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Background and aims Addictive behaviours are among the greatest scourges on humankind. It is important to estimate the extent of the problem globally and in different geographical regions. Such estimates are available, but there is a need to collate and evaluate these to arrive at the best available synthetic figures. Addiction has commissioned this paper as the first of a series attempting to do this. Methods Online sources of global, regional and national information on prevalence and major harms relating to alcohol use, tobacco use, unsanctioned psychoactive drug use and gambling were identified through expert review and assessed. The primary data sources located were the websites of the World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC) and the Alberta Gambling Research Institute. Summary statistics were compared with recent publications on the global epidemiology of addictive behaviours. Results An estimated 4.9% of the world's adult population (240 million people) suffer from alcohol use disorder (7.8% of men and 1.5% of women), with alcohol causing an estimated 257 disability-adjusted life years lost per 100 000 population. An estimated 22.5% of adults in the world (1 billion people) smoke tobacco products (32.0% of men and 7.0% of women). It is estimated that 11% of deaths in males and 6% of deaths in females each year are due to tobacco. Of ‘unsanctioned psychoactive drugs’, cannabis is the most prevalent at 3.5% globally, with each of the others at

The study investigates patient preferences and beliefs and treatment program factors related to the decision to prescribe either buprenorphine or methadone to opiate-dependent patients. The sample (N = 192) was recruited from 10 addiction treatment services in London. Data were collected by means of a single structured interview conducted with patients commencing a treatment episode at the participating agencies. Data on patient demographics, beliefs, attitudes, and preferences were collected using a structured interview. Data regarding treatment goals and prescribed medication were collected from interviews with clinical staff. Oral methadone had a higher preference rating than buprenorphine. Clinical prescribing practices were influenced by patient preferences (both positive and negative), by prior treatment experiences, and by current treatment goals. Patient preferences and beliefs about opioid agonist medications served as an important influence upon clinical prescribing practices. The odds of being prescribed buprenorphine were three times greater among those patients who reported a preference for buprenorphine. The odds of receiving a prescription for methadone were about twice as great among those for whom methadone was the more preferred medication. Preferences were related to previous treatment experiences with these opioid agonists, and for patients in both groups, personal experience was the most important source of information about the treatment options. Buprenorphine was more likely to be prescribed for short-term detoxification and methadone for maintenance treatment.

Changes in criminal convictions were investigated among 1075 clients admitted to 54 drug misuse treatment services across England as part of the National Treatment Outcome Research Study (NTORS). Convictions data during the year prior to treatment, and at 1 year, 2 years, and 5 years after treatment intake were collected from the Home Office Offenders' Index, a national database of all convictions in adult and youth courts. Clinical data were collected by face-to-face interviews at intake to treatment, and at follow-up 1 year, 2 years, and 4-5 years after admission to treatment. During the year prior to treatment, 34% of the sample had been convicted of at least one offence. Conviction rates at all follow-up points were significantly lower than at intake. During the year prior to the 5-year follow-up, 18% of the sample had been convicted of at least one offence. Statistically significant reductions in the mean number of convicted offences were also found between treatment intake and 5-year follow-up. Reductions in convictions were found for acquisitive, drug selling, and violent crimes. Reductions in crime were associated with reductions in regular heroin use, age, and with stable housing. The results replicate previously reported findings of crime reductions among the NTORS cohort as indicated by self-reported measures of offending behaviour. The observed reductions in crime among drug misusers after treatment represent substantial changes in behaviour and have considerable personal, social and clinical significance. Reduced criminality also provides substantial economic benefits to society.

