial proportion of drug-related deaths., Aims: To investigate the relative toxicity of the major classes of antidepressant drugs, with the specific objective of assessing this in relation to the cause of death; and to analyse the deaths where there were multiple mentions of antidepressant drugs or other psychoactive drugs with antidepressants., Method: Mortality data were collected from the National Programme of Substance Abuse Deaths, and antidepressant prescription data were collected., Results: Most deaths from antidepressant drugs were suicides (80%). Tricyclic antidepressants (TCAs) accounted for more drug mentions than did other antidepressant drugs (12 per million prescriptions). Selective serotonin reuptake inhibitors (SSRIs) were associated with a significantly lower risk of toxicity, but 93% of deaths from SSRIs occurred in combination with other drugs, especially TCAs (24.5%). In 'combination' deaths patients were significantly more likely to have had a history of drug misuse., Conclusions: The efficacy and safety of augmentation therapy with TCAs in SSRI-resistant patients should be monitored carefully, and patients prescribed antidepressants should be screened for drug use/misuse.

The present study reports on all deaths related to taking ecstasy (alone, or in a polydrug combination) occurring in England and Wales in the time frame August 1996-April 2002. Data presented here are based on all information recorded in the National Programme on Substance Abuse Deaths (np-SAD) database. The np-SAD regularly receives all information on drug related deaths in addicts and non addicts from coroners. A total of 202 ecstasy-related fatalities occurred in the chosen time-frame, showing a steady increase in the number of deaths each year. The ratio male:female was 4:1 and 3 of 4 victims were younger than 29. In 17% of cases ecstasy was the sole drug implicated in death and in the remaining cases a number of other drugs (mostly alcohol, cocaine, amphetamines and opiates) have been found. According to toxicology results, MDMA accounted for 86% of cases and MDA for 13% of cases; single deaths were associated with MDEA and PMA. This is the largest sample of ecstasy related deaths so far; possible explanations are given for the observed steady increase in ecstasy-related deaths and a tentative 'rationale' for this polypharmacy combination is then proposed., (Copyright 2003 John Wiley & Sons, Ltd.)

Introduction: The aim of this study was to compare the characteristics of patients who completed (completers) inpatient treatment of drug dependence with those who failed to complete this programme (noncompleters)., Method: Participants were assessed at admission using the Substance Abuse Assessment Questionnaire (SAAQ) to obtain information about the sociodemographic background, history of drug and alcohol use, physical health, mental health, offending behaviour, and interpersonal relationships. Follow-up interviews were carried out 3, 6, 9, and 12 months after discharge using the SAAQ-Follow-up. To form the three comparison groups, participants were divided on the basis of completion of detoxification and receipt of aftercare., Results and Conclusions: Significantly better treatment outcome was observed amongst those who completed detoxification and went on to spend at least 6 weeks in a recovery and/or residential rehabilitation unit. In contrast, there were no significant differences between noncompleters and completers who had no aftercare on the majority of measures of drug use during follow-up.

Stimulated by the ever present demand to consider the financial implications in management decisions, this study examines the use of urinalysis and self-report in the treatment of drug users, to question if urinalysis, rather than being a routine investigation, could be used with greater discrimination without jeopardising its effectiveness. It concludes that urinalysis remains of importance, as an adjunct to self-report, in providing information and in the treatment of drug users. Suggestions are made as to how it might be used more selectively in treatment based on a clinical knowledge of individual patients and their progress in treatment. However further research is needed to support and define this more clearly.

Background: The opioid addiction test is based on the measurement of pupil dilatation in opioid-dependent people in response to conjunctivally applied naloxone hydrochloride. A positive response (pupil dilatation) indicates that the subject is dependent on opioids., Aims: To evaluate the test in an out-patient setting and to identify factors affecting its outcome., Method: Pupil size was measured using binocular pupillometry in 100 new patients attending an out-patient clinic for assessment and treatment of opioid use. Measurement was repeated 40 minutes after the unilateral instillation of naloxone drops into the conjunctival sac., Results: We performed 127 tests, of which 103 (81.1%) were positive. Males, and those not on methadone at the time of the test, were more likely to have a negative test result., Conclusions: The opioid addiction test proved to be a very useful tool for the rapid diagnosis of opioid dependence in the out-patient clinic. Specialist pupillometric equipment increases the number of patients correctly identified as opioid-dependent on the first visit, but is not essential.

Since a high prevalence of physical morbidity is associated with substance misuse, drug misusers are frequently admitted to general hospitals. Medical staff often perceive drug misusers as a particularly difficult patient group, feeling that they lack the knowledge and skill to deal with them adequately without specialist support. We review the common physical complications of substance misuse likely to be encountered in a general hospital, and provide comprehensive guidelines for the assessment and management of drug dependence in this setting.

This paper outlines some of the evidence that tobacco smoking is maintained by addiction to nicotine. Smokers often perceive that tobacco helps them cope with stress and aids their mental alertness. Nicotine withdrawal symptoms are one important factor preventing many smoker from quitting (only about 3% succeed with each unaided quit attempt). A number of policies are suggested to reduce the health consequences of smoking more quickly than at present. These include (a) banning all tobacco advertising and prosecuting retailers who sell illegally to children, in order to reduce the number of young people becoming addicted, (b) increasing the real price of tobacco in order to encourage more people to try to stop smoking, (c) providing specialist smokers' clinics in every large general hospital in order to assist highly motivated but addicted smokers to quit and (d) increasing the rate at which tobacco manufacturers must reduce permissible tar and carbon monoxide yields, such that in 20 years time only nicotine delivery products which are free of tar and carbon monoxide will be allowed.

Medical students from 13 medical schools in England, Scotland and Wales were asked about their use of tobacco, alcohol and other drugs. Data from 1,278 students (68% response rate) are presented here. 10% of the respondents were current smokers, 10% ex-smokers. In a typical week 17% of the respondents exceeded the recommended limits for sensible drinking. Other drugs besides tobacco or alcohol had been used by 37% of the respondents. Most of the students who had used drugs had done so on no more than 10 occasions. 9% were current users. Although the majority of medical students neither smoke nor drink heavily nor take drugs, a significant minority either persist in or develop potentially harmful substance use behaviour during their studies. The scope for preventive efforts is considerable.

In-patients with psychotic symptoms and cannabis-positive urine analysis were assessed by PSE within one week of admission and again at one and six months. Concurrently admitted psychotic patients with drug-free urine analysis were controls. At one week the two groups differed significantly on only five PSE items: changed perception, thought insertion, non-verbal auditory hallucinations, delusions of control, and delusions of grandiose ability. One item (delayed sleep) differed at one month, and none at six months. The symptom cluster at one week is consistent with acute cannabis intoxication. Subjects and controls were mostly single, poorly educated, unemployed people with histories of psychotic disorders, and given major tranquillisers on admission. Compared with controls, subjects were younger, less likely to have psychiatric histories, more often male, Afro-Caribbeans with a history of convictions and compulsory admissions. The commonest diagnosis was schizophrenia. Use of the label 'cannabis-induced psychosis' may obscure a diagnosis of paranoid schizophrenia. A short-lived psychotic episode does occur in clear consciousness after cannabis intoxication, but chronic cannabis-induced psychosis was not found.

Elements of a systems approach to analysing service delivery are outlined. A specific example--St George's Hospital Addiction Behaviour Department--is detailed. Dynamics of the system--from the client's perspective and the workers viewpoint--demonstrate some of the ways in which emotional conflict surrounding the task is handled. The conclusions focus on what might constitute adaptive resolution of systems dilemmas as well as highlighting the public-health concerns relating to AIDS which, we argue, compromise the primary task of an addiction service at the present time.

A sample of 908 patients drawn from two London Psychiatric Hospitals is described in terms of age, sex, self-reported drug and alcohol history, drug urinalysis results and initial psychiatric diagnosis. Some (34.5%) of respondents admitted to using cannabis at least once in their lifetime and 13% of those tested had urines positive for cannabis on admission. Cannabis use is commoner in young males. These is a higher likelihood that an initial diagnosis of 'psychosis' will be made at admission if patients either report use of cannabis or present a urine sample positive for cannabis.

A survey of the educational activities of schools of nursing on psychoactive drugs in 99 countries was carried out. All the schools that replied gave specific teaching and many also included the rational use of these drugs. The amount of time devoted to this teaching and the methods used varied greatly. Most schools felt that this topic needed more emphasis and many agreed that guidelines on teaching methods and approaches, as well as broad teaching aims and objectives, would be useful.

The gastric emptying rate of 8 heroin-dependent males was measured by means of a radioactive isotope method. A simultaneous oral glucose tolerance test was carried out. The glucose response showed a low, flat curve with a delayed peak, and increased secretion of insulin and growth hormone occurred. As the gastric emptying rate proved to be normal the observed metabolic abnormalities are not due to the effect of heroin on the gastro-intestinal tract, but must be attributed to some other effect of chronic heroin administration.