The increase in cocaine use in young people has been reflected in an increase in the number of deaths in which cocaine is identified post mortem. This increase is evident in relation to police custody deaths. In the current analysis, 43 drug-related deaths in custody are considered with cocaine identified in 24 of the post mortem examinations. The article examines the characteristics of these deaths, with particular attention paid to the method and related reasons for drug consumption. Crucially, these deaths contrast with national drug mortality data as they generally involve cocaine consumed by swallowing at the point of arrest. A total of 18 of 24 cocaine deaths involved oral ingestion with at least 15 of these possible attempts at drug concealment occurring at the point of arrest. There is likely to be a considerable risk of loss of life among street-level drug dealers who swallow to avoid drug detection; the article examines the risks associated with this behaviour and possible preventative strategies.

The article uses a semi-structured interview method to assess the acquisition, preparation and use of heroin in a cohort of 114 drug users in contact with treatment services in south-east London, and examines the impact of the increase in crack availability on heroin use and preparation in this population. Seventy-six participants reported using heroin on a daily basis, involving an average of 2.8 hits and using a mean of 0.75 g on each using day. Although almost all of the sample bought their own heroin, very few were confident of assessing its quality, and the mean estimated purity level of heroin bought was 22.7%. Similarly, most of the sample believed that the heroin purchased was adulterated and, although most believed that the heroin quality was evident during the preparation stage, relatively few would ask about quality at the point of purchase, and it is apparent that the beliefs held by much of the sample about drug purity issues did not impact upon their behaviour. Seventy individuals reported t...

The study assessed prevalence of volatile substance abuse (VSA), and its link to other forms of psychoactive substance use and to other problem behaviours among 14–15 year olds recruited from sixteen secondary schools in south-west London. Lifetime use of volatile substances was reported by 126 young people (6% of the sample) whose mean age of first use was 12.6 years. Using logistic regression analysis, lifetime use of volatile substances was found to be associated with more frequent cigarette smoking and more frequent drinking in the previous month, with higher levels of anxiety, greater involvement in delinquent acts, and lower levels of educational aspirations. Among volatile substance abusers, more frequent use was associated with higher levels of psychological distress and greater delinquent activity. Volatile substance abuse may be a marker for other forms of substance use and for other behaviour problems. This issue remains inadequately explored by researchers and clinicians.

While dual diagnosis research has often focussed on substance misuse disorders among mental health clients, relatively little is known about comparable rates of dual diagnosis in community mental health and substance misuse settings because of, inter alia, limitations and lack of consistency in screening. In the current study clinicians administered a brief screening tool, which detects problematic alcohol, drug use, psychosis and common mental health symptoms, to 50 substance misuse and 50 mental health treatment attenders. Sixty-four per cent of the total sample screened positive for dual diagnosis (positive for any psychiatric disorder and either a drug or alcohol problem). Highest rates were observed in the alcohol sample (92.3%), followed by the drug sample (87.5%), and lowest in the community mental health (CMHT) sample (38%). Current depression and social phobia were most prevalent in alcohol clients compared to psychosis, mania and suicidal ideation in CMHT clients. Around one-third of CMHT clients reported using drugs (mainly cannabis) and around a fifth reported problematic alcohol use. The study demonstrates the feasibility of incorporating a dual diagnosis screen into routine clinical practice. The screen can be used in both mental health and substance misuse treatment settings, which are evidently managing complex client caseloads.

Opioids are very addictive drugs because of their powerful effects on reward and pain pathways in the brain. Opioid addiction is currently a worldwide problem and injecting heroin presents serious health risks including death from overdose. The increase in the nonmedical use of prescription opioids and the increase in overdose deaths are worrying trends in North America. There is therefore an increasing need for access to effective treatments. The 2 major drug treatments, methadone and buprenorphine, have proven efficacy but are not necessarily administered in the most effective doses or under optimum conditions. Alternative approaches such as slow-release oral morphine, tincture of opium, and the use of the opioid antagonist naltrexone to maintain abstinence are used seemingly effectively in some countries but have yet to be fully evaluated in randomized controlled trials. Heroin-assisted treatment has proven to be a valuable and effective treatment when administered in specialized clinics but is only appropriate for those who have failed to improve on optimal methadone or buprenorphine maintenance. Recent innovations and substitution treatment as an alternative to incarceration are described. Drug treatment of opioid addiction is most effective when administered as part of a therapeutic program as demonstrated in the initial methadone evaluations and the more recent trials with heroin-assisted treatment.

Publisher Summary This chapter examines the extent to which treatment is primarily driven by the patient’s best interests, as opposed to the interests of government, the treatment industry, and the pharmaceutical industry. Drug use can be initially considered a matter of personal responsibility, and persistent use despite experiencing harm may be considered a failure of personal responsibility. It seems plausible to hypothesize that there is a subpopulation of heroin users that is more likely to take risks, less likely to be deterred by social disapproval or penal sanctions, and particularly vulnerable to developing the chronic, relapsing type of addiction. A divergence of views about the most effective way to use methadone is compatible with the assumption that opioid substitution treatment (OST) is at least a well-intentioned attempt to improve the health of heroin addicts. Ethical concerns over OST go further. Prescribing opioids to heroin addicts is counterintuitive and from its inception has challenged the dominant paradigm of addiction treatment, which is based on the principle that abstinence is necessary for recovery from addiction.

Summary points About a third of adults in the UK have tried cannabis, and 2.5 million people, mostly 16-29 year olds, have used it in the past year.1 Although most people who smoke cannabis will develop neither severe mental health problems nor dependence, regular use of cannabis may be associated with a range of health, emotional, behavioural, social, and legal problems, particularly in young, pregnant, and severely mentally ill people.2 3 The past decade has seen a shift in available cannabis preparations from resinous “hash” to intensively grown high potency herbal preparations, often referred to as skunk, which now dominates the UK market.4 Compared with traditional cannabis preparations, skunk tends to have higher levels of tetrahydrocannabinol, the main psychoactive constituent of cannabis, and lower levels of the anxiolytic cannabinoid cannabidiol. In January 2009 cannabis was returned to its original class B classification (from class C) under the UK Misuse of Drugs Act. Despite high levels of use, only 6% of those seeking treatment for substance misuse in England cite cannabis as their …

BackgroundControversy remains as to whether cannabis acts as a causal risk factor for schizophrenia or other functional psychotic illnesses.AimsTo examine critically the evidence that cannabis causes psychosis using established criteria of causality.MethodWe identified five studies that included a well-defined sample drawn from population-based registers or cohorts and used prospective measures of cannabis use and adult psychosis.ResultsOn an individual level, cannabis use confers an overall twofold increase in the relative risk for later schizophrenia. At the population level, elimination of cannabis use would reduce the incidence of schizophrenia by approximately 8%, assuming a causal relationship. Cannabis use appears to be neither a sufficient nor a necessary cause for psychosis. It is a component cause, part of a complex constellation of factors leading to psychosis.ConclusionsCases of psychotic disorder could be prevented by discouraging cannabis use among vulnerable youths. Research is needed to understand the mechanisms by which cannabis causes psychosis.

Adults suffering from psychosis have high rates of cannabis use. However, there remains controversy as to whether this is a cause or consequence of the psychosis. This review tests the hypothesis that cannabis can cause psychosis by reviewing studies verifying three important criteria for causality in psychiatry: association, temporal priority, and direction, with the emphasis put on prospective longitudinal population-based studies that tested temporal priority. Evidence supports a causal role for cannabis in the development of psychosis but it appears that cannabis use is neither a sufficient nor a necessary cause for psychosis. Rather, it is a component cause - part of a complex constellation of factors leading to psychosis. On an individual level, cannabis use appears to confer only a two-to three-fold increase in the relative risk for later schizophrenia. On a population level, elimination of cannabis use could lead to a 7-13% reduction in incidence of schizophrenia. Thus, some cases of psychotic disorder could be prevented by discouraging cannabis use, particularly among vulnerable youths. More research is needed to better understand the mechanisms by which cannabis causes psychosis.