A conference was held in London in March 1980 on the use and misuse of psychotropic substances. The conference noted that there was a preponderance of medical practitioners who prescribed psychotropic substances. The topics covered ranged from the extent of use of psychotropic substances to the effects of their use in producing different types of morbidity. Consideration was given to controls of psychotropic substances, including steps to reduce their misuse without restricting their legitimate use.

During January 1970 to December 1974, 134 deaths in people aged 10-50 years investigated by coroners in Greater London were recorded as being due to drug addiction. Over three-quarters of the addicts were under 30, and 105 (78%) were male; 55 (41%) were unknown to the Home Office. Barbiturate overdose accounted for over half of the deaths, though two-thirds of these were in people registered as addicts to notifiable drugs. Since the Home Office index is concerned with addiction to one class of drugs only, it fails to reflect accurately the prevalence of all serious forms of addiction. Owing to the continuous change in drug-taking behaviour, however, probably no one method of assessment can provide a complete picture, and thus complementary research methods are essential.

This paper presents a review of the literature on the effects of maternal narcotic addictions upon the foetus and newborn infant. Six children born to 'registered' narcotic addicts were studied, and particular attention was paid to any signs of narcotic withdrawal that might occur after birth. Although all the mothers took heroin or methadone regularly up to the time of delivery, minor physical signs which might have been considered part of the withdrawal syndrome occurred in only one baby. The absence of major withdrawal signs found in this study contrasts with previous findings. The reasons for these differences are discussed, and the implications of these observations for the management of the pregnant narcotic addict and her newborn infant are considered.

During a study of drug incidents dealt with in one month by 62 casualty departments in Greater London, 395 drug-dependent individuals were identified. The great majority of these patients were seen in hospital following an overdose, and barbiturates were the drugs used most frequently. A high incidence of multi-drug use was noted, and many individuals had obtained their drugs from an illicit source. A history of repeated overdosing was common, and one fifth of the patients behaved aggressively while they were in casualty. The implications of these findings are discussed, with particular reference to the demands that are made on casualty departments by drug-dependent individuals.

A survey of the educational activities of schools of pharmacy on psychoactive drugs in 92 countries was carried out. All the schools which replied felt that there was a need for specific education on psychoactive drugs, and the majority felt that the rational use of such drugs should also be taught. Both the amount of teaching given and the methods used varied. This was particularly true for related subjects such as alternatives to psychoactive drug use. Almost a third of schools considered that they did not devote adequate time to psychoactive drugs and their rational use, and many would be grateful for specific educational guidelines in this area.

A survey of patients with drug-related problems seen in London casualty departments during the course of one month revealed 1,706 separate incidents. In 477 cases the patients were dependent on drugs, and more than 40 per cent were dealt with by only five hospitals, all in the West End of London. The remaining 1,229 incidents involved nondependent patients who had taken a drug overdose, and these cases were distributed more evenly between hospitals all over the Greater London area. The implications of this study for service planning and for further monitoring of the patterns of drug misuse are discussed.

A case-note study of 2276 opiate addicts revealed that 112(5%) had a history of asthma and that in 31(1.4%) cases there appeared to be a definite temporal relationship between heroin abuse and the onset of asthma. This rarely-reported complication of heroin dependence has a higher incidence among female addicts (3.3%) than among male addicts (0.7%).

Epidemiological information on the abuse of opioid agonist-antagonists is scanty. Most of the available information relates to pentazocine, the 'oldest' of this class of drugs, and it appears that a sporadic episode of its intravenous abuse in several cities in the United States, is subsiding: reformulation of pentazocine tablets to contain naloxone may have contributed to the decline in this abuse. Apart from a few reports of buprenorphine abuse, there are only occasional accounts of abuse of other drugs in this class. However, the lack of data does not necessarily mean that abuse does not occur and it is essential that epidemiologically sound investigations should be made to explore the existence and extent of any such problem. The interpretation of epidemiological data relating to agonist-antagonist abuse is discussed.

The circadian rhythm of corticosteroid secretion was investigated in six heroin dependent subjects by measuring plasma corticosteroids at 09.00 hours and 24.00 hours. All results were within the normal range and it seems unlikely that chronic heroin dependence affects the hypothalamic control of corticosteroid secretion.

Hospitalised drug addicts were categorised according to the time lapse between onset of their opiate abuse and their first notification to the Home Office. Late notification correlated with a lower level of dependence, a more intermittent pattern of misuse, and a greater likelihood of alcohol abuse. It is postulated that there may be two types of addiction which lie along a continuum.